How to Tell a Patient Their Cancer Has Spread

A Q&A with crisis communication expert Lisa Dinhofer, MA, CT

Q. As a counselor and communicator, you are expert and experienced in managing serious situational difficulties up to and including coping with sudden unexpected death. How would you think it best to approach a person with cancer who is being told, “your cancer has spread”?

A: I’ll answer this question by posing another—how did you discuss the diagnosis initially? Did you jointly establish expectations for addressing this illness going forward?

How a diagnosis is delivered plays a critical role in future conversations around how the illness is responding—or not—to treatment. This initial conversation is the foundation for many more that could go in various directions dependent on disease progression, regression, and patient tolerance.

It’s about process and setting the expectation that you are partnering with the patient in their care, which will include honest and compassionate discussion about options as they become available or diminish. How individuals view a diagnosis changes over time. What can’t be imagined initially may become preferred eventually. Leave room for the unknown.

Initial communication principles that include, “As we address this illness, as we see how your illness is responding, we can continue to make decisions based on what we’re seeing,” set a stage for gentle openers and segues if the need to relay unwanted news becomes necessary. Referencing the illness’s response versus the patient’s, “failure” to respond to treatment rests on the disease not the person.

Strive for balance between optimism, hope, and acknowledgement of the situation’s seriousness. Hope and honesty are not binary. Neither are pragmatism and sensitivity. When allowed, hope’s definition can change in meaning resonant with fluid situations.

A talented artist friend battling lung cancer that had spread to her brain remarked that “hope had become a leash” used by family to drag her from coping and conversing honestly in a way she so desperately needed and wanted in her remaining time. She became more prolific as her illness progressed, enough for a successful gallery show, and used her work to “break through” to her family. Her hope transformed from being cured to preparing her young daughter and husband for what lay ahead. We met in pottery class where she made the urn for her cremains.

The following phrasing suggestions incorporate points above with basics for giving bad news:

  1. “(Patient’s name), we need to discuss your latest test results. Honestly, they are disappointing.” (Pause). This is a “warning shot,” giving the patient an opportunity to psychologically “suit up.”
  2. “The tests reveal the illness has spread to ________.  (Pause for a few beats to sink in. Rushing on increases the likelihood they won’t hear anything else.) I’m so sorry, (name.)” (This is an apology for their circumstances, not your failure).
  3. “What this means is _______________.”
  4. “Here are options for us to consider_____________.”

If a terminal condition, that does not mean there are no options; it means there are different options than before. The goals of your care might change from treatment to palliative, dependent on a patient’s perspective.

The most important principles for delivering difficult news are preparation, controlling beforehand any personal discomfort so as to completely focus on them rather than rushing to end the conversation, telling what you know when it is known to be true, and remembering that this is about them, not you.

Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Super Patient: Honesty and Openness Help Lori Through the Holidays


When it comes to the holiday season, Lori Wallace, a mother of two sons, is accustomed to being in charge. “I’m the mom, I’m kind of the epicenter of my family,” she says. “So I make Christmas.”

But in early April of 2011, Lori woke up with pain in her breast from what she thought was a small toy left in her bed by her five-year-old. No toy was there, and the pain persisted. She soon had her diagnosis: stage IIA invasive ductal carcinoma. Continue reading…


Clinical Trial Versus Standard Protocol: Why and How to Enroll in a Trial


My job at Cancer Commons is to help cancer patients better understand and make decisions about their treatment. Through our Ask Cancer Commons service, I also strive to inform patients about new drugs in trials that they can discuss with their oncologists. Sometimes, I explain the rationale behind a patient’s current or upcoming treatment, and sometimes I try to convince patients to actually get treated, rather than hope that a vegetarian diet and herbal supplements will cure their metastatic disease. Continue reading…


Blood Thinner Safe for Cancer Patients with Brain Metastases

“Cancer patients with brain metastases who develop blood clots may safely receive blood thinners without increased risk of dangerous bleeding, according to a study, published online today in Blood, the Journal of the American Society of Hematology

“Cancer increases a patient’s risk of developing blood clots. When a patient with cancer develops a clot, treatment with a blood thinning medication called an anticoagulant is often added to their treatment regimen in order to prevent the potentially fatal complication of blood clots traveling to the lungs. However, if cancer spreads to the brain, anticoagulant treatment may be withheld because it could cause dangerous bleeding in the patient’s head, which is already a risk for these patients. The task of preventing dangerous blood clots and avoiding life-threatening bleeding presents a particular challenge for specialists in patients with tumor metastases in the brain. Until recently, no data had confirmed whether blood thinners could be safely administered in these patients.

“In order to determine whether administering blood-thinning medication to patients with brain metastases and blood clots increases bleeding, researchers studied the medical records of 293 patients, 104 of whom had received a widely used blood thinner (enoxaparin). The remaining 189 patients did not receive blood-thinning treatment. Researchers matched the patients in each group by year of brain metastases diagnosis, tumor type, age, and gender.”


C. noyvi-NT Shrinks Tumors When Injected into Rats, Dogs and Humans

Editor’s note: This interesting article describes new research in which a type of bacteria called C. novyi was modified by researchers and injected into a soft tissue cancer patient to shrink a metastatic tumor in her arm. Ongoing research aims to determine which other kinds of cancer patients might benefit from the new treatment.

“A modified version of the Clostridium novyi (C. noyvi-NT) bacterium can produce a strong and precisely targeted anti-tumor response in rats, dogs and now humans, according to a new report from Johns Hopkins Kimmel Cancer Center researchers.

“In its natural form, C. novyi is found in the soil and, in certain cases, can cause tissue-damaging infection in cattle, sheep and humans. The microbe thrives only in oxygen-poor environments, which makes it a targeted means of destroying oxygen-starved cells in tumors that are difficult to treat with chemotherapy and radiation. The Johns Hopkins team removed one of the bacteria’s toxin-producing genes to make it safer for therapeutic use.

“For the study, the researchers tested direct-tumor injection of the C. noyvi-NT spores in 16 pet dogs that were being treated for naturally occurring tumors. Six of the dogs had an anti-tumor response 21 days after their first treatment. Three of the six showed complete eradication of their tumors, and the length of the longest diameter of the tumor shrunk by at least 30 percent in the three other dogs.”