Most Terminal Cancer Patients Believe Chemo Is Curative

Nick Mulcahy

October 23, 2012

A majority of patients with advanced lung or colorectal cancer mistakenly believe that chemotherapy might cure their disease, according to a study published in the October 25 issue of the New England Journal of Medicine.

Although chemotherapy is the primary treatment for these patients, it is not curative, say the authors, led by Jane C. Weeks, MD, from the Dana-Farber Cancer Institute in Boston, Massachusetts.

Nevertheless, in a national survey of 1193 advanced-stage patients, 69% of patients with lung cancer and 81% of those with colorectal cancer misunderstood the intent of chemotherapy.

These findings raise questions about whether patients have "met the standard for...consent to their treatment," the study authors write.

This study fills a gap in the medical knowledge about what advanced cancer patients understand about chemotherapy, say Dr. Weeks and colleagues.

However, in an accompanying editorial, 2 clinicians suggest that the study's black and white findings might actually be mired in grey.

"Perhaps the problem here is the word 'cure'," write Thomas J. Smith, MD, and Dan Longo, MD, from the Sidney Kimmel Cancer Center at Johns Hopkins University in Baltimore, Maryland.

"To a patient with advanced disease, [cure] may mean something very different from eradication of all disease without return. It may mean an end to pain or a hope for a better tomorrow with fewer incapacities," they explain.

The editorialists ask blunt questions that are not answered in the study: "Were the patients who were surveyed not actually told that their disease was incurable? Or were they not told effectively...[or] did they choose not to believe the message?"

"Nearly all" patients want to know whether or not they can be cured, and most want to know their prognosis, say Drs. Smith and Longo, citing previous research (Semin Oncol. 2011;38:380-385).

The trick is learning how to break bad news. An essential skill for practitioners is the conversational art known as "ask, tell, ask," they say. "This consists of asking patients what they want to know about their prognosis, telling them what they want to know, and then asking, 'What do you now understand about your situation?' "

Clarity helps patients "choose wisely" about end-of-life matters, including undergoing chemotherapy, say the editorialists. "Most people want to live as long as they can, with a good quality of life, and then transition to a peaceful death outside the hospital."

Are Bearers of Bad News Punished?

The study authors used data from patients participating in the national prospective observational cohort Cancer Care Outcomes Research and Surveillance (CanCORS) study. Data were obtained from an extant patient survey conducted by professional interviewers.

All patients in this study were alive 4 months after diagnosis and received chemotherapy for newly diagnosed metastatic (stage IV) lung or colorectal cancer. They reported their expectations of chemotherapy for life extension, symptom relief, and cure.

Patients were prompted to categorize their belief in chemotherapy's being curative as very likely, somewhat likely, a little likely, not at all likely, or don't know/no response. As noted above, the majority of lung and colon cancer patients believed in 1 of the first 3 options. Interestingly, patients in both disease groups were most inclined to believe in a "very likely" probability over the other 2 degrees of likelihood.

On multivariable analysis, education level, functional status, and the patient's role in decision making were not associated with inaccurate beliefs about chemotherapy.

However, the risk for inaccurate beliefs was higher in patients with colorectal cancer than in those with lung cancer (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.29 to 2.37). It was also higher in black (OR, 2.93; 95% CI, 1.80 to 4.78) and Hispanic (OR, 2.82; 95% CI, 1.51 to 5.27) patients than in white patients.

In a "paradoxical" finding, inaccurate beliefs about chemotherapy were higher in patients who rated communication with their physician very favorably than in those who rated it less favorably (highest third vs lowest third OR, 1.90; 95% CI, 1.33 to 2.72).

The bearer of bad news is being punished because patients prefer good news, the authors suggest.

"In an era of greater measurement and accountability in healthcare, we need to recognize that oncologists who communicate honestly with their patients, a marker of a high quality of care, may be at risk for lower patient ratings," the authors write.

This study was supported by grants from National Cancer Institute and the Department of Veterans Affairs. Some of the authors report receiving grants from nonprofits and government, but not from industry, as detailed in the paper. Dr. Smith and Dr. Longo have disclosed no relevant financial relationships.

N Engl J Med. 2012;367:1616-1625, 1651-1652. Abstract, Editorial

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