There is a great deal of speculation and anecdotal evidence connecting psychological factors and both the risk of developing cancer and its prognosis. Much of the research on the relationship between stressful life experiences and the onset of cancer has been poorly designed. However, the few well-conducted trials have failed to establish a link. A large study of women with newly diagnosed breast cancer found that women who have a severely stressful life experience in the year before the diagnosis, or in the 5 years afterwards, do not seem to be at increased risk of developing a recurrence of the disease. Moreover, a meta-analysis addressed the influence of psychological coping strategies (including fighting spirit, helplessness/hopelessness, denial and avoidance) on cancer survival and recurrence. This meta-analysis found that there was little consistent evidence that psychological coping styles play an important part in survival from or recurrence of cancer.

Even after successful curative treatment of cancer, patients continue to suffer psychological morbidity. The psychological sequelae in cancer survivors may relate to the illness and its treatment as well as family and personal issues. The majority of children who survive cancer cope well with long-term adjustment although adults generally fare less well. Three well-recognized scenarios in this context are:

• The Lazarus syndrome (difficulty with returning to normal life)
  
• The Damocles syndrome (fear of recurrence and terror of minor symptoms)
  
• The Survivor syndrome (guilt about surviving where others have died)

Cancer survivors also suffer social problems including financial difficulties, particularly with insurance and mortgages. They have also been found to have greater problems in obtaining employment and keeping jobs and these may be compounded by frequent follow-up clinic visits.

Breaking bad news to patients requires preparation and this aspect is very often overlooked. The setting for these discussions should be quiet, comfortable and confidential, so that the whole ward does not eavesdrop and so that your bleep and mobile phone do not constantly intrude. An adequate period of time (at least 30 minutes) should be set aside and the patient should be asked if she/he wants someone else present. The conversation should open with a question to find out how much the patient already knows. An open question such as “What have you already been told about your illness?” can reveal not only what has been said and how much has been understood but also the emotional state of the patient (“I’m so terrified it’s cancer”). This opening gambit frequently takes care of much of the hard work for you (“I think it’s cancer but the doctors do seem to want to say”). Under these circumstances the diagnosis can be confirmed in an empathetic fashion. If this initial question does not open up a useful avenue, a warning shot should be fired off (“I have the results of your biopsy and I’m afraid that the news is not good”). Following this warning shot, wait for the patient to respond and check if the patient wants to be told more. This cycle of warning shot, pause and checking should be repeated when elaborating on details of the diagnosis and treatment options. In this way the patient determines how much information is delivered. Certainly long monologues are overwhelming and confusing and it is hopeless and insensitive to use this opportunity to try and teach pathophysiology. Learning to identify and acknowledge a patient’s reaction is essential to breaking bad news. In general, prognostication with respect to “how long have I got Doc?” and the quoting of 5-year-mortality statistics are rarely helpful. Few doctors can explain the implications of skewed distributions, medians and confidence intervals, let alone in a way that is accessible to patients. Many patients will ask for these predictions hoping for reassurance. In these circumstances it is always easier to give false reassurance but the temptation must be resisted as you will not be doing your patient a favour in the long run. After answering the patient’s enquiries, it should be possible to synthesize their concerns and medical issues into a concrete plan. Even in the bleakest of situations setting short-term achievable plans leaves the patient with a goal for the future and hope. The plan should include an explicit arrangement for following up the conversation and a method for the patient to contact you if something arises before the next planned visit.

The immense bravery and gallows humour of a few patients in the face of death can bring unexpected, almost guilty comfort to bad news breakers. Francois Truffaut, the French new wave film director died of brain cancer at the age of 52. In his last published letter, he wrote “film critics were 20 years ahead of conventional medicine, when my second film (Tirez sur le pianiste) came out they said it could only be made by someone whose brain was not functioning properly”.

Increased interaction and empathy with cancer patients has costs to health-care professionals that need to be appreciated and addressed. Improved communications bring health-care professionals closer to the patient and may increase feelings of inadequacy when faced with insoluble issues and of failure when patients die. Health-care professionals dealing with dying patients and their families risk burn-out, and although the medical profession is notoriously resistant to external help, a team spirit, adequate training through communication workshops and peer support are important elements in coping with these emotional stresses. Another technique that is frequently employed is distancing, which may protect the doctors from their feelings but often reduces their compassion and their capacity to care for patients. Although the burden of caring for people with cancer falls most heavily on doctors and nurses, other staff members may also be affected. Indeed, when patients are dying their distress and that of their caregivers trickle down to everyone in the clinic or ward.

The depletion of physical and mental resources induced by excessive striving to reach an often unrealistic work-related goal is termed burn-out. Burn-out of staff working in cancer care is common and victims often describe themselves as workaholics. The Maslach burn-out inventory is a tool that measures burn-out and a quarter of consultant oncologists in the United Kingdom have scores that denote this. The consequences of medical burn-out include emotional exhaustion, leading to psychological detachment from patients and the sensation that little is being achieved in terms of personal accomplishment. This may account for the high frequency of experienced oncologists changing roles in their 50s, taking on management positions or jobs with cancer charities or immersing themselves increasingly in research rather than patient contact.