68 4. Communication and Decision Making It would seem obvious that realistic goals and expectations of treatment, specifics about the potential harms and benefits of cancer therapies, and timely feedback regarding scans and other tests to ascertain current disease status would all be essential components of informed decision making for MBC patients. Nevertheless, research indicates that patients are often not well informed in any of these areas. Many MBC patients persist in believing a cure is likely, when it is not. According to 1 study[76] , two thirds of patients with metastatic cancers were not informed of the likely impact of a given treatment on their quality of life, and nearly one third were unaware of the uncertainty around the described benefit. One problem with patient–clinician communication is that, although almost all patients say they wish to receive all possible information around their diagnosis, good or bad, not all truly wish to know the details[77] . The available research strongly suggests that patients are less anxious and depressed when their role in making treatment decisions is congruent with their wishes, suggesting that communication of at least patients’ desires is critical. Busy oncologists do not always have the time, skills, or inclination to offer details in a form that patients or family members can easily grasp, especially when treatment choices are unclear and the prognosis may be poor. According to one review, “time constraints in busy clinics, and physicians’ belief that they know the amount and kind of information that is best for their patients to receive, may contribute to consultations that are physician-directed and physician-dominated, leaving patients with unmet communication needs and feelings of dissatisfaction”[78] . Some research suggests that even when communication is clear, patients and families may overestimate the likely prognosis and benefits from treatments, which may in turn interfere with good decision making. This is especially likely to occur toward the end of life, when an approach that emphasizes palliative care may enhance quality of life and even extend survival. A recent, large survey of MBC patients[61] demonstrates the magnitude of the problem, even in an educated, insured, and advantaged population. The survey found that nearly all patients received information about their type of cancer but two thirds did not receive any guidance or tools to assist in decision making. As a consequence, nearly half of those who didn’t write down their questions before consultation with their physician felt unprepared to make treatment decisions. Busy oncologists do not always have the time, skills, or inclination to offer details in a form that patients or family members can easily grasp, especially when treatment choices are unclear and the prognosis may be poor. MBC patients strongly desire better communication with their health care providers.