There is great variability in cancer patients' preferences regarding the content and format of communication from their physicians28,29-31
. Matching communication to patient preferences contributes to quality patient decision making and satisfaction32, 33
. Thus tools to assist physicians in identifying relevant patient preferences and guiding communication accordingly could improve clinical outcomes. The data we present indicate that a values preference for length vs. quality of life may be simply measured, and is associated with a desire for more supportive and less pessimistic communication from the oncologist.
Communication skill in the cancer context is particularly critical given that patients are commonly facing mortality and “bad news,” treatment outcomes are characterized by uncertainty, and treatment is associated with significant potential for morbidity. Previous reports have identified a variety of patient characteristics that bear on their wishes regarding physician communication. For example, women and patients with higher levels of educational attainment have been shown to want more detailed information about their prognosis.31, 34, 35
Female gender is also associated with desire for a supportive communication style over a blunter approach, while patients with more education31
and older patients36
; have been shown to prefer a more fact-oriented style of communication). The data we present support the hypothesis that preference regarding quality and length of life is a key value that impacts treatment goals and desires regarding physician communication. We also observed that older age (p=0.001), male gender (p=0.004), and higher education (p=0.068) were associated with a preference for quality of life. Even after propensity score adjustment, the QOL/LOL preference was predictive of patient communication preferences.
It is notable that patients with less cancer-related distress were more likely to favor quality of life over length of life. The direction of causation in this relationship cannot be inferred from these data. It is possible that increased distress is associated with greater difficulty in processing quality of life issues when faced with a life-threatening illness, and therefore a focus on length of life is preferred. It is also plausible that a greater concern for one's length of life leads to greater anxiety in the context of an immediate threat to longevity. In either case, high levels of distress can negatively impact risk information processing and communication, and ultimately decision making. The fact that those patients who favor length of life seek a more supportive communication style and content is consistent with a desire to minimize additional distress in this patient subgroup. Further, an alternate explanation exists; patients who rely more heavily on blunting or denial as a way to manage their distress may be more inclined to avoid thinking about end of life and report a preference for length of life without fully considering the range of options, namely, shorter but enhanced quality of life. This subgroup of individuals may be more inclined to prefer provider communications that “soften the blow” and avoid discussion of a difficult reality, and experience heightened distress when provided too much threat-relevant information37
. Further research is required to more finely delineate the relationship between these cognitive and affective influences on downstream events.
Although patients who value length of life over quality of life prefer a more supportive communication style, this does not imply that communication of “bad news” should be avoided. Withholding of negative prognostic information may result in loss of trust in the physician, decreased compliance, communication barriers between partners, patient isolation and loss of control, and a lost opportunity to adapt to new circumstances38-40
. Furthermore, recent data suggest that prognostic disclosure may be associated with increased hope, even in the face of poor prognosis41
. Our data support the recommendation that communication must be tailored such that medical information is conveyed in a manner that serves the cognitive and affective needs of individual patients28, 38-40
Our findings also show that patients who value LOL over QOL have lower scores on indicators of mental health with a trend for these patients to score lower on indicators of physical health. We previously reported that the decision to take part in an experimental therapy program (perhaps indicative of a length of life focus) was related to a patient's reference point regarding the threat that their cancer posed to their quality adjusted survival.42
Further exploration of the relationship between health state and preferences regarding quality and length of life is warranted.
Because the study population in this report is racially homogenous and relatively well educated, it is difficult to generalize these results to a more diverse population. It is possible that the relationships we observed between distress, QOL and LOL preferences, and communication preferences may differ in various socioeconomic or racial groups. Furthermore, this study is limited in that the assessment was conducted at a single time point, and does not capture potential variations in values and goals over the course of illness. Finally, the method we used to classify patients' preferences for length vs. quality of life assumed that a 1-point difference on a 5-point scale represents a precise, meaningful difference. If such differences were not meaningful, there would be greater noise in our classification of patients' preference, thus leading to an underestimation of the relationships reported here. It is important to note that before this classification method is adopted as a component of routine care, further work to establish its discriminant ability is appropriate. Nevertheless, this study represents one of the largest surveys of cancer patient preferences reported to date, and patient ascertainment procedures sought to identify and enroll all eligible subjects.
In summary, this study provides evidence that patient differences in the value placed on quality and length of life can be easily assessed, and these values are associated with preferences for the content and format of physician communication. We are conducting a prospective randomized clinical trial (NCT00244868) to assess whether reporting patient values and preferences to the oncologist before the initial consultation will impact communication content and format, and improve patient satisfaction with the consultation.