Adnan returns to see Dr Bollands to receive the results of his blood tests.

Dr Bollands has told Adnan that he has chronic leukaemia. It is important that the type of leukaemia, chronic or acute, is shared with a patient, as public perception of leukaemia is often just about acute.

Breaking bad news to an angry patient

Adnan displayed anger towards Dr Bollands during the first consultation and this was exacerbated when he received the results of the blood tests during the second consultation.

Dr Cathy Heaven, Associate Director of Education at The Christie, talks about the general principles of breaking bad news to patients, focussing on how to do this with a patient who is obviously angry like Adnan.

VIDEO BEING EDITED (to replace below video!)

Communicating results and making a referral are forms of breaking bad news, especially if the patient isn’t expecting it. Therefore, it is important that the patient dictates the pace at which information is shared. Be gentle but be honest. This honesty will help maintain health practitioner-patient trust and potentially minimise the number of missed appointments.

It is also essential to be open with the patient about any uncertainty regarding their condition and to hold this uncertainty for them. The approach for delivering significant information should be altered based on whether the patient is or is not aware that something is wrong.

Click on the footsteps to reveal the outline for delivering significant information

Even though Adnan is clearly angry, Dr Bollands must share bad news with him. She:

• Takes time to share the news at a pace Adnan dictates
• Is brave in her use of language and delivers the results clearly, despite his anger
• Is gentle and kind with Adnan when breaking bad news

 How can we best support a patient who is displaying anger?

•  See anger for what it is. It is normally a sign of painful or frightened emotion
• Try not to respond directly to the anger, but to acknowledge it and try to emphasise with it
• Use apologetic language for having to share bad news, rather than apologising for any possible delay in diagnosis
• Allow the patient to express their anger. Attempting to suppress it can exacerbate the situation
• Do not shy away from giving the necessary information to the patient

 How can we deal with anger on a personal level?

• Imagine that the anger is not coming at you, but at the situation the patient finds themself in
• Empathise with the patient

Living with CML

Dr Adrian Bloor talks to Dr Sarah Taylor about living with CML.

Key points:

• Patients should be reassured that CML is a chronic disease that can be managed in a similar way to blood pressure or elevated cholesterol
• Typically, patients with CML will respond to treatment and effect a remission that is high quality and durable

Treatment

CML is not a curable disease, but it can be managed through treatment. A new class of drugs called tyrosine kinase inhibitors (TKIs), has transformed the treatment of CML. A stem cell transplant can cure the disease in a small number of younger and/or fitter patients but with TKIs having a good success rate, bone marrow or stem cell transplants to treat CML are rare.

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Targeted therapy

Targeted therapy using tyrosine kinase inhibitors (TKIs) is the usual first choice of treatment for CML. The treatment targets the abnormal protein (tyrosine kinase) produced by the BCR-ABL gene. This has transformed the outlook for CML patients. Before TKIs were introduced the average survival after diagnosis was about seven years. Now it is expected that many, probably most, CML patients will have a good quality of life and a normal or near-normal life expectancy. All of the currently available TKIs are taken orally, which most patients prefer to any type of injection.

There is evidence to suggest that some patients may be able to stop taking TKIs, or at least reduce the amount of TKI they are taking, without their CML returning. In patients who do stop treatment under medical advice, and whose CML does return, this usually responds well to restarting treatment. At present, there is not enough evidence to know which patients can safely stop treatment.

Chemotherapy

Chemotherapy is the use of cytotoxic drugs to destroy or damage leukaemia cells. It is most likely to be used if the TKIs aren’t effective or they cause severe side effects. The chemotherapy drug is that is used is called hydroxycarbamide and comes in a tablet form.

Chemotherapy is not currently widely used in treatment of CML.

Stem cell transplant

A stem cell transplant involves the use of high dose chemotherapy to kill as many leukaemia cells as possible. This option is only suitable for a small number of CML patients who are fit enough and have a very well-matched donor. Stem cell transplants are rarely performed for CML patients and normally only done if a patient hasn’t responded to TKIs.

This is generally considered the only potential cure for CML, but for most patients the risk of a transplant is greater than the benefit. This is especially true given the very good results of treatment with TKIs.

Additional resources

Reference: Heaven, C.M. and Maguire, P. (1993) Assessing Patients with Cancer: the Content, Skills and Process of Assessment
Link: CML, a guide for patients, Leukaemia Care (2018)
Link: Treatment – Chronic Myeloid Leukaemia, NHS (2019)