Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

Doctors' stress responses and poor communication performance in simulated bad-news consultations

PURPOSE

No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors' stress responses and poor communication performance during a simulated BBN task.

METHOD

In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years' experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years' experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout.

RESULTS

High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores.

CONCLUSIONS

These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

Nurse responsiveness to cancer patient expressions of emotion

OBJECTIVE

This theoretically based study examined nurse responses to cancer patient expressions of emotion using a videotaped, simulated cancer patient.

METHODS

This study used an experimental crossover design with a videotaped patient expressing anger, sadness, and neutral emotion to elicit nurse responses. Seventy-four nurses from eight sites participated. Responses were coded using Roter interaction analysis system. Correlations explored relationships between variables that impact communication (age, gender, work experience, trait anxiety, work stress, self-efficacy). Regression models explored the effect of variables on nurse affective responsiveness.

RESULTS

Patient expressions of sadness elicited more affective responses than anger. Expressions of anger or neutral emotion elicited more instrumental behaviors than sadness. Variables such as age, work stress and work experience were significantly correlated. No variables predicted affective responsiveness to patient expressions of anger or sadness.

CONCLUSION

Nurse communication showed significant variation in response to patient emotional expressions. Understanding the relationships between demographic, personality, and work variables, and identification of new variables that influence nurse-patient communication, has implications for interventional studies.

PRACTICE IMPLICATIONS

Over 90% of the participants indicated that the videotape simulation would be a useful method for teaching and practicing communication skills with patients expressing emotions.

Information disclosure to terminally ill patients and their relatives: self-reported practice of Belgian clinical specialists and general practitioners

Objective of this study is to examine physicians' practices regarding information disclosure to terminally ill patients and to their relatives, without informing the patient. A questionnaire had been sent to a random sample of 3014 Belgian physicians from different specialties frequently involved in end-of-life care. Responses were analysed using weighted percentages, Chi-square, Mann-Whitney U-tests and a multivariate ordinal logistic regression. Response rate was 58%. Both clinical specialists and general practitioners (GPs) discuss most topics related to terminal illness with their patients except end-of-life hastening options, spirituality, life expectancy and options to withhold/withdraw life-sustaining treatment. The topics which most physicians always discuss with relatives without informing the patient are the aim of treatment, palliative care and incurability. There is a significant difference between clinical specialists and GPs. Clinical specialists and GPs discuss most end-of-life topics with the patient but omit important issues such as end-of-life hastening options and life-expectancy.

Developing a self-rating measure of patient competence in the context of oncology: a multi-center study

OBJECTIVE

Concepts of patient competence (PC) are being increasingly used, but seldom clearly defined in the context of shared medical treatment decision making and coping with cancer. The meaning of such concepts should therefore be clarified, and measures developed that permit the assessment of different facets of this patient characteristic. Consequently, this study attempted to contribute to the definition and measurement of PC.

METHODS

Employing literature reviews and qualitative interviews, we developed a working definition of PC in the context of cancer from which we designed a self-rating measure of this patient characteristic that was then tested for validity and reliability in a sample of N=536 patients with cancer.

RESULTS

Using factor analyses, we developed five problem- and three emotion-focused subscales that measure distinct facets of PC with satisfactory reliability. Additional analyses provide preliminary evidence of the instruments' validity.

CONCLUSIONS

This study represents an essential first step in developing a reliable self-rating measure of PC in the context of cancer. Although further refinement of this measure is clearly required, it provides a preliminary methodological basis for empirically investigating the determinants and potential health effects of PC.

Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy

PURPOSE

To determine the interval from breast-conserving surgery (BCS) to radiation therapy (RT) that affects local control or survival.

PATIENTS AND METHODS

The 10-year Kaplan-Meier (KM) local recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) were computed for 6,428 women who had T1 to 2, N0 to 1, M0 breast cancer that was diagnosed in British Columbia between 1989 and 2003, and who were treated with BCS and RT without chemotherapy. Intervals from BCS to RT were grouped by weeks as follows: < or = 4 (n = 83), greater than 4 to 8 (n = 2,288; reference group); greater than 8 to 12 (n = 2,606); greater than 12 to 16 (n = 961); greater than 16 to 20 (n = 358); and greater than 20 weeks (n = 132). Cox proportional hazards models and matching were used to control for confounding variables.

RESULTS

The median follow-up time was 7.5 years. The 10-year KM outcomes were as follows: LRFS, 95.4%; DRFS, 90.5%; and BCSS, 92.5%. Compared with the greater than 4 to 8 weeks group, hazard ratios (HR) were not significantly different for any outcome among patients who were treated up to 20 weeks after BCS. However, LRFS (hazard ratio [HR], 2.00; P = .15), DRFS (HR, 1.86; P = .02) and BCSS (HR, 2.15; P = .009) were inferior for women with BCS-to-RT intervals greater than 20 weeks compared with those greater than 4 to 8 weeks. The matched analysis yielded similar results.

CONCLUSION

Outcomes were statistically similar for BCS-to-RT intervals up to 20 weeks, but they were inferior for intervals beyond 20 weeks. Time can be reasonably allowed for the breast to heal and for patients to consider treatment options, but RT should start within 20 weeks of BCS.

The perception of support received from breast care nurses by depressed patients following a diagnosis of breast cancer

INTRODUCTION

Due to their specialist training, breast care nurses (BCNs) should be able to detect emotional distress and offer support to breast cancer patients. However, patients who are most distressed after diagnosis generally experience least support from care staff. To test whether BCNs overcome this potential barrier, we compared the support experienced by depressed and non-depressed patients from their BCNs and the other main professionals involved in their care: surgeons and ward nurses.

PATIENTS AND METHODS

Women with primary breast cancer (n = 355) 2-4 days after mastectomy or wide local excision, self-reported perceived professional support and current depression. Analysis of variance compared support ratings of depressed and non-depressed patients across staff types.

RESULTS

There was evidence of depression in 31 (9%) patients. Depressed patients recorded less surgeon and ward nurse support than those who were not depressed but the support received by patients from the BCN was high, whether or not patients were depressed.

CONCLUSIONS

BCNs were able to provide as much support to depressed patients as to non-depressed patients, whereas depressed patients felt less supported by surgeons and ward nurses than did non-depressed patients. Future research should examine the basis of BCNs' ability to overcome barriers to support in depressed patients. Our findings confirm the importance of maintaining the special role of the BCN.

'It's going to shorten your life': framing of oncologist-patient communication about prognosis

In this qualitative study, we used grounded theory techniques to analyze transcripts of 29 first-time encounters between oncologists and patients referred to them with previously diagnosed, incurable cancer. We found that 23 (79%) of the transcripts included 166 examples of prognostic talk. The language used ranged from general to personal, with 25% of statements mentioning no patients (e.g., 'the tumor will usually come back'), 13% mentioning patients other than the current patient (e.g., 'some patients with tumor response will be around for 2-5 years'), 11% mentioning the current patient in the context of others (e.g., 'on average, people like you live a couple of years'), and 51% directly focusing on the patient (e.g., 'this thing's going to kill you eventually'). More statements pertained to treatment-related prognosis than to disease-related prognosis (67 versus 33%). While 31% of statements focused on negative outcomes (loss framing), the remainder either focused on positive outcomes (gain framing) or discussed a combination of positive and negative outcomes (mixed framing). When discussions focused on negative outcomes, general and indirect language was commonly used, perhaps to buffer the patient from news of the poor prognosis.

Communication skills of health-care professionals working in oncology--can they be improved?

Communication skills' training has been placed high on the agenda by the National Institute of Clinical Excellence guidelines and the National Health Service in the UK. The paper reviews the importance of good communication skills in cancer care for the patient and describes research that has identified ways in which health-care professionals (HCP) can improve their communication with patients. The evidence as to why there is a lack of facilitative skills is reviewed along with what skills are required in order to improve communication with patients. The paper describes evidence of increased facilitative skills post-training, discusses whether there is evidence of transfer of these skills into clinical practice and how this might be best achieved. To conclude, research evidence would support the fact that training in communication skills needs to provide the best possible outcomes for HCP and their patients. Patient concerns, needs and preferences need to be elicited and the impact of concerns identified, so that the HCP can appropriately tailor their information giving, advice, treatment and plan of care.

Perceived barriers to self-management in Malaysian women with breast cancer

Naturalistic inquiry using focus group interviews was undertaken to explore experiences and perceived barriers to self management in women with breast cancer. The aim was to identify their perceived barriers to self management to aid the development of rehabilitation programmes. Successful programmes are strongly linked to patients' perceived needs. Four focus groups consisted of 39 women, were purposively recruited. Women's needs within the three areas of medical, emotional and role management of breast cancer were explored. The main barriers were unavailability of information, inability to access services-and-support, and socioeconomic-cultural issues (entrenched myths, low-socioeconomic status, and inadequate insurance-health legislative coverage). The findings provide the critically lacking 'expert-view' of survivors, who verified the importance of the medical, emotional and role management tasks, and highlighted barriers and structural solutions. With breast cancer becoming recognised as a form of chronic illness, this study is timely.

Major depression after breast cancer: a review of epidemiology and treatment

OBJECTIVE

While many breast cancer patients experience "normal" distress, there is a subset who experience clinically significant depression. We examined the current knowledge about the prevalence, impact and treatment of major depression in women with breast cancer.

METHOD

We reviewed the evidence for the prevalence of depression in women with breast cancer from the last 20 years and summarized the medical literature on the pharmacology and psychotherapy of depression in this population.

RESULTS

Despite evidence that depression significantly impacts quality of life in breast cancer patients, few studies focus on the epidemiology and treatment of major depression. Treatment studies have focused on distress and mixed depressive states, with resulting lack of replicable studies showing treatment efficacy. Potential biological and psychosocial determinants of major depression following breast cancer are discussed in a proposed model. The need for further research on the epidemiology and treatment of major depression in this population is proposed.

CONCLUSION

Major depression is a frequent but underrecognized and undertreated condition among breast cancer patients, which causes amplification of physical symptoms, increased functional impairment and poor treatment adherence. More research on the epidemiology and treatment of major depression in this population is needed.

Prevalence and risk of depressive symptoms 3-4 months post-surgery in a nationwide cohort study of Danish women treated for early stage breast-cancer

BACKGROUND

Elevated levels of depressive symptoms are generally found among cancer patients, but results from existing studies vary considerably with respect to prevalence and proposed risk factors.

PURPOSE

To study the prevalence of depressive symptoms and major depression 3-4 months following surgery for breast cancer, and to identify clinical risk factors while adjusting for pre-cancer sociodemographic factors, comorbidity, and psychiatric history.

PATIENTS AND METHODS

The study cohort consists of 4917 Danish women, aged 18-70 years, receiving standardized treatment for early stage invasive breast cancer during the 2 1/2 year study period. Of these, 3343 women (68%) participated in a questionnaire study 12-16 weeks following surgery. Depressive symptoms (Beck's Depression Inventory II) and health-related behaviors were assessed by questionnaire. The Danish Breast Cancer Cooperative Group (DBCG) and the surgical departments provided disease-, treatment-, and comorbidity data for the study cohort. Information concerning sociodemographics and psychiatric history were obtained from national longitudinal registries.

RESULTS

The results indicated an increased prevalence of depressive symptoms and major depression (13.7%) compared to population-based samples. The pre-cancer variables: Social status, net-wealth, ethnicity, comorbidity, psychiatric history, and age were all independent risk factors for depressive symptoms. Of the clinical variables, only nodal status carried additional prognostic information. Physical functioning, smoking, alcohol use, and BMI were also independently associated with depressive symptoms.

CONCLUSION

Risk factors for depressive symptoms were primarily restricted to pre-cancer conditions rather than disease-specific conditions. Special attention should be given to socio-economically deprived women with a history of somatic- and psychiatric disease and poor health behaviors.

Do patients consider postoperative maintenance therapy for Crohn's disease worthwhile?

BACKGROUND

Treatment decision making for postoperative Crohn's disease is complex because of the increasing number of maintenance therapies available with competing risk-benefit profiles. The main objective of this study was to determine the distribution of patients' preferences for selected postoperative maintenance therapies.

METHODS

The study was a cross-sectional survey in which patients with Crohn's disease completed a standardized interview. Each participant completed 5 tasks that compared: (1) no medication and 5-ASA, (2) fish oil and 5-ASA, (3) metronidazole and 5-ASA, (4) budesonide and 5-ASA, and (5) azathioprine and 5-ASA. For each task, the minimum change in treatment effect size between the 2 treatments that the participant considered worthwhile was determined.

RESULTS

The distribution of the participants' preference scores varied widely for each task. When fish oil, metronidazole, budesonide, and azathioprine were considered equally effective to 5-ASA, 92.9%, 28.8%, 38.4%, and 19% of the participants, respectively, preferred these medications relative to 5-ASA. These percentages increased to 98.4%, 54.8%, 61.9%, and 50.8%, respectively, when fish oil, metronidazole, budesonide, and azathioprine were considered to offer a 5% absolute risk reduction relative to 5-ASA. Regression analysis did not identify any clinical or demographic variables predictive of the participants' treatment preferences.

CONCLUSIONS

The participants' preferences for postoperative maintenance therapies were widely distributed, and no clinical or demographic factors predicted these preferences. This emphasizes the need for effective communication between physician and patient in order to select the treatment options most consistent with a patient's informed preferences.

Breaking the news in spinal cord injury

Breaking the bad news in terms of prognosis for significant motor recovery following a neurologically complete spinal cord injury (SCI) is one of the most difficult tasks for the spinal cord medicine specialist. Learning the skills to facilitate this communication is extremely important to better assist patients to understand their prognosis as well as foster hope for their future. If bad news is delivered poorly it can cause confusion and long-lasting distress and resentment; if done well, it may assist understanding, adjustment, and acceptance. This article provides the physician who cares for patients with SCI with some concepts to consider when discussing prognosis with patients and their families.

Using Bedside Rounds to Teach Communication Skills in the Internal Medicine Clerkship

BACKGROUND

Physicians' communication skills, which are linked to important patient outcomes, are rarely explicitly taught during the clinical years of medical school. This paper describes the development, implementation, and evaluation of a communication skills curriculum during the third-year Internal Medicine Clerkship.

METHODS

In four two-hour structured bedside rounds with trained Internal Medicine faculty facilitators, students learned core communication skills in the context of common challenging clinical situations. In an end-of-clerkship survey students evaluated the curriculum's educational effectiveness.

RESULTS

Over the course of a year, 160 third-year students and 15 faculty participated. Of the 75/160 (47%) of students who completed the post-clerkship survey, almost all reported improvement in their communication skills and their ability to deal with specific communication challenges.

CONCLUSIONS

The curriculum appears to be a successful way to reinforce core communication skills and practice common challenging situations students encounter during the Internal Medicine Clerkship.

Preferences for involvement in treatment decision-making generally and in hormone replacement and urinary incontinence treatment decision-making specifically

OBJECTIVE

To explore whether preferences for involvement in treatment decision-making change depending on the context and factors associated with preferences.

METHODS

A national telephone survey of 1000 randomly selected Norwegian women aged 18 years or over using the Control Preferences Scale (CPS) to assess preferences.

RESULTS

More women preferred an active role when asked about hormone replacement therapy (HRT) and urinary incontinence (UI) treatment decision-making specifically than when asked a question about preferences for involvement when generally making treatment decisions. Higher education and very good general health were significantly associated with preferring an active role in HRT and UI treatment decision-making. A negative attitude towards HRT was also significantly associated with preferring an active role when considering HRT. Women with higher educational levels were significantly more likely to choose an option from the CPS that indicated a preference for wanting more involvement in HRT decision-making compared to treatment decision-making generally.

CONCLUSIONS

Women's preferences for involvement in treatment decision-making change depending on the context as do factors associated with role preferences.

PRACTICE IMPLICATIONS

Health care professionals need to be aware that patients' preferences may change depending on the context of the treatment decision.

Applying quality-of-life data formally and systematically into clinical practice

The systematic integration of quality-of-life (QOL) assessment into the clinical setting, although deemed important, infrequently occurs. Barriers include the need for a practical approach perceived as useful and efficient by patients and clinicians and the inability of clinicians to readily identify the value of integrating QOL assessments into the clinical setting. We discuss the use of QOL data in patient care and review approaches used to integrate QOL assessment into the clinical setting. Additionally, we highlight select QOL measures that have been successfully applied in the clinical setting. These measures have been shown to identify key QOL issues, improve patient-clinician communications, and improve and enhance patient care. However, the work done to date requires continued development. Continued research is needed that provides information about benefits and addresses limitations of current approaches.

Impact of providing audiotapes of primary treatment consultations to men with prostate cancer: a multi-site, randomized, controlled trial

BACKGROUND

The purpose of this investigation was to systematically examine the efficacy of providing men with prostate cancer with an audiotape of their primary treatment consultation.

METHOD

Participants included 425 men newly diagnosed with prostate cancer and 15 radiation oncologists from 4 cancer centers in Canada. Patients were block randomized to one of four consultation groups: 1. Standard care control--not audio-taped; 2. Audio-taped--no audiotape given; 3. Audio-taped--patient given audiotape; and 4. Audio-taped--patient offered choice of receiving audiotape or not (4 patients declined; 94 accepted). Patient outcomes were measured at 12 weeks post-consultation: perceived degree of information provision; audiotape satisfaction and use; communication satisfaction with oncologist; mood state; and cancer-specific quality of life.

RESULTS

Patients receiving the consultation audiotape reported having been provided with significantly more disease and treatment information in general (p=0.04), and more information about treatment alternatives (p=0.04) and treatment side effects (p=0.01) in particular, than patients who did not receive the audiotape. Audiotape benefit was not significantly related to patient satisfaction with communication, mood state or quality of life at 12 weeks post-consultation, and was not significantly affected by choice of receiving the audiotape. Patients rated the audiotape intervention positively, with an average score of 83.0 out of 100.

CONCLUSION

Consultation audiotapes are rated highly by men with prostate cancer, and these audiotapes help to enhance their perception of having been provided with critical disease- and treatment-related information.

Depression, quality of life and breast cancer: a review of the literature

Depression is misdiagnosed and undertreated among breast cancer population. Risk factors for depression in the 5 years after diagnosis are related more to the patient rather than to the disease or its treatment. The breast cancer stage (early and advanced) is not statistically significant in terms of rates of psychosocial distress except for recurrence. Risk factors of depression might impair quality of life such as fatigue, past history or recent episode of depression after the onset of cancer, cognitive attitudes of helplessness/hopelessness, resignation. Body image impairment from mastectomy and sexuality aftermath generates higher rates of mood disorders. The link between increased risk of breast cancer and depression is controversial among the literature. Some studies suggest a protective factor, others find a relation between stress, immunity and cancer occurrence or even mortality. Breast cancer survivors report a higher prevalence of mild to moderate depression with a lower quality of life in all areas except for family functioning. Treatment of depression in breast cancer women improves their quality of life and may increase longevity. Antidepressant medications remain the cornerstone of depression treatment. The hypothetical link between their prescription and increased breast cancer risk is not supported by literature's data.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

Short-Term and Long-Term Psychosocial Adjustment and Quality of Life in Women Undergoing Different Surgical Procedures for Breast Cancer

BACKGROUND

The various surgical procedures for early-stage breast cancer are equivalent in terms of survival. Therefore, other factors, such as the procedures' effect on psychosocial adjustment and quality of life (QOL), take on great importance. The aim of the current study was to prospectively examine the short- and long-term effects of mastectomy with reconstruction, mastectomy without reconstruction, and breast conservation therapy on aspects of psychosocial adjustment and QOL in a sample of 258 women with breast cancer.

METHODS

Participants completed questionnaires before surgery and then again 1, 6, 12, and 24 months after surgery. Questionnaires assessed depressive symptoms, anxiety, body image, sexual functioning, and QOL.

RESULTS

Adjustment patterns differed throughout the 2-year period after surgery. Some short-term changes in adjustment (less anxiety, less overall body satisfaction) were similar across surgery groups, whereas others (satisfaction with chest appearance, QOL in physical health domain) were higher for women who had breast conservation therapy. However, women who had mastectomy with reconstruction reported greater satisfaction with their abdominal area. During the long-term follow-up period (6 months to 2 years after surgery), women in all three groups experienced marked improvements in psychosocial adjustment (depressive symptoms, satisfaction with chest appearance, sexual functioning) and QOL in physical and mental health domains. In fact, the level for most variables returned to baseline levels or higher.

CONCLUSIONS

Overall, the general patterns of psychosocial adjustment and QOL are similar among the three surgery groups.

Seeking informed consent to cancer clinical trials; evaluating the efficacy of doctor communication skills training

INTRODUCTION

Clinical trials have come to be regarded as the gold standard for treatment evaluation. However, many doctors and their patients experience difficulties when discussing trial participation, leading to poor accrual to trials and questionable quality of informed consent. We have previously developed a communication skills training program based on a typology for ethical communication about Phase II and III clinical trials within four categories. The training program consisted of a 1 day experiential workshop that included didactic teaching, exemplary video and role play. The aim of this study was to evaluate the effectiveness of the communication skills training workshop.

METHOD

Oncologists were recruited from three major teaching hospitals conducting oncology outpatient clinics in three Australian capital cities. Ten oncologists and 90 of their adult cancer patients who were eligible for a Phase II or III clinical trial participated. Ninety informed consent consultations were audiotaped before (n = 59) and after (n = 31) training, and fully transcribed. The presence or absence of each domain component was coded and these were summed within categories. A coding manual was produced which enabled standardization of the coding procedure. Patients completed questionnaires before and after the consultation, and doctors completed a short measure of satisfaction after the consultation.

RESULTS

Doctors increased their use of some aspects of shared decision-making behavior (t(87) = -1.945, p = 0.05) and described some aspects of essential ethical/clinical information more commonly. In addition they used less coercive behaviors (z = -1.976, p = 0.048). However, they did not provide more clinical information or structure their consultations in the recommended fashion. Patients in the post-training cohort reported more positive attitudes to clinical trials, but other outcomes were not affected by the intervention.

CONCLUSIONS

This short training programme demonstrated limited success in improving the oncologist's communication skills when gaining informed consent. A larger randomized controlled trial of extended training is now underway.

Patients? perceptions of transrectal prostate biopsy: a qualitative study

This study explored men's experiences of transrectal prostate biopsy. Fifty men who had had a prostate biopsy talked about the experience as part of an in-depth interview; 36 were interviewed in 2000 about all aspects of prostate cancer, and 14 in 2005 about their experience of prostate-specific antigen testing, subsequent investigations and treatment. Men were recruited via urologists, general practitioners and support groups. In both studies, we aimed to include men of various ages, from different backgrounds, who lived, and had been investigated and treated, in different parts of the UK. A qualitative interpretive approach was taken, combining thematic analysis with constant comparison. Most men described the procedure as merely 'uncomfortable', but some found it stressful, exhausting and extremely painful. Worries included the fear that cancer cells might pass from a man to his wife during ejaculation, and that a biopsy might spread cancer cells to other parts of the body. Men should be given detailed information before a biopsy, so that they are well aware of what might happen. They should also be given the opportunity to voice their fears, so that they can be reassured, and offered some form of pain relief.

General preferences for involvement in treatment decision making among European women with urinary incontinence

Current health care policies advocate patient participation in treatment decision making. Little evidence on possible differences between European women's preferences for involvement in this process exists. In this study we explore preferences for involvement in treatment decision making in 15 European countries in a sample of 9434 women seeking treatment for urinary incontinence in an outpatient setting. Their generally preferred role in treatment decisions was assessed using the Control Preferences Scale. Results show variations within and between countries in preferences for involvement in treatment decision making. The 'collaborative role' was the most preferred role in Austria, Belgium, Denmark, France, Germany, Ireland, Sweden, Switzerland, the Netherlands and the UK. In Greece, Portugal and Spain the 'passive role' was most preferred. Over a third of women in Denmark, Finland and Norway preferred an 'active role'. Multinominal regression analyses found that, after adjusting for case mix and factors previously associated with role preferences, country membership was strongly associated with role preferences, with women living in Southern European countries preferring a more passive role. Such clear differences are of interest in the current health care environment where active patient participation is being encouraged. Greater efforts need to be made to establish whether patient preferences are genuine or merely a learned response influenced by cultural attitudes and traditions so that a balance can be struck between assisting women to play a more active role in the treatment decision-making process without disregarding some women's genuine preferences to play a more passive role.

Is self-efficacy a predictor of short-term post-surgical adjustment among Chinese women with breast cancer?

BACKGROUND

High self-efficacy (SE) is regarded as beneficial for cancer patients in facilitating adaptation and therefore desirable. However, this may not always be the case.

DESIGN

A longitudinal cohort study of women receiving breast cancer surgery. Path analysis examined impact of high and low baseline SE scores on outcome. Post hoc analysis stratified outcome expectations by SE.

METHODS

405/529 eligible Chinese women aged 28-79 years receiving breast cancer surgery in six regional Hong Kong hospitals were interviewed within 1 week of surgery. After assessing SE, incongruence between expectancy and outcome of surgery (E-OI), and psychological morbidity, 91% of women were followed for 1 month when psychological and social morbidity were assessed (follow-up).

RESULTS

After adjustment for demographic and histopathological factors, psychological morbidity was predicted by E-OI. Women with high E-OI had more impairment of sexuality and self-image. Women with high SE had better self-image and relationships with friends, but tended to underestimate the negative consequences of surgery on appearance. This increased E-OI and thereby psychological morbidity.

CONCLUSIONS

High post-surgical SE benefits early social adaptation, but also leads to under-estimating the negative impacts of surgery, impairing psychological adjustment. High SE can thereby contribute indirectly and significantly to increased psychological morbidity.

Health information sources of individuals with cancer and their family members

The purpose of this study was to understand health information sources of individuals and families impacted by a cancer diagnosis. Overall, the findings support the Freimuth, Stein, and Kean (1989) model of health information acquisition. The cancer patients and family members who participated reported having significantly more health information along the continuum of cancer care, from causes to prevention, after a cancer diagnosis. Although a wide variety of interpersonal and mediated information sources are available, participants reported that the only consistently (88.1%) used source of information was doctors. The most important information sources were, in descending order, doctors, family members, nurses, friends, the Internet, other medical personnel, and other patients. Individuals, however, were most satisfied with family and friends as sources of information, followed by nurses, other patients, and doctors. Patients and family members rated the importance of and their satisfaction with various information sources differently. Patients rated nurses, other medical personnel, and support groups as more important than did family members, and patients were significantly more satisfied with doctors and nurses, whereas family members were significantly more satisfied with the Internet.

Treatment decision difficulties and post-operative distress predict persistence of psychological morbidity in Chinese women following breast cancer surgery

BACKGROUND

The patterns and determinants of longer-term psychological morbidity in women following breast cancer surgery have not been described for Chinese populations.

METHODS

Chinese women were assessed at 3-days, 4-months and 8-months following breast surgery, on treatment decision-making difficulty (TDMD), satisfaction with treatment outcome (E-OI), self efficacy (GSeS), optimism (C-LOT-R), consultation satisfaction (C-MISS-R), physical symptom distress (PSD) and psychological morbidity (CHQ-12) and compared using polynomial logistic models.

RESULTS

Of 303/405 women providing complete data, 33% received chemotherapy and 26% radiotherapy. GSeS, CLOTR and TDMD scores were moderate. Though the proportion of women meeting psychological morbidity case-criteria declined from 78% (95% Confidence Interval 73-83%) at Baseline to 64% (59-69%) at 8-months, almost 50% (44-54%) of women remained distressed over the 8-month period. After adjustment for demographic and clinical factors, severity of psychological morbidity at 4-months was predicted by PSD, disappointment and higher Baseline CHQ12, and among moderate/severe cases only, greater TDMD and pessimistic outlook. At 8-months, CHQ12 scores were predicted by PSD, Baseline CHQ-12, and difficulties with TDM.

CONCLUSION

TDM difficulties, early post-surgical psychological and physical symptom distress indicate risk for prolonged distress in Chinese women following breast cancer surgery.

SURGICAL MANAGEMENT OF BREAST CANCER IN A SMALL PERIPHERAL NEW ZEALAND HOSPITAL

BACKGROUND

Peripheral hospitals are perceived to be at a disadvantage in providing treatment for breast cancer, especially with regard to breast conservative surgery (BCS) because of the requirement of adjuvant radiotherapy. Wairau Hospital is a 100-bed peripheral hospital in New Zealand with no on-site radiotherapy unit.

METHODS

A retrospective audit of the surgical management of breast cancer between 1998 and 2002 was carried out.

RESULTS

One hundred and fifty-seven presentations during the audit period. Despite the lack of tertiary resources, we report an overall BCS rate of 58.6%, consistent with the appropriate New Zealand guidelines. Of screen-detected cancers, 81.6% underwent BCS. Only five patients requested mastectomy and of those undergoing BCS, five patients refused subsequent adjuvant radiotherapy. This was because of frailty from age and comorbidities and the inconvenience of travel.

CONCLUSION

High rates of BCS are possible in peripheral hospitals. We postulate that intensive support and a visiting outpatient oncological service help empower patients to seek BCS if appropriate. A strong partnership between surgical, radiological and oncological services is also vital.

The enhancing connections program: pilot study of a cognitive-behavioral intervention for mothers and children affected by breast cancer

In 2005, approximately 211,240 women in the US will be diagnosed with early stage breast cancer and an estimated 22% will be child rearing. Research reveals that both mothers and children have elevated distress attributed to the cancer; struggle with how to talk about and deal with the impact of the cancer; and both fear the mother will die. The Enhancing Connections Program (EC) was developed to reduce this cancer-related distress and morbidity. The program involves five, 1-hour educational counseling sessions delivered at 2-week intervals by specially trained clinicians. This study reports on the program's short-term impact on mothers' and children's adjustment. Thirteen households were recruited within 7.5 months of the mother's diagnosis with early stage breast cancer. Impact was evaluated within a single group design using data obtained from standardized questionnaires with established reliability and validity. Results revealed significant improvements in the mother's depressed mood, anxiety, and self-confidence to assist her child (mother report). There were also significant decreases in the child's behavioral problems (mother and father report); the child's cancer-related worries (child report); and the child's anxiety/depressed mood (mother and father report). Further evaluation is warranted within a clinical trial.

Do prostate cancer patients want to choose their own radiation treatment?

PURPOSE

The aims of this study were to investigate whether prostate cancer patients want to be involved in the choice of the radiation dose, and which patients want to be involved.

METHODS AND MATERIALS

This prospective study involved 150 patients with localized prostate cancer treated with three-dimensional conformal radiotherapy. A decision aid was used to explain the effects of two alternative radiation doses (70 and 74 Gy) in terms of cure and side effects. Patients were then asked whether they wanted to choose their treatment (accept choice), or leave the decision to the physician (decline choice). The treatment preference was carried out.

RESULTS

Even in this older population (mean age, 70 years), most patients (79%) accepted the option to choose. A lower score on the designations Pre-existent bowel morbidity, Anxiety, Depression, Hopelessness and a higher score on Autonomy and Numeracy were associated with an increase in choice acceptance, of which only Hopelessness held up in multiple regression (p < 0.03). The uninformed participation preference at baseline was not significantly related to choice acceptance (p = 0.10).

CONCLUSION

Uninformed participation preference does not predict choice behavior. However, once the decision aid is provided, most patients want to choose their treatment. It should, therefore, be considered to inform patients first and ask participation preferences afterwards.

Patient involvement in treatment decision-making: the case for a broader conceptual framework

OBJECTIVE

To consider the conceptualisation of patient involvement in treatment decision-making.

METHOD

Conceptual review.

RESULTS

Current models and measures of patient involvement in treatment decision-making tend to focus on communication within consultations and/or on the patient's use of information to consider the selection of one treatment option from a well-defined set. These narrowly focused models and measures may obscure the relevance of patient involvement in decision-making for some health care contexts and limit investigations of the relationships between patient involvement in decision-making and health care outcomes. We outline a broader conceptual framework that reflects more of the complexity of the concept of involvement. It acknowledges that patients can be involved not only because of what they say and do to influence a decision, but also by virtue of what they think and feel about their roles, efforts and contributions to decision-making and their relationships with their clinicians. The framework encompasses the full range of activities associated with decision-making.

CONCLUSION

The proposed conceptual framework may broaden the relevance of patient involvement in decision-making and encourage a more comprehensive characterisation that may facilitate more sophisticated investigations of the relationships between patient involvement in decision-making and health care outcomes.

PRACTICE IMPLICATIONS

Clinicians who aspire to facilitate patient involvement in decision-making need to look beyond the way they discuss health care options with patients. They should also consider how they might enable patients to engage in the full range of decision-making activities and to develop a positive sense of involvement in these activities and with their clinicians.

Die Rolle des Arztes und die Kommunikation mit Sterbenden

In palliative medicine, the doctor's role towards the patient changes from curing to looking after and depends on the different organizational forms. A key topic for the doctor remains the decision, how far medical treatment should be extended - according to patient's will. Studies for palliative medicine have also showed considerable communication deficits. This leads to the following aims of communication with the dying: Recording of somatic, psychic, social and spiritual problems of the patients, informing about illness and prognosis, responding to the patient's emotional situation and to the existential dimension of dying as well as involving relatives in communication. "Active listening" is proposed as a communication form to be learned by doctors. Training programs and possibilities of improving the emotional situation of doctors are described.

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life

BACKGROUND

Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.

OBJECTIVE

To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.

DESIGN

Thematic literature review.

RESULTS

The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.

CONCLUSIONS

Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.

Health-related quality of life in disease-free survivors of breast cancer with the general population

BACKGROUND

Although most of the literature about health-related quality of life (HRQoL) focuses on breast cancer patients, few studies compared the HRQoL in disease-free breast cancer survivors with that of the general population.

MATERIALS AND METHODS

We administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Quality of Life Questionnaire Breast Cancer Module, McGill Quality of Life Questionnaire, Beck Depression Inventory, and Brief Fatigue Inventory to 1933 disease-free survivors for over 1 year after being diagnosed with stage 0 to III breast cancer. We performed multivariate-adjusted analyses in all HRQoL comparisons.

RESULTS

The scores for some health-related quality of life [corrected] HRQoL scales were comparable for both disease-free breast cancer survivors and the general female population, but [corrected] there was a [corrected] clinically significant difference between the two groups [corrected] in cognitive and social functioning, fatigue, insomnia, financial difficulties, body image, future perspective, breast symptoms, and arm symptoms. [corrected]

CONCLUSIONS

Disease-free survivors of breast cancer had good HRQoL, which was less affected by the type of treatment than it was by demographic characteristics, time since surgery, comorbidity, fatigue, and depression.

The role of child abuse and age in vulnerability to emotional problems after surgery for breast cancer

Emotional problems are common after breast cancer, but patients differ in their vulnerability. Childhood abuse is a risk factor for emotional problems in adult women, and we tested whether it explains some of the variability in emotional problems after breast cancer. Women with primary breast cancer (N=355) 2-4 d after surgery (mastectomy or wide local excision) self-reported current emotional distress, post-traumatic stress, self-blame, bodily shame and recollections of childhood sexual, physical and emotional abuse. Multiple logistic regression analyses tested the relationship of each emotional problem to abuse, distinguishing three age-groups, divided at 50 and 65 years. Emotional distress, post-traumatic stress, self-blame and shame were present in 49%, 8%, 22% and 13% of women, respectively. Each problem was more common in women who recalled one or other form of abuse. Apart from emotional distress, emotional problems were less common in older women. Older women were also less likely to recall abuse, and recall of abuse contributed statistically to explaining the relationship of youth to emotional problems. Childhood abuse is a risk factor for emotional problems after surgical treatment for breast cancer, and the challenge of identifying and helping those patients in whom emotional problems reflect pre-morbid vulnerabilities needs careful consideration. Because both emotional problems and abuse are strongly age-linked, future research should avoid generalisations across the age spectrum.

Barriers in providing psychosocial support for patients with cancer

There is sound evidence to support the notion that the provision of effective psychosocial care improves the outcomes of patients with cancer. Central to the implementation of this care is that health professionals have the necessary communication and assessment skills. This study aimed to identify key issues related to providing effective psychosocial care for adult patients admitted with hematological cancer, as perceived by registered nurses with 3 or more years of clinical experience. An exploratory qualitative design was used for this study. Two focus group interviews were conducted with 15 experienced cancer nurses. The provision of psychosocial care for patients with cancer is a dynamic process that has a professional and personal impact on the nurse. The 5 analytic themes to emerge from the data were as follows: When is it a good time to talk? Building relationships; Being drawn into the emotional world; Providing support throughout the patient's journey; and Breakdown in communication processes. The findings from this study indicate an urgent need to develop a framework to provide nurses with both skill development and ongoing support in order to improve nurses' ability to integrate psychosocial aspects of care and optimize patient outcomes.

Interactive technologies and videotapes for patient education in cancer care: systematic review and meta-analysis of randomised trials

GOALS OF WORK

Patients diagnosed with cancer need education as they face complex decisions. There is limited evidence about the impact of new educational technologies for cancer patients. This paper investigates whether interactive technologies and videotapes for patient education in cancer care improve knowledge, satisfaction or other outcomes.

METHODS

Literature search of five computerised databases (Medical Literature Analysis and Retrieval System, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Controlled Trials Register and Cochrane Database of Systematic Reviews) and bibliography searches identified relevant randomized controlled trials. Two reviewers independently assessed trial quality. Summary effects for knowledge and satisfaction were calculated using random-effects models (RevMan 4.2 software). Continuous data were summarised as weighted mean differences and dichotomous data as odds ratios, each with their respective 95% confidence interval. Standardised effect sizes for these outcomes were calculated and contrasted.

RESULTS

Nine randomised control trials with 1,678 patients were identified. Three evaluated the use of videotapes, and six evaluated computer technologies. Studies were of good-quality design but were variable in instruments, content, populations, outcomes and results. Educational technologies showed improved patient knowledge (effect sizes ranging from 0.12 to 1.03). Satisfaction was improved in some studies, but the overall effect was more equivocal--effect sizes ranged (0.05 to 0.40) of benefit for knowledge and from 0 to 0.40 for satisfaction.

CONCLUSIONS

The trials present preliminary evaluations of the technology in North America, the UK and Australia. There is a trend to improved knowledge and satisfaction. The ways in which the interventions are delivered and the extent of communication with a health professional affect patient responses.

Pushing up daisies: implicit and explicit language in oncologist-patient communication about death

GOALS OF WORK

Although there are guidelines regarding how conversations with patients about prognosis in life-limiting illness should occur, there are little data about what doctors actually say. This study was designed to qualitatively analyze the language that oncologists and cancer patients use when talking about death.

SUBJECTS AND METHODS

We recruited 29 adults who had incurable forms of cancer, were scheduled for a first-time visit with one of six oncologists affiliated with a teaching hospital in Australia, and consented to having their visit audiotaped and transcribed. Using content analytic techniques, we coded various features of language usage.

MAIN RESULTS

Of the 29 visits, 23 (79.3%) included prognostic utterances about treatment-related and disease-related outcomes. In 12 (52.2%) of these 23 visits, explicit language about death ("terminal," variations of "death") was used. It was most commonly used by the oncologist after the physical examination, but it was sometimes used by patients or their kin, usually before the examination and involving emotional questioning about the patient's future. In all 23 (100%) visits, implicit language (euphemistic or indirect talk) was used in discussing death and focused on an anticipated life span (mentioned in 87.0% of visits), estimated time frame (69.6%), or projected survival (47.8%).

CONCLUSIONS

Instead of using the word "death," most participants used some alternative phrase, including implicit language. Although oncologists are more likely than patients and their kin to use explicit language in discussing death, the oncologists tend to couple it with implicit language, possibly to mitigate the message effects.

The choice is yours? How women with ovarian cancer make sense of treatment choices

OBJECTIVE

Much has been made of the need for cancer patients to be involved in choices about their treatments. We explore the different approaches to involvement described by women with ovarian cancer and consider why being invited to make a choice can sometimes seem inappropriate and untimely.

METHOD

Qualitative interviews were conducted in the UK with women with ovarian cancer. Interviews were audio tape recorded and transcribed for qualitative analysis. The interviews were collected as part of a broader study of experiences of ovarian cancer as part of the DIPEx (personal experiences of health and illness) project which runs a website featuring further analyses and video and audio clips from the interviews.

RESULTS

Women did not always recall being involved in decisions -some felt there had been no 'real' decisions to make or said they preferred their medical team to decide on their behalf. Other women described asking questions and seeking second opinions but still 'going along with' their doctor's recommendation. A few women (including some of those who had felt unable to participate in decisions soon after their diagnosis) said that they had learnt enough to take control or make at least some of their own treatment decisions. The manner in which options were offered to women sometimes led to confusion and concern, especially if women felt the doctor was unwilling to express his or her own preference. Some worried that not accepting the doctor's advice would prejudice their future care.

CONCLUSION

Patients and doctors are often uncertain how best to share in decisions about treatments. Being asked about their preferences can surprise or shock women. Clinicians need to explain about clinical uncertainty and how individual values and preferences may relate to treatment decisions. Presenting the rationale for choice can be difficult and even when well presented, women can be left feeling ill prepared, panicky and trying to second guess what they think the doctor 'really' wanted them to do.

PRACTICE IMPLICATIONS

When patients are invited to make choices their clinicians need to explain about clinical uncertainty and how individual values and preferences may relate to treatment decisions. The options should be communicated in a clear manner, differences in opinion should be acknowledged and the doctor's own preference stated. Patients need to be encouraged and supported to make their decision-whether or not it reflects their doctor's preference. Patients should also be reassured that whichever decision they make their subsequent care and relationship with their medical team will not be adversely affected.

Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians

BACKGROUND

No study has yet assessed the impact of physicians' skills acquisition after a communication skills training programme on the evolution of patients' anxiety following a medical consultation. This study aimed to compare the impact, on patients' anxiety, of a basic communication skills training programme (BT) and the same programme consolidated by consolidation workshops (CW), and to investigate physicians' communication variables associated with patients' anxiety.

PATIENTS AND METHODS

Physicians, after attending the BT, were randomly assigned to CW or to a waiting list. The control group was not a non-intervention group. Consultations with a cancer patient were recorded. Patients' anxiety was assessed with the State Trait Anxiety Inventory before and after a consultation. Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual.

RESULTS

No statistically significant change over time and between groups was observed. Mixed-effects modelling showed that a decrease in patients' anxiety was linked with screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' distress (P < 0.001). An increase in anxiety was linked with breaking bad news (P = 0.050) and with supportive skills (P = 0.013). No impact of the training programme was observed.

CONCLUSIONS

This study shows the influence of some communication skills on the evolution of patients' anxiety. Physicians should be aware of these influences.