James Khatcheressian, MD

Oncologists often do not give honest prognostic and treatment-effect information to patients with advanced disease, trying not to “take away hope.” The authors, however, find that hope is maintained when patients with advanced cancer are given truthful prognostic and treatment information, even when the news is bad.

The use of the term "futility" in cancer care has been prompted, in part, by increasing requests from patients for treatments thought to be ineffective as well as costly.[1] The appropriate role of chemotherapy near the end of life is a complex issue.[2]

Twenty years of research in controlling symptoms such as pain andnausea have shown persistent suboptimal performance by the US oncologysystem. The data suggest that some of the tools of palliative careprograms can improve physical symptoms of seriously ill patients at acost society can afford. To fix these problems will require recognitionof the symptoms or concerns, a system such as an algorithm or careplan for addressing each, measurement of the change, and accountabilityfor the change. Symptom assessment scales such as the EdmontonSymptom Assessment Scale or Rotterdam Symptom Check List work tomake symptoms manifest. Listing symptoms on a problem list is a necessarystep in addressing them. Physical symptoms such as pain can beimproved by use of computer prompts, algorithms, dedicated staff time,team management, or combinations of these strategies. Less concreteproblems such as medically appropriate goal-setting, integrating palliativecare into anticancer care sooner, and informing patients aboutthe benefits and risks of chemotherapy near the end of life require morecomplex solutions. We review what is known about symptom control inoncology, how and why some programs do better, and make suggestionsfor practice. Finally, we suggest a practical plan for using symptomassessment scales, listing the problems, and managing them accordingto algorithms or other predetermined plans.