VOLUME

23

NUMBER

JANUARY

20

2005

JOURNAL OF CLINICAL ONCOLOGY

T H E

A R T

O F

O N C O L O G Y:

When the Tumor Is Not the Target

Humor and Oncology

Anthony M. Joshua, Angela Cotroneo, and Stephen Clarke
From the Department of Medical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada; Department of Social Work, Royal Prince Alfred Hospital, Sydney; and Central Clinical School, University of Sydney, Sydney, Australia. Submitted September 7, 2004; accepted September 17, 2004. Authors disclosures of potential conicts of interest are found at the end of this article. Address reprint requests to Anthony M. Joshua, MBBS, Department of Medical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada; e-mail: anthony.joshua@doctor.com. 2005 by American Society of Clinical Oncology 0732-183X/05/2303-645/$20.00 DOI: 10.1200/JCO.2005.09.064

INTRODUCTION

ing, whether physical, emotional, cognitive, or spiritual. Classication of Humor Practically, the classication of humor in oncology falls into two broad categories. Firstly, the vast majority being the general repartee, both unplanned and spontaneous, during a conversation occurring between an oncology professional and a patient or their family. Secondly, there is a large body of prepared humor, often found in patient literature that is generally designed to make patients see the lighter side of aspects of cancer care. What Is the Evidence to Date? In one of the few studies examining the issue of humor in the terminally ill, data were collected from a structured interview of 14 terminally ill adults, aged 32 to 77 years, all of whom were cognitively alert with a prognosis of 6 months, at maximum. Of these, 85% indicated that humor would be useful at this time in their illness, but only 14% described any humor in their lives. Every participant described humor in terms of its importance as a mechanism for social bonding. More than half (64%) felt that humor enabled them to alter their perceptions of situations that would otherwise be overwhelming. Finally, 85% of participants described humor as empowering hope, which was important in enabling them to face realities of everyday existence.3 The occasional use of humor has also recently been found to be among the ten highest rated hope-giving behaviors demonstrated by oncologists,4 as ranked by 126 patients with metastatic cancer. Why Would Patients Benet From Humor? Humor, both spontaneous and planned, is generally recognized to have three direct
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Most clinical oncologists face the general perception that their specialty is constantly both humorless and depressing. The truth, as many medical oncologists are aware, is that the specialty offers a great deal of emotional variability. Anecdotally, the use of humor is widespread in the oncologist-patient relationship and in patient literature. Humor serves many roles for the patient, their family, and the treating physician. Limited evidence suggests that the use of humor is becoming more widespread within patientbased literature; the profession has largely ignored this aspect of cancer care. Denition of Humor Laughter may not always add years to your life, but it will add life to your years. Author unknown There is no universally accepted denition of humor, and certainly not one that can reect the subtleties in a dynamic doctorpatient relationship. In fact, the word humor can be used to refer to a stimulus (eg, comedy lm), a mental process (eg, perception or creation of amusing incongruities), or a response (such as laughter or exhilaration).1 In the context of oncologic care, a useful denition is provided by the Association for Applied and Therapeutic Humor,2 which denes therapeutic humor as any intervention that promotes health and wellness by stimulation of a playful discovery, expression, or appreciation of the absurdity or incongruity of lifes situations. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or cop-

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Joshua, Cotroneo, and Clarke

benets in a health care settingpsychological, communication, and social.5 Psychological Role of Humor in Oncology The role of humor as a psychological defense mechanism has great importance in oncologic care. Humor, along with altruism, anticipation, asceticism, sublimation, and suppression, is acknowledged to be a mature defense mechanism,6 allowing a person to adjust to an anxiety-provoking stressor in an adaptive and productive manner. It has been suggested that the use of humor permits patients to psychologically distance themselves from their own death, while still allowing an acknowledgment of their terminal condition, thus helping to limit their psychological level of awareness of their condition7 and being an acceptable way to deny reality. This effect is well summarized in this poignant quote: The other reactionsanger, depression, suppression, denialtook a little piece of me with them. Each made me feel just a little less human. Laughter made me more open to ideas, more inviting to others, and even a little stronger inside. It proved to me that, even as my body was devastated and my spirit challenged, I was still a vital human.8 Role of Humor in Communication The oncologic consultation, compared with other medical specialties, is unique in many aspects. The topic for discussion is often an incurable, if not terminal, disease, frequently without any warning signs. Due to the nature and impact of

the disease and treatment options available, the patients social context becomes an important factor in the overall care plan. Patients are asked to cooperate with treatments that bring with them a vast array of side effects that impact signicantly on their lifestyle. Further to this, they are asked to delve into conversations that are highly confrontational and often involve dealing with end-of-life issues. As these issues come about quite suddenly and often need to be addressed early in the doctor-patient relationship, it is optimal to have a form of interaction that quickly provides a sense of familiarity, does not offend, and is easily facilitated. Humor can often meet these criteria; it can set the tone for a more relaxed atmosphere and can act as a leveling agent between the patient, their family, and their oncologist, aiding the formation of a therapeutic alliance. Secondly, it can also relieve the tension or embarrassment that both patient and doctor experience when undertaking intimate questioning or examination. Finally, and perhaps most importantly, it can provide a sense of familiarity and kinship often needed for the prolonged relationship an oncologist will develop with a patient and their family. It lets the patient know that the oncologist exists as a human outside the strict connes of a therapeutic relationship. Social Role of Humor The number of people involved with patients and their family in the initial diagnosis and management of cancer is generally underestimated. Medical, nursing, and allied health and secretarial staffs all become involved. Humor has an important role in establishing these relationships by breaking the ice, reducing the fear of the unfamiliar, and encouraging a sense of trust. Victor Borges edict that laughter is the shortest distance between two people holds true. Extent of Patient Literature To explore the extent of patient exposure to this latter category, we used an Internet-based search strategy, using the popular search engines Google and Yahoo (Table 1). The Web pages found were written mostly by patients for patients, although a few had professional assistance, especially for illustrative purposes.

Table 1. Patient-Oriented Information Regarding the Use of Humor in Cancer Accessible on the Internet Source Google.com, cancer jokes Google.com, cancer humor Amazon.com, keywords Cancer and humor Yahoo.com, cancer humor Yahoo.com, cancer jokes Googlegroups, cancer jokes Googlegroups, cancer humor No. of References 294 349 18 books available 241 209 255 43

Fig 1. Examples of humor from Cancer Island. Reprinted with permission from Buck Cash.

NOTE. Google.com is an automated search engine with 3,307,998,701 Web pages stored (4/1/04); Amazon.com is an online bookstore; Yahoo.com is a selective search engine; Googlegroups searches the Usenet discussion forums.

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The Art of Oncology: When the Tumor Is Not the Target

The patient literature dealt with every stage of the cancer process from diagnosis, the impact on family, relationships with medical professionals, effects of operations and chemotherapy, to death. A few of the more established Web sites are discussed in the following paragraphs. CancerClub: www.cancerclub.com The CancerClub is the most high-prole organization that advocates the use of humor as a coping mechanism through the diagnosis and treatment of cancer. The Cancer Club was created in 1995 by breast cancer survivor Christine Clifford in response to her experience with breast cancer. She initially published a recollection of her experience under the title Not Today, Im Having a No Hair Day, and has since expanded by publishing further books and supportive materials. Ms Cliffords recollection of her experience draws on a number of the themes discussed above. She often emphasizes the social benets of humor: Its a strange phenomenon what happens to people when they hear that a friend or loved one has cancer. Most people dont know what to say. They dont want to say the wrong thing so they often end up saying nothing. A cycle of avoidance and denial only deepens the loneliness and isolation the cancer patient feels. I found humor to be a great connector of people. . .I did not want to face this disease alone. I quickly found that if I could use humor to put people at ease and allow them to feel more comfortable with my diagnosis that they interpreted my humor as having a positive attitude and low and behold they wanted to surround me with support. There are also psychological benets, which she describes as follows: Finding the humor in lifes challenges, and particularly as it relates to the cancer experience, is what helps us to get through the day, reminds us of lifes absurdities, and provides relief from the stress and strain of our treatments. If you have been feeling sad or low, perhaps it is time to search for the humor in your life.9 Cancer Island: www.buckcash.com/cancerisland Musician, artist, and poet Buck Cash was diagnosed with non-Hodgkins lymphoma in October 2001. His humor site has had close to 2,500 hits since its inception in March 2002. Mr Cash describes his approach in fairly deant terms, I can hear you screaming now: Why?! Who the heck are you to make fun of cancer?!. . . .Dont you know how much they suffer from it before death?! Dont you know thats nothing to make fun of?!. . .Yeah. I know. I got it. Not the message, cancer. Yeah, Ive got cancer. NonHodgkins Lymphoma, to be exact. . . .However much time I have left will be time spent ENJOYING LIFE. That includes laughter, jokes, cartoons, and the SMILING, LAUGHING company of my family and friends. Obstacles to the Use of Humor in Oncology Life does not cease to be funny when people die any more than it ceases to be serious when people laugh. George Bernard Shaw
www.jco.org

There are multiple obstacles to the development of humor as a tool in cancer care. Firstly, there are sparse references to the use of humor in the medical literature. There is no mention of humor in a leading oncology textbook by DeVita et al, titled, Cancer: Principles and Practice of Oncology. Standard medical databases (PreMedline, Medline and EMBASE) only have 24 available articles using broad search criteria. The vast majority of these refer to various nursing interventions.10,11 There have been no articles in oncologic medical journals. Secondly, it is a challenge to quantify humors effect on recovery, because humor is difcult to dene; is not strictly a physical response, and it has different meanings for different people. Furthermore, research is relatively scant, as there seems to be a widespread, perhaps tacit, opinion that the pursuit of joy is not a respectable subject for academic study.12 Thirdly, the use of humor may have some detrimental effects on the patient. Haig13 identied a number of potentially destructive aspects of humor in psychiatric care; however, only a few of these are relevant to oncology. The destructive aspects that might apply to oncology practice include, rstly, the excessive use of humor by either the patient or the doctor as a mechanism of avoiding delicate issues. Undoubtedly, the best place for humor in the oncology clinic is after there is a mutual understanding of the therapeutic goals. Secondly, and perhaps most importantly, the greatest fear among oncologists is the inappropriate use of humor with a patient or their family, thereby undermining condence in therapy or medical care. Condence or trust is understood to be essential in humor of any type. We laugh because we identify with the joke teller; we trust them not to offend and to permit us enjoyment. Similarly, trust is an essential element of the oncologist-patient relationship, perhaps more so than other specialities. Establishing this trust and condence is a prerequisite to introduce appropriately timed humor (R. Buckman, Personal Communication, October 2003). Use of Humor by Oncologists Like patients, oncologists have to protect themselves from the harsh realities they deal with on a day to day basis. Freud coined the expression gallows humor to explain the therapeutic effect of humor on individuals in difcult or life-threatening situations. While the use of gallows humor by medical professionals has been well documented,14,15 formal literature relating to oncologists is limited.16 Perhaps not surprisingly, oncology is recognized as a high burnout specialty.17 The use of gallows humor has been specically suggested as a useful strategy to alleviate oncology burnout.18 The nature of such humor is impossible to characterize as it is often spontaneous and ranges from subtle word-play; for example, you know what they say about those stem cells, here today, gone to-marrow,19
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Joshua, Cotroneo, and Clarke

to more formal jokes. While perhaps more morbid than general medical humor, oncology gallows humor is part of a long-standing tradition in medicine and ultimately serves a similar psychological role to the use of humor by patients as a socially acceptable coping mechanism. Where to Go From Here? The rst step to addressing a problem is to recognize and understand it. While the profession readily recognizes and encourages patients to cry and grieve appropriately, we are far from formally recognizing griefs counterpartlaughter.5 There are a few principles that assist the appropriate use of humor in the oncology clinic; a trusting relationship, where the major issues have been dealt with, is a prerequisite. On a day-today basis, bringing a smile into each consultation, asking patients if they have heard any good jokes, and being prepared to tell one yourself are all useful starting points. Emerson20 studied the use of humor in the hospital setting and found only three circumstances when humor did not occur: when patients were seriously threatening not to cooperate with staff, when patients were extremely upset, and when staff were interacting with the relatives or visitors of dying patients. Certainly, the latter two occur frequently in oncologic practice, so the use of humor must be timely. In this regard, humor must be used extremely judiciously during discussions of initial diagnosis, disease progression, and endof-life care. Clearly each consultation is different and there is no one-size-ts-all approach, but when appropriate, the use of humor must be introduced slowly, at times almost subconsciously, into a consultation if it is to ourish. It is often reasonable to try gentle humor, perhaps thought of as inviting the patient to laugh, but if the patient does not respond, or has a negative response, this tact should be abandoned. Another useful principle is that if the patient initiates the use of humor, either overtly or subtly, then the oncologist may feel free to respond in part (R. Buckman, Personal Communication, October 2003). As with most types of humor, jokes or repartee relevant to the patient, which the patient can identify with, are more likely to introduce a smile into the consultation than anything unrelated. The physical examination is a particular area where humor can be used effectively, as the unnatural intimacy involved is invariably embarrassing for the patient; This is just a quick massage, there is no extra charge is a useful introduction to the examination of the cervical lymph nodes, for example. Several nursing papers21,22 have suggested the development of a repertoire of resources on oncology units based on humor therapy. These resources could include videos, books, and a laff-cart.23 There are also Internet sites, such as the ones described earlier, which advocate the use of humor. The waiting room has also been suggested as an appropriate place to display humorous material.24 While these are all useful ideas, they are best introduced by a health

professional familiar with the patient, rather than unintentionally forced on patients who may nd it inappropriate. In the longer term, there seems to be very little to fear from encouraging increased research into the use of humor in oncology, and increased support from professional bodies. It has become an increasingly important part of the larger aspect of psychosocial care, so perhaps we really should take humor more seriously.

Acknowledgment We thank Professor Phyllis Butow, Dr Richard White, and Dr Robert Buckman for reviewing this manuscript. Authors Disclosures of Potential Conicts of Interest The authors indicated no potential conicts of interest.
REFERENCES
1. Martin RA: Humor, laughter and physical health: Methodological issues and research ndings. Psychol Bull 127:504-519, 2001 2. Association for Applied and Therapuetic Humor Web site. http:// www.aath.org 3. Herth K: Contributions of humor as perceived by the terminally ill. Am J Hosp Care 7:36-40, 1990 4. Hagerty R, Butow P, Ellis P, et al: Communicating with realism and hope: Incurable cancer patient views on the disclosure of prognosis. J Clin Oncol: in press 5. Robinson VM: Humor and the health professions: The therapeutic use of humor in health care. Thorofare, NJ, SLACK Incorporated, 1991 6. Behavenet, Inc Web site. http://www.behavenet.com/capsules/treatments/analytic/defense.htm 7. Langley-Evans A, Payne S: Light-hearted death talk in a palliative day care context. J Adv Nurs 26:1091-1097, 1997 8. Anonymous: Why not laugh? http://www.cancer.med.umich.edu/ share/humorwhynot.htm 9. Clifford C: As simple as A,B,C. http://www.thebreastcaresite.com 10. Hunt AH: Humor as a nursing intervention. Cancer Nurs 16:34-39, 1993 11. Erdman L: Laughter therapy for patients with cancer. Oncol Nurs Forum 18:1359-1363, 1991 12. Bellert JL: Humor: A therapeutic approach in oncology nursing. Cancer Nurs 12:65-70, 1989 13. Haig RA: The Anatomy of Humor, Biopsychosocial and Therapeutic Perspectives. Springeld, IL, Charles C. Thomas publishers, 1988 14. Cushner FD, Friedman RJ: Humor and the physician. South Med J 82:51-52, 1989 15. Goodman JB: Laughing matters: Taking your job seriously and yourself lightly. JAMA 267:1858, 1992 16. Kash KM, Holland JC, Breitbart W, et al: Stress and burnout in oncology. Oncology (Huntingt) 14:1621-1637, 2000 17. Olkinuora S, Asp S, Juntunen J, et al: Stress symptoms, burnout and suicidal thoughts in Finnish physicians. Soc Psychiatry Psychiatr Epidemiol 25:81-86, 1990 18. Lyckholm L: Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol 2:750-755, 2001 19. Richards J, quoted in Clifford C: Cancer has its privileges: Stories of hope and laughter. Perigee Books, New York, NY, 2002 20. Emerson J: Social function of humor in a hospital setting. Unpublished PhD, University of California Berkeley, 1963 21. Johnson P: The use of humor and its inuences on spirituality and coping in breast cancer survivors. Oncol Nurs Forum 29:691-695, 2002 22. Simon JM: Humor techniques for oncology nurses. Oncol Nurs Forum 16:667-670, 1989 23. Support services at the South Carolina Cancer Centre Web site. http://www.psycho-oncology.net/supportserv.html 24. Bennett HJ, quoted in Medical Crossre. http://www.medicalcrossre .com/debate_archive/1999/Feb99/humorFEB99.htm

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