Abstract & Commentary
Synopsis: There is significant variability in how physicians approach information disclosure to cancer patients.
Source: Baile WF, et al. J Clin Oncol. 2002;20: 2189-2196.
To examine the attitude of oncologists in disclosure of unfavorable medical information to cancer patients, Baile and colleagues administered a questionnaire to a group of physicians who attended the 1999 Annual Meeting of the American Society of Clinical Oncology. The questionnaire assessed demographic and practice-related information and the frequency of patient encounters in which unfavorable cancer-related information was disclosed. Participants were also asked about difficulties they had when approaching stressful discussions and communication strategies used in giving unfavorable information. The questionnaire was completed by 167 oncologists. Sixty-four percent were medical oncologists. Thirty-eight percent practiced in North America, 26% practiced in Europe, 13% practiced in South America, and 13% practiced in Asia. Participants gave bad news to patients an average of 35 times per month. Discussing no further curative treatment and hospice was reported as most difficult. In disclosing the cancer diagnosis and prognosis, physicians from Western countries were less likely to withhold unfavorable information from the patient at the family’s request, avoid the discussion entirely, use euphemisms, and give treatments known not to be effective so as not to destroy hope than physicians from other countries. There was significant variability in opinions regarding the best time to discuss resuscitation, with 18% of respondents believing that it should be done close to the end of life. They concluded that there was significant variability in how physicians approach information disclosure to cancer patients. Factors such as geographical region and cultural and family variables may be important influences in this process.
Comment by David M. Gershenson, MD
Baile et al have been among the international leaders in the area of "breaking bad news." They and others have been extremely active in conducting formal courses and workshops and developing guidelines for giving bad news to cancer patients and their families. This paper highlights several important aspects of physician-patient communication. There are still major cultural differences in the information provided to patients and their families between Western and non-Western physicians. Non-Western physicians are more likely to avoid discussing prognosis, to withhold information from the patient at the family’s request, and to offer patients futile treatments to preserve hope. However, Western physicians also face several challenges regarding giving unfavorable news. The most problematic areas are providing information about a poor prognosis and the timing of providing counseling about "do not resuscitate" orders, discontinuing therapy, and hospice care. My sense is that most oncologists, including myself, broach the latter set of issues much too late in the course of many patients’ care. In addition to cultural differences, this study explored gender differences. And it is no surprise to me that women were more adept at discussing hospice care and other difficult issues than men. As Baile et al point out, further research is needed in this area. One strategy that is gaining popularity is to query newly diagnosed patients on very specific issues related to how much she wants to know prior to the physician consultation. In this manner, the patient can actively participate in the decision concerning prognostic information, the stickiest issue for most oncologists.
Dr. Gershenson is Professor and Chairman, Department of Gynecology, M.D. Anderson Cancer Center, Houston, Tex.