Expectations as outcome of effectiveness for patients with metastatic lung cancer

Lung cancer remains the leading cause of cancer-specific death in men and women. Unfortunately, the majority of patients with non-small-cell lung cancer (NSCLC) have locally advanced or metastatic disease at diagnosis with a 5-year survival rate of only 4% (1). For these patients, chemotherapy and target agents are the standard of palliative treatment to prolong survival and improve quality of life (QoL) (2). In addition, the clinical goal for these patients is not only to improve survival time but as first, to decrease pain and suffering, thereby enhancing the remainder of the patient’s life (3,4). Most of patients with thoracic cancers, developed tumor-related symptoms as cough, shortness of breath, dyspnoea, chest and cancer pain, bronchial obstructions, haemoptysis or other troublesome symptoms, that could be treated with palliative and loco regional treatment, as in particular radiotherapy with palliative intent to relieve tumor-related symptoms and to improve health-related QoL (5,6). Radiation therapy (RT) can be used to palliate symptoms from intra- and extra-thoracic disease, caused by tumor growth that may be safely and adequately encompassed by an RT field (6). Although palliative RT is effective at relieving symptoms, it is not curative, and patient’s expectations differing from physician expectations in terms of results treatment related. To analyse this point of view, in a recent issue of Journal of Clinical Oncology, Chen et al. reported the results of an interesting survey about expectations of the effectiveness of RT among patients with incurable lung cancer (7). This survey was developed because there are considerable evidence that suggests that patients with neoplastic disease may hold unrealistic beliefs about prognosis and the potential efficacy of treatment. The authors, collected data from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS), identifying 384 patients with advanced or metastatic lung cancer that received palliative RT. These patients completed a telephone survey about their expectations of goals of RT regarding the following questions: after talking with your doctors about RT, how likely did you think it was the radiation would… help you live longer? Cure your lung cancer? Help you with problems you were having because of your lung cancer? Response options included “very likely”, “somewhat likely”, “a little likely”, “not at all likely”, “don’t know”, or refuse. Starting from these questions, the study explored different issue regarding expectations about the effectiveness of RT. 67% of patients reported that they felt that RT was very or somewhat likely to help them with problems related to their cancer; 78% felt that RT was very or somewhat likely to help them live longer and 43% felt that it was very or somewhat likely to cure their cancer. About 2/3 of patients believe that palliative RT could be useful to help them with cancer-related problems and to improve their survival, but it is interesting to underline that 43% of patients reported that they think that palliative RT it is able to cure their cancer. To understand better the patients’ opinion about expectations about the effectiveness of palliative RT, it is need to contextualize the results based on different variables, such as information that patients received from physicians before treatment and at the time of diagnosis; the role of family and caregiver support and mainly it is needed to evaluate patients expectations based on the different site of action of RT. Indeed, patients with advanced lung cancer that received RT for lung or mediastinal lesion, think more positive about the effectiveness of RT about cure their cancer; while patients that received RT for bone or brain lesion, have a different perceptions of their disease.

The issue of expectations about the effectiveness of palliative treatment need a particular attention to evaluate the expectations of effectiveness not only regarding RT. As first, it is very important to evaluate the role of information that our patients received from physicians at the time of diagnosis and before starting treatment. Usually, physician utilize positive communication skills when explain to their patients expected survival and choice of treatment related to their survival. Communications relationship between patients and physician is the corner stone of “relationship” between patients and disease. In fact, we must to separate patients that received accurate information regarding palliative treatment, (including prognosis, presentation of management option, assessment of understanding, and supportive remarks) from patients that initially refused to receive complete information regarding their disease. At second, management of patients with incurable lung cancer need a multidisciplinary approach, with a dedicate team ready to follow and help our patients during all time of their disease. In fact, as reported by Temel et al., support of multidisciplinary team associated with early palliative care, improve survival and QoL in patients with metastatic lung cancer (3).

Chen et al., reported that it is not surprising that inaccurate patients beliefs regarding cure from cancer treatment arise, indeed although patients received accurate information about their metastatic disease, frequently they think that they were treated for cure; and even when presented with accurate information many patients may retain inaccurate beliefs. It is clear, that there are psychological denial behaviour that our patient active to protect themselves from ideas of cancer, but especially of death.

It is clear, that patients with advanced or metastatic lung cancer do not understand their prognosis deeply. In fact, sometimes their prognosis appears overestimate, changing the sensations of utilize of end of life palliative treatment of (8,9), reducing its quality.

In the study, in about 80% of patients were evaluated not only for expectation regarding RT, but also about chemotherapy. The results showed that patients with inaccurate beliefs about RT were significantly more likely to also have inaccurate beliefs about chemotherapy. These concept, underline than independently from the kind of palliative treatment, patients present the same attitude of beliefs, regarding their survival.

This interesting paper brings to our knowledge the difficult issue of expectations of palliative treatment in patients with incurable lung cancer. This issue is very intricate because includes not only the beliefs of our patients but in particularly, the relationship of communication between physician, patients and their family. In this study, there is no difference between patients that received accurate information compared with who never received accurate information. It is our care and responsibility, to give to our patients the most accurate information about disease, survival and treatment strategy. For patient who will never receive accurate information, it will very difficult to understand limit and merits of every single treatment strategy, beyond psychological aspect (10,11). In fact, patient’s denial is the primary impediment to realistic treatment expectations, and this situations, require adequate support strategy to help patients with terminal illness and management strategy. In addition, could be interesting evaluate the difference in treatment-compliance between patients that present high expectations of effectiveness from patients with low expectations of effectiveness of RT or other treatment. High expectations could be increase compliance to palliative treatment, improving QoL of our patients.

In our patients that receive palliative treatment, we should consider expectations of effectiveness as outcome of treatment and not consider these expectations similar between patients and physician.

Acknowledgements

Disclosure: The authors declare no conflict of interest.

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