Communicating with patients is paramount to delivering good care in oncology. Of course, the most important thing on a cancer patient’s mind is the prognosis, which is the likely outcome of the disease and treatment.
Complex concepts concerning a patient’s own life and death, including subtleties of clinical trials and outcome statistics, can often be exceedingly difficult to convey. Bad news is hard to give and even harder to take. Delivering it takes a toll on both physician and patient.
My favorite tool that I use whenever possible for these difficult conversations is the game of American baseball. With its slow pace, opportunity for sudden reversal and surprise, layers and levels of allowable substitutions and strategies, and more, the game encompasses a treasure of metaphorical clarity applicable to oncology.
I often use the following metaphors, because they are both accurate and fairly easy for patients to understand, even for those who may not be baseball fans.
Swinging for the fences
(Giving very aggressive chemotherapy with hopes for a cure)
You may miss the ball and strike out – in fact the odds are this is exactly what will happen. But if you connect and hit the ball, you may defeat your enemy.
Swinging for the fences is not taking an unreasonable chance, nor one with a miniscule chance of success. When used properly it is an apt metaphor because it encourages patients to give the treatment chance their best shot.
The patient may not succeed because the pitcher (the cancer) may be too strong or fast for them. But the fact is that pitches (therapies) can frequently be successful and worth a try. A good example of this is bone marrow transplant in a relapsed leukemic patient or use of IL-2 therapy in renal cell patients, in which the chance is small for a positive response.
The game is never over as long as you still have one at-bat
A team can be down by 10 runs. But until three outs are made in the final inning, the team can send players to bat and continue to score runs indefinitely. Baseball has no set time limit, as Yogi Berra stated when he said, “It ain’t over till it’s over.” Oncologists often stress this point and say that as long as a patient has good performance status, time may allow development of novel therapies.
Like the practice of oncology, baseball is an endeavor that requires patience and recurrent renewals of hope. Cancer, like life, has no certain time limit and its end is never known with certainty. Like the life of a terminally ill patient, the game’s outcome becomes more clear the closer one gets to the end, but it may often surprise the players and the fans by going into extra innings.
The game is never over until it’s over. It is a “patient” game that exhibits the ups and downs we all experience in life’s oscillations, including occasional miracles.
The bases are loaded and the game is on the line
(Regarding risk benefit in terms of response rates)
You are the manager and have the choice of using a .300 hitter or a .150 hitter. The higher batting average hitter has a better chance but does not always succeed. It nicely illustrates the concept of risk benefit in cancer treatment.
Often there are two or more approved regimens with different response rates but vastly different toxicities. This metaphor illustrates why being more aggressive (higher batting average) is often the right choice. After all, the game is on the line and we don’t want to throw away a chance to win it.
Bart Giamatti’s description of baseball
(The bittersweet nature of oncology)
The ex-baseball commissioner described the game by saying, “It breaks your heart. It is designed to break your heart. The game begins in spring when everything begins again and it blossoms in summer, filling the afternoons and evenings and then as soon as the chill rains come, it stops and leaves you to face the fall alone.”
I feel the same sentiment upon meeting a new metastatic lung cancer patient, which is someone with a very poor prognosis. As with the beginning of every spring training, I hope that this will be the exceptional year when that one patient will beat the odds and win the World Series.
Admittedly, any set of metaphors may be arcane or irrelevant in an increasingly multicultural, multi-tasking society. But with baseball’s continued status as “our national pastime,” some terms are still in our lexicon, and I’ve found these analogies very reasonable to try, even frequently.
They may not appeal to everyone, but when they do appeal to someone and there is that shared experience of something human and nonmedical between doctor and patient, this can be nothing short of – you guessed it— a home run.