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Should the decision to operate be made by patients with NSCLC or their doctors?
The central point of the argument in the paper by Dowie and Wildman in this issue of Thorax1 is that it is the patient, not the doctors, who should decide whether to take the risk of an operation in the hope of curing lung cancer. I agree, and I know from working with a number of chest physicians on a regular basis that the patient's preference is genuinely central in decisions made about treatment. What is less certain is whether the choices being made are as explicit and as fully informed as would be necessary to implement decision analysis as espoused in this paper.2 My purpose is to ground the ideas in the context of current clinical practice and to see how near or far we are from patient determined decision making.
MAKING THE DIAGNOSIS
Firstly, the diagnosis must be known—including stage and cell type—and an estimate of prognosis made before the decision table can be entered. Dowie and Wildman's starting point is stage Ia non-small cell lung cancer. Clinicians will know that preoperative staging is never certain (if it were, we could claim a 100% surgical cure rate for N0M0 disease), but with increasing use of FDG-PET (fluoro-deoxyglucose positron emission tomography) in addition to CT scanning and mediastinoscopy as appropriate, we get as near to a diagnosis of stage Ia disease as is currently possible.
INFORMING THE PATIENT
We must also tell the patient. There are strategies for “breaking bad news” and it is never easy; it is we, the clinicians, who have to do it, but do it we must.3 In current practice not telling the patient can rarely be justified and we cannot have a decision analysis based on “gradual disclosure”4 and other forms of …