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CME/CE

Clarifying Diagnosis and Prognosis in Cancer: Guidance for Healthcare Providers

  • Authors: Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jaime H. Von Roenn, MD
  • CME/CE Released: 3/30/2011
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 3/30/2012
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Target Audience and Goal Statement

This activity is intended for physicians, nurses, and interdisciplinary care providers who care for patients with cancer.

The goal of this activity is to provide clinicians with the tools needed to discuss prognosis with patients and families in an effective and compassionate manner to enable informed patient decision making in planning and implementing care.

Upon completion of this activity, participants will be able to:

  1. Describe the difficulty inherent in prognostication
  2. Compare and contrast current prognostic models
  3. Apply the SPIKES 6-step protocol to communicate and clarify diagnosis and prognosis


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Linda Emanuel, MD, PhD

    Author, researcher, educator, previously practicing clinician; Principal, The EPEC Project; Director, Buehler Center on Aging, Heath and Society (where the EPEC Project and its derivatives are housed), Northwestern University Feinberg School of Medicine, Chicago, Illinois

    Disclosures

    Disclosure: Linda Emanuel, MD, PhD, has disclosed no relevant financial relationships.

    Dr. Emanuel does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the US Food and Drug Administration (FDA) for use in the United States.

    Dr. Emanuel does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Frank D. Ferris, MD

    Director, International Programs, Institute for Palliative Medicine at San Diego Hospice, San Diego, California; Professor, Department of Family and Preventative Medicine, University of California School of Medicine, San Diego, California; Co-principal, The EPEC Project

    Disclosures

    Disclosure: Frank D. Ferris, MD, has disclosed no relevant financial relationships.

    Dr. Ferris does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.

    Dr. Ferris does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Charles F. von Gunten, MD, PhD

    Medical Director, Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, California; Associate Clinical Professor, University of California, San Diego, School of Medicine; Co-principal, The EPEC Project; Past Chairman, The American Board of Hospice and Palliative Medicine

    Disclosures

    Disclosure: Charles F. von Gunten, MD, PhD, has disclosed no relevant financial relationships.

    Dr. von Gunten does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the US Food and Drug Administration (FDA) for use in the United States.

    Dr. von Gunten does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Jaime H. Von Roenn, MD

    Medical Director, Palliative Care and Home Hospice Program, Northwestern Memorial Hospital, Chicago, Illinois; Professor of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Co-Principal, The EPEC Project; Editor, EPEC-O Curriculum; Editor-in-Chief, The Journal of Supportive Oncology

    Disclosures

    Disclosure: Jamie H. Von Roenn, MD, has disclosed the following relevant financial relationships:
    Serves as a consultant for: GX International Inc.

    Dr. Von Roenn does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.

    Dr. Von Roenn does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor(s)

  • Cheryl Arenella, MD, MPH

    Cancer Education Program Specialist, Contractor, National Cancer Institute, Office of Education and Special Initiatives, Rockville, Maryland

    Disclosures

    Disclosure: Cheryl Arenella, MD, MPH, has disclosed no relevant financial relationships.

  • Laura Stokowski, RN MS

    Clinical Nurse, Inova Fairfax Hospital for Children, Falls Church, Virginia; Editor, Medscape Ask the Experts Advanced Practice Nurses

    Disclosures

    Disclosure: Laura Stokowski, RN, MS, has disclosed no relevant financial relationships.

  • Susan Yox, RN, EdD

    Director, Editorial Content, Medscape from WebMD

    Disclosures

    Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Nurse Planners

  • Laurie Scudder, DNP, NP

    CME Accreditation Coordinator, Medscape, LLC

    Disclosures

    Disclosure: Laurie Scudder, DNP, NP, has disclosed no relevant financial relationships.

  • Susan Yox, RN, EdD

    Director, Editorial Content, Medscape From WebMD

    Disclosures

    Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.


Accreditation Statements

    For Physicians

  • Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape, LLC designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Contact This Provider

    For Nurses

  • Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 1.5 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

    Accreditation of this program does not imply endorsement by either Medscape, LLC or ANCC.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape Education encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.

CME/CE

Clarifying Diagnosis and Prognosis in Cancer: Guidance for Healthcare Providers

Authors: Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jaime H. Von Roenn, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME/CE Released: 3/30/2011

Valid for credit through: 3/30/2012

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Editor's Note:

This text has been excerpted and adapted from: Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J, editors. EPEC™-O: Education in Palliative and End-of-life Care for Oncology (Module 8: Clarifying Diagnosis and Prognosis. Copyright The EPEC™ Project, Chicago, Ill, 2005). The EPEC™-O curriculum was produced by The EPEC™ Project, with major funding provided by the National Cancer Institute, and with supplemental funding provided by the Lance Armstrong Foundation.

Accurate prediction and disclosure of diagnosis and prognosis are essential for both treatment and personal decision-making for patients with cancer. Research has shown that physicians are systematically overly optimistic in formulating survival estimates and even more optimistic when they disclose prognostic information to patients and/or their families. This article reviews physician prognostication skills, sources of prognostic information, and the role and limitations of integrated prognostic models. A 6-step protocol to guide the communication and clarification of diagnosis and prognosis follows. Approaches for handling unrealistic expectations and denial are also discussed.

Case Study: RS, a 68-Year-Old Farmer

RS, a 68-year-old corn farmer, was referred by a surgeon to radiation oncology for treatment of hemoptysis secondary to stage IIIB non-small cell lung cancer. The patient reported a 6-month history of cough with occasional hemoptysis that did not seem to him to be much different from his smoker's cough.

At his wife's insistence, RS saw a physician. A chest radiograph showed "maybe a pneumonia" in the left lung and antibiotics were prescribed. Nothing changed. A repeat chest radiograph showed that "it wasn't better." A CT scan showed a mass and increased size of some of the lymph nodes. A bone scan was negative. RS underwent mediastinoscopy, which gave the diagnosis of stage IIIB non-small cell lung cancer. He has continued to work and has had his usual level of energy. His social history is remarkable for starting smoking when he was 14. He was married at 18 and kept smoking until about 5 years ago when his 6 kids and his wife finally convinced him to quit. He works on the family farm, although 3 of his sons help out a lot.

How Long Do I Have Left to Live?

Most Americans want to know if they have a life-threatening illness and how long they have left to live.[1,2] Studies in other cultures yield surprisingly similar data.[3,4] Although legitimate cultural variations are important, communicating diagnosis and prognosis in a direct and compassionate manner is likely to improve the patient's and family's ability to plan and cope; encourage realistic goals and autonomy; support the patient emotionally; strengthen the clinician-patient relationship; foster collaboration among the patient, family, physicians, and other professionals; and be reassuring that the healthcare team will be honest, even when the news is not good.

Some patients ask about their prognosis. Most expect the physician or other member of the healthcare team to introduce the subject. Most patients want to have a sense of the future so they can plan their lives. Some are terrified and hope that the healthcare team will reassure them that things are not so serious.

A cancer diagnosis and prognosis can be confusing to patients and families and challenging to physicians and other healthcare providers. Patients and families do not always translate metastatic disease to mean incurable disease, which is usually, but not always, the actual meaning of the situation. Furthermore, the word respond (as in "a certain percentage of cancer patients will respond to treatment") is often misinterpreted by patients and families as cured ("a certain percentage will be cured").

Some family members do not want the healthcare provider to inform the patient of his or her prognosis. Some fear that the news will be so distressing that it will affect the patient adversely or even cause his or her death.

It can also be difficult for physicians and members of the healthcare team, who want to be on the "hope team," to share information that they don't want to believe either. To make this process easier, it can be helpful to reflect that carefully shared information is a gift to the patient and family who want the information, and minimizes the risk that patients will distrust the healthcare team.[2]

Developing prognostication and communication skills can make difficult discussions with patients and families easier and at the same time provide patients and families with information they will need to make informed decisions about their care and treatment.[5]

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