It is always difficult to give bad news. Physicians sometimes avoid telling the patient the diagnosis in accurate and specific terms at the outset, resorting to such euphemisms as “lump,” “mass,” and “lesion.” Further inhibiting communication may be the ill-advised, although well-intentioned, insistence of family members that the diagnosis be kept from the patient out of fear of precipitating a severe depression. Such concerns are usually ill conceived. It is rare that ignorance of the diagnosis or prognosis is helpful for the patient or family. Quite the contrary, patients and their families deal better with cancer when they are well informed.

The goal in communicating the diagnosis and prognosis is to be accurate without destroying all hope. First and foremost, the words “cancer” and “malignant tumor” should be used at the outset of the interview and not avoided, although constant repetition of the terms is usually unnecessary. The term “fatal” ought to be omitted in discussions of the prognosis because it implies little hope of control. When informed of an incurable malignancy, the patient and family want to know, “How much time is left?” A rough estimate may be necessary when patients must arrange their affairs, but if possible, the physician should avoid indicating a specific period of time because it is apt to be inaccurate. Preferably, the physician should direct the patient toward realistic therapeutic approaches while emphasizing living life as fully as possible instead of initially focusing on dying.

The candor expressed by telling the diagnosis “as it is” facilitates the development of trust among patient, family, and medical staff and breaks down the barrier that often isolates cancer patients from their families. Being well informed also helps alleviate the sense of hopelessness and loss of control that can be one of the most frightening aspects of living with a malignant disease. Families are especially grateful for full and frequent reports of the patient’s status and prognosis.

The consequences of not fully informing the patient and family can be considerable. The patient who is unaware of the diagnosis and prognosis may fail to put affairs in order and continue to have unrealistic plans or uncomfortable relationships with other members of the family, which might otherwise be resolved if all were to understand the prognosis. Similarly, the uninformed family is unable to grieve gradually over time, and death may appear to be sudden.

The resulting unresolved grief may profoundly affect the surviving family members (see Chapter 227). Both patient and family may need to grieve and resolve their own fears and anxieties. By virtue of having a long-standing relationship with the patient and family, the primary physician is in an ideal position to provide effective support and guidance.

Cancer patients have been observed to pass through a series of emotional states. These include periods of denial, hostility, anger, hope, depression, and finally acceptance. The physician can help alleviate the more dysfunctional reactions and facilitate the patient’s coping. The reactions of patients at the time of presentation of the diagnosis depend on preconceived ideas about cancer and what the specter of cancer suggests to them. Common misconceptions include the certainty of death, intractable pain, and erosive, disfiguring disease.

To avoid needless worry, it is essential at the outset to address these common concerns directly, even if the patient does not express them. Nonetheless, a good number of patients will respond with denial, hostility, rejection of loved ones, regression, or even withdrawal. It is important to recognize such reactions as psychological defense mechanisms and respond to them in an understanding and patient manner.

Reactions of the family are critical to the patient’s well-being and to aiding the health care team in providing maximum support. Thus, the physician must be concerned with the family’s responses to the patient and the diagnosis. The physician is frequently obliged to deal with many members of the family, often with differing levels of need for information and support. Not uncommonly, complete families—wives, husbands, and children—may be alienated by the patient, who disallows them the opportunity to resolve their confusion. Such alienation, which may approach pathologic proportions, can be understood with the help of the physician. A frequent family reaction is to provide smothering protection in compensation for guilt over previous misunderstandings with the patient and the need to resolve such differences. Again, the physician can help alleviate such pathologic reactions.

Adjuvant therapy involves the addition of chemotherapy and/or radiation to surgical procedures. The rationale for adding radiation therapy is primarily to promote the local control of presumed residual microscopic tumor. In theory, chemotherapy functions as an adjuvant modality because of the possibility that microscopic tumor cells have spread beyond the local area even though they cannot be detected. It may be possible to cure these micrometastases before they have a chance to proliferate and for populations of resistant cells to expand.

Adjuvant therapy is an established approach to management for a number of malignancies and continues to be evaluated in ongoing trials for treatment of others. For example, in breast cancer, women with different stages of resected disease benefit from the addition of some combination of hormonal therapy, chemotherapy, targeted agents (e.g., trastuzumab for HER2+ cancers), and/or radiation therapy as appropriate for the specific tumor and stage. It has reduced the incidence of recurrence and prolonged overall survival. In patients with rectal cancer extending beyond the bowel wall or spread to regional lymph nodes (stage IIb, IIc, and III lesions), the use of radiation therapy has reduced local recurrence rates and, in combination with chemotherapy, increased median survival. In certain situations (e.g., rectal cancer), preoperative radiation therapy and chemotherapy may offer advantages over postoperative radiation therapy and chemotherapy because of reduced toxicity and potentially making the surgical resection easier. A survival advantage has now been demonstrated for many cancers (e.g., breast, NSCLC, esophageal cancer, gastric cancer, pancreatic cancer, colon cancer, rectal cancer) treated with adjuvant or neoadjuvant hormonal and/or chemotherapy (including targeted agents) often in combination with radiation therapy.