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In Cancer, Talking About Bad News Can Be Good

Possible benefits in terms of future quality of life

(Sacramento, Calif.) - Giving bad news is never easy, especially when it's life or death. But when an oncologist delivers a poor prognosis to a cancer patient, does it harm their relationship?  Some research studies have suggested it can.

A new study by UC Davis and University of Rochester researchers demonstrates that it does not. In fact, it found that the patient-doctor alliance can be strengthened after a discussion about prognosis.
Appearing  today in the Journal of Clinical Oncology, the study may provide reassurance to oncologists worried that talking about a patient's chances of survival may do more harm than good.

"We hope this information will reassure clinicians about any negative impacts of these discussions on their relationships with patients," said lead author Joshua Fenton, a professor of family and community medicine at UC Davis. "Discussing prognosis doesn't undermine trust, and informing patients may have large benefits in terms of future quality of life."

Fenton explains that while patients with illnesses that may limit their lives rely on their physicians to talk with them about their disease and prognosis, many oncologists instead emphasize treatment options, spending little time discussing prognosis or end-of-life options such as palliative care and hospice. The result can be greater use of intensive, hospital-based services, higher health care costs, lower quality of life for patients, more difficulties for caregivers and even shortened survival.

"Prognosis discussions don't happen early and often, and, as a result, it's been clearly documented that many patients often completely misunderstand their prognosis so treatment decisions made near the end of life might not be totally aligned with the patients' and caregivers' priorities," he said.

The study is an outgrowth of earlier research which found that patients with stage III or IV cancer reported far more optimistic expectations for survival than their oncologists thought they had communicated, which has implications for the kinds of decisions made near the end of life.

For the new study, the researchers recruited 238 adult patients with advanced cancer visiting 38 oncologists within community and hospital-based cancer clinics in Western New York and Northern California, including at the UC Davis Comprehensive Cancer Center.

Patient visits with oncologists were audiotaped and the tapes then analyzed for prognosis discussions. Patients were surveyed 2-7 days after their visit and again at three months to evaluate any changes in the doctor-patient relationship. An analysis of the findings showed that having had a prognosis discussion did not negatively affect the doctor-patient relationship within one week of the conversation and that it actually improved the relationship three months later.

The study contradicts two, more limited studies which found that these discussions can increase a patient's depressive symptoms and disrupt the doctor-patient relationship.

Fenton said that in addition to educating oncologists about the importance of prognosis discussions, he hopes that medical educators enhance their curriculum to train future oncologists in these communications strategies.

"Giving patients bad news is a very small part of our training as clinicians," he said.

Other authors on the study include Richard Kravitz, Guibo Xing and Daniel Tancredi at UC Davis; and Paul Duberstein, Kevin Fiscella, Supriya Mohile and Ronald Epstein at the University of Rochester.
The research was supported by grants from the National Cancer Institute (RO1 CA140419-05 and RO1 CA168387).

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