Do doctors know when their patients don't? A survey of doctor-patient communication in lung cancer.

OBJECTIVES: a) To determine how much patients with recently diagnosed lung cancer know about their illness and its treatment, and b) to find out if doctors know what their patients know and what they don't. PATIENTS AND METHODS: One hundred patients with recently diagnosed lung cancer, who were undergoing radiotherapy or chemotherapy, were interviewed to determine their view of their diagnosis, the extent of the cancer, the intent of treatment, and the risks and benefits of treatment. Their attending physicians' view were elicited contemporaneously, using a self-administered questionnaire. The principle outcome measure of the study was the level of agreement between the views of the patients and the doctors about the disease, the treatment, and the prognosis. Concordance between doctors' and patients' views was expressed in terms of percentage agreement, and Kappa (kappa). RESULTS: Ninety-nine percent of the patients knew that they had lung cancer. Sixty-four percent (64%) agreed with their doctor about the extent of the disease (kappa = 0.48). Most of those who disagreed underestimated the extent of their cancer. Seventy-two percent (72%) agreed with their doctor about the intent of treatment (kappa = 0.49). Thirty-six percent (36%) agreed with their doctors about their probability of cure, (kappa = 0.17): most of those who disagreed systematically overestimated it. Sixty-eight patients were receiving palliative treatment. Of these, 56% agreed with their doctor about the probability of symptomatic benefit (kappa = 0.42), but only 14% agreed with their doctor about the probability that the treatment would prolong life (kappa = 0.06). Doctors frequently failed to recognize their patients' misconceptions about the intent of treatment and the prognosis. CONCLUSION: Many patients did not understand their situation well enough to make a truly autonomous treatment decision, and their doctors often failed to recognize this.

Psychiatric illness and psychosocial concerns of patients with newly diagnosed lung cancer.

OBJECTIVE: To determine the nature and incidence of psychiatric illness, symptoms of potential psychiatric significance, substance abuse and psychosocial concerns among patients with newly diagnosed lung cancer. DESIGN: Case series. SETTING: Kingston Regional Cancer Centre, a tertiary care facility for ambulatory cancer patients. PATIENTS: Seventy-one consecutive English-speaking patients with recently diagnosed lung cancer undergoing radiotherapy or chemotherapy were asked to participate; 52 of the 57 patients who agreed were available for evaluation. OUTCOME MEASURES: Current and previous psychiatric diagnoses of affective, anxiety and adjustment disorders, and alcohol and tobacco abuse; symptoms of sadness, fear, shock, anger, denial, acceptance, guilt, suicidal ideation, thoughts of death, insomnia, loss of libido, impaired concentration and reduced level of work or interest; psychosocial concerns about family, work and finances; and an impression of coping. RESULTS: At the time of the interview two (4%) of the patients were found to have an affective disorder, none had an anxiety disorder, and six (12%) had an adjustment disorder. Previously, 16 patients (31%) had had an affective or anxiety disorder or both. Two (4%) had had an adjustment disorder following the diagnosis of their lung cancer that had resolved before the interview. At some point in their lives 24 patients (46%) had abused alcohol, and 7 (13%) were currently abusing alcohol. All had smoked, 33 (63%) having been tobacco dependent. Feelings of sadness were expressed by 23 (44%), fear by 15 (29%), anger by 2 (4%), shock by 9 (17%) and guilt by 4 (8%). Seven (13%) had considered suicide, and thoughts of death were reported by 16 (31%). Twenty (38%) were accepting of their diagnosis, and 5 (10%) expressed optimism. Twenty-seven (52%) had insomnia, which was reported to be severe by 15 (29%). Loss of libido was reported by 25 (48%) and was severe in 14 (27%). Difficulty concentrating was reported by 10 (19%) and a reduced ability to work or loss of interest by 17 (33%). Fifteen patients (29%) were concerned about their families and 4 (8%) about work or finances. Most (41 [79%]) had good family support, and 23 (44%) found support in religion. Seven patients (13%) seemed to be coping poorly. CONCLUSIONS: Although psychiatric illness was infrequent, symptoms of potential psychiatric significance and psychosocial concerns were common in this patient population. Attention to these symptoms and concerns should be addressed in a systematic and effective way by all health care professionals and agencies planning the care of patients with lung cancer.

Systemic adjuvant therapy for node-negative breast cancer.

In response to recent advice from the US National Cancer Institute concerning the use of systemic adjuvant therapy for node-negative breast cancer we reviewed the literature and found that several studies have shown evidence of a disease-free, but not an overall, survival advantage for treated patients. The benefits have been modest and may not outweight the cost and toxic effects of such therapy. Routine use does not seem to be justified. Factors must be identified to differentiate between patients at low risk and those at high risk. It should then be determined if adjuvant therapy is truly beneficial in those who are at high risk.

Cancer patients' perceptions of their disease and its treatment.

One hundred cancer patients undergoing active treatment were interviewed to determine how they perceived their illness and how their perceptions compared with those of their attending physicians. Ninety-eight patients recognized that they had cancer and 87 correctly identified the tumour type. Sixty-four of 67 patients with local or regional disease were aware of this, but 11 of 33 patients with metastatic disease incorrectly believed that the cancer was localized. Five of 52 patients being treated for cure thought they were being treated palliatively, and 16 of 48 patients receiving palliative treatment believed that the doctor's aim was to cure them. Forty of these 48 patients significantly overestimated the probability that the treatment would prolong their lives. Patients with little secondary education were significantly more likely to underestimate the seriousness of their condition. Interactions between doctor and patients were not observed directly and it was therefore not possible to determine whether patients' inaccurate views of their illness were due to suboptimal communication or denial. Doctors frequently failed to recognize their patients' misconceptions. In only one of the 16 cases in which a patient, who was being treated palliatively, believed that the treatment was curative did the doctor recognize that this misunderstanding existed.

Erythroblast multinuclearity in bone marrow and spleen. Congenital dyserythropoietic anemia-like abnormalities without functional evidence of dyserythropoiesis.

A dyserythropoietic syndrome with coincidental immune thrombocytopenia seen during pregnancy is discussed. The morphological and serological results in this case most resemble type II congenital dyserythropoietic anemia. However, functional evidence of dyserythropoiesis was absent and the patient was not anemic. Splenectomy was performed for the resistant thrombocytopenia and microscopic examination of the spleen showed evidence of extramedullary dyserythropoiesis. The significance of these findings is discussed with regard to the spectrum of recognized dyserythropoietic disorders and the unusual discrepancy between the abnormal morphology and the absence of functional dyserythropoiesis.

Comparison of intraining evaluation with tests of clinical ability in medical students.

Seventy-two medical students were studied regarding the predictive value of a number of evaluation procedures as they rotated through the Department of Medicine during their four-year undergraduate medical program at Queen's University in Kingston, Ontario, Canada. Scores obtained in two subjective evaluation procedures--one compiled at the completion of the second-year clinical skills course and the other at the end of the fourth-year clerkship--were compared with each other and with scores obtained on an objective structured clinical examination, two multiple-choice examinations, and two oral examinations. Even in this fairly homogeneous group of teachers and students, correlation between the different evaluation procedures was absent or slight.

Iron therapy.

Iron deficiency is a very common disorder. It is always worthwhile to confirm the diagnosis by measuring both serum iron and serum iron binding capacity, before instituting treatment. A diagnosis of iron deficiency demands that its cause be established. Therapy requires that the lost iron be replaced, and that the underlying condition be treated. Replacement may be achieved safely, cheaply and effectively with oral iron therapy. There is very rarely a need to treat an iron deficient patient with parenteral therapy.

The presence of distinct and stable skills among students assessed for clinical competence in oncology.

Several aspects of clinical competence in oncology were assessed among sixty-one fourth-year medical students, and results correlated with success in other areas of the curriculum as well as the extent of previous exposure to cancer patients. The inter-relationships identified by factor analysis among the outcome and predictor measures suggest that several distinct competencies were being assessed. In addition, certain skills, such as the ability to generate appropriate diagnostic hypotheses and to perform well on multiple-choice exams, appear to have been stable across time. These findings imply that there are distinct components to clinical competence, and that various methods of evaluation reflect these competencies differently.

O2 transport during exercise following blood reinfusion.

Reasons for an increase in maximal O2 consumption (VO2max) following blood reinfusion remain unclear; thus the present investigation was undertaken to examine the arterial and femoral venous blood gases during submaximal and maximal exercise. Four untrained males (22-25 yr) performed modified Balke work capacity tests under control conditions (Hct = 42.4 +/- 0.8%; Hb = 14.7 +/- 0.5 g X 100 ml-1) and following autologous blood reinfusion (Hct = 46.2 +/- 1.3%; Hb = 16.4 +/- 0.9 g X 100 ml-1). VO2 was determined by open-circuit spirometry and cardiac output by the N2O method; radial arterial and deep femoral venous blood were sampled at each work load throughout the incremental work tests. Following blood reinfusion, subjects' VO2max increased (P less than 0.05) from 4.0 (in control) to 4.5 1 X min-1. Throughout submaximal exercise arterial PO2 remained relatively constant (between 80.1 +/- 4.4 and 89.1 +/- 5.0 Torr) and cardiac output unchanged, comparing the two experimental conditions. Femoral venous PO2 values were almost identical throughout the work capacity tests, declining at exhaustion to 15.7 +/- 1.5 Torr in control and to 13.8 +/- 3.3 Torr postreinfusion. It appeared that the subjects' increase in VO2max postreinfusion was due to an increased O2 supplied to the tissue [i.e., cardiac output (Q) X arterial O2 content (CaO2)] by the central circulation. This resulted from a small (10%) increase in Q and a constant elevation in CaO2 of 1.7-2.2 ml X 100 ml-1, since virtually no changes were observed in the femoral venous blood postreinfusion and the acid-base status and temperature, important determinant of O2 dissociation, were (almost) identical, comparing the two experimental conditions.

Hematologic changes in a patient with Hodgkin's disease in relapse.

A patient with Hodgkin's disease also had anemia, hypochromia, and thrombocytosis, which were clues to an otherwise silent relapse. These features were corrected following chemotherapy. Repeated lymphangiography is shown to be of value in diagnosis.

Myeloproliferative disorders: a paradox of in-vivo and in-vitro platelet function.

A patient with features of a myeloproliferative disorder developed an acute multisystems illness and died. In-vitro platelet aggregation was imparied, but necropsy revealed widespread platelet-rich thromboemboli and multiple organ infarctions. It is suggested that platelets are damaged during disseminated intravascular platelet aggregation (DIPA) and that disaggregation of platelet thrombi and recirculation of platelets give rise to their subsequent hypofunction when tested in vitro.

Platelet function in patients with high platelet counts.

Platelet function tests were done to ascertain whether they might have discriminatory significance in the differentiation of a myeloproliferative disorder from secondary thrombocytosis in a patient with an elevated platelet count. Amongst 14 subjects with polycythaemia vera and essential thrombocythaemia, significant abnormalities of platelet aggregation were the rule, while defective aggregation was unusual in 16 subjects with secondary thrombocytosis. Measurements of the bleeding time and of platelet factor 3 activity were of some value, but significant overlap was noted. Platelet function in four of five subjects with chronic myeloid leukaemia was essentially normal.