Reflections from an Early-Career Uro-Oncologist

When Communication Becomes Treatment

Cancer care is often perceived through the lens of diagnosis, surgery, chemotherapy, radiation, immunotherapy, and survival outcomes. Yet somewhere between the scans, staging discussions, operative consent forms, and follow-up visits lies another equally important aspect of oncology — communication. 

In modern oncology, communication is no longer merely a soft skill or a tool of effective counselling. It has increasingly become a part of treatment strategy itself. 

“Doctor, It Is Only a Tiny Spot. Why Remove the Whole Prostate?” 

One of the most difficult conversations in oncology is explaining early-stage cancer to an asymptomatic 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 valid question. 

From a patient’s perspective, the visible disease appears disproportionately smaller than the proposed treatment. But oncological surgery is often guided not only by what is visible on imaging, but also by the possibility of microscopic disease beyond the index lesion. 

To doctors, this logic feels scientific and evidence-based. To patients, it can feel frightening. 

“Am I the Only One Going Through This?” 

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 the ways we deal with it.” 

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

It was not the discussion about hydronephrosis, kidney drainage, ureteric stents, or surveillance imaging that overwhelmed her. It was the realisation that someone else had walked this path before her — and survived it. 

She was a patient with stage III cervical carcinoma who had developed treatment-related urological complications requiring long-term follow-up. I had been called to evaluate her kidney drainage issues and discuss possible stent removal. If hydronephrosis recurred, re-stenting and serial surveillance would again become necessary. Since she lived far away, tele consultation was also discussed as a possible mode of continued follow-up. 

Medically, it was a routine discussion.
Emotionally, it meant much more to the patient. 

“Why Do I Need Another Scan?” 

Many patients arrive with extensive investigations already performed elsewhere. Occasionally, imaging CDs fail to load properly, scans are incomplete, or additional characterisation becomes necessary for surgical planning. Understandably, patients often ask whether repeat imaging is truly necessary, especially when investigations such as CT scans, MRI, or PET scans can be financially burdensome. 

One patient with a six-centimeter renal mass arrived after outside imaging had raised uncertainty regarding staging. Because of the tumour’s unfavourable location, it remained unclear whether the lesion represented localized disease suitable for partial nephrectomy or locally advanced disease requiring radical nephrectomy. A single staging detail had the potential to completely alter treatment planning.To patients, an additional scan may appear repetitive. To an oncologist, it may represent the difference between preserving a kidney and removing it. 

Many oncologists today 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 along with 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. During discussions, I often draw kidneys, ureters, bladder anatomy, or the prostate on plain paper while explaining disease location and surgical planning.  

“This is your kidney.”  

“This is where the tumour lies.”  

“This is how the urine drains.” 

 The drawings are simple and rough, 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 visualized the disease we were preparing to fight together.  

Sometimes I simply turn the CT scan screen toward the patient and explain the anatomy directly. “This is your right kidney. This is your left kidney. Do you see this irregular bright area here? That is the tumour.” Visual explanation often transforms abstract fear into something understandable, and patients begin to trust that nothing is being hidden from them. 

“Could You Explain That Again?” 

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

“Doctor, we did not fully understand that part. Could you explain it again?” 

Earlier in training, repeated counselling sometimes felt repetitive. Over time, I learned that repetition in oncology is rarely about lack of intelligence, but rather about how anxiety interferes with comprehension. 

Families often need to hear difficult information multiple times before they can emotionally absorb it. They notice whether you rush through explanations. They notice whether you tolerate questions patiently. They notice whether you remain calm while discussing difficult possibilities. 

Over time, I realised that making a patient comfortable does not mean becoming overly friendly or behaving like a family member. Oncology patients are not necessarily searching for exaggerated reassurance. What many of them seek instead is a calm and sincere presence — someone who appears steady enough to guide them through uncertainty. 

“Will I Be Normal Again?” 

Even the most informed patients eventually ask one deeply human question: 

“Will I be normal again?” 

Cancer also changes the emotional atmosphere of a family almost instantly. Before pathology reports arrive and before treatment decisions are finalized, the diagnosis itself begins reorganizing lives. Families begin discussing finances, insurance approvals, work leave, caregiving responsibilities, travel arrangements, accommodation near treatment centres, and logistical planning. The patient may still appear physically healthy, but emotionally, an entirely different reality has already begun. 

Patients are often fearful not only of cancer itself, but also of infertility, altered body image, loss of an organ, long-term functional changes, or the possibility that life may not fully return to what it once was. 

Radical cystectomy may save the life of a patient with muscle-invasive bladder cancer, but it may also require lifelong stoma care. Many patients gradually adapt remarkably well and return to work and social life, although the initial 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 regarding ejaculatory dysfunction, while pre-chemotherapy discussions may include fertility preservation and sperm banking. In many such situations, counselling extends beyond oncological control alone and becomes equally focused on quality of life and survivorship. 

“What If Things Do Not Go As Planned?” 

One of the most delicate parts of oncology counselling is balancing hope with realism. 

When discussing surgery with patients, I often explain the desired outcome honestly. But I also explain that postoperative recovery is not always predictable. Sometimes recovery is smooth. Sometimes it becomes prolonged, complicated, or unexpectedly difficult. 

Preparing patients emotionally for uncertainty is not the same as removing hope. In many situations, honest preparation protects hope. 

Patients tolerate difficult outcomes better when they feel informed beforehand. What often damages trust is not merely a complication, but the feeling of being blindsided by it. 

Another important discussion involves reassuring families that not every cancer diagnosis is an overnight emergency. Once staging and evaluation are completed, many cancers can still be treated within a safe planned window. Families deserve time to arrange finances, organise leave from work, and mentally prepare for the journey ahead. 

“The Architecture of Difficult Conversations” 

Modern oncology training increasingly recognizes that difficult conversations require both empathy and structure. Frameworks such as the SPIKES protocol provide a systematic approach to breaking bad news, emphasizing setting, patient perception, invitation for information, delivery of knowledge, empathy, and discussion of strategy. 

Research has consistently shown that effective doctor–patient communication improves patient satisfaction, treatment compliance, trust, and overall healthcare experience. Patients frequently value clear explanations, adequate listening time, emotional support, professionalism, continuity of care, and accessibility during follow-up. 

Poor communication, on the other hand, often contributes to dissatisfaction, mistrust, treatment non-compliance, and even medico legal conflict. 

“The Long Journey Ahead” 

I often tell patients: 

“You are not choosing me or this hospital for one operation alone. You are choosing us for the long journey ahead.” 

Because cancer survivorship is not simply follow-up. 

Survivorship includes the physical, psychological, social, sexual, and financial consequences of cancer and its treatment. It includes surveillance, adaptation, recurrence anxiety, long-term side effects, and learning to live with the memory of having once heard the words: 

“You have cancer.” 

Today, oncology is increasingly precise and multidisciplinary, integrating advanced imaging, molecular profiling, minimally invasive surgery, targeted therapies, immunotherapy, and risk-adapted treatment approaches. 

Yet despite all these advances, the heart of oncology remains profoundly human. 

Patients may forget percentages, staging terminology, or operative details. But they rarely forget how they felt while sitting inside that consultation room. 

They remember whether someone listened.
Whether someone explained patiently.
Whether someone tolerated repeated questions.
Whether someone stayed calm.
Whether someone helped make uncertainty feel survivable. 

Perhaps that is why communication in cancer care is not separate from treatment. 

It is part of treatment itself. 

Author: Dr. Sachi Sankhala  

Consultant Urologist and Uro-Oncologist 

Email: sachisankhalapln@gmail.com