People with advanced colon or lung cancer who are offered chemotherapy by their physician often do not understand that such treatment isn't going to be nor is it intended to be curative, a recent study in the New England Journal of Medicine concluded. As Rick and I discuss in PodMed, this illustrates an opportunity for everyone involved to look more closely at communication, expectations, and end of life plans in the interest of compassionate care. So what did the study do?
Patients with newly diagnosed metastatic lung or colorectal cancer from five different geographic regions in the United States were enrolled into the Cancer Care Outcomes and Research and Surveillance (CanCORS) study. About 10,000 patients older than 20 years who received such a diagnosis between 2003 and 2005 participated. All study participants had stage IV cancer at diagnosis and opted to receive chemotherapy.
Experience of care, outcomes, personal characterisitcs and decision making on the part of each subject were all assessed by a professional interviewer by telephone 4 to 7 months after their diagnosis. If the subject was not available due to death or illness a surrogate was queried. Almost 94% of patients with stage IV lung or colorectal cancer who were alive at the time of the baseline survey chose to receive chemotherapy; 69% of patients with lung cancer and 81% of patients with colorectal cancer had inaccurate expectations about whether chemotherapy was likely to cure their cancer.
African Americans and Latinos were more likely to maintain misconceptions than white patients. Ironically, those patients who rated their physician's communication skills more poorly were less likely to harbor misconceptions about the potential role of chemotherapy in their treatment. Interestingly, education, functional status and the patient's own role in decision making had no impact on patient perception about chemotherapy.
Why are we so concerned about inaccurate patient perceptions? Must we emphasize the terminal nature of someone's disease and then continue to revisit the issue until we're convinced they get it? The authors make the point that when someone has inaccurate perceptions about the goals of care, they cannot be said to be giving truly informed consent to their treatment. Moreover, as Tom Smith, director of palliative care here at Hopkins points out, such misperceptions may preclude a person's volition and ability to make end of life plans consistent with their own wishes, and that can be tragic.
How can providers help? The training program at Johns Hopkins teaches physicians to revisit the idea of prognosis and likely outcomes at each stage of disease with their patients, so awareness is greater and choices can be made. Tom Smith advocates for an open discussion about things like power of attorney for healthcare, advance directives and the like. In his clinical experience he reports that far from being upset by such topics, people welcome the opportunity to carefully consider their options.
Other topics this week include treatment of knee osteoarthritis, when and what modality is needed for colon cancer screening following an initial negative colonoscopy, and sulfonylureas for diabetes, all in Annals. Until next week, y'all live well.