G-13 Pamplona,Sherina Anne E.

needs of the individual patient, and we feel it provides

insights into the successes and failures of our
11- Our Lady of Good Counsel communication with cancer patients. It is important
that difficult discussions are personalized to the
The experiences of cancer patients individual patients’ wishes. These can vary dramatically
both in the area of disclosure of bad news in prognosis
C. Alifrangis L. Koizia A. Rozario S. Rodney M.
and in end-of-life decision making. This study provides
Harrington C. Somerville T. PeplowJ. Waxman compelling evidence for good advanced care planning at
QJM: An International Journal of Medicine, Volume an early stage in the management of patients with
terminal cancers.
104, Issue 12, 1 December 2011, Pages 1075–
Introduction
1081, https://doi.org/10.1093/qjmed/hcr129 Communication between patients and physicians
following a diagnosis of cancer requires an
Published: 10 August 2011 understanding of patients’ emotions and sensitivities,
Abstract needs to be individualized and cannot be formulaic.
Objectives: To assess the needs of cancer patients for It is clear that the evaluation of communication with
information about their condition and to understand patients must be an iterative process. But it is unclear
the psychological impact of their illness. what it is that patients need from their communication
Background: The discussion of prognosis and treatment with medical staff. The information base on which
options in the palliative setting is an important and doctors rely for their conversations with patients about
difficult part of oncology practice. To evaluate this, we prognoses has traditionally been limited, with individual
examined the experiences of cancer patients of the doctors relying on their own experiences and that of
physical and psychological impact of their disease on their clinical teachers to inform their own method of
their life, and their opinions on the communication of ‘talking’ to their patients about matters of life and
end-of-life decisions and treatment options. death. But do we really understand what patients feel
Methods: A patient questionnaire was designed that about having cancer?
encompassed communication regarding treatment and The National Cancer Survey in the UK of 67 710 patients
prognosis, quality-of-life attitudes subsequent to cancer reported recently has provided insights into patients’
diagnosis, end-of-life care and cancer drug funding. One views on how well supported they feel and described
hundred and twenty-five patients with a diagnosis of their opinions on key issues such as the role of clinical
cancer were asked to participate and 96 questionnaires nurse specialists, the significance of pain management
were completed and available for analysis. The and the quality of cancer services provided by the
questionnaire consisted of 63 questions and was NHS.1 However, the survey did not examine how
completed in both an inpatient and outpatient setting. healthcare professionals communicate prognosis to
Results: This survey brought to light a number of patients nor identify what patients want to learn about
controversial issues in cancer service provision, their cancer. One study in Japan has looked specifically
highlighting the emotional and psychological changes at the wishes of cancer patients regarding the disclosure
brought about by a cancer diagnosis. Major concerns of of prognosis and found that ∼86% of the patients
our patients include fear of death and pain, changes in wanted a full and realistic picture of their disease and
interpersonal relationships and financial constraints. outlook.2
Only 66% of the patients wanted to be given a prognosis The discussion of treatment options in the palliative
by their clinicians and just 70% of the patients recalled setting is clearly an important area. Keating et al.
being given a detailed prognosis. 11% of the patients examined the significance of the role that patients take
were not prepared to undergo palliative treatment. In in the decision making process related to their
all, 7% were not prepared to accept treatment for 1 management. Shared decision making between the
year and 2% for 5 years of life in exchange for the patient and the physician were found to be more
potential side effects of cytotoxic chemotherapy. 12% of common when there was a good evidence base for an
the patients would not want to be in possession of the intervention, and when the evidence was uncertain for
information that they were in the terminal phase of the an intervention, patient control was greatest. However,
illness with a short time to live and 16% would not want we know very little of how oncologists communicate
this discussed with their next of kin. risk benefits in terms of potential treatment options in
Conclusions: This study informs medical professionals the palliative setting, and what actually constitutes a
about the importance of tailoring information to the meaningful gain in life expectancy for patients taking
part in these difficult discussions. Some recent studies There was a 1:1 ratio of men to women and 96% had
have addressed some of the central themes in these undergone treatment (Figure 2).
discussions.3,4,5 Our objective was to find out cancer Figure 2.
patients’ views in a UK cancer centre on a range of
issues surrounding communication of prognosis and View largeDownload slide
end-of-life decisions. Treatments experienced by patients who undertook
In this study, we sought to ascertain what potential survey.
gains in lifespan would be acceptable to patients in
exchange for the side-effects associated with cytotoxic Communication of issues surrounding cancer and
chemotherapy. We aimed to better understand prognosis
patients’ views and experiences of communication of Of the patients, 66% recalled being given a prognosis
prognosis and treatment options, with the aim of related to their malignancy, while only 61% had asked
informing future clinical practice. We also sought to to discuss prognosis (Figure 3). Eight percent of the
elicit frank opinions regarding changes in patients’ patients felt that physicians should not communicate
attitudes and lifestyle with a diagnosis of cancer, bad news to patients, and 14% that clinicians should
patients’ views as to the exchange of information only communicate good news to patients. Information
surrounding cancer and to understand what the most was sourced from the Internet by 31% of the patients
significant issues were in confronting and dealing with a and 7% of the patients sought information from other
cancer diagnosis. patients (Figure 5). Ninety percent of the patients felt
Finally, we saw this as a forum for a freeform exchange that they received the clearest information about their
of ideas between patients and ourselves. As an cancer from their physicians (Figure 6). It is of interest
anonymous survey, it enabled patients to give their that patients gained support in dealing with their illness
honest impressions of their journey through an NHS from a variety of people that ranged from family and
cancer centre and an opportunity at a local level to friends, nurses and doctors (Figure 7), but family for the
inform us as to what we could do to improve the majority of patients was the most important support
doctor–patient relationship. (Figure 8).
Methods Figure 3.
A questionnaire was designed that encompassed View largeDownload slide
patient demographics, communication regarding Patients’ views regarding communication of prognosis.
treatment options and prognosis, changes in quality of Figure 4.View largeDownload slide
life and attitude subsequent to a cancer diagnosis, and Why do you think you are being treated?
quality of treatment in the NHS, including the role of Figure 5.
NICE and the funding of cancer drugs. The questionnaire View largeDownload slide
was designed as an audit of patient experiences, and How have you informed yourself about your condition?
was compiled following consultation with medical and Figure 6.
paramedical staff within the Department of Oncology. View largeDownload slide
The questionnaire was completed in both an inpatient Who has given you the clearest information about your
and outpatient setting at the Hammersmith Hospital cancer?
between January and July 2010. The questionnaire Figure 7.
contained areas where freeform responses were View largeDownload slide
encouraged. A copy of the questionnaire is shown Who has been the most helpful in dealing with your
in Figure 1. illness?
Figure 1. Figure 8.
View largeDownload slide
View largeDownload slide Which family members have you told about your
Demographics of patients completing the survey. illness?

Results Changes in lifestyle and attitudes following a diagnosis

Demographics of cancer
All ranges of ages were represented, 59 patients (61%) Patients were asked about their relationships following
were of the age group 61–80 years (Figure 1). Of the a cancer diagnosis, and approximately one-third of
patients, 65% had gone on to secondary or university patients acknowledged a change in their relationship to
education and 78% had English as their first language. a close family member (Figure 9). One third of the
patients noticed a change in their attitude to financial think that anything was being withheld deliberately … as
matters. We asked the patients how cancer had information relating to my condition is in a constant
affected their lives. Amongst the worst aspects of their state of flux and change”
illness was the time spent in hospital and time lost in “I sense that patients may be confused by not being
travelling to and from hospital. Our patients expressed given a detailed prognosis which may lead to a
concerns about pain (12%), fear of death (12%) and breakdown in communication between the doctor and
sickness (10%) (Figure 10). patients of a certain disposition”
“Being provided with a full picture can undermine the
Figure 9.
very positive approach which is required to face up to
View largeDownload slide
such a serious health situation”
Since your diagnosis has your attitude changed towards Patient comments on changes in attitudes since their
partner, children, friends and finance? diagnosis.
Figure 10. “I have developed a more positive attitude to those
View largeDownload slide around me”
What are the worst aspects of your illness? “I try not to think about the illness so it can't affect my
life”
Treatment Decisions in Palliative care “Getting to hospital so regularly is too expensive”
We were interested in understanding how patients “It showed me who my real friends were”
valued the costs to them of a notional extension of their “I Listen more to my partner”
lives. It is no surprise that 98% of the patients were “I appreciate my friends more because of the support
willing to accept the considerable toxicities of they give me”
chemotherapy for a 5-year extension to their lives, but “Money seems a bit more trivial”
it is possibly surprising that 89% would accept “I have had to cut down on what I can do and had to
chemotherapy for a 3-month extension to life. Only a learn to cope with that”
Discussion
minority of the patients would not be prepared to
This survey sought to highlight patients’ views on the
accept a gain of lifespan alone when balanced with the
difficult decisions that are discussed regularly in
side effects of chemotherapy (Figure 11). Patients oncology. One hundred and twenty-five patients were
understanding of why they were being treated varied issued questionnaires and 96 questionnaires were
(Figure 4) from symptom relief to cure. completed and available for analysis. This response rate
Figure 11. of 76.8% compares favourably to the 2010 National
View largeDownload slide Cancer survey response rate of 67%.1 The cohort of 96
If you were offered treatment that had side effects such patients were drawn from all age groups and were
as hair loss, infection, sickness and loss of appetite receiving a wide selection of oncology interventions
would you accept this if there was a chance that you including chemotherapy and radiotherapy.
were to gain. The subject of prognosis disclosure in the palliative
setting has been the focus of much research in recent
We wanted clarity whether or not patients wanted to years. The paternalistic practice of withholding
know if they had just a short period of life left in the information, previously justified as being in the patient's
terminal phases of their illness. The clear majority of ‘best interest’ has been shown to be confusing and even
patients wanted to be informed that time was short but harmful to patients psychological well-being.6 Our
12% of the patients would not want to be told if they questionnaire revealed that most patients do want to be
given accurate information with regard to prognosis,
had a very short time left to live, and 16% of the
even if this is bad news, and the large majority do not
patients would not want their family to be told (Figure
support withholding of information. However, this view
12). is not universal and a small minority of patients do not
Figure 12. want to know if the prognosis is poor. It is clear,
View largeDownload slide therefore, that the dissemination of information needs to
If you were very seriously ill with a short time to live. be tailored to the patient.
Patients obtain information about their cancer from a
Comments from patients variety of sources and if we as cancer physicians are not
This study welcomed comments from patients and we taking the lead in finding out what the individual wants
reproduce some of their remarks because of their to know of their prognosis early on in their management
informative value. process, they are likely to use one of these other sources
Patient comments on the issue of prognosis to fill in the gaps in their understanding in order to come
“I trust my caregivers to provide me with information as to terms with their malignancy. Our study has shown
and when I need to know and I would never necessarily
how wide the range of information is that patients use, more precision with patients who may then elect to not
and with this breadth of range come problems as this undergo therapy.
may lead to the patient being misled. We have observed Should we be telling patients that they are dying? A
that patients have used other patients and the internet as recent study has shown that patients who were informed
sources of information. What they learn may be accurate of their terminal state had significantly less emotional
and relevant, but equally it may not be appropriate. This distress, and interestingly, fewer symptoms than those
may lead to a divergence in management expectations who had to guess at their condition.9 It may, therefore,
between the patient and medical team, and ultimately an be beneficial for patients to know that they are in the
erosion in trust. terminal phase of their illness, but how many patients
Patients have a diverse social support network and rely would want that information to be shared with them?
on friends, family and healthcare providers to cope with Twelve percent of the patients in this study have
their diagnosis. A third of the patients felt that their indicated that they would not want to be informed if they
illness had changed their relationship with their family. were seriously ill with a short time to live, and 16%
It is not surprising, therefore, that one of the greatest would not want their families to be informed. This fact
concerns after a diagnosis of cancer was a breakdown in clearly demonstrates the need for advance planning in
family relationships as well as a change in attitudes of cancer management and that as physicians we need to
friends. Other expected concerns included the fear of obtain a clear picture of what level of information the
death, pain, loss of income and a loss of dignity. individual would like to possess. However, views do
Organizations including Macmillan Cancer Care in the change as treatment progresses, and so clinicians do
UK have resources allocated specifically to address these need to be aware that patients’ opinions on their
difficult psychological sequelae, and it is clear from this information needs may alter with the course of their
survey that these resources are important and in demand. cancer. To this end, the UK General Medical Council
A surprising feature of our survey was the high document ‘End-of-Life Care’ gives clear guidance to
proportion of patients who expressed that time in clinicians regarding advance planning in the palliative
hospital, and more specifically difficulties getting to setting.
hospital for appointments was their major concern in Conclusions
importance. We recommend that this aspect of care be This study aimed to give oncologists in the UK an
the focus of providers of healthcare. impression of our patients’ opinions about areas of
When offering palliative radiotherapy or chemotherapy communication and management that have been
with the aim of improving symptoms and prolonging life controversial. Prognosis and end-of-life care are difficult
oncologists often have to use time frames to describe to areas and there are often conflicting opinions about what
patients what the potential benefit could be. It is the patient should know, and what part they play in the
alarming that a recent study showed that approximately decision-making process. Patients’ opinions vary as to
two-thirds of the patients undergoing palliative what they wish to know about their prognosis and end-
chemotherapy had not had a clear indication of the of-life care, and also as to what benefit is acceptable
intended duration of benefit of the treatment in terms of when undertaking life prolonging but not curative
life expectancy.7 Similarly another study in the Phase 1 treatment. Significantly, there appears to be a minority
setting highlighted failings in this discussion between of patients who do not want to know if their prognosis is
oncologists and patients.8When doctors give a prognosis poor or when they are approaching the end of their life.
to patients, their estimates are currently just ‘estimates’. In the same way, a minority of patients do not wish for
Despite this limitation, the patient needs to understand life-prolonging treatment at the cost of potential side
risks and benefits of treatment in the context of life effects, no matter how great the gain may be. The results
expectancy. Our study has shown that not all patients are presented here weigh strongly against any attempt to
willing to accept the ill defined or abstract concept of a make generalized assumptions about cancer patients’
general prolongation of life in exchange for a life views. In one way to do so betrays the fundamental
burdened by the side effects of treatment. Furthermore, a principle of individuality and autonomy that must guide
defined subset of patients are consistently not willing to oncologists when discussing these issues with their
accept 3 months, 1 year or even 5 years more in life patients. We suggest that this study shows that we must
expectancy gained as a result of treatment. In many focus on advance care planning. Furthermore, we
situations, the gain from palliative chemotherapy will be advocate clear documentation of ‘what if’ discussions
modest and measured in weeks. In our view, the early on in a palliative patients’ management.
observation that a significant minority of patients do not
want the treatment that we offer them is relevant and
practice changing. Accordingly, we need to discuss J Med Ethics. 2006 Dec; 32(12): 693–697.
treatment goals that may be of limited efficacy with doi: 10.1136/jme.2005.015487
PMCID: PMC2563347
PMID: 17145907 were the first 124 Greek‐speaking adults diagnosed 6–24
The truth‐telling issue and months before sampling, to obtain roughly equal
numbers of men and women. All selected patients were
changes in lifestyle in patients in good performance status (performance status = 0
according to the Eastern Cooperative Oncology
with cancer Group)6 without any pre‐existing cardiovascular
V Kostopoulou and K Katsouyanni diseases. Informed consent forms were signed by all the
Author information Article notes Copyright and License patients.
information Disclaimer Each patient was asked to report on changes made in
This article has been cited by other articles in PMC. lifestyle after the diagnosis of the specific health
Abstract problem they were being or had been treated for in that
Although life‐threatening health events can motivate hospital. They were asked if they had made any changes
patients to undertake health promotion activities,1there in their dietary habits to improve their health. If yes, they
are few data regarding changes in lifestyle in response to were asked to specify the kind of change choosing from
a diagnosis of cancer. The increasing incidence of cancer a list of options: (a) ate more fruits and vegetables; (b)
suggests the necessity to prompt a range of initiatives to ate less meat; (c) ate less fat; (d) fasted more often; (e)
raise awareness of the problem and convince patients to used dietary supplements; (f) followed a weight‐
adopt a healthy lifestyle that can positively influence reduction diet; (g) consumed less alcohol; and (h) other.
outcome. Given the central role of oncologists and the This method of assessing changes in diet was used in
trust placed on their advice, the delivery of health other studies of trends in diet.7In a similar way, patients
messages aimed at changing lifestyle towards a healthier were asked if they had begun any physical activity aimed
way may be especially meaningful.2 In such a context, at improving their health. If yes, they were asked to
disclosure of the true diagnosis is a prerequisite to specify by choosing among (a) worked out in a gym; (b)
transmit the medical information, present a practical and worked out at home; (c) walked more; (d) started any
realistic message about lifestyle factors and elicit the kind of sport; and (e) other. For the above questions,
collaboration of the patient in developing a strategic plan more than one answer was allowed. Patients were finally
for the future. asked if they were smokers, ex‐smokers or non‐smokers.
Attitudes about the truth‐telling issue are related to Smokers and ex‐smokers were asked if they had given
convictions about the benefit or harm to the patient up or reduced smoking after the diagnosis of the health
caused by being informed, and are strongly connected to problem they were being or had been treated for in that
social, geographical and cultural factors,3 varying from a hospital to improve their health. The information
paternalistic approach mostly encountered in the regarding the awareness of the patient of the diagnosis of
Mediterranean population, viewing the doctor as a cancer was either extracted cautiously from him or her or
powerful figure exercising unilateral decisions,4 to the given by the patient's family member. Patients who had
more autonomous American perspective based on made at least one change in lifestyle were also asked to
providing thorough information and enabling the patient indicate their source of information for this change: (a)
to make informed choices and plan health‐promoting their doctor; (b) mass media; and (c) their relatives or
strategies.5 The principles of informed consent and friends.
patient autonomy have created clear ethical and legal Sociodemographic data on age, education and sex were
obligations to provide patients with as much information collected. Data on the disease, such as type of cancer,
as they desire about their illness and their treatment. stage of disease, number of treatments received (one,
Disclosing the truth means that the patients get all the two, three or more different kinds of treatments), time
medical information they need to make decisions about since histological diagnosis and type of patient (inpatient
their body and their life. Our study investigated the or outpatient), were also collected using the hospital
relationship between changes in lifestyle and awareness registries.
of the diagnosis among patients with cancer, in a Statistical comparisons between the two groups of
population in which a substantial proportion of patients patients (informed and uninformed) were made with
with cancer ignores the accurate diagnosis of their χ2tests or Fisher's exact tests (where needed). Logistic
illness. regression analysis was used to estimate odds ratios
(ORs) as the measure of association of changes in
In all, 124 patients with histologically confirmed lifestyle with awareness of the diagnosis, education (in
prostate, breast and colorectal cancer were personally years, ⩽6, >6), age (in years, ⩽65, >65), time from
interviewed by the investigator (VK), an MD working at diagnosis (in months, ⩽12, >12), stage of disease (local
the hospital, while being treated as inpatients or during or distant) and type of patient (inpatient or outpatient).
their follow‐up visits as outpatients, in “Metaxa” Cancer Variables were divided into categories by using the
Hospital of Piraeus‐Athens, in 2004. Eligible patients median values. All ORs are adjusted for confounding
factors (age, education, sex, stage, number of treatments, were also strongly associated. Adjusted for other
type of cancer and type of patient). It is important to note sociodemographic factors and for the confounding effect
that because of the types of cancer selected for our study, of education (an index of socioeconomic status), patients
sex and type of cancer are confounded, given that all who were aware of the diagnosis of cancer were more
patients with breast cancer were women and all patients than twice as likely to change dietary habits towards a
with prostate cancer were men. To reduce the healthier way as patients who were not informed
confounding effect, and to achieve a good interpretation (p<0.1). Compared with men affected by colorectal
of the results, a new variable was created containing cancer, women with breast cancer were 65% less likely
diagnosis and sex, which divided patients into four to make dietary changes after a diagnosis of cancer.
groups: (1) men affected by colorectal cancer; (2) Overall, older patients were 97% less likely to add new
women affected by colorectal cancer; (3) breast cancer; physical activity (p<0.01); among older patients, more
and (4) prostate cancer. Interactions among independent educated ones were about 20 times as likely to add new
variables were also checked for possible associations physical activity (data not shown), whereas among
with changes in lifestyle. younger patients, more educated ones were only 4% as
likely to start exercising (data not shown). This implies
The sample comprised 124 adult patients with cancer, of an interaction between age and education. Compared
whom 50 had breast cancer, 50 had colorectal cancer and with men affected by colorectal cancer, women affected
24 had prostate cancer. A total of 55% of the patients by the same type of cancer and patients with breast
were women, 55% were newly diagnosed (within the cancer were, respectively, about 15 and 17 times as
previous 12 months, the mean age was 62.3 (standard likely to change their smoking habit (p<0.05 and
deviation 12.4) years, 60% had an elementary education p<0.001, respectively). Compared with newly diagnosed
and 22% of the patients were not informed about the patients, those diagnosed more than 12 months
diagnosis of cancer. previously were 75% less likely to change their smoking
Table 11 shows the most common changes in lifestyle, habit (p<0.1).
defined as changes that at least 5% of the patients Informed and uninformed patients were equally advised
reported making. Overall, changes in lifestyle were by their doctor, their relatives and friends or informed by
common among patients with cancer, as about 80% of mass media about dietary and exercise changes, although
them reported making at least one change: about 40% informed patients were more conscious on acquiring
made dietary changes, 15% added new physical activity information from mass media about giving up their
and 25% reduced or stopped smoking. Among dietary smoking habit (p = 0.014).
changes, the most common were drinking less alcohol
and eating less fat; for physical activity, the most Our study indicates that most patients with cancer
common change was walking more; for changes in reported making changes in lifestyle to improve their
smoking activity, almost half the patients stopped health and well being after a diagnosis of cancer. These
smoking.. data are consistent with a survey of 536 cancer
Table 22 shows the association between awareness of survivors, which also showed that about 70% of the
the true diagnosis and patients' characteristics patients reported making changes in lifestyle: 40% made
(sociodemographic data and changes in lifestyle). dietary changes and 20% added physical activity.7
Table 2 Association of awareness of the diagnosis After controlling for sex, education, type of cancer, age,
with clinical characteristics among patients with stage of disease, number of treatments, type of patient
breast cancer (n = 50), colorectal cancer (n = 50) and and time since diagnosis, patients to whom the diagnosis
prostate cancer (n = 24) was disclosed were 2.5 times as likely to change their
†The model includes awareness of the diagnosis, age, diet to a healthier one than patients from whom the truth
sex, education, stage, medical treatments, diagnosis date was withheld. The trend to significance of this
and type of patient. Therefore, the ORs reported are association implies a strong connection between
adjusted for the other variables. awareness of the diagnosis of cancer and dietary
Table 44 shows the association between changes in changes, given the small sample size. Although physical
lifestyle and source of information in the groups of exercise is a particularly attractive option among
informed and uninformed patients. interventions designed to improve survival in patients
Table 4 Association between changes in lifestyle with cancer because of its other known health benefits
and source of information in the two groups of and its positive influence on biological systems
patients (informed and uninformed) associated with anticancer defence,8those patients who
Among changes in lifestyle, dietary changes were were not likely to add new physical activity probably
associated with awareness of the true diagnosis attributed it to their conviction of being more fragile and
(p = 0.049), whereas among other patients' having to avoid exposure to potentially harmful
characteristics, age (p<0.001) and education (p<0.001) environmental factors.
Older patients were less likely to adopt new lifestyle improve health. Data from a survey in New Zealand
practices in response to a diagnosis of cancer, whereas about the effect of an initiative to increase physical
women were more likely to make changes. These results activity at a population level resulted in increases in
are similar to findings from studies on prevalence of message recognition and in the intention to become more
changes in lifestyle among patients with cancer active.
Newly diagnosed patients were more likely to change Our study has several limitations. The prevalence
their smoking habit than patients diagnosed more than estimates of changes in lifestyle calculated cannot be
12 months previously, which can be explained by the generalised to all patients with cancer because of
strong initial motivation offered by the seriousness of the collection of data from only one cancer institute and
diagnosis. It should, however, be noted that the selected selection of cancer types with high survival rates.
cancer sites are not the ones primarily related to Because of good prognosis, motivation to make changes
smoking, so the motivation may have been lower. in lifestyle for these patients could be different. On the
Overall, changes in diet and smoking were more other hand, the gain in patients with good prognosis is
frequent among newly diagnosed patients, whereas proportionally larger. Additional studies would be
physical activity was undertaken more often after 12 needed to assess changes in lifestyle in more patients
months of the diagnosis, given the poor physical status affected by various types of cancer treated in different
during cancer treatment. cancer institutes all over the country. Finally, the data
In our study, more than 77% of patients with cancer collected were based on self report and were in many
seemed to be aware of the diagnosis, which is a high cases gathered during hospitalisation for treatment.
percentage considering the Mediterranean approach to Therefore, it is possible that the answers given were
the truth‐telling issue. Data from a study on oncologists somewhat affected by psychological factors. All
practising in North America, Europe, South America or patients, however, had the same motivation to report a
Asia and their attitudes in giving bad news suggested healthier profile. Thus, the ORs should not be biased.
that doctors from Western countries were less likely to The results of these data suggest that patients with
withhold unfavourable information from the patient at cancer are highly motivated to make changes in lifestyle
the family's request or avoid the discussion entirely than and therefore represent a group that could benefit from
doctors from other countries.3Other data from studies on counselling on diet, physical activity and smoking status.
different countries about attitudes towards informing In this context, truth telling is an alternative to the
patients suggest that in Italy opposition from relatives to practice usually followed of withholding the truth, an
disclosure of the diagnosis appears to be alternative with many difficulties, which requires
common, whereas in Pakistan, crucial decisions are often particular professional and individual skills.
made by family members or are left entirely up to the J Am Diet Assoc. 2003 Mar;103(3):323-8.
attending doctor.Paternalistic attitudes favouring
concealment of serious diagnoses prevail among doctors
in Lebanon,whereas healthcare workers from Taiwan
recorded truth telling as one of their most frequent daily
References:
dilemmas in caring for patients.In a survey conducted in https://academic.oup.com/qjmed/article/104/12/107
Greece to assess the public attitudes to the disclosure of 5/1546457
the diagnosis issue in patients with good prognosis, 1. National Cancer Patients’, Experience Survey
doctors themselves replied “Yes” less often (41.3%) than Programme, 2010
all other professionals (50.8%) to a highly significant [www.dh.gov.uk] Accessed 8 July 2002
level (p<0.001). In the same study, the reasons given to 2. Miyata H, Takahashi M, Saito T, Tachimori H, Kai
justify truth telling could be described as emotional, such I. Disclosure preferences regarding cancer diagnosis
as the patient's motivation to follow the doctor's and prognosis: to tell or not to tell?,
instructions accurately, to be more careful, to organise J Med Ethics , 2005, vol. 31 (pg. 447-51)
his or her life in a better way. Our study proposes one 3. Kiely BE, Soon YY, Tattersall MH, Stockler MR.
more reason: the possibility of deferring, through How long have I got? Estimating typical, best-case,
making changes in lifestyle, the time of death for as long and worst-case scenarios for patients starting first-
as possible. Data from a study on American adults line chemotherapy for metastatic breast cancer: a
indicate that limited awareness of health problems has systematic review of recent randomized trials, J Clin
emerged as a greater barrier to their management.14 As Oncol , 2011, vol. 29 (pg. 456-63)
knowledge and information can influence control, the 4. Kostopoulou V, Katsouyanni K. The truth-telling
media can play a powerful part in influencing health issue and changes in lifestyle in patients with cancer,
behaviour. The application of social marketing principles J Med Ethics , 2006, vol. 32 (pg. 693-7)
to health promotion has proved effective in motivating 5. Fallowfield L. Participation of patients in decisions about
people to make complex behaviour changes that can treatment for cancer, Br Med J , 2001, vol. 323 pg. 1144
6. Fallowfield LJ, Jenkins VA, Beveridge HA. Truth survivors: a comprehensive review and future directions.
may hurt but deceit hurts more: communication in Cancer 200294539–551. [PubMed]
palliative care, Palliat Med , 2002, vol. 16 (pg. 297- 9. Boon H, Stewart M, Kennard M A. et al Use of
303) complementary/alternative medicine by breast cancer
7. Audrey S, Abel J, Blazeby JM, Falk S, Campbell survivors in Ontario: prevalence and perceptions. J Clin
R. What oncologists tell patients about survival Oncol 2000182515–2521. [PubMed]
benefits of palliative chemotherapy and implications 10. Pucci E, Balardinelli N, Borsetti G. et al Relatives'
for informed consent: qualitative study, BMJ , 2008, attitudes towards informing patients about the diagnosis
vol. 337 pg. a752 of Alzheimer's disease.J Med Ethics 20032951–54.
8. Jenkins V, Solis-Trapala I, Langridge C, Catt S, [PMC free article] [PubMed]
Talbot DC, Fallowfield LJ. What oncologists believe 11. Jafarey A M, Farooqui A. Informed consent in the
they said and what patients believe they heard: an Pakistani milieu: the physician's perspective. J Med
analysis of phase I trial discussions, J Clin Oncol , Ethics 20053193–96. [PMC free article] [PubMed]
2011, vol. 29 (pg. 61-8) 12. Hamadeh G N, Adib S M. Changes in attitudes
9. Yun YH, Kwon YC, Lee MK, Lee WJ, Jung KH, regarding cancer disclosure among medical students at
Do YR, et al. Experiences and attitudes of patients the American University of Beirut. J Med Ethics
with terminal cancer and their family caregivers 200127354 [PMC free article] [PubMed]
toward the disclosure of terminal illness, J Clin Oncol 13. Chiu T Y, Hu W Y, Cheng S Y. et al Ethical
, 2010, vol. 28 (pg. 1950-7) dilemmas in palliative care: a study in Taiwan. J Med
10. General Medical Council, Treatment and Care Ethics 200026353–357. [PMC free article] [PubMed]
Towards the End of Life: Good Practice in Decision 14. Egan B M, Lackland D T, Cutler N E. Awareness,
Making [http://www.gmc- knowledge, and attitudes of older Americans about high
uk.org/static/documents/content/End_of_life.pdf] blood pressure: implications for health care policy,
Accessed 1 January 2010 education, and research. Arch Intern Med 2003163681–
687. [PubMed]
https://www.ncbi.nlm.nih.gov/pmc/articles/P 15. Bauman A, McLean G, Hurdle D. et al Evaluation of
the national ‘Push Play' campaign in New Zealand—
MC2563347/ creating population awareness of physical activity. N Z
Med J 2003116U534 [PubMed]
1. Rowland J H, Massie M J. Breast cancer. In: Holland
JC, ed. Psychooncology. New York: Oxford
University Press, 1998
https://pdfs.semanticscholar.org/86a1/5f3cfa42fcf1b54e3
2. Rock C L, Demark‐Wahnefried W. Nutrition and
3bf477a8c210830ad06.pdf
survival after the diagnosis of breast cancer: a review of
the evidence. J Clin Oncol 2002203302–3316. [PMC
free article] [PubMed]
3. Baile W F, Lenzi R, Parker P A. et al Oncologists'
attitudes toward and practices in giving bad news: an
exploratory study. J Clin Oncol 2002202189–2196.
[PubMed]
4. Dalla‐Vorgia P, Katsouyanni K, Garanis T N. et al
Attitudes of a Mediterranean population to the truth‐
telling issue. J Med Ethics 19921867–74. [PMC free
article] [PubMed]
5. Surbone A. Truth telling to the patient. JAMA
19922681661–1662. [PubMed]
6. Oken M M, Creech R H, Tormey D C. et al Toxicity
and response criteria of the Eastern Cooperative
Oncology Group. Am J Clin Oncol 19825649–655.
[PubMed]
7. Patterson R E, Neuhouser M L, Hedderson M M. et al
Changes in diet, physical activity, and supplement use
among adults diagnosed with cancer. J Am Diet Assoc
2003103323–328. [PubMed]
8. Fairey A S, Courneya K S, Field C J. et al Physical
exercise and immune system function in cancer