Patients with advanced incurable cancer face complex physical, psychological, social, and spiritual consequences of disease and its treatment. Care for these patients should include an individualized assessment of the patient's needs, goals, and preferences throughout the course of illness. Consideration of disease-directed therapy, symptom management, and attention to quality of life are important aspects of quality cancer care. However, emerging evidence suggests that, too often, realistic conversations about prognosis, the potential benefits and limitations of disease-directed therapy, and the potential role of palliative care, either in conjunction with or as an alternative to disease-directed therapy, occur late in the course of illness or not at all. This article addresses the American Society of Clinical Oncology's (ASCO's) vision for improved communication with and decision making for patients with advanced cancer. This statement advocates an individualized approach to discussing and providing disease-directed and supportive care options for patients with advanced cancer throughout the continuum of care. Building on ASCO's prior statements on end-of-life care (1998) and palliative care (2009), this article reviews the evidence for improved patient care in advanced cancer when patients' individual goals and preferences for care are discussed. It outlines the goals for individualized care, barriers that currently limit realization of this vision, and possible strategies to overcome these barriers that can improve care consistent with the goals of our patients and evidence-based medical practice.

Chronic, nonmalignant pain is a substantial public health problem in the United States. Research over the past 2 decades has defined chronic pain by using a "biopsychosocial model" that considers a patient's biology and psychological makeup in the context of his or her social and cultural milieu. Whereas this model addresses the pathology of chronic pain, it also places many demands on the physician, who is expected to assess and manage chronic pain safely and successfully. There is a growing body of evidence suggesting that opioids can be effective in the management of chronic pain, but there has also been a rise in opioid-related overdoses and deaths.Clinicians should be aware of assessment tools that may be used to evaluate the risk of opioid abuse. A basic understanding of chronic pain pathophysiology and a uniform approach to patient care can satisfy the needs of both patients and physicians. pain is of short duration and quickly forgotten. Unfortunately, for some the pain does not pass but becomes a continuous burden, an unrelenting suffering, and the "perfect misery" described in Paradise Lost.1 With these patients, however, the physician faces one of the greatest challenges: the relief of chronic pain.In a 2011 report, authors at the Institute of Medicine 2 underscored that "effective pain management is a moral imperative, a professional responsibility, and a duty of people in the healing profession." Nonetheless, few physicians are formally trained in effectively managing pain, and achieving this goal remains problematic.In the current review we examine chronic pain, discuss theories regarding its cause, evaluate nonpharmacologic and pharmacologic therapy, address the unique aspects of prescribing opioids, and provide a list of take-home points regarding the problem of chronic pain (Figure 1). Chronic pain is defined as pain that persists for longer than 3 to 6 months, or the "normal healing" time of an injury. 2 A physician may be frustrated by the lack of objective findings in a patient with chronic pain, because the extent of an injury does not always correlate with the severity of the patient's discomfort.The "biopsychosocial model" is currently accepted as the optimal conceptual approach, 5 one that envisions chronic pain in terms of the biological parameters in conjunction with the psychological, social, and cultural contexts of the patient. processing. Melzack 6 developed the "neuromatrix theory," which suggests that pain is "produced by the output of a widely distributed neural network that is genetically determined and modified by sensory experience." Accordingly, chronic pain is affected by neural output and not only by sensory input from tissue injury.

Patients with NSGCT who achieve a serologic and radiographic CR with primary chemotherapy (group A) can be safely observed without surgical intervention, regardless of initial tumor bulk. Patients with a teratoma-negative primary tumor who achieve a serologic CR and a > or = 90% radiographic remission and are followed-up without surgical resection (group E) are at an increased risk of relapsed NSGCT. Decisions about postchemotherapy resection in this group remain complicated and controversial. Options include observation with serial radiologic evaluation or surgical resection of persistent mass or masses.

BackgroundThe National Academy of Medicine recommends that cancer patients be knowledgeable of their prognosis to enable them to make informed treatment decisions, but research suggests few patients receive this information.ObjectiveThis qualitative study describes oncologists’ language during discussions of prognosis and treatment goals in clinical interactions with African American patients diagnosed with cancer.DesignWe analysed transcripts from video recordings of clinical interactions between patients with Stage III or IV cancer (n=26) and their oncologists (n=9). In‐depth discourse analysis was conducted to describe and interpret oncologists’ communication behaviours and common linguistic features in the interactions.Setting and participantsData were from a larger study of patient‐provider communication between African Americans and oncologists at two cancer hospitals in Detroit.ResultsPrognosis was discussed in 73.1% (n=19) of the interactions; treatment goals were discussed in 92.3% (n=24). However, analysis revealed that oncologists’ description of prognosis was vague (e.g. “prognosis is a bit worse in your case”) and rarely included a survival estimate. Oncologists often used ambiguous terminology, including euphemisms and jargon, and emphasized uncertainty (e.g. “lesions are suspicious for the disease”). Conversation about prognosis was frequently brief, moving quickly to the urgency and details of treatment.DiscussionThis study demonstrates how oncologists’ language may obscure discussion of prognosis and treatment goals. The identified behaviours may lead to missed opportunities in eliciting and discussing patients’ knowledge about and preferences for their care. Patient‐, provider‐ and system‐oriented interventions are needed to improve clinical communication, especially among minority patients with advanced cancer.