There is limited evidence in the literature about how oncologists should discuss bad or serious news with their patients. A recent study sought to understand what patients with cancer value when their doctors communicate news of recurrence.1 The ASCO Post spoke with the study’s lead author, Anthony L. Back, MD, of the Seattle Cancer Care Alliance, about how the results might affect clinical care. Dr. Back is also Affiliate Member in the Clinical Research Division at Fred Hutchinson Cancer Research Center, and Professor in the Oncology Division and Adjunct Associate Professor of Medical History and Ethics at the University of Washington School of Medicine.
Study Background
What was the purpose of your study on what patients prefer when hearing about cancer recurrence?
Giving serious or bad news is a fundamental communication task for oncologists. Although there are multiple recommendations about best approaches in the literature, they have not been evaluated from the patient perspective. So our study was designed to provide doctors with recommendations for communication that had been vetted by patients with cancer.
How was the study designed?
We recruited 23 participants who had been treated for a gastrointestinal cancer at the Seattle Cancer Care Alliance within the past 2 years. They were cancer free but had been treated recently enough to still be at risk for recurrence. While listening to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient, the participants paused the recording to comment on what they liked or disliked about the way the oncologist was communicating with the patient.
Implications of Findings
Did you learn anything from the study that could be used in clinical practice?
Yes, there were actionable takeaway points related to what doctors should and shouldn’t do in this clinical scenario. First, doctors should communicate a sense that they understand what their patients are going through.
In the literature, there are many examples of papers stressing a need for doctors to show more empathy, but we found that patients don’t really need their doctor to share their emotions, but rather to understand what they were going through, it’s what we called “recognition”—how the oncologist responds to the gravity of the news they’re communicating. The patients also don’t want their doctor to seem overwhelmed with how bad their situation might be because of the news of recurrence.
To date, most of the emphasis with regard to giving bad news is on being honest and leaving space for the patient’s emotions. However, we found that patients want to be guided through their care by the doctor’s expertise, and this is a perspective that really doesn’t appear in the literature. We call this “guiding” because patients want doctors to individualize a care plan for them, not use a standard algorithm approach.
So when giving bad news, the doctor should shift between recognition and guiding. These conversations are not linear—they ebb and flow in cycles—and the doctor needs to be able to swing back and forth between the two functions. In fact, we had patients tell us that they want the doctor to know when to hold their hand and when to give them medical advice. We call that ability to move back and forth between recognition and guiding, “responsiveness.”
Giving bad news about cancer recurrence is a high-stakes situation, and these are conversation tools to help doctors have a meaningful conversation with their patients. I think of this as a more advanced level of communication skills for oncologists who already know the basic conversation components taught in medical courses.
Patient Frankness
Was it difficult to get vulnerable patients with cancer to speak openly about cancer doctors?
Patients with cancer are reluctant to criticize their doctors. However, one thing that enabled us to capture honest dialogue was that we had patients listening to the conversations of other patients and doctors, and because it wasn’t their doctor, there was a sort of emotional shield that fostered much franker responses. So having patients on an observational level helped us bring objective clarity to the way the conversations were critiqued.
Provisional Clinical Opinion
ASCO’s recent provisional clinical opinion on palliative care stressed open and honest doctor-patient conversations. What impact do you think that guideline is having in clinical practice?
ASCO’s interest in this area is tremendously powerful in setting the standard of care that people in academia and the community ought to aspire to. I think we’re seeing a turning point in awareness, and having ASCO’s growing support, as reflected by the provisional clinical opinion, sends a strong message that palliative care is an essential component of best practices.
Oncotalk
The audio recordings for the study were produced during an Oncotalk communication skills retreat. Please describe the purpose and function of the Oncotalk website.
The Oncotalk site (www.oncotalk.info) was based on two NIH grants to advance intervention methods for improving how doctors communicate with their patients. We developed models for oncologists to help them learn and teach each other better ways of communicating with their patients in a variety of clinical scenarios. Based on the success, we’re currently working with several foundations to acquire funding so we can disseminate the Oncotalk model to a wider audience in the oncology community (via a new project called VITALtalk).2
This is one way to expand the work ASCO is doing in evidence-based training. We can help raise the bar in the palliative care field by using electronic technologies. Moreover, on the Oncotalk site there is a bank of information about enhancing communication skills, plus educational videos. We’ve also referenced our book, Mastering Communication with Seriously Ill Patients,3 which is a step-by-step manual of sorts that is written and organized in a very user-friendly format.
Improved Outcomes with Better Communication
What are the most promising signs that better doctor-patient communication will become fully integrated into standard oncology practice?
We now see recognition across the field that communication in difficult clinical scenarios is not something a doctor is born with; it is a learned skill that is malleable and improvable for virtually everyone. This recognition is based on data and an attitudinal change that has taken firm root in the community.
The other sign is that there are more and more studies producing good data linking better patient outcomes with better communication. For instance, patients who are asked what their expectations are for end-of-life care are much less likely to wind up in the intensive care unit, their family members have less stress and regret, and the whole process is less fractured. The ripples of positive outcomes from good communication go beyond just the doctor and patient. We’re finally beginning to accelerate the global awareness that good communication is part of good cancer care. ■
Disclosure: Dr. Back reported no potential conflicts of interest.
References
1. Back AL, Trinidad SB, Hopley EK, et al: What patients value when oncologists give news of cancer recurrence: Commentary on specific moments in audio-recorded conversations. Oncologist 16:342-350, 2011.
2. Back AL, Fryer-Edwards K, Tulsky J, et al: A manifesto for VITALtalk. Available at vitaltalk.blogspot.com. Accessed May 15, 2012.
3. Back AL, Arnold R, Tulsky J: Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. Cambridge, UK; Cambridge University Press; 2009.
