When the scan shows the treatment has stopped working

This week's conversation

Your patient is 64 and on her second line of treatment for metastatic colon cancer. She has tolerated it well and tells everyone she feels stronger. This morning's restaging scan shows new liver lesions. The treatment is not controlling the disease.

She comes to clinic with her son, who carries a binder. He has read about trials, writes his questions out in advance and usually opens the visit by asking what the numbers say.

The moment you dread comes right after you say it. She goes quiet. He leans forward and asks, "Okay. So what's the next option?"

Why it goes sideways

The mechanism is the urge to rescue. Delivering bad news is uncomfortable for us too, and a plan is the fastest way out of the silence. The son's question invites it. So we pivot to options within a sentence of the news, and the family hears the plan instead of the fact. Weeks later they say, "Nobody told us it had stopped working."

SPIKES helps most at the two steps people tend to skip. The first is checking what the patient understands before you speak. The second is responding to emotion before you move to strategy. The son's push is often fear with a practical face. A NURSE statement (naming, understanding, respecting, supporting, exploring) gives that fear somewhere to go. Once it has been acknowledged, the conversation about next steps can actually happen.

What to say

Open by checking their perception, then give the news plainly and stop talking:

"Before we look at the scan together, can you tell me what you've been expecting to hear today?"

"I'm afraid the scan shows the cancer has grown. This treatment isn't controlling it anymore."

When he pushes straight to the plan:

"I can hear how much you want a plan, and we will make one together. I don't want us to rush past what this means. What's going through your mind right now?"

To close, turn agreement into a commitment:

"Here's what happens next. I'll go through the options with you at a visit on Thursday, and you can bring every question in that binder. Before you go, can you tell me in your own words what we talked about today, so I know I explained it clearly?"

• Instead of "The scan wasn't great, but the good news is..." try "The scan shows the cancer has grown," and then pause.
• Instead of "There's nothing more we can do," try "This treatment has stopped working. We're going to keep caring for you, and we'll work out the next step together."
• Instead of "Do you have any questions?" try "What questions do you have?"

Two-minute drill

Say your headline sentence out loud: "The scan shows the cancer has grown." Then count silently to ten without speaking. Repeat it three times. Notice the moment you want to fill the gap, because that is the urge to rescue. Ten seconds feels long in an empty room. In clinic, it is where the news finally lands.

Practice it

Rehearse this conversation before you have it for real. On the free practice page, choose the Healthcare domain and the "Demanding Advocate" persona, then describe the situation in a sentence. If you have an account, open "Treatment Is No Longer Working" from Healthcare → Breaking Bad News in the app's library. Practice this conversation

The plan can wait a few minutes. The news shouldn't be skipped.

— Dan