the continually increasing life expectancy , the growing incidence of certain cancers and progress in treatment have led to an increasing number of cancer patients to be managed at all stages of the disease . imaging examinations are increasingly numerous and are repeated throughout the course of the disease , and radiologists are faced with the anxiety of their patients and the need to announce bad news . in our experience we have observed the difficulties sometimes encountered when trying to establish a good quality relationship with some patients ; there is the risk of inappropriate behaviour and unfortunate remarks that remain engraved in the patient s memory [ 1 , 2 ] . supervised by a psychiatrist working in a cancer centre , three radiologists review their practices and analyse their relational modalities in an attempt to improve their relationship with cancer patients based on better communication skills . although there is no universally valid standard approach , a better understanding of the sources and manifestations of the patient s anxiety , training in certain interview techniques , application of a number of rules of organization of clinical departments and individual behaviour of personnel , based on deliberate empathy with the patient , while respecting of their integrity and their rights , are the basis for improved patient management . although we may feel that we are doing the right thing in our everyday practice , our medical behaviour must evolve because the doctor  patient relationship has changed along with changes in society , mentalities , medical practice and modes of access to information patients now more often want to understand their disease and develop a more balanced relationship with their doctor . patients are better informed by the media , internet or associations and they are also more demanding , resulting in a certain questioning of the medical system . in 1988 , the french huriet law brought research into the open , allowing the patient to actively participate in the therapeutic approach , with the introduction of informed consent . the patient , who was previously the object of care , has become the subject of care or a partner in care . with the law of 4 march 2002 ,  the doctor is now required to prove that he / she has provided honest , clear and appropriate information   ,  and to ensure that it has been clearly understood. however , it would be all too simple to rely on legal texts to avoid the complexity of relationships with patients suffering from serious diseases . it is not because patients have the right to know about their state of health that it can be announced without taking certain precautions . even when they express the right or the need to know , many patients do not actually want to know all of the truth and some do not want to know anything at all [ 5 , 6 ] . understanding of the patient s exact expectations in terms of information always requires detailed and comprehensive analysis of the patient , with the possibility of surprise reactions , obliging the doctor making the announcement to be particularly attentive during this key step in the relationship [ 710 ] . all these examinations are stressful for patients , related to the procedure itself ( injections , pain , claustrophobia ) and especially the result , an immediate verdict that determines subsequent treatment and the patient s life . many patients , including those considered to be cured and undergoing systematic surveillance , express their anxiety in relation to these follow - up assessments , their difficulty with repeatedly dealing with the uncertainty and anxiety of the future . the manifestations of their relief at the end of examination , when they are told that everything is normal , clearly reflect their previous anxiety : you ca nt imagine what i ve been going through. the radiologist is in the forefront , often discovers abnormalities   and must find the first words , without being able to propose a treatment , that may partially reassure the patient by establishing a  joint treatment project. this task is made all the more difficult by the radiologist s lack of specific training in psychology , and in the management of difficult situations such as announcing bad news . in highly anxiogenic situations , such as the incidental discovery of metastases , an emotional response may take over and , in these circumstances , there is a great risk of a clumsy or inappropriate approach that can be damaging to the patient . after a radiological examination , the relationship with a patient is brief ; the radiologist has little information concerning the patient s psychological or somatic state . the radiologist does not always know what the patient has already been told about his / her disease , hence the importance of networking , a shared medical file and especially the  information given heading , in which the prescribing doctor indicates what he / she has told the patient . there is no universal solution ; the radiologist must adapt his / her personal approach to each individual case , requiring reflection about his / her relational modalities . the radiologist must have the necessary know - how , but mastery of the technique is not sufficient and must be accompanied by an ability to establish an attentive relationship with the patient . the radiologist must know just how much to say to the patient , but especially not standing in the corridor , between two doors , in just a few minutes . although there may not be a good way to announce bad news , there are certainly bad ways . finally , the radiologist must be able to provide the patient with clinical competence , empathy and respect of their desires and their rights , those defined by law and those that they rightly claim in the name of respect , listening , information and psychological support . emotions and anxiety may be expressed in verbal , non - verbal and behavioural attitudes , such as fear , sadness , disappointment , anger , and sometimes also by aggressiveness perceptible even in the waiting room , which can be de - dramatized by dialogue . agitation , lack of understanding of simple instructions , false conviviality , perspiration , tachycardia perceptible underneath the ultrasound transducer are all manifestations of anxiety . some patients try to blame their disease on someone , either themselves (  i waited too long ) , or on another person , particularly doctors (  he missed the diagnosis ) . these comments are sometimes related to the lack of dialogue with previous doctors . some patients feel as if they are being judged (  they are sitting examinations ) or that they are incapable , as they are considered to be a  poor responder to chemotherapy . we sometimes meet warm , charming , courageous patients , with whom the personnel often become over - attached . inversely , vindictive and aggressive patients are perceived as unpleasant and are sometimes rejected , while we tend to forget or pay less attention to silent , withdrawn patients , whose apparent passivity often reflects a high level of anxiety . it is essential for the doctor to be aware of the patient s emotional state , to avoid the reflex of being unpleasant to a vindictive patient , or destabilized by a very anxious patient . the first step consists of examining and questioning our practices and learning a number of basic elements of the doctor patient relationship and announcement of bad news , a problem which has been the subject of numerous publications in the literature . in particular , it is important to learn the elements of a negotiated communication between doctor and patient . the doctor possesses precise and structured information about the patient s disease ; the appointment list or session and the time allotted to each patient are clearly defined , and the doctor must adopt a rational approach to the situation . the doctor enters into a professional relationship with the patient ; the situation is commonplace for the doctor , who remains independent . the patient , on the other hand , is in an exceptional situation and is dependent on the healthcare professional . the relationship is very important for the patient , regardless of the time allotted , and the patient s approach is essentially subjective . the risk , as in a game of tug - of - war , is that each person tries to draw the other into his / her own world , while a good quality relationship requires each person to make an effort to understand the other , to negotiate a compromise , an alliance , allowing elaboration of a joint project . it is the doctor s role to structure the modalities of the relationship , which subsequently determines the patient s attitudes and reactions . technicians , nurse - aids , nurses , and secretaries participate in information , each in his / her own field of competence . they help to reassure the patient , explain the examination , its uncomfortable aspects , inform the radiologist about the patient s physical and psychological state , and obtain the patient s request for the results . the head of department plays a decisive role , as he / she defines the team s common values and rules of behaviour , for example : reinforce the quality of patient reception and the availability of each member of staff ; avoid making patients wait or explain the reasons for the delay , give an approximate waiting time ; avoid , whenever possible , making children , bedridden patients and patients with an infusion share the same waiting room . before the examination , it is important to prepare the dialogue with the patient , carefully read the patient s file when it is available and examine the psycho - oncologist s notes when the patient has received a psychological or psychiatric assessment . in contact with the patient , the fact of introducing oneself and indicating one s qualification ( the patient does not have the same questions for a nurse - aid as for the doctor ) , introducing a junior doctor , when present , and briefly explaining the procedure , contributes to the development of a relationship of confidence [ 1 , 12 ] . in general , the attitude towards the patient must be based on empathetic and respectful listening . empathy consists of an attitude of relational openness and not the expression of one s own emotions . it must be deliberate , systematic and professional , in order to control personal feelings of sympathy or , on the contrary , sometimes feelings of antipathy generated spontaneously by the first minutes of the interaction . a relational protocol composed of tact and attentive listening cancer imaging procedures are anxiogenic , independently of the radiologist , who can not assume the patient s burden of anxiety in his / her place . the situation is clearly unbalanced , a long way from the ideal partnership relationship , but it reflects the event experienced jointly by the radiologist and the patient from very different points of view . during the examination , especially examinations involving direct contact with patients , such as ultrasound , the radiologist must avoid the various disturbances inherent to the life of the department ; do not be interrupted by the telephone , lock the door during internal examinations , cover naked patients with a sheet , give clear explanations when seeking a colleague for another opinion . talking to another person , discussing technical problems , showing surprise in front of the screen , resulting in a patient  doctor - screen triangular relationship with the anxious patient attentively watching the doctor s face and interpreting his / her every reaction , only tend to increase the patient s anxiety . in some clinical settings , after computed tomography ( ct ) scan or magnetic resonance imaging ( mri ) , patients are systematically seen by the radiologist , which raises the problem of patients who do not wish to be informed , and this wish must be respected . in hospitals in general and in cancer centres in particular , radiologists only see those patients who explicitly request a consultation , which is far from always being the case . many patients do not ask for anything , while others demand to see the doctor and are willing to wait until the examination has been interpreted . regardless of the conditions , the patient must be seen in an adequate setting , ideally in a room devoted to this purpose . the physician s attitude must consist of acceptance of a dialogue allowing the patient to talk and ask questions , by looking at the patient directly and by listening to him / her without ever saying too much , without saying more than the patient has asked for . it is useless , for example , to give too many medical and technical explanations and to describe the lesions in detail . it is important to carefully listen to the formulation of the patient s questions , as some patients , despite significant treatments , have a poor knowledge about their disease or do not want to know about it , and sometimes drop words like  cancer or they try to verify the existence of a possible contradiction between various doctors , or they may simply use these words to express their suffering . if the patient feels that the doctor is receptive , they may take advantage of this opportunity to talk and ask questions that they have never asked , and sometimes pour out their feelings . the relationship between the radiologist and the patient at the end of examination is sometimes a difficult moment , but it can provide the patient with an opportunity to talk , which often surprises the patient himself . for some patients , the radiologist s receptive attitude and the possibility of a dialogue may have a paradoxically distressing effect . outside doctor to interfere with their disease and cross the barriers that they are trying to set up . these patients do not ask any questions , either because they do not want to hear the answers or because they only want to deal with their attending physician . it is important to respect this desire and to never give results when the patient does not specifically ask for them or answer questions that have not been formulated . the patient often reacts by remaining silent or by formulating the question by removing the question mark :  you did nt see anything abnormal , nothing nasty ,  everything ok , which correspond more to statements than real questions . in these rhetorical questions , the interrogative tone is adopted  not to indicate a doubt and trigger a reply , but to indicate , on the contrary , a solid conviction and to defy those to whom one is talking to deny this certainty or even to reply . i hope you re not going to find something else!. avoid focussing on technical aspects :  you have a hypoechoic nodule in the left lobe of the liver or falsely reassuring paternalist attitudes (  it could be worse ,  but everyone has to die some day , i am also going to die! , or  the progression is not generalized , the brain ct is normal )   or inappropriate premature solutions (  you ll be better after chemotherapy ) . changing the subject raised by the patient without transition or suddenly doing something else all too obviously reflects the doctor s lack of interest or embarrassment . it is useful to reformulate what has been said , to repeat the patient s last sentences . the patient can also be encouraged to talk about his / her health and ongoing treatments . the fact that the radiologist is able to look at and listen to the patient indicates that he / she is not afraid of dialogue and patients often want to talk about things other than their cancer . the most difficult relational situation occurs when the radiologist detects clinically unsuspected lesions during a routine follow - up examination . although the radiologist can not say that the examination is normal , he also can not insist on a painful truth that the patient does not want to hear . the doctor should indicate that there is a doubt that needs to be clarified by other examinations , but regardless of what he says or does , he will trigger a terrible anxiety in the patient . . it may be legitimate , in these circumstances , to use excuses such as the need to review the patient s file or old films , the need to perform other examinations to define a probable abnormality , in agreement with the attending physician . it is useful , in all of these cases , to prepare the subsequent course , for example by calling to inform the chemotherapist or surgeon that new lesions have been found before he / she sees the patient . the interview should be closed by accompanying the patient to the door and directing him / her to the next appointment . parents of children with a malignant tumour are very well informed by clinicians ; they know about the disease , the size of the tumour , the course , risks , statistics , etc . the long - term surveillance of children treated several years previously and cured of a malignant disease such as lymphoma or wilms tumour is one of the more pleasant moments of cancer radiology . over time , a real relationship is formed between the child , the parents and the doctor who examines the child with an atraumatic apparatus ( especially in the case of ultrasound ) . this relationship is reinforced by the unspoken memory of the very difficult times of the initial diagnosis and follow - up examinations during chemotherapy . the radiologist must avoid talking exclusively to the parents , but must also talk to the child about his / her disease . when the clinical signs are suggestive of recurrence , the parents expect that the examination will confirm this suspicion , which is obviously a major source of anxiety . , he can mention the treatment options that will be proposed by the clinical teams . for elderly patients , increasingly numerous in oncology , it is useful to recognize and distinguish the main geriatric syndromes , especially depression and concomitant diseases such as deafness . although the natural tendency is to talk to the accompanying person , the elderly person must not be ignored by excluding him / her from the discussion . disease and age  death correlations to be  normal. the great majority of elderly people , even when they are ill , do not want to die any more than younger people ( except in the case of severe depression , where morbid thoughts can be expressed to the various healthcare professionals dealing with the patient ) . a survey conducted by slevin et al .   showed that 60% of elderly patients were willing to accept chemotherapy even for a benefit of only 1% on survival , while less than 20% of nurses and oncologists reported that they would accept this option . in the context of clinical trials , patients receiving yet another line of chemotherapy , often with metastatic disease , are theoretically well informed about their state , and have signed an informed consent form . they place great hopes in the new treatment , despite the complex procedure related to the protocol ( numerous examinations , questionnaires , visits ) , which sometimes represents an additional factor of reassurance . they are very cooperative , more optimistic and obviously very depressed when treatment fails . very tired and weak patients , who have suffered for a long time , and at the terminal phase of their disease , generally do not ask any questions . sometimes , however , they disconcertingly ask the radiologist to confirm that the examination is normal , while disease progression is obvious , but repressed or masked . the question is formulated in the affirmative and these patients do not expect an impossible answer . patients with a genetic predisposition live with feelings of uncertainty and are submitted to a routine of ritual and annual surveillance , and often the weight of their family history . although they do not have any symptoms , they are always at risk of a diagnostic discovery and a potentially mutilating treatment , a situation that can accentuate anxiety especially during the period preceding screening examinations . paradoxically , some patients experience a form of relief at the announcement of the diagnosis of cancer (  at last i am going to get rid of it ) . several international surveys [ 9 , 1820 ] have shown that clinicians and radiologists agree that the radiologist should inform the patient about the results of a normal or only slightly pathological examination . however , when the examination is frankly abnormal , radiologists and especially clinicians are not in favour of the radiologist giving the results [ 9 , 18 ] . another survey showed that 70% of patients wanted to have the results immediately after a ct scan . oncologists increasingly tend to ask radiologists to prepare the patient for bad news [ 6 , 11 ] . clinicians use imaging to give explanations to their patients and to justify the treatment decision . they increasingly show the tumour to the patients , as some patients need to be faced with this reality in order to accept the announcement and intensive treatment , or , on the contrary , discontinuation of an ineffective treatment . note that absence of direct information ( face - to - face or by telephone ) to the clinician by the radiologist is a new cause for lawsuits in the united states , even when the report sent by mail is explicit . radiologists can not hide behind the technical aspects of their specialty , as they are faced with these problems of announcement and dialogue with cancer patients . they must become involved , but , like other doctors , they lack time , resources and training . in an imaging department or clinic , for many reasons , there is a high risk of psychological aggression , but it also provides room for expression that differs from a visit to the doctor . the patient meets another doctor , with whom he / she is often alone , which gives him / her an opportunity to talk about his / her disease , suffering or something completely different . listening and dialogue requires a personal effort from the doctor , which may not be easy , but which is truly worth the trouble .
progress in medicine and changes in our society have led to an increasing number of patients with cancer and a change in the doctor  patient relationship . 
 patients rights are now defined in several countries by laws . 
 the course of cancer involves numerous imaging examinations in which the radiologist is primarily involved . 
 it is often the radiologist who discovers abnormalities and who must break the news to the patient . 
 this task is made all the more difficult by the radiologist s lack of specific training in the management of difficult situations such as announcing bad news . 
 there is a high risk of inappropriate responses that can have a seriously damaging effect on the patient s state of mind . 
 even with the best intentions , it can be very profitable to review and improve our relational modalities and to more effectively meet the patient s increasing demand for information . the radiologist 
 s technical know - how is not sufficient , as he must also be able to give just the right amount of information based on his clinical competence , and his relationship with patients while respecting their wishes and their rights .