Many providers try to “fix” patients’ fears by offering reassurance in the form of factual statements, such as “your chances of long-term remission are greater than 50%.” However, this factual approach can make patients feel that their fears are being trivialized and that they are not being heard. Another common strategy is to be a cheerleader, telling patients to “focus on the positive,” or “be tough—you have to think positive.” This approach can leave patients feeling guilty, as though their negative thoughts or lack of strength caused their illness or will increase the likelihood of recurrence. Addressing feelings before facts is a key strategy for dealing with emotions.

Addressing feelings before facts requires recognizing and naming emotions. Empathic opportunities emerge when patients express negative emotions. Empathy means putting yourself in the other person’s shoes and imagining what his or her life is like (Back et al. 2009). Patients have less anxiety and depression and report greater satisfaction and adherence to therapy when oncologists seize empathic opportunities by responding with “continuer” statements that encourage patients to continue expressing emotions rather than with “terminator” statements that discourage disclosure (Pollak et al. 2007). An example of a continuer statement is, “I can imagine how scary it must be for you to wonder whether your cancer will come back.” An example of a terminator statement is, “We are doing everything we can to monitor your situation, so if your cancer recurs, we will catch it early.” This statement may seem reassuring, but it is likely to cut off further expression. Continuer statements can be categorized into five groups represented by the mnemonic “NURSE,” as detailed in Table 27.1 (Pollak et al. 2007).

Emotional expression often takes the form of crying. According to Dr. David Spiegel, a psychiatrist well known for his work with support groups, “We physicians are trained to treat crying as bleeding, to apply direct pressure to stop it” (Spiegel et al. 1989; Hope 2005). However, crying is often very therapeutic, so providers should let it happen. When patients cry, it does not mean that the provider has been cruel to them; in fact, just the opposite. Patients are most likely to open up emotionally and cry when they know that the provider cares about them. Crying is often a sign of trust and rapport. When patients cry, providers should give them space by sitting with them silently, offering a tissue, and perhaps touching them gently on the forearm. Providers should resist the temptation to immediately reassure or offer factual information. If the provider says anything when a patient cries, it should be something empathic, such as, “I can see how difficult this is for you. I wish things were different.” Responding to patients’ emotions with empathic statements may seem very time consuming, but it extends the length of consultations by an average of only 21 seconds (Kennifer et al. 2009). The more attentive and empathic providers are, the less emotional distress their patients experience (Zachariae et al. 2003).

Empathy is very powerful “medicine” for just about any negative emotion, including the grieving or sadness that patients feel when they experience permanent side effects of cancer or its treatment, such as lymphedema following mastectomy and radiation, altered cognition related to chemotherapy or radiation therapy, and neuropathy. Providers can refer patients to lymphedema specialists, physical therapists, neurologists, occupational therapists, and psychiatrists, but they cannot “fix” these problems. These challenges therefore represent opportunities for providers to show how much they care by simply listening and offering empathy.

Respectful and supportive statements are most effective after patients have had the opportunity to express their emotions. Examples of supportive statements are listed in Table 27.2. These are often most useful at the end of a clinic visit, so that the visit ends on a positive note. These statements also make it clear to patients that the provider will not abandon them in their time of greatest need (Epner et al. 2011).