Anthony Papagiannis
Thessaloniki, Greece 

The man facing me across the desk is outwardly calm. He gives an innocent enough history of a vague pain in his back which eventually led his family physician to send him for a chest film. Something did not look right, and a computed lung scan followed. This was the reason for his presence in my office.

The scan images tell a grim tale. The mass in the right hilum with a bulky complement of lymph nodes, combined with a heavy smoking past, does not bode well. The whole appearance is that of an inoperable tumor. The patient does not seem to suspect the truth. And once more I have to be the jury that will find him “guilty” and the judge who will pass sentence on his case. Even though the treatment prospects for lung cancer are now considerably better than they were just a few years back, the disclosure of the diagnosis is not any easier for either the “transmitter” or the receiver.

What has also changed, along with management prospects, is the desire of most patients to openly discuss the bad news. In my training days so-called “conspiracies of silence” were the rule for both doctors and patients. Various euphemisms were invented to hide emotionally loaded words like cancer, and older colleagues in Greece still resort to such devices. I was taught otherwise by my British mentors, and my studies in doctor-patient communication convinced me that openness and sincerity are sine qua non conditions for building a relationship of trust with the patients. Most if not all patients welcome the chance to talk frankly and have their questions answered in a candid manner. Once the initial shock of the difficult diagnosis is delivered in an appropriate manner, there is a palpable relief on the part of the patient: the uncertainty is gone, we have a common name for the disease, and we can proceed with whatever steps are necessary for the best possible management of the problem.

All these developments, positive though they are, do not relieve my uneasy feeling that I am a judge of old days wearing the black cap and about to pronounce the ultimate sentence for the person sitting across my desk. Despite all the modern advances in medical science and communication techniques the diagnosis and announcement of a new cancer is still a small daily death for the conscientious and empathetic physician.