SIOG 2015

Cancer versus time: How to balance doctor and patient agendas

Dr Robert Glynne-Jones - Mount Vernon Hospital, Middlesex, UK

You are talking here in the context of older patients with cancer, all sorts of cancers, and you’ve got a lot of experience, of course, with colorectal cancer. But what are the big issues? We’ve been hearing a lot about the way you assess patients, this comprehensive geriatric assessment, but there are other issues, I believe, that concern you about patients.

We have a lot of choices in terms of the treatments that we use in colorectal cancer, particularly in rectal cancer, and if we’re going to personalise treatment we also need to some extent to know what the individual’s agenda is and what’s driving them and that assessment is not just a physical assessment, it’s an emotional and psychological assessment.

Individualising therapy, of course, is quite a theme in modern oncology but you’re talking about a different kind of individualisation.

As I said, we’ve got lots of choices of the treatment on the one hand and we’ve got lots of individuals and the patient lots of agendas and lots of priorities there. What individualisation is is fitting those two together.

Can you give me some examples of how doctors need to take cognizance of this?

For an oncologist your agenda is, in a sense, to give this huge amount of information to this person sitting in front of you in what time you’ve allotted yourself, five or ten minutes. Sometimes you forget that the patient in front of you also has an agenda. I think it’s marrying up those two agendas. So you really need to find out, as an individual, what drives the person in front of you.

What’s the procedure?

There are facilitative questions and the two facilitative questions that I find most useful is saying, ‘Coming to see me today, knowing that you were coming to see the oncologist, knowing that you had cancer, so what were your best hopes, your best hopes, from this meeting with me today?’ Yes, you get some 96 year olds who will say, ‘I want to live to 100,’ which is what you might imagine all of us want to live as long as possible, but actually when it boils down to it you get some guys that say, ‘Well my wife probably only has 6-12 months to live, and I don’t care about me, I just want to be able to be reasonably well in order to look after her and to stay at home in our flat and not to be separated for her to go into one hospital and me to go into another.’ That makes you choose a completely different treatment that is going to have relatively low toxicity.

Is this different depending on the stage and grade of the tumour, though, whether it’s potentially curable?

You have to negotiate then but you know the negotiators on his side, you know where he’s coming from. Like most negotiations you start with something like this or like this and you gradually balance things out but you know where you’re going. Otherwise how do you know where you’re going? You just say, ‘This is the most effective treatment, take it or leave it.’

Often you have treatments which are going to prolong life, how do you approach the whole subject and what’s a typical example of the outcome when you really do consult the patient?

Patients are individuals, we are individuals. If I said to you, ‘OK, you’re not an elderly patient so with rectal cancer there are an awful lot of issues. There are issues of do you want a stoma, do you not want a stoma? Do you want to avoid having any local recurrence in the future? Do you want to have low toxicity, will you accept low toxicity for that? Do you want an operation, do you want an operation that means a bag?’ There are all kinds of different issues there and I’ll bet you that if I asked everyone in this room how they prioritised those they will prioritise them differently. So someone will say, ‘I don’t care about the stoma, I’ve got kids of 15, 16, I want to live and see them grow up.’ Other people will say, ‘Whatever you say, I’m not having a stoma; even if that jeopardises my outcomes or my survival, I’m not having a stoma under any circumstances.’ So we know that with all patients there are priorities and probably in elderly patients those priorities are much starker and wider.

Recently there was a survey that I seem to remember in which patients were surveyed for their attitudes towards quality of life or length of life and doctors were similarly surveyed and while the doctors tended more to choose quality of life the patients often just went out for the longest life they could get. What’s your experience?

You have to reflect that if you ask someone who is threatened with death because they have cancer or they have metastatic cancer, they are likely to say different things than if you take an average 85 year old who is not threatened by death and you ask them in the cold light of dawn what their priorities might be if they got cancer. It’s prudent to reflect that we will have different ways of thinking about that depending on where we are and what the actual risk is and how sharp that risk is.

What are the overall benefits, then, to the practice of individualising therapy in this way?

There are two main benefits, one is you feel better about it because you feel you’ve really done the best you can and you’ve taken this patient as an individual and you’ve fitted the patient’s treatment ideally to the patient. But also the patient is going to feel validated that you have listened to them. Our problem is we have very big workloads, patients come in one after the other and I think sometimes we don’t listen enough.

Is there not an issue that doctors are very comfortable in the curative mode because they really want to cure patients and that perhaps they find it quite difficult to cope with the more palliative mode?

I think you’re right, that we all feel that this is the best treatment because this is going to actually cure you or has the best chance of curing you. But when you tape doctors’ consultations they focus more on the positive outcomes, the oncological outcomes in terms of the cancer not coming back, preventing local recurrence and things. Although we pay lip service to telling you what the side effects are and we probably do tell patients really in quite good detail about the acute side effects, we’re pretty scanty on the late side effects, what the late outcomes are and what the reality of two years, three years, four years down the line is.

Could you summarise your recommendations to your colleagues about this issue of consulting the patient more to find out the patient agenda?

You need to spend some of the consultation finding out exactly what the patient’s agenda is and exactly what the patient’s priorities are and exactly what the family background is, the carers, the family there, before you can really offer a menu of what the possible potential treatments might be.