Breaking bad news

How do you break the news to a patient that he or she has cancer? If this study is any indication, these conversations aren’t always conducted in ways that are helpful to patients.

The study, which was published this week in the Journal of Clinical Oncology, involved a survey of 437 patients undergoing cancer treatment at the National Institutes of Health Clinical Center in Bethesda, Md. Questions in the survey addressed issues such as how the patient was told of the diagnosis, how long the discussion lasted, and whether treatment options were discussed.

The findings ought to raise a few eyebrows. Although 54 percent of the respondents were told of their diagnosis in a face-to-face visit in the physician’s office, 18 percent got the news over the phone. The remaining 28 percent were told in the hospital. Forty-four percent said the conversation lasted less than 10 minutes, and 31 percent said there was no discussion of treatment options. Distressingly, 39 percent of patients had no one else present, such as a spouse, parent or other family member, when the bad news was delivered.

I was curious to know what kind of discussion the survey might have sparked on some of the online cancer message boards, so I checked out a couple of sites. Sure enough, people were talking about it. One site even started an entire thread, inviting people to share their own stories.

Much of the conversation seemed to confirm the findings from the survey. Most said they were told in person of their cancer diagnosis. One individual, though, found out on his own by looking up his pathology report in his online medical record. And more than a few were informed over the phone. One woman said the news that her husband had cancer was conveyed by a physician’s assistant who left a message on their phone late on a Friday afternoon.

A common theme running through the anecdotes was that patients were often left dangling, sometimes for several agonizing days, before having their diagnosis confirmed. Several said their diagnosis and the next steps to take weren’t explained clearly. “No idea what that meant” is how one individual described the clinical description he was given of his cancer.

To be sure, there’s no easy way to break this kind of news. Is it kinder to tell the patient right away, even if it means having the conversation by phone? Who should do the telling – the patient’s primary care doctor, an oncologist or the surgeon who did the biopsy? Is it better to give the patient and family some time for the news to sink in, and schedule a separate appointment later to discuss treatment options?

From the provider’s point of view, it can be an emotional minefield, especially since patients and families often differ widely in individual values and preferences. The findings from the JCO survey suggest, however, that most patients do prefer a personal approach, with enough time allowed to explain their diagnosis and answer their questions. “Physicians should disclose a cancer diagnosis in a personal setting, discussing the diagnosis and treatment options for a substantial period of time whenever possible,” the authors wrote. While it seems there’s no way to entirely cushion the blow, some ways of conducting these conversations are clearly better than others.

Photo: Wikimedia Commons

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