Patient-Oncologist Communication: Sharing Decisions in Cancer Care

In the ASCO guideline summary on patient-clinician communication, Gilligan et al reviewed 47 publications, including guidelines, systematic reviews, meta-analyses, and randomized controlled trials, published from 2006 through October 1, 2016.1 The guideline informs oncology clinicians about how to communicate effectively and how to enhance patient participation in the consultation. Mention is made of communication skills training, which includes skills practice and role-play scenarios. Communication skills course work is obligatory in some oncology training programs. Nine key recommendations are included in the guideline summary. I found them proscriptive and lacking in guidance about how to engage with the patient and caregiver to reach appropriate shared decisions. The recommendations could be enhanced by a checklist for the oncologist that can be referred to during the consultation and with subsequent discussion at a later visit. In addition, the guidelines do not advocate the provision of a question prompt list (QPL) for patients to assist them and their caregivers with preparing for an oncology consultation. QPLs for patients with cancer have been developed and investigated in 16 studies2,3 and evidence for the effectiveness of such interventions in enhancing patient participation includes the asking of questions. For instance, QPL interventions can influence psychological outcomes (anxiety) and enhance information recall. Thus, I recommend the provision of appropriate QPLs to patients and their caregivers to enable their participation in the cancer consultation. The misunderstanding of clinician communication by patients with cancer is widespread; therefore, oncologists must routinely check patient understanding during an oncology consultation. However, only 10% of oncologists in an Australian study checked patient understanding.4 The ASCO guideline presents a framework of practices that improve communication. The goals of care and discussion of prognosis, however, are not sufficient to inform patient understanding and reduce misunderstanding of these issues. I believe that the guideline attention to estimating prognosis and describing life expectancy should be strengthened. Discussion of prognosis is particularly variable such that the guideline should make specific suggestions to inform the estimation of prognosis and how to discuss life expectancy. I recommend a review of the publications of Kiely and colleagues,5-9 including the use of scenarios to explain life expectancy in patients with cancer. In conclusion, the guideline summary by