Editor’s Note
	Til death do us part

The relationship between medical oncologist and cancer patient can be among the most intimate in medicine, and both parties must be in agreement about their roles and responsibilities. This issue of Meet The Professors begins with a common clinical situation that often strains this delicate partnership: the patient who will not accept a standard treatment recommendation.

When oncologist Rich Zelkowitz told me about a 36-year-old woman he had recently evaluated, I immediately wondered how our faculty panel would approach her case. Nancy Davidson, Kathy Miller, Mark Pegram and Skip Burris are more than just excellent investigators; they are good doctors who provide the type of thoughtful, compassionate and highquality care that all of us would seek for a loved one.

Rich’s patient had recently been diagnosed with a 1.8-cm, sentinel node-negative, poorly differentiated ER/PR-positive, HER2-positive infiltrating ductal carcinoma. Two oncologists had previously evaluated this nulliparous woman, and both recommended chemotherapy and hormone treatment. The patient, however, refused to accept chemotherapy as an option because she had recently wed and wished to one day bear children. She sought a third opinion and finally found an oncologist she could work with in Dr Zelkowitz.

Like the two other physicians, Rich also recommended chemotherapy, but he was willing to accept this woman’s wishes, and he asked to present this case to our meeting participants to obtain input about optimal endocrine treatment in this situation. There was general agreement among the faculty and community panel that aggressive hormone therapy was indicated, particularly since the patient might elect to suspend treatment before the recommended duration of therapy in order to pursue childbirth. There was a consensus that ovarian suppression plus either tamoxifen or an aromatase inhibitor was a reasonable option, and Rich and his patient will see where this leads.

During this case discussion, I mentioned to the attendees that last year, our CME group conducted a national telephone survey of 260 patients with metastatic breast cancer. The goal of this project was to assess patient satisfaction with medical oncologists, oncology nurses and office support staff. One of the most interesting findings from the study — which has resulted in accepted abstracts to ASCO, ONS and the San Antonio Breast Cancer Symposium^1-4 — was that 21 percent of these patients had switched oncologists because they were dissatisfied with the care they had received.

Interestingly, however, the survey demonstrated a high overall level of satisfaction with both physicians and nurses, although perhaps slightly less so with regard to provision of information (Table 1.1). Some oncologists who have reviewed these findings have suggested that patients may “shoot the messenger” when they hear bad news, but the satisfaction levels of patients with their current oncologists who had “fired” previous oncologists were essentially identical to the rest of the patients. This suggests that perhaps patients in this grave situation “shop around” a bit until they find their match.

I love the candor that emerges during our MTP sessions, and one of the most interesting interchanges during the discussion of this young woman’s case came from several of the community-based physicians, beginning with a veteran Miami Beach oncologist.

DR BLAUSTEIN: As saintly as we all are, sometimes there are patients we just don’t like, and we’re uncomfortable with these folks. I don’t think it lends to good medicine and perhaps leads to more problems with litigation than there should be, because patients pick up on the fact that you’re not comfortable with them.

Under those circumstances, it behooves us to make sure the patient has the opportunity to see another physician. I think oncologists — physicians, in general, but oncologists particularly — should look a lot more often at whether they’re uncomfortable dealing with a patient.

DR LAMBERT-FALLS: One of the things I say to new patients is, “What do you expect from this visit?” I find that’s just a good starting point and it kind of sets the tone, because sometimes you see people you just don’t mix with.

DR SEIGEL: Another phenomenon that I’ve encountered is, if you are the first oncologist to see a patient, particularly someone with bad disease, and when you lay everything out and it is a lot worse than they have anticipated, they kind of blame you. Frequently, these patients move on to another oncologist.

DR LOVE: In our telephone survey of 260 patients with metastatic breast cancer, we asked them to rank the qualities they value in a medical oncologist in order of importance (Table 1.2).

The number one rated factor, which was rated by these 260 patients cumulatively as 4.93 on a 5 scale, was listening. Does that surprise you, Dr Luedke?

DR LUEDKE: I think patients want to be validated. If we don’t listen, they’re not. Patients all have concerns that come from their own personal experiences. These may or may not be relevant to what you’re suggesting, but if they don’t participate, then they’re not going to be happy and they’re not going to receive what they need.

DR WERTHEIM: As medical oncologists, we tend to be very data driven and, in some ways, dogmatic. Sometimes you have to step back for that and really listen.

Listening has turned into my life occupation, and when I venture outside of the sunny confines of South Florida to attend scientific meetings like ASCO, I often encounter listeners to our CME audio programs who recognize my voice or name badge. One of the frequent comments from these loyal patrons is that they take great comfort in hearing well-known research leaders struggle and squirm as I attempt to pin them down with regard to the common therapeutic dilemmas that have no good solutions. This issue of our series includes a number of such challenges, and it is inspiring to hear how experienced, empathetic and sincere oncologists like Rich Zelkowitz reach out to frightened patients and help them find answers to the unanswerable.

—Neil Love, MD
NLove@ResearchToPractice.net

¹ Love NH, Carlson R et al. A report card on medical oncologists and oncology nurses: Survey of patients with metastatic breast cancer and companion surveys of medical oncologists and oncology nurses. San Antonio Breast Cancer Symposium 2004;Abstract 3069.

² Paley MF, Love N et al. Preferences for oral and parenteral antitumor therapy: A survey of 260 patients with metastatic breast disease. Proc ASCO 2005; Abstract 619.

³ Love NH, Stanley KJ et al. Preferences for oral versus parenteral antitumor therapy: A survey of patients with metastatic breast cancer. Oncology Nursing Society Congress 2005;Abstract 243.

⁴ Stanley KJ, Love N et al. A report card on oncology nurses: Survey of patients with metastatic breast cancer. Oncology Nursing Society Congress 2005;Abstract 64.