Should we involve patients more actively? Perspectives of the multidisciplinary team on shared decision-making for older patients with metastatic castration-resistant prostate cancer

Novel hormone therapy and coordination of care in high-risk biochemically recurrent prostate cancer

Biochemical recurrence (BCR) occurs in 20-50% of patients with prostate cancer (PCa) undergoing primary definitive treatment. Patients with high-risk BCR have an increased risk of metastatic progression and subsequent PCa-specific mortality, and thus could benefit from treatment intensification. Given the increasing complexity of diagnostic and therapeutic modalities, multidisciplinary care (MDC) can play a crucial role in the individualized management of this patient population. This review explores the role for MDC when evaluating the clinical evidence for the evolving definition of high-risk BCR and the emerging therapeutic strategies, especially with novel hormone therapies (NHTs), for patients with either high-risk BCR or oligometastatic PCa. Clinical studies have used different characteristics to define high-risk BCR and there is no consensus regarding the definition of high-risk BCR nor for management strategies. Next-generation imaging and multigene panels offer potential enhanced patient identification and precision-based decision-making, respectively. Treatment intensification with NHTs, either alone or combined with radiotherapy or metastasis-directed therapy, has been promising in clinical trials in patients with high-risk BCR or oligometastases. As novel risk-stratification and treatment options as well as evidence-based literature evolve, it is important to involve a multidisciplinary team to identify patients with high-risk features at an earlier stage, and make informed decisions on the treatments that could optimize their care and long-term outcomes. Nevertheless, MDC data are scarce in the BCR or oligometastatic setting. Efforts to integrate MDC into the standard management of this patient population are needed, and will likely improve outcomes across this heterogeneous PCa patient population.

Shared decision-making in healthcare in mainland China: a scoping review

Background

Shared decision-making (SDM) facilitates the participation of healthcare professionals and patients in treatment decisions. We conducted a scoping review to assess SDM's current status in mainland China, referencing the Ottawa Decision Support Framework (ODSF).

Methods

Our review encompassed extensive searches across six English and four Chinese databases, and various gray literature until April 30, 2021. Results were synthesized using thematic analysis.

Results

Out of the 60 included studies, we identified three key themes based on the ODSF framework: decisional needs, decision support, and decisional outcomes. However, there appears to be a lack of comprehensive understanding of concepts related to decisional needs in China. Only a few studies have delved into feasibility, preference, choice, and outcome factors in the SDM process. Another challenge emerges from an absence of uniform standards for developing patient decision aids (PDAs). Furthermore, regarding health outcome indicators, their predominant focus remains on physiological needs.

Conclusion

SDM is in its infancy in mainland China. It is important to explore the concept and expression of decisional needs in the context of Chinese culture. Subsequent studies should focus on constructing a scientifically rigorous and systematic approach for the development of PDAs, and considering the adaptation of SDM steps to the clinical context in China during SDM implementation. Concurrently, The focus on health outcomes in Chinese SDM studies, driven by the unique healthcare resource landscape, underscores the necessity of prioritizing basic needs within limited resources.

Systematic review registration

https://inplasy.com/?s=202130021.

The Role of Nurse on the Treatment Decision Support for Older People with Cancer: A Systematic Review

Background: The number of older adults with cancer is increasing worldwide. The role of nurses in supporting patients' decision-making is expanding, as this process is fraught with complexity and uncertainty due to comorbidities, frailty, cognitive decline, etc., in older adults with cancer. The aim of this review was to examine the contemporary roles of oncology nurses in the treatment decision-making process in older adults with cancer. Methods: A systematic review of PubMed, CINAHL, and PsycINFO databases was conducted in accordance with PRISMA guidelines. Results: Of the 3029 articles screened, 56 full texts were assessed for eligibility, and 13 were included in the review. We identified three themes regarding nurses' roles in the decision-making process for older adults with cancer: accurate geriatric assessments, provision of available information, and advocacy. Nurses conduct geriatric assessments to identify geriatric syndromes, provide appropriate information, elicit patient preferences, and communicate efficiently with patients and caregivers, promoting physicians. Time constraints were cited as a barrier to fulfilling nurses' roles. Conclusions: The role of nurses is to elicit patients' broader health and social care needs to facilitate patient-centered decision-making, respecting their preferences and values. Further research focusing on the role of nurses that considers diverse cancer types and healthcare systems is needed.

Sharing decision-making between the older person and the nurse: A scoping review

BACKGROUND

Sharing decision-making is globally recognised as an important concept in healthcare research, policy, education and practice which enhances person-centred care. However, it is becoming increasingly evident shared decision-making has not been successfully translated into everyday healthcare practice. Sharing decision-making has strong links with person-centred practice. Core to person-centredness and shared decision making, is the need to recognise that as we age, greater reliance is placed on emotion and life experience to inform decision making processes. With the world's ageing population, older persons facing more complex decisions and transitions of care, it is more important than ever it is understood how shared decision-making occurs.

OBJECTIVES

This scoping literature review aims to find out how sharing decision making between nurses and older persons in healthcare settings is understood and presented in published literature.

METHODS

This scoping review utilised the Arksey and O'Malley methodological framework, advanced by Levac et al. Electronic databases and grey literature were searched, returning 362 records which were examined against defined inclusion criteria. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Twenty-two records met inclusion criteria for the review. Results indicate while shared decision-making is included in research, education and policy literature, it has not been effectively translated to inform practice and the relationship between a nurse and an older person. The records lack definitions of shared decision-making and theoretical or philosophical underpinnings. There is also no consideration of emotion and life experience in decision-making and how nurses 'do' shared decision-making with older persons.

CONCLUSIONS

The findings demonstrate sharing decision-making between nurses and older persons is not well understood in the literature, and therefore is not translated into nursing practice. Further research is needed.

Multicenter study on multidisciplinary committees in advanced prostate cancer

INTRODUCTION AND OBJECTIVE

Although Multidisciplinary Teams (MDTs) are recommended in the management of Advanced Prostate Cancer (APC), their functioning in real practice has been poorly evaluated. We carried out a multicenter study with the objective of evaluating the functioning of uro-oncology MDTs in 6 hospitals.

MATERIALS AND METHODS

A descriptive cross-sectional study was performed. The level of Compliance with the Fundamental Quality Requirements (CFQR) of the MDTs was evaluated by means of a questionnaire filled out by the coordinators of the MDTs in each hospital. The information on the perspective of the members of the MDTs was evaluated through an anonymous survey.

RESULTS

A high level of CFQR in MDTs was evidenced (75%), showing deficiencies in terms of protocol update, agendas, audits, and scientific production. The survey was answered by 62.32% of the 69 physicians surveyed (urologists, oncologists, radiation therapists, radiologists, and pathologists). The 88.4% consider the duration of the meetings appropriate. There are disparate opinions concerning the protection of the MDT meeting time as well as protocol update. Of the patients with APC presented at the MDTs meeting, 62,8% require intervention from two specialties. Only 50% of respondents believe that all CRPC cases are discussed and that there is a prior agenda. The decisions made by the MDTs are reflected in the clinical history in 65.1% and are binding only in 60.5% of the cases. Half of the respondents have not been trained in MDTs. Most participants (90.7%) agree on the fact that MDTs. convey benefits.

CONCLUSIONS

The evaluations of the MDTs identify rectifiable deficiencies by modifying hospital inertia and care planning.

Patient, Family Caregiver, and Nurse Involvement in End-of-Life Discussions During Palliative Chemotherapy: A Phenomenological Hermeneutic Study

The aim of this study was to investigate current nursing practice related to end-of-life discussions with incurable lung cancer patients and their family caregivers from the perspectives of patients, family caregivers, and nurses in an oncology outpatient clinic. This phenomenological hermeneutic study included nine patients, eight family caregivers, and 11 nurses. Data were collected using participant observation, informal and semi-structured individual or joint interviews with patients and family caregivers, and focus group interviews with nurses. A Ricoeur-inspired approach was used to analyze the data. Three themes were identified: (a) content of end-of-life discussions, (b) timing of end-of-life discussions, and (c) challenges in end-of-life discussions. End-of-life discussions were seldom initiated; when they were, it was often too late. Discussions addressed treatment, place of care, practical/economic concerns, and existential matters. The physical environment at the outpatient clinic, lack of continuity, and nurses' instrumental task workloads and time pressure posed challenges to initiating end-of-life discussions.

Mobile Audio Recording Technology to Promote Informed Decision Making in Advanced Prostate Cancer

PURPOSE

Men with metastatic castration-resistant prostate cancer increasingly encounter complex treatment decisions. Consultation audio recordings and summaries promote patient informed decision making but are underutilized. Mobile recording software applications may increase access. Little is known regarding the feasibility of implementation in clinical encounters.

METHODS

We conducted a mixed-methods pilot study in men with progressive metastatic castration-resistant prostate cancer. We instructed patients to use a mobile software application to record an oncology visit. Patients could share the recording with our patient scribing program to receive a written summary. We assessed feasibility and acceptability with postvisit surveys. We measured patient-reported helpfulness of the intervention in decision making and change in Decisional Conflict Scale-informed subscale. We conducted semistructured interviews to explore implementation and analyzed transcripts using thematic analysis.

RESULTS

Across 20 patients, 18 (90%) recorded their visits. Thirteen of 18 (72%) listened to the recording, and 14 of 18 (78%) received a summary. Eighteen of 20 (90%) visits were telehealth. Fourteen patients (70% of all 20; 78% of 18 question respondents) found the application easy to use. Nine patients (50% of 18 recording patients; 90% of 10 question respondents) reported that the recording helped treatment decision making. Decisional conflict decreased from baseline to 1-week postvisit (47.4-28.5, P < .001). Interviews revealed benefits, facilitators, contextual factors, and technology and patient-related barriers to recordings and summaries.

CONCLUSION

In this single-institution academic setting, a mobile application for patients to record consultations was a feasible, acceptable, and potentially valued intervention that improved decision making in the telehealth setting. Studies in larger, diverse populations are needed.

Does greater patient involvement in healthcare decision-making affect malpractice complaints? A large case vignette survey

Background

Although research findings consistently find poor communication about medical procedures to be a key predictor of patient complaints, compensation claims, and malpractice lawsuits (“complaints”), there is insufficient evidence to determine if greater patient involvement could actually affect the inclination to complain.

Objectives

We conducted an experimental case vignette survey that explores whether greater patient involvement in decision-making is likely to influence the intention to complain given different decisions and consequences.

Methods

Randomized, national case vignette survey with various levels of patient involvement, decisions, and outcomes in a representative Danish sample of men. We used prostate specific antigen (PSA) screening in men aged 45 to 70 years as the intervention illustrated in 30 different versions of a mock clinical encounter. Versions differed in the amount of patient involvement, the decision made (PSA test or no PSA test), and the clinical outcomes (no cancer detected, detection of treatable cancer, and detection of non-treatable cancer). We measured respondents’ inclination to complain about care in response to the scenarios on a 5-point Likert scale (from 1: very unlikely to 5: very likely).

Results

The response rate was 30% (6,756 of 22,288). Across all scenarios, the likelihood of complaint increased if the clinical outcome was poor (untreatable cancer). Compared with scenarios that involved shared decision-making (SDM), neutral information, or nudging in favor of screening, the urge to complain increased if the patient was excluded from decision-making or if the doctor had nudged the patient to decline screening (mean Likert differences .12 to .16, p < .001). With neutral involvement or nudging in favor of intervention, the desire to complain depended highly on the decision reached and on the patient’s course. This dependence was smaller with SDM.

Conclusions

Greater patient involvement in decision-making appears to be associated with less intention to complain about health care, with SDM resulting in the greatest reduction in complaint likelihood.

Nurses' involvement in end-of-life discussions with incurable cancer patients and family caregivers: An integrative review

AIM

To review current evidence of nurses' involvement in end-of-life discussions with incurable cancer patients and their family caregivers.

DESIGN

We conducted a systematic integrative review in accordance with PRISMA guidelines: PROSPERO, registration number: CRD42020186204.

DATA SOURCES

CINAHL, Medline, PsycInfo, Embase. We searched for primary research between 2010 and 2020.

RESULTS

Of 3,271 references, we found 15 eligible articles: qualitative (n = 12) and quantitative (n = 3). The studies focused on oncology nurses' perspective of involvement in end-of-life discussions. The data analysis resulted in four overall themes: (1) Nursing roles; the advocating, supporting, and reframing roles, and an undefined task, for example in medical consultations, (2) Trust building, (3) Nurse competences, and (4) Medical issues.

SIGNIFICANCE OF RESULTS

The nurses have several roles in end-of-life discussions, but insufficient competencies to be involved in that kind of discussions, for example to involve and communicate with families. The findings implicate an educational need among the nurses. However, it also points toward an organizational change in the outpatient clinics, for example that end-of-life discussions follow a more structured approach, are offered in a scheduled manner, and that nurses invite the family caregivers to attend.

Treatment decision-making in acute myeloid leukemia: a qualitative study of older adults and community oncologists

Little is known about the characteristics of patients, physicians, and organizations that influence treatment decisions in older patients with AML. We conducted qualitative interviews with community oncologists and older patients with AML to elicit factors that influence their treatment decision-making. Recruitment was done via purposive sampling and continued until theoretical saturation was reached, resulting in the inclusion of 15 patients and 15 oncologists. Participants' responses were analyzed using directed content analysis. Oncologists and patients considered comorbidities, functional status, emotional health, cognition, and social factors when deciding treatment; most oncologists evaluated these using clinical gestalt. Sixty-seven percent of patients perceived that treatment was their only option and that they had not been offered a choice. In conclusion, treatment decision-making is complex and influenced by patient-related factors. These factors can be assessed as part of a geriatric assessment which can help oncologists better determine fitness and guide treatment decision-making.

Involvement of radiologists in oncologic multidisciplinary team meetings: an international survey by the European Society of Oncologic Imaging

Objectives

Multidisciplinary tumour boards (MTBs) play an increasingly important role in managing cancer patients from diagnosis to treatment. However, many problems arise around the organisation of MTBs, both in terms of organisation-administration and time management. In this context, the European Society of Oncologic Imaging (ESOI) conducted a survey among its members, aimed at assessing the quality and amount of involvement of radiologists in MTBs, their role in it and related issues.

Methods

All members were invited to fill in a questionnaire consisting of 15 questions with both open and multiple-choice answers. Simple descriptive analyses and graphs were performed.

Results

A total of 292 ESOI members in full standing for the year 2018 joined the survey. Most respondents (89%) declared to attend MT-Bs, but only 114 respondents (43.9%) review over 70% of exams prior to MTB meetings, mainly due to lack of time due to a busy schedule for imaging and reporting (46.6%). Perceived benefits (i.e. surgical and histological feedback (86.9%), improved knowledge of cancer treatment (82.7%) and better interaction between radiologists and referring clinicians for discussing rare cases (56.9%)) and issues (i.e. attending MTB meetings during regular working hours (71.9%) and lack of accreditation with continuing medical education (CME) (85%)) are reported.

Conclusions

Despite the value and benefits of radiologists’ participation in MTBs, issues like improper preparation due to a busy schedule and no counterpart in CME accreditation require efforts to improve the role of radiologists for a better patient care.

Key Points

• Most radiologists attend multidisciplinary tumour boards, but less than half of them review images in advance, mostly due to time constraints.

• Feedback about radiological diagnoses, improved knowledge of cancer treatment and interaction with referring clinicians are perceived as major benefits.

• Concerns were expressed about scheduling multidisciplinary tumour boards during regular working hours and lack of accreditation with continuing medical education.

A clinician's guide for developing a prediction model: a case study using real-world data of patients with castration-resistant prostate cancer

PURPOSE

With the increasing interest in treatment decision-making based on risk prediction models, it is essential for clinicians to understand the steps in developing and interpreting such models.

METHODS

A retrospective registry of 20 Dutch hospitals with data on patients treated for castration-resistant prostate cancer was used to guide clinicians through the steps of developing a prediction model. The model of choice was the Cox proportional hazard model.

RESULTS

Using the exemplary dataset several essential steps in prediction modelling are discussed including: coding of predictors, missing values, interaction, model specification and performance. An advanced method for appropriate selection of main effects, e.g. Least Absolute Shrinkage and Selection Operator (LASSO) regression, is described. Furthermore, the assumptions of Cox proportional hazard model are discussed, and how to handle violations of the proportional hazard assumption using time-varying coefficients.

CONCLUSION

This study provides a comprehensive detailed guide to bridge the gap between the statistician and clinician, based on a large dataset of real-world patients treated for castration-resistant prostate cancer.

Men's view on participation in decisions about prostate-specific antigen (PSA) screening: patient and public involvement in development of a survey

Background

Prostate-Specific Antigen (PSA) screening for early detection of prostate cancer (PCa) may prevent some cancer deaths, but also may miss some cancers or lead to unnecessary and potentially harmful treatment. Therefore, involving patients in decision-making about PSA screening is recommended. However, we know little about the attitude of men regarding participation in decisions about PSA screening and how to assess such attitudes. The purpose of this paper is to describe patient and public participation in the development of a national, web-based case vignette survey for studying men’s view on participation in decision-making about PSA screening.

Methods

The project group developed a first draft plan for the survey, its vignettes and choice of measurements. This included multiple vignette variants representing various levels of patient participation in decision-making about PSA screening with different outcomes. Additionally, it included questions on respondents’ satisfaction with imagined courses of health care, their propensity to initiate a malpractice complaint, their own health care experiences, socio-demography, personality, and preferences for control regarding health care decision-making. Following feedback from a workshop with academic peers on the draft plan, a group of 30 adult men was engaged to help develop case vignette versions and questionnaire items by providing feedback on structure, comprehension, response patterns, and time required to complete the survey. Furthermore, a panel of three patients with PCa experience was assembled to assist development through a separate review-and-feedback process.

Results

Based on reviews of survey drafts, the large group made further suggestions about construction of the survey (e.g. clarification and modification of case vignette versions, deletion of items and adjustment of wording, instructions to guide respondents, replacement of technical terms, and optimization of sequence of survey elements). The patient panel ensured fine-tuning of vignette versions and questionnaire items and helped review the internet version of the survey.

Conclusions

Patient and public involvement during various phases of the survey development helped modify and refine survey structure and content. The survey exemplifies a way to measure health care users’ satisfaction with imagined courses of health care and wish to complain, taking into account their characteristics.

Shared decision making for men facing prostate cancer treatment: a systematic review of randomized controlled trials

Aims: To synthesize the empirical evidence on the effectiveness of shared decision making (SDM) compared to usual care for prostate cancer (PC) treatment. Methods and results: A systematic review of academic (MEDLINE, EMBASE, Cochrane Library, CINHAL, PsychINFO, and Scopus) and grey (clinicaltrials.gov, WHO trial search, meta-Register ISRCTN, Google Scholar, opengrey, and ohri.ca) literature, also identified from contacting authors and hand-searching bibliographies. We included randomized controlled trials (RCTs): 1) comparing SDM to usual care for decisions about PC treatment, 2) conducted in primary or specialized care, 3) fulfilling the key SDM features, and 4) reporting quantitative outcome data. Four RCTs from Canada (n=3) and the USA were included and comprised 1,065 randomized men, most (89.8%) of whom were in PC stage T1-T2. The studies reported 24 outcome measures. In 62.5% study estimates, SDM was similar to usual care at improving patient satisfaction and mood, and at reducing decisional conflict and decisional regret. In 37.5% study estimates, SDM significantly improved knowledge, perception of being informed and patient-perceived quality of life (QoL) at four weeks. There was a dearth of outcome data, particularly on the adherence to treatment and on patient-important and clinically relevant health outcomes such as symptoms and mortality. Conclusion: SDM may positively influence men's knowledge and may have a positive but short-term effect on patient-perceived QoL. The (long-term) effects of SDM on patient-related outcomes for decisions about PC treatment are unclear. Future research needs consensus about the interventions and outcomes needed to evaluate SDM and should address the absence of evidence on health outcomes.