Facilitating patient-centered cancer communication: a road map

Research Participants' Perspectives on Precision Diagnostics for Alzheimer's Disease

BACKGROUND

Understanding research participants' responses to learning Alzheimer's disease (AD) risk information is important to inform clinical implementation of precision diagnostics given rapid advances in disease modifying therapies.

OBJECTIVE

We assessed participants' perspectives on the meaning of their amyloid positron emission tomography (PET) imaging results for their health, self-efficacy to understand their results, psychological impact of learning their results, experience receiving their results from the clinical team, and interest in genetic testing for AD risk.

METHODS

We surveyed individuals who were being clinically evaluated for AD and received PET imaging six weeks after the return of results. We analyzed responses to close-ended survey items by PET result using Fisher's exact test and qualitatively coded open-ended responses.

RESULTS

A total of 88 participants completed surveys, most of whom had mild cognitive impairment due to AD (38.6%), AD (28.4%), or were cognitively unimpaired (21.6%). Participants subjectively understood their results (25.3% strongly agreed, 41.8% agreed), which could help them plan (16.5% strongly agreed, 49.4% agreed). Participants with a negative PET result (n = 25) reported feelings of relief (Fisher's exact p < 0.001) and happiness (p < 0.001) more frequently than those with a positive result. Most participants felt that they were treated respectfully and were comfortable voicing concerns during the disclosure process. Genetic testing was anticipated to be useful for medical care decisions (48.2%) and to inform family members about AD risk (42.9%).

CONCLUSIONS

Participants had high subjective understanding and self-efficacy around their PET results and did not experience negative psychological effects. Interest in genetic testing was high.

Integrating evidence-based communication principles into routine cancer care

PURPOSE

The global incidence of cancer and available cancer-directed therapy options is increasing rapidly, presenting patients and clinicians with more complex treatment decisions than ever before. Despite the dissemination of evidence-based communication training tools and programs, clinicians cite barriers to employing effective communication in cancer care (e.g., discomfort of sharing serious news, concern about resource constraints to meet stated needs). We present two composite cases with significant communication challenges to guide clinicians through an application of evidence-based approaches to achieve quality communication.

METHODS

Composite cases, communication skills blueprint, and visual conceptualization.

RESULTS

High-stakes circumstances in each case are described, including end-of-life planning, advanced pediatric illness, strong emotions, and health inequities. Three overarching communication approaches are discussed: (1) content selection and delivery; (2) rapport development; and (3) empathic connection. The key takeaways following each case provide succinct summaries of challenges encountered and approaches used. A communication blueprint from the Memorial Sloan Kettering Cancer Center Communication Skills Training Program and Research Laboratory has been adapted and is comprised of strategies, skills, process tasks, and sample talking points. A visually concise tool - the Communication Blueprint Traffic Circle - illustrates these concepts and demonstrates the iterative, holistic, and agile considerations inherent to effective communication.

CONCLUSION

Evidence-based communication is foundational to person-centeredness, associated with improved clinician and patient/caregiver outcomes, and can be integrated throughout routine oncology care. When used by clinicians, evidence-based communication can improve patient and caregiver experiences and assist in ensuring goal-concordant cancer care delivery.

Communication Between Cancer Patients and Physicians About Complementary and Alternative Medicine: A Systematic Review

Objectives: Complementary and alternative medicine (CAM) has become increasingly popular among cancer patients and is often used concomitantly with standard cancer therapies. Nonetheless, disclosure of CAM utilization by cancer patients to physicians, along with the provision of information on CAM therapies by physicians, is poor. This review explores the literature to synthesize existing information on communication about CAM usage, reasons for nondisclosure, and the clinical implications thereof. Methods: A search of medical literature published between December 1, 2009, and October 1, 2021 (last searched on April 18, 2022), on communications between physicians and cancer patients about CAM treatments was conducted through MEDLINE and EMBASE. Results were screened for inclusion, dually reviewed, and assessed using the QualSyst quality appraisal instrument. Findings were categorized and synthesized for review. Results: A total of 30 articles were located (n = 8721 total participants), which discussed elements related to patient disclosure of CAM use (n = 16), provider experiences or perceptions related to communication about CAM (n = 3), patterns of this communication (n = 6), and recommendations for effectively discussing CAM with cancer patients (n = 5). Reports indicate that nondisclosure is common throughout the cancer care spectrum. Factors influencing nondisclosure range from patient beliefs and attitudes about their provider, demographic characteristics, disease progression, physician-patient relationship, physician noninquiry, and type of CAM used; ultimately creating a gap in care that may have serious medical implications. Discussion: Many of the studies identified are small and confined to a single-center, hospital-network, or geographic setting, thereby limiting the applicability of findings and recommendations. Nonetheless, improving patient-physician communication is essential in delivering evidence-informed, patient-centered care and crucial for achieving patient satisfaction and positive health outcomes. The lack of adequate CAM dialogue about CAM use increases the risk of adverse interactions with conventional cancer treatments and results in missed opportunities for providers and patients to engage in vital information exchange. Future research and education are necessary to further identify barriers surrounding patient-provider communication about CAM treatments.

Community Member and Health Care Provider Perspectives on Communication With Chinese American Patients With Cancer: A Qualitative Study

PURPOSE

Effective health care provider-patient discussions of cancer diagnoses and prognoses are essential to enhance health outcomes in oncology. Chinese Americans have been designated an underserved population in oncology by the National Institutes of Health. We explored the perspectives of Boston Chinese American community members and health care providers regarding communication preferences and decision making in oncology care.

METHODS

In this inductive, qualitative study, we conducted virtual, semi-structured interviews with 21 health care providers with experience in caring for Chinese American patients with cancer and 25 older Boston Chinatown community members who self-identify as Chinese or Chinese American. Thematic analysis was performed.

RESULTS

Two major themes were identified. First, provider communication should incorporate a gentle but truthful approach, careful word choice, authority-led style, and professionalism. Second, the family plays a large role in medical and nonmedical settings, and a family-centered approach to communication should be used.

CONCLUSION

Our study builds on and challenges current knowledge regarding oncologic communication with Chinese American patients. A focus on the improvement of provider-patient cancer communication for Chinese Americans will improve care quality and satisfaction among patients and clinicians alike and serve to decrease disparities in care.

Cancer Survivors' Emotional Well-being: Roles of Internet Information Seeking, Patient-centered Communication, and Social Support

Cancer survivors' emotional well-being is an integral part of their overall health and may influence their recovery and survival. The current study used the 2018 Health Information National Trends Survey (HINTS) 5 Cycle 2 (N = 593) to evaluate the determinants of cancer survivors' emotional well-being. Internet cancer information seeking, social support, patient-centered communication, cancer beliefs, and self-efficacy to take care of one's health were examined as factors to be associated with cancer survivors' emotional well-being using structural equation modeling. Social support, cancer beliefs, and self-efficacy to take care of one's health were found to be significantly associated with emotional well-being among cancer survivors. Cancer beliefs mediated the associations of cancer information seeking using the Internet, social support, and patient-centered communication with cancer survivors' emotional well-being while health self-efficacy mediated the associations of social support and patient-centered communication with cancer survivors' emotional well-being. It is important for health practitioners to focus on improving social support, self-efficacy for managing health, and cancer-related beliefs in order to enhance the emotional well-being of cancer survivors.

Twenty-first Century Bedside Manner: Exploring Patient-Centered Communication in Secure Messaging with Cancer Patients

Patient-centered communication (PCC) is integral to providing high-quality health care and is recommended to be incorporated during face-to-face consultations. Electronic communication, such as the use of secure messaging (SM) within patient portals, is a popular form of patient-provider communication, but preliminary studies have shown that PCC is rarely utilized by providers in SM. As a consequence, the patient-provider relationship can be negatively affected, especially for cancer patients who have greater electronic health information needs than the general population. Therefore, our objective was to determine the importance of SM to cancer patients and to identify which attributes of PCC are preferred to be incorporated into secure messages. Five focus groups were conducted, comprised of patients with a current or previous cancer diagnosis (three all-female; two all-male). Participants recalled their own experiences and reviewed simulated messages. Three main topics emerged from the thematic analysis: (1) the normalization of SM, (2) SM quality can affect perceptions of care, and (3) patients need guidance. Overall, participants valued the ability to communicate with their care team using SM and indicated that electronic communication may have the potential to have just as big of an impact on a patient's care than in-person communication.

Predictors of Patient-Centered Communication among U.S. Adults: Analysis of the 2017-2018 Health Information National Trends Survey (HINTS)

An essential component of patient-centered care is the communication between patients and their providers, which can affect patients' health outcomes A cancer care model, developed by Epstein and Street, includes a multi-dimensional patient-centered communication (PCC) framework with six functions: foster healing relationships, exchange information, respond to emotions, manage uncertainty, make decisions, and enable patient self-management. Seven domains that describe the functions were included on the Health Information National Trends Survey (HINTS) to assess PCC. We examined the association between sociodemographic and health-related factors and PCC as well as how U.S. adults, by different age groups, ranked different domains of PCC.Nationally representative data (n = 5,738) from 2017 to 2018 HINTS were merged to examine predictors of PCC among U.S. adults. Weighted statistics describe the study sample and prevalence for ratings of PCC domains. A multivariate linear regression model was computed to assess associations among predictors and PCC.Participants rated their communication with doctors in the last year with an overall mean of 80 out of 100. Older age, those reporting excellent health, and those with higher confidence in taking care of one's health predicted better PCC. Individuals who reported being non-Hispanic Asian and having lower household income were associated with poorer communication. Participants' lowest rating of PCC concentrated on providers dealing with their emotional needs.Findings suggest that many patients do not feel that their providers adequately manage, communicate, nor respond to their emotional needs. Future efforts should enhance interpersonal exchanges among sub-populations who report poorer communication with providers during clinical visits.

Perceptions of cancer as a death sentence: Tracking trends in public perceptions from 2008 to 2017

OBJECTIVE

There has been steady progress in reducing cancer mortality in the United States; however, this progress hasn't been evenly distributed across regions. This paper assesses trends in cancer mortality salience (CMS), that is, agreeing that getting cancer is a death sentence, over time in the United States and examines correlates of CMS.

METHODS

Data from three administrations of the Health Information National Trends Survey (HINTS), gathered in 2008, 2013, and 2017, were merged, resulting in a total sample of 10,063 respondents. Trends in changes in CMS over time were examined as well as maps of the distribution of CMS in the United States. A logistic regression model was conducted, regressing CMS on a set of sociodemographic, psychological, health-related, and environmental predictors.

RESULTS

The aggregated percentage of US adults who agreed with the CMS statement changed over time and was modified by age. Geographic distribution of agreement with CMS was inconsistent across the United States. In the adjusted logistic model, perceived health (worse health), cancer prevention, fatalism, and confusion, and cancer status (no cancer) were all significantly associated with CMS. There was also a significant interaction between survey year and age.

CONCLUSION

Despite recent information that cancer mortality rates are decreasing, most US adults still see cancer as a death sentence and this is especially an issue in certain subgroups. These findings have ramifications for groups of people who may be at risk for developing cancer given their attitudes and beliefs that there isn't much they can do to prevent or control it.

Communication With Older Patients With Cancer Using Geriatric Assessment: A Cluster-Randomized Clinical Trial From the National Cancer Institute Community Oncology Research Program

Importance

Older patients with cancer and their caregivers worry about the effects of cancer treatment on aging-related domains (eg, function and cognition). Quality conversations with oncologists about aging-related concerns could improve patient-centered outcomes. A geriatric assessment (GA) can capture evidence-based aging-related conditions associated with poor clinical outcomes (eg, toxic effects) for older patients with cancer.

Objective

To determine whether providing a GA summary and GA-guided recommendations to oncologists can improve communication about aging-related concerns.

Design, Setting, and Participants

This cluster-randomized clinical trial enrolled 541 participants from 31 community oncology practices within the University of Rochester National Cancer Institute Community Oncology Research Program from October 29, 2014, to April 28, 2017. Patients were aged 70 years or older with an advanced solid malignant tumor or lymphoma who had at least 1 impaired GA domain; patients chose 1 caregiver to participate. The primary outcome was assessed on an intent-to-treat basis.

Interventions

Oncology practices were randomized to receive either a tailored GA summary with recommendations for each enrolled patient (intervention) or alerts only for patients meeting criteria for depression or cognitive impairment (usual care).

Main Outcomes and Measures

The predetermined primary outcome was patient satisfaction with communication about aging-related concerns (modified Health Care Climate Questionnaire [score range, 0-28; higher scores indicate greater satisfaction]), measured after the first oncology visit after the GA. Secondary outcomes included the number of aging-related concerns discussed during the visit (from content analysis of audiorecordings), quality of life (measured with the Functional Assessment of Cancer Therapy scale for patients and the 12-Item Short Form Health Survey for caregivers), and caregiver satisfaction with communication about aging-related patient concerns.

Results

A total of 541 eligible patients (264 women, 276 men, and 1 patient did not provide data; mean [SD] age, 76.6 [5.2] years) and 414 caregivers (310 women, 101 men, and 3 caregivers did not provide data; mean age, 66.5 [12.5] years) were enrolled. Patients in the intervention group were more satisfied after the visit with communication about aging-related concerns (difference in mean score, 1.09 points; 95% CI, 0.05-2.13 points; P = .04); satisfaction with communication about aging-related concerns remained higher in the intervention group over 6 months (difference in mean score, 1.10; 95% CI, 0.04-2.16; P = .04). There were more aging-related conversations in the intervention group's visits (difference, 3.59; 95% CI, 2.22-4.95; P < .001). Caregivers in the intervention group were more satisfied with communication after the visit (difference, 1.05; 95% CI, 0.12-1.98; P = .03). Quality of life outcomes did not differ between groups.

Conclusions and Relevance

Including GA in oncology clinical visits for older adults with advanced cancer improves patient-centered and caregiver-centered communication about aging-related concerns.

Trial Registration

ClinicalTrials.gov identifier: NCT02107443.

Patient perspectives on primary care and oncology care coordination in the context of multiple chronic conditions: A systematic review

BACKGROUND

Patients' views on the optimal model for care coordination between primary care providers (PCPs) and oncologists in the context of cancer and multiple chronic conditions (MCC) are unclear. Thus, the purpose of this systematic review is to evaluate the perceptions of patients with both cancer and MCC regarding their care coordination needs.

METHODS

Following PRISMA guidelines, the literature was systematically searched through PubMed, CINAHL, and PsycINFO for articles pertaining to patients' perspectives, experiences, and needs regarding care coordination between PCPs and oncologists during the cancer care continuum, in the context of patients with cancer and MCC. English-language articles were included if they met the following criteria: 1) published between 2008 and 2018; 2) peer-reviewed study; 3) patients aged 18 years or older diagnosed with any type or stage of cancer; 4) patients have one or more chronic comorbid condition; 5) inclusion of patient perceptions, experiences, or needs related to care coordination between PCPs and oncologists; and 6) ability to extract results. Data extraction was performed with a standardized form, and themes were developed through qualitative synthesis. A grounded theory approach was used to qualitatively evaluate data extracted from articles and create a framework for providers to consider when developing patient-centered care coordination strategies for these complex patients. Risk of bias within each study was assessed independently by two authors using the Mixed Methods Appraisal Tool.

RESULTS

A total of 22 articles were retained, representing the perspectives of 8,114 patients with cancer and MCC. Studies were heterogeneous in the patients' respective phases of cancer care and study design. From qualitative synthesis, four themes emerged regarding patients' needs for cancer care coordination and were included as constructs to develop the Patient-centered Care Coordination among Patients with Multiple Chronic Conditions and Cancer (PCP-MC) framework. Constructs included: 1) Communication; 2) Defining provider care roles; 3) Information access; and 4) Individualized patient care. Care navigators served as a communication bridge between providers and patients.

CONCLUSIONS

Findings highlight the importance that patients with both cancer and MCC place on communication with and between providers, efficient access to understandable care information, defined provider care roles, and care tailored to their individual needs and circumstances. Providers and policymakers may consider the developed PCP-MC framework when designing, implementing, and evaluating patient-centered care coordination strategies for patients with both cancer and MCC.

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

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

Patient-reported care domains that enhance the experience of "being known" in an ambulatory cancer care centre

Purpose

This study explored patients' perceptions of "being known" in an ambulatory chemotherapy unit.

Methods

Using a qualitative descriptive design, 10 participants with various cancer diagnoses were recruited from a large cancer centre in Montreal, Quebec. Audiotaped individual interviews were transcribed verbatim. Textual data were coded and analyzed thematically.

Findings

Participants spoke of their need to have the staff approach them as individuals first and then as persons with cancer. They further underscored the importance of: (1) feeling truly welcome in the cancer care environment, (2) being provided with person- and situation-responsive care, and (3) considering occupational and social roles that go beyond the "sick role". Mutual patient-nurse disclosure also contributed to perceptions of a personalized care approach.

Implications for nursing

In addition to key elements construed as crucial for enhancing perceptions of being known, future studies should further document how the interplay among demographic, physical/psychological, and cultural factors affect these perceptions.

Glaucoma patient-provider communication about vision quality-of-life

OBJECTIVE

The purpose of this study was to: (a) describe the extent to which ophthalmologists and glaucoma patients discuss vision quality-of-life during office visits, and (b) examine the association between patient and ophthalmologist characteristics and provider-patient communication about vision quality-of-life.

METHODS

Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited at six ophthalmology clinics. Patients' visits were video-tape recorded and quality-of-life communication variables were coded. Generalized estimating equations were used to analyze the data.

RESULTS

Two hundred and seventy-nine patients participated. Specific glaucoma quality-of-life domains were discussed during only 13% of visits. Older patients were significantly more likely to discuss one or more vision quality-of-life domains than younger patients. African American patients were significantly less likely to make statements about their vision quality-of-life and providers were less likely to ask them one or more vision quality-of-life questions than non-African American patients.

CONCLUSION

Eye care providers and patients infrequently discussed the patient's vision quality-of-life during glaucoma visits. African American patients were less likely to communicate about vision quality-of-life than non-African American patients.

PRACTICE IMPLICATIONS

Eye care providers should make sure to discuss vision quality-of-life with glaucoma patients.

Impact of provider-patient communication on cancer screening adherence: A systematic review

Cancer screening is critical for early detection and a lack of screening is associated with late-stage diagnosis and lower survival rates. The goal of this review was to analyze studies that focused on the role of provider-patient communication in screening behavior for cervical, breast, and colorectal cancer. A comprehensive search was conducted in four online databases between 1992 and 2016. Studies were included when the provider being studied was a primary care provider and the communication was face-to-face. The search resulted in 3252 records for review and 35 articles were included in the review. Studies were divided into three categories: studies comparing recommendation status to screening compliance; studies examining the relationship between communication quality and screening behavior; and intervention studies that used provider communication to improve screening behavior. There is overwhelming evidence that provider recommendation significantly improves screening rates. Studies examining quality of communication are heterogeneous in method, operationalization and results, but suggest giving information and shared decision making had a significant relationship with screening behavior. Intervention studies were similarly heterogeneous and showed positive results of communication interventions on screening behavior. Overall, results suggest that provider recommendation is necessary but not sufficient for optimal adherence to cancer screening guidelines. Quality studies suggest that provider-patient communication is more nuanced than just a simple recommendation. Discussions surrounding the recommendation may have an important bearing on a person's decision to get screened. Research needs to move beyond studies examining recommendations and adherence and focus more on the relationship between communication quality and screening adherence.

Patient-Centered Cancer Care Programs in Italy: Benchmarking Global Patient Education Initiatives

In Italy, educational programs for cancer patients are currently provided by the national government, scientific societies, and patient advocate organizations. Several gaps limit their effectiveness, including the lack of coordinated efforts, poor involvement of patient feedback in the planning of programs, as well as a lack of resources on innovative cancer-related topics. This process is parallel to a strong shift in the attitude of patients towards health in general and taking charge of their own health conditions in particular. The National Cancer Institute in the USA and the Organization of European Cancer Institutes encourage comprehensive cancer centers in providing educational programs conceived to overcome these gaps. The goal of this paper is to identify and describe the key elements necessary to develop a global patient education program and provide recommendations for strategies with practical examples for implementation in the daily activities of cancer institutes. A multidisciplinary committee was established for patient education, including patient representatives as equal partners, to define, implement, verify, and evaluate the fundamental steps for establishing a comprehensive education program. Six essential topics were identified for the program: appropriate communication of cancer epidemiology, clinical trial information, new therapeutic technologies, support in the use of medicines, psycho-oncological interventions, age-personalized approaches, and training programs for healthcare providers. Integration of these topics along with patient feedback is the key to a successful model for educational programs. An integrated educational program can transform a comprehensive cancer center to an institution that provides research and care for and with patients.

Care team identification in the electronic health record: A critical first step for patient-centered communication

Patient-centered communication is essential to coordinate care and safely progress patients from admission through discharge. Hospitals struggle with improving the complex and increasingly electronic conversation patterns among care team members, patients, and caregivers to achieve effective patient-centered communication across settings. Accurate and reliable identification of all care team members is a precursor to effective patient-centered communication and ideally should be facilitated by the electronic health record. However, the process of identifying care team members is challenging, and team lists in the electronic health record are typically neither accurate nor reliable. Based on the literature and on experience from 2 initiatives at our institution, we outline strategies to improve care team identification in the electronic health record and discuss potential implications for patient-centered communication. Journal of Hospital Medicine 2016;11:381-385. © 2016 Society of Hospital Medicine.

The Impact of Patient Participation in Health Decisions Within Medical Encounters

Background: Although there are compelling moral arguments for patient participation in medical decisions, the link to health outcomes has not been systematically explored. Objective: Assess the extent to which patient participation in decision making within medical encounters is associated with measured patient outcomes. Methods: We conducted a primary search in PubMed—excluding non-English and animal studies—for articles on decision making in the context of the physician–patient relationship published through the end of February 2015, using the MeSH headings (Physician-Patient Relations [MeSH] OR Patient Participation [MeSH]) and the terms (decision OR decisions OR option OR options OR choice OR choices OR alternative OR alternatives) in the title or abstract. We also conducted a secondary search of references in all articles that met the inclusion criteria. Results: A thorough search process yielded 116 articles for final analysis. There was wide variation in study design, as well as measurement of patient participation and outcomes, among the studies. Eleven of the 116 studies were randomized controlled trials (RCTs). Interventions increased patient involvement in 10 (91%) of the 11 RCTs. At least one positive outcome was detected in 5 (50%) of the 10 RCTs reporting increased participation; the ratio of positive results among all outcome variables measured in these studies was much smaller. Although proportions differed, similar patterns were found across the 105 nonrandomized studies. Conclusions: Very few RCTs in the field have measures of participation in decision making and at least one health outcome. Moreover, extant studies exhibit little consistency in measurement of these variables, and results are mixed. There is a great need for well-designed, reproducible research on clinically relevant outcomes of patient participation in medical decisions.

Patient-physician communication about early stage prostate cancer: analysis of overall visit structure

BACKGROUND

We know little about patient-physician communication during visits to discuss diagnosis and treatment of prostate cancer.

OBJECTIVE

To examine the overall visit structure and how patients and physicians transition between communication activities during visits in which patients received new prostate cancer diagnoses.

PARTICIPANTS

Forty veterans and 18 urologists at one VA medical centre.

METHODS

We coded 40 transcripts to identify major communication activities during visits and used empiric discourse analysis to analyse transitions between activities.

RESULTS

We identified five communication activities that occurred in the following typical sequence: 'diagnosis delivery', 'risk classification', 'options talk', 'decision talk' and 'next steps'. The first two activities were typically brief and involved minimal patient participation. Options talk was typically the longest activity; physicians explicitly announced the beginning of options talk and framed it as their professional responsibility. Some patients were unsure of the purpose of visit and/or who should make treatment decisions.

CONCLUSION

Visits to deliver the diagnosis of early stage prostate cancer follow a regular sequence of communication activities. Physicians focus on discussing treatment options and devote comparatively little time and attention to discussing the new cancer diagnosis. Towards the goal of promoting patient-centred communication, physicians should consider eliciting patient reactions after diagnosis delivery and explaining the decision-making process before describing treatment options.

Cancer patients' emotional distress, coping styles and perception of doctor-patient interaction in European cancer settings

OBJECTIVE

As a part of a European study, we cross-culturally examined the rate of emotional distress and maladaptive coping and their association with cancer patients' satisfaction with their interactions with the physician responsible for their care.

METHODS

Cancer patients (n = 302) from one Middle European (Austria) and two Southern European (Italy, Spain) countries completed the NCCN Distress Thermometer (DT), the Mini-Mental Adjustment to Cancer (Mini-MAC) Anxious Preoccupation (AP) and Hopelessness (H) sub-scales, and the Physician Patient Satisfaction with Doctors Questionnaire (PSQ).

RESULTS

The prevalence of emotional distress (DT caseness) was 60% (26.1% mild, 18.8% moderate, and 14.9% severe distress). Maladaptive coping (Mini-MAC cases) was found in 22.8% (hopeless cases), and 22.5% (anxious preoccupation cases). PSQ-MD was significantly correlated with Mini-MAC/H and Mini-Mac/AP, while PSQ-PS was negatively correlated with Mini-MAC/H. DT cases and those with higher levels of hopelessness reported higher scores on PSQ-MD and lower on PSQ-PS than non-cases. Some differences were found between countries both as far as patients' coping and perception of the interaction with doctors. In hierarchical multiple regression analysis, after adjusting for socio-demographic and medical variables, Mini-MAC/H significantly predicted the scores on PSQ-MD (positive direction) and PSQ-PS (negative direction).

SIGNIFICANCE OF RESULTS

The study confirms that about one out of three cancer patients have moderate to high level of emotional distress and about one out of four, clinically significant maladaptive coping. Also, patients showing hopelessness and distress tended to perceive their doctors as both disengaged and less supportive. These results highlights the need for physicians to monitor their patient's level of distress and coping mechanisms and to adjust their own relational and communication style according to patients' psychological condition. Also, cross-cultural issues should be taken into account when exploring psychosocial variables and cancer patients' perception of and satisfaction with the interaction with their doctors.

Communication Efficacy and Couples' Cancer Management: Applying a Dyadic Appraisal Model

The purpose of the present study was to apply Berg and Upchurch's (2007) developmental-conceptual model to understand better how couples cope with cancer. Specifically, we hypothesized a dyadic appraisal model in which proximal factors (relational quality), dyadic appraisal (prognosis uncertainty), and dyadic coping (communication efficacy) predicted adjustment (cancer management). The study was cross-sectional and included 83 dyads in which one partner had been diagnosed with and/or treated for cancer. For both patients and partners, multilevel analyses using the actor-partner interdependence model (APIM) indicated that proximal contextual factors predicted dyadic appraisal and dyadic coping. Dyadic appraisal predicted dyadic coping, which then predicted dyadic adjustment. Patients' confidence in their ability to talk about the cancer predicted their own cancer management. Partners' confidence predicted their own and the patient's ability to cope with cancer, which then predicted patients' perceptions of their general health. Implications and future research are discussed.

Providers' perceptions of communication breakdowns in cancer care

BACKGROUND

Communication breakdowns in cancer care are common and represent a failure in patient-centered care. While multiple studies have elicited patients' perspectives on these breakdowns, little is known about cancer care providers' attitudes regarding the causes and potential solutions.

OBJECTIVE

To examine providers' (1) perceptions of the nature and causes of communication breakdowns with patients in cancer care and (2) suggestions for managing and preventing breakdowns.

DESIGN

Qualitative study of nine focus groups held at three sites (Massachusetts, Georgia and Washington).

PARTICIPANTS

Fifty-nine providers: 33% primary care physicians, 14% oncologists, 36% nurses, and 17% nurse practitioners, physician assistants, and others.

APPROACH

Directed content analysis of focus group transcripts.

KEY RESULTS

Providers' perceptions of the causes of communication breakdowns fell into three categories: causes related to patients, providers, or healthcare systems. Providers perceived that patients sometimes struggle to understand cancer and health-related information, have unrealistic expectations, experience emotional and psychological distress that interferes with information exchange; and may be reticent to share their confusion or concerns. Providers described their own and colleagues' contributions to these breakdowns as sharing inaccurate, conflicting, or uncoordinated information. Providers also described the difficulty in balancing hope with reality in discussions of prognosis. System issues named by providers included insufficient time with patients, payment systems, and changing protocols that inhibit communication and coordination of care. Potential solutions included greater patient engagement, team coordination, and systems that promote patient feedback.

CONCLUSIONS

Providers described multiple causes for communication breakdowns at the patient, provider, and system level. Multi-level interventions that coordinate care and encourage feedback may help to address or prevent communication breakdowns.

Surgical pathology and the patient: a systematic review evaluating the primary audience of pathology reports

The pathology report is a critical document that helps guide the management of patients with cancer. More and more patients read their reports, intending to participate in decisions about their care. However, a substantial subset of patients may lack the ability to comprehend this often technical and complex document. We hypothesized that most literature on pathology reports discusses reports from the perspective of other physicians and not from the perspective of patients. An expert panel of physicians developed a list of search criteria, which we used to identify articles on PubMed, MEDLINE, Cochrane Reviews, and Google Scholar databases. Two reviewers independently evaluated all articles to identify for detailed review those that met search criteria. We identified the primary audience of the selected articles and the degree to which these articles addressed clarity of communication of pathology reports with patients. Of 801 articles identified in our search, 25 involved the formatting of pathology reports for clarity of communication. Recurrent themes in proposed improvements in reports included content standardization, variation in terminology, clarity of communication, and quality improvement. No articles discussed patients as their target audience. No study evaluated the health literacy level required of patients to comprehend pathology reports. In summary, there is a scarcity of patient-centered approaches to improve pathology reports. The literature on pathology reports does not include patients as a target audience. Limited resources are available to help patients comprehend their reports. Efforts to improve patient-centered communication are desirable to address this overlooked aspect of patient care.

Why do some patients prefer to leave decisions up to the doctor: lack of self-efficacy or a matter of trust?

PURPOSE

Decision-making preferences among cancer survivors during their follow-up care remains understudied and limited research examines factors that underlie these preferences. The purpose of this study was to assess cancer patients' decision-making preferences during follow-up care, the role of trust and self-efficacy, and the effect of preferences on health outcomes.

METHODS

Six hundred twenty-three bladder, leukemia, and colorectal cancer survivors were recruited to the Assessment of Patient Experiences of Cancer Care study between April 2003 and November 2004. Respondents were asked about their follow-up care experiences, including decision-making preferences, trust in physicians, self-efficacy, health-related quality of life (HRQOL), and health appraisal. Unadjusted mean scores of trust and self-efficacy measures by decision preference group were examined. Multinomial logistic and linear regressions were conducted to examine predictors of decision-making preferences and the impact of decision-making preferences on HRQOL and health appraisal.

RESULTS

While the majority of patients preferred shared decision-making (61.0 %), 16.1 % preferred to control their decisions and 22.1 % preferred physician control over decisions. Compared to the other groups, patients preferring physician control had greater trust in their physician (p < 0.001), similar self-efficacy for engaging in the decision-making process, and lower self-efficacy for taking responsibility over decisions (p < 0.001). There were no notable differences between decision-making groups on outcome measures.

CONCLUSION

Patients who prefer physicians to control decisions are as confident about participating in the decision-making process and experience similar health outcomes as those preferring greater decisional control. Physicians need to tailor their communication behavior to encourage participation and trust among all patients.

IMPLICATIONS FOR CANCER SURVIVORS

Findings from this study provide unique insights into the decision-making preferences of cancer patients during receipt of follow-up care, which remains an understudied phase of cancer care delivery. Results underscore the need for approaches to decision-making and patient engagement to become more nuanced and to encourage patients to participate in decision-making in ways they are most comfortable. Furthermore, physicians and health care professionals should foster environments that promote trust and clear communication regardless of patient decision-making styles.

Patients' and family members' views on patient-centered communication during cancer care

OBJECTIVES

To explore patients' and family members' views on communication during cancer care and to identify those aspects of clinician-patient communication which were most important to patients and family members.

METHODS

We conducted a secondary data analysis of qualitative data from 137 patients with cancer and family members of patients with cancer. We used a modified version of the constant comparative method and coding paradigm of grounded theory.

RESULTS

Patients want sensitive, caring clinicians who provide information that they need, when they need it, in a way that they can understand; who listen and respond to questions and concerns, and who attempt to understand the patient's experience. Effective information exchange and a positive interpersonal relationship with the clinician were of fundamental importance to patients and family members. These were interrelated; for instance, failure to provide information a patient needed could damage the relationship, whereas excellent listening could foster the relationship. Information exchange and relationship were also integral to decision-making, managing uncertainty, responding to emotions, and self-management. Clinicians who were responsive to patients' needs beyond the immediate medical encounter were valued.

CONCLUSIONS

The complexity of cancer care today suggests that efforts to improve communication must be multilevel, acknowledging and addressing patient, clinician, organizational and policy barriers, and facilitators. Measurement tools are needed to assess cancer patients' and family members' experiences with communication over the course of cancer care to provide meaningful, actionable feedback to those seeking to optimize their effectiveness in communicating with patients with cancer.

Receipt of psychosocial care among cancer survivors in the United States

PURPOSE

Given the importance of psychosocial care for cancer survivors, this study used population-based data to characterize survivors who reported a discussion with health care provider(s) about the psychosocial effects of cancer and who reported using professional counseling or support groups (PCSG) and tested associations between receipt of psychosocial care and satisfaction with care.

PATIENTS AND METHODS

We examined survivors of adult cancers from the 2010 National Health Interview Survey (N = 1,777). Multivariable logistic regression models examined factors associated with receipt of and satisfaction with psychosocial care.

RESULTS

Most survivors (55.1%) reported neither provider discussions nor use of PCSG; 31.4% reported provider discussion only, 4.4% reported use of PCSG only, and 8.9% reported both. Non-Hispanic blacks (v non-Hispanic whites), married survivors, survivors of breast cancer (v prostate or less prevalent cancers), those treated with chemotherapy, and survivors reporting past research study/clinical trial participation were more likely to report provider discussion(s) (P < .01). Hispanics (v non-Hispanic whites), survivors age 40 to 49 years (v ≤ 39 years), survivors of breast cancer (v melanoma or less prevalent cancers), those diagnosed ≤ 1 year ago (v > 5 years ago), survivors treated with radiation, and past research participants were more likely to report use of PCSG (P < .05). Survivors reporting any psychosocial care were more likely to be "very satisfied" with how their needs were met (P < .001).

CONCLUSION

Many survivors do not report a discussion with providers about the psychosocial effects of cancer, which reflects a missed opportunity to connect survivors to psychosocial services. These data can benchmark the success of efforts to improve access to cancer-related psychosocial care.

Assessing patient-centered communication in cancer care: stakeholder perspectives

PURPOSE

Patient-centered communication is critical to quality cancer care. Effective communication can help patients and family members cope with cancer, make informed decisions, and effectively manage their care; suboptimal communication can contribute to care breakdowns and undermine clinician-patient relationships. The study purpose was to explore stakeholders' views on the feasibility and acceptability of collecting self-reported patient and family perceptions of communication experiences while receiving cancer care. The results were intended to inform the design, development, and implementation of a structured and generalizable patient-level reporting system.

METHODS

This was a formative, qualitative study that used semistructured interviews with cancer patients, family members, clinicians, and leaders of health care organizations. The constant comparative method was used to identify major themes in the interview transcripts.

RESULTS

A total of 106 stakeholders were interviewed. Thematic saturation was achieved. All stakeholders recognized the importance of communication and endorsed efforts to improve communication during cancer care. Patients, clinicians, and leaders expressed concerns about the potential consequences of reports of suboptimal communication experiences, such as damage to the clinician-patient relationship, and the need for effective improvement strategies. Patients and family members would report good communication experiences in order to encourage such practices. Practical and logistic issues were identified.

CONCLUSION

Patient reports of their communication experiences during cancer care could increase understanding of the communication process, stimulate improvements, inform interventions, and provide a basis for evaluating changes in communication practices. This qualitative study provides a foundation for the design and pilot testing of such a patient reporting system.

Conceptualizing how couples talk about cancer

Scholarship on couple communication about cancer employs variable conceptualizations of communication, and common measurement strategies make questionable assumptions about communication. This study provides a descriptive foundation for a multiple-topic, multidimensional approach to studying couple talk about cancer. Based on interviews with persons treated for cancer in the last 5 years and partners, we identified 16 topics and 5 dimensions of talk. "Talk about cancer" covers a broad range of issues. The frequency, openness, difficulty, and focus of talk vary considerably for different topics and can change over time or differ between partners. Disagreements were rare but highly salient, and satisfaction with talk tended to be high. These findings suggest we move away from abstract, general measures of couple communication and that we develop descriptive advice for couples, rather than simply prescribing "be open."

Medical Students Learning Communication Skills in a Second Language: Empathy and expectations

OBJECTIVES

Communications skills (CS) training for medical interviewing is increasingly being conducted in English at medical schools worldwide. In this study, we sought to identify whether Arabic-speaking medical students experienced difficulty with the different components of the CS training that were conducted in English.

METHODS

Individual third-year preclinical medical students (N = 45) were videotaped while interviewing simulated patients. Each student assessed his/her performance on a 13-item (5-point scale) assessment form, which was also completed by the tutor and other students in the group.

RESULTS

Of the 13 components of their CS training, tutors awarded the lowest marks for students' abilities to express empathy, ask about patients' feelings, use transition statements, ask about functional impact, and elicit patients' expectations (P <0.001).

CONCLUSION

The expression of empathy and the ability to elicit patients' feelings and expectations are difficult to develop in medical students learning CS in a second language.

Challenges in ductal carcinoma in situ risk communication and decision-making: report from an American Cancer Society and National Cancer Institute workshop

In September 2010, the American Cancer Society and National Cancer Institute convened a conference to review current issues in ductal carcinoma in situ (DCIS) risk communication and decision-making and to identify directions for future research. Specific topics included patient and health care provider knowledge and attitudes about DCIS and its treatment, how to explain DCIS to patients given the heterogeneity of the disease, consideration of nomenclature changes, and the usefulness of decision tools/aids. This report describes the proceedings of the workshop in the context of the current literature and discusses future directions. Evidence suggests that there is a lack of clarity about the implications and risks of a diagnosis of DCIS among patients, providers, and researchers. Research is needed to understand better the biology and mechanisms of the progression of DCIS to invasive breast cancer and the factors that predict those subtypes of DCIS that do not progress, as well as efforts to improve the communication and informed decision-making surrounding DCIS.

Do radiation oncologists tailor information to patients needs? And, if so, does it affect patients?

BACKGROUND

Our study aims to investigate whether information given by radiation oncologists to their patients is tailored to the patient's desired level of information and, if so, what the effect of tailoring is on patient-reported outcomes, i.e. satisfaction, health, anxiety and self-efficacy.

MATERIAL AND METHODS

Consecutive radiotherapy patients (n = 150) completed a baseline questionnaire one week before their initial consultation, immediately following this consultation, and again one week prior to their first follow-up visit. The initial consultation was videotaped and 10 radiation oncologists' information giving behavior (content and duration) analyzed.

RESULTS

The overall amount of information provided by the radiation oncologists matched with patients' information needs in 50.8% (k = 0.07) of the consultations. No significant associations between tailored information giving and patient-reported outcomes were found, except for tailoring of information on procedures, and patients' anxiety and global health. These associations were no longer significant when correcting for patients' background characteristics.

CONCLUSION

This study shows that radiation oncologists poorly tailor their information to the needs of their patients. However, lack of tailoring is not associated with worse patient-reported outcomes. Until more evidence is available, radiation oncologists may explicitly ask patients about their information preferences and tailor the information provided accordingly.

The patient-physician relationship in patients with breast cancer: influence on changes in quality of life after rehabilitation

PURPOSE

The objective of this study was to examine whether aspects of the patient-physician relationship for breast cancer patients have an influence on the change in health-related quality of life (HRQOL) after inpatient rehabilitation.

METHODS

N = 329 breast cancer patients undergoing inpatient rehabilitation in Germany were surveyed using questionnaires at the beginning of rehabilitation, end of rehabilitation, and 6 months after rehabilitation. Multiple imputations and multilevel models of change were used in the data analyses.

RESULTS

Even after comprehensive adjustment for sociodemographic, medical, psychological variables, and center effects, aspects of the physician-patient relationship were statistically and clinically relevant predictors of HRQOL after rehabilitation. Satisfaction with physician's care appears to have a rather short-term effect, but the effect of promoting patient participation can still be partially determined 6 months after rehabilitation. Other important predictors of HRQOL improvement are optimism, higher level of education, higher income, living with a partner, and the ability to work.

CONCLUSIONS

By taking into consideration the patient's communication and participation needs, physicians can contribute to an improved HRQOL after rehabilitation. The high predictive power of socioeconomic factors shows that rehabilitation care can be more effective if it accounts for the specific situation of socially disadvantaged individuals.

Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach

Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institute's Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.

Factors associated with Americans' ratings of health care quality: what do they tell us about the raters and the health care system?

Consumer satisfaction ratings of health care quality represent a commonly used measure of health care performance. Identifying factors associated with ratings will help us understand the relative influence of individuals' sociodemographic and health characteristics on satisfaction level, thus informing policy making and clinical practice. Existing research has yielded mixed results on key predictors of consumer ratings. Using nationally representative data, this study aims to identify factors associated with Americans' ratings of health care quality. Data from 2008 Health Information National Trends Survey (HINTS) were analyzed using weighted multinomial logistic regressions to estimate consumer ratings. Predictor variables included demographics, health status, care access, and attitude and perceptions about health. Overall ratings were positively skewed; 70% of respondents rated care as "excellent" or "very good." Minority race, psychological distress, not having had cancer, not having a regular health care provider, not having health insurance, lacking confidence in self-care, and avoidance of doctors were significantly associated with lower ratings. The study identifies the psychosocial characteristics associated with lower consumer ratings. The results highlight the importance of using multiple approaches to assess quality of care, including considering patient characteristics, and contribute to the evidence base for evaluating overall quality of care at the dawn of health care reform.