Communication Is Critical
Communication with patients about the goals, risks, and costs of therapy is crucially important.
A recent analysis of patient conversations for 56 oncologists between 2010 and 2013, published in the Journal of Oncology Practice, found that costs were discussed in only 22% of visits and lasted, on average, for 33 seconds.1 Patients tended to raise concerns about the costs of tests, while oncologists more frequently initiated conversations about the cost of antineoplastic agents.
Patients frequently misunderstand the goals of treatment or tests, Dr Goldberg noted.
“Today I sat with a patient with advanced gastric cancer, 3 months into treatment,” he said. “I told her we’re coming up on a CT [computerized tomography] scan. She said if the CT scan is good: ‘I’m done, right?’ I said, ‘no, you’re going to be on this treatment forever.’ She looked like I was talking in tongues. She didn’t understand that the goal of therapy was to slow the cancer, not cure it. But she was totally unaware.”
Discussing treatment futility is similarly fundamental, but talking to a patient about her impending death can be challenging for all involved.
According to Dr Goldberg, “we have technical skills and new drugs, and we want to offer them to the patient without asking the patient: ‘when is enough, enough?’
“It is a very difficult discussion to have. It’s uncomfortable. It also turns out patients don’t bring it up very often. They’ll tell family members they don’t want any more chemotherapy. But they often don’t tell their doctors or health care team, because they don’t want to tell doctor they’re giving up.”
The American Society of Clinical Oncology (ASCO) released a new guideline to help improve clinician communication with patients.2 It calls on clinicians to clearly convey, and to make sure that each patient really understands the prognosis and treatment options — and to discuss the patient’s values, goals, and priorities to make sure that treatment plans reflect the patient’s needs and wishes.2