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Facing Up to Cancer

Terminally ill cancer patients who overestimate how long they will live tend to choose more aggressive treatments, according to a study reported in today's Journal of the American Medical Association (JAMA). But those choices usually don't lengthen their lives, and their physicians are typically much more pessimistic about their chances. The researchers hope that more open communication by physicians will allow patients to make realistic decisions and lessen needless suffering.

Terminal cancer patients usually face the alternatives of palliative care--which only treats pain and symptoms--or aggressive treatments, many of which have severe and discomforting side effects. "You want to be able to give people hope or maximize their quality of life," says lead author Jane Weeks of the Dana Farber Cancer Institute in Boston. "If we allow patients to have false hopes, is there any harm done?" To find out, she and her colleagues interviewed 917 adults with late-stage lung or colon cancer about their impressions of their survival odds and treatment preferences. These results were compared with prognoses by their physicians.

The physicians generally were conservative at predicting whether their patients were going to die and when, Weeks says. For example only 23% of the patients were expected to survive longer than 6 months. But 85% of the patients estimated they had better than even odds of living that long. The actual survival figure was 45%. The patients who were the most optimistic were 2.6 times as likely to choose aggressive anticancer therapies instead of palliative care. Yet they were almost twice as likely to have hospital emergencies, and there is no evidence that as a group they lived any longer.

All of this may suggest a lack of communication between doctor and patient, says Weeks. "It's incredibly hard to convey bad news and to do it well and with compassion." Alternatively, patients may be unable or unwilling to grasp the reality of their plight. Nevertheless, she says, patients must have the proper facts to make informed decisions. "The next step should be to study, in actual practice, how much information is given, how much is received, and the effects on decision-making for those at the end of life," comments Thomas Smith, of Virginia Commonwealth University's Medical School, Richmond, in a JAMA editorial.