ARLINGTON, Va., January 22, 2020 — It's a scene that some cancer patients dream about: they celebrate the end of a course of radiation or chemotherapy by ringing a bell, surrounded by family and cheering cancer clinic staff. Indeed, many patients say they love the graduation-like ceremony and the sense of closure it gives them.

But a study published in the International Journal of Radiation Oncology • Biology • Physics sheds light on some unintended consequences of the widespread practice and raises questions about whether it's time to discontinue its use. The survey of more than 200 patients with cancer – half of whom rang the bell at the end of treatment and half of whom did not – found that those who rang a bell remembered treatment as more distressful than those who finished without ringing a bell.

That outcome surprised the study's lead investigator, Patrick A. Williams, MD, a radiation oncologist who led the study while completing his residency at the USC Keck School of Medicine in Los Angeles. "We expected the bell to improve the memory of treatment distress," he said. "But in fact, the opposite occurred. Ringing the bell actually made the memory of treatment worse, and those memories grew even more pronounced as time passed."
"We think this is because ringing the bell creates a 'flashbulb event' in a patient's life – that is, a vivid snapshot of their memories from that time," said Dr. Williams, explaining that events become more deeply embedded in our memories if emotions are aroused, due to connections in the brain between memory and emotion. "Rather than locking in the good feelings that come with completing treatment, however, ringing the bell appears to lock in the stressful feelings associated with being treated for cancer."

There are other reasons to reconsider the usefulness of ringing a cancer bell at the end of treatment, a practice introduced to the U.S. in 1996 that is now commonplace at cancer clinics across the country – including 51 of 62 National Cancer Institute-designated cancer centers, according to a December 2018 JAMA Oncology article. While this highly symbolic ceremony may be joyful for those ringing the bell, not everyone within earshot feels the same. The practice has received criticism from patient advocates who note that there are other patients whose treatment may not end on a positive note. For these patients, hearing the bell ring can arouse feelings of anger, resentment or depression, since they will not likely be given the option to ever ring a bell.

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