This is written following some CSA preparation with a trainee. Let me start with a usual disclaimer – I am no expert in breaking bad news or discussing this topic! I have spent a number of years trialling different methods of approaching this with patients. I’m still not sure I have it right but I wanted to share some thoughts to help you build on your skills.
I don’t know if there are many people out there who do not know of cancer. I would say the vast majority, if not all, have heard of the word. It may be that they don’t fully understand what that means though. But how good are you at using the word in your consultations and saying it with ease? It’s an easy word to stumble over and turn in to the most awkward conversation you’ve had that day. Even with those patients who have a diagnosis of cancer. So practice saying it aloud regularly. Normalise the word.
Here’s where I think the problem lies. Most of us are all a bit too nervous to say the word aloud to someone who doesn’t already have a diagnosis. So when we sit there worried that their symptoms suggest cancer, and we want to refer them, we try to think of every other way of saying it without using the word. We talk about the need to exclude serious, sinister or worrying causes. But none of these words define cancer. They could define any illness that may be more than something minor, or something that someone may have to live with or need an operation for. Some people may not even be sure what sinister means. So here’s the issue – we tell someone we need to refer them to clinic to rule out something serious (or sinister; or worrying) but we don’t tell them we need to exclude cancer. We then send them via a clinic that is specifically to exclude this, where there’s a reasonable chance someone else is going to use this word. Imagine being the patient at this point in time. You’ve trundled along to the hospital, on your own having taken the bus, thinking you might have something wrong that that the GP can’t quite sort out. You’re then faced with someone telling you that you’re in this clinic to look for cancer. Yep, I’d feel pretty stressed too. What if I’ve got cancer? Am I going to have to get home by myself and hold it together? Especially, if they decide you need further investigations to rule it out.
So this is what we need to do – we need to find a clear, yet sensitive, way of breaking this news to the patient. I would like to hope that somewhere along the way in your medical training you’ve been given some guidance on breaking bad news, and had the opportunity to practice this. (I wish someone would have given some guidance in medical school on how to tell a relative their loved one is dying or has already passed away – it would have made my days a junior doctor a little less painful).
We need to model this explanation and planning upon the breaking bad news methods. Because that’s what we are kind of doing. We are introducing the possibility of cancer to a patient, who may not have even considered this as the cause for their symptoms.
Firstly – have you gathered the patient’s ICE (ideas, concerns and expectations)? If you have then you may have already garnered that they are a) worried they have cancer or b) have a completely different agenda. A good example is the consultation regarding a breast lump. On the whole a woman thinks a breast lump = cancer. They want you to tell them it’s not. So they are still a little surprised when you explain you’d like to refer them onwards, but they understand why from the get go. The opposite is bowel or urinary symptoms I find. They think there’s probably something wrong but they haven’t often considered it might be cancer. They just want you to stop them from opening their bowels several times per day for example. So ICE is your starting point for knowing what your opener needs to be.
Use the above knowledge to start the explanation. Here’s the important part – I really think you need to use the word cancer at some point during this stage of the consultation. How you do it is something to work out for yourself, via practice. If I am not truly convinced it’s cancer but they sit within the criteria for a two week referral I usually say something along these lines:
” From everything you’ve told me I think you fit within the criteria for us to refer you urgently to rule out cancer as a cause. I’m not entirely convinced this is the case, however I think it would be wrong not to consider this”
Or if you’re really nervous about telling them you could try:
“For each area of the body there are set symptoms and time frames that have been listed as a reason to refer someone to rule out cancer. From what you have told be you fit into one of these categories so I really think it would be a good idea to send you to the hospital clinic”
If you’ve examined them and you are really worried because you’ve found a mass for example then tell them:
“When I examined your tummy I could feel a lump there. There are many causes for feeling a lump in the tummy. However, when taking the symptoms you told me you have into consideration, I’m worried this could be a cancer. So I think we need to get this looked at urgently”
The same goes for discussing a result that is highly suggestive, or confirmatory for cancer. Speak the whole truth.
Whichever way you decide to drop the word cancer in. Follow it up with a ‘would that be ok?’ and a ‘do you understand?’ or a how do you feel about that?’ You know roughly the answers to these questions but asking them out loud rather than assuming allows you to open up the discussion about how they are feeling and to do some (metaphorical) hand holding. Acknowledge that you understand this may be worrying, stressful, etc.
Discuss the next steps. Confirm that two week wait means they will be seen within the next fortnight. If it’s such they may have investigations first then explain this. If they’re going to the breast clinic or neck lump clinic then tell them it might be a long day and they might want to take a book. Suggest they may wish to go along with someone for company.
When closing the consultation and planning suggest some follow up so they know they can come back to you. If they don’t have cancer then they will still have the symptoms that need to be managed, and if they do then they might want to talk to you about it. In addition, if appropriate, make sure you offer some management for the symptoms they have in the meantime.
You might have noticed that I have dropped the word cancer into this narrative many time – because it’s an actual word with a definition and we shouldn’t be afraid of it.
It’d be great if anyone else has any good tips to share on how they broach the subject of a two week wait referral.
The GP trainee's survival guide 