Four-way test of mortality: a useful tool for cancer education

The use of a four-way test for the study of adverse outcomes in cancer, such as mortality and relapse, is described. This test facilitates a rapid, structured examination of patients' records that has been useful for teaching about the actual and apparent causes of treatment failure, and thus useful for teaching about how to achieve the best possible outcome for every patient. In this test, four questions are asked about factors identified: Was there evidence of 1) understaging, and/or 2) undertreatment, and/or 3) other factors, and/or 4) other causes? The use of the four-way test is illustrated by a review of 41 consecutive patients with Stage I colorectal cancer, 18 of whom had died at the time the study was conducted. One or more findings that contributed to either actual or apparent treatment failure were readily identified with the four-way test in 17 of the 18 fatal cases.