#Africa&Cancer

Cancer Diagnosis- Delivering Difficult News to Patients and Family

Let's start with "what is bad news?"

Let me take you back to a day in Oncology training when I came across a patient with my professor in our morning routine ward round. She was an elderly lady waiting for her diagnosis after going through batteries of tests to ascertain her disease. The professor gave me the task of explaining her diagnosis, which was metastatic liver cancer, meaning cancer that had spread to other parts of the body.

 I was overcome by the heavy responsibility of saying the right words, which should be accompanied by compassion and candidness with a dash of the truth and kept as short as possible.

I remember my supervisor saying don't assume it's bad news. Then the shocker came when our patient said, "I am so relieved because I have been looking for answers for months." 

Usually, patients stop listening to anything else we say after telling them, "I am afraid to say that we found cancer in your liver." So, we carefully set the stage and choose the right time and place to deliver such a life-changing diagnosis. 

What is the ideal circumstance to deliver such news?

During the Covid era, many patients missed the real-time, onsite location pitted with physical touch and emotions and their family, son, daughter, and spouse while oncologists give such critical information. Moving care to telemedicine or breaking such news over the phone or during zoom meetings can be unsettling. 

Enough preparation before meeting the patient to deliver the cancer diagnosis can be nerve-wracking even for first-time oncologists. We battle with many questions, including the personal emotions, biases in my conversations, and what outcomes we get out of the conversation. If we don't have some level of self-care and compassion, we can't fake empathy, and it's very difficult to pretend to be present. We can't just magically materialize self-care in the hour of need; it must be cultivated.  

So, we follow a stepwise approach called SPIKE, a framework for breaking bad news to patients with cancer. SPIKES is an acronym for presenting distressing information in an organized manner to patients and families. This protocol provides a stepwise approach; each letter represents a step in the six-step sequence. S stands for setting, P for perception, I for invitation or information, K for knowledge, E for empathy, and S for summarizing or strategizing. Breaking bad news is a complex communication task; hence, key components of the SPIKES strategy include demonstrating empathy, acknowledging and validating the patient's feelings, confirming the patient's understanding and acceptance of the bad news, and providing information about possible treatment options. 

Who should deliver the cancer diagnosis?

Ideally, such crucial information on the prognosis and treatment pathways should be done by a qualified oncologist or a nurse practitioner trained in oncology counseling. Often, primary physicians see these patients and refer them to the oncology department for further management.

Still, several poignant questions remain. For example, is it ethical to hide the diagnosis from the patient and instead only reveal it to the family members? or should we accept it when family members tell us not to disclose the diagnosis to the patient in the spirit of "protecting" the mental state of the patient? How much treatment is too much? What are the costs of such treatments? Is the patient insured by some form of health insurance? 
What are the available strategies for end-of-life care and comfort care? Family bereavement and coping mechanisms? And so on.

In the end, patient empowerment with the right expert opinion delivered in a place, time, and manner the patient understands, especially in a vernacular language if the patient doesn't speak English, really leads to improvement in treatment compliance and disease outcomes. 

"Each day comes bearing its own gifts. Untie the ribbons." — Ruth Ann Schabacker.

About the Author

Dr. Omar Abdihamid is a Clinical Oncologist. He is passionate about Global Oncology and cancer care in low- and middle-income countries, particularly cancer awareness and patient education. His main areas of interest are Gastrointestinal cancers, Breast Cancer, Lung, Head and neck, and Genitourinary Cancers. Dr. Omar has a keen interest in cancer research and has published multiple SCI publications in peer-reviewed journals.  He is also an editor and a reviewer for several cancer journals