"If I ran a cancer clinic, there would be no bell in the infusion area," wrote Katherine O'Brien, a patient with stage IV cancer and an advocate for the Metastatic Breast Cancer Network, in a 2018 essay. "How would YOU like to be there week after week in perpetuity attached to an IV pole as others celebrate their final appointments?"

What's more, the ceremony – meant to signify the beginning of life cancer-free – could also set up false hope for people whose cancer recurs, noted Dr. Williams. "Many patients I've spoken with mention a lingering fear of recurrence that may impact their memory of treatment," he said.


Anne Katz, PhD, author of the book After You Ring the Bell...10 Challenges for the Cancer Survivor, notes that patients may experience negative, long-term consequences following cancer treatment including health worries, depression and fatigue. "While the end of active treatment, be it chemotherapy or radiation therapy, is certainly a milestone, it is not the end of treatment or side effects for many," she wrote.

Dr. Williams said he's not ready to call for a ban on ringing the cancer bell but would like to see his study – the first of its kind, he noted – replicated with larger groups of patients.

He also proposed that clinics consider and investigate alternatives, such as ringing the bell to signal the start of treatment or awarding a certificate at the end of treatment in a quieter, less public ceremony. "The important thing is not to stir emotions at the end of treatment," he said. "Some people have small gifts or certificates of completion to mark the end. I think these are okay because they do not arouse emotions in the same way that ringing a bell to a crowd of applauding people does."

"We can consider other avenues that would allow patients to celebrate reaching the end of their treatment, but without negatively reinforcing things that perhaps might best be forgotten," agreed Richard Jennelle, MD, an associate professor of radiation oncology at USC and senior investigator on the study. Dr. Jennelle joined Dr. Williams, as well as Valerie Powell, a cancer survivor, and psychologist Andrea Bonior, PhD, in a recent podcast to discuss the findings, which the researchers conceded are "counterintuitive."

"Many well-intended practices can lead to bad outcomes," concluded Dr. Williams. "We should study interventions before implementing them – even ones that are well-intended."


ABOUT ASTRO
The American Society for Radiation Oncology (ASTRO) is the world's largest radiation oncology society , with more than 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals who specialize in treating patients with radiation therapies. The Society is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy. ASTRO publishes three medical journals, International Journal of Radiation Oncology • Biology • Physics, Practical Radiation Oncology and Advances in Radiation Oncology; developed and maintains an extensive patient website, RT Answers; and created the nonprofit foundation Radiation Oncology Institute.

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