The communication goals and needs of cancer patients: a review

Developing and implementing an advanced communication training program in oncology at a comprehensive cancer center

Cancer patients report significant levels of unmet needs in the realm of communication. Communication skills training programs have been shown to improve clinical communication. However, advanced communication skills training programs in oncology have lacked institutional integration, and thus have not attended to institutional norms and cultures that may counteract explicit communication skills training. We developed and implemented an advanced communication skills training program made up of nine teaching modules for faculty, fellows, and residents. Training included didactic and experiential small group work. Self-efficacy and behavior change were assessed for individual participants. Since 2006, 515 clinicians have participated in this training program. Participants have shown significant gains in self-efficacy regarding communicating with patients in various contexts. Our initial work in this area demonstrates the implementation of such a program at a major cancer center to be feasible, to be acceptable, and to have a significant impact on participants' self-efficacy.

"What am I Going to Say Here?" The Experiences of Doctors and Nurses Communicating with Patients in a Cancer Unit

This paper describes a study investigating the provider-patient communication perceptions, experiences, needs, and strategies of doctors and nurses working together in a UK cancer setting. This was a qualitative study using individual interviews and focus group discussions. Interpretative phenomenological analysis was used to underpin data collection and analysis. Twenty-six staff participated in the project (18 nurses and 8 doctors). Both professional groups identified an inherent emotional strain in their daily interactions with patients. The strategies they adopted to reduce this strain fell into two main categories: (1) Handling or managing the patient to keep negative emotion at bay; and (2) Managing self to keep negative emotion at bay. These strategies allowed staff to maintain a sense of control in an emotionally stressful environment. Most believed that their communication skills were sufficient. In conclusion, communicating with and caring for cancer patients causes considerable psychosocial burden for doctors and nurses. Managing this burden influences their communication with patients. Without recognition of the need for staff to protect their own emotional well-being, communication skills training programs, emphasized in current UK cancer care guidelines, may have little impact on practice.

Eliciting adaptive emotion in conversations with parents of children receiving therapy for leukemia

Clinician-parent communication may often be difficult, especially soon after the diagnosis. The aims of this article are to identify the communication strategies associated with expressions of adaptive emotions in parents and to explore the effect of the type of leukemia and of parent's gender on parents' expressions of emotions. The data are obtained from 4.622 conversational turns of 20 videotaped interviews with 10 mothers and 10 fathers of children at their first hospitalization for leukemia. A coding scheme for parent emotional expressions was reliably applied by two independent judges. An original self-report questionnaire on parents' emotional states was used before and after the interview. Positive politeness of interviewer elicits adaptive emotional expressions in parents. Mothers of children with acute myeloid leukemia and fathers of children with acute lymphoblastic leukaemia appear more distressed during the interview. This interview can be identified as an innovative technique of communication with parents of children with cancer.

Tailored information for cancer patients on the Internet: effects of visual cues and language complexity on information recall and satisfaction

OBJECTIVE

This study was designed to investigate the effects of visual cues and language complexity on satisfaction and information recall using a personalised website for lung cancer patients. In addition, age effects were investigated.

METHODS

An experiment using a 2 (complex vs. non-complex language)×3 (text only vs. photograph vs. drawing) factorial design was conducted. In total, 200 respondents without cancer were exposed to one of the six conditions.

RESULTS

Respondents were more satisfied with the comprehensibility of both websites when they were presented with a visual cue. A significant interaction effect was found between language complexity and photograph use such that satisfaction with comprehensibility improved when a photograph was added to the complex language condition. Next, an interaction effect was found between age and satisfaction, which indicates that adding a visual cue is more important for older adults than younger adults. Finally, respondents who were exposed to a website with less complex language showed higher recall scores.

CONCLUSION

The use of visual cues enhances satisfaction with the information presented on the website, and the use of non-complex language improves recall.

PRACTICE IMPLICATIONS

The results of the current study can be used to improve computer-based information systems for patients.

Specific Training Program Improves Oncologists' Palliative Care Communication Skills in a Randomized Controlled Trial

Purpose

The aim of the study was to demonstrate that COM-ON-p, concise and individualized communication skills training (CST), improves oncologists' communication skills in consultations focusing on the transition to palliative care.

Methods

Forty-one physicians were randomly assigned to a control (CG) or intervention group (IG). At t0, all physicians held two video-recorded consultations with actor-patient pairs. Afterward, physicians in the IG participated in COM-ON-p. Five weeks after t0, a second assessment took place (t1). COM-ON-p consists of an 11-hour workshop (1.5 days), pre- and postassessment (2 hours), and coaching (0.5 hours). Physicians focused on practicing individual learning goals with actor patients in small groups. To evaluate the training, blinded raters assessed communication behavior of the physicians in video-recorded actor-patient consultations using a specific checklist. Data were analyzed using a mixed model with baseline levels as covariates.

Results

Participants in the IG improved significantly more than those in the CG in all three sections of the COM-ON-Checklist: skills specific to the transition to palliative care, global communication skills, and involvement of significant others (all P < .01). Differences between the CG and IG on the global items of communication skills and involvement of significant others were also significant (P < .01). Effect sizes were medium to large, with a 0.5-point improvement on average on a five-point rating scale.

Conclusion

Physicians can be trained to meet better core challenges during the transition to palliative care through developed concise CST. Generalization and transfer into clinical practice must be proven in additional studies.

Impact of Patient-Reported Outcomes in Oncology: A Longitudinal Analysis of Patient-Physician Communication

Purpose

Regularly collecting patient-reported outcomes (PROs) of health-related quality of life with feedback to oncologists may assist in eliciting and monitoring patients' problems during cancer treatment. This study examined how PRO feedback had an impact on patient-physician communication over time to gain a better understanding of how it may influence patient care.

Patients and Methods

Exploratory analyses were performed on a data set from a previous study. Patients were randomly assigned to intervention (regular completion of European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and Hospital Anxiety and Depression Scale with feedback to oncologists), attention-control (completion of same questionnaires without feedback), and control (standard care) arms. The content of consultation audio recordings between 28 oncologists and 198 patients over four consecutive visits (792 consultations) was analyzed. Mixed-effects models and multivariate regressions were used to examine the longitudinal impact of the intervention on patient-physician communication, dynamics of patient-physician interaction, and the association between PROs and the content of clinic discussion.

Results

Patients in the intervention arm discussed more symptoms over time compared with patients in the attention-control (P = .008) and control (P = .04) arms. No study arm effect was observed for function discussions. Discussion topics were predominantly raised by patients/relatives, regardless of arm allocation. Clinic discussions were associated with severity of patient-reported symptoms but not with patient-reported functional concerns.

Conclusion

A positive longitudinal impact of the intervention on symptom discussion was observed, but not for function discussion, suggesting that potentially serious problems may remain unaddressed. Training oncologists in responding to patient-reported functional concerns may increase the impact of this intervention.

Patient preferences for the delivery of bad news - the experience of a UK Cancer Centre

The primary aim of this study was to assess how patients would prefer to be given their cancer diagnosis in a typical UK cancer centre. Two hundred and forty-four patients attending the oncology outpatient department at the Leicester Royal Infirmary, UK, were recruited. Patients were invited to complete the Measure of Patients' Preferences questionnaire, write comments on their own experience of the breaking bad news consultation and choose their preferred role in decision making. Over 90% of questionnaires were completed. Patients rated the items addressing the message content of the consultation as more important than the facilitative or the supportive aspects. Over 80% of patients wrote a detailed account of their experiences, of which 60% were satisfied with the consultation. Most of the patients who were dissatisfied commented on the unsympathetic or pessimistic manner of the doctor. The majority of patients wanted a collaborative role in decision making. Regarding the cancer diagnosis, the majority of patients have information needs, want to be involved in treatment decisions and know their prognosis. The difficulty for physicians is how to meet individual information needs, give hope, but not deliver unrealistic expectations.

Facilitating the implementation of empirically valid interventions in psychosocial oncology and supportive care

PURPOSE

Over the past two decades, the fields of psychosocial oncology and supportive care have seen clinically effective tools as underutilized despite proven benefits to cancer patients and their families. The purpose of this paper is to discuss the reasons for the failure of psychosocial and supportive care interventions in oncology to realize broad clinical implementation and to demonstrate how a knowledge management framework offers several advantages for increasing the probability of successful implementation.

METHODS

This paper is based on a systematic review of the literature pertaining to efforts to implement psychosocial oncology and supportive care interventions.

RESULTS

The struggle to develop, implement, and evaluate promising psychosocial oncology and supportive care innovations has moved academic thought toward the development of models and theories concerning the best ways to move new knowledge into clinical practice. There are critical and common barriers to the successful transfer and implementation of promising interventions, and implementation efforts may be maximized by using knowledge management frameworks to systematically identify and address these barriers.

CONCLUSIONS

The successful implementation of empirically promising interventions requires research networks and practice groups to work together in a concerted, theory-guided effort to identify and address the contextual factors most relevant to any particular intervention. The growing support of knowledge implementation activities by research funders, policy-makers, opinion leaders, and advocates of psychosocial and supportive care interventions is a positive move in this direction.

Patients rate physician communication about lung cancer

BACKGROUND

High-quality lung cancer care includes physician-patient communication about the disease and treatment, patient needs/preferences, and care goals. In this study, the authors evaluated communication with patients at all stages across multiple topics.

METHODS

A standardized questionnaire asked patients with lung cancer to rate (on 5-point, verbal descriptor scale) the extent of communication with physicians on symptoms, spiritual concerns, practical needs, proxy appointment, living will preparation, prognosis, care goals, potential complications of therapy, life support preferences, and hospice. Communication was defined as inadequate if the patient reported discussing ≥5 of 11 questionnaire topics "not at all" or "a little bit." Multivariate logistic regression was used to evaluate the factors associated with inadequate communication.

RESULTS

In total, 276 of 348 (79%) eligible patients were enrolled (mean age [±standard deviation], 65 ± 10 years; 55% white, 21% black, and 19% Hispanic; all disease stages). For most topics, the majority of respondents reported that physicians communicated "not at all" or "a little bit." Low ratings were frequent for discussion of emotional symptoms (56%; 95% confidence interval [CI], 49%-62%), practical needs (71%; 95% CI, 65%-76%), spiritual concerns (80%; 95% CI, 75%-85%), proxy appointment (63%; 95% CI, 57%-69%), living will preparation (90%; 95% CI, 85%-93%), life support preferences (80%; 95% CI, 75%-84%), and hospice (88%; 95% CI, 86%-94%). Communication was inadequate for patients of different ages, stages, and races, although Hispanics were less likely than non-Hispanic whites and blacks to report inadequate communication (odds ratio, 0.31; 95% CI, 0.15-0.65).

CONCLUSIONS

Across all stages, patients with lung cancer reported low rates of physician-patient communication on key topics, which may increase patient distress, impair decision-making, and compromise clinical outcomes and use patterns.

A longitudinal study of changes in provider-patient interaction in treatment of localized prostate cancer

PURPOSE

Whilst much is known as to the met and unmet communication needs of prostate cancer patients, few studies have been conducted on the changes in communication between provider and patient over time. Therefore, the aim of our study is to examine (a) whether there are changes over time in the quality of psychosocial care in long-term treatment of localized prostate cancer and (b) whether those changes are associated with the treatment decision.

METHODS

HAROW is a prospective, observational study designed to collect clinical data and patient reported outcomes (PROs) of different treatment options (hormonal therapy, active surveillance, radiation, operation, watchful waiting) for newly diagnosed patients with localized prostate cancer under real conditions. At 6-month intervals, general clinical data, PROs (e.g. quality of life, quality of physician-patient interaction) and individual costs are documented. We analysed data of N = 1,216 patients at the time of initial diagnosis (T1) and after 6 months (T2).

RESULTS

There is a significant decline in shared decision-making behaviour of physicians for the group of patients undergoing a prostatectomy and for the hormonal therapy group at the time of initial diagnosis and after 6 months. In terms of emotional support by physicians, there is a significant difference between the treatment groups at the time of initial diagnosis with patients undergoing a prostatectomy reporting significantly less support than the hormonal therapy group.

CONCLUSION

Future research from both, the providers' and the patients' perspective, will have to clarify if we can interpret our results as change in the communication behaviour once the treatment decision for prostatectomy or hormonal therapy is made.

Desire for autonomy in health care decisions: a general population survey

OBJECTIVE

To examine factors associated with desire for autonomy in health care decisions in the general population.

METHODS

Mailed survey of 2348 residents of Geneva, Switzerland. Participants answered questions on a scale measuring their desire for autonomy in health care decisions. The scale was scored between 0 (lowest desire for autonomy) and 100 (highest desire for autonomy).

RESULTS

On average the respondents favoured shared or active involvement in medical decisions (mean score 62.0, SD 20.9), but attitudes varied considerably. In the multivariate model, factors associated with a higher desire for autonomy included female gender, younger age, higher education, living alone, reporting an excellent global health and - a new observation compared to previous studies - having made several medical decisions in the past 6 months.

CONCLUSIONS

The attitudes of the general public appear to be consistent with the model of shared decision making. However, people vary considerably in their desire for autonomy.

PRACTICE IMPLICATIONS

An explicit assessment of each individual's desire for autonomy may improve the decision-making process. Such an assessment should be repeated regularly, as familiarity with medical decisions may increase the desire for autonomy.

A comprehensive observational coding scheme for analyzing instrumental, affective, and relational communication in health care contexts

Many observational coding schemes have been offered to measure communication in health care settings. These schemes fall short of capturing multiple functions of communication among providers, patients, and other participants. After a brief review of observational communication coding, the authors present a comprehensive scheme for coding communication that is (a) grounded in communication theory, (b) accounts for instrumental and relational communication, and (c) captures important contextual features with tailored coding templates: the Siminoff Communication Content & Affect Program (SCCAP). To test SCCAP reliability and validity, the authors coded data from two communication studies. The SCCAP provided reliable measurement of communication variables including tailored content areas and observer ratings of speaker immediacy, affiliation, confirmation, and disconfirmation behaviors.

Variation in question asking during cancer clinical interactions: a potential source of disparities in access to information

OBJECTIVE

to investigate whether patient demographic characteristics and patients' companions influence variation in patient question asking during cancer clinical interactions, thus representing a potential disparity in access to information.

METHODS

data included 109 oncologist-patient-companion interactions video recorded at a comprehensive cancer center. Interactions were observed and analyzed using the Karmanos Information Seeking Analysis System (K-ISAS).

RESULTS

significant relationships were found between patient race/ethnicity and question asking. Black patients asked fewer questions and a smaller proportion of direct questions (relative to the total frequency of questions) than White patients. Black patients were also less likely to have companions present during the interaction, which resulted in fewer questions asked on Black patients' behalf.

CONCLUSION

differences in question asking by Black and White patients suggest that Black patients may receive less information from their oncologists than White patients. PRACTICE/RESEARCH IMPLICATIONS: patients should be encouraged to ask more questions and more direct questions and to bring a companion to the interaction to assist them in gaining information from their physician. Future research is needed to investigate ways to eliminate this potential source of disparities in access to information.

Medical communication skills training in the Indian setting: Need of the hour

Advances in science and technology have revolutionized medical services in the last two decades. Medical education in the undergraduate and postgraduate courses has tried to keep pace with the changes and several curriculum modifications have taken effect. One of the commonly seen changes include active participation in "communication skills" training and implementation of the same in practice. This article discusses the practical issues one would face in day-to-day medical communication and highlights the necessity of the same in the Indian setting, with a focus on transfusion medicine.

Effects of communication skills training and a Question Prompt Sheet to improve communication with older cancer patients: a randomized controlled trial

A randomized pre- and post-test control group design was conducted in 12 oncology wards to investigate the effectiveness of an intervention, existing of a communication skills training with web-enabled video feedback and a Question Prompt Sheet (QPS), which aimed to improve patient education to older cancer patients (≥65 years). The effects were studied by analyzing questionnaires and video recordings of patient education sessions preceding chemotherapy with 210 different patients. Patients' recall of information was the primary outcome of the study. Recall was checked against the actual communication in the video-recordings. Moreover, communication skills were assessed by observing the extent to which nurses implemented 67 communication aspects, categorized in seven dimensions, using the QUOTE(chemo). Experimental nurses demonstrated a significant intervention effect on communicating realistic expectations. Within-group improvements were measured in the experimental group for tailored communication, affective communication and interpersonal communication. Although the use of a QPS significantly increased question asking, only limited results were found on older patients' recall scores. The overall proportion recall of recommendations showed a marginally significant pre-/post-change in proportion recall in favour of the experimental group and there was a significant pre-/post-change in two out of six sub-categories. The results indicate that nurses' communication skills can be improved by communication skills training. More research is needed to understand the difficult relationship between patient-provider communication and recall of information.

Study protocol: a randomized controlled trial of patient navigation-activation to reduce cancer health disparities

Background

Cancer health disparities affecting low-income and minority patients are well documented. Root-causes are multifactorial, including diagnostic and treatment delays, social and financial barriers, and poor communication. Patient navigation and communication coaching (activation) are potential interventions to address disparities in cancer treatment. The purpose of this clinical trial is to test the effectiveness of an intervention combining patient navigation and activation to improve cancer treatment.

Methods/Design

The Rochester Patient Navigation Research Program (PNRP) is a National Cancer Institute-sponsored, patient-level randomized trial (RCT) of patient navigation and activation, targeting newly-diagnosed breast and colorectal cancer patients in Rochester, NY. The goal of the program is to decrease cancer health disparities by addressing barriers to receipt of cancer care and promoting patient self-efficacy. The intervention uses trained, paraprofessional patient navigators recruited from the target community, and a detailed training and supervisory program. Recruited patients are randomly assigned to receive either usual care (except for baseline and follow-up questionnaires and interviews) or intervention. The intervention patients receive tailored assistance from their patient navigators, including phone calls, in-person meetings, and behind-the-scenes coordination of care. A total of 344 patients have been recruited. Outcomes measured at three month intervals include timeliness of care, patient adherence, patient satisfaction, quality of life, self-efficacy, health literacy, and cancer knowledge.

Discussion

This unique intervention combining patient navigation and patient activation is designed to address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of patient navigation programs.

Trials Registration

clinicaltrials.gov identifier NCT00496678

The sequelae of anxiety in breast cancer: a human response to illness model

PURPOSE/OBJECTIVES

To provide a critical review of the empirical literature on anxiety in women with breast cancer using the physiologic, pathophysiologic, behavior, and experiential perspectives of the Human Response to Illness (HRTI) Model.

DATA SOURCES

Research articles, clinical articles, and Internet sources on breast cancer and anxiety. Literature sources included CINAHL, PubMed, and PsycINFO, incorporating English language reports through March 2009.

DATA SYNTHESIS

Patients with breast cancer experience fluctuating levels of anxiety throughout their diagnosis and treatment trajectory. Anxiety may influence an individual's response to treatment, treatment decision making, and overall quality of life.

CONCLUSIONS

Research consistently demonstrates that anxiety in patients with breast cancer can have a negative effect on patient outcomes.

IMPLICATIONS FOR NURSING

The insight gained from exploring anxiety within the context of the four interrelated perspectives of the HRTI model fosters the provision of optimal care for patients suffering with anxiety throughout their breast cancer illness trajectory.

Impact of a brief intervention on patient communication and barriers to pain management: results from a randomized controlled trial

OBJECTIVE

This study examined the impact of a brief pain communication/education intervention on patient outcomes in breast cancer. We hypothesized that our intervention would improve patient communication and reduce misconceptions ("Barriers") concerning pain management, and that patients with lower Barriers, or who perceived their physician as being more facilitative and receptive, would report better outcomes.

METHODS

Female breast cancer patients with persistent pain (n=89) were randomly assigned to either a 30-min in-person pain education/communication intervention or control condition and followed for 12 weeks.

RESULTS

Intervention group patients reported a significant decrease in pain Barriers but not in other outcomes. Overall, patients with lower barrier scores reported less distress and better emotional well-being. Patients who scored higher in active communication (e.g., asking questions, giving information) reported fewer Barriers and better pain relief. Individuals who perceived their physicians as being more receptive reported better pain management while those who perceived their physicians as being both more receptive and facilitative were more satisfied with their health care.

CONCLUSION

A brief education/communication intervention reduced patients' Barriers to pain management but did not impact other patient outcomes.

PRACTICAL IMPLICATIONS

Pain outcomes may be improved by addressing patients' pain misconceptions and emphasizing a receptive and responsive communication style.

Measuring cancer patients' reasons for their information preference: construction of the Considerations Concerning Cancer Information (CCCI) questionnaire

OBJECTIVES

This paper describes the further development and psychometric properties of an instrument to measure cancer patients' reasons to want complete or limited information: the Considerations Concerning Cancer Information questionnaire (CCCI). Understanding cancer patients' reasons to want complete or limited information will provide the physician with information that enables him or her to tailor information giving.

METHODS

CCCI's content validity, internal structure, and convergent validity were investigated among 145 cancer patients, new to radiotherapy.

RESULTS

Underlying reasons for information preference among cancer patients were derived from existing qualitative studies, narratives, and interviews. This resulted in the CCCI containing two parts: reasons to favor complete information disclosure and reasons to prefer only limited information about disease and treatment. The four identified dimensions to prefer information consist of: sense of control, expectations of others, anxiety, and autonomy. The four dimensions for reasons to give up on acquiring information consist of: avoidance, optimism, comprehension, and not wanting to be a burden. Confirmatory factor analysis indicated that the measurement model provided good fit to the data. Scales had good internal consistency, satisfactory item-total correlations corrected for overlap and satisfactory convergent validity.

CONCLUSIONS

These findings confirm evidence of the reliability and validity of the CCCI for use in cancer care. Researchers and health-care providers can use the instrument to assess cancer patients' reasons to want complete or limited information and provide tailored care.

Behind closed doors: systematic analysis of breast cancer consultation communication and predictors of satisfaction with communication

OBJECTIVE

The purpose of this investigation was to explicate the content of primary adjuvant treatment consultations in breast oncology and examine the predictive relationships between patient and oncologist consultation factors and patient satisfaction with communication.

METHODS

The recorded consultations of 172 newly diagnosed breast cancer patients from four Canadian cancer centers were randomly drawn from a larger subset of 481 recordings and examined by three coders using the Medical Interaction Process System (MIPS); a system that categorizes the content and mode of each distinct utterance. The MIPS findings, independent observer ratings of patient and oncologist affective behavior, and derived consultation ratios of patient centeredness, patient directedness, and psychosocial focus, were used to predict patient satisfaction with communication post-consultation and at 12-weeks post-consultation.

RESULTS

Biomedical content categories were predominant in the consultations, accounting for 88% of all utterances, followed by administrative (6%) and psychosocial (6%) utterances. Post-consultation satisfaction with communication was significantly higher for older patients, those with smaller primary tumors and those with longer consultations. Smaller tumor, lack of patient assertiveness during the treatment consultation and having the consultation with a radiation rather than medical oncologist were significantly predictive of greater satisfaction at 12-weeks post-consultation.

CONCLUSIONS

Adjuvant treatment consultations are characterized by a high degree of information-giving by the physician, a predominance of biomedical discussion and relatively minimal time addressing patients' psychosocial concerns. Controlled trials are needed to further identify and address the contextual features of these consultations that enhance patient satisfaction.

The implementation and assessment of a comprehensive communication skills training curriculum for oncologists

OBJECTIVE

The objective of this paper is to report the implementation and assessment of the Comskil Training Curriculum at Memorial Sloan-Kettering Cancer Center.

METHOD

Twenty-eight attending physicians and surgeons participated in communication skills training modules as part of a train-the-trainer program. Doctors were video recorded in clinical consultations with patients two times before training and two times after training, resulting in 112 video recordings for analysis. Recordings were coded using the Comskil Coding System.

RESULTS

Communication skills related to two of the six major skill sets, Establishing the Consultation Framework and Checking, increased following training. Limited changes emerged in three skill sets, while one skill set, Shared Decision Making, did not change. Doctors who attended more training modules had higher levels of change. Female participants demonstrated three skills more frequently than males post-training.

CONCLUSIONS

The intervention produced significant communication skills uptake in a group of experienced attending clinicians, mediated by the amount of training. Future research should focus on the dose of training necessary to achieve skills uptake and the effect of skills training on patient outcomes.

Consultation support for rural women with breast cancer: results of a community-based participatory research study

OBJECTIVE

This study asked: (1) What do rural women with breast cancer need to make the most out of their major medical appointments? and (2) What can the community resource centers do to best support those needs?

METHODS

We interviewed 12 doctors, 12 breast cancer survivors and 10 community agency staff, including those who provide services to Latinos and Native Americans. Interviews generated success factors and barriers related to meeting patient information needs. Examples were categorized into themes.

RESULTS

Success factors included making sure patients review high quality educational materials before the visit; and that someone is available to take notes. Doctors felt that a patient list of questions was productive, but some survivors felt doctors did not always respond productively to the list. Respondents did not mention audiorecording unless prompted. Most then endorsed it.

CONCLUSION

Educational materials, question lists, and note-takers can help rural women with breast cancer and their doctors achieve their goals during treatment discussions. Audiorecording may be an implicit but not explicit need.

PRACTICE IMPLICATIONS

Other cancer resource centers and support agencies should consider offering information, question-listing, and note-taking services. They should assess whether audiorecording is an implicit need in their settings.

Emotional and informational patient cues: the impact of nurses' responses on recall

OBJECTIVE

To investigate older cancer patients' informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients' information recall.

METHODS

105 cancer patients (aged >or=65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients' emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS).

RESULTS

Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients' expression of emotional or informational cues did not influence recall; neither did nurses' responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving 'minimal' encouragements (e.g. 'Hmmm'), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores.

CONCLUSION

Responding to patients' emotions is likely to impact information recall.

PRACTICE IMPLICATIONS

These results highlight the importance of addressing patients' expressions of emotions in the context of patient education, as it enhances information recall.

The State of the Science: Informing choices across the cancer journey with public health mechanisms and decision processes

Health decisions involve sharing information and making choices-even if the choice is to leave the decision to others. The way that information is delivered and understood by consumers across their cancer journey in turn influences the health decisions they take. A public health approach to the cancer journey considers the information needs of individuals and the structures and systems that facilitate the provision of credible and timely information. This paper examines emerging research that takes a public health approach to promote information-sharing and health decisions, identifies information-sharing mechanisms used by providers to facilitate shared decisions and evaluates decision support processes designed to improve information-sharing and self-care events. Evidence is presented to guide future research directions.

Improving patient education by an in-service communication training for health care providers at a cancer ward: communication climate, patient satisfaction and the need of lasting implementation

OBJECTIVE

To show the effects of an in-service communication training for health care providers at a cancer ward, to improve the quality and quantity of the patient education, and patient satisfaction with the care received.

METHODS

A 3-year in-service communication training was held at a cancer ward. Pre- and post-data were collected about the quality and quantity of the communication of nurses, physicians and other health care providers (HCPs) towards patients and colleagues (n=22) as well as the satisfaction of the patients with the quality of care (n=90).

RESULTS

The communication training raised significantly the quality and quantity of the communication towards patients and with colleagues. Also patient satisfaction with the quality of care increased. However, the long-term implementation of the benefits was proved disappointing.

CONCLUSION

In-service communication training is an important means for the long-term improvement of the quality of patient education at nursing departments in hospitals. Lasting implementation of the benefits however requires attention to organizational obstacles, budgetary conditions, leadership factors at the ward, and the application of an organizationally oriented theoretical framework.

PRACTICE IMPLICATIONS

Improvement of patient education at nursing wards does not only require educational means, organizational facilities and professional training, but can be improved too by in-service communication training, which increases the quality of the patient-centered care. An organizational oriented change-strategy is needed to ensure the implementation produces lasting effects.

National Cancer Institute partnerships in quality-of-care research

BACKGROUND

Improving the quality of cancer care delivery is a research priority for the National Cancer Institute (NCI). The NCI addresses this priority in part through a variety of research partnerships with public and private organizations designed to measure, monitor, and improve the quality of cancer care delivery.

METHODS

NCI-sponsored quality-of-care initiatives are reviewed in three areas: improving process and outcome measures, building strong data infrastructures to monitor the quality of cancer care, and developing practice-based quality-of-care research partnerships for privately sponsored and government-sponsored delivery programs.

RESULTS

Research partnerships strengthen the overall portfolio of NCI-sponsored research into understanding and improving cancer care delivery. These partnerships have made significant contributions in standardizing metrics of clinical effectiveness and health-related quality of life, in developing monitoring systems to track disparities in cancer care and identify opportunities for improvement, and in understanding ways to intervene in cancer care delivery to improve adherence to evidence-based practice. These partnerships also contribute to the productivity of investigator-initiated quality-of-care studies and often provide leverage for rapid adoption of this science by organizations that participate in these projects.

CONCLUSIONS

Research partnerships in measurement, data infrastructure, and service delivery are an essential part of the NCI's research program to advance the science of quality of cancer care. Collectively, these projects inform participating organizations on gaps in quality and opportunities for improving cancer care delivery. They also foster the development of tools for changing care processes that can lead to better outcomes for cancer patients and survivors.

How do interventions designed to improve provider-patient communication work? Illustrative applications of a framework for communication

In this broad overview for the Conference: "State of the Science in Cancer Care", we review a conceptual framework of physician-patient communication and use the framework to inform the application of theory regarding communication and patient preferences in clinical practice. Using a selection of research, we illustrate how problematic issues in communication can be represented by the framework. We further illustrate how interventions designed to improve communication or to elicit patients' preferences in a medical encounter may have their desired effect, or may be optimally evaluated.

Psychosocial distress in young cancer survivors

OBJECTIVES

To review existing literature about the psychosocial reactions of cancer patients and provide information about the needs of patients wishing to preserve fertility.

DATA SOURCES

Journal articles, research studies.

CONCLUSION

The desire for biological parenthood is an important issue for cancer survivors. Patients may not receive accurate, timely information about fertility-sparing options; those not receiving this information are at increased risk for psychological distress.

IMPLICATIONS FOR NURSING PRACTICE

Fertility-preservation decisions are complex and a team approach may identify patients at risk for psychological distress and provide opportunities for discussion of psychosocial issues involved. Nurses must be informed about the emotional reactions and informational needs of their patients.

Are rural Ohio Appalachia cancer survivors needs different than urban cancer survivors?

INTRODUCTION

Limited information is available about rural cancer survivors' needs and if they differ from urban cancer survivors.

METHODS

A convenience sample of cancer survivors completed a self-administered survey.

RESULTS

Rural Appalachia (n = 99) and urban non-Appalachia (n = 107) cancer survivors completed the survey. Urban survivors reported more needs than rural survivors (p < 0.001), but worry about cancer recurrence and concern about fatigue were reported most often by both urban and rural survivors. Urban survivors (n = 87; 81.3%) and rural survivors (n = 72; 72.9%) indicated that they searched for cancer information, but rural survivors were more likely to obtain information from family members and healthcare providers (p < 0.05). Rural survivors differed from urban survivors by reporting less effort to get the information they needed (p < 0.05) and less concern about the quality of the information (p < 0.01), but they reported having a harder time understanding the information they found (p < 0.05).

DISCUSSION

Rural and urban survivors' most frequent needs focused on cancer recurrence and fatigue. Rural survivors reported fewer needs compared to urban survivors; however, our findings suggest certain needs may be more important to rural survivors. While most survivors reported searching for information about cancer, rural and urban survivors use different sources for finding information and have varying experiences in their searches.

IMPLICATIONS FOR CANCER SURVIVORS

There is an ongoing need to provide survivorship care that is tailored to the unique needs of cancer survivors. It is essential to provide educational materials for all cancer survivors, but using different communication channels for urban versus rural survivors may be beneficial.

Development of decision-support intervention for Black women with breast cancer

BACKGROUND

Adjuvant therapy improves breast cancer survival but is underutilized by Black women. Few interventions have addressed this problem. This preliminary report describes the process we used to develop a decision-support intervention for Black women eligible for adjuvant therapy. Aims were to use qualitative methods to describe factors that influence Black women's adjuvant therapy decisions, use these formative data to develop messages for a treatment decision-support intervention, and pilot test the acceptability and utility of the intervention with community members and newly diagnosed women.

METHODS

Thirty-four in-depth interviews were conducted with breast cancer patients in active treatment, survivors and cancer providers to gather qualitative data. Participant ages ranged from 38 to 69 years. A cultural framework was used to analyze the data and to inform intervention messages. Most women relied on their providers for treatment recommendations. Several women reported problems communicating with providers and felt unprepared to ask questions and discuss adjuvant treatment options. Other factors related to treatment experiences were: spiritual coping, collectivism and sharing breast cancer experiences with other Black survivors.

RESULTS

Using these formative data, we developed an intervention that is survivor-based and includes an in-person session which incorporates sharing personal stories, communication skills training and decision support. Intervention materials were reviewed by community members, researchers/clinicians and patients newly diagnosed with breast cancer.

CONCLUSION

Patients reported satisfaction with the intervention and felt better prepared to talk with providers. The intervention will be tested in a randomized trial to enhance decision support and increase use of indicated adjuvant treatment.

Adaptation of consultation planning for Native American and Latina women with breast cancer

CONTEXT

Resource centers in rural, underserved areas are implementing Consultation Planning (CP) to help women with breast cancer create a question list before a doctor visit.

PURPOSE

To identify changes needed for acceptable delivery of CP to rural Native Americans and Latinas.

METHODS

We interviewed and surveyed 27 Native American and Latino key informants. We coded interviews thematically, and calculated summary statistics for the survey data.

FINDINGS

Native American and Latino respondents endorsed CP as culturally acceptable to their communities, while suggesting changes. Respondents also raised the topic of how to further support patients once they have successfully prepared a question list using CP.

CONCLUSIONS

The resource centers implemented the requested changes.

Modeling patient-centered communication: oncologist relational communication and patient communication involvement in breast cancer adjuvant therapy decision-making

OBJECTIVE

Relational communication refers to those messages communicators naturally express that carry meaning about the type and quality of relationship they share. It is expected that patients of oncologists who express positive relational communication will be more communicatively involved in their office visits, and regret their decision for adjuvant therapy following surgery less.

METHODS

One hundred eighty (180) audio-recorded discussions between oncologists (n=40) and early stage (I-III) breast cancer patients were coded with the Siminoff Communication Content and Affect Program (SCCAP). The data were used to test the relationships between patient demographics, oncologist relational communication, patient communication involvement and self-reported patient decision regret.

RESULTS

After controlling for clinician clusters, oncologists' verbal (i.e., confirming messages) and nonverbal (i.e., direct and inclusive speech) relational communication is indirectly associated with lower patient decision regret via the mediating effect of greater patient communication involvement.

CONCLUSION

Clinician relational communication provides an influential affective climate for decision-making that appears to have important effects on patients' decision confidence.

PRACTICE IMPLICATIONS

Clinicians should recognize the potential of their own relational messages to facilitate patients' communication involvement in decision-making during cancer care.

Implementing decision and communication aids to facilitate patient-centered care in breast cancer: a case study

OBJECTIVE

Decision Services (DS) provide support for breast cancer patients at the University of California, San Francisco to help ensure patient-centered care.

METHODS

We examined a case study to explore whether our program practices matched our program theory, and what the patient in the case thought was effective and ineffective about our decision support interventions.

RESULTS

The patient relied on a decision aid to educate her husband about her condition; felt that her question list contributed to a productive and efficient consultation with her oncologist; credited an audio-recording with helping her remember to follow-up with a genetic counselor; and reviewed the consultation summary 30 days into treatment in order to reflect on her decision. The patient rated the interventions highly on surveys, and experienced desirable reductions in decisional conflict, and improvements in knowledge. However, the question-prompting intervention was associated with a small decrease in self-efficacy, and the patient criticized the decision aid for omitting mention of a prognostic test.

CONCLUSION

This case illustrates how decision support interventions can be deployed to promote patient-centered care.

PRACTICE IMPLICATIONS

Breast care centers should consider distributing decision aids and assisting patients in listing questions, recording consultations, and obtaining written consultation summaries.