Some patients with cancer celebrate the end of a course of radiation or chemotherapy by ringing a bell. Indeed, many patients say they love the graduation-like ceremony and the sense of closure it gives them. However, a study published by Williams et al 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 radiation therapy, 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 University of Southern California Keck School of Medicine.
“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.”
“We expected the bell to improve the memory of treatment distress, 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.”— Patrick A. Williams, MD
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Dr. Williams explained 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,” he said.
Two cohorts of patients completing definitive radiotherapy were enrolled in the study—one control, in which patients completed treatments and then filled out a survey, and an interventional arm, in which patients rang a bell on the final day of treatments and then filled out the same survey. Patients evaluated the overall distress they felt from treatment with the survey, which was made up of an 11-point rating scale in combination with the Verbal Rating Scale. At follow-up, a shorter survey about distress from cancer treatment was also completed.
Of 210 enrolled patients, 163 completed the follow-up surveys. The bell group reported worse overall distress scores than those who did not ring the bell, and this difference worsened at follow-up.
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There are other reasons to reconsider the usefulness of ringing a bell at the end of cancer treatment, a practice introduced to the United States in 1996 that is now commonplace at cancer clinics across the country—including 51 of the 62 National Cancer Institute–designated cancer centers, according to an article published in JAMA Oncology. Although this 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.
What’s more, the ceremony 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.
“Many well-intended practices can lead to bad outcomes. We should study interventions before implementing them—even ones that are well-intended.”— Patrick A. Williams, MD
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“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.”
Dr. Williams concluded, “Many well-intended practices can lead to bad outcomes. We should study interventions before implementing them—even ones that are well-intended.”
Disclosure: For full disclosures of the study authors, visit redjournal.org.