The communication goals and needs of cancer patients: a review

Patient real-time and 12-month retrospective perceptions of difficult communications in the cancer diagnostic period

Communication is a notoriously complex challenge in the cancer care context. Our program of research involves exploration of patient-provider communications across the cancer trajectory from the patient perspective.Toward this end, we have been following a cohort of 60 cancer patients, representing a range of tumor sites, from immediately after diagnosis through to recovery, chronic, or advanced disease. Drawing on interpretive description analytic techniques, we documented patterns and themes related to various components of the cancer journey. In this article, we report on findings pertaining to poor communication during the initial diagnostic period, as described by patients at the time of diagnosis and 1 year later.These findings illuminate the dynamics of communication problems during that complex period, and depict the mechanisms by which patients sought to confront these challenges to optimize their cancer care experience. On the basis of these findings, considered in the context of the body of available evidence, suggestions are proposed as to appropriate directions for system-level solutions to the complex communication challenges within cancer care.

Patients' reflections on communication in the second-opinion hematology-oncology consultation

OBJECTIVE

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients' perceptions of their second-opinion hematology-oncology consultation to investigate physician-patient communication in malignant disease at a critical juncture in cancer patients' care and decision-making.

METHODS

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

RESULTS

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians' consideration of the unique elements of patients' cases, and demonstrations of empathy and respect made patients' feel positively about the encounter, regardless of the prognosis.

CONCLUSIONS

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

PRACTICE IMPLICATIONS

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.

Proper information during the surgical decision-making process lowers the anxiety of patients with high-grade gliomas

PURPOSE

We aim to analyse the relationship between the quality of information during the decision-making process regarding surgery to treat high-grade gliomas and the level of anxiety of the patients.

METHODS

This is a transversal, descriptive and correlational study on 26 patients with a clinical and radiological diagnosis of high-grade glioma. They scored the quality (in terms of comprehension and satisfaction) of information received about the treatment options and prognosis during the surgical decision-making process, and the Hospital Anxiety and Depression Scale questionnaire (HADS) was applied immediately afterward.

RESULTS

Lower levels of anxiety were observed in patients who showed a desire to receive information regarding their illness, those with a higher degree of comprehension, and those with a higher level of satisfaction with the information provided.

CONCLUSIONS

An improvement in the communication process contributes to a decrease in the levels of anxiety, and consequently to enhancement of the well-being of these patients.

How does communication heal? Pathways linking clinician-patient communication to health outcomes

OBJECTIVE

Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient's anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions.

CONCLUSION

Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway.

PRACTICE IMPLICATIONS

Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.

Shifting goals in medical communication. Determinants of goal detection and response formation

OBJECTIVES

Research and education of medical communication different perspective, making the extraction of clear recommendations from research that can be applied in education not always possible. In education, medical communication is encountered from a goal-oriented perspective, which is often lacking in quantitative research where the relationship between process variables and the content of medical practice is often ignored. The aim of this paper is to bring the worlds of research and education together by presenting a comprehensive model of determinants explaining the behavior of physicians in daily practice. A basic notion in this model is that medical communication is goal-oriented, problem-solving behavior. Goals in communication are not fixed, but permanently changing over time. Hence, communication abilities do not rely on behavioral skills only but also on perceptual skills in identifying goals. A number of determinants affect the cognitive processes of goal appraisal and response formation: knowledge, attitudes, social norms, self-efficacy, stressors and interfering goals.

CONCLUSION

Modeling medical communication as goal-oriented problem-solving behavior, and recognizing the complexity of goal appraisal and other key determinants of response formation may provide a common focus for both research and education in measuring, explaining and improving the HCP's behavior.

PRACTICE IMPLICATIONS

In education not only skill practicing but also reflection on the process and outcomes is important to understand how one acts in practice situations and should act in future situations. In research measurements should be expanded to take contextual and goal-oriented dimensions of the process of communication into account to make findings more relevant for education and practice.

Communication, decision making, and cancer: what African Americans want physicians to know

PURPOSE

To explore and identify communication and decision making with health care providers for African Americans living with cancer and for their families.

METHODS

We used focus group interviews to identify and explore cultural perceptions, expectations, and desires as they relate to quality of life domains.

PARTICIPANTS

Of the 42 African American participants, 33 were women. Half of the participants (n = 21) were caregivers of a family member with cancer; the others were cancer survivors and some of them had also cared for a loved one with cancer.

RESULTS

Participants focused on effective communication and decision making as fundamental to overall quality of life. Furthermore, physicians were viewed as having the responsibility to establish and monitor effective communication with patients and families. Within the domain of effective communication, participants stressed that health care providers needed to know the person and family and to tailor communication with them based on that knowledge. Within the domain of decision making, participants emphasized having a sense of control over treatment choices. They also expressed concerns for populations made vulnerable by advanced age, poverty, or low levels of formal education.

DISCUSSION

Our participants indicated that relationship-centered care, in which one's sense of personhood is sought, acknowledged, and worked with, is foundational for effective communication and decision making.

Reflective teaching of medical communication skills with DiViDU: assessing the level of student reflection on recorded consultations with simulated patients

OBJECTIVE

Acquisition of effective, goal-oriented communication skills requires both practicing skills and reflective thinking. Reflection is a cyclic process of perceiving and analysing communication behaviour in terms of goals and effects and designing improved actions. Based on Korthagen's ALACT reflection model, communication training on history taking was designed. Objectives were to develop rating criteria for assessment of the students' level of reflection and to collect student evaluations of the reflective cycle components in the communication training.

METHODS

All second year medical students recorded a consultation with a simulated patient. In DiViDU, a web-based ICT program, students reviewed the video, identified and marked three key events, attached written reflections and provided peer-feedback. Students' written reflections were rated on four reflection categories. A reflection-level score was based on a frequency count of the number of categories used over three reflections. Students filled out an evaluation questionnaire on components of the communication training.

RESULTS

Data were analyzed of 304 (90.6%) students. The four reflection categories Observations, Motives, Effects and Goals of behaviour were used in 7-38%. Most students phrased undirected questions for improvement (93%). The average reflection score was 2.1 (S.D. 2.0). All training components were considered instructive. Acting was preferred most. Reviewing video was considered instructive. Self-reflection was considered more difficult than providing written feedback to the reflections of peers.

CONCLUSION

Reflection on communication behaviour can be systematically implemented and measured in a structured way. Reflection levels were low, probably indicating a limited notion of goal-oriented attributes of communication skills.

PRACTICE IMPLICATIONS

Early introduction of critical self-reflection facilitates acceptance of an important ability for physicians for continued life-long learning and becoming mindful practitioners.

Older cancer patients' information and support needs surrounding treatment: An evaluation through the eyes of patients, relatives and professionals

Background

Providing cancer patients with adequate treatment information is important for patients' health, well-being and satisfaction. Nurses play an important role in patient education. So far, few studies focused on the specific information needs of older cancer patients surrounding chemotherapy treatment. Given the growing incidence of cancer among older individuals, insight in these needs is crucial. This article describes the views of older cancer patients, their relatives and professionals on older patients' specific communication needs regarding chemotherapy treatment.

Methods

A qualitative design was used. Five focus group interviews were held with older cancer patients and their partners (two groups) and professionals with a background in nursing, oncology, gerontology and/or patient-provider communication (three groups). In addition, face to face in-depth interviews were conducted with older cancer patients. A total number of 38 patients and relatives participated, with a mean age of 67.6 years. The focus groups and interviews were audio-recorded for subsequent transcription and analysis.

Results

Older people have more difficulties processing and remembering information than younger ones. A trustful environment appears to be a prerequisite for reflection of older patients on the information provided and individualized information is essential to enhance memory of information. However, the results show that both patients and professionals experienced insufficient exploration of the patients' personal situation and individual information needs. Patients also strengthened the importance of sensitive communication, e.g. showing empathy en emotional support, throughout the continuum of cancer care. Moreover, potential areas of improvement were identified, including engaging the patients' relatives and encouraging patients and relatives to ask questions.

Conclusion

Patient education should be more tailored to older cancer patients' individual information and support needs and abilities by exploring the required amount and content of information, treatment goals and expectations. Nurses can establish a trustful environment by showing empathy and emotional support. Recommendations are given to enhance recall of information in older patients; information giving should be more structured by summarizing and repeating the most important, personally relevant information. To adapt to specific information needs, communication training for nurses and the use of aids such as a question prompt sheet could be useful tools.

Communication in end-stage cancer: review of the literature and future research

Concerns have been raised about the quality of life and health care received by cancer patients at the end of life (EOL). Many patients die with pain and other distressing symptoms inadequately controlled, receiving burdensome, aggressive care that worsens quality of life and limits patient exposure to palliative care, such as hospice. Patient-physician communication is likely a very important determinate of EOL care. Discussions of EOL with physicians are associated with an increased likelihood of the following (1) acknowledgment of terminal illness, (2) preferences for comfort care over life extension, and (3) receipt of less intensive, life-prolonging and more palliative EOL care; while this appears to hold for White patients, it is less clear for Black, advanced cancer patients. These results highlight the importance of communication in determining EOL cancer care and suggest that communication disparities may contribute to Black-White differences in EOL care. We review the pertinent literature and discuss areas for future research.

The role of the clinician in cancer clinical communication

Clinician communication is critical to positive outcomes for patients and families in most health contexts. Researchers have investigated areas such as defining and teaching effective communication and identifying specific outcomes that can be improved through more effective communication. In the area of cancer care, advances in detection and treatment require that clinicians develop new skills to adapt to the evolving needs of patients, families, and other members of the health care team. Some areas that require the attention of researchers are defining, assessing, and teaching effective communication in the context of the specific desires and preferences of individual patients and special populations; and meeting the needs of patients across the cancer continuum from screening, diagnosis, treatment to palliative care and survivorship. This report highlights three areas of research in cancer clinician communication including key areas of current and emerging research and theories and approaches for future research.

Does age really matter? Recall of information presented to newly referred patients with cancer

PURPOSE

To examine age- and age-related differences in recall of information provided during oncology consultations.

PATIENTS AND METHODS

Two hundred sixty patients with cancer diagnosed with heterogeneous cancers, seeing a medical or radiation oncologist for the first time, participated in the study. Patients completed questionnaires assessing information needs and anxiety. Recall of information provided was measured using a structured telephone interview in which patients were prompted to remember details physicians gave about diagnosis, prognosis, and treatment. Recall was checked against the actual communication in audio-recordings of the consultations.

RESULTS

Recall decreased significantly with age, but only when total amount of information presented was taken into account. This indicates that if more information is discussed, older patients have more trouble remembering the information than younger ones. In addition, recall was selectively influenced by prognosis. First, patients with a poorer prognosis recalled less. Next, the more information was provided about prognosis, the less information patients recalled, regardless of their actual prognosis.

CONCLUSION

Recall is not simply a function of patient age. Age only predicts recall when controlling for amount of information presented. Both prognosis and information about prognosis are better predictors of recall than age. These results provide important insights into intervention strategies to improve information recall in patients with cancer.

Perceptions of health care provider communication activity among American cancer survivors and Adults Without Cancer Histories: an analysis of the 2003 Health Information Trends Survey (HINTS) Data

Provider communication is an important determinant of health outcomes. We examined the frequency with which five important communication activities were perceived by cancer survivors and adults without a history of cancer to have been performed by their primary care providers. We analyzed data on more than 5,000 adults drawn from the 2003 Health Information National Trends Survey (HINTS), a public dataset of the National Cancer Institute. We analyzed the responses to a question that asked how frequently the respondent's primary care provider had performed the following communication activities in the past 12 months: (1) listening carefully, (2) explaining things, (3) showing respect, (4) spending enough time, and (5) involving the patient in joint decision making. In addition, we compared responses among demographic subgroups. Results showed that regardless of health status or demographic characteristics, the 2003 HINTS respondents reported less than optimal rates of their providers "always" listening carefully, explaining things, showing respect, spending enough time, and involving them in joint decision making. Being Hispanic and having no usual provider or health insurance were associated with a significantly lower frequency of reporting that providers "always" performed the five communication activities (p < .05).

Using health communication best practices to develop a web-based provider-patient communication aid: the CONNECT study

OBJECTIVE

Although there is broad consensus that careful content vetting and user testing is important in the development of technology-based educational interventions, often these steps are overlooked. This paper highlights the development of a theory-guided, web-based communication aid (CONNECT), designed to facilitate treatment decision-making among patients with advanced cancer.

METHODS

The communication aid included an on-line survey, patient skills training module and an automated physician report. Development steps included: (1) evidence-based content development; (2) usability testing; (3) pilot testing; and (4) patient utilization and satisfaction.

RESULTS

Usability testing identified some confusing directions and navigation for the on-line survey and validated the relevance of the "patient testimonials" in the skills module. Preliminary satisfaction from the implementation of the communication aid showed that 66% found the survey length reasonable and 70% found it helpful in talking with the physician. Seventy percent reported the skills module helpful and about half found it affected the consultation.

CONCLUSION

Designing patient education interventions for translation into practice requires the integration of health communication best practice including user feedback along the developmental process.

PRACTICE IMPLICATIONS

This developmental process can be translated to a broad array of community-based patient and provider educational interventions.

Breast cancer patients' narratives about positive and negative communication experiences

Health staff-patient communication is increasingly considered an important issue in cancer research. However, questionnaires addressing satisfaction with communication limit the issues patients can raise, do not address the context of communication and often show a strong positive skew in responses. Thus, qualitative studies of communication are also needed. Fifteen breast cancer patients were interviewed 3 months after finishing adjuvant treatment. They were asked to tell a 10 minute narrative and recall five experiences from treatment. Themes were extracted using categories derived from previous research while at the same time being sensitive to new elaborations and categories. The participants reported both positive and negative communication-related experiences from a wide range of treatment situations. Two major themes emerged: Information giving as professional care-giving and meeting emotional needs. The analysis suggests that appropriate information giving may have several functions, such as re-establishing the patient's future and reducing worst-case fantasies. Meeting emotional needs was seldom reported as directly talking about negative emotions, but rather through a variety of health staff behaviours. Also, the analysis points to problems in expecting or even pressurizing patients to feel and display negative emotions. The results highlight that meeting medical and emotional needs of patients may be closely intertwined in concrete treatment situations.

Exploration of communicative patterns of consultations in palliative cancer care

Building on the research conducted on institutional communication, and the analysis of actual communication taking place in clinical settings, this study describes and highlights features of palliative care consultations and focuses on the distribution of discursive space (i.e., share of words, lengths of turns), occurring topics and conversational frames. Six consultations between physicians, patients and significant others were videotaped and all participants took part in audio-taped interviews. The recordings were transcribed and analysed in regard to expectations of, the discursive space of, and topics addressed in the consultations. The distribution of the discursive space was unequal; the physicians had the greatest share of words and length of turns in all six consultations, and they mostly initiated discussion of medical issues connected to examinations and treatment, while only patients initiated the topic of the patient's future. During the consultations, institutional framing tended to dominate over client framing. There was found to be room for further study of the structure and content of palliative care consultations with emphasis on how the voice of the patient can manifest itself within the framework of the medical agenda of the consultation and its significance for palliative cancer team work.

Ethics and Patient—Provider Communication

Effective health educator—client communication processes are a prerequisite to the acquisition and appropriate application of new knowledge, to discussions that focus on treatment risks and options, and to the mediation of (a) optimal self-management practices, (b) adherence to health recommendations, (c) client satisfaction, (d) autonomous, responsible decision making, and (e) provision of supportive and helpful advice. But is there room for improvement? To provide more uniform high-quality communications to all citizens and to support the practice principles embedded in the Health Education Code of Ethics, this article outlines results of the related literature, the authors' research, and a specific post hoc analysis of a national sample that strongly suggests that much more needs to be done to ensure health providers effectively communicate health promotion messages without bias in at least five related communication domains.

Communication with breast cancer survivors

Breast cancer survivors must manage chronic side effects of original treatment. To manage these symptoms, communication must include both biomedical and contextual lifestyle factors. Sixty breast cancer survivors and 6 providers were recruited to test a conceptual model developed from uncertainty in illness theory and the dimensions of a patient-centered relationship. Visits were audio-taped, then coded using the Measure of Patient-Centered Communication (Brown, Stewart, & Ryan, 2001). Consultations were found to be 52% patient-centered. Chi-square Automatic Interaction Detection (CHAID) analysis showed that survivor self-reported fatigue level and conversation about symptoms were associated with survivor uncertainty, mood state, and survivor perception of patient-centered communication. Survivors may want to discuss persistent symptom concerns with providers, due to concerns about recurrence, and discuss lifestyle contextual concerns with others.

Communication skills training: describing a new conceptual model

Current research in communication in physician-patient consultations is multidisciplinary and multimethodological. As this research has progressed, a considerable body of evidence on the best practices in physician-patient communication has been amassed. This evidence provides a foundation for communication skills training (CST) at all levels of medical education. Although the CST literature has demonstrated that communication skills can be taught, one critique of this literature is that it is not always clear which skills are being taught and whether those skills are matched with those being assessed. The Memorial Sloan-Kettering Cancer Center Comskil Model for CST seeks to answer those critiques by explicitly defining the important components of a consultation, based on Goals, Plans, and Actions theories and sociolinguistic theory. Sequenced guidelines as a mechanism for teaching about particular communication challenges are adapted from these other methods. The authors propose that consultation communication can be guided by an overarching goal, which is achieved through the use of a set of predetermined strategies. Strategies are common in CST; however, strategies often contain embedded communication skills. These skills can exist across strategies, and the Comskil Model seeks to make them explicit in these contexts. Separate from the skills are process tasks and cognitive appraisals that need to be addressed in teaching. The authors also describe how assessment practices foster concordance between skills taught and those assessed through careful coding of trainees' communication encounters and direct feedback.

Interpersonal sensitivity, partner support, patient-physician communication, and sexual functioning in men recovering from prostate carcinoma

Prostate carcinoma (PC) is the most commonly diagnosed cancer in men. Treatments for localized PC are associated with side effects including sexual dysfunction, which has been linked to decrements in health-related quality of life and elevated distress levels. In this study, we examined the relationship between 2 personality traits, interpersonal sensitivity and lack of sociability, assessed by the Inventory of Interpersonal Problems (IIP; Pilkonis, Kim, Proietti, & Barkham, 1996) and recovery of sexual functioning in 121 men (M age = 60.6 years) recently treated with radical prostatectomy. Interpersonal sensitivity refers to the predisposition to perceive and elicit criticism and rejection from others; lack of sociability refers to chronic difficulties taking the initiative in interpersonal situations. After adjusting for relevant covariates, interpersonal sensitivity, but not sociability, was significantly associated with lower levels of sexual functioning. Patient-physician communication and partner perceived social support were explored as mediators of this relationship. Although interpersonal sensitivity was significantly associated with both poorer patient-physician communication and lower levels of partner support, the results did not support mediation. This study provides preliminary evidence that certain IIP-assessed interpersonal styles may complicate the recovery of sexual functioning after surgical treatment for PC.

Step by step development of clinical care pathways for older cancer patients: necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.

Psychosocial impact of the lack of information given at referral about familial risk for cancer

We aimed to identify patient' information and communication needs irrespective of their risk level, when they are referred for genetic risk assessment and genetic counselling for a predisposition to cancer. Semi-structured telephone interviews were conducted with a purposive sample of individuals referred to a clinical genetics unit for a risk assessment of their genetic predisposition to either breast, ovarian or colorectal cancer and stratified by their level of risk. Triangulation was achieved by focus groups conducted with specialist genetic health professionals. Twenty-three participants were interviewed pre- and post-genetic counselling or risk assessment. A further 11 completed a single interview, five pre-assessment and six post-assessment. Three focus groups were conducted with the genetic health professionals. The results showed that many participants were unaware they had been referred for genetic counselling and as a consequence they felt this caused difficulties in coping with the genetic risk information received. Health professionals corroborated these findings of people's lack of awareness about their referral. This work raises important questions about the psychosocial consequences of inadequate information provision at the point of referral by clinicians in primary and hospital-based healthcare that are responsible for referring the majority of people to clinical genetics units.

Longitudinal screening and management of fatigue, pain, and emotional distress associated with cancer therapy

GOALS OF WORK

Fatigue, pain, and emotional distress are common symptoms among patients with cancer. We sought to learn about patient perceptions of these symptoms and their treatment.

MATERIALS AND METHODS

At a baseline assessment and two monthly follow-up assessments, we asked a diverse sample of patients with solid tumor or lymphoma (N = 99) about their fatigue, pain and distress, their treatment for these symptoms, and their satisfaction with treatment via standardized questionnaires and semistructured interviews.

MAIN RESULTS

In this observational study, patients reported fatigue, pain, emotional distress, and general quality of life at expected levels. Across all assessments, at least half of our sample experienced at least some fatigue, pain, or distress. On the whole, patients and providers do communicate about these concerns, and at least 75% of patients found these discussions helpful when they occurred.

CONCLUSIONS

Improved symptom identification and communication may optimize the detection of those at risk of morbidity and decreased quality of life because of excess symptom burden.

Patient Education About Treatment in Cancer Care

An increasing number of older people are treated for cancer. Several factors, such as comorbidity and sensory deficits, occur more frequently in older patients than in younger patients. In addition, their life circumstances, values, and preferences may differ. These factors ask for tailored nurse-older patient communication. This article reviews recent literature on the specific needs of older patients with cancer in the treatment phase of the disease. No studies addressed treatment-related needs of older patients specifically. Seventeen studies controlled for age showed that many older patients want as much information on disease and treatment as possible, but they are less interested in details than younger patients. Furthermore, older patients reported less need for information on sexual consequences and psychosocial support. The results remain difficult to interpret because of variation in study designs and questionnaires. Moreover, none of the studies controlled for age-related variables. Studies that illuminate the unique needs of older patients with cancer in the treatment phase of the disease are strikingly limited given the demographics of cancer in our society. Research is needed that explicitly investigates these needs and the influence of age-related changes in cognitive, physical, and psychosocial functioning.

Oncologists’ and specialist cancer nurses’ approaches to complementary and alternative medicine and their impact on patient action

High levels of use of complementary and alternative medicine (CAM) have been consistently reported amongst cancer patients over recent years. This is occurring in the context of an apparent increase in sources of information on therapeutic alternatives and a growth in the range of those claiming professional expertise in the field. To date there has been little research on patient experience of discussions about CAM with biomedical cancer specialists in this increasingly complex social environment. This paper addresses three issues: patient experience with cancer specialists; the significance of that experience for patient engagement with CAM; and the nature and significance of inter-professional dynamics. It draws on the results of a qualitative study with cancer patients in the UK. In-depth interviews with 80 purposively sampled patients, incorporating a range of disease types and stages, were conducted. Patients reported three main types of approach by oncologists: explicit or implicit negativity; supportive ambivalence; and, pragmatic acceptance. Crucially, patients' accounts suggest that the type of approach adopted influences (though does not determine) patient action. Specialist cancer nurses emerged as potentially powerful mediators between oncologists and patients. Despite the apparent potential for influence from multiple information sources and 'experts', on the basis of this study we would argue that oncologists remain crucial to patient engagement with CAM. However, this is not to argue that the influence is a simplistic one. Where patient and medical perspectives diverge, strategic alignment with specialist nurses may help patients make choices which conflict with perceived advice.

The yin and yang of integrative clinical care, education, and research

Communication between mainstream clinician scientists and complementary therapists is often problematic, in part because of different perspectives, assumptions, and values. However, a simple conceptual model can help conventional scientists and less conventional practitioners find common ground and appreciate their unique approaches toward achieving the same goals. The model described in this article has grown out of my experience in integrating complementary therapies and approaches into clinical care, education, and research. It uses the familiar yin-yang symbol from Chinese medicine to build bridges between mainstream Western clinician-scientists and complementary therapists from other traditions. Over the past seven years, I have developed and used this model in caring for patients, teaching medical students and residents, and conducting research in conjunction with complementary clinicians. This paper describes the yin-yang model as a way to integrate and enhance the understanding of different cultures of healthcare.

A review of distress and its management in couples facing end-of-life cancer

The aim of this review paper is to (1) provide an overview of the impact of cancer on the couple, (2) to identify potential outcomes for couple's interventions targeted specifically when one spouse is facing end of life, (3) to review and critique the empirical literature on psychosocial interventions for couple's facing end of life to date, and (4) to provide direction for research in this area. Based on our review, we found that there is clear evidence of significant distress arising from the impact of terminal illness on the marital relationship, which can result in greater suffering in the last months and weeks of life. Currently, there is a very small body of evidence on the effectiveness of couple interventions for those where one is in palliative care. Future randomized controlled trials are needed to examine the impact of couple therapy adapted for couples facing the end of life, and to guide in providing information on the number of sessions and format required for this population. Outcomes, such as more effective communication, reduction in the experience of hopelessness, uncertainty, isolation, depression, anxiety, and more adaptive coping strategies should be considered.

Evaluation of a visit preparation intervention implemented in two rural, underserved counties of Northern California

OBJECTIVE

Evaluate satisfaction with visit preparation at three rural resource center sites.

METHODS

The resource centers sent eight employees and two volunteers for training at UCSF in Consultation Planning (CP). CP is a service to help patients make a list of questions before seeing their doctors. Researchers used multivariate ordered logistic regression analysis to investigate the variation in satisfaction among 99 CP Clients served by the resource centers in 2003.

RESULTS

Sixty-seven CP Clients who completed surveys were highly satisfied (mean=8.67, standard deviation (S.D.)=1.85, range=5-10). Variation in satisfaction was associated only with whether or not the CP Provider was a breast cancer survivor serving a breast patient (p=0.005). Satisfaction was not associated with CP Client demographics; type of upcoming medical visit; or CP Provider age, remuneration status, nursing background, and volume of CP Clients.

CONCLUSION

Community-based resource centers have implemented CP to the satisfaction of their clients. Further research should expand the delivery of CP to more underserved members of the community and evaluate its acceptability and impact. There may be a therapeutic alliance formed when survivors provide CP to newly diagnosed patients.

PRACTICE IMPLICATIONS

CP should be considered by patient support programs wishing to expand their client services to include visit preparation.

Quality measures for symptoms and advance care planning in cancer: a systematic review

PURPOSE

Measuring quality of care for symptom management and ascertaining patient goals offers an important step toward improving palliative cancer management. This study was designed to identify systematically the quality measures and the evidence to support their use in pain, dyspnea, depression, and advance care planning (ACP), and to identify research gaps.

METHODS

English-language documents were selected from MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO (1995 to 2005); Internet-based searches; and contact with measure developers. We used terms for each domain to select studies throughout the cancer care continuum. We included measures that expressed a normative relationship to quality, specified the target population, and specified the indicated care. Dual data review and abstraction was performed by palliative care researchers describing populations, testing, and attributes for each measure.

RESULTS

A total of 4,599 of 5,182 titles were excluded at abstract review. Of 537 remaining articles, 19 contained measures for ACP, six contained measures for depression, five contained measures for dyspnea, and 20 contained measures for pain. We identified 10 relevant measure sets that included 36 fully specified or fielded measures and 14 additional measures (16 for pain, five for dyspnea, four for depression, and 25 for ACP). Most measures were unpublished, and few had been tested in a cancer population. We were unable to describe the specifications of all measures fully and did not search for measures for pain and depression that were not cancer specific.

CONCLUSION

Measures are available for assessing quality and guiding improvement in palliative cancer care. Existing measures are weighted toward ACP, and more nonpain symptom measures are needed. Additional testing is needed before the measures are used for accountability, and basic research is required to address measurement when self-report is impaired.

People's perceptions of cancer survivability: implications for oncologists

Individuals typically overestimate survival for lung cancer and underestimate it for melanoma. However, reporting of results generally masks the extent of disagreement between people on survival rates. Most methods used to question individuals are of little use and are not comparable across studies. The topic of people's perceptions of survival for various cancers is under-researched. A clearer definition is needed of survivability, as is a standard way to measure it and then present the information. We have undertaken a review of studies reporting public perceptions of cancer survival rates and compared the results, where possible, with actual survival rates. We also investigate some potential implications of people's underestimation or overestimation of survival for screening and prevention behaviours and delineate implications for oncologists.

Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework

This paper uses the conceptual framework of Feldman-Stewart et al. to organize and review the types of research methodologies used to investigate various aspects of patient-health care professional communication in the context of cancer. Research methods employed are classified as either non-experimental or experimental. Non-experimental designs include naturalistic observational studies (e.g. participant observation, audio- or videotaping of interactions) and retrospective introspective descriptions (e.g. self-report questionnaires, qualitative interview methods). Experimental designs often involve interventions aimed at improving communication, such as physician or patient training, and the use of technology to enhance communication (e.g. audiotapes, computers). Using the conceptualization of the communication framework description, we argue that the outcome measures used in these studies address either primary goals, enabling goals, or secondary communication outcomes. Outcomes that are related to primary goals of the communication exchange include assessing the level of understanding of information conveyed, aspects of decision making, planning around treatments, or general provision of care. Outcomes related to enabling goals focus on elements that affect the ability to achieve primary goals. Outcomes secondary to the communication do not relate directly to what the communication is attempting to achieve. We conclude by identifying priority areas for further research, such as identifying the goals of both participants, understanding how particular aspects of the communication process affect their ability to achieve their goals, and examining the external environment in which communication takes place.

Wintner L, Sztankay M, Tomaszewski K, Hofmeister D, Costantini A, Bredart A, Young T, Kuljanic K, M. Tomaszewska I, Kontogianni M, Chie WC, Kullis D, Greimel E, Zarandona U. La comunicación entre el paciente oncológico y los profesionales. El cuestionario de comunicación de la EORTC

Este trabajo pretende introducir el área de la comunicación entre el paciente oncológico y los profesionales, y destacar el impacto que tiene en el paciente. Además, se presenta el cuestionario de comunicación de la EORTC. La comunicación entre el paciente y los profesionales es uno de los elementos claves del soporte que se ofrece a dichos pacientes. En dicha comunicación participan un rango importante de profesionales. Hay una necesidad de realizar más investigación sobre la comunicación. Se presentan dos modelos principales de atención al paciente: el Paternalista y el de Atención Centrada en el Paciente con cáncer. Este último lleva asociada la Comunicación Centrada en el Paciente - CCP. Se revisa la relación entre comunicación y otros PRO: Calidad de Vida, información, y Satisfacción con los Cuidados. Existen diferencias culturales en comunicación que pueden estar relacionadas con el modelo de atención al paciente. El Grupo de Calidad de Vida de la Organización Europea para la Investigación y Tratamiento del Cáncer-EORTC está desarrollando una escala de comunicación entre el paciente oncológico y los profesionales. La mayoría del contenido de dicho cuestionario se centra en las conductas de los profesionales. Los aspectos culturales tienen un papel fundamental en el desarrollo del instrumento. El cuestionario se basa en el modelo de Comunicación Centrada en el Paciente – CCP. Se presenta el cuestionario EORTC QLQ-COMU26, que consta de seis escalas y cuatro ítems individuales. Se describen las tres primeras fases que se han dado en su creación. En la actualidad su funcionamiento psicométrico se está valorando en un estudio internacional.

La revelación del diagnóstico en oncología: una investigación transcultural Brasil-España

Objetivo: examinar aspectos transculturales de la revelación del diagnóstico de cáncer en pacientes brasileños y españoles. Método: Se realizó una investigación cualitativa en la que fueron entrevistados 28 pacientes en quimioterapia (14 brasileños y 14 españoles). El análisis de contenido identificó tres ejes temáticos: 1) Cómo fue revelado el diagnóstico; 2) Contexto en que el diagnóstico fue revelado y 3) Quién reveló el diagnóstico. Resultados: existen particularidades en la manera de revelar el diagnostico entre los dos países. En Brasil aún ocurre que el enfermo puede ser derivado a un oncólogo sin una explicación satisfactoria previa sobre su estado de salud. Aunque en los dos países existan relatos de comunicación de diagnóstico en el contexto apropiado (consulta), también ha aparecido revelación de manera informal (por teléfono) sin un ambiente adecuado para que el paciente sea acogido y tenga posibilidad de expresar sus miedos y sus dudas. Conclusión: es necesario invertir en la formación profesional para mejorar la habilidad de comunicación y educación en salud para tratar pacientes con cáncer.