Breast Cancer Patients' Preferences for Truth Versus Hope Are Dynamic and Change During Late Lines of Palliative Chemotherapy

Patient, Relative and Staff Experiences of Clinical Trial Participation in Neurooncology: "Maybe You Can Also Show the Positive, No Matter How It Ends"

Purpose

There is a lack of evidence regarding how patients with malignant brain tumor and their relatives experience participation in neurooncological clinical trials. Similarly, insights from the perspective of trial staff caring for this group of patients are missing. This study aims to investigate patient, relative and trial staff experiences regarding participation in clinical neurooncological trials.

Methods

Within a qualitative exploratory study, 29 semi-structured interviews with brain tumor patients, relatives and trial staff were conducted and analyzed using reflexive thematic analysis (RTA) by Braun and Clarke. A patient researcher and patient council were involved in data analysis and interpretation.

Results

Four themes were developed reflecting significant aspects of the trial experience: 1. "It all revolves around hope"; 2. "Trial participation: experiencing unique medical care"; 3. "Everyone's roles are changing"; 4. "Communication as a possible area of conflict". Experiencing trial participation and general medical treatment were found to be interconnected to such a degree that they were often not meaningfully distinguished by patients and relatives.

Conclusion

In addition to assessing traditional endpoints for patient outcomes, we recommend increased emphasis on investigating the impact of the "soft" components constituting trial participation. Due to the interconnectedness of medical treatment and trial participation, we recommend further investigation in comparison to experiences in regular care. A deeper understanding of trial participation is needed to inform improvements for patient experiences and staff satisfaction alongside medical and scientific progress.

Palliative care in the treatment of women with breast cancer: A scoping review

OBJECTIVES

Recent studies on the quality of life in women with breast cancer show a high prevalence of signs and symptoms that should be the focus of palliative care (PC), leading us to question the current role they play in addressing breast cancer. Therefore, the objective of this review is to map the scope of available literature on the role of PC in the treatment of women with breast cancer.

METHODS

This is a methodologically guided scoping review by the Joanna Briggs Institute and adapted to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) Checklist for report writing. Systematic searches were conducted in 8 databases, an electronic repository, and gray literature. The searches were conducted with the support of a librarian. The study selection was managed through the RAYYAN software in a blind and independent manner by 2 reviewers. The extracted data were analyzed using the qualitative thematic analysis technique and discussed through textual categories.

RESULTS

A total of 9,812 studies were identified, of which only 136 articles and 3 sources of gray literature are included in this review. In terms of general characteristics, the majority were published in the USA (35.7%), had a cross-sectional design (44.8%), and were abstracts presented at scientific events (19.6%). The majority of interventions focused on palliative radiotherapy (13.6%). Thematic analysis identified 14 themes and 12 subthemes.

SIGNIFICANCE OF RESULTS

Our findings offer a comprehensive view of the evidence on PC in the treatment of breast cancer. Although a methodological quality assessment was not conducted, these results could guide professionals interested in the topic to position themselves in the current context. Additionally, a quick synthesis of recommendations on different palliative therapies is provided, which should be critically observed. Finally, multiple knowledge gaps are highlighted, which could be used for the development of future studies in this field.

Patient-caregiver dyad concordance of transition readiness assessment for adolescent with cancer: A network analysis

AIMS

The concordance of adolescents with cancer and caregivers was examined, and the core elements of transition readiness were identified.

METHODS

In this cross-sectional study, 196 adolescent-caregiver dyads completed the Chinese version of Self-Management and Transition to Adulthood with Rx = Treatment Questionnaire and its parent version between March 2023 and August 2023. Intraclass correlation coefficients, paired t-tests and network analysis were used for data analysis.

RESULTS

Caregivers reported slightly lower scores for transition readiness than adolescents (3.28 vs. 3.32). Healthcare engagement and provider communication were core elements in transition readiness networks. At the dyad level, agreement between adolescents' and caregivers' transition readiness ranged from poor to fair (intraclass correlation coefficients 0.103-0.486), and a significant difference in structure was found between the two networks.

CONCLUSIONS

Caregivers tended to underestimate adolescents' transition readiness. Attaining better concordance between adolescents and family caregivers is critical to aligning roles and responsibilities in the transition process.

IMPLICATIONS FOR PAEDIATRIC CANCER CARE

This study extends the evidence on the variation in adolescents' transition readiness, clarifying the complex associative relationships among the elements of transition readiness, which can be potential pathways for improving transition readiness. Second, this study is the first to assess transition readiness from a dyad's perspective. The findings highlighted the patient-caregiver incongruence in rating patients' transition readiness, suggesting that targeted dyadic interventions should be developed and implemented to improve patient-caregiver transition readiness concordance, facilitate effective communication and mutuality between patients and caregivers, and contribute to their collaboration during the transition of adolescents and optimization of outcomes. WHAT PROBLEM DID THE STUDY ADDRESS?: Increased long-term survival rates of survivors of paediatric cancer highlighted the significant need for care continuity. Transitional readiness is an important predictor of adolescent survivor's ability to adapt to a long-term survival period. Assessments of adolescents' transition readiness are limited and overlook the synergies between family caregivers and adolescents in the transition period. WHAT WERE THE MAIN FINDINGS?: The levels of agreement on rating transition readiness varied from poor to fair among adolescent-caregiver dyads, and caregivers tended to underestimate adolescents' transition readiness. The findings highlighted the patient-caregiver incongruence in rating patients' transition readiness. Targeted dyadic interventions should be developed and implemented to improve patient-caregiver's transition readiness concordance, and facilitate effective communication and mutuality between patients and caregivers.

REPORTING METHOD

Study methods and results reported in adherence to the STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patients or members of the public were involved in the study.

CONTRIBUTION TO THE WIDER GLOBAL CLINICAL COMMUNITY

The main findings introduce pathways for improving transition readiness, which can enhance healthcare transition among other medical populations.

Cultivating Relationship-Centered Care: Patient, Caregiver, and Provider Communication Preferences for and Experiences with Prognostic Conversations

Prognostic conversations present many challenges for patients, caregivers, and providers alike. Most research examining the context of prognostic conversations have used a more siloed approach to gather the range of perspectives of those involved, typically through the lens of patient-centered care. However, the mutual influence evident in prognostic conversations suggests a relationship-centered care model may be useful in cancer communication research. Similarities and differences in preferences for and experiences with prognostic conversations among oncology patients, caregivers, and providers (N = 32) were explored. Identified themes were then mapped to the principles of the relationship-centered care framework to extend our understanding of prognostic conversations and contribute to a new direction in the application of relationship-centered care. Findings suggest fewer similarities than differences, point to important discrepancies among participant perspectives, and reinforce the utility of relationship-centered care in identifying communication practices that enhance the prognostic conversation experience.

Transition readiness of adolescents with cancer: A cross-sectional study based on self-determination theory

PURPOSE

This study aimed to assess the transition readiness of adolescents with cancer in central China and to explore the paths associated with transition readiness based on self-determination theory (SDT).

METHODS

Self-management and transition to adulthood with Rx = treatment questionnaire, patient activation measure, perceived social support scale and general self-efficacy scale were used to measure transition readiness as well as constructs pertaining to SDT (competence, relatedness and autonomy). The factors influencing transition readiness were evaluated using multiple linear regression. Models 4 and 6 in PROCESS Macro 3.3 were used to test the mediating effects and chain mediating effects, respectively.

RESULTS

A total of 217 adolescents with cancer were included; their mean transition readiness score was 59.95 (11.34). Age (t = 6.086, p < 0.000), duration of diagnosis (t = 2.218, p = 0.028), completion of treatment (t = -2.036, p = 0.043), insurance, and competence (t = 11.149, p < 0.000) were significantly associated with transition readiness. The direct effects of self-efficacy and perceived social support on transition readiness were not significant. However, two chain mediating paths were observed: perceived social support - self-efficacy - patient activation - transition readiness and self-efficacy - perceived social support - patient activation - transition readiness; the effect values of these paths were 0.0678 and 0.0703, respectively.

CONCLUSIONS

The findings of this study add to the evidence supporting the use of SDT-related constructs to promote transition readiness among adolescents with cancer, highlight the importance of encouraging patient activation, and clarify the ancillary roles of social support and self-efficacy in patient activation development during transitional period.

Symptoms and quality of life among men starting treatment for metastatic castration-resistant prostate cancer - a prospective multicenter study

BACKGROUND

Men with metastatic castration-resistant prostate cancer (mCRPC) have an incurable disease. Along with prolonging life, symptom management is one of the main goals with treatment. This is also important from a palliative care perspective where the life prolonging outcomes should be balanced with quality of life (QoL) in this late phase. It is also essential in symptom management to view different dimensions of symptoms, for example how severe or distressing symptoms are, to support best QoL. Therefore, more knowledge is needed about the symptom experience when these treatments are initiated and thus the aim of this study was to describe different dimensions of symptoms in men with mCRPC starting their first-line of life-prolonging treatment, and to describe the association between symptom burden and QoL.

METHODS

Baseline data from a prospective longitudinal study of 143 men with mCRPC starting their first-line life-prolonging treatment were used. Symptoms were measured using the Memorial Symptom Assessment Scale (MSAS) and global QoL was measured by the EORTC QLQ C-30. Data was analyzed using descriptive- and multivariable linear regression analyses.

RESULTS

On average, the men had more than 10 symptoms (range 0-31 of 33). 50% or more reported sweats, lack of energy, pain, problems with sexual activity and sexual desire. The symptoms they reported as most severe, or most distressing were not always the ones that were reported as most frequent. There was an association between QoL and physical symptoms, and also between QoL, and analgesic use and prostate-specific antigen (PSA) values.

CONCLUSION

Even if some men with mCRPC report many symptoms, the dimensions of severity and distress levels vary, and the most frequent symptoms was not always the most burdensome or distressing. There was an association between high physical symptom burden and QoL, suggesting that it is not the number of symptoms that affects QoL but rather the subjective perceived impact of the physical symptoms experienced. The knowledge of how men with mCRPC experience and perceive their symptoms may help health care professionals in symptom management aiming to improve QoL, which is a cornerstone in integrating early palliative care.

Harmful communication behaviors in cancer care: A systematic review of patients and family caregivers perspectives

OBJECTIVE

Issues regarding clinician communication remain an important source of complaints within healthcare. This systematic review aims to determine cancer patients' and their family caregivers' views on which clinicians' communication behaviors can harm (i.e. eliciting negative feelings/consequences for patients/family caregivers).

METHODS

We searched for all types of peer-reviewed studies that determined adult (≥18 years) cancer patients' and/or family caregivers' perspectives on which clinicians' communication behaviors can harm in several databases (PubMed, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO and Academic Search Premier), supplemented by expert-consultation. Studies were screened using the Artificial intelligence screening tool of ASReview and data was analyzed using Thematic Analysis. To assess the quality of the studies the Qualsyst critical appraisal tool was used.

RESULTS

A total of 47 studies were included. Four main themes of harmful communication behaviors were identified: (1) Lack of tailored information provision (e.g. giving too little or too much/specific information) (2) Lack of tailored decision making (ranging from; patient exclusion, to the patients' responsibility, and/or haste) (3) Lack of feeling seen and heard (seen as a disease, not as a human being; not listened to concerns and emotions) (4) Lack of feeling held and remembered (forgotten agreements; lack of care continuity).

CONCLUSIONS

Our results reveal an overview of patients' and family caregivers' perspectives on which clinicians' communication behaviors can harm. Harm could be prevented when information and decision involvement are tailored and patients' and family caregivers' needs to feel seen, heard, held and remembered are met.

Effective communication in palliative care from the perspectives of patients and relatives: A systematic review

OBJECTIVES

In palliative care, effective communication is essential to adequately meet the needs and preferences of patients and their relatives. Effective communication includes exchanging information, facilitates shared decision-making, and promotes an empathic care relationship. We explored the perspectives of patients with an advanced illness and their relatives on effective communication with health-care professionals.

METHODS

A systematic review was conducted. We searched Embase, Medline, Web of Science, CINAHL, and Cochrane for original empirical studies published between January 1, 2015 and March 4, 2021.

RESULTS

In total, 56 articles on 53 unique studies were included. We found 7 themes that from the perspectives of patients and relatives contribute to effective communication: (1) open and honest information. However, this open and honest communication can also trigger anxiety, stress, and existential disruption. Patients and relatives also indicated that they preferred (2) health-care professionals aligning to the patient's and relative's process of uptake and coping with information; (3) empathy; (4) clear and understandable language; (5) leaving room for positive coping strategies, (6) committed health-care professionals taking responsibility; and (7) recognition of relatives in their role as caregiver. Most studies in this review concerned communication with physicians in a hospital setting.

SIGNIFICANCE OF RESULTS

Most patients and relatives appreciate health-care professionals to not only pay attention to strictly medical issues but also to who they are as a person and the process they are going through. More research is needed on effective communication by nurses, in nonhospital settings and on communication by health-care professionals specialized in palliative care.

Hope in the context of life-threatening illness and the end of life

Recent research shows the importance of hope in the context of life-threatening illness and the end of life for patients and their families. While some patients and family members continue to hope for a cure or extending life, others may develop more complex hopes related to quality of life and making the most of the time left. Clinicians often worry about taking hope away with bad news about the patient's prognosis, but patients and family members often appreciate honesty without losing hope. Clinicians should recognize that hopes in the context of serious, progressive illness may be complex, contradictory, culturally based, and evolve over time. Recent interventions have been developed to support hope for these patients, caregivers, and parents.

Discussing Difficult News: Reframing Patient and Family Preferences Surrounding the Content and Style of Communication

Uncomfortable conversations transcend medicine across all sites of care and at all stages of a serious illness. From discussion of prognosis or prognostic uncertainty, to evaluation of competing treatment options, to disclosure of medical errors, to consideration of potentially toxic treatments, clinicians must approach such conversations with sensitivity to a patient's cognitive, emotional, spiritual, and cultural needs. Conversations small and large may be seen as "difficult" by a patient or their family, and there may be discordant views of the perceived "difficulty" of a conversation from the perspective of the medical team as compared to the patient or family.

Characteristics of patients with advanced cancer preferring not to know prognosis: a multicenter survey study

Background

For some patients with advanced cancer not knowing prognosis is essential. Yet, in an era of informed decision-making, the potential protective function of unawareness is easily overlooked. We aimed to investigate 1) the proportion of advanced cancer patients preferring not to know prognosis; 2) the reasons underlying patients’ prognostic information preference; 3) the characteristics associated with patients’ prognostic information preference; and 4) the concordance between physicians’ perceived and patients’ actual prognostic information preference.

Methods

This is a cross-sectional study with structured surveys (PROSPECT). Medical and thoracic oncologists included patients (n = 524), from seven Dutch hospitals, with metastatic/inoperable cancer and an expected median overall survival of ≤ 12 months. For analysis, descriptive statistics and logistic regression models were used.

Results

Twenty-five to 31% of patients preferred not to know a general life expectancy estimate or the 5/2/1-year mortality risk. Compared to patients preferring to know prognosis, patients preferring unawareness more often reported optimism, avoidance and inability to comprehend information as reasons for wanting limited information; and less often reported expectations of others, anxiety, autonomy and a sense of control as reasons for wanting complete information. Females (p < .05), patients receiving a further line of systemic treatment (p < .01) and patients with strong fighting spirit (p < .001) were more likely to prefer not to know prognosis. Concordance between physicians’ perceived and patients’ actual prognostic information preference was poor (kappa = 0.07).

Conclusions

We encourage physicians to explore patients’ prognostic information preferences and the underlying reasons explicitly, enabling individually tailored communication. Future studies may investigate changes in patients’ prognostic information preferences over time and examine the impact of prognostic disclosure on patients who prefer unawareness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09911-8.

Delivering Bad News

Giving bad news is a recurrent and predictable task in our lives as humans interacting with other humans. This article presents frameworks and best practices that can help us to deliver bad news in health care in a way that is experienced as caring and empathic, and supports the patient as they adjust to their new reality. Key skills include responding to patients' emotions empathically, structuring bad news conversations, leading with an exploration of the patient's understanding and expectations, delivering the bad news clearly and concisely, and individualizing the balance of empathy and support with providing information and developing a plan.

Palliative oncology and palliative care

New therapeutic approaches can produce promising results even in severely ill cancer patients. But they also pose new challenges with respect to prognostication, as patients who were once not eligible for treatment, due to age or comorbidities, now are. Palliative oncology constitutes a major part of oncological care, with life prolongation and quality of life as its main goals. Palliative care specialists are experts in symptom control and psychosocial and existential support, and the integration of their expertise early on in patient care can prolong survival. In this article, I discuss the need to integrate specialist palliative care into early cancer treatment plans to achieve quality of life for patients. I also discuss the ways in which palliative care specialists balance the benefits of novel treatments against their adverse effects for patients, particularly for the elderly, the frail and those in advance stages of disease. I highlight the need to ensure equal access to palliative care to improve cancer patients' quality of life but also why futile, burdensome treatments should be avoided especially in the frail, elderly patients. Further, I discuss benefits and problems related to nutritional support in patients with cachexia and exemplify why translational research is needed to link basic research with clinical oncology and effective symptom control.

Anticancer Treatment Goals and Prognostic Misperceptions among Advanced Cancer Outpatients

(1) Background: In the context of cancer incurability, the communication processes involving clinicians and patients with cancer are frequently complex. (2) Methods: A cross-sectional study that investigated outpatients with advanced cancers and their oncologists. Both were interviewed immediately after a medical appointment in which there was disease progression and/or clinical deterioration, and were asked about the patient’s chance of curability and the goals of the prescribed cancer treatment. The patients were asked whether they would like to receive information about prognosis and how they would like to receive it. The analyses of agreement on perceptions were performed using the Kappa’s test. (3) Results: the sample consisted of 90 patients and 28 oncologists. Seventy-eight (87.6%) patients answered that they wanted their oncologist to inform them about their prognosis; only 35.2% (n = 31) of them said they received such information at their present appointment. Regarding how they would prefer prognostic disclosure, 61.8% (n = 55) mentioned that the oncologist should consider ways to keep the patient’s hope up; 73% (n = 65) of the patients reported odds >50% of cure. The agreement between oncologists’ and their patients’ perceptions regarding the treatment goals and curability was slight (k = 0.024 and k = 0.017, respectively). (4) Conclusions: The perceptions of patients and their oncologists regarding the goals of treatment and their chances of cure were in disagreement. New approaches are needed to improve the communication process between oncologists and patients with advanced cancer.

The Association Between Hormone Receptor Status and End-of-Life Care Among Patients With Metastatic Breast Cancer

BACKGROUND

In metastatic breast cancer (MBC), positive estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status allow for more long-term, sequential treatment options compared to ER-negative and HER2-negative diseases. It is unclear if end-of-life care (timely integration of palliative care, discontinuation of chemotherapy, and enrollment into hospice) in MBC is now tailored to the ER and HER2 status.

OBJECTIVES

This article explores the association between ER and HER2 status and the quality of end-of-life care received among patients with MBC.

METHODS

A 20-year MBC clinical database captured demographics, tumor characteristics, and treatment histories of deceased patients with MBC (N = 1,258) at a tertiary hospital located in Pittsburgh, Pennsylvania. Descriptive and inferential statistics were used.

FINDINGS

Patients with ER-positive MBC had greater odds of receiving quality end-of-life care than those with ER-negative MBC. HER2 status was not associated with differences in the quality of end-of-life care.

Prognostic disclosure in cancer care: a systematic literature review

Background:

Collusion in cancer care is the diplomatic concealment of information between a triad of the health care professional (HCP), patient, and caregiver. Free and expressive communication is determined by multiple factors, which establishes a healthy balance between ‘patient-centric’ and ‘family-centric’ decision making. The lack of a universal approach to prognostic disclosure techniques emphasizes the need for a systematic review of contemporary practice.

Methods:

A systematic review of the literature was conducted till June 2020 using themes based on cancer, communication, prognostic disclosure, and collusion by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:

Fifty-three studies involving 10,569 subjects were studied for their utility on prognostic disclosure using different communication methods and interfaces. Twenty-three studies used a face-to-face interview with subjects while in-person telephonic interviews were conducted in two studies, 16 studies implicated semi-structured questionnaires, and 6 studies mentioned the development of a new technique/tool for disclosure. The duration of a session for prognosis-disclosure ranged from 22 min to 1 h. The involvement of palliative care specialists and mental health professionals was limited during the disclosure of the prognosis.

Conclusion:

The findings of the review indicate that patients in cancer care are aware of their diagnosis and to a certain extent of prognosis despite nondisclosure by their family members and treating teams. This review emphasizes the assessment of ‘disclosure wishes’ among patients and caregivers in separate interviews rather than simply relying on one specific method of interviewing. The nonconfrontational approach and training among HCPs are of utmost importance to build therapeutic resilience among the treating team involved in cancer care. Since many factors such as family wishes, cultural dissonance, medical model, and patient perception could become barriers to prognostic disclosure, there is a need to develop a universal approach to prognostic disclosure and handling associated collusion.

Information provision to older patients receiving palliative chemotherapy: a quality study

OBJECTIVES

Cancer treatment has become increasingly successful. However, prolonging and preserving life has become an important goal of therapy since many patients generally receive palliative chemotherapy. The perception of life changes when patients are informed, that no curative treatment is possible. This raises new dilemmas for patients with incurable cancer, but only sparse information is available about the thoughts of these patients.The aim of this study was to explore how older patients experience the information on absence of curative treatment options.

METHODS

Qualitative interviews were performed in eleven older patients with incurable upper gastrointestinal cancer receiving first-line palliative chemotherapy. Median age was 74 (65-76) years. We used a qualitative approach to collect data through semistructured individual interviews conducted at the hospital or by telephone interviews by an experienced researcher. The thematic analysis was conveyed by Braun and Clarke.

RESULTS

The interview findings were grouped around three main themes: hope of being cured, hearing but not comprehending, and desired milestones to reach. Further, it was determined that patients hid their feelings and avoided talking about the disease with the health professionals due to fear of being told the truth.

CONCLUSIONS

Receiving information about their incurable cancer was an ongoing dilemma for the patients. Following the message, patients shared thoughts about reaching important milestones in life, spending time with their family or hope for a cure to be found.

Mind your words: Oncologists' communication that potentially harms patients with advanced cancer: A survey on patient perspectives

BACKGROUND

Many complaints in medicine and in advanced illnesses are about communication. Little is known about which specific communications harm. This study explored the perspectives of patients with advanced cancer about potentially harmful communication behaviors by oncologists and helpful alternatives.

METHODS

An online survey design was used that was based on literature scoping and patient/clinician/researcher input. Patients with advanced cancer (n = 74) reflected on the potential harmfulness of 19 communication situations. They were asked whether they perceived the situation as one in which communication could be harmful (yes/no). If they answered "yes," they were asked whether they perceived the examples as harmful (yes/no) or helpful (yes/no) and to provide open comments. Results were analyzed quantitatively and qualitatively (content analysis).

RESULTS

Communication regarding information provision, prognosis discussion, decision-making, and empathy could be unnecessarily potentially harmful, and this occurred in various ways, such as making vague promises instead of concrete ones (92%), being too directive in decision-making (qualitative), and not listening to the patient (88%). Not all patients considered other situations potentially harmful (eg, introducing the option of refraining from anticancer therapy [49%] and giving too much [prognostic] information [60%]). Exploring each individual patients' needs/preferences seemed to be a precondition for helpful communication.

CONCLUSIONS

This article provides patient perspectives on oncologists' unnecessarily potentially harmful communication behaviors and offers practical tools to improve communication in advanced cancer care. Both preventable pitfalls and delicate challenges requiring an individualized approach, where exploration might help, are described. Although providing difficult and unwelcome news is a core task for clinicians, this study might help them to do so while preventing potentially unnecessary harm.

Mediator Roles of Social Support and Hope in the Relationship Between Body Image Distress and Resilience in Breast Cancer Patients Undergoing Treatment: A Modeling Analysis

Breast cancer and its treatment are particularly distressing for patients because of their potential impacts on body image. The most difficult phase of cancer treatment is usually the first year after a diagnosis. Cancer patients with strong resilience have the positive attitude, internal strength and external resources needed to cope with the disease and its treatment. This cross-sectional study investigated the mediator roles of hope and social support in the association between body image distress and resilience. A structured questionnaire was used to collect data for a convenience sample of 141 breast cancer patients undergoing treatment in southern Taiwan. Structural equation modeling was used for data analysis. The results showed that the final model had a good fit to the data and accounted for 51% of the total variance in resilience. The model of multiple parallel mediators of resilience revealed that hope and social support had mediator roles in the effect of body image distress on resilience. Hope had an important partial mediating role in the association between body image distress and resilience. Social support also had a partial mediating role in the relationship between body image distress and resilience. Social support did not directly affect resilience and indirectly affected resilience through hope. Psychosocial interventions aimed at reducing the impact of body image distress and increasing resilience in breast cancer patients should focus on cultivating hope and increasing social support, particularly support from family members and health professionals.

Addressing challenges in information-provision: a qualitative study among oncologists and women with advanced breast cancer

BACKGROUND

There is a need for more insight into how to address challenges of information-provision for women with advanced breast cancer. We aimed to explore oncologists' and patients' views on (i) the challenges of information-provision, and (ii) possible strategies to address these challenges, meanwhile (iii) exploring the possible facilitating role of positive expectations and empathy.

METHODS

Semi-structured interviews were held with oncologists (n = 10) and women with advanced breast cancer (n = 14). Principles of Thematic Analysis were followed, with two researchers analyzing transcribed data, supported by Atlas.ti software.

RESULTS

Taken together the data from oncologists and patients, we found that when communicating with patients with advanced cancer, oncologists face challenges, including handling patients' unrealistic disease (status) beliefs, and choosing approaches for discussing available treatment options and their side effects. Possible strategies to address these challenges include balancing information with acceptance of denial, and using medical expertise to guide treatment discussions. A sensitive issue is whether to discuss the option of no anti-cancer treatment. Meanwhile, approaches and preferences for discussions of side effects vary. Positive expectations and empathy can facilitate information-provision by creating space and helping patients to open up more.

CONCLUSIONS

Integrating oncologists' and patients' views, oncologists can provide realistic information while also, temporarily, accepting denial, and can use their medical expertise to address challenges around unrealistic beliefs and discussion of treatment options. Finding ways to tailor discussions of no anti-cancer treatment and side-effect information are needed. Positive expectations and empathy might facilitate - tailored - information-provision, leading ultimately to patient-centered care lying at the heart of medicine.

The experiences of health professionals, patients, and families with truth disclosure when breaking bad news in palliative care: A qualitative meta-synthesis

Objective

Disclosing the truth when breaking bad news continues to be difficult for health professionals, yet it is essential for patients when making informed decisions about their treatment and end-of-life care. This literature review aimed to explore and examine how health professionals, patients, and families experience truth disclosure during the delivery of bad news in the inpatient/outpatient palliative care setting.

Methods

A systemized search for peer-reviewed, published papers between 2013 and 2020 was undertaken in September 2020 using the CINAHL, Medline, and PsycInfo databases. The keywords and MeSH terms (“truth disclosure”) AND (“palliative care or end-of-life care or terminal care or dying”) were used. The search was repeated using (“bad news”) AND (“palliative care or end-of-life care or terminal care or dying”) terms. A meta-synthesis was undertaken to synthesize the findings from the eight papers.

Results

Eight papers were included in the meta-synthesis and were represented by five Western countries. Following the synthesis process, two concepts were identified: “Enablers in breaking bad news” and “Truth avoidance/disclosure.” Several elements formed the concept of Enablers for breaking bad news, such as the therapeutic relationship, reading cues, acknowledgment, language/delivery, time/place, and qualities. A conceptual model was developed to illustrate the findings of the synthesis.

Significance of results

The conceptual model demonstrates a unique way to look at communication dynamics around truth disclosure and avoidance when breaking bad news. Informed decision-making requires an understanding of the whole truth, and therefore truth disclosure is an essential part of breaking bad news.

An Artificial Intelligence-Enabled Pipeline for Medical Domain: Malaysian Breast Cancer Survivorship Cohort as a Case Study

Automated artificial intelligence (AI) systems enable the integration of different types of data from various sources for clinical decision-making. The aim of this study is to propose a pipeline to develop a fully automated clinician-friendly AI-enabled database platform for breast cancer survival prediction. A case study of breast cancer survival cohort from the University Malaya Medical Centre was used to develop and evaluate the pipeline. A relational database and a fully automated system were developed by integrating the database with analytical modules (machine learning, automated scoring for quality of life, and interactive visualization). The developed pipeline, iSurvive has helped in enhancing data management as well as to visualize important prognostic variables and survival rates. The embedded automated scoring module demonstrated quality of life of patients whereas the interactive visualizations could be used by clinicians to facilitate communication with patients. The pipeline proposed in this study is a one-stop center to manage data, to automate analytics using machine learning, to automate scoring and to produce explainable interactive visuals to enhance clinician-patient communication along the survivorship period to modify behaviours that relate to prognosis. The pipeline proposed can be modelled on any disease not limited to breast cancer.

Suffering experiences of people with cancer undergoing chemotherapy: A meta-ethnographic study

This meta-ethnography had the objectives of identifying, evaluating, and summarizing the findings of qualitative studies regarding the suffering experiences of people undergoing chemotherapy, as well as developing an explanatory conceptual structure regarding what affects these experiences. A systematic literature review was carried out, covering the past 10 years, in the following databases: CINAHL, Embase, Medline, LILACS and Scopus. By using meta-ethnographic synthesis methods, the following themes were found: the pain of loss; evaluating, measuring, and neutralizing the threat; and social contours of suffering. The experience of living with cancer and undergoing chemotherapy was synthesized into a theoretical-explanatory model with a structure that resembles barbed-wire loops. The model expresses people's suffering experiences as marked by the feeling of loss, restraint of emotions, and resilience. While transcendent movements broke the cycle of suffering, resilience emerged as a learning experience that made patients more resistant to the pain of loss. The results indicated a complex and diverse set of factors that influence suffering, which confirmed that experiences are individual, comprehensive, and continuously reinterpreted.

Exploring the experience of recurrence with advanced cancer for people who perceived themselves to be cancer free: a grounded theory study

PURPOSE

Advances in cancer treatment have led to longer cancer-free periods and overall survival. This study aimed to understand patients' experiences of transitioning out of a state of believing to be cancer free into incurable recurrence with advanced disease.

METHODS

Using constructivist grounded theory with in-depth interviews patients (n = 15) with solid tumors from a major US cancer center participated. Theoretical sampling enabled concepts to be developed until theme saturation. Constant comparative analysis used initial and focused coding to develop themes and concepts to describe this specific period from extended time cancer free and transition to advanced incurable disease.

RESULTS

Three interrelated concepts were identified: reluctant acceptance, seeking survival through continuous treatment, and hope in the face of an uncertain future. A conceptual model of the experience was developed encompassing anger and sadness, at initial recurrence, to reluctant acceptance, and, finally, a cycle of seeking continuous treatment to prolong life leading to a sense of hope in the face of an uncertain future.

CONCLUSION

The cycle between treatment and hope creates a state of personal equilibrium, which provides insights into the importance of treatment for this population. This study provides direction for future research to understand the expectations of people experiencing advanced cancer recurrence.

IMPLICATIONS FOR CANCER SURVIVORS

Many cancer survivors live with advanced cancer. Assessing their needs as they transition from survivor with no disease to survivor with advanced disease requires a new conceptualization of the experience which recognizes expectations and priorities for care of this patient group.

Rehabilitation for Cancer Patients in Inpatient Hospices/Palliative Care Units and Achievement of a Good Death: Analyses of Combined Data From Nationwide Surveys Among Bereaved Family Members

CONTEXT

In end-of-life care, rehabilitation for patients with cancer is considered to be an important means for improving patients' quality of death and dying.

OBJECTIVES

To determine whether the provision of rehabilitation for patients with cancer in palliative care units is associated with the achievement of a good death.

METHODS

This study involved a cross-sectional, anonymous, and self-report questionnaire survey of families of patients with cancer who died in palliative care units in Japan. We evaluated the short version of Good Death Inventory (GDI) on a seven-point scale. A logistic regression model was used to calculate the propensity score. Covariates included in this model were survey year, patients' characteristics, and families' characteristics. The associations between rehabilitation and GDI were tested using trend tests after propensity score matching adjustment.

RESULTS

Of the 1965 family caregivers who received the questionnaires, available data were obtained from 1008 respondents (51.2%). Among them, 285 (28.2%) cases received rehabilitation in palliative care units. There was no difference in total GDI score between the groups with and without rehabilitation. In exploratory analyses, patients receiving rehabilitation were significantly more likely to feel maintaining hope and pleasure (mean 4.50 [SE 0.10] vs. 4.05 [0.11], respectively; effect size [ES] 0.31; P = 0.003), good relationships with medical staff (mean 5.67 [SE 0.07] vs. 5.43 [0.09], respectively; ES 0.22; P = 0.035), and being respected as an individual (mean 6.08 [SE 0.06] vs. 5.90 [0.07], respectively; ES 0.19; P = 0.049) compared with patients not receiving rehabilitation.

CONCLUSION

Rehabilitation in palliative care units may contribute to several domains of quality of death and dying, particularly maintaining hope and pleasure. Further research is needed to investigate whether palliative rehabilitation contributes to the achievement of a good death.

Dying From COVID-19: Loneliness, End-of-Life Discussions, and Support for Patients and Their Families in Nursing Homes and Hospitals. A National Register Study

CONTEXT

Preparation for an impending death through end-of-life (EOL) discussions and human presence when a person is dying is important for both patients and families.

OBJECTIVES

The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from coronavirus disease 2019 (COVID-19), comparing deaths in nursing homes and hospitals.

METHODS

The national Swedish Register of Palliative Care was used. All expected deaths from COVID-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019).

RESULTS

A total of 1346 expected COVID-19 deaths in nursing homes (n = 908) and hospitals (n = 438) were analyzed. Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (P < 0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, P < 0.001), and dying with someone present was much more uncommon (59% vs. 83%, P < 0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, P < 0.0001), and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, P < 0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (P < 0.001). The corresponding figures for staff were 52% and 38% (P < 0.0001).

CONCLUSION

Dying from COVID-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.