Communication: The Often Overlooked Treatment Reflections from a Uro-Oncologist

What does it actually feel like to sit across from a patient who has just heard a cancer diagnosis? 

Early in training, I assumed that most oncology consultations revolved around diagnosis, staging, treatment planning, and operative decision-making. Over time, I realised that many of the most important conversations in cancer care have very little to do with the technical details of treatment itself. They revolve around uncertainty, fear, and helping patients and families find a way forward after life has unexpectedly changed direction. 

Not communication as a soft skill. 

Not communication as bedside etiquette. 

But communication as a clinical tool that helps patients understand, prepare, decide, adapt, and cope. 

Treating More Than What We Can See  

One of the most challenging conversations in oncology is explaining early-stage cancer to an otherwise healthy patient. 

A patient once asked me during counselling for localised prostate cancer: 

“Doctor, if it is only a tiny spot in the prostate, why do you need to remove the whole prostate?” 

It was a completely reasonable question. 

From a patient’s perspective, the visible disease often appears disproportionately smaller than the proposed treatment. To them, the tumour may seem like a small abnormality. To the surgeon, however, treatment decisions are guided not only by what can be seen on imaging, but also by the possibility of disease that extends beyond what is immediately visible. 

Explaining cancer biology is often easier than explaining the rationale behind treatment. Patients are not only trying to understand the tumour they can see; they are trying to understand why a seemingly small disease may require a treatment that appears disproportionately large. 

The challenge is not describing the tumour. The challenge is explaining why cancer surgery is often designed to treat not only the disease that is visible today, but also the disease that may remain unseen and become clinically apparent tomorrow. 

The Need to Feel Less Alone 

A few days ago, while counselling a patient at her bedside, I found myself saying something simple: 

“You are not alone in this. I have seen many patients go through similar journeys, and these are some of the ways we deal with such situations.” 

For a few seconds, she remained silent before becoming unexpectedly emotional. 

It was not the discussion about hydronephrosis, ureteric stents, or surveillance imaging that affected her. It was the reassurance that others had walked this path before her and found a way through it. 

She was a patient with stage III cervical cancer who had developed treatment-related urological complications requiring long-term follow-up. I had been called to discuss the possibility of stent removal, future surveillance, and the potential need for further intervention depending on her clinical course. 

The medical discussion itself was relatively straightforward. 

What stayed with me was her response to a completely different part of the conversation. 

She became emotional not while discussing scans, stents, or follow-up plans, but when she realised that other patients had faced similar challenges before her and had learned to live through them. Sometimes, patients are not only searching for medical answers. They are searching for evidence that life can still move forward. 

Making the Invisible Visible 

Many patients arrive with extensive investigations already performed elsewhere. Occasionally, imaging is incomplete, CDs fail to load, or additional characterisation becomes necessary before treatment planning. 

Understandably, patients often ask: 

“Why do I need another scan?” 

To patients, an additional scan may appear repetitive. To an oncologist, it may provide the critical information that determines whether a tumour can be managed with nephron-sparing surgery or requires radical nephrectomy. 

One patient with a six-centimetre renal mass arrived after outside imaging had raised uncertainty regarding staging. Because of the tumour’s hilar location and proximity to the collecting system, it remained unclear whether the lesion could be safely managed with nephron-sparing surgery or whether oncological and technical considerations would ultimately necessitate radical nephrectomy. A single staging detail had the potential to alter not only the surgical approach, but also the long-term implications for renal function and quality of life. 

Visual aids often become invaluable in such situations. Many clinicians use organ models, imaging software, educational videos, and other visual aids to explain disease processes and treatment strategies. Personally, I often prefer a combination of simple anatomical drawings, imaging, and short educational videos whenever appropriate. 

I have always enjoyed drawing repetitive abstract patterns, and over time, drawing organs during counselling became a natural extension of communication. 

“This is your kidney.” 

“This is where the tumour lies.” 

“This is how the urine drains.” 

The drawings are simple and far from artistic, yet many patients ask if they can keep the paper or take a photograph before leaving. One patient even circled the tumour I had drawn with a red pen and placed a large cross over it, almost as if he had finally visualised the disease we were preparing to fight together. 

At other times, I simply turn the CT scan screen towards the patient and explain the anatomy directly. 

“This is your right kidney.” “This is your left kidney.” “Do you see this area here? That is the tumour.” 

Diagrammatic representations and imaging often transform abstract fear into something understandable. More importantly, they help patients participate in decisions rather than simply receive them. 

Understanding Does Not Happen All at Once 

Sometimes, even after a detailed counselling session, another group of relatives enters the room and asks: 

“Could you explain that again?” 

Earlier in my training, I occasionally wondered why the same discussion needed to be repeated multiple times. Repetition in oncology is rarely a reflection of poor understanding. More often, it reflects the difficulty of processing complex information while simultaneously coping with fear, uncertainty, and the emotional impact of a cancer diagnosis. 

During counselling, I often explain not only the desired outcome, but also the possible alternative pathways that may follow treatment. There may be an ideal recovery, an altered functional outcome, a complication requiring further intervention, or a prolonged recovery course. Each possibility carries its own implications and potential morbidities. Patients and families are often trying to understand all of these possibilities at once while also coming to terms with the diagnosis itself. 

Cancer consultations frequently occur during periods of intense emotional stress. Patients and relatives may remember only fragments of a discussion. They may focus on a single sentence while missing several others. Anxiety often interferes with comprehension, making it difficult to absorb, retain, and process information that might otherwise seem straightforward. 

What appears to be repetition is often part of the process through which understanding gradually develops. 

Patients also notice far more than we realise. They notice whether explanations are rushed. They notice whether questions are welcomed. They notice whether difficult possibilities are discussed calmly and honestly. 

Making a patient comfortable does not mean becoming overly familiar. Most patients are not looking for exaggerated reassurance. What they value is clarity, composure, honesty, and the confidence that someone is willing to guide them through uncertainty. 

More Than Survival 

Eventually, many consultations arrive at a deeply human question: 

“Will I be normal again?” 

Or perhaps more accurately: 

“What is my new normal?” 

The question appears simple, but the concerns behind it are often complex. 

Cancer changes the emotional atmosphere of a family almost instantly. Priorities shift overnight as patients and families begin navigating a reality they had never anticipated. 

Patients are often fearful not only of losing years of life, but also of losing parts of the life they know. The prospect of losing an organ, experiencing long-term functional changes, facing infertility, adapting to an altered body image, or adjusting to social and professional changes can be as distressing as the diagnosis itself. 

Radical cystectomy may save the life of a patient with muscle-invasive bladder cancer, but it may also require lifelong stoma care. Many patients adapt remarkably well and return to work, family life, and social activities, although the adjustment period can be physically and emotionally demanding. 

Similarly, young patients undergoing treatment for testicular cancer frequently ask about fertility, future relationships, and fatherhood. Discussions regarding retroperitoneal lymph node dissection may involve concerns about ejaculatory dysfunction, while pre-chemotherapy consultations often include discussions regarding fertility preservation and sperm banking. 

In many such situations, the conversation extends beyond cancer control alone. Patients are trying to understand not only how treatment will affect survival, but also how it may affect identity, independence, relationships, and quality of life. The question is often less about returning to the life they once had and more about understanding the life that lies ahead. 

Drawing the Roadmap Ahead 

A significant part of oncology counselling involves helping patients understand not only the treatment itself, but also the journey that follows. 

Discussions often extend beyond surgery, chemotherapy, or radiation and move towards recovery timelines, follow-up schedules, surveillance imaging, warning signs that warrant medical attention, and the different pathways recovery may take. 

When counselling patients, I often outline the desired recovery course, but also discuss the possibility of a prolonged recovery, additional interventions, or complications that may alter the expected trajectory. Each pathway carries its own implications and challenges. 

Patients frequently cope better with difficult outcomes when they have been prepared for them beforehand. What often damages trust is not the complication itself, but the feeling of being surprised by it. 

Another important aspect of counselling involves reassuring families that not every cancer diagnosis represents an overnight emergency. Once appropriate staging and evaluation have been completed, many cancers can still be treated safely within a planned treatment window. Explaining this “safe window” is often as important as explaining the treatment itself. It allows families time to organise finances, arrange leave from work, seek second opinions when appropriate, and prepare themselves for the journey ahead. 

Similarly, structured follow-up discussions help patients understand what comes next. Scheduled imaging, surveillance visits, expected milestones, and warning symptoms provide a framework that transforms uncertainty into a plan. 

For many patients, knowing the roadmap ahead does not eliminate fear. It simply makes the journey easier to navigate. 

The Art and Science of Difficult Conversations 

Communication in oncology is often associated with delivering a cancer diagnosis or discussing an unfavourable prognosis. Yet modern cancer care demands far more than breaking bad news. 

As oncology has evolved, so too has the practice of cancer counselling. Patients today seek not only information, but also understanding, guidance, and participation in decision-making. 

This shift has led to the development of structured communication frameworks such as the SPIKES protocol, which remains one of the most widely taught approaches for difficult conversations in oncology. 

SPIKES provides a practical sequence for communication: Setting the conversation appropriately, understanding the patient’s Perception, obtaining an Invitation to share information, delivering Knowledge, responding to Emotions with empathy, and developing a Strategy and Summary for the next steps. 

More than two decades after its introduction, SPIKES remains relevant because the fundamental challenges of oncology communication have changed very little. Patients still seek clarity amid uncertainty, hope amid fear, and guidance while making difficult decisions. 

Research has consistently shown that effective communication improves patient satisfaction, trust in the treating team, treatment adherence, and participation in shared decision-making. More importantly, it helps patients feel informed and emotionally prepared for what lies ahead. 

A diagnosis may not change because of a conversation. However, the way that diagnosis is discussed can profoundly influence how patients understand it, respond to it, and live with it. 

The Conversations That Matter Most 

The relationship between an oncologist and a patient is rarely defined by a single consultation. It is built through a series of conversations that accompany diagnosis, treatment, recovery, surveillance, and survivorship. 

Today, oncology is increasingly precise and multidisciplinary, integrating advanced imaging, molecular profiling, minimally invasive surgery, targeted therapies, immunotherapy, and risk-adapted treatment strategies.Yet for most patients, cancer remains far more than a biological disease. It is an experience that unfolds across months and years. Communication accompanies every stage of that experience. 

In many ways, it is one of the treatments we provide. 

Author : Dr. Sachi Sankhala  

Consultant Urologist and Uro-Oncologist 

Email: sachisankhalapln@gmail.com