Received 13 January 2016; accepted 19 February 2016; published 22 February 2016
Communication can be defined as a voluntary and purposeful sharing of information between two or more participant in an attempt to convey or receive the included massage. Communication plays a vital role in the continuum of health care delivery system worldwide. Effective communication is the basic foundation and the priority pillar in the medical field due to its direct role in the safety, quality of the patient care, patient satisfaction and overall clinical outcome  . Communication between health care workers and the patients account for a major portion of the information flow in the health care sector and any error in this flow system results in substantial increase in morbidity & mortality  . In a retrospective study done in Australia on 16,000 in-hospital deaths, it was found that communication error was the leading cause of death & was twice as frequent as inadequate clinical skills  . A survey done on primary care physicians detected that around 50% of all detected adverse events were due to communication error or difficulties  . Thus, there is a need for optimization of the physician-patient communication dynamics. However, there are various challenges in good communication in different aspects of the clinical field. Some of the barrier against effective communication includes-language & cultural differences; stress, emotional response & psychiatric triggers from medically related conditions; lack of access to auxiliary aids; behavioral & physical barriers, etc.  . All these barriers challenge the good communication in clinical practice. Some of the key tasks in effective communication include―a) elicitation of patients condition, their perception & effect of the condition on both physically & emotionally, b) tailoring of information based on patients understanding, c) elicitation of patients reaction & their concerns, d) categorization & quantification of patients interest in decision making, e) effective discussion of treatment option & implication with the patients, f) maximizing patient compliance  .
In most of the cases, physicians lack these communication skills or they respond to various emotional cues with strategies that block further disclosure by the patients  . Also, patients may withhold information due to various beliefs including nothing can be done or do not want to burden the physician or look pathetic or from a fear of their disease status by the physician  . Thus, depending on the clinical scenarios, physio-mental condition of the patients and communication skills of the health care worker, various challenges are expressed and interpreted. One such communication challenges occur with cancer patients. This write up focuses on the challenges in communication in cancer patients.
Unlike patients with other medical conditions, the communication with cancer patients are unique due to the fact that there are certain level of uncertainties related to treatment, survival & cure, involvement of various treatment protocols & modalities, interaction of multiple clinicians & change in health care team over time  . All these results in various communication related challenges, which are included in Table 1.
All these challenges may play a vital role in the overall disease management and undermine the desired clinical outcome in cancer patients. Various studies looking at the effect of effective communication on good cancer care found that there are many drop outs in cancer care due to patients being unsatisfied or confused about the overall management plan, compliance & lack of confidence on the physicians  . Every year British National Health Service Ombudsman receives many complaints of which majority are due to communication failure  . A study done on 117 cancer patients found that most of the times patients had very few opportunities to ask important question or respond to information conveyed to them with minimal attention paid to patients psychosocial needs  . Various studies found that around 40% of the cancer patients wanted to be fully informed and be involved in decision-making process  . It has also been seen that a majority of the health care workers involved with cancer care are not adequately trained in communication skills. Although there are evidences of the significance of effective communication in medical practice, there is not much research or emphasis on communication skill development in cancer care. This paper will provide a brief overview of ways to overcome the communication challenges in cancer patients.
2. Clinical Outcome & Communication
Effective communication between clinician & patients related to consultation may play an important role and predict health outcomes in cancer patients  . A review of various RCTs found that communication mostly affects health through various indirect pathways through proximal (satisfaction, trust, motivation, etc.) & intermediate outcomes (access to case, compliance, self-care, emotional management, etc.) as shown in Figure 1    . Street et al. found seven pathways through which good communication might indirectly lead to better quality of health in cancer patients  . These include increased health care access, increased patient knowledge and understanding, higher quality of medical decisions, increased social support, enhanced compliance, patient empowerment and improved management of emotions.
Figure 1. Direct & indirect pathways leading communication to health outcome  .
Table 1. Communication challenges in Cancer patients  -  .
Thus, any intervention done to maximize the therapeutic effect of communication and overcome the challenges in communication should focus on achieving these proximal & intermediate outcomes.
3. Improvement of Communication in Cancer Patients
Encounter with cancer patients are very emotion-laden and requires a great deal of clinical & communication skill on part of the health care team. Management of communication challenge in cancer patient include―
3.1. General Considerations
1) Patient-centered care: patient centered care is an interaction between patient, physician & health services and consists of three core attributes as  .
・ Consideration of the need of the patients, their perspectives & experiences.
・ Providing opportunities to the patients to participate in their own care.
・ Effort to enhance & nourish physician-patient relationship.
A seamless equilibrium of these three components is integral to improved health outcome in cancer patients.
2) Ethical consideration in patient communication: Ethical consideration is also an important factor in communication with cancer patients. The oncologists should be able to identify the spectrum of treatment options available and indicated for the patient; cost effectiveness of the management, understand the patient preference
Figure 2. Patient-centered communication.
& goal, respect patient autonomy, ensure appropriate patient situation & communicate properly with patient regarding the risk-benefit of the treatment & overall prognosis  . Ethical consideration is also an important consideration in communication with terminally ill patients in continuation or withdrawal of palliative & lifesaving interventions  . Over all the ethical principles of autonomy, beneficence, maleficence and justice should guide the communication with cancer patients. Equal importance should also be given to patient confidentiality.
3) Communication skill training: Communication skill training focuses on training the health care providers, training in cultural competency & training of the patients  . Physician training are encouraged to be introduced early in medical school as a part of the course curriculum. Training programs should include rehearsal with skilled facilitators, use multiple pedagogical & provide timely feedback   . Cultural training also plays a major role in effective communication. Acknowledgement of various cultural differences, acceptance & respect as well as minimization of the negative effect of the differences can help to improve communication  . There should also be interventions to train patients in an attempt to promote increased patient participation in medical decisions, encourage compliance & reduce barriers to communication leading to more satisfactory decision making    .
4) Intervention of communication at health care settings: A tiered approach to health care setting including intervention at team, practice and health care setting is important to ensure continued care. Improved communication within treatment team of cancer patients; use of web based resources, care diaries, patient-held medical records or direct access to medical records by the patients in clinical practice; appropriate layout and training of staff in appropriate communication technique in health care setting will definitely help to improve patient satisfaction   .
3.2. Specific Interventions
There are various specific protocols in place to enable health care workers to tackle communication challenges in cancer patients. Some of the protocols include-
3.2.1. Protocol for Delivering Bad News
“SPIKES” is a six steps protocol to deliver bad news in cancer patients  . This protocol helps the health care workers to gather information from the patients, transmit medical information, provide support and collaboration with the patients to develop treatment plan and is flexible enough to account for differences among the patients. The steps include  -
・ Step 1: Setting up the interview and maintaining privacy, connecting with patients and minimizing interruption.
・ Step 2: Assessing patient perception through asking open-ended questions and tailoring communication accordingly.
・ Step 3: Obtaining patient invitation so that to get a cue about patients expectation about information disclosure.
・ Step 4: Giving knowledge to the patients while starting at the vocabulary level of the patients, avoiding technical terms and giving information in small chunks and checking back on patients understanding.
・ Step 5: Addressing patients emotions with empathy.
・ Step 6: Strategy and summary-ending the consultation by providing a disease summary and treatment plan.
3.2.2. “REBELS” Model in Clinical Consultation
This model provides a framework of sequence of strategies for the management of challenging situation in clinical practice for health care workers with different level of experience  . It consists of―
・ R―Recognizing and acknowledging that there is a problem to be dealt.
・ E―Expressing empathy, reflecting back and summarizing patients point of view.
・ B―Establishing clear professional, interpersonal and ethicolegal boundaries.
・ E―Emphasizing and putting patients at the center of interaction.
・ L―Using inclusive rather than distancing language.
・ S―Focusing on solutions after being empathic and highlighting the problem and patient’s best interest.
There are many other specific interventions like multimedia interventions, patient-patient communication intervention that are in place to manage challenging communications and also there might be other related evidences, which were beyond the scope of this paper.
Communication in cancer patients is a unique and challenging aspect, which strikes at the very foundation of clinical care, adherence and health outcome. These communications are embedded in multiple layers of the context that needs to be modulated so as to achieve a meaningful and proactive communication. Thus, there is a need to acknowledge the challenges and do further research to get an insight into the various underlying barriers to concordance in the patient-physician communication and design and implement various intervention protocols in cancer patients.
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