The Power of Words

The Power of Words

Don S. Dizon, MD, FACP, FASCO

May 19, 2012
In oncology, there are certain words and phrases that (no matter how carefully said) suck the air out of a room, like "you have cancer," "you've recurred," "incurable," "terminal," and "hospice." Such phrases require careful consideration before they are spoken, and most (if not all) oncologists understand the power of these words, and use them carefully. However, there are others that can be as powerful, yet remain in common usage in our field. 

I still remember my fellowship days at Memorial Sloan-Kettering Cancer Center (MSKCC) like they were yesterday. When I decided to pursue a career specializing in women's cancers, I joined the medical gynecologic oncology clinic of Dr. Paul Sabbatini. In addition to being an amazing clinical researcher, he is a brilliant clinician and, as a fellow, I always sought to impress him.

On one clinic day, I recall seeing a woman in her 60s with ovarian cancer. She had recurred despite treatment. I went in alone, talked with her, examined her, and then presented her to Paul. 

"So, what do you think we should do now?" he asked.

"Well, since she failed this regimen, I think she needs to start on a new salvage treatment. What about a combination?" I recalled saying. Paul's expression changed, and I still remember it like it was yesterday. He looked at me kindly, but with a degree of exasperation. 

"Don—if there's one thing I've learned, it's that people do not fail chemotherapy. The chemotherapy didn't work, but no one failed; she didn't and I didn't. And, we don't salvage people. Salvage is what you do with scrap metal and trash."

I remembered being taken aback by this, primarily because I felt he was criticizing the common language of oncologists. "Salvage" and "failure on treatment" were words and phrases I had heard as a medical resident, and they were phrases used everywhere in oncology. Still, I respected Paul and his experience, and though I did not understand what he was talking about at the time, I was more careful during our clinical discussions after that. 

When I completed my fellowship, I was lucky enough to join the Developmental Therapeutics/Gynecologic Oncology service at MSKCC, and counted Paul as a colleague. In my first year as an attending, I took care of a young patient with ovarian cancer. She had just relapsed from first-line treatment and we had discussed where to go next. 

"I am hopeful treatment can help and prevent the cancer from causing you symptoms," I explained. "Despite the failure of first-line treatment, there are many more options for you."

The words had barely left my mouth when the lesson Paul had tried to teach me came back in full force. My patient, already scared about her recurrence, became teary and turned away from me.

"You make it sound like this was my fault, like I did something wrong!" she said. "I'm sorry I failed chemotherapy, if that's what you think, and I'm sorry I disappointed you."

I was stunned. It was never my intention to place "blame" on something so devastating as a cancer recurrence, and I certainly did not mean to imply that she had failed. I remember using the rest of the visit apologizing, ensuring my patient she had done nothing wrong, and that she did not fail chemotherapy, but rather- chemotherapy failed her. These many years later, I still consider this encounter a watershed moment in my career as an oncologist.

Since then I have been sensitive to words and phrases, particularly when they are used in reference to patients, treatment, and circumstances surrounding recurrent disease. I cringe when I hear someone referred for "salvage treatment" or how it's "too bad she failed therapy." Unfortunately, even today, it is still terminology that is part of the lexicon of oncology.

A quick search on using the search terms FAILURE and CANCER resulted in 145 actively accruing studies, 20 of which had failure in the title. In addition, a search in using the same terms resulted in 54 papers with FAILURE in their title, published in the last five years. While these overall estimates are low, I suspect that in our everyday conversations, it is far more pervasive.  

The language of medicine is a special one, and in the context of a serious medical illness, this is especially true. The way we communicate matters and even when we think our audience is our peers, in the era of social media, we must be cognizant of the wider reach of our words, our lectures, our publications, and our presentations. While our colleagues may understand what we mean when we refer to treatment as "salvage therapy," the same may not be said of how our patients or the public hear it. 

As we look forward to the Annual Meeting, we as an oncology community must commit to a concerted effort to monitor the language of oncology. Words are powerful, and despite our best intentions, can hurt—this is true in life, and it is true in oncology. 


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Lisa Greaves

May, 21 2012 10:38 AM

Thanks so much for your thoughtful comments. A commonly used phrase that I personally take issue with is describing those who die from their disease as having "lost their battle" with cancer. When I reflect on all the people I know who have died from cancer, I don't look at them as losers of a battle. Just like "cancer" is not a single disease, battling cancer is not a single event. It is a series of challenges and choices.

When cancer becomes terminal, patients must make incredibly difficult choices about how to navigate their own end of life. The best doctors become true partners in this journey. What greater triumph is there than this? In truth, we all lose our battle with death at some point. Those who have the courage and grace to make impending death a meaningful part of their life have won in a way that is nothing short of remarkable.

Don S. Dizon, MD, FACP

May, 21 2012 5:45 PM

Dear Lisa,

I appreciate your candid thoughts very much, especially as you highlight one of the truisms of humanity, that ultimately we all lose the battle against death. Cancer is often expressed as a war, but in the end, I agree, there must be a better way to remember those who have died of cancer than to refer to them as having "lost their battle".

With my post I am hoping to begin a dialogue within private offices, clinics, hospitals, and organizations, to begin to reflect on the language of cancer. Ultimately, our words should provide hope, comfort, and honesty. When they don't, each of us has a personal responsibility to make things right.

Cheers, D

Heather Marie Hylton, PA-C

May, 25 2012 8:13 PM

Thank you for writing this most thoughtful piece. I am also grateful for mentors who have provided gentle guidance on implementing more sensitivity in the language we use with our patients.

I recall a similar discussion about a patient with an attending physician in which I used the expression, "The patient failed treatment." He turned to me and said, "Ms. Hylton, patients don't fail treatment.  Our best treatment failed her."  Another oncologist I know once underscored how we should be thanking our patients for tolerating what we put them through--surgery, chemotherapy, radiation, the precautions some must endure--the list goes on.  This poignant remark has since stayed with me and serves as a reminder to us as clinicians to respect how remarkable our patients truly are.

Don S. Dizon, MD, FACP

May, 26 2012 9:59 AM

Dear Heather, I could not agree more. Each of us plays such an important role in our patients' lives and the language we use to communicate with and about their care warrants special consideration. I truly appreciate your comments. See you in Chicago! D

Michael Jordan Fisch, MD, MPH, FASCO

Jun, 01 2012 10:05 AM

Don, I enjoyed this insightful blog as it reminds me that words are indeed an important part of our therapeutic toolbox and they have both efficacy and toxicity.  Like any other treatment modality, we can all learn the nuances of how to harness this modality better and safer.  A Mark Twain quote about the power of words is a favorite of mine: "The difference between the almost right word & the right word is really a large matter--it's the difference between the lightning bug and the lightning."  The quote was shared with me by medical humanist Celia Bandman from the Center for Communiciation in Medicine, who pointed out how both writers and doctors can relate to this point.

Don S. Dizon, MD, FACP

Jun, 06 2012 11:47 AM

Michael, thank you for your insight, as always. I will file the quote from Mark Twain in my mind. It is a great and timely one! BEst to you- D

Katherine Obrien

Jun, 27 2012 12:39 AM

Dr. Dizon
I have metstatic breast cancer. Early on, my doctor talked about "restaging" (vs. "having scans to assess treatment effectiveness"). Well, I was new, so "restaging" sounded hopeful to me. As if perhaps the earlier oncologists, radiologists, etc. had been wrong and maybe I did not after all have Stage IV cancer. Live and learn...

Here is what I would like to say

Don S. Dizon, MD, FACP

Jun, 27 2012 9:01 AM

Dear Katherine, I read your blog piece and think it's really wonderful. I hope you do not mind my sharing it on twitter. Yes- I have learned of other phrasing in oncology-speak that can be less than optimal. Thank you for making me reconsider another phrase that I will admit to using quite liberally. I think we need to choose our words and phrases carefully, no matter what we do in medicine. Yours is a reminder yet again of that valuable lesson. DSD

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