Monday, August 4, 2008

'Averages are dangerous statistics'

Continuing a theme from the above Cancer article, BMJ has a study looking at oncologists' disclosure of the survival benefit of 'palliative'** chemotherapy. This is a small (37 patients, 9 oncologists), single-center (Bristol, UK), qualitative study which involved audio recordings of patients' initial meetings with an oncologist to discuss treatment options after a diagnosis of either advanced non-small cell lung cancer, pancreatic cancer, or colorectal cancer. These conversations were also personally attended by a research assistant who sat (silently) in the room: this person had already met the patient and received permission to be there, etc. The conversations were analyzed via a grounded theory approach.

The researchers describe that the incurable nature of the cancer was nearly always explained, however solid information about survival benefit of treatment was not. They summarize their findings here:

This ranged from giving numerical data, such as "about four weeks"; through an idea of timescales, such as "a few months extra"; to vague references, including "buy you some time"; to not being mentioned at all. During the recorded consultations, only six of the 37 patients were given numerical data about the survival benefit of treatment. These included three of the 23 patients who accepted palliative chemotherapy. In most consultations (26/37) the discussion of survival benefit was either vague or non-existent.
This is in contrast to the patients receiving detailed information about side effects and risks of treatment. The remainder of the paper is a fascinating look into these real conversations - with direct transcripts of excerpts of many of them along with a great discussion about aspects of these conversations: patient/family members blocking of prognostic information, how oncologists responded to direct questioning about survival benefit, the distinction between discussing overall prognosis and just survival benefit from chemo, etc. It's a good one for the teaching file - to look at real-life language and how it's used in these situations. I thought this exchange was notable:
Patient’s wife: You’re going to fight it. You said you would.
Patient 315: Yeah but it doesn’t mean to say it’s only going to be nine months I mean it might be 12, it might be 15, it might be.
Oncologist 103: Averages are dangerous statistics.
Patient 315: Yeah, you never know. I said to you before I’d sooner have a short amount of time with a bit of bonus to it, a bit of benefit. If I had to go into hospital for five weeks every day and, and not benefit from it and even catch something worse and end up back in hospital for the rest of me life basically, then I’d have to top myself.
Chemotherapy was offered and refused; the patient died three months later.

There's a supporting editorial here.

**We've griped on the blog before about how it's confusing to use the term 'palliative' to refer to non-curative but yet disease-modifying (life-prolonging) chemotherapy, but this is the language used in the paper. Along these lines, the same BMJ has a case-report detailing confusion about what level of care was appropriate for a patient - confusion seemingly based in the fact that the patient was labeled as a 'palliative care patient.' In this case the palliative care team advocated for more aggressive life-prolonging/restorative care than was initially considered 'appropriate.' This is a situation I find myself in from time to time - and it was nice to see this discussed in a prominent journal. My clinical team tries to keep on our radar other clinicians' reactions to our involvement as at times people can incorrectly assume we're there because a patient is imminently dying, or that their care goals are 'palliative-only.'

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