Healthy Hope in Cancer: Balancing Presence and Optimism

Hope.

The cancer community uses this word constantly. And I've wrestled with whether hope helps or harms.

I've had days when hope was all I had. Days when the present is nothing but suffering and pain. Days when hope for a better tomorrow is the only thing that kept me going. And on those days, hope is oxygen.

But hope has a shadow side. Hope pulls attention away from the present, directing our gaze toward some desired future. And sometimes that future orientation becomes another form of grasping. Another form of wanting. Another distraction from the beautiful present.

And sometimes hope leads us astray. Leading us to longshot treatments with minimal odds but maximal present suffering.

So which is it? Is hope essential for survival? Or a trap that keeps us from living in the present?

I recently sat down with Dr. Tony Back, an oncologist and palliative care physician who brings a unique perspective to these questions. Tony has trained thousands of doctors in communication. He's also a long-term Zen practitioner.

And he's written a book with "hope" in the title: Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope.

When I asked Tony about hope, what I got was something more valuable than clear answers: two radically different perspectives that somehow both feel true.

The Clinical Case for Hope

From Tony's clinical perspective as a doctor, hope isn't optional.

"Hope is an essential part of how people meet these difficult moments," Tony told me. "If you can't start to see or imagine your way into the next step, it is just so hard to do all the stuff that you have to do."

Cancer treatment requires enduring tremendous present suffering for uncertain future benefit. Without some sense that this suffering serves a purpose, the whole enterprise becomes unbearable.

But Tony emphasized that doctors shouldn't just dispense facts and let patients figure out hope alone.

"I think my job as the doctor is to say: we are your team. We are pulling for you. We are going to be here for you. That's what that hope is about."

This reframes hope powerfully. Hope isn't something patients manufacture alone. Hope is the team commitment. Hope is the present process of working together, not just the future outcome you're working to achieve alone.

Tony referenced a researcher who pointed out that doctors often speak about hope as if it's "a quantity, like there's a box of something I can hand you."

"If hope is the process that we are engaged in together, if hope is generated in the way I work with you and the way my team responds to you, that's a whole different kind of thing."

Tony describes hope as a process, rather than a product. He describes hope as an action, rather than a feeling.

When Hope Becomes Toxic

But Tony was clear about when hope crosses into harm.

"The hope gets turned into this magical way out there Oz thing that says, we have to have hope and how we cultivate it isn't so important. And actually that's what I disagree with."

This is the toxic hope I've occasionally encountered within the cancer community: the insistence on staying positive regardless of circumstances; the pressure to manufacture miracles regardless of reality.

Tony mentioned patients who were offered unproven treatments at the end of life. Treatments offered "because the doctors think we have to give them hope." He said, "I don't think that's ethical. I think that's misleading."

So what makes hope healthy? Tony's answer: boundaries.

"How can I help this person imagine some kind of future, regardless of the situation they're in? And can I give that future some boundaries so that it's tangible and realistic and not just fanciful? That's the trick."

The Zen Critique of Hope

After explaining the clinical necessity of hope from the perspective of a doctor, Tony offered a completely different perspective from the perspective of a Zen practitioner.

"Here's the other side. The Zen side is that hope is completely overrated and we should actually stop wasting our energy. What we should do is pay attention to this present moment and the exact situation we're in."

Wait. The same person who just told me hope is essential is now saying hope is overrated?

"The Zen perspective is that hope is not what we should be cultivating. What we should be cultivating is our ability to be in the present moment without distracting ourselves, without engaging in fantasies."

From this perspective, hope isn't helpful. It's a distraction. Our minds constantly generate fantasies about escaping difficult situations. We pin happiness on future outcomes.

Tony commented that "chasing all the things that our minds produce, as ways to get out of a difficult situation - actually, in the end, it doesn't really help you."

The real work isn't cultivating hope for the future. The real work is being fully present with what's happening right now.

Holding Both

So which perspective is correct?

"They don't knit together," Tony admitted. "They're not logically consistent. But the reality is they're both really important."

Both are true. Both serve different functions at different times.

Tony pointed to Václav Havel's definition of hope as "an orientation of the spirit."

Not optimism about outcomes. Not certainty that things will improve. But an orientation. A way of being that remains constant regardless of circumstances.

What Healthy Hope Looks Like

So, what does ‘healthy hope’ look like in the face of cancer? 

Healthy hope is active. It's the treatment team showing up. The ongoing process of working together.

Healthy hope has boundaries. Tangible goals. Realistic timeframes. Not fanciful fantasies, but grounded visions of what's actually achievable.

Healthy hope doesn't pin everything on future outcomes. It recognizes what's available right now.

Healthy hope is an orientation more than an outcome.

And, what does ‘unhealthy hope’ look like? 

Unhealthy hope is passive. Magical thinking. The pressure to deny reality.

Unhealthy hope has no boundaries. It grasps at any possibility regardless of likelihood.

Unhealthy hope defers life indefinitely. The constant postponement of actually living until some imagined better future.

Both, Not Either

We don't have to choose between hope and presence. We can hold both. We can work with our treatment teams toward realistic goals while also fully inhabiting this moment.

Not hope as escape from present difficulty. Not hope as denial of reality. But hope as an orientation that allows us to meet whatever comes with courage and presence and connection.

Hope that propels us forward without pulling us away from now.

Let's journey together.