Diagnosis with a gynaecological cancer is traumatic for many women. An understanding of the psychology of cancer can assist us to provide better care for these women and their families.

Like most of us, I have been fortunate to never receive the words ‘I’m sorry, you have cancer’ from my doctor. However, I have delivered these words to patients and felt inadequate in my ability to console, reassure or empower them. To some extent I’m not certain what the purpose of the ‘I’m sorry, you have cancer’ conversation is. Is it simply to inform or should there be more to it? Certainly, if somehow you fail to communicate the diagnosis clearly, then you have failed the patient in the interaction. But what then? What should you add? What should the patient say? Are there normal and abnormal responses to the ‘I’m sorry, you have cancer’ statement? Should you be reassuring patients, or letting them find their own path? Does any of it make a difference in the long run?

The psychology of cancer is controversial. Practitioners of one school have had successful careers with techniques others will decry as untested and illogical. This article will focus on two areas of interest to people working with women with gynaecological cancer. The first is the idea of a normal grief process experienced by people diagnosed with a terminal illness; the second is the effect of a positive attitude on the outcome of cancer. It should of be borne in mind that while much of this article focuses on patients facing a terminal illness, for many women the diagnosis of a gynaecological cancer is not necessarily a death sentence. It is just as vital that we communicate effectively the relatively positive prognosis of early-stage endometrial cancer as we sensitively explain the consequences of disease with a worse outcome.

Grief

People may experience grief in many situations. The death of a loved one is perhaps the purest example of the process, however, loss of other important aspects of life, such as a relationship or job, can also elicit a grief response. The reaction of a person to receiving a diagnosis of terminal illness such as cancer can also be understood as a grief process.

The work of Swiss-American psychiatrist Elisabeth Kubler-Ross on patients’ psychological response to terminal illness has been influential since its publication in 1969.¹ For many practitioners and patients, her work remains useful in understanding the effect of a diagnosis of cancer on our patient’s psyche.

Kubler-Ross described the stages of grief thus:

• Denial: ‘ there must be a mistake, this can’t be happening to me.’
• Anger: ‘why me, who can I blame?’
• Bargaining: ‘if I can just survive this then I’ll be a better person.’
• Depression: ‘what’s the point in doing anything?’
• Acceptance: ‘I know that I’m going to die, how can I prepare myself?’

Kubler-Ross believed not all people went through all five stages or went through them in the same order. She believed every person went through at least two stages and that people could go back and forth between stages. The idea of stages of grief, and the desirability of moving from the earlier to later stages, underlies much of the traditional approach to grief counselling. Anecdotally, however, many of us have had experiences with people who appeared to grieve in an adaptive way, not in the order described by Kubler-Ross. A 2007 study of 233 bereaved people confirmed this, with the most common initial stage being acceptance, rather than disbelief.²

More recently, the research of George Bonanno has revealed that the five stages of grief are not universally applicable or necessary. Bonanno performed large empirical studies on populations of people suffering loss and bereavement. Two major facets of his work are the idea of resilience and of the four trajectories of grief. Psychological resilience refers to the ability of some individuals to deal with apparently major losses or trauma without going through a recognisable grief process. These people do not appear to experience any of the five stages of grief and do not suffer long-term psychological sequelae. An important part of Bonanno’s work related to this was his finding that a compulsory ‘one size fits all’ provision of counselling after a major traumatic event harms more people than it helps.

Bonanno identified four trajectories of grief³:

1. Resilience: in which an individual maintains stable, healthy levels of physical and psychological function, despite exposure to an event of loss or threat.
2. Recovery: in which there is a temporary period of clinical or subclinical psychopathology, such as depression or posttraumatic stress disorder, before return to a pre-event level of function.
3. Chronic dysfunction: prolonged suffering and inability to function.
4. Delayed grief or trauma: in which a person appears initially to have coped well, with symptoms appearing later.

In practice, both models provide important lessons. Bonanno’s description of the variety of trajectories of grief highlights that there is not a single correct way of dealing with grief, including receiving a diagnosis of cancer. People respond in many different, yet ultimately adaptive, ways and clinicians should not try and mould them into a ‘correct’ method of grieving. On the other hand, Kubler-Ross’ stages provides one possible model by which clinicians and their patients may begin to understand the psychological effect of their illness.

Positive psychology and cancer

While grief may be seen as an effect of cancer on a person’s psychological state there is the converse consideration of whether psychological state can change the progression of a person’s physical disease. Proponents of positive psychology cite the positive influences of ‘fighting spirit’ and optimism on survival and other outcomes of cancer, and describe personal growth and ‘benefit finding’ experienced by some patients with cancer.

Positive psychology, like many areas of psychology, has vehement supporters and critics. Unfortunately, controlled studies are few and academic literature fails to reach a convincing conclusion. A series of articles published in 2010 highlights these divisions.^4-7 Although evidence for an improvement in survival attributable to fighting spirit or other positive psychological factors has not been demonstrated reliably, it appears short-sighted to deny that there may be other, non-survival based benefits, which some patients may experience from maintaining a positive psychological outlook.

Conclusion

In medicine, theory only leads us so far. We read the literature and make our plan, but there always comes a time to act. Ultimately, we have to cut or not cut, treat or not treat, speak or not speak. There is no optimal way to talk to your patient with cancer. There is no right way for them to grieve and no right attitude for them to have towards their cancer. Person-centred Rogerian therapy uses the terms ‘genuineness’ and ‘empathy’ to describe the therapist’s honesty and desire to understand their patient’s internal frame of reference; these are qualities beneficial to any doctor talking to their patients. In practice, we do more good carefully listening to our patients – and supporting them as they make their own personal choices about their grief and their disease – than we will do attempting to prescribe a course of action for them.