Introduction

The diagnosis of a malignancy is only the beginning of a cancer patient’s journey and throughout this time decisions about how to best manage and care for patients have to be addressed. Before seeing the oncologist, the majority of cancer patients will have been given their diagnosis, most frequently in the outpatient department rather than a hospital ward. The importance of this event cannot be overemphasized and the manner of communicating this information is pivotally important.

When patients do meet their oncologist for the first time, the presence of a family member or friend can be helpful, as the family member can provide emotional support, help in recall of the conversation and can ask supplementary questions. This can be important at a time when patients will be seeking to try to understand their condition and what the future may hold for them. There is little doubt that the majority of patients with cancer want as much information as possible. This often includes the elderly and the incurable. The first, sometimes initially unspoken, question is ‘is it curable?’ and after that ‘is it treatable?’ At some point, most want to know the options there are for treatment and the side effects of possible treatments. Absorbing this information can be traumatic and often patients cannot take in this complex web of information in one consultation. Support nurses, or other healthcare professionals, who are present in the clinic, can provide useful reinforcement and clarification of patients’ questions. Often the oncologist needs to cover the ground more than twice.

This whole process involves relaying information that can severely alter a patient’s view of their future and is challenging for the giver of the information as well as the patient. A useful guide in this process is the ten-step approach to giving bad news (Table 18.1). This model advocates good preparation, finding out what patients want to know, allowing denial and listening to concerns. It also recognizes the importance of encouraging the ventilation of feelings and the important role played by relatives.

Table 18.1 10 steps to breaking bad news

The most important decision at this time is whether the patient should be treated radically with cure as the aim of treatment. But radical treatment may be associated with treatment-induced morbidity and, occasionally, mortality and it is therefore vital to ensure that it is the appropriate route to be taking. Unfortunately, a number of patients will be unsuitable for a radical approach to treatment and palliation will be the appropriate option.

The next question is which is the best treatment modality or modalities for that particular patient. Clearly, the patient needs to have been fully investigated before such decisions can be taken and usually these investigations will have been carried out prior to referral to the oncologist. However, supplementary investigations may need to be carried out. These may include examination under anaesthetic, endoscopy and appropriate radiological investigations such as computed tomography (CT), magnetic resonance imaging (MRI) or isotope bone scans. As the diagnosis of cancer has such possible dire implications, all patients should have histological proof of the diagnosis, if this is possible, especially if radical treatment is planned. To make appropriate management decisions the clinician must take into account tumour and patient factors (listed below).

Frequently, the patient’s management may have been discussed in a multidisciplinary team meeting (MDT) where the patient’s pathology and radiological investigations will have been reviewed. The decision is usually made about whether cure is possible and the appropriate treatment modality. However, only one or two of the treating team may have met the patient at this stage and decisions made at the MDT meeting may not survive the consultation with the patient and oncologist. When discussing treatment options, the patient’s wishes are paramount. However, in practice, the majority of patients will accept the careful reasoned advice of their doctors. Very occasionally, patients ask for radical treatment when this is futile. Somewhat more frequently, such requests come from relatives. However, a doctor is not obliged to provide a treatment that they conscientiously feel is not in the patient’s best interest.

Factors governing clinical decisions

Tumour factors

Organ of origin

The organ in which the cancer develops is an important factor affecting both outcome and treatment. Complete surgical removal of brain tumours is usually impossible, as a complete excision would normally damage vital parts of the brain, leading to either death or an unacceptable neurological deficit. Similarly, the brain is sensitive to ionizing radiation and this limits the dose of radiotherapy that can be given. However, in other sites, such as the kidney, a complete organ can be removed with impunity.

Histological type

Identification of the precise histological type of a tumour governs both treatment and prognosis. For instance, basal cell and squamous carcinomas arising from the epidermis of the skin have a good prognosis and the treatment is straightforward. By contrast, melanomas arising from pigment-producing cells (melanocytes) have a much more serious outlook.

Degree of differentiation

The pathologist can grade the degree of differentiation. Well-differentiated tumours look like the tissue of origin and poorly-differentiated tumours may look primitive and do not look like the tissue from which they arise. For instance, well-differentiated thyroid cancer has a good prognosis and is relatively easily treated by such measures as surgical excision and radioiodine. Anaplastic thyroid cancers rapidly spread and respond poorly to any treatment.

Tumour staging

Where possible, tumours should be staged using the international T, N and M classifications. T stands for primary tumour stage, which is usually decided by the tumour size. N stands for the presence or absence of lymph node metastases, the usual method of spread in carcinomas and some sarcomas. M represents the presence or absence of distant metastases. In practice, other staging systems have been developed and are referred to in the preceding chapters.

Tumour size

In general, the larger the tumour the lower is the chance of cure either by surgery or radiotherapy. It may not be possible to excise completely a large tumour. Similarly, a large tumour treated by radiotherapy contains more clonogenic tumour cells (cells capable of forming colonies of cells following radiotherapy) and an increased proportion of radioresistant hypoxic cells. Stage Ib carcinoma of cervix is tumour confined to the cervix, but this stage is subdivided into stage Ib1 (less than 4   cm) and Ib2 (greater than 4   cm). By and large, stage Ib1 tumours are treated by radical hysterectomy and stage Ib2 by chemoradiotherapy.

Locoregional spread

Spread to regional lymph nodes usually indicates a poorer prognosis and the need for more aggressive therapy. Patients with squamous carcinoma of head and neck with spread to regional lymph nodes may be treated by a radical neck dissection along with primary radiotherapy or surgical excision of the affected organ. As spread to lymph nodes in breast cancer is often associated with occult distant spread, such patients usually receive adjuvant chemotherapy following surgery.

Distant metastases

The presence of distant metastases may suggest that attempts to remove the primary tumour completely are futile, as is the case in lung cancer. However, such metastases may be chemosensitive and a high probability of cure may be possible. A typical case is testicular teratoma where high cure rates are seen following cisplatin-based chemotherapy.

Tumour site

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