G-13 Pamplona,Sherina Anne E.
needs of the individual patient, and we feel it provides
11- Our Lady of Good Counsel
The experiences of cancer patients
C. Alifrangis L. Koizia A. Rozario S. Rodney M.
Harrington C. Somerville T. PeplowJ. Waxman
QJM: An International Journal of Medicine, Volume
104, Issue 12, 1 December 2011, Pages 1075–
1081, https://doi.org/10.1093/qjmed/hcr129
Published: 10 August 2011
Abstract
Objectives: To assess the needs of cancer patients for
information about their condition and to understand
the psychological impact of their illness.
Background: The discussion of prognosis and treatment
options in the palliative setting is an important and
difficult part of oncology practice. To evaluate this, we
examined the experiences of cancer patients of the
physical and psychological impact of their disease on
their life, and their opinions on the communication of
end-of-life decisions and treatment options.
Methods: A patient questionnaire was designed that
encompassed communication regarding treatment and
prognosis, quality-of-life attitudes subsequent to cancer
diagnosis, end-of-life care and cancer drug funding. One
hundred and twenty-five patients with a diagnosis of
cancer were asked to participate and 96 questionnaires
were completed and available for analysis. The
questionnaire consisted of 63 questions and was
completed in both an inpatient and outpatient setting.
Results: This survey brought to light a number of
controversial issues in cancer service provision,
highlighting the emotional and psychological changes
brought about by a cancer diagnosis. Major concerns of
our patients include fear of death and pain, changes in
interpersonal relationships and financial constraints.
Only 66% of the patients wanted to be given a prognosis
by their clinicians and just 70% of the patients recalled
being given a detailed prognosis. 11% of the patients
were not prepared to undergo palliative treatment. In
all, 7% were not prepared to accept treatment for 1
year and 2% for 5 years of life in exchange for the
potential side effects of cytotoxic chemotherapy. 12% of
the patients would not want to be in possession of the
information that they were in the terminal phase of the
illness with a short time to live and 16% would not want
this discussed with their next of kin.
Conclusions: This study informs medical professionals
about the importance of tailoring information to the
insights into the successes and failures of our
communication with cancer patients. It is important
that difficult discussions are personalized to the
individual patients’ wishes. These can vary dramatically
both in the area of disclosure of bad news in prognosis
and in end-of-life decision making. This study provides
compelling evidence for good advanced care planning at
an early stage in the management of patients with
terminal cancers.
Introduction
Communication between patients and physicians
following a diagnosis of cancer requires an
understanding of patients’ emotions and sensitivities,
needs to be individualized and cannot be formulaic.
It is clear that the evaluation of communication with
patients must be an iterative process. But it is unclear
what it is that patients need from their communication
with medical staff. The information base on which
doctors rely for their conversations with patients about
prognoses has traditionally been limited, with individual
doctors relying on their own experiences and that of
their clinical teachers to inform their own method of
‘talking’ to their patients about matters of life and
death. But do we really understand what patients feel
about having cancer?
The National Cancer Survey in the UK of 67 710 patients
reported recently has provided insights into patients’
views on how well supported they feel and described
their opinions on key issues such as the role of clinical
nurse specialists, the significance of pain management
and the quality of cancer services provided by the
NHS.1 However, the survey did not examine how
healthcare professionals communicate prognosis to
patients nor identify what patients want to learn about
their cancer. One study in Japan has looked specifically
at the wishes of cancer patients regarding the disclosure
of prognosis and found that ∼86% of the patients
wanted a full and realistic picture of their disease and
outlook.2
The discussion of treatment options in the palliative
setting is clearly an important area. Keating et al.
examined the significance of the role that patients take
in the decision making process related to their
management. Shared decision making between the
patient and the physician were found to be more
common when there was a good evidence base for an
intervention, and when the evidence was uncertain for
an intervention, patient control was greatest. However,
we know very little of how oncologists communicate
risk benefits in terms of potential treatment options in
the palliative setting, and what actually constitutes a
meaningful gain in life expectancy for patients taking
part in these difficult discussions. Some recent studies
have addressed some of the central themes in these
discussions.3,4,5 Our objective was to find out cancer
patients’ views in a UK cancer centre on a range of
issues surrounding communication of prognosis and
end-of-life decisions.
In this study, we sought to ascertain what potential
gains in lifespan would be acceptable to patients in
exchange for the side-effects associated with cytotoxic
chemotherapy. We aimed to better understand
patients’ views and experiences of communication of
prognosis and treatment options, with the aim of
informing future clinical practice. We also sought to
elicit frank opinions regarding changes in patients’
attitudes and lifestyle with a diagnosis of cancer,
patients’ views as to the exchange of information
surrounding cancer and to understand what the most
significant issues were in confronting and dealing with a
cancer diagnosis.
Finally, we saw this as a forum for a freeform exchange
of ideas between patients and ourselves. As an
anonymous survey, it enabled patients to give their
honest impressions of their journey through an NHS
cancer centre and an opportunity at a local level to
inform us as to what we could do to improve the
doctor–patient relationship.
Methods
A questionnaire was designed that encompassed
patient demographics, communication regarding
treatment options and prognosis, changes in quality of
life and attitude subsequent to a cancer diagnosis, and
quality of treatment in the NHS, including the role of
NICE and the funding of cancer drugs. The questionnaire
was designed as an audit of patient experiences, and
was compiled following consultation with medical and
paramedical staff within the Department of Oncology.
The questionnaire was completed in both an inpatient
and outpatient setting at the Hammersmith Hospital
between January and July 2010. The questionnaire
contained areas where freeform responses were
encouraged. A copy of the questionnaire is shown
in Figure 1.
Figure 1.
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Demographics of patients completing the survey.
Results
Demographics
All ranges of ages were represented, 59 patients (61%)
were of the age group 61–80 years (Figure 1). Of the
patients, 65% had gone on to secondary or university
education and 78% had English as their first language.
There was a 1:1 ratio of men to women and 96% had
undergone treatment (Figure 2).
Figure 2.
View largeDownload slide
Treatments experienced by patients who undertook
survey.
Communication of issues surrounding cancer and
prognosis
Of the patients, 66% recalled being given a prognosis
related to their malignancy, while only 61% had asked
to discuss prognosis (Figure 3). Eight percent of the
patients felt that physicians should not communicate
bad news to patients, and 14% that clinicians should
only communicate good news to patients. Information
was sourced from the Internet by 31% of the patients
and 7% of the patients sought information from other
patients (Figure 5). Ninety percent of the patients felt
that they received the clearest information about their
cancer from their physicians (Figure 6). It is of interest
that patients gained support in dealing with their illness
from a variety of people that ranged from family and
friends, nurses and doctors (Figure 7), but family for the
majority of patients was the most important support
(Figure 8).
Figure 3.
View largeDownload slide
Patients’ views regarding communication of prognosis.
Figure 4.View largeDownload slide
Why do you think you are being treated?
Figure 5.
View largeDownload slide
How have you informed yourself about your condition?
Figure 6.
View largeDownload slide
Who has given you the clearest information about your
cancer?
Figure 7.
View largeDownload slide
Who has been the most helpful in dealing with your
illness?
Figure 8.
View largeDownload slide
Which family members have you told about your
illness?
Changes in lifestyle and attitudes following a diagnosis
of cancer
Patients were asked about their relationships following
a cancer diagnosis, and approximately one-third of
patients acknowledged a change in their relationship to
a close family member (Figure 9). One third of the
patients noticed a change in their attitude to financial
matters. We asked the patients how cancer had
affected their lives. Amongst the worst aspects of their
illness was the time spent in hospital and time lost in
travelling to and from hospital. Our patients expressed
concerns about pain (12%), fear of death (12%) and
sickness (10%) (Figure 10).
Figure 9.
View largeDownload slide
Since your diagnosis has your attitude changed towards
partner, children, friends and finance?
Figure 10.
View largeDownload slide
What are the worst aspects of your illness?
Treatment Decisions in Palliative care
We were interested in understanding how patients
valued the costs to them of a notional extension of their
lives. It is no surprise that 98% of the patients were
willing to accept the considerable toxicities of
chemotherapy for a 5-year extension to their lives, but
it is possibly surprising that 89% would accept
chemotherapy for a 3-month extension to life. Only a
minority of the patients would not be prepared to
accept a gain of lifespan alone when balanced with the
side effects of chemotherapy (Figure 11). Patients
understanding of why they were being treated varied
(Figure 4) from symptom relief to cure.
Figure 11.
View largeDownload slide
If you were offered treatment that had side effects such
as hair loss, infection, sickness and loss of appetite
would you accept this if there was a chance that you
were to gain.
We wanted clarity whether or not patients wanted to
know if they had just a short period of life left in the
terminal phases of their illness. The clear majority of
patients wanted to be informed that time was short but
12% of the patients would not want to be told if they
had a very short time left to live, and 16% of the
patients would not want their family to be told (Figure
12).
Figure 12.
View largeDownload slide
If you were very seriously ill with a short time to live.
Comments from patients
This study welcomed comments from patients and we
reproduce some of their remarks because of their
informative value.
Patient comments on the issue of prognosis
“I trust my caregivers to provide me with information as
and when I need to know and I would never necessarily
think that anything was being withheld deliberately … as
information relating to my condition is in a constant
state of flux and change”
“I sense that patients may be confused by not being
given a detailed prognosis which may lead to a
breakdown in communication between the doctor and
patients of a certain disposition”
“Being provided with a full picture can undermine the
very positive approach which is required to face up to
such a serious health situation”
Patient comments on changes in attitudes since their
diagnosis.
“I have developed a more positive attitude to those
around me”
“I try not to think about the illness so it can't affect my
life”
“Getting to hospital so regularly is too expensive”
“It showed me who my real friends were”
“I Listen more to my partner”
“I appreciate my friends more because of the support
they give me”
“Money seems a bit more trivial”
“I have had to cut down on what I can do and had to
learn to cope with that”
Discussion
This survey sought to highlight patients’ views on the
difficult decisions that are discussed regularly in
oncology. One hundred and twenty-five patients were
issued questionnaires and 96 questionnaires were
completed and available for analysis. This response rate
of 76.8% compares favourably to the 2010 National
Cancer survey response rate of 67%.1 The cohort of 96
patients were drawn from all age groups and were
receiving a wide selection of oncology interventions
including chemotherapy and radiotherapy.
The subject of prognosis disclosure in the palliative
setting has been the focus of much research in recent
years. The paternalistic practice of withholding
information, previously justified as being in the patient's
‘best interest’ has been shown to be confusing and even
harmful to patients psychological well-being.6 Our
questionnaire revealed that most patients do want to be
given accurate information with regard to prognosis,
even if this is bad news, and the large majority do not
support withholding of information. However, this view
is not universal and a small minority of patients do not
want to know if the prognosis is poor. It is clear,
therefore, that the dissemination of information needs to
be tailored to the patient.
Patients obtain information about their cancer from a
variety of sources and if we as cancer physicians are not
taking the lead in finding out what the individual wants
to know of their prognosis early on in their management
process, they are likely to use one of these other sources
to fill in the gaps in their understanding in order to come
to terms with their malignancy. Our study has shown
how wide the range of information is that patients use,
and with this breadth of range come problems as this
may lead to the patient being misled. We have observed
that patients have used other patients and the internet as
sources of information. What they learn may be accurate
and relevant, but equally it may not be appropriate. This
may lead to a divergence in management expectations
between the patient and medical team, and ultimately an
erosion in trust.
Patients have a diverse social support network and rely
on friends, family and healthcare providers to cope with
their diagnosis. A third of the patients felt that their
illness had changed their relationship with their family.
It is not surprising, therefore, that one of the greatest
concerns after a diagnosis of cancer was a breakdown in
family relationships as well as a change in attitudes of
friends. Other expected concerns included the fear of
death, pain, loss of income and a loss of dignity.
Organizations including Macmillan Cancer Care in the
UK have resources allocated specifically to address these
difficult psychological sequelae, and it is clear from this
survey that these resources are important and in demand.
A surprising feature of our survey was the high
proportion of patients who expressed that time in
hospital, and more specifically difficulties getting to
hospital for appointments was their major concern in
importance. We recommend that this aspect of care be
the focus of providers of healthcare.
When offering palliative radiotherapy or chemotherapy
with the aim of improving symptoms and prolonging life
oncologists often have to use time frames to describe to
patients what the potential benefit could be. It is
alarming that a recent study showed that approximately
two-thirds of the patients undergoing palliative
chemotherapy had not had a clear indication of the
intended duration of benefit of the treatment in terms of
life expectancy.7 Similarly another study in the Phase 1
setting highlighted failings in this discussion between
oncologists and patients.8When doctors give a prognosis
to patients, their estimates are currently just ‘estimates’.
Despite this limitation, the patient needs to understand
risks and benefits of treatment in the context of life
expectancy. Our study has shown that not all patients are
willing to accept the ill defined or abstract concept of a
general prolongation of life in exchange for a life
burdened by the side effects of treatment. Furthermore, a
defined subset of patients are consistently not willing to
accept 3 months, 1 year or even 5 years more in life
expectancy gained as a result of treatment. In many
situations, the gain from palliative chemotherapy will be
modest and measured in weeks. In our view, the
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
treatment goals that may be of limited efficacy with
more precision with patients who may then elect to not
undergo therapy.
Should we be telling patients that they are dying? A
recent study has shown that patients who were informed
of their terminal state had significantly less emotional
distress, and interestingly, fewer symptoms than those
who had to guess at their condition.9 It may, therefore,
be beneficial for patients to know that they are in the
terminal phase of their illness, but how many patients
would want that information to be shared with them?
Twelve percent of the patients in this study have
indicated that they would not want to be informed if they
were seriously ill with a short time to live, and 16%
would not want their families to be informed. This fact
clearly demonstrates the need for advance planning in
cancer management and that as physicians we need to
obtain a clear picture of what level of information the
individual would like to possess. However, views do
change as treatment progresses, and so clinicians do
need to be aware that patients’ opinions on their
information needs may alter with the course of their
cancer. To this end, the UK General Medical Council
document ‘End-of-Life Care’ gives clear guidance to
clinicians regarding advance planning in the palliative
setting.
Conclusions
This study aimed to give oncologists in the UK an
impression of our patients’ opinions about areas of
communication and management that have been
controversial. Prognosis and end-of-life care are difficult
areas and there are often conflicting opinions about what
the patient should know, and what part they play in the
decision-making process. Patients’ opinions vary as to
what they wish to know about their prognosis and end-
of-life care, and also as to what benefit is acceptable
when undertaking life prolonging but not curative
treatment. Significantly, there appears to be a minority
of patients who do not want to know if their prognosis is
poor or when they are approaching the end of their life.
In the same way, a minority of patients do not wish for
life-prolonging treatment at the cost of potential side
effects, no matter how great the gain may be. The results
presented here weigh strongly against any attempt to
make generalized assumptions about cancer patients’
views. In one way to do so betrays the fundamental
principle of individuality and autonomy that must guide
oncologists when discussing these issues with their
patients. We suggest that this study shows that we must
focus on advance care planning. Furthermore, we
advocate clear documentation of ‘what if’ discussions
early on in a palliative patients’ management.
J Med Ethics. 2006 Dec; 32(12): 693–697.
doi: 10.1136/jme.2005.015487
PMCID: PMC2563347
PMID: 17145907
The truth‐telling issue and
changes in lifestyle in patients
with cancer
V Kostopoulou and K Katsouyanni
Author information Article notes Copyright and License
information Disclaimer
This article has been cited by other articles in PMC.
Abstract
Although life‐threatening health events can motivate
patients to undertake health promotion activities,1there
are few data regarding changes in lifestyle in response to
a diagnosis of cancer. The increasing incidence of cancer
suggests the necessity to prompt a range of initiatives to
raise awareness of the problem and convince patients to
adopt a healthy lifestyle that can positively influence
outcome. Given the central role of oncologists and the
trust placed on their advice, the delivery of health
messages aimed at changing lifestyle towards a healthier
way may be especially meaningful.2 In such a context,
disclosure of the true diagnosis is a prerequisite to
transmit the medical information, present a practical and
realistic message about lifestyle factors and elicit the
collaboration of the patient in developing a strategic plan
for the future.
Attitudes about the truth‐telling issue are related to
convictions about the benefit or harm to the patient
caused by being informed, and are strongly connected to
social, geographical and cultural factors,3 varying from a
paternalistic approach mostly encountered in the
Mediterranean population, viewing the doctor as a
powerful figure exercising unilateral decisions,4 to the
more autonomous American perspective based on
providing thorough information and enabling the patient
to make informed choices and plan health‐promoting
strategies.5 The principles of informed consent and
patient autonomy have created clear ethical and legal
obligations to provide patients with as much information
as they desire about their illness and their treatment.
Disclosing the truth means that the patients get all the
medical information they need to make decisions about
their body and their life. Our study investigated the
relationship between changes in lifestyle and awareness
of the diagnosis among patients with cancer, in a
population in which a substantial proportion of patients
with cancer ignores the accurate diagnosis of their
illness.
In all, 124 patients with histologically confirmed
prostate, breast and colorectal cancer were personally
interviewed by the investigator (VK), an MD working at
the hospital, while being treated as inpatients or during
their follow‐up visits as outpatients, in “Metaxa” Cancer
Hospital of Piraeus‐Athens, in 2004. Eligible patients
were the first 124 Greek‐speaking adults diagnosed 6–24
months before sampling, to obtain roughly equal
numbers of men and women. All selected patients were
in good performance status (performance status = 0
according to the Eastern Cooperative Oncology
Group)6 without any pre‐existing cardiovascular
diseases. Informed consent forms were signed by all the
patients.
Each patient was asked to report on changes made in
lifestyle after the diagnosis of the specific health
problem they were being or had been treated for in that
hospital. They were asked if they had made any changes
in their dietary habits to improve their health. If yes, they
were asked to specify the kind of change choosing from
a list of options: (a) ate more fruits and vegetables; (b)
ate less meat; (c) ate less fat; (d) fasted more often; (e)
used dietary supplements; (f) followed a weight‐
reduction diet; (g) consumed less alcohol; and (h) other.
This method of assessing changes in diet was used in
other studies of trends in diet.7In a similar way, patients
were asked if they had begun any physical activity aimed
at improving their health. If yes, they were asked to
specify by choosing among (a) worked out in a gym; (b)
worked out at home; (c) walked more; (d) started any
kind of sport; and (e) other. For the above questions,
more than one answer was allowed. Patients were finally
asked if they were smokers, ex‐smokers or non‐smokers.
Smokers and ex‐smokers were asked if they had given
up or reduced smoking after the diagnosis of the health
problem they were being or had been treated for in that
hospital to improve their health. The information
regarding the awareness of the patient of the diagnosis of
cancer was either extracted cautiously from him or her or
given by the patient's family member. Patients who had
made at least one change in lifestyle were also asked to
indicate their source of information for this change: (a)
their doctor; (b) mass media; and (c) their relatives or
friends.
Sociodemographic data on age, education and sex were
collected. Data on the disease, such as type of cancer,
stage of disease, number of treatments received (one,
two, three or more different kinds of treatments), time
since histological diagnosis and type of patient (inpatient
or outpatient), were also collected using the hospital
registries.
Statistical comparisons between the two groups of
patients (informed and uninformed) were made with
χ2tests or Fisher's exact tests (where needed). Logistic
regression analysis was used to estimate odds ratios
(ORs) as the measure of association of changes in
lifestyle with awareness of the diagnosis, education (in
years, ⩽6, >6), age (in years, ⩽65, >65), time from
diagnosis (in months, ⩽12, >12), stage of disease (local
or distant) and type of patient (inpatient or outpatient).
Variables were divided into categories by using the
median values. All ORs are adjusted for confounding
factors (age, education, sex, stage, number of treatments,
type of cancer and type of patient). It is important to note
that because of the types of cancer selected for our study,
sex and type of cancer are confounded, given that all
patients with breast cancer were women and all patients
with prostate cancer were men. To reduce the
confounding effect, and to achieve a good interpretation
of the results, a new variable was created containing
diagnosis and sex, which divided patients into four
groups: (1) men affected by colorectal cancer; (2)
women affected by colorectal cancer; (3) breast cancer;
and (4) prostate cancer. Interactions among independent
variables were also checked for possible associations
with changes in lifestyle.
The sample comprised 124 adult patients with cancer, of
whom 50 had breast cancer, 50 had colorectal cancer and
24 had prostate cancer. A total of 55% of the patients
were women, 55% were newly diagnosed (within the
previous 12 months, the mean age was 62.3 (standard
deviation 12.4) years, 60% had an elementary education
and 22% of the patients were not informed about the
diagnosis of cancer.
Table 11 shows the most common changes in lifestyle,
defined as changes that at least 5% of the patients
reported making. Overall, changes in lifestyle were
common among patients with cancer, as about 80% of
them reported making at least one change: about 40%
made dietary changes, 15% added new physical activity
and 25% reduced or stopped smoking. Among dietary
changes, the most common were drinking less alcohol
and eating less fat; for physical activity, the most
common change was walking more; for changes in
smoking activity, almost half the patients stopped
smoking..
Table 22 shows the association between awareness of
the true diagnosis and patients' characteristics
(sociodemographic data and changes in lifestyle).
Table 2 Association of awareness of the diagnosis
with clinical characteristics among patients with
breast cancer (n = 50), colorectal cancer (n = 50) and
prostate cancer (n = 24)
†The model includes awareness of the diagnosis, age,
sex, education, stage, medical treatments, diagnosis date
and type of patient. Therefore, the ORs reported are
adjusted for the other variables.
Table 44 shows the association between changes in
lifestyle and source of information in the groups of
informed and uninformed patients.
Table 4 Association between changes in lifestyle
and source of information in the two groups of
patients (informed and uninformed)
Among changes in lifestyle, dietary changes were
associated with awareness of the true diagnosis
(p = 0.049), whereas among other patients'
characteristics, age (p<0.001) and education (p<0.001)
were also strongly associated. Adjusted for other
sociodemographic factors and for the confounding effect
of education (an index of socioeconomic status), patients
who were aware of the diagnosis of cancer were more
than twice as likely to change dietary habits towards a
healthier way as patients who were not informed
(p<0.1). Compared with men affected by colorectal
cancer, women with breast cancer were 65% less likely
to make dietary changes after a diagnosis of cancer.
Overall, older patients were 97% less likely to add new
physical activity (p<0.01); among older patients, more
educated ones were about 20 times as likely to add new
physical activity (data not shown), whereas among
younger patients, more educated ones were only 4% as
likely to start exercising (data not shown). This implies
an interaction between age and education. Compared
with men affected by colorectal cancer, women affected
by the same type of cancer and patients with breast
cancer were, respectively, about 15 and 17 times as
likely to change their smoking habit (p<0.05 and
p<0.001, respectively). Compared with newly diagnosed
patients, those diagnosed more than 12 months
previously were 75% less likely to change their smoking
habit (p<0.1).
Informed and uninformed patients were equally advised
by their doctor, their relatives and friends or informed by
mass media about dietary and exercise changes, although
informed patients were more conscious on acquiring
information from mass media about giving up their
smoking habit (p = 0.014).
Our study indicates that most patients with cancer
reported making changes in lifestyle to improve their
health and well being after a diagnosis of cancer. These
data are consistent with a survey of 536 cancer
survivors, which also showed that about 70% of the
patients reported making changes in lifestyle: 40% made
dietary changes and 20% added physical activity.7
After controlling for sex, education, type of cancer, age,
stage of disease, number of treatments, type of patient
and time since diagnosis, patients to whom the diagnosis
was disclosed were 2.5 times as likely to change their
diet to a healthier one than patients from whom the truth
was withheld. The trend to significance of this
association implies a strong connection between
awareness of the diagnosis of cancer and dietary
changes, given the small sample size. Although physical
exercise is a particularly attractive option among
interventions designed to improve survival in patients
with cancer because of its other known health benefits
and its positive influence on biological systems
associated with anticancer defence,8those patients who
were not likely to add new physical activity probably
attributed it to their conviction of being more fragile and
having to avoid exposure to potentially harmful
environmental factors.
Older patients were less likely to adopt new lifestyle
practices in response to a diagnosis of cancer, whereas
women were more likely to make changes. These results
are similar to findings from studies on prevalence of
changes in lifestyle among patients with cancer
Newly diagnosed patients were more likely to change
their smoking habit than patients diagnosed more than
12 months previously, which can be explained by the
strong initial motivation offered by the seriousness of the
diagnosis. It should, however, be noted that the selected
cancer sites are not the ones primarily related to
smoking, so the motivation may have been lower.
Overall, changes in diet and smoking were more
frequent among newly diagnosed patients, whereas
physical activity was undertaken more often after 12
months of the diagnosis, given the poor physical status
during cancer treatment.
In our study, more than 77% of patients with cancer
seemed to be aware of the diagnosis, which is a high
percentage considering the Mediterranean approach to
the truth‐telling issue. Data from a study on oncologists
practising in North America, Europe, South America or
Asia and their attitudes in giving bad news suggested
that doctors from Western countries were less likely to
withhold unfavourable information from the patient at
the family's request or avoid the discussion entirely than
doctors from other countries.3Other data from studies on
different countries about attitudes towards informing
patients suggest that in Italy opposition from relatives to
disclosure of the diagnosis appears to be
common, whereas in Pakistan, crucial decisions are often
made by family members or are left entirely up to the
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
dilemmas in caring for patients.In a survey conducted in
Greece to assess the public attitudes to the disclosure of
the diagnosis issue in patients with good prognosis,
doctors themselves replied “Yes” less often (41.3%) than
all other professionals (50.8%) to a highly significant
level (p<0.001). In the same study, the reasons given to
justify truth telling could be described as emotional, such
as the patient's motivation to follow the doctor's
instructions accurately, to be more careful, to organise
his or her life in a better way. Our study proposes one
more reason: the possibility of deferring, through
making changes in lifestyle, the time of death for as long
as possible. Data from a study on American adults
indicate that limited awareness of health problems has
emerged as a greater barrier to their management.14 As
knowledge and information can influence control, the
media can play a powerful part in influencing health
behaviour. The application of social marketing principles
to health promotion has proved effective in motivating
people to make complex behaviour changes that can
improve health. Data from a survey in New Zealand
about the effect of an initiative to increase physical
activity at a population level resulted in increases in
message recognition and in the intention to become more
active.
Our study has several limitations. The prevalence
estimates of changes in lifestyle calculated cannot be
generalised to all patients with cancer because of
collection of data from only one cancer institute and
selection of cancer types with high survival rates.
Because of good prognosis, motivation to make changes
in lifestyle for these patients could be different. On the
other hand, the gain in patients with good prognosis is
proportionally larger. Additional studies would be
needed to assess changes in lifestyle in more patients
affected by various types of cancer treated in different
cancer institutes all over the country. Finally, the data
collected were based on self report and were in many
cases gathered during hospitalisation for treatment.
Therefore, it is possible that the answers given were
somewhat affected by psychological factors. All
patients, however, had the same motivation to report a
healthier profile. Thus, the ORs should not be biased.
The results of these data suggest that patients with
cancer are highly motivated to make changes in lifestyle
and therefore represent a group that could benefit from
counselling on diet, physical activity and smoking status.
In this context, truth telling is an alternative to the
practice usually followed of withholding the truth, an
alternative with many difficulties, which requires
particular professional and individual skills.
J Am Diet Assoc. 2003 Mar;103(3):323-8.
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