Questions to Ask

Questions to Ask

Hearing your doctor say the word “cancer” may be one of the biggest fears that most have when they go to see the doctor. The word cancer often evokes strong emotions and vivid imagery. To many, thinking of having cancer means losing your hair to chemotherapy or having terrible pain all over the body because of widespread cancer. To many people the word cancer is almost synonymous with knowing that you are about to die. The fear of dying with pain is perhaps one of the greatest fears among those with cancer. Clearly, there is much emotional attachment to this word. The problem with this is that these emotions and reactions often interfere with communication with your doctor about a diagnosis of cancer or the possibility of cancer.

A good doctor will not only treat disease or injury when they occur, but help you to prevent them from happening. This is the logic behind childhood vaccinations. Although some harm might occur from these rarely, the overall good for the population and society is much more beneficial. Go to a country where public health is not a priority or is inadequately funded such as most third world countries and you will see the massive benefits we enjoy in the United States. Part of the role of preventative medicine is to screen for common cancers with the hope that early detection might allow a cure or prevent serious complications of cancer. Some of the commonest cancers are those of the breast, colon, and prostate. For these cancers there is an aggressive screening protocol and guidelines that physicians have to help their patients in avoiding these cancers. Testing for a cancer does not prevent it from occurring, but if found early enough most cancers are treatable.

Your doctor tells you that he or she suspects the presence of a cancer. This will be based upon a screening test (e.g. x-ray or blood work), concerning symptom or abnormality on physical examination. The worst thing to do would be not to mention it or ignore it. Most cancers when left to grow undisturbed will tend to spread outside of their tissue of origin to other areas of the body. In this situation (known as metastasis) cancer is generally incurable. Understanding this should give confidence that you are being well looked after although the process is still anxiety provoking and creates an atmosphere of uncertainty.

Key questions to discuss with your doctor about the possibility of cancer include:

  • How strong is your suspicion for cancer?
    • If the “suspicion” is based upon a test that only very rarely indicates cancer then the confidence level is low compared with a very accurate test such as a colonoscopy.
  • What are the steps needed to confirm or rule out the presence of the cancer.
  • How common is this cancer?
  • How long will the testing process take?
  • What are the risks associated with further testing?
  • What are the implications of not doing further testing?
  • If it turns out I do have this cancer, what are the treatment options?

Other more detailed questions may cause too much time to be spent over a hypothetical situation that might never happen. Depending on your level of medical education or time spent preparing for a cancer evaluation these more sophisticated questions may give you the answers you are looking for.

  • What are the sensitivity and specificity of the proposed test?
  • What is the positive and negative predictive value of the proposed test?
  • What alternative testing strategies are available?

While it is important to get more information, it may be unwise to spend too much time planning for hypothetical situations that might never happen. For example, a woman goes to her doctor because she has some bloody nipple discharge and also had an aunt who died of breast cancer. Her doctor performs an examination and tells her that this could represent a breast cancer but he cannot feel one. The doctor recommends further testing in the form of a mammogram. This woman should follow these recommendations but should not spend a great deal of time thinking about treatment options or possible outcomes before the test is performed. Only 5% or less of woman with bloody nipple discharge will have breast cancer. This should be discussed with the woman as well as the need to perform some type of additional investigation to prove that a cancer is not present.

The woman should discuss, as outlined above, the consequences of the test performed. For example, in this case the mammogram may suggest the presence of a tumor but cannot diagnose and prove the presence of breast cancer. If the mammogram shows evidence of a tumor, some type of sample of cells or biopsy will be needed. At this point the woman may need to see a surgeon or second physician to accomplish the complete investigation. Having at least an idea of what further steps will be taken will better prepare you for the process and take some of the mystery and anxiety out of the process.

REFERENCES:

  1. www.cancer.gov/cancertopics/factsheet/Support/prognosis-stats
  2. Delbanco TL. Enriching the doctor-patient relationship by inviting the patient’s perspective. Ann Intern Med 1992; 116:414.
  3. Impact of patient-reported outcomes in oncology: a longitudinal analysis of patient-physician communication. Takeuchi EE, Keding A, Awad N, Hofmann U, Campbell LJ, Selby PJ, Brown JM, Velikova G. J ClinOncol. 2011 Jul 20;29(21):2910-7. PMID:21690465
  4. This article was originally published on September 3, 2012 and last revision and update was 9/4/2015.