The Most Common Question

What is the most common question that you are asked by patients with a new diagnosis of cancer? This question came to mind recently as I was seeing a patient with a new diagnosis of widely metastatic recurrent melanoma who had undergone a wide local excision with a negative sentinel lymph node biopsy some years prior.

One might think that the most common question is, “Is this cancer curable?” Although the question of curability is frequently asked (and can be very difficult to address with a patient you are meeting for the first time), I have found that the most common questions asked are: “How long has this cancer been inside my body?” and “Why did I get this cancer?”

The common theme is that often patients’ first reaction upon being given a cancer diagnosis is to look back, rather than forward. Receiving a cancer diagnosis can be emotionally devastating and in order to cope with this, some patients may need to process the "why," "what," and "when" questions about their cancer before they can internalize the diagnosis and start looking forward to treatment options and prognosis.

When patients are told they have cancer, there is a sense of personal violation--something unwanted and alien is inside my body and may kill me--which can understandably lead patients to inquire how long the cancer may have been present. Looking back at possible causes and duration of cancer may help patients obtain a sense of understanding and control over a situation that typically engenders feelings of helplessness.  In many cases, simply hearing the words spoken out loud, “It is impossible to know exactly why you have this cancer,” can provide some measure of psychological relief to patients and their families.

Examining patients’ retrospective questions at the time of diagnosis is also important to help us better care for our patients. For smoking-related cancers such as lung cancer, patient introspection at the time of diagnosis provides an opportunity to counsel patients on lifestyle changes such as tobacco cessation, as smoking can render certain therapies less effective and also increase the risk for treatment toxicity. Other times, however, the benefit of taking the time to look backward instead of forward is less obvious, but equally important. By taking the time to address specific patient questions about why, when, and how their cancer developed, we demonstrate to our patients that we hear their concerns, and we are willing to take the time to help them understand the life-altering news that they just received. Ultimately, this leads to the patient having a firmer grasp of their diagnosis, which in turn better equips the patient and their families to participate in an informed discussion regarding treatment options and prognosis.

Let’s return to our patient with metastatic melanoma. His wife’s first question to me was, “How long has the cancer been there?” I explained that it is impossible to know for sure, but that it is common for melanoma to recur at distant sites, even after initial wide local excision and negative sentinel lymph node biopsy. I spent some time talking about the inherent uncertainties in dealing with cancer and we placed an emphasis on the disease-free interval between initial treatment and recurrent disease, during which time the patient’s quality of life was excellent. We then continued to discuss how maintenance of that quality of life would continue to be a major goal in treatment. Finally, we talked about future treatments, and that we would await results of BRAF mutation analysis, as this could guide future systemic therapy options.

My interaction with this patient helped me to understand that taking the time to answer the most common question will also help us answer the most difficult questions ahead.