Your patient with advanced stage four non-small cell lung cancer (NSCLC) is wheeled into the exam room. He can't stand by himself -- he is cachectic and weak. He has shown disease progression on the last two regimens and was just discharged from the hospital with pneumonia. As you get him ready to see the oncologist, he says “I want more chemotherapy. I know Dr. J will have something up her sleeve to give me.” Looking at your patient you know he probably has a short time to live and you wonder what to say to him.
This scenario is played out regularly in the oncology world. A recent study by Zietemann and Duell found that 40 percent to 50 percent of patients receiving second and third line chemotherapy for NSCLC die during or soon after treatment. (Zietemann & Duell, 2010) Even though chemotherapy in advanced cancer may be futile or non-beneficial, it is difficult to tell a patient that there is no further cancer chemotherapy. Patients are often motivated to pursue chemotherapy near the end of life, in part, because of a poor understanding of their disease, hope that chemotherapy will provide benefit, and unrealistic expectations. (Kadakia, Moynihan, Smith, & Loprinzi, 2012)
So this means that earlier conversations need to happen throughout treatment to address these factors. The issues need to be revisited regularly too, not just on the first visit. Key questions that should be included on a regular basis include:
- What is the patient's current understanding of his/her disease? If cure is unlikely, what is the patient's understanding of prognosis?
- What are the patient's goals?
- How aware is the patient of potential risks of treatment and how do these interface with the goals?
- If palliative chemotherapy is being offered, what are the expectations of this therapy?
Options must always be presented to the patient as to what will be done next. If there is no further chemotherapy, options for how to improve quality of life with less aggressive treatment should be provided so the patient never feels abandoned or a failure. Of course, telling the patient "there is nothing more to do" would be a cruel response. Rather, the approach the oncologist should use is "there is no further chemotherapy that is safe to give you now but we will do x, y, z to address your weakness, pain, and respiratory distress," and offer palliative care as an additional service as specialists in symptom management. Hopefully this will not be the first time palliative care is mentioned because this conversation builds on previous ones.
But what does that nurse in the office say to the above patient?
One suggestion is to talk about what the patient is hoping for now and get some understanding of his understanding of his current status. "Tell me how you have been doing the last few days, what had the doctor said about what to expect at this point, what are you hoping for now?" This approach can open up the conversation and then can be followed through with the oncologist.
References:
- Kadakia, K. C., Moynihan, T. J., Smith, T. J., & Loprinzi, C. L. (2012). Palliative communications: addressing chemotherapy in patients with advanced cancer. Ann Oncol, 23 Suppl 3, 29-32.
- Zietemann, V., & Duell, T. (2010). Every-day clinical practice in patients with advanced non-small-cell lung cancer. Lung Cancer, 68(2), 273-277.
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