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Humor and Oncology

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

Address reprint requests to Anthony M. Joshua, MBBS, Department of Medical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada; e-mail: anthony.joshua{at}doctor.com

INTRODUCTION

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 patient-based literature; the profession has largely ignored this aspect of cancer care.

Definition 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 definition of humor, and certainly not one that can reflect the subtleties in a dynamic doctor-patient relationship. In fact, the word "humor" can be used to refer to a stimulus (eg, comedy film), 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 definition is provided by the Association for Applied and Therapeutic Humor,² which defines 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 life's situations. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or coping, whether physical, emotional, cognitive, or spiritual."

Classification of Humor
Practically, the classification 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 Benefit From Humor?
Humor, both spontaneous and planned, is generally recognized to have three direct benefits in a health care setting—psychological, 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 reactions—anger, depression, suppression, denial—took 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 patient's 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 significantly 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 confines 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 Borge's 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.

CancerClub: www.cancerclub.com
The CancerClub is the most high-profile 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, I'm Having a No Hair Day," and has since expanded by publishing further books and supportive materials.

Ms Clifford's recollection of her experience draws on a number of the themes discussed above. She often emphasizes the social benefits of humor: "It's a strange phenomenon what happens to people when they hear that a friend or loved one has cancer. Most people don't know what to say. They don't 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 benefits, which she describes as follows: "Finding the humor in life's challenges, and particularly as it relates to the cancer experience, is what helps us to get through the day, reminds us of life's 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-Hodgkin's 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 defiant terms, "I can hear you screaming now: ‘Why?! Who the heck are you to make fun of cancer?!....Don't you know how much they suffer from it before death?! Don't you know that's nothing to make fun of?!’...Yeah. I know. I got it. Not the message, cancer. Yeah, I've got cancer. Non-Hodgkin's 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

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 humor's effect on recovery, because humor is difficult to define; 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 identified 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, firstly, 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 confidence in therapy or medical care. Confidence 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 confidence 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 difficult 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 specifically 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 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 first 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 grief's counterpart—laughter.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 end-of-life care. Clearly each consultation is different and there is no one-size-fits-all approach, but when appropriate, the use of humor must be introduced slowly, at times almost subconsciously, into a consultation if it is to flourish. 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 papers^21,22 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 find 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.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

View larger version (123K): [in this window] [in a new window]   Fig 1. Examples of humor from Cancer Island. Reprinted with permission from Buck Cash.

We thank Professor Phyllis Butow, Dr Richard White, and Dr Robert Buckman for reviewing this manuscript.

NOTES

Authors' disclosures of potential conflicts of interest are found at the end of this article.

REFERENCES

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3. Herth K: Contributions of humor as perceived by the terminally ill. Am J Hosp Care 7:36–40, 1990[Medline]

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13. Haig RA: The Anatomy of Humor, Biopsychosocial and Therapeutic Perspectives. Springfield, IL, Charles C. Thomas publishers, 1988

14. Cushner FD, Friedman RJ: Humor and the physician. South Med J 82:51–52, 1989[Medline]

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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[Medline]

18. Lyckholm L: Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol 2:750–755, 2001[CrossRef][Medline]

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 influences on spirituality and coping in breast cancer survivors. Oncol Nurs Forum 29:691–695, 2002[Medline]

22. Simon JM: Humor techniques for oncology nurses. Oncol Nurs Forum 16:667–670, 1989[Medline]

23. Support services at the South Carolina Cancer Centre Web site. http://www.psycho-oncology.net/supportserv.html

24. Bennett HJ, quoted in Medical Crossfire. http://www.medicalcrossfire.com/debate_archive/1999/Feb99/humorFEB99.htm

Submitted September 7, 2004; accepted September 17, 2004.

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