UPDATE - Issue 29 - Spring 2007
Breaking Bad News about Prostate Cancer
by Professor Roger Kirby
A patient with prostate cancer may never forget the moment he receives the diagnosis. We at the Prostate Research Campaign UK have recently resolved to improve this sometimes devastating experience.
'harrowing to be the messenger of doom'
In 1961, a landmark paper by Oken revealed that 90% of surgeons in the USA declined to discuss a diagnosis of cancer with their patients. 20 years later, US physicians had completely reversed their attitudes, with more than 90% saying they would definitely tell a patient if they had cancer. However, in the UK, a survey of GPs and hospital consultants in the early 1980s showed that 75% and 56%, respectively, still did not routinely tell their patients the truth about a cancer diagnosis.
Avoidance tactics
It is not difficult to understand the main reasons why doctors might wish to avoid sharing bad news with their patients. It can be a harrowing experience to be the messenger of doom, and subsequently have to provide
'the facts may upset'
'he doesn't want to know'
patients with the support they need while they absorb and grapple with the true nature of their illness and prognosis. Traditionally, clinicians have found two main justifications for keeping patients in the dark. First, the facts may upset them. This is undoubtedly the case, but this line of reasoning is not acceptable to any other profession in which news may be bad, for example, stockbrokers or lawyers. Second, doctors, and sometimes close relatives, presume that patients do not really want to know. In fact, several studies have confirmed the opposite to be true. In a survey of 250 patients attending a cancer centre in Scotland, 79% wanted to know as much as possible about their disease and 96% specifically wanted to know if their disease was cancer. Almost all patients wanted to know their realistic chance of cure and to be given details about possible side-effects of treatment. They also wanted to decide who else should be informed. All patients felt that family members should be informed, provided that the patient had given permission, but nearly two-thirds felt that if the patient did not wish relatives to know, then the family should not be taken into confidence.
How, then, should a caring doctor break bad news to a patient newly diagnosed with prostate cancer? Many of us have had little or no counselling training, and we are often pushed for time in our busy clinics. The difficulty is to convey the information sensitively and supportively, and in a way that the patient can understand. Ideally, we should not be rushed. Many of my own patients have admitted that they understood hardly anything they were told in the traumatic interview when the bad news was broken: 'As soon as you said the word cancer, doctor, my mind
'little or no counselling training'
went blank.' We need to find a quiet, private place, where interruptions are unlikely, to convey the news. Also, attempt to develop a connection with the patient and then offer to share the news with him and his partner, rather than simply blurting it out. It is always important to counterbalance bad news with support and information.
Having a close relative in the consulting room means there is a second
'counterbalance bad news with support and information'
person to absorb the information, as well as to provide emotional support to the affected individual. Providing written information about the prostate cancer, such as that provided by the Prostate Research Campaign UK, which can be digested later when the patient has recovered from the initial impact of the news, is often much appreciated. Ideally, specially trained nurses should be at hand to provide counselling and support for patients, both immediately upon disclosure of the diagnosis, and afterwards as the news gradually sinks in. Information on specific patient support groups can also be very helpful – many now have a valuable presence on the internet.
The impact of cancer on a patient's partner and family is another important, but often neglected, area of concern. For example, the treatments used in prostate cancer commonly affect sexual function and these need to be discussed not only with the patient but also with his spouse. Sympathetic, unhurried counselling of the couple about this aspect of their lives, as well as about treatment options and their possible side-effects, is vital.
The essential skills
Learning how to break bad news sympathetically and effectively is a fundamental skill to acquire. Nowadays, there is no excuse for the clinician who simply does not want to perform this important part of the job. It has been sagely said that, 'If the breaking of bad news is done badly, patients and their families may never forgive us; in contrast, if we get it right they will never forget us'. The challenge is to improve and enhance this most important aspect of their communication skills. We, at the Prostate Research Campaign UK, are planning some workshops to accomplish just this. All suggestions welcome.