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Successful patient–physician communication navigates emotional ‘roller coaster’ of new treatment era
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Descriptions about the uncertainty of cancer therapy at diagnosis and continuing discussions about prognosis throughout treatment are essential strategies for clinicians to employ when they communicate with patients, according to a commentary published in Journal of Clinical Oncology.
These discussions are becoming even more essential in a treatment era in which therapies can significantly prolong survival for some patients.
“The best approach is to be honest with our patients and share new data on novel therapies, but explain that these drugs don’t work in all patients,” Jennifer Temel, MD, clinical director of thoracic oncology at Massachusetts General Hospital Cancer Center and associate director of the Dana-Farber/Partners Cancer Care Hematology/Oncology Fellowship, told HemOnc Today.
HemOnc Today spoke with Temel about the challenges clinicians must overcome to have successful end-of-life discussions with patients, and how these discussions are changing in light of major research advances.
Impact of communication
In their commentary, Temel and colleagues noted that effective patient–clinician communication about end-of-life preferences offers many important benefits for patients, their families and the health care system.
“Patients who are aware their life expectancy is likely short are empowered to make informed decisions about how they want to spend their remaining time,” Temel and colleagues wrote. “Understanding that their prognosis is poor also allows patients to acknowledge that they will potentially miss future events and ensures they have time to communicate their wishes, address unresolved concerns and leave a legacy for loved ones, such as through letters or videos.”
Conversely, patients with advanced cancer may not understand their prognosis and goals of treatment, leading to poor patient outcomes, aggressive care at the end of life and increased health care costs.
Patients who discuss their care preferences with their clinicians are less likely to receive intensive medical interventions — such as cardiopulmonary resuscitation or chemotherapy administration — near the end of life.
As a result, communication about end-of-life care options allows patients to spend less time in the hospital and more time receiving hospice services. Moreover, family members and professional caregivers of patients who receive less intensive medical care near the end of life rate the patient’s quality of death to be better than those who received more intensive medical interventions.
Caregivers also report better outcomes in their own well-being, including lower rates of depression and improved quality of life.
“Patients with advanced cancer prefer their oncologist to be realistic about their future and to discuss prognosis early in the course of illness,” Temel and colleagues wrote.
Highs and lows
Despite patients’ preferences to receive prognostic information that allows them to prepare for the end of life, an article by Weeks and colleagues — published in 2012 in The New England Journal of Medicine — showed that more than two-thirds of patients with metastatic lung or colorectal cancer reported believing that chemotherapy was likely to cure their cancer.
Further, Mack and colleagues reported in 2012 in Annals of Internal Medicine that most clinician–patient conversations about end-of-life care preferences took place within weeks of a patient’s death.
“With improvements in cancer therapeutics in many different cancers, greater prognostic uncertainty is an issue for patient–clinician communication,” Temel told HemOnc Today. “We want our patients to do as well as they can for as long as possible. It feels difficult when their cancer has progressed and their health status has worsened to the point that additional cancer treatment will no longer be helpful, and we need to transition our focus to supportive care.”
In their commentary, Temel and colleagues noted that patients with metastatic disease can survive for years and that clinicians need to help their patients navigate the emotional highs and lows associated with multiple remissions.
Temel and colleagues described a young woman diagnosed with metastatic non–small cell lung cancer who harbored an ALK translocation. Her cancer responded to initial treatments, but her cancer progressed 2 years after her diagnosis, and her clinicians communicated their concerns that she could soon die.
Through IV chemotherapy, the patient experienced a dramatic recovery and returned to work. The patient experienced two similarly dramatic recoveries and expressed to her family and clinicians that she did not feel she could cope with becoming ill and facing death again, only to return to good health.
Temel said the woman’s story highlights the importance of continuing to address patients’ prognosis and goals of care over the course of illness. It also shows the need for clinicians to understand and attend to the psychosocial impact of such treatment decisions.
“These are new experiences for us in oncology — to have patients who are near death recover dramatically with novel therapies,” Temel added. “So, we simply don’t have experience helping patients navigate these situations. For patients who are struggling with this roller coaster ride — or this uncertainty — our colleagues in palliative care or psychology can be an excellent resource.” – by Chuck Gormley
References:
Mack LW, et al. Ann Intern Med. 2012;doi:10.7326/0003-4819-156-3-201202070-00008.
Temel JS, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2016.67.8573.
Weeks JC, et al. N Engl J Med. 2012;doi: 367:1616-1625.
For more information:
Jennifer Temel, MD, can be reached at jtemel@partners.org.
Disclosure: Temel reports research funding or travel expenses from Helsinn Therapeutics and Pfizer. Please see the full commentary for a list of all other authors’ relevant financial disclosures.
Perspective
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Loren Friedman, MD, FAAHPM
Although inpatient palliative medicine is now established in the fabric of hospital-based care, outpatient palliative medicine remains a frontier.
Jennifer Temel, MD, and colleagues changed the landscape of palliative medicine in oncology with the 2010 publication in The New England Journal of Medicine of their study on early palliative care intervention in the management of metastatic lung cancer. Since that time, Temel and colleagues have continued their leadership in promoting the integration of palliative care into the care of oncology patients.
In a beautifully written commentary in Journal of Clinical Oncology, Temel, Walsh and Greer address both the challenge and importance of communicating prognosis amidst the advances in antineoplastic therapies. Uncertainty should not delay early discussion of prognosis. Despite the reluctance of many oncologists to discuss prognosis during their initial encounters with patients with advanced cancer, data show that patients prefer early discussion of likely disease trajectories.
Current recommendations are that discussion of prognosis should begin at the time of diagnosis. Prognostic discussions should be ongoing as the response to treatment is assessed and new treatments become available. Early communication about prognosis enables patients “to address unresolved concerns,” and enables care that is in keeping with the patient’s wishes and goals, Temel and colleagues noted.
In the era of rapid development of new immunotherapeutics, “providing patients with evidence-based information about their prognosis and end-of-life care options remains an essential aspect of quality cancer care,” they wrote.
Even for oncologists with good communication skills, patients often do not understand prognosis and avoid discussions of goals of care. Temel and colleagues, therefore — while advocating for the essential role of the oncologist in these discussions — continue to promote the role of early integration of palliative care in facilitating patient understanding.
Reference:
Temel JS, et al. N Engl J Med. 2010;doi:10.1056/NEJMoa1000678.
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