Talking With Your Family About the Possibility of Cancer

The news about the possibility of cancer is often very concerning and evokes strong emotions.  Getting this news from the doctor is one of the biggest fears that many people have about going to the doctor.  Another facet of dealing with news from your doctor about cancer is discussing this with your family.  There are several issues that arise with this type of discussion.  Most people would not want to create unnecessary worrying until concrete information is available however it is often very helpful to have support and concern from your family in a difficult time.  Balancing these needs is often very difficult.  The purpose of this article is to give a brief overview of possible scenarios about discussion of cancer with your family and to relate common ways they are handled that seem to work.

When you are scheduled to have a screening test for cancer: Certain screening guidelines have been established to help check for the commonest cancer such as breast, colon or prostate.  This type of test is considered a routine check and helps to detect cancer.  Having this type of test does not mean you are at an increased risk for cancer and should not be very concerning.  Most people do not discuss these types of tests with extended family members because most people will get them at some point.

Screening tests will give three types of results including

  • 1) entirely normal,
  • 2) strong evidence of cancer, or
  • 3) indeterminate.

A completely normal screening test is usually quite accurate but most do not entirely exclude the possibility of a cancer still being there.  For example, even when a mammogram is read as “normal” or “no cancer present” there is still a small chance that a cancer may be present or pre-invasive cancer that is not calcified.  Similarly, a colonoscopy that is done and is reported as “no cancer or concerning polyps” may miss about 15-20% of polyps 5 mm or less and up to 5-10% of polyps that are > 10 mm which may contain a small amount of cancer cells within them.  While no screening test is perfect, most are quite accurate and provide with reasonable confidence that a cancer is or is not present.  A screening test may show evidence of a cancer.  In this situation another test to confirm this is often needed.  The second test will usually involve some type of biopsy or sample of cells from that area to prove the presence of cancer under the microscope.  An indeterminate test may indicate that the technique of the study or processing of images was inadequate for proper interpretation.  Generally, this means that the test will need to be repeated.

When your doctor tells you that he or she is very concerned about the presence of a cancer: Thissituation arises when your doctor notices a “red flag” symptom or physical exam finding that cannot be ignored.  A very concerning breast lump or skin mole may be examples of these.  This situation will usually require a combination of imaging study of some sort (e.g. CT Scan or MRI) and a biopsy or sampling of the cells to confirm the presence of cancer.  It is very helpful to have the support of loved ones during this time period because the process will often take a few weeks.

The process of scheduling an x-ray, biopsy and waiting for the biopsy results is often a several week affair.  The next step is to interpret the data and possibly to see a specialist to review treatment options.  Once a cancer is diagnosed, a specialist will also want to know if the cancer has spread elsewhere in the body – a process referred to as cancer staging.  This usually requires additional testing such as bone scan, PET scan, or CT scans of most of the body.  This process is vital because the stage of the cancer dictates both treatment and prognosis.  Sometimes the entire stage cannot be known until after surgery has been done to try and remove the cancer.  For example, a colon tumor is found on colonoscopy and the initial staging studies show no evidence of disease outside of the colon.

A surgery is scheduled to remove the tumor and several lymph nodes are found to contain cancer after analysis of the specimen.  This would be stage III disease and most people will go on to receive chemotherapy after surgical treatment.  By now it should be easy to see that the entire process from finding a lump or concerning symptom to having an accurate picture of treatment plans and cancer prognosis can take weeks to months.  It is helpful discuss this process with family members because they should be aware that all the answers will not be available immediately.

Your doctor is concerned about cancer but you do not want to discuss it with your family: This can be a difficult decision from the vantage point of the doctor, patient and family members.  This is an uncommon choice but there are people who value their privacy and autonomy to an extent that they do not want immediate or extended family members to have knowledge of their diagnosis, treatment or prognosis – even when facing a potentially fatal cancer.

The physician treating you should have the utmost respect and concern for your wishes and privacy.  Difficulties arise with this arrangement when cancer and your health take a turn for the worse and your decision making ability becomes impaired.  Often the next closest relative or spouse is charged with executing your decisions or being a surrogate decision maker for you.  If they have been “out of the loop” for your treatment, it may be difficult for them to perform this role.  The alternative option is to declare a set of written wishes that will make these decisions for you known as a “living will.”

Another option is to specifically designate a surrogate decision maker that knows your wishes; this person would be designated as a health care power of attorney (HCPOA).  These are difficult discussions to have but also they are important as they take the pressure or guilt off of your family members by having to imagine what you might have wanted done in such a dire circumstance.  Most physicians recommend having this type of discussion with your family when facing serious cancer diagnosis in order to make things easier on your loved ones if it should come to a situation such as that.

REFERENCES:

  1. www.cancer.gov/cancertopics/coping/familyfriends
  2. www.cdc.gov/cancer/lung/basic_info/risk_factors.htm
  3. Polyp miss rate determined by tandem colonoscopy: a systematic review. van Rijn JC, Reitsma JB, Stoker J, Bossuyt PM, van Deventer SJ, Dekker E. Am J Gastroenterol. 2006 Feb;101(2):343-50. Review. PMID:16454841
  4. This article was originally published on September 3, 2012 and last revision and update was 9/4/2015.