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Receiving a cancer diagnosis fills most people with dread and many consider it as the number one fear. However, patients who are diagnosed with advanced-stage disease often overestimate their life expectancy. Several small studies have indicated that patients can have high expectations, including those who are treated with chemotherapy with palliative intent or to prolong overall survival for advanced-stage solid tumours. These studies reported that many of these patients believe that palliative chemotherapy could be curative. Now, a study published in the New England Journal of Medicine by Jane Weeks and colleagues, has formally assessed the expectations of patients with metastatic lung or colorectal cancer (CRC), in terms of whether they viewed their treatment as curative. The results are alarming: the researchers found that 69% of patients with metastatic lung cancer and 81% of those with CRC did not understand that their treatment was unlikely to be curative.

The researchers studied patient data from the Cancer Care Outcomes Research and Surveillance study—a national, prospective observational cohort study. Data were obtained from a patient survey conducted by professional interviewers as well as assessment of medical records from almost 1,200 patients with metastatic lung or CRC who were alive 4 months following their diagnosis. The interviewers surveyed patients about their personal characteristics, decision making, experience of care, and outcomes. Week's team characterized the reported patient expectations of the effectiveness of chemotherapy, and identified clinical, sociodemographic, and health system factors associated with whether patients thought their treatment would cure them.

Weeks summarizes the key study findings, “the issue here isn't really over-optimism, but instead thinking that a treatment offers a chance of cure when in fact it doesn't. This deprives these patients of the opportunity to weigh the risks of chemotherapy (including the chance of adverse side effects), against the true benefits (perhaps some symptom relief and a few months longer life, but no chance of cure), and to make their own decisions about their care.”

Factors associated with a greater likelihood of unrealistic expectations of treatment were nonwhite race and ethnic group; nonwhite Hispanic patients were more likely than non-Hispanic white patients to misunderstand the benefits of chemotherapy. Interestingly, patients who reported a favourable communication with their physician were more likely to have unrealistic expectations of their therapy being curative than those reporting a lower score for physician communication. This finding might be related to the fact that patients perceive a better communication with their physician if they have conveyed a more optimistic view of chemotherapy. The authors suggest that because CRC is more chemosensitive than lung cancer, and that discussions of prognosis quickly transitioned to a discussion about treatment options (i.e. chemotherapy), this might have led to a higher level of false optimism among patients with CRC about their prognosis. Patient education levels, functional status and the patient's role in decision making were not associated with inaccurate expectations of chemotherapy.

Crucially, if patients have unrealistic expectations of the likelihood of a cure from their treatment, clinicians are faced with a serious problem. As Weeks points out, “the other downside is that patients who think their chemotherapy might cure them may be less open to discussing end-of-life options and care. We know that when these discussions are delayed, both patients and their families experience more suffering at the end of life.”

Among the most important take-home messages of this study is the role that physicians have in communicating realistic prognosis and treatment expectations with their patients. Emphasis should be given to educate and help physicians compassionately engage with their patients who have terminal cancer, and involve them in discussions about end-of-life care, while maintaining patient's trust.

Weeks offers some concluding remarks about the study findings and outlines how they might affect clinical practice: “our results suggest that both doctors and patients play a role. It's completely understandable that patients want to believe that there's a chance for cure, and also understandable that some physicians find it hard to take away that false hope. So, we really need to help physicians understand that honest communication is the way to best serve their patients, and provide training to help them learn to do it with kindness and skill.”