March 20, 2020
When Amanika Kumar, M.D., with Gynecologic Oncology at Mayo Clinic in Rochester, Minnesota, meets with a family to discuss pelvic exenteration, one of the most important things she says she does is listen.
The purpose of a pelvic exenteration ― a complex surgery that combines several procedures including removal of some or all pelvic organs, intraoperative radiation and vaginal reconstruction ― is to remove cancer in the pelvic organs and to reduce the likelihood that cancer will return. This radical surgery can be used to treat types of cancer, such as cervical, endometrial and vaginal, that have recurred after the patient has already had other treatments, including surgery, chemotherapy or radiation.
A complex procedure that takes several hours to complete, pelvic exenteration also requires a months-long recovery. For that reason, Dr. Kumar is open, honest and realistic with her patients. And, she makes space and time to listen to her patients' questions and concerns.
"Effective communication is the most important thing I do," she says. "As oncologists, our daily practice involves situations that require complex communication skills, including disclosing serious news and discussion of prognosis, treatment decisions and goals of care. I start by reassuring my patients that I'll be there each step of the way."
Advanced communication is critical
Because of the multidisciplinary and integrative care offered at Mayo Clinic, Dr. Kumar has a team surrounding her each step of the way.
"I can bring specific questions, especially in regard to pelvic exenteration, about specific patients to a team of oncologists, radiologists, pathologists, plastic surgeons, social workers, psychologists and urologists," Dr. Kumar says. "They answer my questions so I can go back to my patient and confidently navigate next steps." Mayo Clinic offers options that are sometimes not available to patients in other institutions, including multidisciplinary surgery and intra-operative radiation.
In a study published in Gynecologic Oncology in October 2019, Dr. Kumar and a team of specialists dived deeper into the topic of advanced communication and why it's a critical part of quality cancer care.
"Communication between health care professionals and patients is vital to patient-centered care," says Dr. Kumar. "It improves the patient's knowledge of the illness, allows the patient and family to actively participate in shared decision-making and helps alleviate anxiety during the cancer journey."
While physicians often provide information and explain next steps, the October 2019 review article admits they rarely inquire about patients' understanding of their illness and often fail to address patients' emotional cues with empathy. In their study, Dr. Kumar and the team of specialists included a conversation road map with four components:
- Prepare and gather information; assess patient knowledge and understanding.
- Inform the patient in accordance with the patient's communication preferences.
- Expect emotion and address it with empathy.
- Elicit patient values and create a plan based on those values.
When decisions need to be made about treatments such as surgery, chemotherapy or other interventions, physicians and specialists say a "goals of care" conversation is necessary. The research team discussed one framework ― reframe, expect emotion, map out patient goals, align with goals, propose a plan (REMAP) ― for guiding these conversations.
Transition the conversation with a warning that there has been a significant change in the situation.
The news presented in the reframe is likely to be upsetting. Watch for emotional cues and address them with empathy.
Map out patient goals
Together, and with the patient's family or friends or both, design a treatment plan that encapsulates the patient's goals.
Align with goals
Summarize your understanding of what values are important to the patient.
Propose a plan
Discuss next steps.
Dr. Kumar says that when patients hear that the cancer has returned, they often stop listening, so to continue explaining next steps and options, such as a pelvic exenteration, is often counterproductive. "As physicians, we need to respond with emotional support and align ourselves with our patients' values and goals. We need to treat our patients like real people," she says. "Instead of referencing them as 'the woman with' or 'the patient with,' we need to recognize and remember that these patients are real people with goals and values. And that's who we need to be treating."
For more information
Littell RD, et al. Advanced communication: A critical component of high quality gynecologic cancer care: A Society of Gynecologic Oncology evidence based review and guide. Gynecologic Oncology. 2019;155:161.
Childers JW, et al. REMAP: A framework for goals of care conversations. JCO Oncology Practice. 2017;13:700.