Explicit prognostic disclosure to Asian women with breast cancer: A randomized scripted video-vignette study (J-SUPPORT1601) - Mori et al. (2019) - Article

Background

Prognostic disclosure to cancer patients who are in an advanced stage of their disease is considered to be very important. Explicit prognostic disclosure helps to reduce uncertainty that those patients might experience and it helps them to make realistic decision. Clear prognostic disclosure also helps to get goal-concordant care. Uncertainty means that it is hard to determine what illness-related events mean and leads to ambiguity and unpredictability of the future (medical conditions). Uncertainty also leads to more anxiety, psychological distress and a negative attitude towards health care.

Studies with cancer patients in Western countries showed that they like to have a prognostic conversation with their oncologist. It also showed that advanced cancer patients who had been told the prognosis, had more realistic expectations and a better view on their disease. It was also found that a prognostic conversation did not lead to heightened anxiety or a worse relationship with the doctor. With providing explicit prognostic information, this leads to advanced care planning (ACP). Advanced care planning is a process in which the care that is provided to patients is tailored to their specific needs and also preferences. It is common among the geriatric medicine and has been shown to reduce stress for the patient as well as for the families of the patient.

In Asian countries, most of the patients are also told about the diagnosis of cancer. Advanced care planning is also promoted. But, because of a preference of non-disclosure of bad news and a family centered decision making style, disclosure of poor prognosis is uncommon. Most of the doctors in Asian countries prefer not to talk about end-of-life issues (EOL) or about poor prognosis with advanced cancer patients. Around half of the Japanese and Japanese-American people also did prefer not to talk about the prognosis. In Australia, non-disclosure of a poor prognosis is also common among the Chinese migrant cancer patients and their families. Because of the above mentioned effects of prognostic disclosure on uncertainty, it is important to know whether these effects are also true for cancer patients with an Asian origin.

Methods

With the help of a randomized video-vignette study, Japanese women with breast cancer who had undergone surgery viewed videos of prognostic communication between an incurably ill patient and her oncologist. The difference in the shown videos was that in some of the videos there was explicit prognostic disclosure and in others there was not. The outcomes that were measured were uncertainty, anxiety, satisfaction and willingness to discuss advanced care planning (ACP).

Discussion

The results of these study indicate that explicit prognostic disclosure has positive effects on cancer patients of Asian origin. Explicit prognostic disclosure seemed to reduce uncertainty and increased satisfaction without leading to heightened anxiety in Japanese women with breast cancer. This is in line with the findings in the Western countries.

In Asian culture, tradition is that there is non-disclosure of bad news such as a poor prognosis. Also, in Asian countries, the families are often involved in the communiciation between patient and physician. In Japan, for instance, the citizens prefer not to know about what their condition will be like in the future and rather leave decisions to medical experts. Japanese-Americans however prefer to know what will happen to them. But keep in mind that stating that this is true for all people in an Asian culture is an example of a generalization. It is still preferred that clinicians explore the individual needs of their patients without deciding not to tell something because the patient is from an Asian origin. The suggestion in this study is that, when Japanese patients ask for their prognosis, the doctors should tell hem about it. The doctors also do not have to worry that giving an explicit prognosis will lead to increased anxiety.

There are also some other factors that contribute to what the effect of explicit prognostic disclosure is on patients. For instance, there were order effects. This means that earlier videos in a video-vignette study led to more negative outcomes. Prior literature also showed that marked physical symptoms are also associated with lower uncertainty. Emotion-oriented coping also influences the effect of explicit prognostic disclosure on Asian patients. It leads to negative outcomes after prognostic disclosure. Emotion-oriented coping is seen as a maladaptive coping style and can even lead to more perioperative emotional reactions. These findings suggest that, when clinicians communicate with patients who express emotional responses to stressful situations, they should provide these patients with extra support.

Other results of this study are that explicit prognostic disclosure does seem to improve self-efficacy, but this effect is not significant. Explicit disclosure did not lead to more willingness to discuss advanced care planning. This could be explained by cultural differences. For instance, the Western culture values such things as individualism, independence and autonomy as an individual. In Asian cultures, the general values are more things such as collectivism, interdependency, and autonomy as a family. This leads to the fact that decision making processes are more family centered. This also leads to that patients with an Asian origin might find it hard to develop self-efficacy and are less willing to discuss advanced care planning without discussing this with their family members.

The conclusion of the study is that explicit prognostic disclosure leads to better outcomes than non-disclosure in Japanese women with breast cancer. Therefore, when clincians are asked for a prognosis by patients with an Asian origin, they should feel free to tell them about it. They should not be afraid to give in to these wishes of the patients.