The physician should state that the cancer has returned. Physicians often have difficulty imparting bad news to patients and worry that they will diminish patient hope or leave patients emotionally inconsolable. The SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategize) framework provides a schema for disclosing critical information in a way that allows patients to hear information while supporting their emotional reactions, thereby maintaining hope. In this case, the provider has already addressed the S, P, and I steps of the SPIKES protocol and is at the point of imparting knowledge (K). When delivering the news, it is important for the physician to use short, declarative sentences without jargon or euphemisms. This approach may seem blunt; however, it provides an unambiguous message, thereby improving patient comprehension. After the physician delivers the bad news, the physician will empathically address emotion during step E of SPIKES, preventing the delivery from seeming detached or cold. In the last step of SPIKES, the physician and patient strategize new goals as a method of maintaining hope.

Recounting previous events during bad news delivery, such as explaining the planned surveillance strategy, creates a long-winded response with extraneous information that masks the actual news. There is a high risk that the patient will not hear or understand what is being conveyed. Furthermore, this response attempts to “sugarcoat” the bad news (the patient's cancer has recurred) by implying that it is actually good news (the recurrence was identified). Bad news cannot be turned into good news; the physician can only mitigate the consequences of the bad news. Tempering the delivery of bad news in this way further increases the risk that patients will not understand the news they have been given.

Couching a response in euphemisms (in this case, the word “lesion”) is not appropriate. Euphemisms add a layer of uncertainty in communication, increasing the risk of misunderstanding and delaying truth-telling. There is no doubt that this patient has recurrent prostate cancer, and the physician should communicate this in clear terms.

Telling the patient that the cancer has returned but that there are therapeutic options is also not appropriate. In this response, the term “cancer” is used, but it is immediately followed by an attempt to “fix” the situation. This type of “fixing” response is particularly attractive to many providers, who view it as a means of preventing the patient from losing hope. This response bypasses addressing the emotion that bad news generates (step E in SPIKES), which may make the conversation less messy for the physician; however, processing an emotional response to bad news is a necessary stage for patients before they can strategize next steps. Furthermore, providing a solution before the patient has had a chance to strategize based on personal hopes and goals does not allow the patient to fully participate in the decision-making process.