Peer-reviewed Journal Articles

Cortez, Dagoberto and Michael Halpin. In Press. “Uncertainty and Certain Death: The Role of Clinical Trials in Terminal Cancer Care.” Sociology of Health and Illness.


We consider uncertainty in relation to clinical trials for terminal non-small cell lung cancer, which is an aggressive and difficult to treat form of cancer. Using grounded theory to analyze 85 clinical interactions between doctors, patients, and family members. We argue that uncertainty is a major source of tension for terminally-ill patients, with individuals confronting a choice between transitioning to palliative care or volunteering for an experimental/trial medication that might postpone death. Regardless of the trial’s efficacy, patients must also consider how such experimental treatments might impact their quality-of-life. We contend that clinical trials produce uncertainty through 1) discussions about the efficacy of clinical trials; 2) the physiological consequences of clinical trial medications; and, 3) the impact clinical trials have on patient’s prognostic understanding of their terminal cancer. Accordingly, while study participants encounter high prognostic certainty (i.e., they have fatal cancer), they nonetheless experience considerable uncertainty in relation to their participation in clinical trials.

Cortez, Dagoberto, Douglas Maynard, and Toby Campbell. 2019. “Creating Space to Discuss End-of-Life Issues
in Cancer Care”
 Patient Education Counseling, Special Issue: End of Life.

This paper analyzes entire oncology clinical visits and examines instances in which oncologists have to break the bad news that
patients’ treatments are no longer effective. Using conversation analysis we examine 128 audio recorded conversations between
terminal lung cancer patients, their caregivers, and oncologists. Our results suggest that when oncologists break the bad news
that a patient’s treatment is no longer effective, they often use a conversational device we call an “exhausted current treatment”
(ECT) statement, which avoids discussing prognosis in favor of further treatment options. Analysis suggests that improving
and prioritizing patient-centered care and shared decision making is possible if we first understand the social organization of
clinical visits. ECT statements and their movement towards discussing treatment options means that opportunities are bypassed
for patients and caregivers to process or discuss scan results, and their prognostic implications. When oncologists and patients,
by fixating on treatment options, bypass opportunities to discuss the meaning of scan results, they fail to realize other goals
associated with prognostic awareness. Talking about what "scans mean" may add minutes to that part of the clinic visit, but can
create efficiencies that conserve overall time. We recommend that oncologists, after delivering scan news, ask, “Would you like
to discuss what this means?”

Singh, Sarguni, Dagoberto Cortez, Douglas Maynard, James F. Cleary, Lori DuBenske, and Toby C. Campbell. 2017.
“Characterizing the Nature of Scan Results Discussions: Insights into Why Patients Misunderstand their Prognosis.”
Journal of Oncology Practice.

Patients with incurable cancer often have poor prognostic awareness, which may lead to unrealistic expectations and the pursuit
of inappropriately aggressive therapy. Although it has been demonstrated that patients have poor illness understanding, little is
known about what factors contribute to this prognostic disconnect. Our study sought to further characterize how oncologists
discuss prognostic information with patients with advanced cancer and to identify whether this discussion contributes to patients’ misperceptions. We listened to 128 audio-recorded encounters of multiple oncologists from four academic cancer center hospitals in the eastern, midwestern, and southwestern United States between 2004 and 2007. Eligible patients were English-speaking adults with stage IIIA, IIIB, or IV non–small-cell lung cancer. Sixty-four of these audio-recorded conversations included scan results and were subsequently categorized into good, stable, or bad news on the basis of the content of the recording. We used conversation analysis, a qualitative method for studying human interaction, to present a detailed examination of the dialogue between oncologists and patients in conversations with prognostic implications. Oncologic visits follow a typical phase structure comprising four central components: symptom-talk, scan-talk, treatment-talk, and logistic-talk. Our analysis suggests that oncologists spend little time discussing scan results and the prognostic implications in favor of treatment-related talk. These findings are specific to oncologists and thus not necessarily reflective of the communication practices of other clinicians who care for seriously ill patients. Our study found a need to create space within the typical oncologic visit phase structure for prognosis communication, and we believe the paucity of this conversation significantly contributes to poor prognostic awareness demonstrated by patients with cancer. We offer a question, “Would you like to talk about what this means?” as a communication device that can regularly incorporate occasions for prognosis-talk and
shared decision making. This simple question, already aligned with the way oncologists naturally communicate, could meaningfully affect dialogue surrounding prognosis, leading to enhanced prognostic awareness.

Maynard, Douglas, Dagoberto Cortez, and Toby Campbell. 2016. “’End of Life’ Conversations, Appreciation Sequences,
and the Interaction Order in Cancer Clinics.”
Patient Education and Counseling.

This paper addresses the organization of conversations in oncology visits by taking an “interaction order” perspective and asking how these visits are intrinsically organized. We use conversation analysis to examine audio recorded conversations between oncologists, terminally-ill lung cancer patients, and their family members. Our findings show that oncologists use appreciation sequences, which are designed to elicit patients’ understanding and positive assessment of treatments in terms of their prolongation of life. An “appreciation sequence,” regularly initiated after the delivery of scan results and/or treatment recommendations, simultaneously reminds patients of their mortality while suggesting that the treatment received has prolonged their lives, and in some cases significantly beyond the median time of survival. We end the paper by exploring the functions of the appreciation sequence for cancer care and set the stage for considering where and when physicians have choices about the order and direction the talk can take and how to allocate time for end-of-life and quality-of-life conversations.