Development of a web-based, patient-centered decision aid for oropharyngeal cancer treatment

Exploring the state of shared decision-making in head and neck oncology: Assessing treatment communication

OBJECTIVE

To explore the state of shared decision-making (SDM) in head and neck (HN) oncology by investigating the extent to which SDM is currently employed by HN surgeons and how the perceived levels of SDM relate to the observed levels of SDM. Additionally, surgeon and patient perspectives on patient involvement in SDM and potential associations with observed levels of SDM were explored.

METHODS

Perceived level of SDM and patient involvement were measured by SDM-Q-9/SDM-Q-Doc resp. Control Preference Scale. Observed SDM was measured by analyzing audiotaped consultations (N = 42) using the OPTIONmcc+ instrument. Univariate linear analyses were conducted to identify possible associations with surgeon-observed SDM.

RESULTS

Median perceived SDM scores of surgeons (74.4 %) and patients (71.1 %) were relatively high, whereas observed median OPTION-scores were moderate (surgeons 48 %, patients 42 %, caregivers 24 %). Consultation time and patient OPTION-score were positively associated with surgeon OPTION-score.

CONCLUSION

Surgeons and patients seem to overestimate the extent of SDM compared to the observed reality. Patients' goals, values and preferences need to be addressed more during consultations.

PRACTICE IMPLICATIONS

The findings can be used to raise awareness of SDM among surgeons to improve their skills. Routine training in medical education can benefit from effective integration of SDM principles during consultations.

"I Wish This Tool Was Available to Me Sooner": Piloting a Workplace Autism Disclosure Decision-Aid Tool for Autistic Youth and Young Adults

Background

For autistic youth and young adults, deciding whether to disclose their autism at work may be complex since they are newly entering the workforce and are at an impressionable developmental period. Decision-aid tools can help someone make a choice regarding a topic/situation. We developed a workplace autism disclosure decision-aid tool called DISCLOSURE (Do I Start the Conversation and Let On, Speak Up, and REveal?) to support autistic youth and young adults navigate disclosure decision-making. In this study, we aimed to assess the DISCLOSURE tool's (1) impact on decision-making and self-determination capabilities and (2) usability, feasibility, and acceptability.

Methods

This was a single-arm pre-post pilot study. The DISCLOSURE tool comprises three interactive PDF documents and videos. Thirty participants (mean age of 23.5 years) completed online surveys before and after interacting with the DISCLOSURE tool. We used descriptive statistics for usability, feasibility, and acceptability. We calculated the Wilcoxon signed rank and paired t-tests to determine pre-post changes in decision-making and self-determination capabilities (Decisional Conflict Scale-Low Literacy Version [DCS-LL]; adapted Arc's Self-Determination Scale). We analyzed open-ended data using conventional (inductive) content analysis.

Results

There were significant decreases in DCS-LL total and subscale scores (p < 0.0001) and a significant increase in Arc's total score (p = 0.01), suggesting important improvements. There were no significant increases for Arc's psychological empowerment and self-realization subscales (p = 0.05; p = 0.09). Median scores (4.0/5.0) indicate that participants agreed that the DISCLOSURE tool is acceptable, feasible, and meets the usability criteria. We developed four categories to describe the open-ended data: (1) disclosure capabilities, (2) the role of others, (3) positive tool impact and feedback, and (4) minimal tool impact and constructive feedback.

Discussion

Findings are suggestive of the DISCLOSURE tool's ability to support workplace autism disclosure decision-making. Future studies should ascertain the DISCLOSURE tool's effectiveness, explore others' feedback (e.g., employers), and how to incorporate the tool into relevant employment and vocational programs.

Decisional Conflict and Decision Regret in Head and Neck Oncology: A Systematic Review and Meta-Analysis

Importance

Head and neck cancer (HNC) often requires treatment with a major impact on quality of life. Treatment decision-making is often challenging, as it involves balancing survival against the preservation of quality of life and choosing among treatments with comparable outcomes but variation in morbidity and adverse events; consequently, the potential for decisional conflict (DC) and decision regret (DR) is high.

Objectives

To summarize the literature on DC and DR in HNC, to give an overview of its prevalence and extent, and to advise on clinical practice and future research.

Data Sources

Embase, Web of Science, MEDLINE, and PsycINFO were searched up to February 24, 2023, including all years of publication.

Study Selection

Eligible studies addressed DC and/or DR as primary or secondary outcomes with any instrument in HNC, except cutaneous tumors. Two mutually blinded researchers conducted screening and inclusion with support of an artificial intelligence assistant and conducted risk of bias (ROB) assessment.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed for data extraction. ROB assessments were done using Critical Appraisal Skills Programme (qualitative) and CLARITY (quantitative). Meta-analysis with a random-effects model was used to obtain pooled prevalence estimates for DC and DR when at least 4 sufficiently clinically homogeneous studies were available.

Main Outcomes and Measures

Prevalence of DC (qualitative, Decisional Conflict Scale, SURE questionnaire) and DR (qualitative, study-specific questionnaires, Decision Regret Scale, Shame and Stigma Scale).

Results

Overall, 28 studies were included, with 16 included in meta-analyses for DR prevalence. The pooled prevalence of clinically relevant DR above the cutoff score for validated questionnaires (11 studies; 2053 participants) was 71% (95% CI, 58%-82%; I2 = 94%), while for study-specific questionnaires (5 studies; 674 participants) it was 11% (95% CI, 5%-22%; I2 = 92%). Only 4 studies investigated DC, showing a prevalence of 22.6% to 47.5% above cutoff values. Derived overarching themes found in qualitative studies were preparation, shared decision-making roles, information, time pressure, stress of diagnosis, and consequences.

Conclusions and Relevance

Although limited data on DC and DR were available, the studies performed indicated that DC and DR are highly prevalent issues in HNC. Results suggest that study-specific questionnaires underestimated DR. The findings underscore the rationale to improve counseling and shared decision-making for this patient population.

Decision regret of cancer patients after radiotherapy: results from a cross-sectional observational study at a large tertiary cancer center in Germany

PURPOSE

The decision-making process regarding cancer treatment is emotionally challenging for patients and families, harboring the risk of decision regret. We aimed to explore prevalence and determinants of decision regret following radiotherapy.

METHODS

This cross-sectional observational study was conducted at a tertiary cancer center to assess decision regret following radiotherapy. The study employed the German version of the Ottawa Decision Regret Scale (DRS) which was validated in the study population. Decision regret was categorized as absent (0 points), mild (1-25 points), and strong (> 25 points). Various psychosocial outcome measures were collected using validated questionnaires to identify factors that may be associated with decision regret.

RESULTS

Out of 320 eligible patients, 212 participated, with 207 completing the DRS. Median age at start of radiotherapy was 64 years [interquartile range (IQR), 56-72], genders were balanced (105 female, 102 male), and the most common cancer types were breast (n = 84; 41%), prostate (n = 57; 28%), and head-and-neck cancer (n = 19; 9%). Radiotherapy was applied with curative intention in 188 patients (91%). Median time between last radiotherapy fraction and questionnaire completion was 23 months (IQR, 1-38). DRS comprehensibility was rated as good or very good by 98% (196 of 201) of patients. Decision regret was reported by 43% (n = 90) as absent, 38% (n = 78) as mild, and 18% (n = 38) as strong. In the multiple regression analysis, poor Eastern Cooperative Oncology Group performance status, low social support, and dissatisfaction with care were independent risk factors for higher decision regret after radiotherapy.

CONCLUSIONS

The German version of the DRS could be used to assess decision regret in a diverse cohort of cancer patients undergoing radiotherapy. Decision regret was prevalent in a considerable proportion of patients. Further studies are necessary to validate these findings and obtain causal factors associated with decision regret after radiotherapy.

The development of a decision aid for patients with operable oropharyngeal carcinoma in the Netherlands - A mixed methods study

OBJECTIVE

The aim of this project is to create an interactive online patient decision aid (PDA) for oropharyngeal cancer (OPSCC) patients, eligible for transoral (robotic) surgery with an ultimate goal to assist both physicians and patients in making treatment choices.

MATERIALS AND METHODS

Following the International Patient Decision Aid Standards, a mixed-methods approach was employed. The study involved semi-structured in-depth interviews with patients and physicians, thinking-out-loud sessions, and study-specific questionnaires. Thematic coding and analysis were conducted on verbatim transcriptions of audio-recorded interviews.

RESULTS

The PDA drafts were evaluated by twenty OPSCC survivors and twenty multidisciplinary specialists. Significant revisions were made after phase 1 to enhance readability and reduce text, whilst incorporating videos and graphics. Following all phases, both patients and specialists rated the PDA as comprehensible, feasible, and a valuable addition to regular counseling.

CONCLUSION

This study showcases the development of a PDA for early stage oropharyngeal cancer patients considering surgery and radiotherapy options. The decision aid emphasizes the disparities in short- and long-term side effects between the two treatments. Patients and physicians found the decision aid to be understandable, user-friendly, and helpful for future patients. The PDA is available on https://beslissamen.nl/.

A Codeveloped Web-Based Disability Disclosure Toolkit for Youth With Disabilities: Mixed Methods Pilot Evaluation

BACKGROUND

Youth and young adults with disabilities experience many barriers in securing employment such as discrimination, inaccessible environments, and lack of support. Youth often need to decide whether and how they should disclose their need for accommodations to employers, which can help them to do their best at work. However, few evidence-based toolkits focusing on disability disclosure exist for youth with various types of disabilities. Supporting youth to develop self-advocacy skills is salient because they are an underrepresented and marginalized group in the labor market.

OBJECTIVE

The objective of this study was to conduct a pilot evaluation of a web-based toolkit to enhance disability disclosure for youth and young adults helping to advocate for their needs and request workplace accommodations.

METHODS

We conducted 2 in-person focus groups to codevelop a web-based disability disclosure toolkit, which was followed by a pilot evaluation with a pre-post survey. Primary outcomes focused on the relevance of the toolkit content, preliminary perceived impact on knowledge and confidence, and open-ended feedback on the usefulness of the toolkit. Secondary outcomes focused on effectiveness (ie, measures of self-determination).

RESULTS

A total of 14 youths with various types of disabilities took part in the study (aged 20-25 years; n=11, 78% female) including 3 who participated in the codevelopment focus group sessions and 11 youths who participated in the surveys. Our findings involved three main themes in the codevelopment sessions that included (1) disability disclosure and workplace accommodation experiences (ie, knowing when, whether, and how to disclose their disability and request workplace accommodations), (2) usefulness of the tool (ie, relatable content, format and design, and suggestions for further development), and (3) perceived impact of the toolkit (ie, navigating disclosure decisions and how to approach employers and develop other relevant employment skills). The survey findings showed that the majority of participants (10/11, 91%) reported that the toolkit increased or changed their knowledge or understanding of disability disclosure. Most participants (8/11, 73%) reported that the toolkit helped to increase their perceived confidence in their daily activities. The majority of participants (8/11, 73%) agreed or strongly agreed that the toolkit was easy to understand and comprehensive. Regarding the preliminary impact of the toolkit, participants did not demonstrate any significant improvements in self-determination (all P>.05).

CONCLUSIONS

Our findings emphasize the importance of codeveloping a disability disclosure toolkit with youth to enhance its relevance for their needs. Our toolkit indicates preliminary potential as an educational resource for youth and young adults with disabilities as they search for and secure employment. Further research is needed to assess the impact of the tool with larger samples to understand the impact of workplace disability disclosure decisions for youth with disabilities.

Digital health in head and neck cancer: a systematic review

OBJECTIVE

Digital health tools are increasingly being recognised as effective interventions in monitoring chronic health conditions. This systematic review addressed how digital health is currently utilised in patients with head and neck cancer as an adjunct to care.

METHOD

Studies of the development or evaluation of an eHealth, telemedicine or telemonitoring tool were eligible. A narrative synthesis was performed as per Preferred Reporting Items for Systematic Review and Meta-Analyses reporting guidelines.

RESULTS

Twenty-nine studies of digital health tools in head and neck cancer were identified. Nine were randomised, controlled trials but most had concern of bias. Fourteen (48 per cent) of the interventions used multiple modes of delivery. The primary digital tool functions are symptom tracking and self-care, prehabilitation and rehabilitation, psychological support, and education, including decision aids. Most tools aimed to support patients during active cancer treatment.

CONCLUSION

There are a small number of digital health tools for head and neck cancer patients; however, there is a lack of well-designed randomised, controlled trials to demonstrate effectiveness.

What Are the Best Practices for Co-Creating Patient-Facing Educational Materials? A Scoping Review of the Literature

Co-creating patient-facing educational materials (PEMs) can enhance person-centered care by responding to patient priorities and unmet needs. Little data exist on 'best practices' for co-creation. We followed the Arksey and O'Malley framework to conduct a systematic literature search of nine databases (MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Joanna Briggs Institute, TRIP-April, 2022) to identify empirical studies published in English on PEM co-creation to distill 'best practices'. Following an independent dual review of articles, data were collated into tables, and thematic analysis was employed to synthesize 'best practices' that were validated by a patient experienced in co-creating PEMs. Bias was not assessed, given the study heterogeneity. Of 6998 retrieved articles, 44 were included for data extraction/synthesis. Studies utilized heterogeneous methods spanning a range of health conditions/populations. Only 5/45 (11%) studies defined co-creation, 14 (32%) used a guiding framework, and 18 (41%) used validated evaluation tools. Six 'best practices' were identified: (1) begin with a review of the literature, (2) utilize a framework to inform the process, (3) involve clinical and patient experts from the beginning, (4) engage diverse perspectives, (5) ensure patients have the final decision, and (6) employ validated evaluation tools. This scoping review highlights the need for clear definitions and validated evaluation measures to guide and assess the co-creation process. Identified 'best practices' are relevant for use with diverse patient populations and health issues to enhance person-centered care.

The Development of a Video-based Nutrition Education Curriculum for Patients Undergoing Radical Cystectomy

BACKGROUND

The treatment for patients with muscle-invasive bladder cancer includes neoadjuvant chemotherapy followed by radical cystectomy. The American Urological Association guidelines stress the optimization of patient performance status in the perioperative setting. Therefore, implementation of nutrition education is critical for the multi-disciplinary care of this vulnerable patient population and wide distribution of information is critical.

OBJECTIVE

The goal of our study was to create a nutrition-based video education series for patients undergoing chemotherapy and radical cystectomy for bladder cancer.

METHODS

Scripts for the videos were developed through an iterative process by experts in nutrition, urology, and communication. Providers and patient advocates were recruited to perform semi-structured interviews and surveys for additional feedback. Performer facial emotion recognition (Noldus™) was used to assess displayed emotion by the presenters. Mangold VisionPlayer software was used for participant eye movement tracking of the video content. A knowledge survey was created, and Item Content Validity Index (I-CVI) was calculated with a nutrition expert advisory board. Participants were recruited for cognitive interviewing to understand the mental processes and interpretations while answering questions.

RESULTS

The video series is available to the public on the Bladder Cancer Advocate Network (BCAN) website at the following URL: https://bcan.org/facing-bladder-cancer/nutrition-bladder-cancer/eating-healthy-bladder-cancer/. Cinematic filming methods, (smaller depth of field, lighting, and camera movement) enhanced message delivery along with music and text on screen to anchor important concepts.

CONCLUSIONS

This study can be a framework for the development of a patient education video library accessible through electronic medical records, health care applications, and patient advocacy websites.

Usability: An introduction to and literature review of usability testing for educational resources in radiation oncology

Usability, or the ease with which something can be used, is a key aspect in ensuring end-users can achieve the best possible outcomes from a given educational resource. Ideally usability testing should take place iteratively throughout the design of the resource, and there are several approaches for undertaking usability testing described in the wider literature. Within radiation oncology education, the extent to which usability testing occurs remains unclear. This literature review aimed to assess current practice and provide a practical introduction to usability testing for educational resource design within radiation oncology. Two web databases were searched for articles describing planned or completed usability testing during the design of a radiation oncology educational resource. Fifteen studies were identified. Data was gathered describing the type of usability testing performed, the number of cycles of testing and the number of test subjects. Articles described design of educational resources for both patients and trainees, with the number of test subjects ranging from 8 to 18. Various testing methods were used, including questionnaires, think aloud studies and heuristic evaluation. Usability testing comprised a range of single cycle through to several rounds of testing. Through illustrative examples identified in the literature review, we demonstrate that usability testing is feasible and beneficial for educational resources varying in size and context. In doing so we hope to encourage radiation oncologists to incorporate usability testing into future educational resource design.

Extended-duration thromboprophylaxis for abdominopelvic surgery: Development and evaluation of a risk-stratified patient decision aid to facilitate shared decision making

Background

Extended-duration thromboprophylaxis is used to decrease risk of venous thromboembolism (VTE) after surgery but may increase the risk of bleeding. The decision to complete a course of extended-duration thromboprophylaxis can be challenging.

Objective

The objective of this study was to develop an acceptable patient decision aid (PtDA) to facilitate shared decision making for the use of extended-duration thromboprophylaxis following major abdominal surgery.

Methods

An evidence-based, risk-stratified PtDA was created. The evidence on benefits and harms of a 28-day postoperative course of low-molecular-weight heparin (LMWH) versus in-hospital prophylaxis only were synthesized. Outcomes included minor bleeding, major bleeding, clinically significant VTE, and fatal VTE. Risks were calculated and reported by Caprini score. Alpha testing of the PtDA draft with various stakeholders was performed using a 10-question survey to assess acceptability of the PtDA with patients, thrombosis experts, and surgeons. The primary outcome was the acceptability of the PtDA.

Results

Acceptability testing was performed with 11 patients, 11 thrombosis experts, and 11 surgeons. Most responders felt the language on the PtDA was easy to follow (28/33, 85%), and that the information was well balanced between management options (9/11 [82%] patients; 17/21 [80%] clinicians). Most patients (9/11, 82%) and clinicians (18/22, 82%) believed it would be a useful clinical tool, and were satisfied with the overall quality of the PtDA (27/33, 82%).

Conclusions

A risk-stratified, evidence-based PtDA was created to facilitate shared decision making for the use of extended-duration LMWH following major abdominal surgery. This clinical tool was acceptable with patients and physicians and is available at https://decisionaid.ohri.ca/decaids.html.

Salvage total glossectomy and total glosso-laryngectomy: Are they worth it? A GETTEC French multicenter study

BACKGROUND

Salvage total glossectomy (TG) or total glosso-laryngectomy (TGL) remain controversial, as highly morbid procedures. The objective was to describe oncological and functional outcomes after salvage TG or TGL.

METHODS

We performed a multicenter retrospective study, including patients with previous neck irradiation undergoing TG or TGL for squamous cell carcinoma involving the base of tongue.

RESULTS

We included 42 patients: 27 in the TG group and 15 in the TGL group. For the entire cohort, median OS and DFS were estimated at 19 months (95% IC [14-44]) and 10 months (95% IC [7-13]) respectively, with no difference between the two groups. After a median follow-up of 90 months, 10 patients (24%) were alive and free of disease. Att he end of follow-up, we noted a gastrostomy dependency of 89% and 87 %respectively in the TG and TGL group, and 48% of patients in the TG group had a tracheotomy.

CONCLUSION

Although local control is difficult to achieve after salvage TG or TGL, these procedures are associated with acceptable survival and chance of cure for a last-resort situation. TG and TGL can be proposed in selected motivated patients after careful shared decision-making.