This post was first published on ASCO Connection, February 11, 2019. ASCOConnection.org is the professional networking site for the American Society of Clinical Oncology (ASCO) and the companion website for ASCO’s official member magazine, ASCO Connection.
Dr. Graff is the director of breast oncology at the Lifespan Cancer Institute at Brown University. Follow her on Twitter @DrSGraff.
Sally* looks up, expectantly, biting her lip, and asks the question I know she’s been considering. “But what did I do...you know, that caused this?” I get this question regularly. I can list dozens of risk factors that increase a person’s risk of developing cancer—but I cannot tell you in a room of 100 people with those shared risk factors which 1 or which 20 of them will go on to develop cancer. I also cannot tell you why there are always those with no risk factors who still develop cancer.
So many of my patients dread this question and the inevitable answer. They have spent days or weeks working up the courage to ask, berating themselves for the choices they made that “caused” their cancer. They have sometimes made dramatic changes based on internet searches—no more food with soy, no more soda, no more sugar, no more stress. I have seen patients apologize to children and spouses for “creating this situation.” They have added the burden of blame to the burden of cancer. I have seen patients spiral into a cycle of shame and blame. If I know anything, I know that no one chooses cancer.
“Well, bad luck?” I nervously chuckle. Sally has numerous breast cancer risk factors: obesity, hormone therapy use, moderate alcohol consumption, and she’s never given birth. But I can’t imagine that in this moment enumerating these is going to help Sally undergo cancer treatment. “Honestly, I can point to risk factors. But none of those tell me why you, why now, why this. Sally, you didn’t choose this. You didn’t cause this. Please, on top of everything else, do not assign yourself the blame of getting cancer.”
I think this is an important message for patients, as well as their family and friends, to hear. I have witnessed mothers sob uncontrollably that they passed on the gene that caused a cancer. I have overhead people saying, “Well, he smoked, so he did it to himself.” I have seen family and friends behave in hurtful ways. “If she had been doing her mammograms, this never would have happened.” Uh, she was. Mammograms don’t prevent cancer—they detect it. If someone you know or love has been diagnosed with cancer, do not place the blame on their shoulders. Ask how you can best support them.
I certainly believe in identifying risk factors—it is one reason I run a high-risk clinic for women at an increased risk of developing breast cancer. I also believe in primary and secondary risk reduction—I refer patients for smoking cessation, nutrition services, exercise therapy, and other services that decrease risk of cancer or cancer recurrence. You can bet I’ll vaccinate my children against HPV. I hope every adult talks with their primary care doctor or other medical specialists about steps they could take to lower their risks of any number of diseases and engages in recommended screening programs.
But I don’t believe in blame. When a patient asks, “why me?” I don’t think they are looking for a list of their risk factors. They are looking for absolution. And their doctor has the privilege of offering it.
*Name and details have been changed.