Breaking bad news: learning through experience

Physicians' Self-Perceived Competence on Breaking Bad News to Parents of Children with Neurodisabilities

Delivering difficult news to parents of children with neurodisabilities, often involving new diagnoses, prognosis changes, or declines in function or health, presents a complex task. Our aim was to assess physicians' self-perceived competence in breaking bad news (BBN) within this context. An online survey was administered to neuropediatricians and developmental and rehabilitation pediatricians in Switzerland. Among 247 invited physicians, 62 (25.1%) responded (age of 51 ± 11 years; M/F ratio of 2:3). They rated their BBN competence at 7.5 ± 1.6 out of 10. Factors significantly associated with self-perceived competence in uni- and multivariate analyses included years of professional experience (≤10 years: 6.2 ± 1.8; >10 years: 8.2 ± 0.8), and region of pregraduate training (Switzerland: 7.3 ± 1.6; European Union: 8.3 ± 0.9). The respondents highlighted the positive roles of professional and personal experience, quality relationships with families, and empathy in BBN. In summary, physicians generally expressed a sense of competence in delivering difficult news to parents of children with neurodisabilities. They underscored the significance of life experiences and certain individual qualities in their effectiveness. These findings provide valuable insights into enhancing professional training and support in this crucial yet underexplored aspect of medical practice.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

Improving Child Neurology Residents' Communication Skills Through Objective Structured Clinical Exams

INTRODUCTION

Child neurology has unique challenges in communication due to complex disorders with a wide array of prognoses and treatments. Effective communication is teachable through deliberate practice and coaching. Objective structured clinical exams (OSCEs) are one method of providing practice while assessing communication skills. Yet OSCEs have not been reported for child neurology residents.

METHODS

We developed simulated clinical cases centering on communication skills for child neurology residents, all with challenging clinical scenarios (e.g., disclosure of a medical error, psychogenic nonepileptic events). Standardized patients (SPs) portrayed the parents of pediatric patients and, in some scenarios, an adolescent patient. We used a modified Gap-Kalamazoo Communication Skills Assessment Form to assess communication skills. The assessment was completed by faculty, SPs, and the resident, and we measured agreement among raters. Residents were surveyed afterward regarding their experience.

RESULTS

Nine cases were developed and piloted. A total of 27 unique resident-case encounters with 16 individual trainees occurred over three annual implementations. Scores on the 360-degree assessment of communication skills showed that residents overwhelmingly underassessed their skills compared to other rater groups. Among 18 responses on the post-OSCE survey, the majority (77%) found the experience useful to their education and felt that the feedback from the SPs was helpful (61%) and the case portrayals were realistic (89%).

DISCUSSION

We implemented simulated cases for assessment and formative feedback on communication skills for child neurology residents. We provide a blueprint to develop this educational activity in other programs.

An Objective Structured Clinical Examination of Communication Skills for Child Neurology Residents

BACKGROUND

The purpose of this study was to implement an objective structured clinical examination for child neurology trainees for formative feedback regarding communication skills. Effective communication skills are essential and teachable, but tools to formally assess them are limited. An objective structured clinical examination is one such tool, but these examinations have not been developed for child neurology residents.

METHODS

We developed nine standardized scenarios that highlighted communication challenges commonly encountered in child neurology. Child neurology trainees participated in three objective structured clinical examination events with three scenarios each over three academic years. Standardized patients portrayed patients or their parents. Each trainee-standardized patient encounter was evaluated by an observing faculty member using a modified Gap-Kalamazoo Communication Skills Assessment Form, the standardized patient who provided direct feedback, and by the participating trainee.

RESULTS

We refined the process of case writing, standardized patient training, and trainee evaluation throughout the three-year pilot. Results indicated rater agreement ranging from 32% to 56%. Trainees reported that the cases were challenging and reflective of real life and that the experience helped improve their communication skills.

CONCLUSIONS

An objective structured clinical examination can provide a standardized setting for formative feedback regarding communication skills in child neurology residency programs. The communication challenges posed by common clinical scenarios involving critically ill children, children with undetermined prognosis, and the triad of parent, child, and physician can be realistically modeled in an objective structured clinical examination. We developed cases and a process that were valuable and that we plan to sustain for resident education related to communication skills.

[Recommendations for communicating bad news by phone during the SARS-CoV-2 pandemicRecomendações para a comunicação de más notícias por telefone durante a pandemia do SARS-CoV-2]

La pandemia actual por SARS-CoV-2 presenta desafíos específicos para los profesionales de salud en el campo de la atención sanitaria. En este contexto de emergencia, la comunicación de malas noticias toma especial relevancia por el modo particular en que debe llevarse a cabo: la necesidad de mantener distanciamiento sanitario y las restricciones de movilidad impuestas a la población general hacen que esta tarea deba ser realizada, muchas veces, de manera remota, en su mayoría mediante llamados telefónicos. Esto enfrenta a los profesionales a una serie de obstáculos particulares: a) la mayoría de ellos poseen escasa o nula formación sobre esta clase de habilidades comunicativas, b) la comunicación efectiva de malas noticias depende, en gran parte, del lenguaje corporal utilizado, ausente en este tipo de intercambios, y c) dado que este tipo de diálogo remoto no es recomendable -con excepción de circunstancias particulares como la actual- existe escasa literatura disponible para guiar a quienes deben cumplir esta tarea. Este manuscrito ofrece recomendaciones sobre pautas básicas para la comunicación remota de malas noticias por teléfono, en situaciones en las cuales no se pueda llevar a cabo esta tarea de forma presencial. Se presenta una propuesta estructurada en torno de cuatro “momentos” para orientar la transmisión de malas noticias a distancia, con el fin de mejorar los cuidados a pacientes, familiares y cuidadores durante este intercambio y también reducir el impacto negativo que este intercambio tiene sobre los profesionales de la salud.

Breaking Bad News: A Survey of Radiology Residents' Experiences Communicating Results to Patients

PURPOSE

The practice of radiology often includes routine communication of diagnostic test results directly to patients in breast imaging and interventional radiology. There is increasing interest in expanding direct communication throughout radiology. Though these conversations can substantially affect patient well-being, there is limited evidence indicating that radiology residents are specifically taught methods to effectively convey imaging results to patients. Our purpose is to evaluate resident experience communicating imaging results to patients.

MATERIALS AND METHODS

An IRB-approved study with a total of 11 pilot-tested questions was used. Surveyed programs included radiology residents (PGY2-PGY5) at 2 urban residency programs. Online surveys were administered using SurveyMonkey and e-mailed to residents at both programs (starting November 20, 2015, completed March 31, 2016). Demographics were obtained with survey proportions compared using logistic regression (P < 0.05, statistically significant).

RESULTS

A total of 73 residents responded (93.6% response rate) with similar response rates at each institution (P = 0.689). Most were male (71.2%) with 17.8% planning to go into breast imaging (21.9%, interventional radiology (IR)). Furthermore, 83.6% described no training in communicating radiology results to patients; 91.8% of residents communicated results with patients (87.7% diagnostic imaging tests and 57.5% biopsies). Residents most commonly communicated results in person (75.3%) followed by phone (64.4%), and 79.4% agreed or strongly agreed that additional training relaying results would be helpful.

CONCLUSIONS

A large majority of radiology residents have communicated test results to patients, yet few have received training in how to communicate these results. A large majority of residents expressed interest in obtaining additional communication training. Additional research is required to determine ideal methods to educate residents on communicating test results.

Going straight to the source: A pilot study of bereaved parent-facilitated communication training for pediatric subspecialty fellows

BACKGROUND

Medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. Despite this deficit, few established training programs provide comprehensive, pediatric-specific communication education, particularly in the provision of "bad news." To our knowledge, no programs currently use bereaved parent educators to facilitate communication training for pediatric subspecialty trainees.

PROCEDURE

The authors designed and implemented a pilot communication training seminar in which bereaved parent educators and faculty facilitators led small groups in interactive, role-play scenarios. Surveys incorporating a retrospective preprogram assessment item to account for response-shift bias were used to assess short- and long-term changes in trainee comfort with delivering "bad news."

RESULTS

Fifteen pediatric fellowship trainees participated in the communication seminar; complete data were available for 12 participants. After accounting for response-shift bias, participants reported significant improvement in overall preparedness, breaking bad news to a patient and family, and including the adolescent or young adult patient in conversations. Additionally, participants reported a significant improvement in their ability to address a patient and family's need for information, emotional suffering at the end of life (EOL), if and when a patient should be included in the conversation, and EOL care decisions. The participant's self-perceived improvement in comfort and preparedness persisted over time.

CONCLUSIONS

Communication training for pediatric subspecialty trainees using bereaved parent educators is feasible and effective. Both medical trainee and bereaved parent participants benefited from involvement in this pilot study. Further iterations of this training will be modified to assess objective measures of improvement in trainees' communication skills.

Breaking bad news in prenatal medicine: a literature review

BACKGROUND

The diagnosis of a fetal anomaly in perinatal medicine forces expectant parents and healthcare providers to face the difficult process of breaking bad news.

OBJECTIVES

This exploratory literature review was aimed at providing a medical and psychological view of the psychological experience in expectant parents and physicians in the context of prenatal diagnosis of a fetal anomaly.

METHOD

An exploratory search of PubMed and PsycINFO/PsycARTICLES databases performed by an interdisciplinary team composed of a physician and psychologists. Search terms were: prenatal diagnosis AND bad news; prenatal diagnosis AND psychological consequences; prenatal diagnosis AND psychological sequelae; prenatal diagnosis AND fetal abnormality. The processing of selected articles followed a standardised five-step procedure.

RESULTS

A total of 860 articles were screened of which 32 were retained for analysis. Four main themes emerged from the explanatory content analysis: (1) parents' subjective experience; (2) physicians' subjective experience; (3) encounters between expectant parents and professionals; and (4) ethical challenges in breaking bad news in prenatal medicine.

CONCLUSION

Expectant parents go through a complex and multidimensional experience when the diagnosis of a fetal anomaly is disclosed. Simultaneously, physicians consider breaking bad news as a very stressful event and are poorly prepared in this regard. A better knowledge of factors underlying psychological adjustment of the parental dyad and on the subjective experience of physicians delivering these diagnoses could enable better adaptation for both patients and professionals.

Nurse Practitioners

An impending policy change in Medicare will provide reimbursement for the end-of-life conversation. The rise in numbers of older adults who face serious illness coupled with advances in healthcare technology are increasing the need for providers to address end of life issues in the acute care setting. Doctoral-level nurse practitioners who specialize in acute care of older adults are poised to be leaders and facilitators of this conversation in a particularly challenging context–the intensive care unit. The focus of this article is the new end-of-life policy in relation to the particular contributions that adult gerontology acute care nurse practitioners offer in the acute care setting.

Do pediatric hematology/oncology (PHO) fellows receive communication training?

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) has established communication as a core competency for physicians in training. However, data suggest that most pediatric residents perceive inadequate training in the delivery of bad news and the majority of former trainees in pediatric oncology received no formal training in the delivery of bad news during fellowship. The study examines communication training in ACGME accredited US pediatric hematology-oncology (PHO) fellowship programs.

METHODS

An online survey was distributed to 315 PHO fellows in training via the American Society of Pediatric Hematology/Oncology (ASPHO) fellow email registry. Each fellow received an initial request to participate and 2 reminders, while participation was encouraged through a random incentive drawing.

RESULTS

One hundred and ten fellows (35%) responded. Eighty percent of respondents perceived communication training to be important to fellow education, however only 32% reported receiving communication training (other than direct observation). The most common reported teaching method of fellowship communication training was formal lecture (42%). Twenty-three percent of respondents reported neither communication training nor frequent feedback on their communication skills from faculty observation. This same group was the least satisfied with their programs' approach to teaching communication (P < 0.001).

CONCLUSIONS

There is limited communication training in PHO fellowships despite ACGME requirements and fellows' interest in this training. Didactic learning remains the most frequently described training method, yet educational theory identifies the limitation of didactic lectures alone. Communication training employing novel teaching methods and emphasizing communication challenges identified by fellows should be developed and evaluated.

Application of the core competencies after unexpected patient death: consolation of the grieved

OBJECTIVES

To review and assess educational strategies and formats regarding communication with families/survivors in the aftermath of unexpected and untimely patient death. To propose an integrated curriculum designed and intended to foster proficiency, competence, confidence, and composure in relaying catastrophic information in the context of the professional experience of a cohort of seasoned surgeons.

BACKGROUND

Unexpected and untimely patient death is emotionally and psychologically wrenching for families, surgeons, and healthcare providers. We have previously proffered that 2 distinct, but interactive, phases of response are relevant when communicating with a family before and after the event: a proactive phase intended to establish a positive therapeutic relationship with the family; and a reactive phase intended to respond to the family in a compassionate and respectful manner and to ensure self-care for the physicians and health care providers.

STUDY DESIGN

Survey of a cohort of senior surgeons (membership of the Southern Surgical Association) and Surgical Residency Program Directors (membership of the Association of Program Directors in Surgery).

RESULTS

Sixty percent of the senior surgeons surveyed had experienced unexpected patient death. They advised strategies to cope with that clinical situation commensurate with the core competencies of the Accreditation Council for Graduate Medical Education: Medical Knowledge: maximize objective information/data and minimize subjective opinion; Patient Care: critique the events and conduct postmortem analyses; Interpersonal and Communication Skills: honesty, empathy, and patience; Professionalism: provide emotional and psychological support to family and personnel with privacy and in a nonaccusatory manner; Practice-Based Learning and Improvement: preoperative discussion and documentation in the context of informed consent and advanced directives vis-á-vis risk-benefit, effort-yield, and benefit-burden analyses; and Systems-Based Practice: involve chaplains and hospital personnel. Thirty-six percent of the graduate surgical educational programs surveyed allegedly provided educational venues to enable surgical residents to cope with unexpected patient death, although the formats were not specified.

CONCLUSIONS

Graduate, postgraduate, and continuing educational programs aspire to prepare physicians and surgeons for independent professional practice-scientifically, humanistically, and artistically. Incorporating educational strategies to enable graduates to cope with the emotional and psychological turmoil of unexpected patient death is relevant.

Effects and permanency of the training program "communication with cancer patients" on the opinions of students

Learning to develop the doctor-patient relationship is very important in the treatment of patients with cancer. We aim to train our students in the early years of study about this subject with a course on the patient-doctor communication, prepared for third year students. One hundred fifty-four third year students participated in our study during the 2006-2007 academic years. The same questionnaire was given to the students in the 2009-2010 academic year; their sixth year of study. The rate of return for the questionnaire is 88.7%. Based on this study, we have the opinion that the training given in the third year is beneficial; however, the efficacy of the training diminishes with the advancing years, and therefore, the length of this training should be increased in the upper classes and additional hours should be added.

Teaching medical students how to break bad news with standardized patients

One of the biggest challenges that a physician will face is conveying difficult news (CDN) to a patient.The ability to provide this information may either strengthen or destroy the patient–physician relationship. Despite the importance of this skill, formal education for medical students has been limited. To improve upon skill building in the medical student experience, fourth year medical students(on their oncology clerkship) spent 3 hours partaking ina CDN session. During this session, each student had a videotaped encounter with a standardized patient, followed by a small group discussion and review of the tape with other students and a clinician. We evaluated the experience with pre- and post-questionnaires assessing overall knowledge,satisfaction, and specific components of the curriculum. The objective of this study was to review our institution’s educational program focused on teaching techniques for CDN.

Communication and neurology--bad news and how to break them

How to deliver bad news to patients is a crucial part of medical practice. Many neurological diseases are incurable, progressive and result in physical or cognitive disabilities, which pose special challenges in the process of communication. Information about diagnosis, therapy and prognosis should be given in an appropriate setting and tailored to the patient's needs and cognitive level of functioning. Support and advice to the family and a team-oriented approach in the follow-up of neurological patients are of high importance. Patient autonomy, truth disclosure expectations and the access to other sources of information is important aspects that influence communication. There is a need for a special and continuous focus on communication in the education of neurologists with regard to the specific needs of this field. Attention should be given to the consequences of neurological disease as well as to therapy and prognosis.

Communication to Pediatric Cancer Patients and their Families: A Cultural Perspective

Background:

Communication is a key component of palliative care. The area of pediatric palliative care is emotionally distressing for families and healthcare providers. Inadequate communication can increase the stress and lead to mistrust or miscommunication.

Materials and Methods:

Reviewing the literature on communication between physicians and patients, we identified several barriers to communication such as paternalism in medicine, inadequate training in communication skills, knowledge of the grieving process, special issues related to care of children and cultural barriers. In order to fill the void in area of cultural communication, a study questionnaire was administered to consecutive families of children receiving chemotherapy at a large, north Indian referral hospital to elicit parental views on communication.

Results:

Most parents had a protective attitude and favored collusion, however, appreciated truthfulness in prognostication and counseling by physicians; though parents expressed dissatisfaction on timing and lack of prior information by counseling team.

Conclusion:

Training programs in communication skills should teach doctors how to elicit patients’ preferences for information. Systematic training programs with feedback can decrease physicians stress and burnout. More research for understanding a culturally appropriate communication framework is needed.

Breaking bad news issues: a survey among radiation oncologists

Introduction:

Discussion of bad news and resuscitation in terminal cancer is an important but difficult and often neglected issue in day-to-day oncology practice.

Materials and Methods:

We interviewed 35 radiation oncologists using an indigenous 15-item questionnaire on their beliefs about breaking bad news and resuscitation to terminal cancer patients.

Results:

Most responders had an oncology experience of three to seven years (20/35). Thirty-two were comfortable discussing cancer diagnosis, prognosis and life expectancy-related issues. A similar number believed all cancer-related information should be disclosed, while only four believed in imparting all information in one visit. All agreed that disclosing sensitive information did not affect survival. When requested by relatives to withhold truth from patients, 11 said they would not comply, 22 agreed to tell the truth only if asked and two agreed to avoid difficult questions. Twenty responders denied having been adequately trained in breaking bad news and were keen on dedicated classes or sessions in this area of practice. Most (33/35) believed that Indian patients were keen on knowing their diagnosis and prognosis. Although all agreed to the importance of discussing resuscitation, only 17 believed patients should be involved. Majority (20/35) agreed that the issue needs to be discussed while the patient was conscious. Patients with unsalvageable disease were deemed unsuitable for aggressive resuscitation by 30 responders while the rest believed it should be offered to all. Most (21/35) admitted to feeling depressed after breaking bad news though only seven felt disclosure was more stressful than untruthful statements. Only four knew of a law regarding resuscitation in cancer.

Conclusion:

Observing the widely varied beliefs and practices for disclosing bad news, it is recommended that such training be a regular part of medicine curriculum, especially in the Oncology setting.

Moral imagination in simulation-based communication skills training

Clinical simulation is used in nursing education and in other health professional programs to prepare students for future clinical practice. Simulation can be used to teach students communication skills and how to deliver bad news to patients and families. However, skilled communication in clinical practice requires students to move beyond simply learning superficial communication techniques and behaviors. This article presents an unexplored concept in the simulation literature: the exercise of moral imagination by the health professional student. Drawing from the works of Hume, Aristotle and Gadamer, a conceptualization of moral imagination is first provided. Next, this article argues that students must exercise moral imagination on two levels: towards the direct communication exchange before them; and to the representative nature of simulation encounters. Last, the limits of moral imagination in simulation-based education are discussed.

The intersection of ethics and communication in prenatal imaging: challenges for the pediatric radiologist

Pediatric radiologists who practice prenatal imaging are often at the front lines of communication with pregnant patients and their partners. The communication process is particularly complex when a fetal abnormality is diagnosed. Regardless of whether the information is completely new and unexpected, or the patient is referred for tertiary imaging and counseling, few pediatric radiologists are trained specifically in the communication skills necessary to provide optimal care to the prospective parents. This paper reviews current literature regarding communication with patients about unexpected or difficult information, and illustrates key clinical and ethical features that make conversations with pregnant patients particularly challenging in the setting of fetal abnormalities.

Teaching breaking bad news using mixed reality simulation

BACKGROUND

Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress.

METHODS

Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training.

RESULTS

Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum.

CONCLUSION

This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education.

Physician challenges in communicating bad news

Communicating bad news is never easy and for physicians these interactions may be a significant source of stress. To examine the characteristics that make delivering of bad news stressful, two studies were conducted. In the first study, 37 physicians generated 192 responses describing the characteristics that influence how difficult it is to break bad news. After sorting the responses in terms of common themes, six categories were identified: Physician, Patient, Institutional, Illness, Relationship, and Mishap. In Study 2, 115 physicians rated the degree of stress associated with each factor. Using principle component and reliability analyses, empirical support was found for six categories. A higher-order factor analysis suggested the existence of one over-arching factor. Items in the Mishap category were rated on average as the most stressful. Stress scores were largely unrelated to years in practice, experience delivering bad news or training.

Urology resident training with an unexpected patient death scenario: experiential learning with high fidelity simulation

PURPOSE

Communicating unexpected news of a patient death is rarely encountered in urology. We evaluated resident performance during an unexpected patient death scenario involving high fidelity simulation. We also studied simulation as a tool to teach and assess nontechnical skills in urology.

MATERIALS AND METHODS

An unexpected patient death scenario was developed at a simulation center using high fidelity mannequins, urology residents, critical care fellows, nurses, hospital chaplains and actors. Scenario objectives addressed Accreditation Council for Graduate Medical Education core competencies. The 19 urology residents in training years 2 to 6 participated in the scenario. Performance was evaluated using 5-point Likert scale questionnaires and checklists completed by residents, faculty and actors.

RESULTS

Overall resident performance was satisfactory in the simulation scenario. Verification of code status was identified as an area requiring improvement. Euphemisms for death were more commonly used in the initial delivery (16 residents or 84.2%) than the preferred words died or death (3 or 15.8%). After completing the scenario the perceived competency of residents increased from 73.7% before to 94.7% after the scenario. In addition, all residents agreed that the simulation experience was useful and overall realistic, and it should be part of the training curriculum.

CONCLUSIONS

Evaluation of urology resident performance was possible during an unexpected patient death scenario. Upon completion of the scenario perceived competency of the simulation task was increased. High fidelity simulation was found to be an effective method for teaching and assessing the acquisition of nontechnical skills. All residents agreed that the simulation was useful and should be included in urological training.

Cetuximab in the treatment of metastatic colorectal cancer

Cetuximab is a chimeric monoclonal antibody that binds to the epidermal growth factor receptor and thereby inhibits cell proliferation, metastasis and angiogenesis. Preclinical studies indicate that cetuximab induces synergistic antitumor activity when combined with chemotherapy or radiation. This observation is supported by clinical trials demonstrating that cetuximab improves tumor response when used in conjunction with modern chemotherapy in patients with metastatic colorectal cancer. Improved treatment efficacy may help to increase the rate of hepatic metastasis resection after downsizing of initially unresectable lesions. In pretreated patients, cetuximab may restore the sensitivity to irinotecan and, therefore, has been registered in this setting. Ongoing studies are investigating the integration of anti-epidermal growth factor receptor and anti-vascular endothelial growth factor strategies into new treatment regimens. Promising results have already been obtained in a trial combining irinotecan, bevacizumab and cetuximab.