Gender and the Tolerability of Anti–PD-1 Therapy

Sharing serious news is a key communication task that occurs frequently throughout the trajectory of caring for a cancer patient. When sharing serious news, it is important to consider many factors, including those related to patient diversity, such as cultural and family background; language barriers; socioeconomic factors; and health literacy. Importantly, the way in which serious news is discussed signifi cantly affects many outcomes and aspects of patient care. Sharing serious news is not an innate skill but can be effectively taught and learned. ES1071428_ONC0718_334. pgs 07.04. 2018 01:11 ADV black yellow magenta cyan JULY 2018 TheOncologyJournal.com | ONCOLOGY 335 seen rather as an innate ability. [9,10] Oncologists are rarely trained in techniques for sharing serious news. [11,12] Additionally, physicians of en experience negative emotions, such as anxiety and fear of being blamed, when they must tell their patients that treatment has not worked. [13,14] Consequently, there is a danger that they may react to patient emotion by of ering false hope or premature reassurance, or that they may omit important information from the disclosure. [15] Patient diversity, including dif erences in cultural and family background, language, socioeconomic status, and health literacy, can also make sharing serious news more dif cult. [16-18] In a meta-synthesis of more than 40 qualitative studies of breaking bad news, researchers identif ed several factors that af ected these discussions. Among the important factors were the characteristics of the family and cultural considerations. [5] As described previously, cultural background greatly inf uences many aspects of the communication process. Although some cross-cultural descriptive studies have been conducted, especially on views about disclosure of the diagnosis,[19,20] relatively little is known about the specif c inf uence of culture on the interaction between patients and their healthcare practitioners. T e ways in which cultural variables might af ect the information that patients want, their preferred and assumed participatory style, and other aspects of the interaction warrant future study. T ere are many ways in which ef ective communication skills can help clinicians when sharing serious news with patients and their families. Ef ective communication can provide structure for the consultation, enhance the relationship between patients and their families, and may make consultations more ef cient. How the Way Clinicians Communicate Can Impact Patients and Other Key Outcomes T ere is a growing body of empirical research examining the associations between aspects of communication and patient outcomes. Ef ective communication helps establish a working relationship between the practitioner and the patient and plays an important role in the diagnosis and treatment of medical illnesses, including cancer. [21] According to a recent review of physician-patient communication, the three main goals of ef ective communication are: • To create a good interpersonal relationship. • To facilitate exchange of information. • To include patients in decision making. [22] Consistently across the literature, practitioner-patient communication has been identif ed as one of the most essential facets of patient care. [23] Research has shown that aspects of the practitioner-patient interaction impact patient outcomes, including satisfaction, distress, knowledge, and adherence. [24-27] For example, studies have found that empathic communication is associated with improved satisfaction and decreased distress among patients. [25-30] T ese f ndings emphasize the benef ts of ef ective communication between practitioners and their patients and that training practitioners in communication skills may improve their communication with their patients. However, in discussing benef ts of ef ective practitioner-patient communication, it is also important to highlight what constitutes inef ective communication. In a qualitative study of negative feedback from patients about physicians, 38 causes of complaints were analyzed and coded. [31] Results indicated that inef ective communication involved these verbal/nonverbal physician behaviors: • Inadequate information provided to the patient. • Poor quality of information (ie, no rationale given, inadequate explanations). • Lack of empathy and lack of respect. • Poor nonverbal behaviors (ie, lack of eye contact, negative facial expressions, problems with volume/tone of voice). • Poor verbal behaviors (ie, not listening, patients not given a chance to ask questions, inappropriate choice of words). T e deleterious patient outcomes when serious news is shared in an inef ective manner include increased distress and suf ering, failure to thrive, nonadherence, and dissatisfaction with medical care. [25,32,33] Since poor communication has also been found to be associated with medical malpractice suits, this is another important reason to strive to communicate serious news as ef ectively as possible. [34,35] Specific Guidelines and Recommendations for Sharing Serious News Studies have shown that the majority of physicians do not have a consistent plan or strategy when they share serious news with their patients. For example, Baile et al[11] found that among a sample of physicians attending an annual meeting of the American Society of Clinical Oncology, 22% reported that they did not have a consistent approach to the task of breaking bad news to patients, and 51.9% reported that they had several techniques or tactics but did not have an overall plan. Determining what patients believe to be important in the interaction may help ref ne the current guidelines and yield specif c evidence-based recommendations that can help with this challenging task. [3] Guidelines provide a useful roadmap for key steps or issues to focus on when sharing serious news. However, as with any other complex skill, sharing serious news is best learned through practice. One protocol or method for disclosing serious news is represented by SPIKES,[3] a six-step approach that comprises: • Setting up the interview (choosing the right location, establishing rapport). • Understanding the patient’s Perception of the medical situation. • Asking the patient permission to explain, or getting an Invitation. • Addressing Emotions that might occur during bad news disclosure. • Strategizing a treatment plan and Summarizing the plan for the patient and family. SPIKES is a useful approach because it is short, easily understandable, and focuses on specif c skills that can be practiced. Moreover, it Address all correspondence to: Patricia A. Parker, PhD Department of Psychiatry and Behavioral Sciences Memorial Sloan Kettering Cancer Center 641 Lexington Ave, 7th Fl