Introduction: Although guidelines do not recommend chemotherapy for patients with advanced cancer when death is imminent, many reports suggest the tendency to continue this treatment has been increasing every year. This study aimed to construct a model to clarify the beliefs and communication of doctors who administer chemotherapy to patients with recurrent or metastatic (hereafter, “recurrent/metastatic”) breast cancer, and determine how these beliefs are related to the process of treating patients.
Materials and methods: Semi-structured interviews were conducted with 21 breast surgeons, and interview contents were analyzed using the grounded theory approach in order to conceptualize the treatment process.
Results: The process of chemotherapy for patients with recurrent/metastatic breast cancer differed based on two beliefs held by doctors. One was a “belief that the patient is an entity who cannot accept death,” and throughout the treatment process, these doctors consistently avoided sharing bad news that might hurt patients, and always discussed aggressive chemotherapy. They proposed treatments as long as options remained, and when they ultimately judged that the physical condition of patients could not withstand further treatment, treatment was terminated despite the patient hoping for continuation. The other was a “belief that the patient is an entity who can accept death.” From early on after recurrence/metastasis, these doctors repeatedly gave patients information including bad news about prognosis, and when they judged that further treatment would hinder a patient’s ability to have a good death, they proposed terminating treatment.
Conclusion: We demonstrated that breast surgeons treating recurrent/metastatic breast cancer patients have two beliefs and constructed a model of the treatment process based on those beliefs. This offered breast surgeons, who make decisions regarding treatment without clearly-defined guidelines, a chance to reflect on their own care style, which we believe will contribute to optimal patient care.


Keywords: palliative chemotherapy, end-of-life, decision-making process, qualitative research


INTRODUCTION

Although guidelines of the American Society of Clinical Oncology do not recommend chemotherapy when patients are near death, chemotherapy is continued in some cases until immediately before death. Numerous reports suggest that this trend is increasing every year.1–3 Several studies have reported that these decisions to continue chemotherapy are influenced by the beliefs held by doctors and their background,4 as well as by a “never give up” relationship fostered between doctors and patients.5 While some studies have touched on patterns of the treatment process and terminal stage continuation or suspension of chemotherapy,6 the manner in which these patterns are influenced by the physician’s thinking has not been addressed.

Against this backdrop, the present study examined breast surgeons who perform palliative chemotherapy for patients with recurrent or metastatic (hereafter, “recurrent/metastatic”) breast cancer, aiming to clarify their beliefs, how these beliefs relate to patient-doctor communication, and the treatment process leading from a diagnosis of recurrence/metastasis to patient death. The aim was to construct a model of relationships between the beliefs held by doctors, the palliative chemotherapy process, and patient-doctor communication.

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The first reason we narrowed our focus to breast cancer is that breast cancer is highly sensitive to chemotherapy, and the disease appears in patients at a relatively young age. Because these characteristics have been identified as factors associated with doctors continuing chemotherapy into the terminal stage,3 we believed it to be highly likely that breast surgeons would propose aggressive anti-cancer therapy for these patients. The second reason is the variety of anti-cancer therapies from which to choose when treating patients with breast cancer recurrence/metastasis. Thus, compared to other cancers, if one treatment is ineffective, other options to continue treatment exist.

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