Denial is a commonly encountered concept in clinical practice for those dealing with serious illnesses. It has a myriad of meanings and definitions. It has been considered to be both positive as well as negative in clinical situations. Various factors affect denial including demographic, types of illnesses and cultural background. Management of denial has become an important issue in dealing with serious medical illness and terminal illness as it may interfere with treatment. This article focuses on the definitions of the concept, factors related to denial, and assessment and management of denial.

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The standard treatment for patients who have carcinoma of an unknown primary has not been established to date. The prognosis for patients with carcinoma of unknown primary is poor. As a group, the median survival is approximately 3-4 months with less than 25% and 10% of patients alive at 1 and 5 years, respectively. Materials and Methods: In this retrospective analysis of 104 patients with carcinomas of unknown primary site, those treated with radiotherapy, chemotherapy or a combination of both was included. Radiation dose varied from 8 Gy in a single fraction to 60 Gy in 30 fractions over 6 weeks. In chemoradiation, cisplatin 30 mg/m ² was given concurrently with radiation dose of 40 Gy in 20 fractions over 4 weeks. Chemotherapy regimens used were cisplatin-based in nine patients and adriamycin-based in five patients. All drugs were administered intravenously on a once in every 21-day cycle. Results: Twenty-eight patients (28%) presented with two or more sites involved. The pathologic diagnosis was adenocarcinoma (30 patients; 30%) squamous carcinoma (30 patients; 30%) and metastatic carcinoma not otherwise specified in 26 (26%) patients. In patients with chemotherapy, four patients had complete response and four had partial response. Disease stabilization was seen in three patients. In patients treated with chemoradiation, complete response was seen in ten patients, these patients had neck node metastases with squamous histology mainly (seven patients). The median response duration was 7 months and the median time to progression was 9 months. Median overall survival was 6 months. Grade 3 and 4 haematological toxicities were more frequent in the patients treated with cisplatin and adriamycin chemotherapy. Conclusions: In patients with an unknown primary, squamous histology responds better as compared with adenocarcinomas. Patients with squamous histology can be cured with chemoradiation even with neck node metastases. However, the majority of patients are suitable only for palliative treatment because of advanced disease and poor general condition.

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