Communication is poor when it comes to chemo, but who is to blame?

New study published in the NEJM. “Patients’ Expectations about Effects of Chemotherapy for Advanced Cancer“:

BACKGROUND: Chemotherapy for metastatic lung or colorectal cancer can prolong life by weeks or months and may provide palliation, but it is not curative.

METHODS: We studied 1193 patients participating in the Cancer Care Outcomes Research and Surveillance (CanCORS) study (a national, prospective, observational cohort study) who were alive 4 months after diagnosis and received chemotherapy for newly diagnosed metastatic (stage IV) lung or colorectal cancer. We sought to characterize the prevalence of the expectation that chemotherapy might be curative and to identify the clinical, sociodemographic, and health-system factors associated with this expectation. Data were obtained from a patient survey by professional interviewers in addition to a comprehensive review of medical records.

This feels like the flip side of yesterday’s post, where big effects were often found to be outliers. In this study, patients were asked about their expectations for chemotherapy for metastatic lung or colorectal cancer. The bad news is that these cancers have terrible prognoses. Chemotherapy is still the treatment of choice, but the effect we’re hoping for is an extension of life by weeks to months. Maybe you’ll see some relief of symptoms. But it’s not going to be curative. There are also, of course, significant side effects.

Therefore, there is no “right” answer with respect to whether to engage in therapy. Some choose to use the chemo, some don’t. But what we really want is for those decisions to be informed.

That’s what this study was trying to measure. They asked almost 1200 patients with incurable cancer what their expectations with chemotherapy were. The results weren’t good. Almost 70% of those with lung cancer and more than 80% of those with colorectal cancer did not understand that chemotherapy wasn’t going to cure their cancer. What was surprising to me was that people who reported that they had good communication were more likely to believe incorrectly that chemotherapy might cure them. Being more educated did not improve understanding, nor did an improved functional status or the patient’s role in decision making.

It’s hard to know where the lesion is here. Is it with patients, who aren’t listening well? Is it with physicians, who aren’t able to convey the bad news? We can’t tell. I’m a bit concerned that the reasons misinformed patients were more likely to report favorably about communication with their physicians is that patients who heard good news from their doctors liked their doctors more. That bodes poorly for the ability of both sides to make this better.


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