A pathway linking patient participation in cancer consultations to pain control

What Encourages Patients to Recommend Their Doctor After an Online Medical Consultation? The Influence of Patient-Centered Communication, Trust, and Negative Health Information Seeking Experiences

The doctor-patient relationship in China has become increasingly tense, with patients lacking trust in doctors. Meanwhile, online healthcare flourished, accelerated by the COVID-19 pandemic. This study utilized the direct and indirect pathway model of clinician-patient communication to health outcomes and online trust theory to examine the associations between online patient-centered communication (OPCC), benevolence and ability trust in doctors, negative online health information seeking experiences, and willingness to recommend doctors. The findings revealed that benevolence and ability trust mediated the relationship between OPCC and willingness to recommend doctors. Additionally, when participants had a high level of negative online health information seeking experiences, OPCC had a stronger effect on ability trust; meanwhile, the mediation effect of ability trust between the relationship of OPCC and willingness to recommend was stronger. This study also discussed theoretical and practical implications.

Linking patient-centered communication with cancer information avoidance: The mediating roles of patient trust and literacy

OBJECTIVES

This study, drawing on the pathway mediation model developed by Street and his colleagues (2009) that links communication to health outcomes, explores how patient-centered communication affects cancer information avoidance.

METHODS

Data was gathered through online access panel surveys, utilizing stratified sampling across Germany, Switzerland, the Netherlands, and Austria. The final sample included 4910 non-cancer and 414 cancer patients, all receiving healthcare from clinicians within the past year.

RESULTS

The results demonstrated that patient-centered communication is directly associated with reduced cancer information avoidance, especially among cancer patients. Additionally, this association is indirectly mediated through patient trust and healthcare literacy.

CONCLUSION

The findings provide empirical evidence that reveals the underlying mechanism linking clinician-patient communication to patient health information behavior.

PRACTICE IMPLICATIONS

The potential of clinician-patient communication in addressing health information avoidance is highlighted by these findings. Future interventions in healthcare settings should consider adopting patient-centered communication strategies. Additionally, improving patient trust and literacy levels could be effective in reducing cancer information avoidance.

Understanding the pathways linking patient-centered communication to cancer survivors' emotional health: examining the mediating roles of self-efficacy and cognitive reappraisal

PURPOSE

Many cancer survivors commonly face psychological health issues upon cancer diagnosis, both during and after treatment. Patient-centered communication can play an important role in improving health outcomes among cancer survivors across the cancer continuum. The current study examined the influence of patient-centered communication on self-efficacy in managing health, cognitive reappraisal, and emotional distress among cancer survivors.

METHODS

The analysis was conducted on a subsample of 809 cancer survivors acquired from a nationally representative 2019 Health Information National Trends Survey 5 (Cycle 3). Multivariate regression analysis was conducted to explore the pathways through which patient-centered communication can be associated with cancer survivors' emotional distress, mediated by self-efficacy and cognitive reappraisal.

RESULTS

The results indicated that effective patient-centered provider communication led to higher self-efficacy in managing health, greater involvement in cognitive reappraisal, and decreased emotional distress among cancer survivors. Additionally, the results revealed that the effect of patient-centered communication that led to decreased emotional distress was fully mediated through self-efficacy and cognitive reappraisal.

CONCLUSIONS

Although patient-centered communication positively relates to various emotional health outcomes among cancer survivors, it does not affect their emotional health directly. Self-efficacy and cognitive reappraisal play a crucial role in explaining the underlying mechanisms of such effects.

IMPLICATIONS FOR CANCER SURVIVORS

Future interventions to promote patient-centered communication in cancer care should give more emphasis to managing patients' emotions. Providers should not only recognize, elicit, and respond to patient's emotions, but also develop emotional regulation skills among patients, and improve their ability to cope with emotional distress.

The Effect of Exercise on Pain in People with Cancer: A Systematic Review with Meta-analysis

INTRODUCTION

Cancer-related pain is common and undertreated. Exercise is known to have a pain-relieving effect in non-cancer pain.

OBJECTIVES

This systematic review aimed to evaluate (1) the effect of exercise on cancer-related pain in all cancers, and (2) whether the effect of exercise differed according to exercise mode, degree of supervision, intervention duration and timing (during or after cancer treatment), pain types, measurement tool and cancer type.

METHODS

Electronic searches were undertaken in six databases to identify exercise studies evaluating pain in people with cancer, published prior to 11 January 2023. All stages of screening and data extraction were conducted independently by two authors. The Cochrane risk of bias tool for randomised trials (RoB 2) was used and overall strength of evidence was assessed using the GRADE approach. Meta-analyses were performed overall and by study design, exercise intervention and pain characteristics.

RESULTS

In total, 71 studies reported in 74 papers were eligible for inclusion. The overall meta-analysis included 5877 participants and showed reductions in pain favouring exercise (standardised mean difference - 0.45; 95% confidence interval - 0.62, - 0.28). For most (> 82%) of the subgroup analyses, the direction of effect favoured exercise compared with usual care, with effect sizes ranging from small to large (median effect size - 0.35; range - 0.03 to - 1.17). The overall strength of evidence for the effect of exercise on cancer-related pain was very low.

CONCLUSION

The findings provide support that exercise participation does not worsen cancer-related pain and that it may be beneficial. Better pain categorisation and inclusion of more diverse cancer populations in future research would improve understanding of the extent of benefit and to whom.

PROSPERO REGISTRATION NUMBER

CRD42021266826.

Health Communication Research Informs Inflammatory Bowel Disease Practice and Research: A Narrative Review

Background

In the absence of targeted empirical evidence on effective clinical communication in inflammatory bowel disease (IBD), a broad overview of existing evidence on effective communication in healthcare and available recommendations for communication in telehealth is provided and mapped onto IBD research and practice.

Methods

A narrative literature review was conducted using Pubmed and Scopus databases and snowballing literature search.

Results

Evidence-based relationship building strategies include communicating emotions, acknowledging and addressing patients' hesitancy, and ensuring continued support. A particular recommendation regarding telehealth interaction is to avoid long stretches of talk. Effective informational strategies include facilitating and supporting information exchange and considering patients' preferences in decision-making. In teleconsultations, clinicians should ask direct questions about patients' emotional state, clarify their understanding of patients' concerns and check patients' understanding, address at least one patient-reported outcome when discussing the recommended treatment, and shorten the consultation where possible. Strategies for maximizing effective clinical communication in the spoken communicative mode include using infographics and simple language, and assessing adherence at the beginning of the consultation. For teleconsultations, clinicians are advised to allow patients to explain the reason for their call at the beginning of the teleconsultation, probe additional concerns early and before ending the teleconsultation, and be mindful of technical issues such as voice delays.

Conclusions

Use of question prompt lists, decision aids, micro-lessons, and communication training interventions for clinicians could be beneficial in IBD care. Further research into the implementation of such interventions as well as clinical communication concerns specific to IBD is warranted.

The Link between Patients' Aggressive Communication and Nurses' Emotional Health Outcomes

The aggressive conduct of patients is a perennial problem that nurses face in health care. Studies have shown that such aggressiveness can be detrimental to the work and emotional wellbeing of nurses. Yet, the literature has had inconsistent findings; in some cases nurses are negatively affected by aggression, while in other cases nurses are not affected. Street and colleagues contended that such inconsistencies in research exist because social mechanisms embedded in communication are often not taken into consideration. This study adopts Street et al.'s pathways model and links patients' aggressive communication to nurses' emotional health outcomes, via the proximal outcome of communication satisfaction and the intermediate outcome of organizational identity. Results support Street et al.'s postulation and demonstrates that patients' aggressive communication does not have a direct effect on nurses' emotional health. Instead, the effect is indirect, mediated by communication satisfaction and organizational identity.

Managing uncertainty and responding to difficult emotions: Cancer patients' perspectives on clinician response during the COVID-19 pandemic

OBJECTIVE

Patients undergoing cancer treatment during the COVID-19 pandemic have experienced stress and uncertainty with respect to disruptions in cancer care and COVID-19 related risks. We examined whether clinicians' responsiveness to patients' uncertainty and difficult emotions were associated with better health and well-being.

METHODS

Patients were recruited from cancer support communities and a market research firm. Respondents assessed clinicians communication that addressed uncertainty and difficult emotions. Health status measures included mental and physical health, coping during the pandemic, and psychological distress.

RESULTS

317 respondents participated in the study. Patients' perceptions of their clinicians responsiveness to patient uncertainty and negative emotions were associated with better mental health, physical health, coping, and less psychological distress (all p-values <0.001). Respondents with greater self-efficacy and social support also reported better health.

CONCLUSION

Even when controlling for patients' personal and health-related characteristics, clinicians' communication addressing patients' uncertainty and difficult emotions predicted better health, better coping, and less psychological distress. Access to social support and self-efficacy also were associated with better health status.

PRACTICE IMPLICATIONS

Clinicians' communication focused on helping with uncertainty and difficult emotions is important to cancer patients, especially during the pandemic. Clinicians should also direct patients to resources for social support and patient empowerment.

[The management of multimorphic cancer pain, from diagnosis to treatment]

Cancer pain remains a major public health issue. Despite progress in pain medicine thanks to the interest shown in early and timely supportive care, more than half the patients managed for cancer are in pain. One of the key factors in high quality multidisciplinary management throughout the care pathway is to assess more than just pain: it is necessary to assess the patient as a whole. Understanding the complexity of cancer pain - or the various types of pain - through the innovative multimorphic cancer pain model, effectively opens up new perspectives for a targeted, personalised, and multimodal approach. The subsequent treatment strategies, whether drug-based with opioids, or interventional, are codified by guidelines based on scientific evidence for the healthcare professionals and, ultimately, patients.

Exploring the Role of Social Support in Promoting Patient Participation in Health Care among Women with Breast Cancer

Scholars have adopted Street's (2003) ecological model of communication in medical encounters to investigate the factors promoting patient participation in health care. However, factors demonstrated in the ecological model were bounded in the context of medical care primarily focusing on health care providers and patients. Social factors, such as patients' relationships and supportive communication with others outside the context of health care remain relatively unexplored. To expand the purview of our understanding of factors that influence patient participation, this research integrated social support literature into the research on physician-patient communication and proposed a model which described a process through which social support can enhance patient participation in health care. The data analyzed in this study were a part of two larger clinical trials in which 661 women with breast cancer were recruited from three cancer institutions in the United States. The results from structural equation modeling analysis from cross-sectional and longitudinal data provided strong evidence for the hypotheses predicting that perceived social support was positively associated with health information competence, which in turn fully mediated the association between social support and patient participation in health care. Theoretical and practical implications are discussed.

DISCO App: study protocol for a randomized controlled trial to test the effectiveness of a patient intervention to reduce the financial burden of cancer in a diverse patient population

Background

Financial toxicity, the material and psychological burden of the cost of treatment, affects 30–50% of people with cancer, even those with health insurance. The burden of treatment cost can affect treatment adherence and, ultimately, mortality. Financial toxicity is a health equity issue, disproportionately affecting patients who are racial/ethnic minorities, have lower incomes, and are < 65 years old. Patient education about treatment cost and patient-oncologist cost discussions are recommended as ways to address financial toxicity; however, research shows cost discussions occur infrequently (Altice et al. J Natl Cancer Inst 109:djw205, 2017; Schnipper et al. J Clin Oncol 34:2925-34, 2016; Zafar et al. Oncologist 18:381-90, 2013; American Cancer Society Cancer Action Network 2010). Our overall goal is to address the burden of financial toxicity and work toward health equity through a tailorable education and communication intervention, the DISCO App. The aim of this longitudinal randomized controlled trial is to test the effectiveness of the DISCO App on the outcomes in a population of economically and racially/ethnically diverse cancer patients from all age groups.

Methods

Patients diagnosed with breast, lung, colorectal, or prostate cancer at a NCI-designated comprehensive cancer center in Detroit, MI, will be randomized to one of three study arms: one usual care arm (arm 1) and two intervention arms (arms 2 and 3). All intervention patients (arms 2 and 3) will receive the DISCO App before the second interaction with their oncologist, and patients in arm 3 will receive an intervention booster. The DISCO App, presented on an iPad, includes an educational video about treatment costs, ways to manage them, and the importance of discussing them with oncologists. Patients enter socio-demographic information (e.g., employment, insurance status) and indicate their financial concerns. They then receive a tailored list of questions to consider asking their oncologist. All patients will have up to two interactions with their oncologist video recorded and complete measures at baseline, after the recorded interactions and at 1, 3, 6, and 12 months after the second interaction. Outcome measures will assess discussions of cost, communication quality, knowledge of treatment costs, self-efficacy for treatment cost management, referrals for support, short- and longer-term financial toxicity, and treatment adherence.

Discussion

If effective, this intervention will improve awareness of and discussions of treatment cost and alleviate the burden of financial toxicity. It may be especially helpful to groups disproportionately affected by financial toxicity, helping to achieve health equity.

Trial registration

ClinicalTrials.gov NCT04766190. Registered on February 23, 2021

Patient-centered communication and emotional well-being in the era of medical violence in China

The past decade has witnessed an increasing number of patient assaults on doctors in China. Patient-centered communication (PCC) may be one way to mitigate this problem. This study examined the effects of PCC and patient trust on emotional health outcome, especially how patients' attitude toward medical violence affected this relationship. Data were drawn from the China Governance and Public Policy Survey administered in 2017 with a sample size of 3784. The results showed that PCC had no direct effect on emotional well-being. Instead, patient trust completely mediated this path. Also, patients' attitude toward medical violence increased the indirect effect of PCC on emotional well-being, suggesting a moderated mediation model. We call for education programs to promote PCC for both providers and patients, mass media campaigns to condemn violence against doctors and stricter law enforcement to stop medical violence.

Characterizing patient-oncologist communication in genomic tumor testing: The 21-gene recurrence score as an exemplar

OBJECTIVE

Women with early-stage, ER + breast cancer are recommend to receive genomic profiling tests, such as the 21-gene Recurrence Score (RS) test, to guide treatment decisions. We examined test- and treatment-related information discussed and the associations between RS categories and aspects of communication during patient-oncologist clinical encounters.

METHODS

As part of a larger trial, clinical encounters (N = 46) were audiorecorded and coded for 1) RS- and treatment-related information, 2) shared decision making, 3) patient active participation, and 4) oncologist patient-centered communication. We examined differences by RS category using mixed models, adjusting for nesting within oncologist.

RESULTS

Patients with a high RS were more likely to receive a chemotherapy recommendation (p < .01), hear about the risks/side effects of chemotherapy (p < .01), and offer their preferences (p = .02) than those with intermediate or low RS. Elements of shared decision making increased with RS. Oncologist patient-centered communication (M = 4.09/5, SD = .25) and patient active participation (M = 3.5/4, SD = 1.0) were high across RS.

CONCLUSION

Findings suggest that disease severity, rather than clinical uncertainty, impact treatment recommendations and shared decision making.

PRACTICE IMPLICATIONS

Oncologists adjust test- and treatment-related information and shared decision making by disease severity. This information provides a framework to inform decision making in complex cancer and genomics settings.

Social inequalities in supportive care needs and quality of patient-centered care of cancer patients in Mexico

PURPOSE

To evaluate educational and health insurance-related inequalities in supportive care (SC) needs and quality of patient-centered care (PCC) for cancer patients in Mexico.

METHODS

We conducted a cross-sectional survey in one Mexican Institute of Social Security (IMSS) and one Ministry of Health (MoH) oncology hospital in Mexico City. Formal labor market workers and their families have access to social health insurance that IMSS provides, while unemployed and informal workers receive care at the MoH. The study population comprised breast, colorectal, prostate, and hematologic cancer patients, aged ≥ 18 years, who attended outpatient consultations. Patients responded a short-form SC-needs questionnaire and a quality of PCC questionnaire. We used multiple logistic regression models to determine the independent association between educational attainment and high SC-needs and quality of PCC after controlling for sociodemographic and clinical covariates.

RESULTS

We included 1058 IMSS and 606 MoH cancer patients. MoH patients perceived higher SC-needs and lower quality of PCC than IMSS patients. MoH patients with low education had a greater probability of high psychological and health system SC needs and lower likelihood of being informed for treatment decision-making and care for their biopsychosocial needs. IMSS patients with low educational levels had lower probability of receiving timely care and clarity of information than those with high education. Receiving high-quality PCC was associated with decreased SC needs.

CONCLUSION

Uninsured cancer patients with low educational attainment have higher SC-needs and receive lower quality of PCC than their counterparts. Health services should face these challenges to reduce inequalities in Mexico.

The Communicative Ecology of Chinese Patients' Experiences with Health Care

Patient satisfaction and trust are important intermediate outcomes along pathways linking clinician-patient communication to improve well-being, but they are difficult to achieve in Chinese health care. Problematic physician-patient interactions, questionable health-care organizational practices, and media coverage of medical scandals may have contributed to this problem. Nevertheless, there isscant literature documenting reasons underlying dissatisfaction with Chinese health care. Using Street's ecological model of communication in medical encounters as a conceptual framework, this study explores how media and organizational factors affect Chinese patients' satisfaction and trust both directly and as mediated by the quality of patients' past communication experiences with clinicians. A survey was conducted among 257 Ob-gyn patients in a top-tier hospital in Sichuan, China. The results show that several organizational and media factors, along with patients' experiences with physician communication, predict patient satisfaction and trust. Perceptions of physician communication mediated some of the relationships between organizational and media factors with outcomes. Theoretical and practical implications are discussed, particularly with respect to improving health-care services in China.

The influence of a question prompt list on patient-oncologist information exchange in an African-American population

OBJECTIVES

Question Prompt Lists (QPL) increase patient active participation in oncology interactions, but questions remain regarding how QPLs influence patient-oncologist information exchange. We examined how a QPL influenced information exchange during oncology interactions with African-American patients.

METHODS

Data were self-reports and video recordings from a parent study testing the effects of a QPL in the outpatient clinics of two urban cancer hospitals. In this secondary analysis, we investigated which QPL questions patients identified as ones they wanted to ask their oncologists, how frequently patients/companions used patient active participation statements to seek information related to each QPL question, whether oncologists provided QPL-related information unprompted or prompted by patients/companions, and how frequently patients' QPL-related information needs were addressed or unaddressed.

RESULTS

The QPL influenced information exchange by increasing patients' and companions' (if present) prompting for QPL-related information from their oncologists. Patients/companions most often prompted for QPL-related information about side effects and patient experience.

CONCLUSION

This study builds on prior research on QPL interventions by expanding the object of study to information exchange and by analyzing patients' information needs.

PRACTICE IMPLICATIONS

This research demonstrates that a QPL supports patient/companion participation in oncology consultations by making information exchange more interactive.

Assessing cancer pain-the first step toward improving patients' quality of life

PURPOSE

Numerous studies on cancer patients have shown that cancer pain still remains underestimated, poorly assessed, and under-treated. Pain relief should be considered as early as possible within personalized care and as an integral part of quality healthcare in many countries. Nevertheless, personalized care is still insufficiently taken into consideration, partly due to improper or incomplete assessment of cancer pain. The objective of this article is to propose a practical approach to this complex assessment, as the first step to improving patients' quality of life.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Assessment of cancer pain means evaluating the pain intensity over time, the dimensions of pain (sensory-discriminative, cognitive, emotional, and behavioral), the pathophysiological nature of pain (neuropathic, nociceptive, and nociplastic), the etiology, and the patient's perception (diffuse, localized, global). Cancer patients may have simple or multiple forms of pain (mixed, overlapped, combined, and associated). Furthermore, with the use of new specific therapies, the symptomatology of pain is also changing, and certain cancers are becoming chronic. Thus, cancer pain is an archetype of multimorphic pain, and its dynamic assessments (regular and repeated) require a multimodal and targeted approach in order to offer personalized pain management. Multimodal pain treatment must be adapted to the elements that disrupt cancer pain, to the patient's cancer and to the specific treatments.

CONCLUSIONS

The dynamic assessments of pain demand the simplest, and the most complete possible procedure, to avoid feasibility problems or self-/hetero-assessment excesses that might lead to less precise and less reliable results. Multimodal and interdisciplinary approaches are being developed, making it possible to optimize cancer pain management.

Strategies of complementary and integrative therapies in cancer-related pain-attaining exhaustive cancer pain management

PURPOSE

Complementary integrative therapies (CITs) correspond to growing demand in patients with cancer-related pain. This demand needs to be considered alongside pharmaceutical and/or interventional therapies. CITs can be used to cover certain specific pain-related characteristics. The objective of this review is to present the options for CITs that could be used within dynamic, multidisciplinary, and personalized management, leading to an integrative oncology approach.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Most CITs only showed trends in efficacy as cancer pain was mainly a secondary endpoint, or populations were restricted. Physical therapy has demonstrated efficacy in motion and pain, in some specific cancers (head and neck or breast cancers) or in treatments sequelae (lymphedema). In cancer survivors, higher levels of physical activity decrease pain intensity. Due to the multimorphism of cancer pain, certain mind-body therapies acting on anxiety, stress, depression, or mood disturbances (such as massage, acupuncture, healing touch, hypnosis, and music therapy) are efficient on cancer pain. Other mind-body therapies have shown trends in reducing the severity of cancer pain and improving other parameters, and they include education (with coping skills training), yoga, tai chi/qigong, guided imagery, virtual reality, and cognitive-behavioral therapy alone or combined. The outcome sustainability of most CITs is still questioned.

CONCLUSIONS

High-quality clinical trials should be conducted with CITs, as their efficacy on pain is mainly based on efficacy trends in pain severity, professional judgment, and patient preferences. Finally, the implementation of CITs requires an interdisciplinary team approach to offer optimal, personalized, cancer pain management.

Exome sequencing disclosures in pediatric cancer care: Patterns of communication among oncologists, genetic counselors, and parents

OBJECTIVE

To examine communication patterns and behaviors during disclosure of exome sequencing (ES) results to parents of pediatric cancer patients, and describe common themes in parental communication.

METHODS

Using mixed methods, we analyzed transcripts of sessions where parents of pediatric cancer patients received ES results from an oncologist and genetic counselor. Seventy-six transcripts were analyzed for frequency of clinician information-giving, partnering-supportive talk, and active parent participation. A subset of 40 transcripts were analyzed using thematic content analysis.

RESULTS

Disclosures consisted mostly of clinician talk (84% of total talk), which was focused on providing information (62% of clinicians' utterances) with occasional partnering-supportive talk (7% of clinicians' utterances). Most parents assumed a passive, listening role (16% of total talk). Themes in parental communication included expressing relief and the significance of an answer, concern about sharing results and responsibility for inheritance, and seeking clarification of health implications of results.

CONCLUSION

Our finding of low levels of active parent participation during ES disclosures highlights the need to improve patient/parent engagement and understanding in a genetic setting.

PRACTICE IMPLICATIONS

Clinician communication strategies that could encourage parent participation and understanding include checking for parent understanding, partnership-building, and tailoring ES discussions to address parent concerns and preferences.

Pathways Linking Patient-Centered Communication to Health Improvement: A Longitudinal Study in China

The Chinese health care system has suffered from severe tension between patients and doctors during the past decade. Patient-centered communication (PCC) may play a significant role in mitigating this problem. With a general basis of the pathway model linking communication to health, this paper illustrates social mechanisms that underlie how PCC improves health outcomes in China. Using three-wave panel data collected in China, the results showed that PCC failed to directly influence health. Instead, PCC at Wave 1 predicted patient satisfaction and patient trust at Wave 2, which in turn enhanced self-reported health outcomes at Wave 3. In addition, bonding social capital positively moderated the effect of PCC on patient trust.

The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

BACKGROUND

Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.

OBJECTIVE

To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.

DESIGN

Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions.

PARTICIPANTS

Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white.

MAIN MEASURES

Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment.

KEY RESULTS

SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81).

CONCLUSIONS

Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain.

TRIAL REGISTRATION

NCT01501006.

Treatment of Pain in Cancer: Towards Personalised Medicine

Despite increased attention to cancer pain, pain prevalence in patients with cancer has not improved over the last decade and one third of cancer patients on anticancer therapy and half of patients with advanced disease still suffer from moderate to severe pain. In this review, we explore the possible reasons for the ongoing high prevalence of cancer pain and discuss possible future directions for improvement in personalised pain management. Among possible reasons for the lack of improvement are: Barriers for patients to discuss pain with clinicians spontaneously; pain measurement instruments are not routinely used in daily practice; limited knowledge concerning the assessment of undertreatment; changes in patients’ characteristics, including the ageing of the population; lack of significant improvement in the treatment of neuropathic pain; limitations of pharmacological treatment and lack of evidence-based nonpharmacological treatment strategies. In order to improve cancer pain treatment, we recommend: (1) Physicians proactively ask about pain and measure pain using assessment instruments; (2) the development of an optimal tool measuring undertreatment; (3) educational interventions to improve health care workers’ skills in pain management; (4) the development of more effective and personalised pharmacological and nonpharmacological pain treatment.

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

OBJECTIVE

Communication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.

METHODS

Participants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.

RESULTS

The intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.

CONCLUSION

This QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.

PRACTICE IMPLICATIONS

This QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.

Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer

BACKGROUND

Clinical trials that study cancer are essential for testing the safety and effectiveness of promising treatments, but most people with cancer never enroll in a clinical trial - a challenge exemplified in racial and ethnic minorities. Underenrollment of racial and ethnic minorities reduces the generalizability of research findings and represents a disparity in access to high-quality health care.

METHODS

Using a multilevel model as a framework, potential barriers to trial enrollment of racial and ethnic minorities were identified at system, individual, and interpersonal levels. Exactly how each level directly or indirectly contributes to doctor-patient communication was also reviewed. Selected examples of implemented interventions are included to help address these barriers. We then propose our own evidence-based intervention addressing barriers at the individual and interpersonal levels.

RESULTS

Barriers to enrolling a diverse population of patients in clinical trials are complex and multilevel. Interventions focused at each level have been relatively successful, but multilevel interventions have the greatest potential for success.

CONCLUSION

To increase the enrollment of racial and ethnic minorities in clinical trials, future interventions should address barriers at multiple levels.

Patient-provider communication about the emotional cues and concerns of adolescent and young adult patients and their family members when receiving a diagnosis of cancer

OBJECTIVE

This study aimed to examine how emotional cues/concerns are expressed and responded to in medical consultations with adolescent and young adults (AYA), an understudied patient group, at the time of cancer diagnosis.

METHODS

Nine consultations in which AYA patients aged 12-25 years were informed about their cancer diagnosis and treatment plans were audio recorded. Expressions of emotional cues/concerns and physicians' responses were identified and coded using The Verona Coding Definitions of Emotional Sequences (VR-CoDES).

RESULTS

A total of 135 emotional cues/concerns (range: 2-26, median: 13) were identified. Cues or concerns that were expressed by patients and relatives following questions from physicians were more often explicit than patient-initiated cues/concerns. Questions about medical and practical issues could often be understood as ways of expressing emotional cues. When patients or relatives expressed less explicit verbal cues about underlying concerns, physicians often responded by presenting medical information without commenting on the emotional aspect indicated by the cue.

CONCLUSION

The communication was dominated by information-giving, but the questions from patients and relatives and their responses to the information often had emotional connotations.

PRACTICE IMPLICATIONS

Patients' requests for information may include an emotional aspect. These preliminary findings should be tested in a larger sample.

Development of the Chronic Pain Coding System (CPCS) for Characterizing Patient-Clinician Discussions About Chronic Pain and Opioids

OBJECTIVE

To describe the development and initial application of the Chronic Pain Coding System.

DESIGN

Secondary analysis of data from a randomized clinical trial.

SETTING

Six primary care clinics in northern California.

SUBJECTS

Forty-five primary care visits involving 33 clinicians and 45 patients on opioids for chronic noncancer pain.

METHODS

The authors developed a structured coding system to accurately and objectively characterize discussions about pain and opioids. Two coders applied the final system to visit transcripts. Intercoder agreement for major coding categories was moderate to substantial (kappa = 0.5-0.7). Mixed effects regression was used to test six hypotheses to assess preliminary construct validity.

RESULTS

Greater baseline pain interference was associated with longer pain discussions (P = 0.007) and more patient requests for clinician action (P = 0.02) but not more frequent negative patient evaluations of pain (P = 0.15). Greater clinician-reported visit difficulty was associated with more frequent disagreements with clinician recommendations (P = 0.003) and longer discussions of opioid risks (P = 0.049) but not more frequent requests for clinician action (P = 0.11). Rates of agreement versus disagreement with patient requests and clinician recommendations were similar for opioid-related and non-opioid-related utterances.

CONCLUSIONS

This coding system appears to be a reliable and valid tool for characterizing patient-clinician communication about opioids and chronic pain during clinic visits. Objective data on how patients and clinicians discuss chronic pain and opioids are necessary to identify communication patterns and strategies for improving the quality and productivity of discussions about chronic pain that may lead to more effective pain management and reduce inappropriate opioid prescribing.

Oncology healthcare professionals’ perspectives on the psychosocial support needs of cancer patients during oncology treatment

This study explored oncology healthcare professionals’ perspectives on the psychosocial support needs of diverse cancer patients during oncology treatment. Six themes were identified using thematic analysis. Healthcare professionals highlighted the importance of their sensitivity, respect and emotional tact during appointments in order to effectively identify and meet the needs of oncology patients. Participants also emphasised the importance of building rapport that recognises patients as people. Patients’ acceptance of treatment-related distress and uncertainty was described as required for uptake of available psychosocial supportive services. We offer some practical implications that may help improve cancer patients’ experiences during oncology treatment.

Adherence to Analgesics for Cancer Pain: A Comparative Study of African Americans and Whites Using an Electronic Monitoring Device

Despite well-documented disparities in cancer pain outcomes among African Americans, surprisingly little research exists on adherence to analgesia for cancer pain in this group. We compared analgesic adherence for cancer-related pain over a 3-month period between African Americans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were recruited from outpatient medical oncology clinics of an academic medical center in Philadelphia (≥18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain, and at least 1 prescription of oral around-the-clock analgesic). African Americans reported significantly greater cancer pain (P < .001), were less likely than whites to have a prescription of long-acting opioids (P < .001), and were more likely to have a negative Pain Management Index (P < .001). There were considerable differences between African Americans and whites in the overall MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53% vs 74%, P < .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34% (for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic adherence for African Americans but not for whites. Perspective: Despite evidence of disparities in cancer pain outcomes among African Americans, surprisingly little research exists on African Americans' adherence to analgesia for cancer pain. This prospective study uses objective measures to compare adherence to prescribed pain medications between African American and white patients with cancer pain.

Undertreatment of caner pain

Pain is a burdensome symptom that can commonly exist chronically along the cancer trajectory. Uncontrolled pain will impact on cancer patients' quality of life, even further negatively affect cancer survivors' employment. Based on systemic reviews of studies for past 10 years, the paper reported that although there is enormous advancement on the knowledge of cancer pain and pain management, studies still documented undertreatment of cancer pain globally. Additionally, pain distress a significant portion of cancer survivors. The pain in cancer survivors distinct from the pain related with cancer, instead emphasize on pain related with cancer treatment, such as neuropathic pain, muscular syndrome. Evidence-based pain management with common pain problems in cancer survivors is lacking. Further studies are needed to understand the pain in cancer survivors and to develop effective strategies in helping cancer survivors to manage their pain.

Therapeutic Education in Improving Cancer Pain Management: A Synthesis of Available Studies

This literature review aims to synthesize available studies and to update findings in order to obtain a current, comprehensive estimate of the benefits of pain education. Forty-four original articles obtained from the PubMed database were analyzed to investigate which protocols could be most effective in improving pain management. Recent studies indicate a growing interest in evaluating patients' skills and attitudes; these include satisfaction with cancer pain treatment, patient-reported improvement, and patient participation-all of which could be dependable benchmarks for evaluating the effectiveness of educational programs. Besides pain measurement, recent studies advance support for the importance of assessing newly developed outcome criteria. In this sense, patients' active participation and decision making in their pain management are probably the most relevant goals of pain education.