Feature

Researcher advocates ‘straight-talk’ approach for patients with advanced cancer

Donald A. Brand, PhD
Donald A. Brand

Shielding a patient from the facts of an advanced-cancer diagnosis could compromise the patient’s ability to make informed treatment choices, according to an article published in Journal of General Internal Medicine.

“I recommend straight talk about late-stage cancer that can give patients realistic hopes instead of false hopes that are apt to betray later on,” Donald A. Brand, PhD, adjunct professor at NYU Long Island School of Medicine, said in a press release. “Oncologists may be well-meaning in their efforts to mitigate the shock of bad news, but glossing over the facts of efficacy may explain why so many patients believe their metastatic cancer can be cured and why so few patients with advanced cancer decline chemotherapy.”

Healio spoke with Brand about what prompted his article, titled “The stage IV shuffle,” why this discussion is important and what oncologists can do to change the discussion.

Question: What prompted this article?

Answer: I have had several relatives with one type or another of stage IV cancer and in each case when I accompanied them to their office visit, I noticed a pattern of indirectness from the oncologist. The oncologist seemed to divert attention from the disease trajectory and talk more about technical things that were not necessarily on the patient’s mind. I also noticed that the presentation of treatment efficacy data in the medical literature makes it difficult for anyone who is not a statistician to figure out what it really means. About 2 years ago, another relative was diagnosed with stage IV cancer. My wife and I accompanied him to his initial session with an oncologist at a leading cancer center, so I was expecting things to be different. I was shocked to find that nothing had changed — we experienced the same indirectness.

Q: Why is this discussion important for the medical community?

A: This is a pervasive problem for patients with advanced disease, not just for patients with cancer. It is difficult to balance tact with candor, and often tact wins. A lot of people may feel that tact means withholding certain things because they are very painful and that candor means revealing the harsh truth. It may not be easy to tell the truth to a patient, or to a friend for that matter, who is facing a terminal illness. This is an important discussion to have.

Q: What can oncologists do to change the discussion of advanced cancer with their patients?

A: Oncologists should try to focus as much as possible on the patient’s perspective. Naturally, oncologists have certain topics they are most comfortable talking about. But these are not necessarily things patients care about. The oncologist is likely to be very comfortable talking about microscopic descriptions of cells, types of treatment, treatment schedules, and things that are initially of less interest to the patient than whether or not they will make it and how long they have to live. Although this is not easy, my recommendation is that oncologists think about how they can avoid leaving patients feeling that they need to go directly to the literature to find out the real truth about their diagnosis.

Q: Should this be taught in medical school?

A: Absolutely. I am sure that it is, to a certain extent, being taught because medical students are bound to encounter patients with advanced stages of disease during their clinical rotations. However, there is no formula or right answer. Mentors are paying attention to these issues and trying in earnest to be more forthright with patients, which will in turn be handed down to the medical students.

Q: Is there anything else that you would like to mention?

A: I realize that oncologists cannot talk about everything in the first or second session, that it is a complex conversation and that the clinician must pay attention to what the patient can handle. Still, the emotionally charged issues need to be addressed over time. Perhaps the tenor of the initial meeting could be changed to focus more on simple things that really mean something to the patient. These issues are extremely challenging, and I am not sure I would do a good job myself, but it is a goal to strive toward — transparency and compassion rolled into one. No one is going to do a perfect job, but it is worth the effort. – by Jennifer Southall

Reference:

Brand DA. J Gen Intern Med. 2019;doi:10.1007/s11606-019-05158-5.

For more information:

Donald A. Brand, PhD, can be reached at NYU Long Island School of Medicine, 222 Station Plaza North, Floor 5, Mineola, NY 11501; email: donald.brand@nyulangone.org.

Disclosures: Brand reports no relevant financial disclosures.

Donald A. Brand, PhD
Donald A. Brand

Shielding a patient from the facts of an advanced-cancer diagnosis could compromise the patient’s ability to make informed treatment choices, according to an article published in Journal of General Internal Medicine.

“I recommend straight talk about late-stage cancer that can give patients realistic hopes instead of false hopes that are apt to betray later on,” Donald A. Brand, PhD, adjunct professor at NYU Long Island School of Medicine, said in a press release. “Oncologists may be well-meaning in their efforts to mitigate the shock of bad news, but glossing over the facts of efficacy may explain why so many patients believe their metastatic cancer can be cured and why so few patients with advanced cancer decline chemotherapy.”

Healio spoke with Brand about what prompted his article, titled “The stage IV shuffle,” why this discussion is important and what oncologists can do to change the discussion.

Question: What prompted this article?

Answer: I have had several relatives with one type or another of stage IV cancer and in each case when I accompanied them to their office visit, I noticed a pattern of indirectness from the oncologist. The oncologist seemed to divert attention from the disease trajectory and talk more about technical things that were not necessarily on the patient’s mind. I also noticed that the presentation of treatment efficacy data in the medical literature makes it difficult for anyone who is not a statistician to figure out what it really means. About 2 years ago, another relative was diagnosed with stage IV cancer. My wife and I accompanied him to his initial session with an oncologist at a leading cancer center, so I was expecting things to be different. I was shocked to find that nothing had changed — we experienced the same indirectness.

Q: Why is this discussion important for the medical community?

A: This is a pervasive problem for patients with advanced disease, not just for patients with cancer. It is difficult to balance tact with candor, and often tact wins. A lot of people may feel that tact means withholding certain things because they are very painful and that candor means revealing the harsh truth. It may not be easy to tell the truth to a patient, or to a friend for that matter, who is facing a terminal illness. This is an important discussion to have.

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Q: What can oncologists do to change the discussion of advanced cancer with their patients?

A: Oncologists should try to focus as much as possible on the patient’s perspective. Naturally, oncologists have certain topics they are most comfortable talking about. But these are not necessarily things patients care about. The oncologist is likely to be very comfortable talking about microscopic descriptions of cells, types of treatment, treatment schedules, and things that are initially of less interest to the patient than whether or not they will make it and how long they have to live. Although this is not easy, my recommendation is that oncologists think about how they can avoid leaving patients feeling that they need to go directly to the literature to find out the real truth about their diagnosis.

Q: Should this be taught in medical school?

A: Absolutely. I am sure that it is, to a certain extent, being taught because medical students are bound to encounter patients with advanced stages of disease during their clinical rotations. However, there is no formula or right answer. Mentors are paying attention to these issues and trying in earnest to be more forthright with patients, which will in turn be handed down to the medical students.

Q: Is there anything else that you would like to mention?

A: I realize that oncologists cannot talk about everything in the first or second session, that it is a complex conversation and that the clinician must pay attention to what the patient can handle. Still, the emotionally charged issues need to be addressed over time. Perhaps the tenor of the initial meeting could be changed to focus more on simple things that really mean something to the patient. These issues are extremely challenging, and I am not sure I would do a good job myself, but it is a goal to strive toward — transparency and compassion rolled into one. No one is going to do a perfect job, but it is worth the effort. – by Jennifer Southall

Reference:

Brand DA. J Gen Intern Med. 2019;doi:10.1007/s11606-019-05158-5.

For more information:

Donald A. Brand, PhD, can be reached at NYU Long Island School of Medicine, 222 Station Plaza North, Floor 5, Mineola, NY 11501; email: donald.brand@nyulangone.org.

Disclosures: Brand reports no relevant financial disclosures.