Breaking Bad News: Pancreatic Mass on CT

Clinical Scenario

Henry Hayes, 47, has a video consultation booked as urgent to discuss CT scan results. He was seen 2 weeks ago by a colleague (Dr Ahmed) for right upper quadrant pain. An ultrasound showed a possible mass in the head of the pancreas, and an urgent CT was arranged. The CT report has now been received and confirms a 3.5cm mass in the head of the pancreas with possible local lymph node involvement, consistent with pancreatic malignancy. Henry is expecting to discuss gallstones — he has no idea the scan has shown something far more serious. You are the on-call GP delivering these results.

What This Case Tests

Delivering a likely cancer diagnosis using a structured breaking bad news framework (SPIKES); managing the patient's shock and emotional response; being honest about the likely diagnosis while acknowledging that histological confirmation is needed; arranging urgent oncology referral; providing immediate support and follow-up planning.

Common Mistakes Trainees Make

The three most common mistakes are: being too indirect or euphemistic (using phrases like 'there is an abnormality' or 'a shadow' without ever clearly stating the concern is cancer — this creates confusion and delays emotional processing), rushing through the information without allowing the patient to absorb the shock (trainees often deliver bad news then immediately move to management because they are uncomfortable with silence), and not checking what the patient already knows or expects (Henry thinks this is about gallstones — the gap between his expectation and reality is enormous and must be bridged carefully).

The Consultation Challenge

This is the most emotionally demanding type of SCA consultation. You are about to change someone's life with a single sentence. The SPIKES framework provides structure, but the core skill is being genuinely human while delivering devastating news.

Setting: Check Henry is in a private space. "Before we start, can I check you are somewhere private where we can talk without being interrupted? This is an important conversation and I want to make sure we have the time and space for it."

Perception: Assess what Henry already knows and expects. "Henry, can you tell me what your understanding is of why the CT scan was done? What are you expecting from today?" He will likely mention gallstones. This reveals the gap you need to bridge.

Invitation: Check how much detail he wants. "The scan results have come back, and I need to discuss them with you. Some people want all the details straight away, others prefer the headlines first. What would work best for you?"

Knowledge: Deliver the news clearly, with a warning shot. "I am sorry to tell you that the CT scan has not shown gallstones. It has shown a growth — a mass — in the head of your pancreas. I know this is not what you were expecting, and I am very sorry to give you this news." Then pause. Let the silence sit. Henry needs time to process.

Emotions: Respond to whatever Henry feels. He may cry, go silent, become angry, or dissociate. All are normal. "I can see this is a huge shock. Take all the time you need." Do not fill the silence with information — emotional processing must come before clinical planning.

Strategy and Summary: Only when Henry is ready, discuss next steps. "I want to make sure you get the right specialist assessment as quickly as possible. I am going to refer you urgently to the pancreatic surgery team — you should be seen within 2 weeks. They will need to do a biopsy to confirm exactly what this is, because the CT scan alone cannot give us the final answer." This last point is important — the CT is strongly suggestive but not histologically confirmed. There is a small but real possibility that the mass is benign.

Offer immediate support: "Is there someone I can call for you? Would you like me to arrange for you to speak to someone today? I am going to book you a follow-up appointment this week so we can talk through everything again once you have had time to process this."

Time check: Setting and Perception in the first 3 minutes. Deliver the news by minute 5 — do not defer. Allow emotional response between minutes 5-8 (this is not wasted time — it is the consultation). Discuss next steps between minutes 9-11. Use the final minute for immediate support and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you check what the patient already knows (the perception step — Henry expects gallstones), review the CT findings accurately, and communicate the diagnosis clearly without excessive jargon. They also look for whether you acknowledge that CT alone does not provide histological confirmation — maintaining honesty about what is and is not confirmed demonstrates clinical precision.

Clinical Management and Medical Complexity: Examiners expect an urgent oncology/pancreatic surgery referral via the 2WW pathway, knowledge that biopsy is needed for histological confirmation, and a follow-up plan. They also look for immediate practical support: who can be with Henry today, a follow-up appointment within days, and signposting to cancer support services. Management is important but secondary to communication in this case.

Relating to Others: The dominant domain. Examiners assess whether you use a structured breaking bad news framework, deliver the diagnosis clearly (not hidden behind euphemisms), allow adequate time for emotional processing, respond to Henry's reaction with genuine empathy, and avoid information-dumping during the shock phase. The ability to sit with silence after delivering the news is a specific skill being tested.

Example Opening

Strong opening: "Hello Henry, thank you for making time for this appointment. Before we start, can I check you are somewhere private and comfortable? I want to make sure we have the time and space for this conversation."

The warning shot: "The CT scan results have come back, and I need to discuss them with you. I am afraid the news is not what we were hoping for."

Delivering the diagnosis: "The scan has shown a growth in the head of your pancreas. I know this is a huge shock, and I am very sorry to have to tell you this."

After delivering: allow silence. Do not fill it. When Henry is ready: "I want to make sure you get the best possible care. The next step is an urgent referral to a specialist team who will need to do further tests, including a biopsy, to confirm exactly what this is."

Avoid: "There is a shadow on your pancreas that we need to look into further." (Euphemistic, unclear, and delays the emotional processing by creating ambiguity).

How This Appears in the SCA

Breaking bad news about a likely cancer diagnosis is one of the highest-stakes SCA scenarios. The examiner is primarily assessing Relating to Others — your ability to deliver devastating news with humanity, manage the emotional response, and provide support. Clinical knowledge matters, but the communication is what determines the mark.

Key Statistic

Pancreatic cancer has a 5-year survival rate of approximately 7-10%, though outcomes are better for early-stage disease amenable to surgery. Approximately 10,000 people are diagnosed with pancreatic cancer annually in the UK. The SPIKES framework is the most widely taught breaking bad news model in UK medical education.

Relevant Guidelines

• NICE NG85: Pancreatic cancer in adults — diagnosis and management
• NICE NG12: Suspected cancer — recognition and referral
• SPIKES framework for breaking bad news (Baile et al, 2000).

Frequently Asked Questions

What is the SPIKES framework and how do I apply it?

SPIKES is a structured six-step approach to breaking bad news: Setting (ensure privacy and adequate time), Perception (assess what the patient already knows), Invitation (ask how much detail they want), Knowledge (deliver the news with a warning shot then clearly), Emotions (respond to the emotional reaction with empathy), and Strategy/Summary (discuss next steps when the patient is ready). The framework provides structure without being rigid — adapt to the patient's response at each stage.

How do I handle silence after delivering bad news?

Silence is not empty — it is processing time. After saying "the scan has shown a growth in your pancreas," stop talking. The urge to fill silence is powerful but counterproductive. The patient needs seconds to minutes to absorb the information before they can hear anything else. Watch for cues: when the patient makes eye contact, asks a question, or visibly recomposes, they are ready for the next step. Comfortable silence is one of the most powerful consultation skills.

Should I use the word "cancer" or use softer language?

Be clear without being brutal. Using terms like "growth" or "mass" initially is appropriate, followed by "the concern is that this could be cancer" if the patient does not make the connection. Avoid euphemisms like "shadow" or "abnormality" that create ambiguity. If the patient asks directly "is it cancer?", answer honestly: "The scan findings are very concerning for cancer, but we need a biopsy to confirm. I want to be honest with you rather than give you false reassurance."

What if the patient becomes completely shut down or dissociated?

This is a normal shock response. Do not push more information. Acknowledge what is happening: "I can see this is a lot to take in. You do not need to say anything right now." Offer practical support: "Is there someone I can call for you?" Keep the conversation focused on immediate needs rather than clinical detail. Arrange a follow-up appointment within 2-3 days when the patient has had time to process and can absorb the management plan.

How do I maintain hope while being honest about a serious diagnosis?

Hope does not mean false optimism. Honest hope sounds like: "I want to get you seen by the right specialist team as quickly as possible — they will have the most up-to-date information about treatment options." Or: "The CT tells us there is a growth, but we do not yet know all the details — the biopsy will give us more information, and the specialist team will discuss what this means for you specifically." Avoid making promises about prognosis, but also avoid removing all hope.