Breaking bad news: explaining cancer diagnosis and prognosis

Based on a literature review and recommendations of a consensus panel of doctors (with input from patients with cancer), Girgis and Sanson-Fisher² published some useful guidelines on conveying information to patients about serious disease or death. Their guidelines included ensuring privacy and allowing adequate time, assessing patients' understanding, giving information about diagnosis and prognosis simply and honestly, avoiding euphemisms, encouraging patients to express feelings, being empathic, giving a broad but realistic time-frame concerning prognosis, and arranging a review. The crucial question is how well these recommendations are followed in clinical practice, as discussing prognosis should be part of the process of breaking bad news.

Audiotape recordings of consultations have shown that doctors break the bad news of a cancer diagnosis to patients in a predictable and routine way regardless of patients' individual information needs.³ Although the doctors gave reassurance that something could be done, few attempted to elicit patients' thoughts and feelings about the symptoms and their cause. They gave the information in a consistent order -- diagnosis, the relevant evidence, the need for further investigations, the treatments being considered and the probable outcome -- with no heed to which issues patients wished to address first. Obvious verbal and non-verbal cues of distress were not acknowledged and patients' immediate concerns were not explored.

This consultation structure led patients to believe they were not entitled to talk about their feelings or their major concerns. Consequently, their preoccupation with these feelings and concerns meant that they did not assimilate the information and advice given. On being interviewed at the end of the consultation, patients reported that they were left with important, but undisclosed, concerns and also felt that the information given had been inadequate for their needs.

The important article by Lobb and colleagues⁴ published in this issue of the Journal looks at one aspect of breaking bad news to cancer patients -- explaining prognosis to women with breast cancer. It was clear from the women's answers to a questionnaire and a clinical vignette that many had problems understanding prognostic information in the form it is usually presented. The women also varied considerably in what prognostic information they would like to receive and how they preferred it to be presented. The study's findings showed that not all women will desire or understand standard methods of giving prognostic information.

It has been suggested that giving patients the opportunity to talk with nurses after consultations in which they have been told they have cancer, or have been given complex information about cancer prognosis, would result in their disclosing concerns and misunderstandings and these could then be fed back to the treating clinicians.⁵ However, this solution ignores important evidence that nurses are just as reluctant as doctors to acknowledge patients' distress and elicit their underlying concerns.⁶ Like doctors, nurses in these situations have been found to adopt behaviours designed to prevent further disclosure.⁷ These "blocking behaviours" include telling patients that any distress is normal, switching the subject to neutral topics, giving information and advice before patients' concerns have been identified, focusing only on physical aspects of the condition, and using leading, closed and multiple questions.⁷

Doctors and nurses avoid exploring patients' feelings and concerns because they fear that it will provoke too much emotion, which could be harmful to patients.⁸ They feel that their training has not equipped them with the necessary skills to explore these issues and respond appropriately.^9,10 Feeling that they are not being supported emotionally and practically by colleagues and supervisors has also been linked to a greater use of these "blocking behaviours".^6,11

The lack of adequate training of doctors and nurses in communicating information to patients with cancer can have important negative psychological consequences for the patients. The development of clinical anxiety and depression is more likely when patients have unresolved concerns and perceive that they have been given inadequate information.^12,13 So, how can these communication deficiencies be remedied?

The data collected by Lobb et al⁴ could be used as a basis for ongoing research to identify how best to structure and describe prognostic information so that concepts such as "median survival" and "relative risk" are made understandable. It would then be possible to develop training programs in communication skills that teach doctors how to elicit patients' preferences for information about prognosis.

The use of intradisciplinary¹⁰ and multidisciplinary workshops¹⁴ has been advocated. While objective evidence of the value of intradisciplinary workshops is awaited, multidisciplinary workshops have proved successful in helping doctors and nurses acquire key communication skills.¹⁴

Despite workshops being effective in changing key communication behaviours, it is not certain how much of what is learnt is applied to clinical practice. Two randomised trials are being conducted in the United Kingdom in an effort to determine this. The Cancer Research Campaign (CRC) Psychosocial Oncology Group is studying whether training doctors in small groups enables them to be more effective in communicating with patients and better able to cope with breaking bad news and dealing with patient concerns. The CRC Psychological Medicine Group is assessing whether senior doctors benefit from six sessions of individual feedback on their "bad news" consultations and whether this results in better patient recall and less patient distress in future consultations (as measured by a patient interview and the Hospital Anxiety and Depression Scale), as well as a reduction in the level of burnout in the doctors themselves.

Without systematic training, the breaking of bad news and discussions of cancer prognosis are likely to fall short of existing guidelines and patients' needs and expectations. Consultations of this type can be difficult and painful. Yet, for too long, we have expected doctors and nurses to undertake these difficult tasks without the necessary training and support.

G Peter Maguire
Consultant Psychiatrist; and Director Cancer Research Campaign
Psychological Medicine Group, Manchester, UK

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