Quality of breaking bad news to patients diagnosed with neoplasia of the uterine cervix

The comment, “You see only the disease, but not the human being involved,” highlights the perspective of a patient diagnosed with cervical cancer who sought a second opinion from A.S. several years ago regarding further therapeutic steps. Dissatisfied with the communication of her life-threatening diagnosis and treatment, this patient perceived the delivery of bad news (BN) as suboptimal. Bad news can be defined as any information that adversely and significantly affects an individual’s perception of their future (Buckman 1992). However, accurately estimating the impact of bad news requires evaluating the recipient’s expectations and understanding.

Breaking bad news (BBN) is a complex communication task that extends beyond verbal delivery (Parker et al. 2001). It necessitates addressing patients’ emotions, fears, and psychological status, involving them in decision-making without causing undue stress or frustration, managing their expectations for a cure, considering the involvement of loved ones, family members, and friends, and navigating the challenge of maintaining hope in challenging circumstances (Baile et al. 2000). To train physicians in effectively delivering bad news, a six-step protocol known as SPIKES was developed by a panel of experts (Table 1). This protocol, evaluated by 500 participants at a symposium in ASCO 1998, emphasizes setting up the interview in a suitable environment, assessing the patient’s perception and understanding, determining the patient’s desired level of information, providing knowledge and information in an open, honest, and optimistic manner while avoiding medical jargon, addressing the patient’s emotions with empathy, and discussing strategies and next steps (Baile et al. 2000).

The evaluation of BBN in women with gynecologic cancer remains limited, with few studies available. An English survey of 359 patients diagnosed with epithelial ovarian cancer over a 2 year period revealed poor quality of BBN, including inadequate recording of prognosis (21%) and limited collusion with relatives (10%), which was more common in patients older than 65 years. Furthermore, information was frequently poorly documented in patient records (Kirwan et al. 2003). A review conducted in England focused on women diagnosed with cervical cancer detected through screening programs. The review concluded that while patients experience distress upon disclosure, there are also potential positive aspects such as enhanced trust and improved perception of care. Recommendations included the availability of patient representatives or psychologists and the value of input from pathologists (Sherman et al. 2013).

Notably, the preferences of women diagnosed with cervical neoplasia regarding the delivery of bad news according to the SPIKES protocol have not been thoroughly evaluated. To address this gap, we used a survey based on the key elements of the SPIKES protocol. Our evaluation included three cohorts: women with cancer who underwent fertility-preserving surgery, those requiring radical hysterectomy or chemo-radiation, and women with cervical intraepithelial neoplasia grade 3 treated by loop excision. By gathering information on how bad news was communicated in reality and how patients envision an ideal communication process, our study aims to improve understanding and enhance the delivery of bad news in these specific clinical contexts.

This study examined the practice of delivering bad news to German women diagnosed with cervical neoplasia. We investigated patients’ preferences compared to the perceptions of the actual delivery of bad news relating to the SPIKES-protocol. In total, many patients were satisfied with the communication process but in almost all SPIKES-categories the communication process of conveying challenging medical information to patients showed possibilities for improvement.

The dissonance between patient preferences and the reality of bad news delivery disjunction was not consistent across the treatment groups but extended to specific elements of the SPIKES protocol. The CIN group had almost no significant differences between the preference and reality scores showing higher levels of satisfaction. Thus, in the two other groups, most of the SPIKES scales setting, invitation/perception, emotions, knowledge, and strategy/summary showed discrepancies between the experiences patients made and the wishes they had. The most highly rated items belonged to the “Setting up” domain, including ensuring an undisturbed atmosphere and allowing enough time for the conversation. On the other hand, the most significant disparities were observed in the “Perception” and “Strategy/Summary” domains. This is in line with previous findings of bad news delivery in a large sample of cancer patients (Seifart et al. 2014), showing that numerous important communication aspects were not fulfilled.

The most notable disparities between patients’ perceived reality and their preferences were evident in four specific communication aspects: for instance, the discrepancy seen in “involve the patient in further planning” highlights the need for healthcare providers to actively engage patients in the decision-making process. Only 42% of patients reported experiencing involvement in further planning, while 80% expressed a preference for such engagement. This emphasizes a communication gap that could potentially impact patients’ feelings of control and satisfaction with their care journey. Moreover, the finding is in line with the results of Polish researchers who found in a sample of 226 cancer patients that the SPIKES domains setting up, knowledge and emotions were delivered in a satisfying way, but perception, invitation and strategy and summary need improvement by more training (Marschollek et al. 2019).

“Inform about effects of the disease on life circumstances” also showed a discrepancy, with 56% of patients preferring to receive this information compared to the lower 48% who reported it in reality. This gap signifies an opportunity for clinicians to better address the holistic impact of the disease on patients’ lives, fostering a more comprehensive and patient-centered approach to communication. Moreover, fertility concerns may play a role here. Empathy discrepancies raises concerns about the potential emotional toll faced by patients who perceive their hopes being hindered. This resonates with previous research highlighting the significance of acknowledging patients’ hopes and aspirations during bad news delivery (Baile et al. 2000). Incorporating frameworks like the HOPES acronym can facilitate a more holistic approach that factors in patients’ emotional well-being and their hopes for the future (Temple 2018; Whitney et al. 2008).

A similar pattern was found in the item “inform about alternative treatment methods” that was part of the conversation in 24% of the patients but wished by 66%. Interestingly, our study’s outcomes reveal a disparity in the delivery of empathetic asking during the conversation. The contrast between “ask about the patient’s concerns” in reality (33%) and patient preference (79%) emphasizes the significance of actively seeking and addressing patients’ concerns during discussions. Furthermore, the gap observed in the item “Ask for the patient’s previous knowledge and what she further wants to know” could indicate that patients should be granted a more proactive role in the conversation. Moreover, as Seifart et al. (2014) recommend a two-step process, a second conversation could be useful to address concerns that patients may have forgotten during the initial shock of diagnosis transmission (Mirza et al. 2019). Helpful may be a short pre-appointment communication, that encourages patients to submit questions or concerns in advance of the BBN conversation.

An important issue, that could have a great influence on the quality of breaking bad news could be the time component. Time is a precious commodity in nowadays health care systems and BBN can easily take a considerable amount of time, the more so when a second or possible third follow-up meeting is considered. Thus, some considerations for an effective time management can be: providing educational materials (Mirza et al. 2019) and resources in advance of BBN encounters; forming interdisciplinary teams that include not only oncologists and gynecologists, but also family physicians, social workers (Spiegel et al. 2009), and nurses can distribute the communication workload (Wan et al. 2020); utilizing telemedicine and virtual communication platforms that can facilitate ongoing communication between patients and healthcare providers; providing healthcare professionals with training in time management and effective communication techniques can help them convey information efficiently without compromising empathy and compassion; and patient-centered care planning: collaboratively developing care plans with patients and their families can help set clear expectations and prioritize the most critical topics for discussion during BBN encounters, reducing the time required for decision-making.

Our study’s findings also align with international literature suggesting opportunities for improvement in breaking bad news procedures (Fallowfield and Jenkins 2004). Several countries have explored innovative approaches to communication skills training, such as Switzerland’s use of simulated patients (Carrard et al. 2020) and the Netherlands’ emphasis on diverse feedback sources (Brouwers et al. 2019). In a continuous feedback loop, a feedback mechanism where patients and families can provide input on their BBN experience could be established. This feedback can inform ongoing improvements in communication practices. A French virtual peer role-play model, introduced in response to the pandemic, highlights the potential of technology in training effective communication (Bouaoud et al. 2022). In a study from Belgium, it could be demonstrates that training triadic communication skills improves the communication skills and should be included in resident curriculum (Merckaert et al. 2013).

The COVID-19 pandemic has further catalyzed changes in communication dynamics, necessitating adaptability in the way bad news is conveyed (Hauk et al. 2021). The shift to remote communication methods introduced a new layer of challenges that warrant exploration in future research. The study by Goumas et al. (2023) underscores the need for studies assessing the impact of distance communication on both patients and healthcare professionals in the era of pandemic-driven virtual interactions. Such research can inform the adaptation of communication practices to evolving healthcare landscapes.

This study has several potential limitations. Patients were asked to recall their initial diagnosis disclosure, and it is likely that their perception and emotional state changed over time. The mean interval to diagnosis was 1/2 year for the CIN group, 10 years for the RVT group, and 5 years for the HE/RCT group which could have led to recall bias and has to be considered in the interpretation of the data. Additionally, the return rates of questionnaires differed considerably among the three groups (70% for CIN, 35% for RVT, and 20% for HE/RCT). This fact could also produce bias because maybe only the persons especially satisfied or dissatisfied answered to the study request. This could impact the generalizability of the findings to the broader population of individuals with the respective conditions. Nevertheless, even if the return rates differ, the data from those who responded provide valuable information relevant to understand the specific group and their experiences. Another limitation is the lack of information about physicians’ communication approaches, styles, training in communication skills, and preferences for breaking bad news in a cross-cultural context. The survey and questionnaire were based on the SPIKES protocol’s recommendations, potentially missing other important aspects. Furthermore, the questionnaires were distributed and answered during the COVID-19 pandemic, a stressful period that could have influenced patients’ emotional states and their responses.

In conclusion, our study emphasizes the need for improved bad news delivery practices in the realm of cervical neoplasia diagnoses. By acknowledging the communication discrepancies between patient preferences and the perceived reality, we can shape a more empathetic and patient-centered approach that respects individual differences and hopes and may reassure a more proactive role of the patient. As most relevant clinical implications, it can be recommended taking a second conversation a few days later as a two-step approach, including relatives into the communication process, granting patients a more proactive role in the conversation and including the patients in further treatment planning. As healthcare landscapes continue to evolve, integrating innovative communication training methods will be essential in bridging the gap between patients’ emotional needs and the communication process.