Informing patients of a cancer diagnosis is never easy and requires skills not systematically taught in US medical schools and residency programs. The absence of a universally accepted best method for delivering bad news presents an additional challenge. In specialties like pathology, practitioners typically have little patient contact. Training programs, including Cytopathology fellowships, in which patient encounters are routine during fine-needle aspiration (FNA) procedures, offer minimal education on this topic. Formal teaching in this area is lacking, even in medical fields where physicians frequently must present bad news to patients, such as palliative care and oncology.[1, 2] Without adequate training, delivering bad news to patients is made more difficult for physicians in all fields, and the FNA pathologist in particular may be reluctant to participate in patient care beyond obtaining the FNA sample.
In the FNA clinic setting, the pathologist-patient relationship is limited. Encounters are largely spent obtaining consent for and performing the procedure, and it is often the first and only meeting with the patient. The FNA pathologist, thus, may feel relatively uncomfortable discussing FNA results with the patient. The referring physician may hold a similar view and may prefer to be the one to disclose the results as someone who has an established relationship with the patient. Because a preliminary FNA diagnosis is often available, however, pathologists are in a unique position to provide immediate results that expedite treatment planning and eliminate anxiety-filled waiting periods. This is particularly meaningful for out-of-area patients who are unable to easily return for follow-up. In addition, some oncologists prefer that the FNA pathologist deliver news of a malignancy to patients so that their initial shock passes by the time they meet with the oncologist, and discussions about treatment and prognosis may be more productive. Face time with patients may be brief, but this should not deter the pathologist from taking a more active role in the patient's care experience. With practice and the help of guidelines such as SPIKES (a 6-step protocol: setting, perception, invitation, knowledge, empathizing and exploring, and strategy and summary), it is possible to establish patient rapport quickly and effectively.
When first meeting the patient, describe the procedure and explain that the purpose of the adequacy check is to ensure there is enough material for evaluation but that, in some cases, a diagnosis is also possible. This lets the patient know an immediate interpretation is possible. If you are confident the diagnosis is benign, then it is all right to tell the patient in order to alleviate anxiety. However, unless you are completely familiar with the clinical situation, be careful not to commit. In cases of cancer diagnoses, follow the patient's lead and provide as much as information as requested.
Information given about a cancer diagnosis should be tailored to the patient's needs. The conversation should not be rushed and should occur after the biopsy is complete. Medical jargon should be avoided. Sensitivity and good judgment are obviously needed when delivering a diagnosis of malignancy. Issuing a “warning shot” with gentle tone of voice (eg, “I'm afraid it isn't good news”) allows the patient a moment to prepare for the actual delivery of the news. When relaying the news itself, the patient is more likely to absorb the information if it is given slowly using clear language and short sentences. The precise words used should take into account the patient's starting point, emotional state, level of understanding, and how definitive the findings are. Is this an unexpected or first diagnosis of malignancy or metastasis in a well-informed patient with cancer history? Has a clinician discussed likely diagnoses with the patient? Did the patient suspect cancer because of family history? Be responsive to the patient's body language as well: does the patient appear apprehensive, concerned but calm, withdrawn?
After disclosing a diagnosis of malignancy, observe quietly for several moments, and try to read and respond to the patient's emotions. Displaying genuine feeling or touching the patient conveys warmth and empathy and can be very powerful in the setting of a new cancer diagnosis. Once there has been time to process the information, patients often try to make sense of the events leading up to the diagnosis. It can be helpful if family or friends are present to offer the patient emotional support. However, reactions to stress are difficult to predict, and unexpected situations may arise, such as a distraught spouse leaving suddenly or failing to acknowledge the patient's distress. In such challenging situations, it can be helpful to refocus the discussion on planning the patient's next step. Tell the patient you will notify the referring provider of the diagnosis and someone will soon be in touch. Ideally, call the referring clinician and inform them of the malignant FNA diagnosis. It is best they hear it from you immediately than from the patient (which can make them look bad or uninformed). It is valuable for patients to be able to debrief immediately with established care providers and have a sense that all the participants in their care are communicating and working together.
Be careful about how much treatment information you provide. As the pathologist, you are often not aware of the entire clinical picture and might provide the wrong message. Unless you have examined the patient, reviewed their imaging, and are aware of patient preferences and family history, it is best not to opine on the likely course of treatment.
There are occasions when it may be inappropriate to disclose a malignant diagnosis to a patient. If the patient has not asked for results by the end of the visit or seems in a rush to leave, then not discussing the findings is reasonable because the patient may not be prepared to hear the information. Be cautious in telling highly anxious patients who came to the FNA clinic alone a first diagnosis of cancer if a social support network is not available for them. If pressed by such patients for results, choose your words carefully to avoid blind-siding them without being dishonest. Saying that there are some worrisome findings but that you need to look at all the material more carefully before making a diagnosis is one approach.
Pathologists are integral members of the clinical team, and cytopathologists in particular need to develop communication skills for discussing disease with patients. Deciding whether and how much to tell a patient about the FNA diagnosis is subject to personal judgment and the unique interaction between a patient and pathologist.