Clinical Therapeutic Communication (CTC) in Oncology: Translating Pain into Perspective

Clinical Therapeutic Communication (CTC) in Oncology: Translating Pain into Perspective

– Dr. Ravi Kiran Pothamsetty, Madurai

In the world of oncology, words are not merely tools for conveying information — they are instruments of healing. Whether it’s the moment a diagnosis is shared, a quiet reassurance offered to an anxious caregiver, or the heavy silence following a PET/CT scan result, these interactions are far more than routine clinical exchanges. They are emotionally charged encounters, where hope is not lost but gently redefined.

In Indian cancer care settings — and indeed, across the globe — this kind of mindful communication is not optional; it is essential. It forms the delicate bridge between cure and care, science and solace. The time has come to rethink how we speak with patients and families — not only with clinical precision, but with deep, therapeutic compassion. Because how we speak truly matters — just as much, if not more, than what we say.

Despite our best efforts to tailor supportive care as the condition evolves, heartfelt questions from caregivers — “Why can’t you do something for my Amma?” or “Is this the maximum you can do?” — create a vacuum within us. They stir an unsettling doubt: Are our carefully designed protocols, mnemonics, and decision tools truly enough? Or do they sometimes fall short in capturing what truly matters?

In many tier II cities, hope is often built on what can be seen — the oxygen mask, the IV drip, the molecules targeting the cancer. These visible signs of effort become symbols of love, trial, and persistence. For families, doing something isn’t just a medical decision — it’s an emotional gesture, a way of saying: I haven’t given up.

In such settings, trust is closely tied to visible intervention. Even when a team provides thoughtful, tailored supportive care, caregivers may not perceive it as enough — or even as care at all. This creates a painful communication gap, where families express frustration:

“Doctors or staff are doing nothing… If they had done something, the condition would have improved.”

It’s not that they don’t value care — it’s that caregivers equate care with action. So, when the focus shifts from active interventions to de-prescription and comfort care, it may feel like no therapy, or even abandonment. The quietness of symptom control may seem inadequate compared to the noise of machines and medicines.

This is where communication becomes fragile — and critical. Just like patients have a therapeutic window for treatment, caregivers too have a therapeutic window for communication. Missed or delayed, it can turn understanding into confusion, and trust into distress. No protocol, tool, or mnemonic can substitute for that one well-timed, heartfelt conversation.

Reframing the Vocabulary

“Breaking bad news” is the phrase we clinicians often use when explaining difficult realities to patients and their families. But over time, the term started to sound harsh — as if I were shattering something irreparably. It felt like repetition without resonance. It created an inner conflict: Is there a better way to name this difficult, but essential, conversation — one that feels constructive rather than violent?

Language is not just about words — it is a carrier of information, emotion, and intent. The shift from “DNR” (Do Not Resuscitate) to “AND” (Allow Natural Death) is a powerful example of how rephrasing can reduce psychological resistance and stigma, and help guide decision-making.

Inspired by this, I reframed “breaking bad news” into something more hopeful and relationship-centered: Clinical Therapeutic Communication (CTC).

While SPIKES gave me a structure, it was CTC that gave me presence and connectedness. CTC isn’t a textbook model in the conventional sense — it is a routine practice wrapped into a thoughtful pathway.

The CTC Framework

Many clinicians write in records: “Poor prognosis explained.” But that may not fully convey what was said — or what was left unsaid. The reasons vary: a desire not to rupture emotional equilibrium, or an internal hesitation — a kind of vocal paralysis. And the silence that follows can feel heavier than anything spoken, creating the illusion that the loop has closed, even when it hasn’t.

CTC is built around six core questions:

• Who are we talking to?
• What needs to be conveyed?
• When is the right moment?
• Where should it occur?
• Why now?
• How do we best say it?

These feed into three interconnected domains:

1. Clinical (Information & Intent): The 5 Ps

I often think of the 5 Ps as a stethoscope for difficult conversations — helping us listen not just to heartbeats, but to the hope and hesitation between the lines.

• Parallel  Planning
  Holding space for both curative intent and comfort-focused care — not either/or, but both/and. It keeps hope alive while gently preparing families for other possibilities.
• Prognosis
  Sharing the outlook with honesty, humility, and personalization — not just about tumor size or scan results, but how illness will affect this person’s life.
• Perception
  Understanding how the patient and family are processing information. Sometimes, the real conversation happens in whispers between family members.
• Preferences
  What matters most — more time, dignity, function, peace? These values should shape decisions, not just clinical protocols.
• Pacing
  Not all truths need to be told at once. Information must flow according to cultural readiness and emotional resilience — in doses that don’t overwhelm.

We’ve learned to ask, “What matters most to the patient?”

Now, we must also ask caregivers:

“What is the most distressing or frightening thought on your mind right now?”

2. Therapeutic (Treatment Engagement & Emotional Healing)

CTC invites us to care beyond prescriptions. It helps us see suffering through a layered clinical lens:

• Physical – Pain, breathlessness, fatigue, insomnia, appetite loss — care is about restoring comfort, not just removing symptoms.
• Psychological – Anxiety about finances, depression behind silence, unspoken fears of abandonment.
• Social – Role reversals, sibling dynamics, the caregiving burden falling on one person.
• Spiritual – Beliefs around karma, guilt, prayer, and moksha deeply influence decisions.
• Practical – Transport, shifting between clinics and hospices, purchasing medicine in small instalments — caregivers juggle many quiet burdens.
• Anticipatory – Families need practical and emotional support for symptoms that may arise.
• Decision-making – Consent is often collective and influenced by elders, priests, and community perceptions.
• Legal – Advance directives are rare. Wills, documentation, and guardianship are often last-minute concerns.

3. Communication (Insight & Impact): The 4 As

In Indian families navigating incurable illness, I often observe four key phases:

• Awareness
  A subtle shift when illness becomes emotionally real.
  “Why now?” the caregiver asks. “Was everything we did in vain?”
• Acknowledgement
  A slow nod. A silence.
  “We understand… but can we try one more cycle?”
  Hope remains, scattered but strong.
• Assimilation
  Information is understood logically but not yet emotionally.
  “Can my patient still recover?” they ask, repeatedly, across the team.
• Acceptance
  The focus shifts from prolonging life to preserving meaning.
  “What now? How do we make it peaceful?”
  This is not surrender. It’s not failure. It’s part of care.

Listening Beyond Words

The path from assimilation to acceptance is rarely linear. Between the two lies a fragile zone — I call it the “emotional hijack.” It’s a space filled with unanswered questions. Much like anaphase in cell division — where sister chromatids pull apart to form new identities — this is when emotional complexity and factual truth begin to repel and reorient, creating room for a new lived reality.

Caregiver emotions and medical facts often collide in this space:

“We believe you — but let’s try one more chemo.”

“Don’t give up — my patient is a fighter.”

“Do everything. Please.”

This resistance is neither a failure of communication nor denial — it’s a neuro-emotional response under extreme stress. The fight–flight–freeze reflex overrides cognition. Reasoning gives way to protection. These beliefs are shaped by trauma, faith, culture, family history, and love. Challenging them in moments of vulnerability isn’t just difficult — it can feel deeply threatening.

A Compass, Not a Manual

CTC isn’t something new. Many of us already practice it — in moments, silences, gestures. I only gave it a name. Because communication is not a pause in therapy — it’s a U-turn to care.

It reminds us that care remains active, even after disease-directed therapy stops. While chemotherapy may appear “active” and stopping it may seem passive, CTC shows us that continuum of care is a form of therapy — not abandonment.

Caregivers often ask:

“What would you do if you were in my place?”

It’s a question that can feel like an ambush — or an invitation. The CTC framework doesn’t give us a script, but it offers a compass — to navigate our own discomfort and fear of saying the wrong thing.

And yet, some questions have no perfect answers. Like:

“How do I go on after the death of my loved one?”

Despite all our training, empathy, and structured frameworks, that moment is never easy. I don’t wish to debate whether death is good or bad — only that it is real, and none of us is immune.

CTC is not limited to end-of-life care or the realm of palliative medicine. Guarded prognoses are discussed across specialties. This framework doesn’t need to be memorized — it’s a rhythm, an intuitive flow, a natural algorithm. CTC can begin early — even during palliative chemotherapy — as a way to build understanding, reduce emotional fracture, and prevent missing the therapeutic window for communication.

Because even when guidelines are followed, the right thing said at the wrong time, or in the wrong place, may fail to heal.