"You have cancer." For Pam Khosla, MD, decades of experience don't ease the burden that comes with saying those words.
"I've been practicing for 22 years, and delivering bad news is just as anxiety provoking as 22 years ago," Dr. Khosla, chief of hematology oncology at Mount Sinai Hospital in Chicago, told Becker's. "There's just no good way to do it."
In recent months, Dr. Khosla has found herself delivering more advanced stage cancer diagnoses, compounding an already difficult task.
As the curtains of the COVID-19 crisis begin to draw in, another crisis emerges: a wave of progressing cancer cases that went undetected throughout the pandemic. The drop in routine cancer screenings and care during the spring and winter of 2020 has been well-established by research, with physicians and patients now seeing the aftermath in the form of more late-stage, harder to treat disease.
During the early months of the pandemic, Dr. Khosla said cancer screenings at Mount Sinai Hospital dropped 90 percent, temporarily closing the screening disparity typically seen between patients of lower and upper socioeconomic status.
Now, "It's exhausting to deliver bad news repeatedly," she said.
Pre-pandemic, about 50 percent of patients with lung cancer tumors at the hospital had early, detectable tumors. The other half were advanced.
"That has just fallen off to where 90 percent of lung cancer [we've seen] in the last few months was all undetectable, metastatic tumors," she said, describing a similar situation for patients with brain tumors.
And the trend extends beyond Chicago. A recent survey conducted by the American Society for Radiation Oncology found that among 117 radiation oncologists surveyed in the U.S., 66 percent reported that patients are presenting with more advanced-stage cancers.
Push through the bad news
Research has indicated physicians lack of formal training when it comes to navigating difficult conversations with patients. One such study, led by researchers at Dallas-based Baylor University Medical Center, found that while 93 percent of physician respondents perceived delivering bad news as a very important skill, just 43 percent felt they had adequate training to do so.
Lately for some physicians, being the bearer of particularly bad news more frequently has both reinforced the importance of a careful approach when delivering such diagnoses to patients, and underlined the lack of training they received for this responsibility.
"I always tell my residents or students to kind of rush through the bad news," Dr. Khosla said, who often leans on her own personal experiences and sense of empathy to deliver difficult diagnoses. "Rush through the things that could have been better retrospectively."
Instead, emphasize the next steps to help redirect patients' focus, she says.
"You immediately jump to OK, but we have a plan … this is at least treatable," she said. "You start latching onto the positives and highlighting those, and getting into a very detailed description of the side effects, treatment plan, the schedule. Patients are left overwhelmed, but they kind of have something else to latch onto when they leave the appointment."
No matter what stage a patient's disease is at, conveying a sense of confidence in the care team's abilities is meaningful, said Ravi Salgia, MD, PhD, endowed chair in medical oncology and associate director for clinical sciences at Duarte, Calif.-based City of Hope Comprehensive Cancer Center.
"I don't buy that we can't do anything," Dr. Salgia said. "Even if we're not able to give therapy — let's say chemotherapy, radiation therapy or surgery — we're still able to provide pain management, we're still able to provide supportive care, we're still able to provide oxygen if somebody's hypoxic."
Avoid emphasizing information that would evoke feelings of guilt
While the pandemic and people's fear of visiting a healthcare setting during it are factors in the later stage diagnoses now surfacing, there's no use in pointing that out to patients, the physicians explained.
"You're mincing your words, trying not to make them feel worse than they already are, and trying not to highlight the pandemic," Dr. Khosla said. "They already know that deep down."
In many cases, the state of a person's disease at the time of diagnosis can, in large part, be linked to their action or inaction. While it's important to acknowledge that, honing in on what a person did or did not do is counterproductive, Dr. Salgia added.
"My biggest philosophy and our biggest challenge is not to make the patients feel guilty," he said. "In certain circumstances, smoking can cause lung cancer, but are we going to make that person feel guilty about smoking? Absolutely not … We're here to meet the patients where they're at in their journey, [whether it's] later in the journey, earlier in the journey."
Encourage care
Last year, the National Cancer Institute estimated there would be nearly 10,000 excess breast and colorectal cancer deaths over the next decade linked to pandemic-related care delays in both diagnosis and treatment –– and that doesn't include any other cancer types.
However, this forecast can still be mitigated by making care more accessible and encouraging people to seek it, the physicians said.
Even though clinics have largely reopened, Dr. Khosla said doing more telehealth visits to supplement in-person visits is helping keep no-show rates from rising, especially among patients who may still be hesitant to visit a clinical setting.
To prevent late-stage diagnoses from becoming a drawn out trend, it is especially important that health systems reach patients who still haven't resumed preventive screenings or sought care for a problem.
"Even if you haven't done something about your lump in the underarm, go do something now," Dr. Salgia said. "It's never too late."