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Journal of Clinical Oncology, Vol 23, No 6 (February 20), 2005: pp. 1278-1288 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.11.138 Communicating With Realism and Hope: Incurable Cancer Patients' Views on the Disclosure of PrognosisFrom the Medical Psychology Research Unit, University of Sydney, Sydney, New South Wales, Australia Address reprint requests to Phyllis Butow, PhD, Medical Psychology Research Unit, School of Psychology, Mungo MacCallum Building, A17, University of Sydney, New South Wales 2006, Australia; e-mail: phyllisb{at}psych.usyd.edu.au
PURPOSE: To identify preferences for the process of prognostic discussion among patients with incurable metastatic cancer and variables associated with those preferences. PATIENTS AND METHODS: One hundred twenty-six (58%) of 218 patients invited onto the study participated. Eligible patients were the consecutive metastatic cancer patients of 30 oncologists, who were diagnosed within 6 weeks to 6 months before recruitment, over 18 years of age, and without known mental illness. Patients completed a postal survey measuring patient preferences for the manner of delivery of prognostic information, including how doctors might instill hope. RESULTS: Ninety-eight percent of patients wanted their doctor to be realistic, provide an opportunity to ask questions, and acknowledge them as an individual when discussing prognosis. Doctor behaviors rated the most hope giving included offering the most up to date treatment (90%), appearing to know all there is to know about the patient's cancer (87%), and saying that pain will be controlled (87%). The majority of patients indicated that the doctor appearing to be nervous or uncomfortable (91%), giving the prognosis to the family first (87%), or using euphemisms (82%) would not facilitate hope. Factor analysis revealed six general styles and three hope factors; the most strongly endorsed styles were realism and individualized care and the expert/positive/collaborative approach. A range of demographic, psychological, and disease factors were associated with preferred general and hope-giving styles, including anxiety, information-seeking behavior, expected survival, and age. CONCLUSION: The majority of patients preferred a realistic and individualized approach from the cancer specialist and detailed information when discussing prognosis.
The communication of distressing news is demanding for both doctor and patient.1-3 Disclosure of a short life expectancy has been specifically identified by both clinicians and patients as an important and contentious issue,4,5 with the debate having previously focused on whether to tell the patient the prognosis, but in more recent times, the debate has focused on what information to give and how to convey it.6-8 Prior research demonstrates that a clear majority of cancer patients in the Western world reports a preference for detailed information about their disease and expected outcome,9-13 although information needs can vary across different phases of the illness.14-16 Legal rulings have emphasized the responsibility of doctors to provide all necessary information in some jurisdictions.17 Nevertheless, patients often misunderstand the status of their disease and the aim of treatment13 and commonly overestimate their life expectancy.18 This may impact on decision making, particularly concerning anticancer treatment that may have side effects and reduce quality of life.19,20 Issues that concern clinicians about communicating life expectancy to patients include how much information to give, difficulties with prognostication, and disclosing prognostic uncertainty without increasing anxiety, reducing trust, and destroying hope.5,14,21-25 Others, however, believe expressing this prognostic ambiguity carefully to patients is one means of engendering hope4,19 and that providing information decreases anxiety associated with ignorance and uncertainty.14,26-28 The need for optimism and hope to be sustained in the process of honestly delivering bad news and a limited life expectancy is an ideal expressed by both doctors and patients.4,5,12,15,29 However, there is a delicate balance between fostering realistic hope and unethically creating unrealistic expectations of longevity.5,19,21,29 Furthermore, hope is a broad concept that can hold different meanings for each individual. Similarly, prognosis, a term often thought of as synonymous with life expectancy, encompasses broader issues surrounding the future course of the disease and how this may impact on the quality of life of the patient.19,27,30,31 Despite the complex issues surrounding this topic, apart from one study on communicating hope in the diagnosis of early-stage cancer,31 research is lacking in determining how patients define hope and how health professionals communicate hope to patients.14,32 Much of the communication literature has focused on how to break bad news.6,33,34 Few studies or guidelines have targeted the communication of prognosis specifically, and these few studies focus on either early-stage disease10,35 or palliative and end-of-life issues.12,13,29,36,37 There is a lack of evidence-based information on discussing a poor prognosis, a context that arguably demands more resources from both doctors and patients.5,38 Furthermore, although patient preferences for general information have been associated with demographic, psychological, and disease variables, for example, age,11,26,28,39 sex,11,16,39 religiosity,16 education level,26 involvement preference scores,16,40 anxiety and depression levels,35,41 and disease status,16,28 it has not yet been clarified whether such variables specifically influence metastatic cancer patient preferences for prognostic information. In the current study, we aimed to identify the context and the way in which patients with incurable metastatic cancer wanted to be informed about their prognosis and to explore what features in the delivery of prognostic information they would experience as more or less hopeful. We hypothesized that the majority of patients would want detailed prognostic information as well as communication that facilitated hope. We also expected some variation in preferences according to patient demographic, disease, and psychological characteristics.
Sample All oncologists in New South Wales (n = 106), Australia, were invited to participate. Patients of participating oncologists attending outpatient clinics who were diagnosed with metastatic cancer within the time frame of 6 weeks to 6 months previously, were over 18 years of age, were English speaking, and had no psychiatric illness were recruited onto the study. The oncologists were asked to identify consecutive patients who fulfilled the eligibility criteria, briefly inform them about the study, and gain consent for the researcher to contact them. The researcher then telephoned or spoke to patients face to face and gained verbal consent to participate. Patients were then mailed a copy of the survey, together with a written consent form and a stamped, addressed return envelope, or completed the survey immediately in the clinic. Timing of recruitment was chosen to ensure that patients had time to adjust to their diagnoses, be exposed to information about their own prognosis, and make any treatment decisions before being approached to participate, thus reducing the potential for causing distress while still ensuring survey completion at a time when the issues explored were salient. Institutional review boards at all participating centers reviewed and approved the conduct of the study.
Measures Demographics and disease details. Participants were asked about the following: age, relationship status, occupation, highest educational level achieved, medical or allied health training, language spoken at home, parents' country of birth, whether or not they have children, and whether or not they have a religious denomination or spiritual belief. Oncologists provided patient disease information, including type of cancer, dates of diagnosis of primary and metastatic cancer, mode of treatment, and estimated survival. Doctor style. Thirty-five doctor informational and supportive behaviors when discussing prognosis, which were derived from earlier studies of prognostic information preferences,10,31 were listed. Patients rated their response to each item on a 5-point Likert scale (agree completely, agree, neutral, disagree, and disagree completely). Examples of items included, "I would like my cancer specialist to: (a) check my understanding of what he/she has told me, (b) be realistic, (c) be optimistic, and (d) tell me about cancer support groups." Definition of hope. Participants were provided with four exemplar hope definitions, using the words of patients from a previous study.45 The definitions were as follows: a feeling or expectation (1) that things can go well; (2) that because one thing has gone wrong, it doesn't mean that other things will not go well; (3) that you have just as good chances (if not better) as the next person of having the best outcome; (4) that you can still enjoy a good quality of life, even if life expectancy is uncertain; or (5) other. Participants were asked to indicate what hope means to them in their current situation; they could select more than one item and/or write their own definition under other. Participants were also asked a separate open question about what else (apart from doctor communication) helps them to be hopeful. What patients find hopeful. Thirty doctor behaviors that might convey or discourage hope, such as "gave me survival statistics," "appeared nervous or uncomfortable," and "was occasionally humorous," were listed. The items were derived from Sardell and Trierweiler31 and our earlier qualitative study exploring ideal prognostic communication in the metastatic setting.5 Participants were asked to indicate on a 5-point Likert scale how hopeful each of the behaviors would make them feel (ie, very hopeful, hopeful, neutral, not hopeful, and hopeless). Preference for prognostic information, timing, and manner of presentation. Patients were asked to indicate their preference for specific prognostic facts, mode of presentation of statistics, and the timing of prognostic information and who should initiate the discussion. These results have been presented elsewhere.46
Information and involvement preferences.
Participants' preferences for information and involvement were elicited using the seven-item binary Information subscale of the Krantz Health Opinion Survey (
Depression and anxiety.
Levels of depression and anxiety were measured by the 14-item Hospital Anxiety and Depression Scale self-assessment tool devised by Zigmond and Snaith48 (
Statistical Analyses
Patients were recruited from 12 clinics in New South Wales, Australia, by 30 participating oncologists, of whom 19 were medical oncologists and 11 were radiation oncologists. Eighteen of 106 invited oncologists actively refused to participate (primarily because of insufficient time or because they were no longer practicing in oncology), whereas 58 did not respond. Data were available on oncologists who refused and accepted. No differences were found in age, years in practice, specialty (medical or radiation oncology), and number of total cancer and metastatic cancer patients seen per year between these groups. Nevertheless, it is possible that the resulting patient sample has some bias because they were accrued from a small (although apparently representative) group of oncologists.
Of the 218 patients approached to participate, 10 were ineligible, and 22 refused. Of the remainder, 126 patients completed the survey. The most common reason cited for not completing the survey was ill health. No significant differences were found between those who completed the survey and those who did not complete the survey on the variables of age (F2,194 = 0.180; P = .672), sex ( Fifty-six percent of participants were male, whereas 25% had breast cancer, 18% had colorectal cancer, 16% had prostate cancer, 10% had lung cancer, and 31% had other cancer types. The mean time since diagnosis of metastases was 13 weeks (range, 1 to 39 weeks; standard deviation [SD], 8.7 months). The majority of patients had an expected survival estimated by their oncologist of months (42%), or years (42%) and were receiving either systemic anticancer therapy or radiotherapy (92%; Table 1).
Information and Involvement Preferences The average score on the Krantz Health Opinion Survey: Information Preferences Subscale was 3.9 (SD, 2.15), which is in the medium score range, indicating that, overall, participants did not have either a particularly high or low desire to ask questions or to be informed about medical decisions.46
Anxiety and Depression
Preference for Doctor Style
Hope-Giving Behavior Of the 30 listed doctor behaviors, those rated as being most hopeful included being offered the most up to date treatment (90%), the oncologist appearing to know all there is to know about the patient's cancer (87%), the occasional use of humor (80%), being told that the pain will be controlled (87%), and being told all treatment options (83%; Table 3).
Behaviors that were rated as causing the patient to feel not hopeful or hopeless were the doctor appearing to be nervous or uncomfortable (91%), giving the prognosis to the family first (87%), the use of euphemisms (82%), avoiding talking about cancer and only discussing treatment (75%), and giving the good news first and then the bad news (72%); however, almost half of the patients rated this last item as neutral (46%). Thirty percent of participants rated giving statistics about how long they will live as likely to make them feel hopeful; however, similar percentages of patients rated this item as not hopeful (32%) and neutral (38%). Similarly, participants rated expressing uncertainty about the course of the cancer (ie, said that the course of the cancer cannot be predicted) evenly across the options, with 35%, 30%, and 35% rating this as hopeful, not hopeful, and neutral, respectively (Table 3).
Patient Definition of Hope Of the alternatives proposed, the most common themes were quality of life and fulfillment of goals (23%; for example, "To get on with life, make sure you make the most of it for as long as you can; set a distant goal and work like hell to get there"), receiving the best treatment that would provide the best cancer and symptom control (8%; for example, "Hope for me is a general expectation that everyone involved in my treatment is doing their best"), and the hope for cure or remission (8%; for example, "... hope that they may find a cure or extend my life").
General Factors Influencing Hopefulness
Factor Analysis
Three factors were identified among the 30 hope items, which accounted for approximately 54% of the variance (Table 5). These were as follows: factor 1, expert/positive/collaborative (expertise, humor, and inclusion of patient as part of the team); factor 2, avoidant (avoiding or appearing uncomfortable about discussing the cancer, using euphemisms, and giving the prognosis to others first); and factor 3, empathic (expressing one's own feelings or asking the patient about his or her own reaction to the prognosis; Table 5). One item ("asked me if I would like a second opinion") did not weigh on any of the factors.
The strength of preference for these styles was determined by calculating the total scores for each factor. Because different factors included varying numbers of items, the totals were normalized to allow direct comparison. Thus, scores could range from 20 to 100. The most strongly endorsed doctor style was realism and individualized care (mean score, 88.9; SD, 9.6), and the least endorsed doctor style was personal approach (mean score, 59.9; SD, 14.1). The most strongly endorsed hope-giving style was the expert/positive/collaborative approach (mean score, 78.4; SD, 14.4).
Variables Significantly Associated With Preferences
Age was the only variable significantly associated with preference for factor 2, with younger patients more likely to prefer an emotionally supportive approach (t103 = –4.53; P < .001). Higher anxiety scores (t115 = 2.80; P = .006) and female sex (t115 = –2.68; P = .008) predicted preference for the facilitation of the coping with dying approach (factor 3). Patients who scored higher on information seeking (t108 = 3.10; P = .002) were more likely to prefer the informative approach (factor 4). Younger patients (t114 = –3.65; P < .001) were more likely to prefer the emphasizing all options approach (factor 5). Patients who stated they had a religious belief (t109 = 3.40; P = .001) were more likely to prefer the personal approach (factor 6; Table 6). Hope-giving style. Table 6 lists the mean scores on the hope-giving factors by those variables found to be significant in multivariate analyses. Older patients rated the expert/positive/collaborative (factor 1) and empathic (factor 3) approaches as significantly more hope giving than younger patients (factor 1: t97 = 2.08; P = .04; factor 3: t102 = 3.18; P = .002). Anxiety was also significantly associated with these factors (factor 1: t97 = 2.20; P = .03; factor 3: t102 = 2.43; P = .02; Table 6). None of the variables explored were found to be significantly associated with the avoidant approach (factor 2).
We surveyed patients with metastatic cancer regarding their preferences for the process of prognostic communication, including how hope is conveyed. A clear majority of patients in this sample found individualized and realistic disclosure from a confident, collaborative, and supportive cancer specialist more hopeful than an avoidant approach. Detailed information about discussing prognosis, an opportunity to ask questions, and the clinician checking patient understanding were also favored. The results of this study provide a useful taxonomy of physician approaches and hope-giving approaches preferred by metastatic cancer patients, which may provide guidance to clinicians working in this setting. There was some variability in preferences according to patient characteristics, which allows some insight into who may prefer which style. Overall, younger, anxious patients placed a stronger focus on emotional support for themselves and their families. This is understandable given that these patients are more likely to have a dependent family whose support needs during their illness and after their death may be a primary concern for them. These patients seemed to have high needs and high expectations for medical care. This is in accordance with other studies that report that younger patients have a preference for more information and have high unmet needs.26,52 Patients who had been diagnosed with metastatic disease for a longer period and those with longer expected survival were more likely to want realism (factor 1). Perhaps patients are better able to cope with realism over time. In earlier work, we found that patients who are in routine follow-up, without relapse, develop stronger preferences for involvement in decision making over time.16 A longer expected survival would be understandably easier to discuss frankly. Interestingly, because these data were derived from oncologists' prognostic estimates, it would seem that these patients had some awareness of their own prognosis. English speakers were also more likely to prefer realism. Those who speak another language at home are possibly influenced by a culture where avoidance and paternalism is more common. It is well documented that, in some cultures, communication of prognosis is viewed as harmful and brutal.53-57 Overall, however, the majority of patients in all groups preferred a realistic approach. Generalizations concerning a group linked by cultural factors can lead to stereotyping. Thus, information about beliefs and practices within particular cultures and groups never obviates the need for exploring individual preferences and needs. Notably, patients who did have a religious belief wanted this to be acknowledged by the cancer specialist in the context of discussing prognosis. Only two variables were associated with preferences for hope-giving behaviors. Older patients were more likely to rate both the expert and empathic approaches as more hope giving. However, older patients were less likely to prefer the emotionally supportive approach as a general doctor style. It seems that older patients want direct emotional support from their doctor as opposed to more formal organized support. This supports previous findings in the literature.58,59 Anxiety was also associated with these factors, although, on examination of the means, it seems that the relationship may be curvilinear, with patients scoring high or low showing less interest in these approaches. This is difficult to interpret, and further research may clarify these relationships. Some of the results are not consistent with current practice guidelines.37,60 For example having another medical person present during prognostic discussion and offering an audiotape of the discussion were not endorsed by participants in this study. A personal approach that involved sitting next to the patient or sharing some personal information was also less valued. These results are similar to those of Schofield et al61 who reported that patient preferences do not always reflect published consensus guidelines, which may need to be modified in light of this feedback. There were several limitations to the study. Cultural factors have not been well considered because non-English speakers were excluded from the sample. It is known that cancer patients from other cultures have different views and information needs.53-57 It is also not certain, although probable, that these results would be relevant to the cancer populations of Britain and North America. Furthermore, some subgroups in the sample (eg, particular cancers) are quite small, and therefore, this study did not allow detection of differences between these groups. A larger sample may have produced more significant and reliable results. Only 30 of 106 oncologists invited to participate in this study took part. Although no demographic or practice differences were observed between those who accepted and those who actively refused to participate, more subtle differences (such as interest in communication) that we did not measure may have differentiated these groups and, therefore, influenced the results. Furthermore, no data were available on oncologists who did not respond at all. Not all oncologists may have complied with the instruction to recruit consecutive eligible patients. They may have invited patients who felt more comfortable with their diagnosis or who were less symptomatic; few patients were receiving symptomatic care only. Although this is characteristic of outpatient oncology patients with a recent diagnosis of metastases,42,62-65 the potential for bias in the study sample remains significant. It is possible that participants were more comfortable with addressing prognostic issues than nonparticipants. There was a low prevalence of probable cases of anxiety and depression in the sample; however, the levels were similar to levels of anxiety and depression reported in a sample of 159 patients with advanced disease recruited in a large English study,49 which suggests that we did not have a particularly psychologically resilient sample. The exemplar hope items and predictor variables included in this study were chosen on primarily empirical grounds (for example, those variables that had been found to be associated with general information preferences previously) rather than on theoretical grounds. Relevant theory (apart from the work on monitoring and blunting of Miller66) is lacking. There is a need for further development of appropriate theory to underpin future work in this field. Nevertheless, this study provides the first data of its kind in this area, and it is hoped that the data will prove useful for clinicians struggling to communicate effectively with their patients with incurable cancer. Future research could use a more qualitative, in-depth approach to better explore some of the issues raised by these data.
The authors indicated no potential conflicts of interest.
We are grateful for the contribution of M. Boyer, F. Boyle, S. Clarke, J. Clayton, S. Crossing, D. Goldstein, F. Kirsten, M. Stockler, A. Sullivan, S. Crossing, and S.K. Lo, and we thank all participating oncologists and their patients.
Supported by New South Wales Cancer Council, Australia. Presented at the 15th International Symposium of the Multinational Association of Supportive Care in Cancer, Berlin, Germany, June 2003. Authors' disclosures of potential conflicts of interest are found at the end of this article.
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ABSTRACT
INTRODUCTION
= .74 in this sample).
2 = 0.294; df = 1; P = .588), clinic where recruited (metropolitan or nonmetropolitan; 
