Breaking bad news

Receiving bad news is painful to any patient. Table 1 summarises the essential steps in breaking bad news .

The physician’s dilemma in this situation is challenging as the management involves two persons: the mother and the foetus. Although treatment modalities and timing are individualised, the obstetrician and oncologist should offer optimal maternal therapy while maintaining the foetal well-being . Breaking bad news should always include information on the ongoing pregnancy and impact of the disease on the mother and the baby . This helps to relativise possible unrealistic concepts.

Coping with the diagnosis

Experiencing conflicting emotions of happiness being pregnant and fear of life can be very challenging at the time of diagnosis. Questions that are emotionally based are sometimes difficult to answer. Assistance from the family including the partner is vital. In this context, it is vital to consider the patient’s ideas on life ambitions when preference-sensitive decisions are made about the future course of action. During this difficult time, the patient may need frequent counselling to relieve her from misconceptions.

Counselling about prognosis

Patients require information about the prognosis to make treatment decisions. Most patients want specific and honest information about the prognosis. It is best to negotiate the timing, format and amount of detail they want. Depending on the patient, this might be as follows:

• a)
  

  Specific, for example, median survival

  
  
• b)
  

  General, for example, ‘I think your chances are good’.

  
  
• c)
  

  Statistical, for example, average time gain

  
  
• d)
  

  Exceptional cases, for example, survival against the odds

Where possible, hopeful aspects appropriate to the person’s situation must be emphasised.

Counselling for treatment

Patients vary in their need for information, and their needs will change as treatment proceeds. Table 2 illustrates this point further. There are several ways in which patients can share in the decision making process ( Table 3 ).

When initiating counselling about treatment, the following factors should be taken into account:

• 1.
  

  Is the natural history of the cancer affected by the pregnancy?

  
  
• 2.
  

  Is the foetus affected by the cancer?

  
  
• 3.
  

  Does termination of pregnancy offer any therapeutic advantage?

  
  
• 4.
  

  Is the foetus affected by the treatment?

  
  
• 5.
  

  Is a follow-up required during antenatal period?

  
  
• 6.
  

  What is the mode of delivery?

  
  
• 7.
  

  Is a follow-up required during the post-partum period?

  
  
• 8.
  

  Are future pregnancies possible?

Two rules must be followed to form a logical treatment plan:

• a)
  

  Cancer should be treated in spite of and not regardless of the pregnancy.

  
  
• b)
  

  The primary concern should be not to save the pregnancy at the expense of curing the malignancy.

Cancer at an early and curative stage will progress, if left until foetal maturity.

The following two scenarios demonstrate the above point:

• 1.
  

  In the case of a mother with stage I cervical cancer diagnosed at 10 weeks of gestation, the delay in treatment to save the life of the foetus will have an impact on the mother’s life.

  
  
• 2.
  

  A mother who is diagnosed with stage III cervical cancer in the third trimester can wait until the delivery is completed to initiate the treatment with chemo-irradiation.

A realistic and honest approach is essential to maintain the patient’s confidence and support . Overloading information using medical jargons, hiding news, false reassurance and a paternalistic approach disregarding patient’s concerns would hinder confidence .

Shared decision-making about management

Information given on diagnosis, prognosis and treatment in the context of cancer during pregnancy is complex and should involve both maternal and foetal well-being. The basis of shared decision-making is to exchange information in a clear, evidence-based unbiased manner, giving due consideration to patient’s values, concerns, beliefs and priorities in life. Without this process, the patient cannot arrive at important decisions such as termination or continuation of pregnancy and cancer treatment.

Towle has suggested definite measures in order to involve the patient in the decision-making process .

Information for decision-making can be provided in two forms:

• 1.
  

  Information based on scientific evidence

Decision-making in this manner is straightforward and unambiguous, requiring only a short time period.

• 2.
  

  Information provided to take preference decisions

Here, the decision-making depends on personal values, wishes and fears. These decisions are subjected to bias. In this context, risks and benefits in counselling are complex. The rational evaluation of problems may be hindered when the patients are highly emotional. In certain hopeless situations, the patient may request other people to take decisions on her behalf.

Role of the partner and family in counselling

Cancer threatens the whole family changing their aspirations and life course. Optimally, the partner has an active part in the decision-making process. The support given by the partner and the family is a resource for the patient in her effort to stay healthy. Occasionally, family bonding may have a negative impact. Family members are often emotionally close to the patient and will have similar fears and concerns, which may reduce the effectiveness of their support.

Counselling during pregnancy, delivery and post-partum

The obstetrician and the oncologist should play a synergistic role in the provision of care to reassure the patient. The availability and accessibility of specialised referral centres should always be taken in to consideration, for example, referral to a foeto-maternal consultant. While the oncology team evaluates the individual medical situation, the obstetric team assesses the foetal and maternal well-being. A multidisciplinary approach is essential, and management should be based on recommendation from the scientific evidence. During pregnancy, studies have shown the association between maternal exposure to stress and adverse outcomes, such as preterm labour, low birth weight, neurodevelopmental impairments and disabilities . Distress during pregnancy is also known to affect mother–infant attachment, with its important impact on child development and maternal identity . Stress-relieving techniques, such as relaxation and meditation, may be helpful. Guided images have been shown to be effective in dealing with reduced side effects and anxiety .

Counselling to support foeto-maternal bonding

Patients’ emotions are twofold: (1) concentrating about the illness and (2) the welfare of the baby and preparing for motherhood. It is natural that attention on the disease process could override bonding with the baby. Therefore, it is essential that the obstetrician counsel the patient regarding foetal well-being and enhance measures to enhance foetomaternal bonding. Performing ultrasound scans to assess the growth and regular palpation of the abdomen can reassure the mother. Any patient requiring chemotherapy in pregnancy should have regular foetal growth assessment with ultrasound scan to measure the liquor volume along with umbilical Doppler .

Timing of delivery

The decision to end the pregnancy depends on the requirement to treat the mother. Terminating the pregnancy or delivery of a preterm baby should be considered if the maternal outcome or survival is reduced by delaying treatment. Neonatal complications can be decreased by offering antenatal corticosteroids such as respiratory distress syndrome and intraventricular haemorrhage. Gestational age and the type of cancer determine the mode of delivery.

Post-partum management

During the post-partum period, issues such as caring for the baby, including breastfeeding and child-rearing responsibility, should be discussed with the family . During this period, bonding for the newly arrived baby can be affected as the focus is towards the treatment of the disease. However, regular visits to the paediatrician reassure the patient about the baby’s development. The risk of developing post-partum depressive disorders are common in women with maladaptive coping strategies. During pregnancy and the first year post partum, studies have revealed that point prevalence of both major and mild depression ranges from 6.5 to 12.9 . During this period, the medical team must be familiar with the detection of symptoms of depression. If the patients are already on chemotherapy, due to immunosuppression, they are more prone to post-partum infections . Malignancy increases the risk of thromboembolism, which is treated by thromboprophylaxis. Caesarean sections increase the risk of haemorrhage and hysterectomy.

Counselling to cope up stress

The extent to which a person with cancer has support and feels supported has been identified as an important factor in coping . In addition to the psychological and emotional challenges in relation to diagnosis and treatment, the patient’s life may be further disrupted by changes in role, family function, occupation, employment and financial status. By providing additional information and practical assistance, different counselling teams may play an important role in strengthening the patient’s own resources. Meta-analysis of randomised control trials demonstrate the efficacy of both supportive and cognitive behaviour therapy in reducing the depressive disorders .

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  Key points

  
  
• 
  

  People who perceive that they have poor support are more likely to experience greater psychological distress .

  
  
• 
  

  Partners and children of patients with cancer are also vulnerable to psychological distress and are in need of support.

Counselling cancer survivors about future reproduction

Endocrine and gonadal dysfunctions are common after anticancer treatment . Due to the early diagnosis and improvement in treatment, many countries are seeing a rapid increase in the number of cancer survivors. Many prospective studies indicate that the subsequent pregnancies have no detrimental effect on women’s health .

Women treated with cytotoxic therapy remain fertile and do not seem to be at an increased risk of birth defects . Issues of women who survive cancer and become pregnant for the second time have different concerns compared with the first pregnancy. Cancer recurrence and death, risk of being a sick mother, childcare and raising responsibilities are some additional concerns that need to be addressed . Women who are interested in future reproduction should be referred to a fertility specialist.