Ringing the cancer bell leads to ‘sharpened, starker memory’ of treatment pain
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For many patients with cancer, it is a moment of triumph and closure: the ringing of the cancer bell to signify the completion of treatment.
This tradition, introduced in the United States in 1996, is now a fixture at many cancer centers, including 51 of the 62 NCI-designated centers. The bell-ringing is considered a celebratory event, often attended by the patient’s family and clinic staff. However, it does not always lead to fond memories or a positive view of the treatment experience.
According to study results published in International Journal of Radiation Oncology, patients who rang a bell had more upsetting recollections of cancer treatment than those who finished treatment without ringing a bell.
Patrick A. Williams, MD, a radiation oncologist who conducted the study with colleagues during his residency at Keck School of Medicine of University of Southern California, said ringing the bell provokes the patient’s emotions, and these emotions may become attached to the ordeal of treatment rather than the completion of it.
“Basically, the patient has been in misery or pain, they’ve just finished getting radiation plus or minus chemotherapy, and now they are ringing this bell and people are clapping for them,” Williams said in an interview with Healio. “Their emotions are definitely being aroused, but they’re being aroused at precisely the wrong time.”
Williams spoke to Healio about the “peak-end rule” of psychology that prompted the study, the unexpected findings, and his thoughts on whether ringing of the bell should continue.
Question: What inspired this study?
Answer: I’m very interested in psychology, and cancer survivorship is becoming an increasingly important topic. As cancer treatments improve, people live longer and have more time to think about their diagnosis, to worry about it. Meanwhile, there are many psychological heuristics and biases in our daily lives. The more famous ones, like confirmation bias and loss aversion, have been coined mostly by one psychologist, Daniel Kahneman, PhD, who is referenced in the study. He also came up with the peak-end rule, a psychological phenomenon that led to the hypothesis for the bell study. The peak-end rule holds that people tend to remember a painful episode based on how bad the pain was at the peak of the pain and at the end of the pain. People’s memory of pain is not as influenced by the beginning of pain, the total pain or the average. It’s the peak and the end.
No one wants to go through radiation. So, I thought, maybe if we can reduce either the peak or the end pain, we can improve the patient’s memory of their treatment.
Lowering peak pain would be challenging. However, there is an opportunity to lower the end pain. Then I remembered the ringing of the bell at the end, and thought maybe the bell is helping to lower this end pain. My hypothesis was that ringing the bell would make that memory better. We evaluated 200 patients with cancer; half rang the bell and half did not.
We had patients fill out a debriefing questionnaire. We asked about the total amount of stress they experienced on a scale of one to 10, how bad the pain was at its worst point, and how unpleasant the treatment was.
Q: What did you find?
A: On the day of treatment completion, patients who rang the bell had a sharpened, starker memory of how painful the treatment was. At follow-up about 3 months later, those who rang the bell had an even worse memory of the distress. In our findings, the peak-end rule did not describe what was going on. I investigated the literature for something to explain this and found emotional arousal. This is a phenomenon that explains why the salience of a memory is coupled with the emotional response at the time of the event. Events that provoke intense emotions are especially well-remembered. We think ringing the bell causes emotional arousal, which helps the patient to better remember how they felt at the end of their inherently unpleasant cancer treatment and therefore worsens the patient’s memory of their treatment.
Q. Based on these results, what do you recommend as far as continuing this tradition?
A: I’m a bit reluctant to say we should stop ringing the bell, because some people seem to enjoy doing it. Just yesterday, in fact, a patient I saw in clinic said, “So, next Wednesday is when we’re finishing, right? Because my kids have taken off work so they can be here to see me ring the bell.” We still have patients who value this quite a bit. What I would recommend is to make ringing the bell optional. I’ve read that a lot of clinics nudge patients and encourage them to ring the bell. We should not do that. We want to keep emotions neutral. Instead, maybe the oncologist can give the patient a small gift to mark the occasion. I read Twitter about one doctor who makes origami animals and gives them to patients. These are much more peaceful ways to signify the end of treatment that don’t arouse the patient’s emotions. If their emotions become stimulated, it could steer their memory toward what they went through, and they might remember it negatively.
I would like to see another study done on the ringing of the bell. It’s very widespread, not just in North America, but also in Europe. This is the only study that has ever looked at it. It’s a good reminder that even well-intended rituals like this one can lead to bad outcomes. – by Jennifer Byrne
For more information:
Patrick A. Williams, MD, can be reached at 1441 Eastlake Ave. Los Angeles, CA 90033; email: patalbwil@gmail.com.
Reference:
Williams PA, et al. Int J Radiat Oncol Biol Phys. 2019;doi 10.1016/j.ijrobp.2019.06.012.
Disclosure: Williams reports no relevant financial disclosures.