What is the best way for a doctor to tell a patient he has cancer?

So what is the best way for a doctor to tell a patient that he or she has cancer?

I suppose that can range all the way from

"You have advanced cancer. I don’t think you'll live more than another few months. I'm sorry."

to

"Yes, it's cancer, but please realize there's a lot we can do. For example … (positive discussion continues)."

Doctors are going to vary on this. I rather liked the way my own uro broke it to me back in 2011 at my own PCa diagnosis:

"Well it looks like you do have a little bit of cancer in there."

Everything in that statement is compact, in one sentence, and the phrase "little bit," with the suggestion that there is indeed hope, is right there with "cancer," and even precedes the word "cancer," sort of delivering the good news first.

I thought that was well done.

The article below, though a bit old, still makes some good points on how doctors can effectively relay this bad news to their patients, if that's what they have to do.

HIGHLIGHTS:

"… most medical schools don't offer students any formal
instruction in breaking bad news, and physicians often have to devise their own methods."

"… doctors rank discussing a recurrence of cancer with patients as one of the most difficult tasks they perform."

"Doctors are taught that in order to apply their technical expertise, they have to be detached emotionally, but patients may experience this aloofness as insensitivity."

OTHER: if possible, discuss face-to-face, not over telephone. Doctors should not overuse technical language. Doctors must LISTEN more. ("Studies have shown that in an average office visit, patients talk a mere 18 seconds before their physician interrupts them. Less than a quarter of patients even get to finish their opening statements"). Also, let patients vent if they need to.

And one rather interesting perspective:

"… Physicians should never say "We got it all" after a course of treatment. This sort of pronouncement implies that the patient has been cured of cancer, an overstatement that can come back to haunt both the patient and doctor if the disease recurs. A better phrase would be "We got everything we could see at this time."

www.cancernetwork.com/articles/how-doctors-break-bad-news

Of course delivery of a diagnosis can be tailored to the individual patient's temperament, if the doctor knows what that is, but, in general, how should doctors deliver a cancer diagnosis?

What do you think?

NKinney said...

Most PC cases are favorable-risk and need the best care and attention to help patients not get a “cancer hysteria” and leap into a potentially unnecessary aggressive, irreversible treatment which is very possible to cause treatment regret later. (Reference the numerous HWPC threads on the subject of treatment regret.)

You'd love my old uro. He came in, said...."You've got cancer. It's non-aggressive. I wouldn't do anything with it so I'll go ahead and enroll you in our AS program. I'll see ya back here in about 6 mos. for another PSA check". Turned around and walked out the door.

My diagnosis experience was more peculiar. I went to the pathologist counter, I received an envelope with the biopsy results and I opened it just as soon as I was away from the nurse view. I was relieved because it said G6, two cores and 5% max. involvement after a more ominuous mpMRI test (that unfortunately was confirmed to be more accurate later) . My uro was on summer vacation and I spent a few days on the seaside as well. I hoped he was to advice me AS when he returned but he was not so happy with the results and I took him seriously. In the stressing months before treatment I had the feeling that I needed to do something soon to avoid future problems but I did not have the feeling of being seriously ill. My path report changed that perception.

He should explain all the pros and cons of the diagnosis{there are pros}...the treatment options available...if he knows little about them ...he should admit it...but recommendations of specialist are ok...be forthright...folks should not be shielded from the bad...the good or the ugly...in the 99% of the cases...It is up to the patient to or their advocate to decide the reality for them from that...by learning about their disease themselves

My jerk Uro told me he would call with the results of the biopsy, which he did not. I had to wait a month, wondering, until my next appointment to be told. I did not appreciate that.

My uro called me at work the very next day after the biopsy. We chatted about how I was feeling after the biopsy, and then he asked if I had few minutes to discuss the results. In the midst of an adrenaline dump I got a piece of paper, went to a conference room, and the world stopped turning.

He was rather matter-of-fact, saying about half of the cores were positive, the percentages were pretty high, mostly 70% up to 100%, and all were Gleason 9. I was rather shocked, as I knew full well what those kind of numbers implied. He said we have a few more tests to do, so let's get them scheduled.

He also said he was glad I had come to him when I did, though he would have liked to have seen me six months earlier. We perhaps caught it just barely in time. He said mine was the situation they try to find with screening; serious enough to treat, and hopefully early enough to treat successfully. He was generally positive, though I sure wasn't!

The news wouldn't have been any easier in his office, though it would have been better for both my wife and I to hear it at the same time. The drive home, and trying to figure out what and how I was going to tell her, was really tough.

My Dr called which was a dead giveaway the results were not negative. He schedule me for a conference the next day to discuss my options. I had 3 cores of G6. He said I was marginal for AS or I could have open surgery (not eligible for laparoscopic due to previous heart problems, or could opt for radiation. I was also not a candidate for seeds as my prostate was 137 in size at the first biopsy. I had been researching for months since I had been referred to urologist for rising PSA. I elected to pursue AS. My subsequent biopsies were about the same but my prostate size has fallen to 40 (on finasteride) and my psa has fallen to under .8 in the last 3 1/2 years. I plan to have one more biopsy in June and if it comes back still G6 I will forgo anymore biopsies unless my PSA rises. Now at age 70.

Having had it twice in my life (Malignant Melanoma in 2006, PC in 2014), I have had it both ways. With the MM, I had the biopsy, and the first pathologist reported "inconclusive", so they sent the slides to Mayo. Then, one day, I got a call from my GP's PA at work, "could you come by the office on your way home from work today?" So, I knew it wasn't good news. And then, at the office, my GP--who had been mine and my family's doctor for 15+ years--comes in with my file folder and a bookmarked copy of the Merck index. He tells me what the diagnosis is, what it meant, and that I had an appointment for the next week with a surgeon.

With PC, I had the biopsy on a Monday. The following Friday, I got home from work to a blinking light on the answering machine. Message was to call nurse X at the Uro's office. I called her, and she told me over the phone, and made an appointment for me and my wife to meet with the Uro in a week or so. At that meeting--which he had with us at the end of his workday, where he sent the staff home and then sat with us for as long as we needed--he went through the findings and the available options.

So--is there a 'best' way? I don't know. It's so darned individual.

Mine handed me a biopsy report, and left the room, saying I'll be back to go over it with you in a few minutes. he left the door ajar, and I could hear him on his cell phone arguing with a mortgage broker over the financing of an investment property he was acquiring. I read the report and understood it. he yelled and cursed on the phone and hung up on his broker. Then, red in the face, he came back and asked me to come into his office.

He said, "You have prostate cancer, and there's a short video I'd like you to watch -- I'll be right back." So he started the video on his laptop for me to watch, and went back out to call his broker back. It was very nicely done and explained the basics and the treatment alternatives. He came back in and asked, "any questions?" I congratulated him on the video (he starred in it) and commented on the good production values. He gave me a copy of the video to keep. I wondered if he would charge me for it. He said, "the way the DaVinci works is the surgeons are only assigned certain days and hours to use it on patients. A patient dropped out, so I will have an opening in two weeks. Otherwise, you may have to wait a couple of months."

I told him that I'd like to think about it, and potency preservation was a big concern. He said, "at your age (57) surgery is really the best alternative. It's what I'd tell my own father to do." Does he hate his father? "Potency preservation is better than average." I told him I wanted more time and promised to get back to him. I never did.

Is there really a best way? I think I have always felt that people who are sick, no they are sick. That’s how it works for me. I suppose The agonizing pain and blood in my urine is what cute me in to that but if I didn’t already suspected something was wrong and my doctor telling me that I have cancer was my first clue then I suppose I would rather be told about the Mini treatment options available to me and that I still

I believe that it is best for the doctor to be forthcoming with information, so that the patient has an idea of the severity of the situation. To illustrate my point, I will tell the parable of the man who had three doctors.

- The first doctor was a urologist. Although the man had seen this doctor many times over the years, the doctor said very little, giving only terse, dismissive answers to the man's questions. The discussion was limited to "your PSA is high", and "we need to do a biopsy". And when asked what's next, he only said "repeat the biopsy".

At no point did the urologist EVER use the word "cancer". The doctor was NOT forthcoming with any information. If he had attempted to INFORM the patient of the severity of the situation, then the man's cancer journey would have been far less traumatic.

- The second doctor was also a urologist. When first consulted by the man he acted immediately and ordered an MRI. When the MRI indicated a suspicious area he conducted a fusion biopsy. He then called the man at home and said "you have cancer", as though he was delivering the news that "it's a boy!"

He then informed the man that he would order some additional tests and a consult with a radiation oncologist. After the tests they discussed treatment options. Surgery was performed promptly and the doctor told the man the results of the treatment. The man was thankful that the doctor had been honest with him.

- The third doctor was an ENT. After completing a course of radiation as follow-up to the prostate surgery, the man began to experience difficulty with speech and eating. The ENT identified a mass at the base of the man's tongue. He informed him that it could possibly be base of tongue oropharyngeal cancer. He even presented a possible diagnosis of P16+ OPC as he was aware of an epidemic of such cancers among men of the man's age.

The ENT ordered an MRI which did not identify any suspicious tissue within the mass. The man thanked the doctor for "taking him seriously" and for being forthcoming with information. This type of gratitude would not be necessary if every physician acted as though each of their patient's concerns were valid, unlike the first doctor.

After my TURP, Doc says "we discovered some G 3+3, which isn't too bad, but also some G 3+4 which is a concern. Brachy seeds aren't an option because of your reduced size prostate, and radiation isn't advisable because of your ulcerative colitis. When can I schedule surgery? BTW, I don't do robotic surgery."

When I told him I'd need to do some research, have a 3T MRI and probably a biopsy, he got up a left. That was that. Uro's are sooooo odd in my experience.

As with all things human....alot of this is personality driven. And there's 2 personalities interacting here.

I'll just say....

The doctors....or lawyers....or teachers....or any other profession that I have gotten along with best are the one's that can pick up on what others needs are. They know...that I do not know...what I do not know. And they also know...that I'm a guy...who likes to be in control....ie.....I need *alot* of information. All the information that I don't know I need. And they can tell I'm bright enough to be able to have an intelligent conversation with them....equals as human beings....though they are the ones with the knowledge....the insightfulness to know what they sense I need to know...and letting loose with the info...coupled with the respect to not insult my intelligence with bs.

These types of people can be difficult to find in any profession. Medicine being the most important....(for obvious reasons)

What that does....is....it builds trust. My gastroenterologist has always been this way with me....from day one. As has my current uro.

These guys have no ego. They have no fear. Their only agenda is what's best for *this human being* (which, in our case, is me). And they are fearless. They do not fear scaring me. They know...there is nothing .... nothing...that the world can do to them.....because....they are open books. And are unafraid of their flaws being seen.

and they know...with me....they don't have to get it right. But they do have to be honest. Which is not a problem for them....because....they have no agendas...except to learn...themselves...