Can cancer patients influence the pain agenda in oncology outpatient consultations?

"Fortunately I felt pain, or I would have thought I was on my way out": experiencing pain and negotiating analgesic treatment in the context of cancer

OBJECTIVES

To explore cancer patients' experience of pain and coping strategies as well as beliefs and representations associated with pain, pain management and treatments.

METHOD AND PARTICIPANTS

A qualitative study based on semi-structured interviews was conducted among 16 patients with cancer. The inductive research strategy adopted derived from the Grounded Theory approach and the data transcribed verbatim were gradually analyzed involving researcher triangulation.

FINDINGS

The experience of pain and the coping strategies developed by patients to deal with it are shaped by the experience and representations of cancer associated with death and suffering. Pain acts both as an indication to the patients that they are still alive and as an indicator of the progression of the disease. Cancer also models patients' relationships to analgesic treatments and health care providers, since pain is an area in which patients can take back control of what is happening to them. Patients' expression of reluctance to accept analgesic treatments is also influenced by the significance of opioid treatments in this context, which are perceived as an indication that the end of life is close.

CONCLUSIONS

The contextualization of pain through the particularities of cancer is critical in order to understand cancer patients' experience of pain.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Not only patients' knowledge but also the meaning-making of pain should be incorporated in interventions targeting pain management.

A survey of perceptions, attitudes, knowledge and practices of medical oncologists about cancer pain management in Spain

PURPOSE

To monitor oncologists' perspective on cancer pain management.

METHODS

An anonymized survey was conducted in two waves. First, over a convenience sample of oncologists known to be particularly concerned with the management of pain. Second, using a random sample of oncologists.

RESULTS

In total, 73 and 82 oncologists participated in the first and second wave, respectively. Many oncologists reported to have good knowledge of analgesic drugs (95.9%), the mechanism of action of opioids (79.5%), and good skills to manage opioid-related bowel dysfunction (76.7%). Appropriate adjustment of background medication to manage breakthrough pain was reported by 95.5% of oncologists. Additionally, 87.7% (68.3% in the second wave, p = 0.035) of oncologists reported suitable opioid titration practices, and 90.4% reported to use co-adjuvant medications for neuropathic pain confidently. On the other hand, just 9.6% of oncologists participated in multidisciplinary pain management teams, and merely 30.3 and 27.1% reported to routinely collaborate with the Pain Clinics or involve other staff, respectively. Only 26.4% of the oncologists of the second wave gave priority to pain pathophysiology to decide therapies, and up to 75.6% reported difficulties in treating neuropathic pain. Significantly less oncologists of the second wave (82.9 vs. 94.5%, p = 0.001) used opioid rotation routinely.

CONCLUSIONS

Unlike in previous surveys, medical oncologists reported in general good knowledge and few perceived limitations and barriers for pain management. However, multi-disciplinary management and collaboration with other specialists are still uncommon. Oncologists' commitment to optimize pain management seems important to improve and maintain good practices.

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.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis

BACKGROUND

While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent.

OBJECTIVE

To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting.

METHODS

Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis.

RESULTS

The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter.

CONCLUSIONS

This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.

Communicating bodily changes: physicians' ways of enabling patient understanding in gastrointestinal cancer consultations

OBJECTIVE

To explore how physicians communicatively enable patients' understanding of bodily changes in gastrointestinal cancer care consultations.

METHOD

Two datasets were used. The first consisted of transcribed video-recorded palliative care consultations with three oncologists and six patients diagnosed with advanced gastrointestinal cancer, in the context of outpatient palliative care. The second dataset was audio-recorded transcriptions from diagnostic consultations with six surgeons and seven patients diagnosed with colorectal cancer, in the context of cancer surgery. An inductively driven and iterative analysis of interaction was performed, guided by Wetherell et al. (2001).

RESULTS

Two overarching communicative strategies were identified: (1) "visualizing strategies," with the dimensions: visible strategies (visualizing with what you actually or potentially can see), sensory strategies (visualizing with what is possible to feel), and imaginative strategies; and (2) "contrasting strategies," with the dimensions: contrasting subjective experiences and contrasting between the patient and other people.

SIGNIFICANCE OF RESULTS

The visualizing and contrasting communicative strategies form parts of physicians' tacit and experience-based knowledge. The strategies employed by physicians reveal clear potentials to enable patients' understanding and sense making of bodily changes. However, these strategies need to be explicated and problematized as parts of both consultation practice and basic medical education. By means of increased awareness, physicians can more easily identify turning points in patients' levels of understanding, thereby enriching ordinary medical consultations with reflected pedagogical strategies and skills in how to dialogue in a person-centered manner.

Utility, caller, and patient profile of a novel Chemotherapy Telephone Helpline service within a regional cancer centre in Northern Ireland

BACKGROUND

The telephone is an accepted and useful means of communication for the management of patient care. The Chemotherapy Telephone Helpline (CTH) service, located in a large inner-city Trust within the United Kingdom, is a unique nurse-led service within Northern Ireland.

OBJECTIVE

The objective of the study was to investigate the utility, caller, and patient profile of a novel CTH.

METHODS

This was a retrospective study of telephone contacts during 2007 to the CTH. Calls were categorized by caller and patient characteristics, reason for call, and subsequent action.

RESULTS

A total of 7498 calls were made to the CTH during 2007. Of these, 25.6% occurred outside 8AM-4PM. Callers included patients (45.8%), lay carers (31%), and health care professionals (20.5%); 35.2% of calls concerned patients with polysymptomatic problems; 36.8% of calls led directly to patients being medically assessed.

CONCLUSIONS

The utility of the CTH service confirms the need of this nurse-led service. This service facilitates access to specialist advice and support for patients, their families, and allied health care professionals.

IMPLICATIONS FOR PRACTICE

The international significance of these findings for practice includes its demonstration of the multifaceted symptom experience of patients receiving chemotherapy and highlights the importance of rapid access to specialist cancer services for patients and their lay and professional carers. In addition, it demonstrates the capacity of helplines to identify gaps in professional skills and training.

The meaning and significance of routine follow-up in lung cancer - a qualitative study of patients' experiences and interpretations

PURPOSE

Questions have been raised about the benefits of routine follow-up for patients with lung cancer and a number of studies have now explored alternative models of care for this patient group. This study explores the experiences of lung cancer patients attending routine follow-up and illustrates factors which might influence patients' interpretations of the meaning and significance of follow-up.

METHOD

This qualitative study was undertaken to gain insight into patients' experiences of attending routine follow-up clinics after treatment completion. A purposive sample of ten patients was interviewed, including patients of both genders, different lung cancer types, treatment intent, treatment received, performance status and experience of follow-up.

RESULTS

Analysis of the transcripts revealed patients' confidence and faith in their consultants and the importance of having a connection with the oncology department. The meaning and significance of follow-up is constructed by what they bring to the consultation (anxiety, vulnerability, uncertainty, symptoms) as well as what happens within that consultation (reassurance, relief, encouragement). Although some participants were anxious about attending, all express expectation and desire for follow-up to continue. Many were, however, prepared to consider nurse-led follow-up.

CONCLUSION

Although small, this study highlights the significance that patients with lung cancer attach to attending follow-up clinics and the need to consider patients' experiences in the design of future follow-up care and also consideration should be given to complementary and innovative approaches to follow-up.