Why many oncologists fail to share accurate prognoses: They care deeply for their patients

Prognostic Value of Hematological Parameters in Oral Squamous Cell Carcinoma

INTRODUCTION

Oral squamous cell carcinoma (OSCC) remains a significant public health concern. The variables utilized to determine appropriate treatment for this disease also represent its most unfavorable prognostic factors, with these parameters solely determined by the neoplasm and its behavior. However, a lack of well-established indices is evident in the literature that specifically relate to the patient and indicate a worse prognosis.

OBJECTIVE

To assess the prognostic impact of hematological indices in patients with OSCC.

METHODS

This retrospective cohort study included patients with oral squamous cell carcinoma (OSCC) who underwent curative-intent treatment. Treatment encompassed surgery, followed by adjuvant therapy, as necessary. Laboratory tests were conducted immediately prior to surgery, and demographic information was obtained from medical records.

RESULTS

The cohort comprised 600 patients, with 73.5% being male subjects. Adjuvant treatment was recommended for 60.3% of patients. Throughout the follow-up period, 48.8% of participants died. Univariate analysis indicated that perineural invasion, angiolymphatic invasion, pT4 tumors, lymph node metastases, extranodal extravasation, RDW > 14.3%, NLR (neutrophil-lymphocyte ratio) > 3.38, PLR (platelet-lymphocyte ratio) > 167.3, and SII (systemic inflammatory/immune response index) > 416.1 were factors associated with increased mortality. These threshold values were established through ROC curve analysis. In the multivariate analysis, angiolymphatic invasion (HR = 1.43; 95% CI: 1.076-1.925; p = 0.014), pT4a/b tumors (HR = 1.761; 95% CI: 1.327-2.337; p < 0.001), extranodal extravasation (HR = 1.420; 95% CI: 1.047-1.926; p = 0.024), and RDW (HR = 1.541; 95% CI: 1.153-2.056; p = 0.003) were identified as independent risk factors for decreased overall survival.

CONCLUSIONS

RDW > 14.3% was proven to be a reliable parameter for assessing overall survival in patients with OSCC. Further studies are required to evaluate the clinical applicability of other hematological indices.

Maintaining High-Touch in High-Tech Digital Health Monitoring and Multi-Omics Prognostication: Ethical, Equity, and Societal Considerations in Precision Health for Palliative Care

Advances in digital health, systems biology, environmental monitoring, and artificial intelligence (AI) continue to revolutionize health care, ushering a precision health future. More than disease treatment and prevention, precision health aims at maintaining good health throughout the lifespan. However, how can precision health impact care for people with a terminal or life-limiting condition? We examine here the ethical, equity, and societal/relational implications of two precision health modalities, (1) integrated systems biology/multi-omics analysis for disease prognostication and (2) digital health technologies for health status monitoring and communication. We focus on three main ethical and societal considerations: benefits and risks associated with integration of these modalities into the palliative care system; inclusion of underrepresented and marginalized groups in technology development and deployment; and the impact of high-tech modalities on palliative care's highly personalized and "high-touch" practice. We conclude with 10 recommendations for ensuring that precision health technologies, such as multi-omics prognostication and digital health monitoring, for palliative care are developed, tested, and implemented ethically, inclusively, and equitably.

Study of Patient and Physician Attitudes Toward Automated Prognostic Models for Patients With Metastatic Cancer

PURPOSE

For patients with cancer and their doctors, prognosis is important for choosing treatments and supportive care. Oncologists' life expectancy estimates are often inaccurate, and many patients are not aware of their general prognosis. Machine learning (ML) survival models could be useful in the clinic, but there are potential concerns involving accuracy, provider training, and patient involvement. We conducted a qualitative study to learn about patient and oncologist views on potentially using a ML model for patient care.

METHODS

Patients with metastatic cancer (n = 15) and their family members (n = 5), radiation oncologists (n = 5), and medical oncologists (n = 5) were recruited from a single academic health system. Participants were shown an anonymized report from a validated ML survival model for another patient, which included a predicted survival curve and a list of variables influencing predicted survival. Semistructured interviews were conducted using a script.

RESULTS

Every physician and patient who completed their interview said that they would want the option for the model to be used in their practice or care. Physicians stated that they would use an AI prognosis model for patient triage and increasing patient understanding, but had concerns about accuracy and explainability. Patients generally said that they would trust model results completely if presented by their physician but wanted to know if the model was being used in their care. Some reacted negatively to being shown a median survival prediction.

CONCLUSION

Patients and physicians were supportive of use of the model in the clinic, but had various concerns, which should be addressed as predictive models are increasingly deployed in practice.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background: This article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for identifying hidden emotions in clinical communication. Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, introduced here: https://aquila.usm.edu/ojhe/vol17/iss1/7/.

Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions

OBJECTIVES

To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs).

METHODS

A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP.

RESULTS

At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC.

SIGNIFICANCE OF RESULTS

Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background : Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: "Why did he say that?" The article then proceeds to answer this question by showing how physicians' most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare's only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care's "Verbatim" education modules. While the need for physicians' emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care's "Verbatim" education modules for physicians-in-training. Methods : This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care's "Verbatim" education modules for identifying hidden emotions in clinical communication. Results : Using a profound personal example from the author's firsthand experience of the suggested training tool, the "Verbatim" module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion : Spiritual Care's "Verbatim" education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians' emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background: Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread conversation analysis training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for conversation analysis and emotional intelligence.   Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these conversation analysis modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

Using Process Indicators to Monitor Documentation of Patient-Centred Variables in an Integrated Oncology and Palliative Care Pathway-Results from a Cluster Randomized Trial

BACKGROUND

Despite robust evidence from randomized controlled trials (RCTs) demonstrating clinical and patient-reported benefits of integrated oncology and palliative care, the tumour-centred focus is predominant. This single-centre process evaluation monitors documentation of required patient-centred variables during an RCT.

METHODS

Performance status, patient self-reported symptoms, weight and summaries to general practitioners were assessed from June 2017 to July 2020 in three consultation types: first oncological after study inclusion and palliative and oncological consultations during chemotherapy. Descriptive statistics were used to monitor if the pre-defined program fulfilment of ≥85% documentation was reached.

RESULTS

435 consultations were monitored in 76 patients; 60.5% males, 86.8% with GI cancers; 76 (17.5%) were from the first oncological consultations, 87 (20.0%) and 272 (62.5%) from palliative or subsequent oncological consultations. Program fulfilment differed across consultation types with 94.8% in the palliative consultations (83.3-100%), relative to 65.8% (62.5-75.0%) and 69.2% (57.0-84.3%) for first and subsequent oncological consultations over time, respectively. Use of self-reported symptoms was consistently lower in the oncological consultations.

CONCLUSIONS

The documentation level of required core variables was not satisfactory, notwithstanding their high clinical relevance and continuous reminders during study. Pre-trial optimization strategies are paramount to promote integration and reduce professional and personal barriers towards a more patient-centred focus.