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Optimizing communication between cancer patients and oncology medical teams
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The importance of effective communication between oncologists and their patients cannot be overstated.
From a thorough explanation of complex management options and detailed descriptions of often toxic medications to a discussion of end-of-life choices, it is critical that there be an open and honest relationship with the patient and family, built on a framework of trust for the physician's medical knowledge and his reciprocally sincere interest in the patient's well-being.
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This commentary highlights several recent reports that emphasize the importance and potential difficulty of genuinely open communication between cancer patients and their physicians - and by extension, the entire medical team.
In the first report, investigators noted that one-third of patients (72 of 212 participants) who had recently been enrolled in highly experimental phase-1 clinical trials at the University of Chicago were taking biologically-based complementary and alternative medicine.
These individuals were self-administering the medications despite the fact they were about to embark on a treatment program where the use of such agents could quite realistically increase the toxicity of the program (either by an interaction with, or completely independent of, the prescribed anti-neoplastic agent), or actually even negate the positive effects of the experimental drug (eg, enhanced hepatic metabolism and subsequent accelerated drug elimination).
Further, increased observed toxicity incorrectly ascribed to the experimental agent could result in an inappropriate decision by the oncologist to reduce the dose or even discontinue a medication that was producing a favorable clinical effect in that individual. Why would patients make such a decision without consulting with their physician regarding the potential negative impact of the use of such agents on their outcome?
Spiritual support
A second report described a survey of advanced cancer patients who had failed their first-line chemotherapy regimen. The survey was conducted to investigate the importance of and need for spiritual support among this group of individuals.
In this population (n=230), almost 90% of patients responded that religion had "at least some importance to them," and more than two-thirds of the group stated "their spiritual needs were supported minimally or not at all by the medical system."
It is clearly recognized that the issue of the appropriate role for physicians in attempting to help satisfy the religious and spiritual needs surrounding the clinical state of progressive cancer, with its associated end-of-life discussions and decisions, is profoundly complex.
One perspective on this topic is that physicians should actually play a limited role in this arena, specifically to ensure that the doctor or other members of the health care team do not impose or appear to impose their personal religious and spiritual beliefs on the patient.
Although few would question the general wisdom of this rational perspective, the data in this report would suggest that there often exists a fundamental difference in what the members of the health care team feel is their role in the arena vs. the opinion and choice of the patient.
In striking contrast to the above noted study, a report describing the results of a survey involving more than 1,100 physicians of all subspecialties provides a rather different view regarding how some oncologists might deal with controversial clinical issues that conflict with their personal religious philosophy.
The majority of physicians (86%) in this survey indicated that they felt all management options should be provided to patients, irrespective of the physician's own moral beliefs, and a similarly high proportion (71%) felt referral to another physician would be indicated if there was a major conflict between the physician and the patient regarding the performance of a particular procedure.
However, 8% of physicians responded "no" to the specific question of whether they "have an obligation to present all possible options to the patient," and another 6% were undecided.
Comfort care
What if the procedure in question is the delivery of increasing quantities of IV morphine in the setting of intractable pain in a patient with rapidly progressive terminal cancer?
If severe respiratory suppression is a secondary and unquestionably unintended outcome of this therapeutic maneuver and a physician has an irreconcilable moral objection to his efforts potentially being the proximal cause of death in a patient, does this mean a physician in the "8%" group noted above would not feel an obligation to inform the patient he will refuse to provide this comfort measure, if needed?
In fact, terminal sedation was one of the controversial clinical practices included in the above noted study, and 17% of the physician respondents objected to this specific management.
Of course, there are no simple answers to these and many other questions that one can ask based on the three thought-provoking reports.
But perhaps that is the point. As every married couple and parent knows, human nature is complex, and achieving success in interpersonal communication requires considerable and ongoing effort.
Add to this equation a life-threatening illness, the need to quickly learn to trust an individual who is essentially a complete stranger (the oncologist), and the multiple profoundly difficult messages that may need to be conveyed during what is often a distressingly short period, and the challenge is more than clear.
That being said, by constantly striving to develop a better appreciation of the nonmedical needs of the patient and seeking ways to fulfill those needs without compromising personal moral beliefs or professional ethical requirements has the potential to improve - even if not to truly optimize - communication. After all, is that not one of the genuine goals and measures of effective oncologic care?
For more information:
- Maurie Markman, MD, is vice president for clinical research at The University of Texas M.D. Anderson Cancer Center. He is also Hem/Onc Today's section editor for Gynecologic Cancers.
- Hlubocky FJ, Ratain MJ, Wen M, et al. Complementary and alternative medicine among advanced cancer patients enrolled in phase I trials: A study of prognosis, quality of life, and preferences for decision making. J Clin Oncol. 2007;25:548-554.
- Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol. 2007;25:555-560.
- Curlin FA, Lawrence RE, Chin MH, et al. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007;356:593-600.