Patients’ perceptions of the announcement of cancer diagnosis in Morocco “Cancer patients cases treated in the Fez-Meknes Region”

Abstract

BACKGROUND:

The announcement of a cancer diagnosis represents a real turning point, significantly and pessimistically changing the patient’s vision of his future. The task of the healthcare professional in communicating bad news is complex. It requires careful use of words, establishing a relationship of trust, a patient approach, and encouraging the person affected by cancer to express their emotions. This is a sociological study of a series of cancer patient cases designed to reveal the different perceptions and experiences of cancer patients with regard to the announcement of the diagnosis of cancer by healthcare professionals.

MATERIALS AND METHODS:

This descriptive qualitative study was done in 2022. The participants were selected from cancer patients cases treated in the Fès-Meknès Region. Participants in this study were 35 patients selected using a purposeful sampling method. Data were collected using in-depth semi-structured interviews. The qualitative content analysis approach was used to analyze the data using Atlas.ti software.

RESULT:

A double suffering has been observed among cancer patients with regard to the announcement of their cancer diagnosis. In addition to the intensification of negative feelings and distress at the time of the announcement, dissatisfaction has been observed with the way in which the cancer diagnosis is communicated. The announcement does not address the holistic needs of the cancer patient, particularly with respect to health literacy. This finding is justified by limitations in relation to the basic training of the medical and nursing cops with regard to the announcement of the diagnosis.

CONCLUSION:

This event represents a critical moment, requiring a multidisciplinary approach and involving various professionals involved in cancer management. Health professionals need to develop the skills necessary to accurately but smoothly announce a cancer diagnosis in order to maintain hope regardless of prognosis. Thus, an indispensable aspect to take into account in diagnostic communication is the cancer patient’s level of literacy.

Introduction

Learning that one has cancer is frequently a destabilizing event for affected individuals and their loved ones.[1] The impact of this sudden new reality can have a profound and lasting effect on the daily life and identity of each affected person.[2] This is why the moment of diagnosis is often perceived as a moment of rupture in the course of life, marking a clear distinction between a period before and a period after the announcement.[3] Indeed, it officially signifies entry into the “status of a sick person.”[4] This status is not simply given, or even attributed, by doctors and their etiological categories. It is constructed over time as a function of social representations of the disease, the patient’s history, and social context.[5] It can be the subject of a long process of identification or differentiation, acceptance or rejection, appropriation or distancing of this new identity, which augurs a long career as a patient.[6] And in order to provide optimal conditions at the time of the cancer diagnosis and for the establishment of a long-term care relationship, announcement consultations have seen the light of day. The aim is to secure the loyalty of patients who are going to have to undergo long, regular follow-up care, so as to avoid losing sight of them after a poorly-made or traumatic announcement.[7]

Building on previous research, the intention is to adopt a sociological perspective to examine how patients perceive the announcement of a cancer diagnosis. The aim is to explore the clarity of the process of communicating the diagnosis and to provoke reflection on the extent to which it is understood and accessible to all people with cancer.

Materials and Methods

Study design and setting

This is a qualitative sociological study of a series of cancer patient cases designed to reveal the different perceptions and experiences of cancer patients with regard to the announcement of the diagnosis of cancer by healthcare professionals. This study was done in 2022 in the different cancer care facilities in the FES-MEKNES Region.

Study participants and sampling

The participants in this study were patients selected using a purposeful sampling method. In addition, a summary of the interviewees was created in the form of a summary table [Table 1]. This table presents data on 35 cancer patients, including details such as gender, age, interview duration, place of recruitment, socio-economic status, type of cancer, presence or absence of recurrence, medical coverage, and family situation.

Table 1.

Socio-demographic data of patients

Structure	Genre	Age	Localisation	Profession	Study level	Family situation	Provenance	Medical cover
*CROM	Woman	57	Breast	No	Illiterate	Married	Meknes	*RAMED
CROM	Man	81	Lung	Retired	College	Married	Tinghir	*CNSS
*HOF	Woman	56	Breast	No	College	Married	Fes	RAMED
CROM	Woman	37	Breast	No	Illiterate	Single	Taroudant	RAMED
CROM	Woman	52	liver	Saleswoman	university	Divorced	Meknes	RAMED
CROM	Man	55	lung	A daily labor	Illiterate	Married	Meknes	RAMED
CROM	Woman	52	Breast	No	Illiterate	Married	Meknes	RAMED
CROM	Woman	45	Breast	No	Illiterate	Divorced	Bhalil	RAMED
CROM	Woman	43	Breast	A daily labor	Illiterate	Divorced	El Hajeb	RAMED
CROM	Woman	60	Breast	No	Illiterate	Divorced	Meknes	RAMED
CROM	Man	29	Bladder	No	Illiterate	Married	M’rirt	RAMED
CROM	Woman	50	Liver cancer	No	Illiterate	Married	M’rirt	RAMED
CROM	Woman	54	Breast	No	Primary	Divorced	Taoujdate	RAMED
CROM	Man	63	Prostate	A daily labor	Primary	Married	Agourai	RAMED
HOF	Woman	39	Breast	No	university	Married	Fes	CNSS
CROM	Woman	42	Ovary	No	secondary	Divorced	Er-Rich	RAMED
HOF	Woman	40	Spine	No	College	Divorced	Fes	RAMED
CROM	Woman	51	Clavicle	No	Illiterate	Married	Meknes	RAMED
CROM	Woman	72	Lung	No	Illiterate	Divorced	Khénifra	RAMED
CROM	Man	70	Stomach	No	Illiterate	Married	Meknes	RAMED
CROM	Woman	58	Breast	No	Illiterate	Married	Midelt	RAMED
CROM	Man	66	Lung	A daily labor	Illiterate	Married	Meknes	RAMED
CROM	Woman	40	Breast	No	Illiterate	Married	M’rirt	RAMED
CROM	Woman	39	Uterus	No	Illiterate	Divorced	Meknes	RAMED
HOF	Woman	50	Intestine	No	Illiterate	Widow	Fes	RAMED
CROM	Woman	44	Breast	No	Primary	Married	Agourai	RAMED
HOF	Man	67	Stomach	A daily labor	Illiterate	Married	Fes	RAMED
CROM	Woman	49	Breast	Teacher	College	Married	Meknes	RAMED
Private	Woman	54	breast	Professor	university	Married	Meknes	*CNOPS
Private	Woman	48	Breast	Nurse	university	Married	Meknes	CNOPS
Private	Woman	51	liver	Civil servant	university	Married	Meknes	CNOPS
Private	Woman	44	Breast	Director	university	Married	Meknes	CNOPS
Private	Woman	36	Breast	Employee	college	single	Meknes	CNSS
Private	Woman	47	Breast	Employee	Primary	Divorced	Meknes	CNSS
Private	Woman	40	Breast	Employee	college	Single	Meknes	CNSS

*–ROC=Regional oncology center. *–HOF=Fes oncology hospital. *–RAMED=Medical aid scheme for economically deprived persons. *–CNSS=National social security fund. *–CNOPS=National fund of social welfare organizations

Data collection tool and technique

Information was obtained by conducting semi-structured interviews with individuals with cancer. To analyze the semi-structured interviews using ATLAS.ti software, we established correspondences between the specific key terms identified and the answers provided by the interviewees. We then established links between the various responses in order to draw relevant conclusions.

Ethical consideration

During the data collection process, the researchers implemented all necessary measures to guarantee respect for the rights and freedoms of study participants. Consequently, the study fully adhered to the fundamental rights set out in the Code of Ethics, in particular: a) the right to make autonomous decisions; b) the right to maintain privacy; c) the right to remain anonymous and preserve confidentiality; d) the right to be protected from discomfort or harm; and e) the right to fair and just treatment. In this respect, the study was thoroughly reviewed and received approval from the Ethics Committee of the University Hospital of Fez, Morocco, on September 3, 2022, with reference number 15/21.

Result

Table 2 presents an analysis of patient satisfaction with the way their cancer diagnosis was announced. It highlights the variety of patients’ reactions and opinions to the announcement of their cancer diagnosis, underlining the complexity of individual emotions and assessments in such a delicate situation. The “dissatisfied” category includes 14 cases, equivalent to 40.0% of the sample. This suggests that a significant proportion of patients surveyed were dissatisfied with the way their diagnosis was announced. The “I don’t know” category covers 7 cases or 20.0% of the sample. These responses reflect uncertainty about patients’ level of satisfaction with the diagnosis, perhaps indicating mixed feelings or difficulty in clearly assessing their own feelings. The “moderately satisfied” category includes 6 cases, equivalent to 17.1% of the sample. This category highlights patients who expressed a moderate level of satisfaction with the way their diagnosis was communicated. The “not at all” category accounts for 4 cases or 11.5% of the sample. These patients expressed complete dissatisfaction with the way the announcement was made. The “satisfied” category comprises 5 cases, equivalent to 11.4% of the sample. These responses indicate that some patients were satisfied with the way their cancer diagnosis was announced.

Table 2.

Satisfaction with cancer diagnosis

	Workforce	Percentage	Valid percentage	Cumulative percentage
Valid
Dissatisfied	14	40,0	40,0	40,0
I don’t know	7	20,0	20,0	60,0
Moderately satisfied	6	17,1	17,1	77,1
Not at all	4	11,5	11,5	88,6
Satisfied	5	11,4	11,4	100,0
Total	35	100,0	100,0

Looking at the cumulative percentages, we can see that 60.0% of patients expressed either dissatisfaction (“dissatisfied” and “not at all”) or uncertainty (“I don’t know”) about their level of satisfaction. Furthermore, 77.1% of patients indicated that they were either “moderately satisfied,” “dissatisfied,” or “not at all satisfied.”

Table 3 shows the different ways of announcing a diagnosis, and the corresponding data in terms of numbers and percentages. Three categories of the announcement are listed: “brutal,” “I don’t know,” and “progressive.”

Table 3.

How to advertise

	Workforce	Percentage	Valid percentage	Cumulative percentage
Valid
Brutale	20	57,1	57,1	57,1
I don’t know	5	14,3	14,3	71,4
Progressive	10	28,6	28,6	100,0
Total	35	100,0	100,0

The “brutal” category represents 20 cases or 57.1% of the total sample. This means that in just over half the cases, the diagnosis was announced suddenly and directly, without preparation or care. The “I don’t know” category includes 5 cases or 14.3% of the sample. These cases indicate uncertainty as to how the diagnosis was announced, perhaps suggesting that patients were unable to perceive clearly how the announcement was made. The “progressive” category accounts for 10 cases or 28.6% of the sample. This category describes a gradual and progressive announcement of the diagnosis, where information is communicated in a gentle and gradual manner to help the patient assimilate the news in a more appropriate way. Looking at the cumulative percentages, we can see that 57.1% of announcements were abrupt, while 71.4% of announcements were either abrupt or of an indeterminate nature (“I don’t know”).

The cross Table 4 below examines the relationship between satisfaction with the announcement of a cancer diagnosis and the manner in which the diagnosis was announced, distinguishing between the “brutal,” “I don’t know,” and “progressive” categories. The table shows the numbers of each combination of satisfaction and manner of announcement, as well as the totals.

Table 4.

Cross-tabulation of advertising satisfaction* Manner of advertising

Workforce
	Announcement			Total
	Brutal	I don’t know	Progressive
Ad satisfaction
Dissatisfied	13	0	1	14
I don’t know	2	5	0	7
Moderately satisfied	1	0	5	6
Not at all satisfied	4	0	0	4
Satisfied	0	0	4	4
Total	20	5	10	35

Looking at the results: Of the patients who received a “brutal” announcement, 13 expressed dissatisfaction, 2 answered “I don’t know,” 1 was moderately satisfied, and 4 answered “not at all satisfied.” None of the patients who received an abrupt announcement were classified as “satisfied.” For patients who received an “I don’t know” announcement, none expressed dissatisfaction, 5 were unsure of their level of satisfaction, and none were moderately satisfied or “not at all satisfied.” Nor were any classified as “satisfied.” Of the patients who received a “progressive” announcement, 1 expressed dissatisfaction, 5 were moderately satisfied, 4 were satisfied, and none were classified as “not at all satisfied.” Overall, this table highlights certain trends:

“Brutal” announcements are associated with a greater number of dissatisfactions and discontents, while “progressive” announcements seem to be more closely linked to levels of satisfaction and average satisfaction. “I don’t know” announcements seem to be less clearly correlated with specific levels of satisfaction, with a high number of uncertainties.

However, it is important to note that this table offers a partial view of the situation and that other factors related to socio-economic status could also influence patients’ responses in terms of satisfaction and manner of announcement.

Table 5 presents a cross-analysis of satisfaction with the announcement of a cancer diagnosis according to patients’ level of education, distinguishing between “illiterate,” “middle school,” “high school,” “primary school,” and “university” levels. Data are presented in headcount form for each combination of education and satisfaction, as well as totals. Looking at the results: among patients with an education level of “illiterate,” 9 were dissatisfied, 7 didn’t know, 2 were satisfied and none were moderately satisfied or “not at all satisfied.” For patients with a “college” education level, 1 was dissatisfied, 2 were moderately satisfied, 3 were “not at all satisfied,” and none were classified as “satisfied” or “don’t know.” Patients with an education level of “high school” were all moderately satisfied. Among patients with a “primary” education level, 2 were dissatisfied, 2 were moderately satisfied, and none were “not at all satisfied,” “satisfied,” or “don’t know.” Patients with a “university” level of education were more evenly distributed, with 2 dissatisfied, 1 moderately satisfied, 1 “not at all satisfied” and 2 satisfied.

Table 5.

Cross-tabulation level of education* Ad satisfaction

	Dissatisfied	I don’t know	Moderately satisfied	Not at all satisfied	Satisfied	Total
Study level
Illiterate	9	7	0	0	2	18
College	1	0	2	3	0	6
High school	0	0	1	0	0	1
Primary	2	0	2	0	0	4
University	2	0	1	1	2	6
Total	14	7	6	4	4	35

Overall, this table suggests that the level of education may have an influence on satisfaction with the cancer diagnosis. Illiterate patients appear to have a higher rate of dissatisfaction, while patients with a university education have more varied responses in terms of satisfaction. It should be noted that this table also offers a limited perspective and that other factors could also contribute to patients’ satisfaction and reactions to the announcement of their diagnosis.

Discussion

When cancer is diagnosed, this moment often involves the announcement of the disease by the healthcare professional[8] which leads to intense emotional reactions on the part of the sufferer and those around him or her. Relationships with healthcare professionals and social support play an essential role in this phase, as they can help to understand and cope with the new reality of the disease. This is an important stage in the life of the patient and those around him.[9] At the time of the announcement, it is obvious that a disparity arises between the patient’s perception of the disease and those affected by it, and the way he perceives himself.[10] This discrepancy can manifest itself in reactions such as “This can’t be true! I can’t have cancer!,” and calls into question the fundamental meaning of cancer and the status of a sick person. Obviously, “this is a real shock and destabilization for all patients. It is a major upheaval in the lives of patients, a biographical rupture that impacts all spheres of the patient’s life and marks the transition from the world of well-being to that of illness.”[11] This announcement was considered by many patients¹ as “shocking” and “traumatic.” As soon as the diagnosis is announced, death is presented in a very powerful way in the collective imagination.[12] And it is often perceived as an incurable disease caused by modernity.[13] For some, cancer is the result of a spell or an evil eye, making it a spiritual illness. In some situations, cancer is seen as a disease that emerges following a transgression, symbolizing a trial or punishment. Patient testimonies also revealed the importance attached to destiny, interpersonal and emotional relationships, and the consideration of illness as a sudden event over which disadvantaged patients have no control. In this sense, some patients, such as Zahra² said “ah…the cancer at the beginning I said to myself… it’s my destiny it’s waiting for death…”. Hayat³ said, “It’s very difficult to accept. cancer, the bad disease, am I going to tell the people around me, how am I going to go on living with it.” Confirmation of a cancer diagnosis generates a mixture of uncertainty and fear in affected patients. According to a descriptive cross-sectional study that was conducted at the All India Institute of Medical Sciences, Rishikesh, from July 2020 to December 2020, 80% of patients felt great anxiety about cancer. They had persistent concerns about the development of cancer-related complications, even after treatment, and harbored apprehensions that cancer might eventually lead to their death.[14] Other patients, on the other hand, accepted the diagnosis, preferring to face the disease head-on, as in the case of Fati⁴, who says, “I was unsettled for 5 minutes and then decided to face this disease.” She sees it as an insidious deterioration that she can delay as long as possible.

In addition, the results of the study revealed that many patients were dissatisfied with the way in which the disease was announced. As Rita⁵ points out “…after a mammogram, the doctor gave me a slap in the face when he told me straight out, without thinking about my situation, you have to remove your breast…you have to remove your breast…I told him why doctor?…because you have cancer…I felt like the earth was spinning around me…”. Nema⁶ also declares in this sense “…the moment the doctor told me you must remove your breast, I felt like I was drowning in the sea, it was really unacceptable… unacceptable…at that moment I cried so much, and I begged the doctor to find me another solution…you know my brother what he told me in a state of anger…what am I going to do with your breast? What am I going to use it for? Then he threw my file on the table…”. Rida⁷ also complained about the manner of this annone “…It’s hard when the doctor tells you the disease ‘cancer’ as something very normal…”. Med⁸ on her part states “…the doctor told me the disease too quickly…he’s in a hurry…sometimes he doesn’t even look at you…, I would at least have liked to know what to expect, even the nature of the disease was not clearly explained to me and even for the treatment.”

The results of the interviews highlighted the difficulties encountered by patients waiting for the diagnosis to be announced. Indeed, patients’ experiences during this stage were fraught with strong emotions, uncertainty, anxiety, fear, despair, and frustration. This observation was made by all patients, regardless of the nature of the diagnosis. Thus, a large proportion of patients showed their refusal of the diagnosis, which revealed attempts to resist the disruption of identity and medical control that it prefigures. These patients refuse to see their existence framed by medical standards and burdensome treatments. These are protective strategies used by cancer patients to maintain their existence intact in the face of the social threat posed by their illness.[15] In the same vein, Majda⁹ says “the doctor who saw me for the first time told me the result… it was hard and I couldn’t believe it… Pfffff even the environment was very stressful… at first I had even decided to give up treatment for good.” For Zahra¹⁰ “…oh!!!…waiting for the results, it’s very difficult…no words can describe it…after the announcement, the negative feelings of anxiety and fear left such a mark on me and especially with the behavior of some hospital staff who didn’t take our shock and suffering into consideration…the idea of abandoning this treatment was always present…” As for Hanane¹⁰ “the doctor certainly reassured me, but it wasn’t enough for what I was feeling…” For Nora¹¹, with tears in her eyes, “…understanding the suffering of women awaiting a diagnosis is not easy…the doctor told me I have a nodule… she tried to reassure me… but it only increased my suffering, my future is unknown.”

According to the verbatims of the participants in the study, some therapeutic relationships are characterized by a lack of listening, empathy, and humanity. The attitudes of underprivileged cancer sufferers towards the body, health, and illness are not well taken into account in the process of announcing the disease, given that among the most underprivileged populations (working-class and rural), human relationships are characterized more by a valuing of affective dimensions, and the human dimension is strongly solicited in social relationships. This may be explained by the fact that doctors anticipate that patients from modest social backgrounds will be less able to bear the psychological costs of a difficult announcement. Patients from a compatible socio-cultural background are more likely to be given a full announcement. The tendency of doctors to announce the disease perfectly to members of the upper social classes is evident.[16] The study also revealed the attitudes of certain healthcare professionals, which converge in their concern to maintain an emotional distance and a minimum of formalism in the relationship between service recipients and providers. This attitude is reflected in the use of technical and abstract language, which guarantees objectivity and at the same time acts as a bulwark against the effects of emotional over-investment.[17] These are, of course, areas of incomprehension that characterize the relationship between healthcare professional and cancer patient as a singular, unpredictable, asymmetrical, and unequal encounter built around a particularly complex double language, that of the body and speech. These areas of incomprehension cannot be bridged simply by popularizing science, but the real aim is to come to terms with the universe of popular meanings and explanations of illness, not to bypass it.

So, sometimes families still ask that patients not be informed of the diagnosis. This creates ethical dilemmas for healthcare providers in obtaining their patients’ informed consent to treatment.[18] However, autonomy suggests that each individual has the right to decide his or her own course of action and to design a course of action that he or she has defined.[19] Cancer diagnosis, which is considered delicate, complex, and painful, is not fully integrated into the care process for cancer patients in public health facilities in the Fès-Meknès region. This observation can be justified by the limitations of basic medical and nursing training courses in terms of announcing the diagnosis of a chronic disease. With this in mind, a review of existing evidence in the literature on the effectiveness of such training was carried out. Only seven controlled trials were found, four of them randomized, and these four suggest that training doctors and post-graduates in communicating bad news can be beneficial, but there are significant limitations to reaching a definitive conclusion. An analysis of outcomes after completion of the training does not assess doctors’ ability to adapt to changes in the job market, nor does it assess doctors’ ability to retain learning skills in the long term.[20] A quite different finding was observed for patients cared for in some private oncology centers. They expressed a certain satisfaction with the presence of an on-site psychologist to help them come to terms with their illness; they also expressed a sense of contentment with the climate of trust and support provided by doctors and nurses.

Limitation and recommendation

The limitations of the study were patients who agree to take part in an interview do not necessarily represent their entire population. They are probably the most interested and motivated individuals. The present study therefore presents a motivational bias. However, this bias is typical of most sociological research. Another limitation was linked to biases linked to the design of instrumentation in Arabic adapted to the patient’s level of education. It may not correspond to the original English version. Similarly, the translation of responses leaves some room for subjectivity on the part of the interviewer.

In terms of recommendations, it appears that health literacy is an essential factor in improving the quality of care for cancer patients, of which the announcement of a cancer diagnosis is an integral part. It’s a shared responsibility between cancer patients and healthcare professionals to provide safe, holistic care that takes into account all the social determinants of health.

Conclusion

The importance of this study lies in its sociological approach to the question of the perception of diagnosis by cancer patients. Some insensitivity on the part of healthcare professionals has been observed, as they open at a time that strongly marks the relationship between healthcare professionals and cancer patients, focusing exclusively on the physical and technical aspects of care. This means that doctors and nurses need to develop the skills to accurately and sensitively communicate the cancer diagnosis in order to convey a message of hope, regardless of the prognosis. Similarly, an important aspect to consider in diagnostic communication is the literacy level of the cancer patient. Achieving this objective depends on two essential approaches. The first should emphasize the dialogue between the cancer patient and the healthcare professional. Actions based on this approach should focus on the individual capacities of patients and healthcare professionals. The second is a public health approach that pays particular attention to the social factors underlying literacy levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.