How Should Clinicians Respond to Cancer Humor?

How Should Clinicians Respond to Cancer Humor?

James Randolph Hillard, MD

Oct 14, 2015

One of the limited number of positives about having cancer is being able to get away with making cancer jokes. Before I got cancer, I thought up what I believe is the greatest-ever pun involving Midwestern geography and malignant neoplasms, but I was never able to share it—until now. I will include it later in this post, unless I chemobrainedly forget.

So, that last paragraph contained at least two attempts at cancer humor (not counting the ridiculous pun that I am hoping to forget to share): 1) comparing the very huge burden of having cancer with the very modest consolation of being able to joke about it, and 2) making light of chemobrain.

Were those first paragraph attempts at humor funny? If so, why? If not, why not? For that matter, why is anything funny?

Freud, of course, viewed everything in terms of the id, ego, and super ego: The id is all about “what I want or feel right now”—sex, aggression, fear, that sort of thing; 2) the superego is all about “what I should be doing;” and 3) the ego has the often thankless task of mediating between both of these irrational entities and the demands of the outside world.

Freud’s main theory of humor was that when the id feels something that the superego disapproves of, the ego can trick the superego into letting the id get away with it. To do this, jokes often start out seeming to go one socially acceptable direction, and then suddenly change direction to allow the id to share something else entirely. That is when we laugh. (BTW, Freud never said, “I don’t want to belong to any club that would accept me as a member”—although it is something that he would have probably found funny. That quote is really most appropriately attributed to Groucho Marx, in spite of what Woody Allen or Annie Hall might say.)

Of course, Freud’s formulation does not cover all types of humor. If you would prefer another formulation, then just Google “Why are jokes funny?” You will get “About 79,800,000 results (0.34 seconds).” Interestingly enough, if you Google “cancer” plus “humor,” you will get “About 38,500,000 results (0.34 seconds).”

From a semi-Freudian point of view, both jokes in my first paragraph express fear of my cancer. My superego thinks admitting fear is weak and childish. Each joke allows some of that fear to come out by seeming to be going toward one place and then ending up in another. My superego is tricked into thinking (probably incorrectly) that this makes me look witty and intelligent, which my superego approves of.

But seriously . . . How should cancer clinicians respond to cancer humor? Smiling is usually good. Smiling shows that you appreciate that the patient is doing their best to deal with a bad situation and that they want you to be a fellow human being with them, not just a clinician.

But laughing may not be the best response when a patient (for example me) says something like, “I always wanted to be first in my medical school class. Now I will be; I will be the first one to die!” This joke is expressing, although indirectly, feelings of bitterness and hopeless. When you laugh at it, you can be perceived as accepting that these are exactly the feelings that the facts of the patient’s illness demand.

How do you make the differential diagnosis of whether or not a situation is laughable? 1) Pick up on the emotion that the patient is expressing, rather than just on the content. If patients say something that they genuinely find funny and that you genuinely find funny, of course you can laugh with them. 2) If the emotion and the content do not match, whatever the patient said is probably not something to laugh at.

Under those circumstances, it is better to ask yourself: What are the impulses, hopes, or fears that the patient may be hiding through humor? You do not need to get all psychiatric, but, in response to the “first in the class” joke above, it is probably good to say something like, “It is too soon to conclude that you are going to be dying right now.” If you are feeling a little humorous yourself, it might be good to say something like, “Hey, it is not time to start planning your valedictory address quite yet.”

That brings us to the question of whether you, as a clinician, are safe in being humorous with patients. When I was in residency, the general response from psychiatrists would have been, “No, the two main things that your id wants to express are sex and aggression, and you do not want to express those to your patient, do you?” Well, it is a good idea to do a quick check to make sure that your humor on a particular occasion is not letting out anything that could be perceived as sexual or aggressive. On the other hand, if your humor is letting you share “weak” feelings about how difficult the human condition can be for your patient and for you, that sort of humor will probably be reassuring. If you say something that a patient is offended by, you can always apologize.

If you cannot ever express humor with patients or accept patients’ expressions of humor, your patient may read that as you think their situation is completely hopeless. For what it is worth, I would encourage you to have the courage to share some humor with your patients. You can trust your intuition to know which ones will respond well and which ones will not.

Oh, and that reminds me . . . The head of the Cancer Center at the University of Cincinnati, where I used to work, was always referring to Cincinnati as “Cancer City.” This was because Cincinnati had a somewhat higher rate of cancer deaths than the country as a whole. When she referred to the city this way one time too many, I wanted so badly to ask her whether it was “Cancer City, Cancers” or “Cancer City, Misery.”

Thank you for letting me get that off my chest. :)


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