By Jennifer M. Gangloff

Mastectomy or lumpectomy for breast cancer. Watchful waiting or radiation for early-stage prostate cancer. Hospice care or one last-ditch round of chemotherapy. Cancer treatment involves difficult choices for patients. Family and friends may disagree with the patient’s decisions, and these disagreements may turn into conflicts.

“When you’re diagnosed with cancer, you’re going to get a lot of solicited and unsolicited advice,” says Marisa Weiss, MD, president and founder of breastcancer.org and director of breast radiation oncology at Lankenau Hospital in Wynnewood, Pennsylvania. “You have to decide where you’re going to draw the line with that advice.”

Family and friends can influence a patient’s choice of doctors, hospitals, treatment and care. And indeed, their opinions can be a valuable part of a patient’s decision-making process. They may encourage the patient to seek better care or get a second opinion. They may help the patient explore options and sort through the pros and cons of various treatments.

But with such weighty decisions to make, a variety of situations can trigger conflicts. Caregivers may want the patient to keep pushing and try everything possible to fight their cancer, while the patient believes it’s time to stop treatment. Patients may want to pursue alternative treatments, upsetting caregivers who want them to stick to conventional medicine. Or patients may feel a great sense of urgency to make a decision immediately and rush into treatment—anything to get started—while a sibling may push them to see a doctor they heard about from a friend.

Conflicts about treatment are often more intense when the cancer recurs or is diagnosed at an advanced stage with expectations of a shorter survival, says Bonnie Teschendorf, PhD, director of quality of life science for the American Cancer Society. “In these cases, the issues rise to the surface more quickly,” she says. “You may have to make a decision more quickly and you may believe the decisions are more critical.”

Nancy Clark, RN, knows all about the conflicts that can arise between patients and their support network. In late 2003, Clark was diagnosed with invasive ductal carcinoma—an early-stage breast cancer that had not spread to her lymph nodes. In January 2004, she had a double mastectomy with reconstruction using a procedure called transverse rectus abdominal muscle (TRAM) flap.

Her recovery was slow and painful, but worse, in May 2004, doctors discovered that her breast cancer had actually metastasized to her lungs, despite the apparently early diagnosis. And that’s when a good friend began questioning Clark’s treatment decisions and her trust in the doctors.

“My friend would constantly challenge me about the care I was getting,” says Clark, a nurse case manager for a worker’s compensation company in New Jersey. “She was drilling me about why they were doing this, why they weren’t doing that, and believing I should sue my doctors even though they weren’t to blame.”

Clark grew exhausted and annoyed by her friend’s criticism. “I decided that the amount of emotional energy it was taking to cope with this person was more than I had to spend, and I just pulled away from her.”

At the same time, Clark’s brother, who had been her main source of support, began to pull away from her. But because she was unwilling to abandon that relationship, Clark has tried to reinforce the positive communication between them to diffuse the stress. “I can’t make him more supportive of me than he is able to be,” she says. “All I can do is encourage him when he is doing things right and tell him how much I appreciate it, and then I hope that he continues to do that.”

For Clark, the conflicts that arose about her treatment were an opportunity to practice assertiveness and set limits.

“It’s enough to have to go through this without having someone question your decisions,” she says. “I’m not going to be pushed in a direction that I don’t want to be pushed. This is my life, my body, my decisions to make. I began telling people that this was my decision and that I was sorry if they couldn’t agree with it or weren’t comfortable with it, but I choose not to discuss it any further, end of story.”

Experts say these conflicts are often driven by communication problems, lack of information or different values that only come to light after a crisis. “A cancer diagnosis can bring out weaknesses in a relationship,” Dr. Teschendorf notes.

In some cases, a patient facing end-of-life decisions may be more interested in quality of life and opt to end chemotherapy or radiation if the side effects are intolerable, often to the dismay of caregivers who aren’t ready to accept what that means. Or a woman with breast cancer may decide that preserving her breast is most important, while her spouse or children can’t understand how body image could play a role when cancer is involved.

Sometimes caregivers weigh in with advice when they don’t have all of the information about the type of cancer, treatment or potential side effects. In addition, family members may also bicker with each other over the best options for the patient.

“In the end, the patient is the boss and has the right to be in charge of decisions,” Dr. Weiss says. “That’s just the reality.”