Treatment decision-making in breast cancer: the patient-doctor relationship. Endoscopy. 2008;112 Suppl 1:5-13. [PMID: 738222 DOI: 10.1007/s10549-008-0077-3]

Trends in Presentation, Management, and Survival of Women With Breast Cancer in a Multiethnic, Middle-Income Asian Setting

PURPOSE

Granular data on breast cancer (BC) are pertinent for surveillance, planning, and monitoring of cancer care delivery. We determined the trends in clinical presentation, management, and survival of women with BC in a multiethnic middle-income Asian setting over 15 years.

METHODS

Data of 7,478 Malaysian women newly diagnosed with invasive BC between 2005 and 2019 from three hospital-based cancer registries were included. Trends in demographic, tumor, and treatment characteristics were compared across period 1 (P1): 2005-2009, period 2 (P2): 2010-2014, and period 3 (P3): 2015-2019. Overall survival and net survival were determined.

RESULTS

More women in P3 than P1 were older than 60 years at diagnosis. Only a marginal increase in proportion of women with stage I disease was observed (23.7% v 27.2% in P1 and P3, respectively, P = .004). Nonetheless, patients were increasingly presenting with smaller tumors, fewer axillary node involvement, well-differentiated tumors, and hormone receptor expression in recent times. Proportion of women with human epidermal growth factor receptor 2 (HER2)-overexpressed tumors significantly decreased. Among indicated patients, receipt of anticancer therapies was somewhat similar over the calendar periods, except for neoadjuvant chemotherapy and anti-HER2 therapy, where increases in administration were noted. Significant improvements in survival were observed over the 15 years, particularly for HER2-overexpressed BCs.

CONCLUSION

Although the improvements in BC survival that we have observed validate ongoing cancer control efforts and treatment advances, study findings suggest that more could be done for earlier detection and improved access to effective therapies in our settings.

Concerns raised by people treated for head and neck cancer: a secondary analysis of audiotaped consultations in a health services follow-up clinic

PURPOSE

People treated for head and neck cancer (HNC) face various barriers in communicating concerns with consultants. Our aim was to investigate the number of concerns raised between patients using the Patient Concerns Inventory (PCI) and those who did not. The PCI is a 57-item prompt list used in routine HNC follow-up clinics. Additionally, we aimed to examine whether who initiated the concerns differed between groups and the factors that may predict this initiation.

METHODS

Secondary data analysis included 67 participants across 15 HNC consultants from specialist cancer centres in Liverpool and Leeds. Seven consultants utilised the PCI and eight did not, assigned by preferential and random assignment.

RESULTS

Patients in the PCI group raised on average 2.5 more concerns than patients in the non-PCI group (p < .001). There was no significant relationship between group and who initiated the first concern (p = .28). A mixed-effects logistic regression was found to significantly predict who initiated the first concern in consultations (p < .05).

DISCUSSION

The number of concerns raised by patients increased when the PCI was introduced pre-HNC consultation. A number of factors were shown to predict the number of concerns raised in consultations by both patient and consultant. As concerns may not be raised further following the concern mentioned, we propose that the discussion of concerns needs to be maintained by the clinician throughout the consultation and not solely at the start.

CONCLUSION

The PCI promoted the sharing of concerns in follow-up consultations between patient and consultant.

Attitudes of medical students in Khartoum, Sudan towards the doctor-patient relationship: a cross-sectional study

Background/Objectives

The doctor-patient relationship is essential to the delivery of high-quality medical care. A strong doctor-patient relationship that improves patient outcomes and satisfaction depends on effective communication. The purpose of this study was to assess medical students' attitudes toward the doctor-patient relationship during their clinical years at the University of Khartoum. We also looked at how gender and study year affected patient-centeredness.

Participants/Setting

The study was conducted on medical students in their clinical years from December 2020 to March 2021. Students were selected from years 3 to 6. A total of 353 medical students constituted the study sample.

Design

The cross-sectional study utilized the Patient Practitioner Orientation Scale (PPOS) for the measurement of student attitudes towards the doctor-patient relationship. PPOS scores are calculated as a mean score that ranges from 1 (indicating doctor or disease-centered inclinations) to 6 (indicating patient-centered or egalitarian inclinations). Medical students' demographic data was collected, including their gender, age and study year.

Results

A total of 313 students completed the survey (response rate: 89%). The average total PPOS score and the scores for the caring and sharing subscales for the entire cohort were 4.08 ± 0.53, 4.43 ± 0.58, and 3.72 ± 0.72, respectively. Female gender was significantly associated with more patient-centered attitudes (p < 0.001). When compared to the start of their clinical curriculum, students' attitudes were significantly more patient-centered by the conclusion of their studies (p < 0.001).

Conclusion

A satisfactory level of patient-centeredness was demonstrated by medical students at the University of Khartoum, and gender had an impact on this quality. Additional consideration should be given to the finding that students' orientations were more patient-centered in the caring dimension and less so in the sharing one. Once addressed, improvements in that area could create an environment that enhances attitudes among students in the sharing domain, with great potential gains to patients.

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors

Purpose

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.

Methods

We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.

Results

During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.

Conclusions

Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06752-8.

Progression-free survival and quality of life in metastatic breast cancer: The patient perspective

Introduction

Objective

Materials and methods

Results

Conclusion

•

Overall survival benefit combined with good QoL are the most important endpoints for mBC patients.

•

Time without disease progression is meaningful to patients when coupled with no worsening in or improvements in QoL.

•

Quality of life is highly individual and evolves throughout the treatment journey.

•

Surrogate endpoints are confusing; more patient-centered language is needed.

•

Healthcare professionals should account for disease and psychological well-being.

Development of Japanese Versions of the Control Preferences Scale and Information Needs Questionnaire: Role of Decision-Making and Information Needs for Japanese Breast Cancer Patients

PURPOSE

The importance of shared decision-making (SDM) between physicians and patients is increasingly recognized. In Japan, patients have shown more willingness to participate in treatment if medical professionals provide sufficient information; however, relationships between physicians and patients have traditionally been asymmetric, with patients accepting information from physicians without discussion. To explore the benefits of SDM in cancer treatment, including confidence in treatment decisions, satisfaction with treatment, and trust in healthcare providers, this study developed Japanese versions of the Control Preference Scale (CPS) and Information Needs Questionnaire (INQ).

PATIENTS AND METHODS

Reliability and validity of the CPS and INQ were tested with 49 breast cancer patients.

RESULTS

The CPS showed good test-retest reliability (kappa coefficient: 0.61, weighted kappa coefficient: 0.61, Kendall's tau coefficient: 0.61) and acceptable criterion validity. The INQ showed adequate consistency; the mean number of circular triads and coefficient of consistency were 3 (range 0-19) and 0.9 (range 0.37-1), respectively. Using the CPS and INQ to identify patients' roles in decision-making and information needs, results further suggested that breast cancer patients in Japan want to participate in SDM. Medical issues, including disease spread and cure, were found to be of high interest, while social and psychological issues, including sexual attractiveness, genetic risk, and family impact, tended to be low.

CONCLUSION

The Japanese CPS and INQ can be used to assess patients' needs to improve care. Further, as patients' information needs change along the care trajectory, these tools should be used throughout treatment.

Do You Transfer Your Skills? From Sports to Health Management in Cancer Patients

Skill transfer is a process where personal cognitive and behavioral abilities are applied to contexts that are different from the one in which they were originally learned. Literature demonstrates that skill transferability is possible: for example, people can apply skills learned in sports to other life-domains (such as school, work, or health management) with the aim to improve individual characteristics and reach personal goals. To do this, several factors, such as positive communication, adequate context, a person-centered perspective, and specific strategies, are necessary. On the basis of this, the aim of this contribution is explore the relationship between sports and health management skills to enhance the coach/athlete as well as the patient/physician relationships. Useful strategies for skill transfer from sports to cancer management are shown.

Defining the patient experience in medical oncology

PURPOSE

Higher patient satisfaction is associated with improved health outcomes, treatment adherence, and quality of life. The goal of this study was to explore oncology patients' perceptions on their hospital experience, focusing on the quality of care in medical oncology.

METHODS

A qualitative and quantitative study design was implemented with a sample of 58 patients at Smilow Yale New Haven Hospital. Data were collected from patient interviews and observation of rounds.

RESULTS

Two themes emerged: hospital experience and physician communication skills. Within hospital experience, subthemes identified include: attended to (49%), facility/staff (35%), nurses (33%), long wait time (29%), doctors (20%), coordination of care (18%), unnecessary medical procedures (10%), medications (6%), night awakenings (4%), pain (4%), not getting better (4%), and decreased mobility (2%). Within physician communication skills, subthemes identified include: involving the patient and/or family in the care process (41%), method of information sharing (18%), lack of coordination of care (15%), use of medical jargon (10%), attending to patient's needs (8%), and lack of patient's perspective (8%). Patients reported that effective engagement of patients in the care process and attending to patient-specific needs were desired qualities in their hospital experience as well as patient-centered communication with their physician. The quantitative data supported qualitative results with 72% of patients giving the highest score in overall satisfaction with their patient experience.

CONCLUSION

Physician attentiveness or lack thereof is a defining aspect of the quality of patient experience and physician communication. The results are intended to inform clinical and operational interventions that care providers might incorporate into practice.

Health care professionals' experiences and enactment of person-centered care at a multidisciplinary outpatient specialty clinic

INTRODUCTION

Person-centered care (PCC) appears particularly suitable for patients with complex diseases and in multidisciplinary care. However, previous research tends to focus on each profession and condition separately.

PURPOSE

We studied how health care professionals (HCPs) understand PCC, and whether their clinical practice is aligned with their theoretical understanding, when starting clinical practice at a novel multidisciplinary clinic.

METHODS

In total, 16 semi-structured interviews with HCPs and 31 non-participatory observations of outpatient meetings and other activities at the clinic such as team meetings were conducted at a multidisciplinary, integrated outpatient clinic in Sweden. All patients had simultaneous diabetes mellitus, chronic kidney disease and established cardiovascular disease. The clinic employed a PCC approach. Data were analyzed using an inductive thematic approach.

RESULTS

Two key findings emerged. First, PCC requires a holistic view of the patient at all times during care, with everything focused on the patient. This requires that the HCPs know the patient well enough as an individual to be able to tailor the care together with them. Second, working with a PCC philosophy leads to transformed roles for HCPs in patient meetings, with more active involvement by the patient and often also their next of kin. The observations, in comparison with the interviews, showed that not all HCPs applied their views on PCC in patient meetings. Observations showed that some patient meetings were less person-centered than others, potentially due to stress or lack of time.

CONCLUSION

PCC require HCPs to have a holistic view of the patients and a deeper understanding of their situation, as individuals. Working with PCC also leads to a more coaching, supportive role of the HCPs.

Patient Involvement in Care and Breast Cancer Patients’ Quality of Life- a Structural Equation Modeling (SEM) Approach

In cancer patients, improving the quality of life is a basic goal of treatment, with the patient – physician relationship as a major factor. Therefore the aim of this structural equation modeling study was to analyze the influence of patient involvement in care on quality of life in 411 breast cancer patients undergoing outpatient chemotherapy and radiotherapy. Two questionnaires were used: 1-patient-physician questionnaire, 2-EORTC QLQC-30 (to measure QOL). The structural equation model exhibited an excellent data fit (Chi-Square= 31.04 / RMSEA= 0.042), T-values for all paths with the exception of that between patient satisfaction and emotional- cognitive function, were significant. According to the findings, various aspects of the physician-patient relationship are significantly and positively associated with quality of life and increasing patient involvement in care by increasing trust and satisfaction, was associated with marked improvement. The findings of this study emphasized the importance of an effective relationship between doctor and patient as a contributing factor for improving the quality of life. Therefore it is suggested that policymakers and decision-makers active in strategic planning for the health system and physicians responsible for treatment pay more attention to developing and improving relationships with patients as an approach to improving patient outcomes, particularly with reference to quality of life.

Understanding Breast Cancer Knowledge and Barriers to Treatment Adherence: A Qualitative Study Among Breast Cancer Survivors

Disparities in breast cancer treatment receipt are common and multifactorial. Data are limited on how knowledge about one's breast cancer and understanding treatment rationales may impact treatment completion. In this qualitative analysis, we explored barriers to care with a focus on knowledge. We conducted 18 in-depth interviews with women from diverse socioeconomic backgrounds who were treated at Dana-Farber Cancer Institute (n = 12; Boston, MA) and Columbia University Medical Center (n = 6; New York, NY) and had undergone neo/adjuvant breast cancer treatment within the prior 3 years. Interviews focused on treatments received, adherence, barriers experienced, and questions related to breast cancer knowledge and treatment rationales. We analyzed transcribed interview recordings in N'Vivo using a two-stage coding process that allowed for both preconfigured and emergent themes. Answers for breast cancer knowledge were confirmed using medical records. In our analysis, over one-third of women reported incomplete therapy, including never initiating treatment, stopping treatment prematurely, or missing/delaying treatments due to logistical reasons (childcare, transportation) or patient preferences. Others reported treatment modifications because of provider recommendations. Nearly all women were able to accurately describe the rationale for recommended treatments. Among 17 women for whom medical records were available, women correctly reported 18–71% of their tumor characteristics; incorrect reporting was not consistently associated with treatment incompletion. In conclusion, logistical issues and patient preferences were the main reasons for incomplete therapy in our study. Understanding of treatment rationale was high, but breast cancer knowledge was variable. Further assessment of how knowledge may impact cancer care is warranted.

Patient satisfaction with a rapid diagnosis of suspicious breast lesions: Association with distress and anxiety

Few studies have explored with standard measures patient satisfaction with care at the time of the diagnosis through rapid diagnostic pathways. This study aimed to assess satisfaction levels at the time of the diagnosis in a One-Stop Breast Unit and to examine associations with psychological states. An anonymous cross-sectional survey was conducted at a single center's One-Stop Breast Unit, to assess patient satisfaction regarding several aspects of the Unit. Two days after the diagnosis, 113 participants completed self-reported questionnaires evaluating satisfaction (Out-Patsat35), anxiety (State Anxiety Inventory), and psychological distress (Distress Thermometer). Overall, patients were very satisfied (80.7±20.7) with the One-Stop Breast Unit. The highest mean satisfaction scores concerned nurses' technical skills, interpersonal skills and availability. The lowest mean scores concerned physicians' availability, waiting time, and the provision of information. The results revealed a significant association between high state anxiety levels, lower levels of satisfaction with doctors' interpersonal skills (r=-.41, P<.001) and lower levels for information provided by nurses (r=-.38, P<.001). Moreover, greater psychological distress was associated with less satisfaction with the different aspects of care (doctors' interpersonal skills, doctors' availability and waiting-time). The results of regression models showed that doctor-related satisfaction scales explained 20% of the variance in anxiety (P<.01). Facing cancer diagnosis remains a stressful situation. However, our study suggested that a substantial part of this anxiety is sensitive to the quality of the patient-doctor relationship. Consequently, further efforts should be expended on adapting patient-doctor communication to improve patient reassurance.

Influential factors on treatment decision making among patients with colorectal cancer: A scoping review

PURPOSE

In recent years, a greater emphasis has been placed on shared decision-making (SDM) techniques between providers and patients with the goal of helping patients make informed decisions about their care and subsequently to improve patient health outcomes. Previous research has shown variability in treatment decision-making among patients with colorectal cancer (CRC), and there is little comprehensive information available to help explain this variability. Thus, the purpose of this study was to evaluate the current state of the literature on factors that are influential in treatment decision-making among patients with CRC.

METHOD

A priori search terms using Boolean connectors were used to examine PubMed, PsycINFO, Web of Science, CINAHL, and MEDLINE for relevant studies. Eligibility criteria for inclusion in the study included patients with CRC and examination of influences on CRC treatment decision-making. All relevant data were extracted including, author, title and year, study methodology, and study results.

RESULTS

Findings (n = 13) yielded influences in four areas: informational, patient treatment goals, patient role preferences, and relationship with provider. Quality of life and trust in physician were rated a high priority among patients when making decisions between different therapeutic options. Several studies found that patients wanted to be informed and involved but did not necessarily want to make autonomous treatment choices, with many preferring a more passive role.

CONCLUSIONS

Providers who initiate a dialog to better understand their patients' treatment goals can establish rapport, increase patient understanding of treatment options, and help patients assume their desired role in their decision-making. Overall, there were a small number of studies that met all inclusion criteria with most used a cross-sectional design.

Second Flexner Century: The Democratization of Medical Knowledge: Repurposing a General Pathology Course Into Multigrade-Level "Gateway" Courses

Starting in 1910, the "Flexner Revolution" in medical education catalyzed the transformation of the US medical education enterprise from a proprietary medical school dominated system into a university-based medical school system. In the 21st century, what we refer to as the "Second Flexner Century" shifts focus from the education of medical students to the education of the general population in the "4 health literacies." Compared with the remarkable success of the first Flexner Revolution, retrofitting medical science education into the US general population today, starting with K-12 students, is a more daunting task. The stakes are high. The emergence of the patient-centered medical home as a health-care delivery model and the revelation that medical errors are the third leading cause of adult deaths in the United States are drivers of population education reform. In this century, patients will be expected to assume far greater responsibility for their own health care as full members of health-care teams. For us, this process began in the run-up to the "Second Flexner Century" with the creation and testing of a general pathology course, repurposed as a series of "gateway" courses on mechanisms of diseases, suitable for introduction at multiple insertion points in the US education continuum. In this article, we describe nomenclature for these gateway courses and a "top-down" strategy for creating pathology coursework for nonmedical students. Finally, we list opportunities for academic pathology departments to engage in a national "Democratization of Medical Knowledge" initiative.

Physician role in physical activity for African-American males undergoing radical prostatectomy for prostate cancer

Purpose

Physical activity is recognized as a complementary therapy to improve physical and physiological functions among prostate cancer survivors. Little is known about communication between health providers and African-American prostate cancer patients, a high risk population, regarding the health benefits of regular physical activity on their prognosis and recovery. This study explores African-American prostate cancer survivors’ experiences with physical activity prescription from their physicians.

Methods

Three focus group interviews were conducted with 12 African-American prostate cancer survivors in May 2014 in St. Louis, MO. Participants’ ages ranged from 49 to 79 years, had completed radical prostatectomy, and their time out of surgery varied from 7 to 31 months.

Results

Emerged themes included physician role on prescribing physical activity, patients’ perceived barriers to engaging in physical activity, perception of normalcy following surgery, and specific resources survivors’ sought during treatment. Of the 12 men who participated, 8 men (67%) expressed that their physicians did not recommend physical activity for them. Although some participants revealed they were aware of the importance of sustained physical activity on their prognosis and recovery, some expressed concerns that urinary dysfunction, incontinence, and family commitments prevented them from engaging in active lifestyles.

Conclusions

Transitioning from post radical prostatectomy treatment to normal life was an important concern to survivors. These findings highlight the importance of physical activity communication and prescription for prostate cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3505-7) contains supplementary material, which is available to authorized users.

Women's experiences of making healthcare decisions about their breast cancer: A phenomenological study

There are few studies about how healthcare decisions are made for women with breast cancer in China and this knowledge is vital, both to further develop person-centered health care and to ensure that women have a voice in their healthcare decisions. This phenomenological study explored the meaning of women's lived experiences of making healthcare decisions about their breast cancer in China. Semistructured, in-depth interviews were conducted with a purposive sample of eight women with breast cancer. Data were analyzed using Colaizzi's phenomenological analytic method. The results of this study identified four themes: authority and expertise, lack of knowledge, family support, and Chinese cultural and social influences. Women were deferential to medical authority and perceived expertise, but they wanted to be involved to a greater degree in healthcare decisions. It is important for health professionals to optimize women's participation in decision-making by removing barriers and advocating on their behalf.

At the intersection of lay and professional social networks: how community ties shape perceptions of mental health treatment providers

BACKGROUND

The therapeutic alliance is a critical determinant of individuals' persistence and outcomes in mental health treatment. Simultaneously, individuals' community networks shape decisions about whether, when, and what kind of treatment are used. Despite the similar focus on social relationship influence for individuals with serious mental illness, each line of research has maintained an almost exclusive focus on either 'inside' (i.e. treatment) networks or 'outside' (i.e. community) networks, respectively.

METHOD

For this study, we integrate these important insights by employing a network-embedded approach to understand the therapeutic alliance. Using data from the Indianapolis Network Mental Health Study (INMHS, n = 169, obs = 2206), we target patients experiencing their first major contact with the mental health treatment system. We compare patients' perceptions of support resources available through treatment providers and lay people, and ask whether evaluations of interpersonal dimensions of the therapeutic alliance are contingent on characteristics of community networks.

RESULTS

Analyses reveal that providers make up only 9% of the whole social network, but are generally perceived positively. However, when community networks are characterized by close relationships and frequent contact, patients are significantly more likely to report that treatment providers offer useful advice and information. Conversely, when community networks are in conflict, perceptions of treatment providers are more negative.

CONCLUSION

Community-based social networks are critical for understanding facilitators of and barriers to effective networks inside treatment, including the therapeutic alliance. Implications for community-based systems of care are discussed in the context of the USA and global patterns of deinstitutionalization and community reintegration.

Impact of online training on delivering a difficult medical diagnosis: Acquiring communication skills

This paper deals with developing and assessing the training of physicians to deliver a difficult diagnosis to patients. The training is provided by a web-based self-training package. This online training emphasizes the structural, functional and relational dimensions of interviews delivering a serious diagnosis, and a logical set of recommendations for behavior towards the patient. The content is illustrated by numerous delivery interview sequences that are described and for which commentary is provided. This online package was expected to enable physicians to acquire new skills and change their mental picture of diagnosis delivery. Here we discuss the assessment of training in managing the delivery of a serious diagnosis. The approach taken and the methods used to measure knowledge and skills are presented.

Consensus in controversy: The modified Delphi method applied to Gynecologic Oncology practice

OBJECTIVES

To determine the degree of consensus regarding the probabilities of outcomes associated with IP/IV and IV chemotherapy.

METHODS

A survey was administered to an expert panel using the Delphi method. Ten ovarian cancer experts were asked to estimate outcomes for patients receiving IP/IV or IV chemotherapy. The clinical estimates were: 1) probability of completing six cycles of chemotherapy, 2) probability of surviving five years, 3) median survival, and 4) probability of ER/hospital visits during treatment. Estimates for two patients, one with a low comorbidity index (patient 1) and the other with a moderate index (patient 2), were included. The survey was administered in three rounds, and panelists could revise their subsequent responses based on review of the anonymous opinions of their peers.

RESULTS

The ranges were smaller for IV compared with IP/IV therapy. Ranges decreased with each round. Consensus converged around outcomes related to IP/IV chemotherapy for: 1) completion of 6 cycles of therapy (type 1 patient, 62%, type 2 patient, 43%); 2) percentage of patients surviving 5 years (type 1 patient, 66%, type 2 patient, 47%); and 3) median survival (type 1 patient, 83 months, type 2 patient, 58 months). The group required three rounds to achieve consensus on the probabilities of ER/hospital visits (type 1 patient, 24%, type 2 patient, 35%).

CONCLUSIONS

Initial estimates of survival and adverse events associated with IP/IV chemotherapy differ among experts. The Delphi process works to build consensus and may be a pragmatic tool to inform patients of their expected outcomes.

Attitudes of medical students in Lahore, Pakistan towards the doctor-patient relationship

Background. A good doctor–patient relationship is the centre stone of modern medicine. Patients are getting increasingly aware about exercising their autonomy and thus modern medicine cannot deliver all its advances to the patients if a good doctor–patient relationship is not established. We initiated this study with the aim to assess the leaning of medical students, who are the future physicians, towards either a doctor-centered or a patient-centered care, and to explore the effects of personal attributes on care such as gender, academic year, etc.

Materials & Methods. A cross-sectional study was conducted between July and Sep 2013. CMH Lahore Medical and Dental College Ethical Review Committee approved the study questionnaire. The study population consisted of 1,181 medical students in years 1–5 from two medical colleges. The English version of Patient Practitioner Orientation Scale (PPOS) was used to assess attitudes of medical students towards doctor–patient relationship. PPOS yields a mean score range of 1–6, where 1 signifies tendency towards a doctor centered relationship and 6 signifies patient-centered relationship. The relationship between PPOS scores and individual characteristics like gender, academic year etc. were examined by multiple regression.

Results. A total of 783 students formed the final sample (response rate = 92%). Mean PPOS score of the entire sample was 3.40 (± .49 S.D.). Mean sharing sub-scale score was 3.18 (± 0.62 S.D. Mean caring sub-scale score was 3.63 (± 0.56 S.D.). Characteristics associated with most patient-centered attitudes were advanced academic year, having a clinical rotation, foreign background and studying in a private college. Gender, having doctor parents, relationship and residence status had no bearing on the attitudes (p > 0.05).

Conclusion. Despite ongoing debate and the emphasis on a patient-centered curriculum, our study suggests that the current curriculum and its teachings are not producing the results they are designed to achieve. Students should be adequately exposed to the patients from the beginning of their medical education in clinical settings which are more sympathetic to a patient-centered care.

Implementing and evaluating shared decision making in oncology practice

Engaging individuals with cancer in decision making about their treatments has received increased attention; shared decision making (SDM) has become a hallmark of patient-centered care. Although physicians indicate substantial interest in SDM, implementing SDM in cancer care is often complex; high levels of uncertainty may exist, and health care providers must help patients understand the potential risks versus benefits of different treatment options. However, patients who are more engaged in their health care decision making are more likely to experience confidence in and satisfaction with treatment decisions and increased trust in their providers. To implement SDM in oncology practice, physicians and other health care providers need to understand the components of SDM and the approaches to supporting and facilitating this process as part of cancer care. This review summarizes recent information regarding patient and physician factors that influence SDM for cancer care, outcomes resulting from successful SDM, and strategies for implementing SDM in oncology practice. We present a conceptual model illustrating the components of SDM in cancer care and provide recommendations for facilitating SDM in oncology practice.

Informing women with breast cancer about endocrine therapy: effects on knowledge and adherence

OBJECTIVE

Adherence to adjuvant endocrine therapy in women with breast cancer is low, and patients are not informed sufficiently. This study analyzes the effects of a structured treatment information on patients' satisfaction, knowledge, and adherence.

METHODS

An interventional single cohort study of postoperative women with estrogen-receptor-positive breast cancer was conducted to study the effects of enhanced information about endocrine therapy given additionally to clinical routine information. Knowledge and satisfaction with additional information given 1-3 weeks after surgery were assessed before and after informing patients; adherence and knowledge were measured 3 months after start of treatment.

RESULTS

A total of 137 patients were analyzed before and after provision of enhanced treatment information as well as 3 months after start of endocrine therapy. Enhanced information increased satisfaction with information and knowledge. The percentage of patients who knew their estrogen receptor status increased from 50% to 93%. At 3 months follow-up, 60% still had correct knowledge. Patients who learned their receptor status were older, and those who forgot had lower cognitive abilities and lower educational level. Patients with higher satisfaction, better learning, and comprehension directly after enhanced information showed better adherence at 3 months follow-up.

CONCLUSION

Patients, especially older ones, can benefit from enhanced treatment information given additionally to routine care. Enhanced information about mode of action and potential side effects of endocrine therapy when included into clinical routine might foster patient autonomy and prevent early disruptions in adherence.

Patients' perceptions of how healthcare providers communicate with them and their families following a diagnosis of colorectal cancer and undergoing chemotherapy treatment

PURPOSE

Chemotherapy can result in many unpredictable and often debilitating side-effects hence patients undergoing chemotherapy treatment may have to rely on their loved ones to support them through this most challenging period. In view of this possibility then good communication skills between patients, healthcare providers and family members is of paramount importance for effective patient outcomes. The aim of this study therefore, was to explore patients' perceptions of how healthcare providers communicate with them and their family members whilst undergoing chemotherapy treatment for cancer.

METHODS

Using a qualitative methodology and a descriptive design, data were collected using unstructured interviews with patients undergoing chemotherapy (n = 14) and analysed by content analysis.

RESULTS

Participants expressed that both they and their family members were treated with compassion, kindness, empathy and understanding. They appreciated the time given to them and their family members to listen and answer their questions before, during and/or after treatment. In addition they commented positively on the warm and cheerful environment and the selective use of appropriate humour by oncology healthcare providers in the chemotherapy units.

CONCLUSION

The data highlights in particular the positive communication encounters between patients with cancer and their healthcare providers and family members. Oncology nurses were identified as being particularly supportive to both patients and their family members. Despite chemotherapy units being a difficult place to be a part of, this study highlights that healthcare providers can help make this a less daunting place for patients and their family members through their appropriate use of professional communication.

Patients' self-assessment versus investigators' evaluation in a phase III trial in non-castrate metastatic prostate cancer (GETUG-AFU 15)

BACKGROUND

Toxicity, which is a key parameter in the evaluation of cancer treatments, can be underestimated by clinicians. We investigated differences between patients and physicians in reporting adverse events of androgen deprivation therapy (ADT) with or without docetaxel in a multicentre phase III trial in non-castrate metastatic prostate cancer.

METHODS

The 385 patients included were invited to complete a 26-symptom questionnaire 3 and 6 months after the start of treatment, among which eighteen symptoms were also assessed by physicians, reported in medical records and graded using the Common Toxicity Criteria of the National Cancer Institute. Positive and negative agreements as well as Kappa concordance coefficients were computed.

FINDINGS

Data were available for 220 and 165 patients at 3 and 6 months respectively. Physicians systematically under-reported patients' symptoms. Positive agreement rates (at respectively 3 and 6 months) for the five most commonly reported symptoms were: 61.0% and 64.3% hot flushes, 50.0% and 43.6% fatigue, 29.4% and 31.1% sexual dysfunction, 24.4% and 14.4% weigh gain/loss, 16.7% and 19.3% for joint/muscle pain. For symptoms most frequently reported as disturbing or very disturbing by patients, the clinicians' failure to report them ranged from 50.8% (hot flushes) to 89.5% (joint/muscle pain) at 3 months, and from 48.2% (hot flushes) to 88.4% (joint/muscle pain) at 6 months.

INTERPRETATION

Physicians often failed to report treatment-related symptoms, even the most common and disturbing ones. Patients' self-evaluation of toxicity should be used in clinical trials to improve the process of drug assessment in oncology.

FUNDING

French Health Ministry and Institut National du Cancer (PHRC), Sanofi-Aventis, Astra-Zeneca, and Amgen.

When cure is no option: how explicit and hopeful can information be given? A qualitative study in breast cancer

OBJECTIVE

To investigate how oncologists can balance explicit with general and realistic with hopeful information when discussing various topics at the transition from curative to palliative care in breast cancer.

METHODS

Qualitative analysis of focus groups consisting of female breast cancer survivors and healthy women.

RESULTS

Perceptions of survivors and healthy women largely overlapped. Participants thought that oncologists can help patients regain a future perspective during this consultation. To achieve this, four themes seemed important: honest medical information, availability of continued support, hope has many faces, and space to choose. Moreover, participants stressed they would need time to let the message sink in before any further information was provided.

CONCLUSION

Participants thought that when confronted with this type of consultation they would need - more or less explicit - medical information and information regarding support. In order to maintain hope, knowledge about (treatment) possibilities is important, but also the certainty not to be abandoned by the hospital at a later stage of the disease and the confidence to remain able to make one's own decisions.

PRACTICE IMPLICATIONS

A life-limiting diagnosis may shatter patients' future perspective; however, this study provides suggestions for oncologists to create a new perspective.

Communicating shared decision-making: cancer patient perspectives

OBJECTIVE

To contribute to the evolving dialogue on optimizing cancer care communication through systematic analyzes of patients' perspectives.

METHODS

Using constant comparative analysis, inductively derived thematic patterns of communication preferences for shared decision-making were drawn from individual interviews with 60 cancer patients.

RESULTS

Thematic patterns in how patients understand barriers and facilitators to communication within shared decision-making illuminate the basis for distinctive patient preferences and needs. Prevailing cancer communication considerations included focusing attention on the tone and setting of the consultation environment, the attitudinal climate within the consult, the specific approach to handling numerical/statistical information, and the critical messaging around hope. The patient accounts surfaced complex dynamics whereby the experiences of living with cancer permeated interpretations and enactment of the shared decision-making that is emerging as a dominant ideal of cancer care.

CONCLUSION

In our efforts to move beyond traditional paternalism, shared decision-making has been widely advocated as best practice in cancer communication. However, patient experiential evidence suggests the necessity of a careful balance between standardized approaches and respect for diversities.

PRACTICE IMPLICATIONS

Shared decision-making as a practice standard must be balanced against individual patient preferences.

Patient preferences and healthcare outcomes: an ecological perspective

This article examines the nature of patients' preferences for healthcare and whether clinician accommodation of patient preferences influences health outcomes. First, we provide a conceptualization of patient preferences along with their key attributes. Second, we review research on the relationship between health outcomes and patient preferences for treatments and for the process of care (e.g., preferred involvement in decision-making). Third, following a critique of this literature, we present an ecological model of patient preferences that, while acknowledging that patient preferences may emerge from various contexts (e.g., family or media exposure), we focus on the important role that clinical encounters and patients' health-related experiences play in the elicitation and construction of patient preferences. Fourth, we propose two pathways, one behavioral (adherence) and the other psychological (sense of autonomy or satisfaction with decision), through which meeting patient preferences could lead to better health outcomes. Fifth, we discuss how preferences can be elicited and clarified through patient-centered conversations. We conclude with implications for future research and clinical practice.

Effect of anti-anxiety treatment on sevoflurane requirement and postoperative recovery in patients undergoing radical gastrectomy

AIM: To investigate the effect of anti-anxiety treatment with lorazepam and midazolam on sevoflurane requirement and postoperative recovery in patients undergoing radical gastrectomy.

METHODS: Sixty patients undergoing radical gastrectomy were divided into two groups: observation group and control group. The observation group was administered with lorazepam the night before surgery and midazolam 40 min before the induction of anesthesia, while the control group was not given such drugs. BIS monitoring was used to control the depth of anesthesia. The Spielberger State-Trait Anxiety Inventory (STAI) scores were obtained preoperatively, while the requirement of sevoflurane during operation and the VAS scores 2 h, 6 h and 24 h postoperatively were also calculated.

RESULTS: The observation group had lower STAI scores (S-AI: 53.6 ± 4.45 vs 62.70 ± 3.98, P < 0.05; T-AI: 54.78 ± 3.97 vs 65.65 ± 4.21, P < 0.05) and less requirement of sevoflurane during operation (34.7 ± 0.46 vs 36.2 ± 0.44, P < 0.05). The VAS scores at 6 and 24 hours postoperatively were lower in the observation group (6 h: 3.45 ± 1.60 vs 4.89 ± 1.91, P < 0.05; 24 h: 3.51 ± 1.76 vs 5.17 ± 1.71, P < 0.05) than in the control group. There were no significant differences in awaking time and extubation time between the two groups (both P > 0.05).

CONCLUSION: Combined use of lorazepam and midazolam can reduce preoperative anxiety, intraoperative sevoflurane requirement, and postoperative pain in patients undergoing radical gastrectomy.

Patients' decision-making in radiation oncology

Recently, growing attention has been devoted to developing patient decision aids and decisional support interventions to aid patients in their decision-making when making treatment choices in oncology. Treatment discussions are challenging, both for physicians to transfer medical information to patients, and for patients to conceptualize these risks and benefits and to form a treatment decision. This article provides an overview of the recent literature on decision-making preferences, treatment preferences and decisional support development in radiation oncology. We review the findings from studies that were conducted in radiation oncology that investigated patients' preferences for radical or palliative radiotherapy across all cancer sites and discuss the challenges of transferring medical information to patients.

Patients' regrets after participating in a randomized controlled trials depended on their involvement in the decision making

OBJECTIVE

To identify the factors associated with long-term regrets expressed a posteriori by randomized controlled trial (RCT) participants questioned about their decision to participate in an RCT.

STUDY DESIGN AND SETTING

Participants were questioned 6 years on average after their inclusion in a breast cancer adjuvant therapy RCT. Among 115 women from 21 centers, 93 (81%) answered a self-administered questionnaire based on the Decision Regret Scale (DRS).

RESULTS

Mean DRS score was 16.8 (standard deviation=15.9); 43.0% of participants expressed mild regret, and 25.8% expressed moderate to strong regret. A quarter of the women (25.6%) said that the decision was taken by the doctor alone, and 13.5% said it was not consistent with their own wishes. In the multivariate ordinal regression analysis, an involuntarily passive role in decision making was found to be associated with greater regret (cumulative proportional odds ratio=7.3, 95% confidence interval=2.0-27.6), regardless of age and being allotted or not to the standard treatment in the RCT.

CONCLUSION

Whether patients' regret depended on their level of participation in the decision making or vice versa could not be determined in this cross-sectional survey, but efforts should be made to ensure that patients' participation in trials is always based on an active personal decision.

Communicating about breast cancer: rural women's experience of interacting with their surgeon

OBJECTIVE

This study examined rural women's satisfaction with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Differences in satisfaction were investigated between treatment groups (mastectomy and breast conservation surgery) and demographic variables (age, marital status, education level, employment status and place of residence). Practice was compared with clinical practice guidelines.

DESIGN

The study was designed as a cross-sectional survey.

SETTING

The study was set in Eastern regional Victoria, Australia.

PARTICIPANTS

Seventy women diagnosed with early breast cancer participated in the study.

MAIN OUTCOME MEASURES

The main outcome measures used by the study were satisfaction in three areas of practice: (i) telling a woman she has breast cancer; (ii) providing information and involving the woman in the decision-making; and (iii) preparing the woman for specific management.

RESULTS

No differences in satisfaction were found between treatment groups and demographic variables. Overall, women in this study were highly satisfied (>93%) with the interaction and communication with their surgeon. Women reported that the surgeon created a supportive environment for discussion, that they were provided with adequate information and referrals, and that they were actively involved in the decision-making. Practice could have been improved for women who were alone at diagnosis as women without a partner made a quicker decision about treatment.

CONCLUSION

Rural women in Victoria Australia were largely satisfied with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Current practice was predominately in line with clinical practice guidelines.

Breast cancer and menopause: perceptions of diagnosis, menopausal therapies and health behaviors

OBJECTIVES

The aim of this study was to investigate the perception and experience of menopause diagnosis and therapies, the information provided and health behaviors in younger women with breast cancer.

METHODS

The questionnaire study was completed by 114 women, aged 40-51 years, with non-metastatic breast cancer. Women were recruited from outpatient clinics and the community. Descriptive statistics were completed.

RESULTS

Most women were satisfied with the manner in which they were informed of the breast cancer (69%) and the menopause (59%) diagnoses. Although 80% of women were given breast cancer information, only 54% were given menopause information at diagnosis. Women were least satisfied (26%) with information regarding the long-term complications of menopause. Women perceived exercise (68%) and improving lifestyle (61%) as most effective in alleviating symptoms of menopause. The majority of women reported that they did not understand the risks/benefits of 'bioidentical' hormones (79%) and herbal therapies (78%), while 58% perceived hormone replacement therapies as associated with an increased risk of breast cancer. Most women reported weight gain (68%) and osteoporosis (67%) as the most common problems/fears regarding menopause. However, regarding health behaviors, only 56% reported having relevant tests including a blood sugar test or a bone density test.

CONCLUSION

While information needs regarding breast cancer appear well met in younger women, unmet information needs regarding menopause after breast cancer persist. Further education and support are required for these women to optimize health screening and prevention behaviors and to ensure informed decision-making regarding menopause treatment options.

Knowledge, satisfaction with information, decisional conflict and psychological morbidity amongst women diagnosed with ductal carcinoma in situ (DCIS)

OBJECTIVE

To assess knowledge, satisfaction with information, decisional conflict and psychological morbidity amongst women diagnosed with ductal carcinoma in situ (DCIS) and to explore the factors associated with less knowledge and greater confusion about DCIS.

METHODS

A cross-sectional survey of women diagnosed with DCIS in Australia (N=144).

RESULTS

This study found misunderstanding and confusion amongst women diagnosed with DCIS and a desire for more information about their breast disease. Approximately half of participants worried about their breast disease metastasizing; approximately half expressed high decisional conflict; 12% were anxious and 2% were depressed. Logistic regression analysis demonstrated that worry about dying from the breast disease was significantly associated with not knowing that DCIS could not metastasize (OR 3.9; 95% CI 1.03-14.25); and confusion about whether DCIS could metastasize was significantly associated with dissatisfaction with information (OR 12.5; 95% CI 3.8-40.2).

CONCLUSION

Good communication about how DCIS differs from invasive breast cancer is essential to alleviating the confusion and worry amongst women with DCIS.

PRACTICE IMPLICATIONS

Recommendations about how best to communicate a diagnosis of DCIS, including the uncertainties, are needed to guide health professionals to promote better understanding about DCIS and increase the well-being of women with DCIS.

Is the toxicity of adjuvant aromatase inhibitor therapy underestimated? Complementary information from patient-reported outcomes (PROs)

Adjuvant endocrine treatment-related adverse effects have a strong impact on patients' quality of life and thereby limit therapy's risk benefit ratio resulting in morbidity and treatment discontinuation. Still, many AI adverse effects remain untreated given that they are unrecognized by conservative methods (e.g., proxy ratings). The ability of complementary patient-reported outcomes (PROs) to provide a more comprehensive assessment of side-effects is to be explored. A cross-sectional study sample of 280 postmenopausal, early stage breast cancer patients was subjected to a comprehensive PRO assessment (FACT-B/+ES) at their after-care appointment. Prevalence and severity of patient-reported physical side-effects and psychosocial burden related to adjuvant AI therapy were compared with prevalences derived from pivotal phase IV trials (ATAC 2005, BIG1-98 2005). Across all symptom categories, highest prevalence rates were found for joint pain (59.6%), hot flushes (52%), lost interest in sexual intercourse (51.4%), and lack of energy (40.3%). Overall, PROs resulted in significantly higher prevalence rates as compared to physician ratings for all symptoms published in pivotal clinical trials except vaginal bleeding and nausea. The treatment duration exerted no significant impact on symptom frequency (P > 0.05). Established prevalence rates of endocrine treatment-related toxicity seem to be underestimated. The incorporation of PRO data should be mandatory or at least highly recommended in clinical treatment planning to arrive at a more accurate assessment of a patient's actual symptom burden enabling improved individualized management of side-effects and mediating the preservation of treatment adherence.

Are patients' preferences for information and participation in medical decision-making being met? Interview study with lung cancer patients

We examined the degree to which newly diagnosed patients with advanced lung cancer wanted to be informed and involved in medical decision-making, and whether the patients felt their preferences were met. Patients from 13 hospitals in Flanders were interviewed with a standard questionnaire. A total of 128 patients (68%) participated. Of the patients who wanted to be informed about life expectancy, half (53%) reported they were informed, and of those who wanted to be informed about palliative care and end-of-life decisions, 25% and 31% said they were informed, respectively. With regard to participation in medical decision-making (in general, about treatment, transfer or end-of-life), patients who preferred the doctor to make decisions or those who preferred to make the decision themselves often achieved this (in their perception), while patients who wanted an in-between position with some involvement, often did not. To conclude, preferences of patients with lung cancer for information concerning delicate topics and for shared decision-making with the physician were not well met.

[How to improve cancer patients' satisfaction with medical information]

The medical information becomes integrated into a communications strategy, the generally admitted model of which is centered on the patient; that is in the listening of these concerns and these values. The medical quality information is facilitated by the preliminary collection of the symptoms and the needs of the patients thanks to the questionnaires of quality of life, if they are used during the consultation to direct the discussion. Satisfactory medical information includes a discussion about the questions of the patients in terms of outcomes. Patient's individual factors can influence the need of medical information, as the age and the pathology. Patient's needs can also vary with time and according to the phase of the disease. Cultural factors are essential, in particular as regards the information about prognosis. Tools to help giving the medical information are now validated as the audio cassettes or video. Those tools can take the shape of a prompt list to help patients to ask questions. The majority preference of style of participation in the medical and therapeutic decisions and is the collaborative mode. Physician's attitude is determinant to leave the patients who wish it to have an active role, what allows them a very beneficial feeling psychologically of control over the disease. Decision-making helps are successfully sometimes elaborated to support the participation of the patients. In palliative phase, the need of medical information about prognosis associated with preservation of hope is not still understood by physicians who oscillate between saying the all or none. Honest information at the right time is the majority wish of the patients, although certain patients adopt clearly a strategy of avoidance. The medical communication requires a specific training on this subject. Talking time must be opened to the doctors to approach the relational problems which they meet. The clinical research has to continue to understand better the interactions in doctors/patients communication.

Unanticipated toxicities from anticancer therapies: survivors' perspectives

CONTEXT

Improved therapies in oncology have resulted in increased survival across numerous malignancies, shifting attention to other aspects of the cancer experience. In particular, the impact of treatment-related toxicities has gained considerable attention, due to their physical and psychosocial effects, and possible impact on clinical outcome. These untoward events have not been examined from the survivors' perspective.

OBJECTIVE

To identify and describe treatment-related toxicities having a negative effect on quality of life from the perspective of cancer survivors.

DESIGN

Quantitative study using written questionnaires and content analysis.

SETTING

Cancer survivors' workshop across the United States.

PARTICIPANTS

A total of 379 participants from six survivor groups: breast (n = 250), ovarian (n =27), lung (n = 23), colorectal (n = 15), genitourinary (n = 23), and other cancers (n = 45).

OUTCOME MEASURES

Survivors' perceptions on treatment-related dermatologic, gastrointestinal, and constitutional toxicities.

RESULTS

Survivors reported an increased concern regarding dermatologic toxicities, including irritated and dry skin, after receiving their cancer treatment. These events had a negative effect on their lives. Although gastrointestinal and constitutional toxicities also had a negative effect, the concern over their development was unchanged prior to and after treatments.

CONCLUSION

The impact of dermatologic toxicities is unanticipated prior to cancer treatments. Since these events have a negative effect on survivors' lives, pretreatment counseling and effective interventions are vital in order to maximize quality of life and minimize unnecessary treatment interruptions or discontinuations.

Preferences of advanced lung cancer patients for patient-centred information and decision-making: a prospective multicentre study in 13 hospitals in Belgium

OBJECTIVE

To identify preferences of advanced lung cancer patients for receiving information and participating in decision-making concerning treatment options, health-care-setting transfers and end-of-life decision-making.

METHODS

Over the course of 1 year, pulmonologists and oncologists in 13 hospitals in Flanders, Belgium, invited patients with an initial diagnosis of non-small-cell lung cancer IIIb/IV to participate in the study. Shortly after inclusion, the patients were interviewed with a structured questionnaire.

RESULTS

One-hundred and twenty-eight patients with a median estimated survival time of 10 months participated. Almost all wanted information on diagnosis, treatment and cure rate and slightly fewer on life expectancy (88.2%). Information about palliative care was desired by 63.5% of patients and information about end-of-life decisions by 56.8%. The percentage of patients who preferred personal control over medical decision-making increased to 14.8% for treatment, 25.0% for transfer and 49.2% for end-of-life decisions, all of which were higher than for medical decisions in general (9.3%).

CONCLUSION

Information and participation preferences of advanced lung cancer patients differ depending on the type of information or decision.

PRACTICE IMPLICATIONS

As part of a patient-centred approach, physicians should not only check the general but also the specific information and participation preferences of their patients.