Communicating prognosis in cancer care: a systematic review of the literature

Risk-Prediction Models for Clinical Decision-Making in Sarcoma Care: An International Survey Among Soft-Tissue Sarcoma Clinicians

INTRODUCTION

Risk prediction models (RPMs) are statistical tools that predict outcomes on the basis of clinical characteristics and can thereby support (shared) decision-making. With the shift toward personalized medicine, the number of RPMs has increased exponentially, including in multimodal sarcoma care. However, their integration into routine soft-tissue sarcoma (STS) care remains largely unknown. Therefore, we inventoried RPM use in sarcoma care during tumor board discussions and patient consultations as well as the attitudes toward the use of RPMs to support (shared) decision-making among STS clinicians.

MATERIALS AND METHODS

A 29-item survey was disseminated online to members of international sarcoma societies.

RESULTS

This study enrolled 278 respondents. Respectively, 68% and 65% of the clinicians reported using RPMs during tumor board discussions and/or patient consultations. During tumor board discussions, RPMs were used primarily to assess the potential benefits of (neo)adjuvant chemotherapy. During patient consultations, RPMs were used to predict patient prognosis upon request and to assist in decision-making regarding (neo)adjuvant therapies. The reliability of patient risk predicted by RPMs and the absence of guidelines regarding the use of RPMs were identified as barriers. Additionally, some clinicians questioned the applicability of estimates from RPMs to individual patients and expressed concerns about causing unnecessary anxiety when discussing prognostic outcomes.

CONCLUSIONS

Responding STS clinicians frequently use RPMs to support decision-making about (neo)adjuvant therapies. However, they expressed concerns about the applicability of RPM estimates to individual patients and reported challenges in communicating prognostic outcomes with patients. These findings highlight the difficulties clinicians face when integrating RPMs into patient consultations.

Impact of Implementing Serious Illness Conversations Across a Comprehensive Cancer Center Using an Interdisciplinary Approach

BACKGROUND

Gaps in communication of end-of-life care preferences increase risk of patient harm. Adoption of oncology practice guidelines advocating serious illness communication for patients with advanced cancer is limited.

OBJECTIVES

(1) Increase Serious Illness Conversation (SIC) use across oncology teams via an interdisciplinary quality improvement (QI) approach and (2) assess patient reported shared decision making (SDM) experiences with clinicians engaged in SIC implementation.

DESIGN

QI methodology was applied to spread the implementation of SIC across 4 oncology teams. CollaboRATE scores were used to evaluate patient reported outcomes of SDM for patients with advanced cancer.

SETTINGS/SUBJECTS

The SIC QI initiative was a component of the Promise Partnership Learning Health System (PPLHS) piloted in the Dartmouth Cancer Center, Lebanon, NH, USA.

MEASUREMENTS

(1) The percentage of eligible patients with documented SIC and (2) a comparison of a patient reported measure of SDM (CollaboRATE) among SIC eligible patients in encounters with providers who took part in the implementation versus those who did not.

RESULTS

Oncology teams screened a total of 538 patients, identified 278 eligible patients, and completed 144 SIC conversations. The teams improved the proportion of documented SIC among eligible patients from near 0% to a collective frequency of 52%. For clinicians' top-box CollaboRATE scores, a chi-squared test demonstrated a statistically significant association between providers implementing SIC into practice and patient reported shared decision making (.16, p = .031).

CONCLUSIONS

This approach allows for tailoring of iterative improvement cycles to mitigate barriers and improve the practice of SIC among oncology teams.

Treatment goals, desire for disclosure, and perception of cancer treatment outcomes in older patients with cancer: An observational study from a tertiary care center in India

INTRODUCTION

There is little information regarding the perceptions of older adults with cancer about intent of therapy, desire for disclosure of diagnosis and prognosis, treatment priorities, and influencing factors.

MATERIALS AND METHODS

We conducted a retrospective analysis of a prospectively maintained database at the geriatric oncology clinic of the Tata Memorial Hospital, Mumbai (India) where older patients with cancer (aged ≥60 years) were referred by their primary treating oncologists. Our three objectives were to understand the goals of cancer-directed therapy, evaluate the proportion of patients who desired disclosure of diagnosis and prognosis, and assess the proportion of patients who did not accurately understand the intent of cancer-directed therapy. We assessed the association of demographic and clinical factors and the results of geriatric assessment with patients' perceived intent of therapy and their desire for disclosure of diagnosis and prognosis using chi-square test and multivariate logistic regression.

RESULTS

Between November 2020 and December 2023, we enrolled 2599 patients. The median age was 67 years (IQR, 63-72), 77.7 % were male, and 62.6 % were being treated with palliative intent. Most patients (71.7 %) wanted a full disclosure of the diagnosis and prognosis; in 23.1 % of the cases, family members refused permission to disclose these details to the patients. Factors associated with a decreased desire for disclosure included palliative intent of therapy, female sex, illiteracy, performance status ≥2, and impaired function. Among patients receiving curative intent therapy, 79.3 % prioritized complete cure, 14.6 % prioritized quality of life (QoL)/symptom relief, and 5.1 % prioritized prolongation of life. Among patients receiving palliative intent therapy, 79.1 % prioritized QoL/symptom relief and 20.6 % prioritized prolongation of life. Misperception of intent of therapy was noted in 34.1 % of patients and was significantly higher in patients on palliative intent treatment (44.5 %) than patients receiving curative intent therapy (16.7 %). Factors associated with increased misperception of intent of therapy were female sex, illiteracy, and palliative intent therapy.

DISCUSSION

Understanding the perceptions and priorities of older individuals with cancer will help to identify key areas of intervention to meaningfully improve shared decision making, harmonize cancer treatment, and empower patients to make appropriate decisions regarding their care.

Trauma patients' perspectives on the needs, understanding and usefulness of personalized predictions for life after injury: a qualitative interview study using thematic analysis

PURPOSE

To explore trauma patients' perspectives on the need, understanding and usefulness of personalized predictions after injury to assist in rehabilitation.

METHODS

We performed semi-structured online interviews. Participants (N = 30 trauma patients, admitted to the hospital for an injury in the past 5 years) were exposed to a support tool that provides personalized predictions on recovery after injury. Interview data were transcribed verbatim and thematically analyzed.

RESULTS

Four themes were identified. Patients expressed (1) a need for personal information and felt that information about recovery was lacking. The most important (2) reasons for needing to receive personalized predictions were reassurance and managing expectations. However, (3) understanding the prediction model was challenging. Patients expressed receiving relatively poor predictions would not undermine (4) usefulness in practice, as they would rather know about what life has in store for them so they can prepare for life after injury better.

CONCLUSIONS

Trauma patients have a need for receiving personalized predictions as they perceive them to be a useful addition to clinical practice. Understanding such predictions might be challenging, so more time should be spent on how these can be communicated.

Tips from clinicians about if, when, and how to discuss life expectancy with older adults

OBJECTIVES

Estimates of life expectancy can inform clinical recommendations and decisions for older adults, but many clinicians find it difficult to discuss. We interviewed primary care clinicians to identify best practices for discussing life expectancy with older adults.

METHODS

Twenty-one primary care clinicians (Internal Medicine, Family Medicine, and Geriatrics) completed in-depth interviews on Zoom or by telephone. Topics included estimation and discussion of life expectancy with older patients to guide cancer screening and preventive care decisions. We transcribed, coded, and inductively analyzed interviews using a thematic analysis approach.

RESULTS

Most clinicians recommended individualizing communication about life expectancy versus a standardized approach. Although many clinicians worry that conversations about life expectancy won't go well, successful conversations are possible when clinicians bring humility, care, and attention to these interactions. Clinicians identified seven steps that they find effective for deciding if, when, and how to discuss life expectancy with older patients and detailed tips for using these steps in practice.

CONCLUSIONS

Clinicians can take multiple steps to optimize conversations about life expectancy to personalize medical decision making.

PRACTICE IMPLICATIONS

The tips and language presented provide a helpful starting point for clinicians to have conversations about life expectancy and appropriate care with older adults.

The prognostic reasoning by physiotherapists of musculoskeletal disorders: A phenomenological exploratory study

QUESTION(S)

What are the prognostic reasoning practices of physiotherapists towards musculoskeletal disorders?

DESIGN

Exploratory phenomenological study.

PARTICIPANTS

15 physiotherapists who currently treat musculoskeletal disorders.

DATE ANALYSIS

Semi-structured interviews were implemented to collect data which was analysed using an inductive coding and thematic analysis approach.

RESULTS

Three themes were identified. First, how physiotherapists considered prognosis within clinical practice. Whilst prognosis is an important consideration, in some circumstances it either may not be considered or is implied. Second, how physiotherapists determine prognosis for musculoskeletal disorders. Several factors shaped the ability of physiotherapists to determine prognosis including how they determine prognosis, and the barriers and facilitators towards determining prognosis. Finally, how physiotherapists discuss prognosis with individuals who have a musculoskeletal disorder. These discussions were shaped by the prognostic information provided, as well as the barriers and facilitators towards discussing prognosis.

CONCLUSION

The prognostic reasoning of physiotherapists appears to be influenced initially by whether they consider it or not. It is then shaped by both barriers and facilitators towards determining and discussing prognosis. Facilitators for this prognostic reasoning process appear to be aligned with the biomedical model of health, whilst barriers more aligned with psychosocial factors. To improve prognostic reasoning, physiotherapists should continue to strive to conceptualize prognosis within a biopsychosocial framework. Doing so will improve the ability of physiotherapists to prognosticate, which will subsequently improve outcomes associated with musculoskeletal disorders.

Changes in perception of prognosis in the last year of life of patients with advanced cancer and its associated factors: Longitudinal results of the eQuiPe study

BACKGROUND

Many patients with advanced cancer are unaware of their limited prognosis, however little is known about the change in awareness during the last year of their lives.

AIM

To investigate changes in the perception of prognosis in the last year of life of patients with advanced cancer and its associated factors.

DESIGN

Prospective, longitudinal, multicentre, observational study in patients with advanced cancer (eQuiPe). Patients completed 3-monthly follow-up questionnaires until death.

SETTING/PARTICIPANTS

Adult patients diagnosed with advanced cancer were recruited by their treating physician or self-enrolled in one of the forty Dutch hospitals. Only deceased patients with available prognostic data were included for analysis (n = 801).

RESULTS

Perception of prognosis changes in the last year of life with an increase in the percentage of patients who are aware of their limited prognosis (from 15% to 40%). Especially in the last 6 months of life, most of the changes were towards a more realistic perception of prognosis. Patients who did not want to know their prognosis remained relatively stable in their wish not to know (range: 14%-18%). Time to death was associated with having a perception of prognosis of < 1 year, >1 year or not knowing the prognosis, but was not associated with not wanting to know the prognosis.

CONCLUSION

Becoming aware of their limited prognosis may make patients with advanced cancer more receptive to start end-of-life discussions. Although some patients prefer not to know their prognosis, it remains important to respectfully explore their preferences and wishes for end-of-life care.

A taxonomy of the factors contributing to the overtreatment of cancer patients at the end of life. What is the problem? Why does it happen? How can it be addressed?

Many patients with cancer approaching the end of life (EOL) continue to receive treatments that are unlikely to provide meaningful clinical benefit, potentially causing more harm than good. This is called overtreatment at the EOL. Overtreatment harms patients by causing side-effects, increasing health care costs, delaying important discussions about and preparation for EOL care, and occasionally accelerating death. Overtreatment can also strain health care resources, reducing those available for palliative care services, and cause moral distress for clinicians and treatment teams. This article reviews the factors contributing to the overtreatment of patients with cancer at the EOL. It addresses the complex range of social, psychological, and cognitive factors affecting oncologists, patients, and patients' family members that contribute to this phenomenon. This intricate and complex dynamic complicates the task of reducing overtreatment. Addressing these driving factors requires a cooperative approach involving oncologists, oncology nurses, professional societies, public policy, and public education. We therefore discuss approaches and strategies to mitigate cultural and professional influences driving overtreatment, reduce the seduction of new technologies, improve clinician-patient communication regarding therapeutic options for patients approaching the EOL, and address cognitive biases that can contribute to overtreatment at the EOL.

Early palliative care in metastatic uveal melanoma (early together): protocol of a prospective randomized Phase III trial

Metastatic uveal melanoma (UM) patients often initially present with limited symptoms despite a poor prognosis, complicating communication with patients and caregivers. Early Together (NCT04728113) is a randomized Phase III trial that integrates early palliative care through systematic joint visits involving the palliative care team and the medical oncologist, compared with standard oncological care, in 162 metastatic UM patients beginning systemic treatment. This collaboration aims to enhance patient functioning, improve quality of life and facilitate coping mechanisms. Patients' quality of life and needs for information, care and support are assessed over 12 months using validated questionnaires in both groups. Investigators receive training throughout the study to improve communication skills in addressing uncertainty and poor prognosis. This article describes the trial protocol.

Recording diagnostic conversations for communication research purposes in pediatric leukemia

Recordings of patient-doctor interactions is a recommended method in communication research. However, concerns are expressed regarding audio-recording of conversations with vulnerable patients. Our study examined experiences of children, parents, and oncologists with recording diagnostic conversations in the pediatric acute leukemia setting. Results show that recording conversations is generally well received by virtually all children and parents. Pediatric oncologists seem to overestimate the expected emotional burden for children and parents, which may lead to gatekeeping by professionals. This in turn may lead to a decrease in patient autonomy and research quality when addressing relevant questions in communication science.

What influences provision of information about recovery on stroke units? A focused ethnographic case study

OBJECTIVE

Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units.

METHODS

Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken.

RESULTS

Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers.

CONCLUSIONS

The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision.

PRACTICE IMPLICATIONS

Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs.

Evaluating surgeon communication of pancreatic cancer prognosis using the VitalTalk ADAPT framework

BACKGROUND AND OBJECTIVES

Few data exist to guide optimal communication practices for surgical oncologists. VitalTalk, an evidence-based communication skills training model for clinicians, offers the five-step ADAPT tool for discussing prognosis. This study aimed to characterize surgeon communication of pancreatic cancer prognosis using VitalTalk's ADAPT framework.

METHODS

Contemporaneous audio recordings from 12 initial surgeon-patient encounters for borderline resectable pancreatic cancer were transcribed. Directed qualitative content analysis based on ADAPT (Ask, Discover, Anticipate, Provide, and Track) was used to deductively code transcripts.

RESULTS

All encounters contained at least one ADAPT step while only one (8%) incorporated four or five steps. Surgeons provided prognostic information (Provide) in all but one encounter (92%); most was qualitative and clustered into themes: serious illness, surgical candidacy, prognostic ambiguity, and cancer recurrence. Surgeons elicited understanding (Ask), requested information preferences (Discover), anticipated ambivalence (Anticipate), and responded to emotion (Track) in a minority of encounters (25%-42%); of 15 patient emotional cues, six were not addressed by surgeons.

CONCLUSIONS

During an initial encounter for pancreatic cancer, surgeons focus heavily on providing information but omit critical prognostic communication steps. Future studies are needed to investigate if surgeon training in palliative care-based communication is feasible and impacts patient-perceived quality of communication.

Facilitating patient-oncologist communication in advanced treatment-resistant cancer: development and feasibility testing of a question prompt list

BACKGROUND

Patients' expectations regarding medical information in advanced stages of cancer are still poorly understood. Tailoring information to advanced cancer patients is a subtle task. We developed a question prompt list (QPL) that serves as a patient-oncologist communication aid in France.

METHODS

A four-step sequential mixed method involving patients with luminal B/triple-negative metastatic breast cancer or metastatic uveal melanoma (N = 110) and patients' partners, oncologists, and researchers (N = 18) was used. In-depth interviews and questionnaires focused on the information needed at the disclosure of metastasis or resistance to treatment (step 1), the formulation of questions and procedures for use in oncology visits (steps 2 and 3), and the acceptability of the final tool (stage 4).

RESULTS

The initial version of the QPL consists of 17 questions covering 5 themes (disease, current treatment, other options, living with cancer, prognosis). In step 2, 13 questions were added, 2 were merged, and 5 were deleted; a short form (4 questions) and recommendations for clinical use were proposed. In step 3, 2 questions were merged, and 6 were deleted. Four oncologists (27% of the target population) took part in step 4, and the QPL was discussed with 20 patients, revealing a positive appraisal.

CONCLUSION

We provide a rigorously developed, relevant, concise, and acceptable question prompt list for clinical application in the advanced cancer care setting in France. Further research needs to assess whether this tool actually facilitates oncologist-patient communication and improves satisfaction with care and health outcomes.

TRIAL REGISTRATION

The study is listed on ClinicalTrials.gov (NCT04118062) and registered under identification n° IRRID "International Registered Report Identifier": DERR1-10.2196/26414.

MSFN: a multi-omics stacked fusion network for breast cancer survival prediction

Introduction: Developing effective breast cancer survival prediction models is critical to breast cancer prognosis. With the widespread use of next-generation sequencing technologies, numerous studies have focused on survival prediction. However, previous methods predominantly relied on single-omics data, and survival prediction using multi-omics data remains a significant challenge. Methods: In this study, considering the similarity of patients and the relevance of multi-omics data, we propose a novel multi-omics stacked fusion network (MSFN) based on a stacking strategy to predict the survival of breast cancer patients. MSFN first constructs a patient similarity network (PSN) and employs a residual graph neural network (ResGCN) to obtain correlative prognostic information from PSN. Simultaneously, it employs convolutional neural networks (CNNs) to obtain specificity prognostic information from multi-omics data. Finally, MSFN stacks the prognostic information from these networks and feeds into AdaboostRF for survival prediction. Results: Experiments results demonstrated that our method outperformed several state-of-the-art methods, and biologically validated by Kaplan-Meier and t-SNE.

Estimating survival scenarios in advanced or metastatic gastric and oesophageal adenocarcinoma: a systematic review of randomized-controlled trials

BACKGROUND

We aimed to summarize survival data from RCTs in patients with GO adenocarcinoma; estimate and explain worst-, typical-, and best-case-scenarios of survival time; and determine if simple multiples of median overall survival (mOS) could estimate these percentiles.

METHODS

We systematically searched RCTs of systemic therapies for GO adenocarcinoma published 2000-2022. The following key percentiles were extracted from overall survival curves: 90th (worst-case), 75th (lower-typical), 25th (upper-typical), and 10th (best-case). We tested if these percentiles could be estimated by simple multiples of mOS: 0.25 of the median for the 90th percentile, 0.5 for the 75th, 2 for the 25th, and 3 for the 10th.

RESULTS

We identified 44 trials (22,447 participants). For first line chemotherapy and immunotherapy combined (CI) trials (n = 3) worst-to-best case survival time ranged from 4 months to not reached, compared to 3-30 months for other trials (n = 27) and 1-23 months for subsequent lines (n = 14). Simple multiples of mOS accurately estimated the following survival percentiles: 90th (n = 3/3 trials), 75th (n = 3/3), and 25th (n = 2/3) in first line CI trials. In other first line trials, the mOS accurately estimated the 90th survival percentile in n = 22/27 trials, 75th percentile in n = 26/27, 25th percentile in 27/27 trials, and 10th percentile in 22/27 trials. Simple multiples of the mOS accurately predicted the 90th, 75th, 25th, and 10th survival percentiles in the majority of trials of second and subsequent lines apart from chemotherapy and immunotherapy only trials.

CONCLUSION

We provide realistic, evidence-based prognostic information as scenarios for survival time which can inform clinical decision-making. Simple multiples of the mOS accurately estimated the percentiles for most groups.

Parent and oncologist perspectives on prognostic disclosure in advanced childhood cancer: communication pearls and pitfalls

PURPOSE

For children with advanced cancer and their families, communication about prognosis is critical. Unfortunately, data demonstrate that prognostic communication occurs infrequently and inconsistently across advancing illness. Prior to developing an intervention to improve prognostic communication, we aimed to (1) characterize parent and oncologist perspectives on "best" approaches for prognostic communication, and (2) explore similarities and differences between parent and oncologist perspectives.

METHODS

Children with poor-prognosis solid tumors, their parents, and oncologists were followed prospectively for 24 months or until death. Matched semi-structured interviews were conducted with parents and oncologists 0-7 days after medical encounters at timepoints of disease progression or relapse. Reflexive thematic analysis was conducted to describe parent and oncologist impressions of communication quality.

RESULTS

A total of 68 interviews were conducted following serial disease reevaluation encounters involving 13 parents and five oncologists. Nine main themes were identified as "best" approaches: (1) speaking with honesty and clarity, (2) leaving room for hope, (3) leaning into a long-standing relationship, (4) personalizing language, (5) empowering the patient and family, (6) collaborating with the multidisciplinary team, (7) providing anticipatory guidance, (8) setting the scene, and (9) creating a therapeutic space. Parents and oncologists generally agreed on themes related to helpful communication approaches, while parents more explicitly described communication pitfalls.

CONCLUSION

Parents and oncologists described clear recommendations for helpful communication strategies and pitfalls to avoid during difficult prognostic disclosure. Future work should integrate patient perspectives in the design and testing of an intervention to improve prognostic communication in advanced childhood cancer.

The trajectory of prognostic cognition in patients with advanced cancer: is the traditional advance care planning approach desirable for patients?

Most patients with advanced cancer initially express a desire to be informed of their prognosis, and prognostic discussions between patients and their oncologists can trigger the subsequent trajectory of prognostic cognitions. On the continuum of prognostic cognition, including inaccurate/accurate prognostic awareness (awareness of incurability of cancer, terminal nature of illness or life expectancy) and prognostic acceptance (accepting one's prognosis), patients' perceptions of being informed of their prognosis by oncologists and patients' coping strategy for serious medical conditions regulate prognostic cognitions. However, nearly half of the patients with advanced cancer have poor prognostic awareness, and few patients achieve prognostic acceptance. These phenomena partly act as barriers to participation in advance care planning. When oncologists engage in advance care planning conversations, they must assess the patient's prognostic cognition and readiness for advance care planning. Considering the inaccurate prognostic awareness in a non-negligible proportion of patients and that astatic patients' preferences for future treatment and care are influenced by prognostic cognition, more research on decision-making support processes for high-quality and goal-concordant end-of-life care is needed along with research of advance care planning. In addition to making decisions regarding future medical treatment and care, oncologists must engage in continuous and dynamic goal-of-care conversations with empathic communication skills and compassion from diagnosis to end-of-life care.

The stigma towards mental illness: Portuguese validation of the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC)

Background

Stigma toward mental illness significantly contributes to a lower quality of healthcare that can be provided. There are few studies on this topic in Portugal, so validating a scale that can evaluate and study the stigma is paramount. The aim of this study was to validate the Opening Minds Stigma Scale for Portuguese healthcare professionals.

Methods

A total of 503 participants were included in this study, and the majority was female (81.1%). The sample consisted mainly of psychologists (39.4%) and physicians (30.8%). Reliability and validity analyses were conducted and included exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

Results

Our results suggest that a 12-item model was the most appropriate (RMSEA = 0.026, SRMR = 0.057, CFI = 0.979, TLI = 0.973, GFI = 0.955) compared to our 15-item model and the original model. Items 8, 9 and 10 were removed. The 12-item scale's internal consistency was adequate (α = 0.71; ω = 0.72).

Conclusion

The 12-item model of the scale showed good reliability and validity and is appropriate for use with Portuguese healthcare professionals.

The Need for Specialized Oncology Training for Clinical Ethicists

Numerous ethical issues are raised in cancer treatment and research. Informed consent is challenging due to complex treatment modalities and prognostic uncertainty. Busy oncology clinics limit the ability of oncologists to spend time reinforcing patient understanding and facilitating end-of-life planning. Despite these issues and the ethics consultations they generate, clinical ethicists receive little if any focused education about cancer and its treatment. As the field of clinical ethics develops standards for training, we argue that a basic knowledge of cancer should be included and offer an example of what cancer ethics training components might look like. We further suggest some specific steps to increase collaboration between clinical ethicists and oncology providers in the outpatient setting to facilitate informed consent and proactively identify ethical issues.

Rethinking parameters of "success" in breaking bad news conversations from patient's perspective: the successful delivery process model

PURPOSE

Studies that focus on improving the difficult process of breaking bad news in oncology should include the patient perspective and be guided by appropriate outcome measures. Endpoints such as "patient satisfaction" fall short to capture the complex nature of breaking bad news (BBN) conversations. However, this is true of many studies. The present study attempts to develop a framework model from a new, patient-centered perspective, which can be applied equally in clinical practice and in education.

METHODS

Semi-structured in-depth interviews with twelve cancer patients were conducted. Transcripts were analyzed by "qualitative content analysis" following Mayring. Outcomes were further extrapolated in interpretational steps, and a model of "success" from patients view in BBN was developed.

RESULTS

Two central needs of the patients could be identified: understanding and feelings. Their fulfillment depends on two groups of variables: first, structural characteristics, such as the inevitable shock, individuality, and processability; second, strongly influenceable variables, such as relationship, transfer of knowledge, and atmosphere. From these results, a framework model for successful breaking of bad news from the patient's perspective was developed: The successful delivery process model (SDP model).

CONCLUSION

As a basic model for the framework for breaking bad news from the patient's perspective, the SDP model can be applied to many different situations in oncology and help to frame the difficult conversations by tailoring the BBN conversations on determinants that favorably influence the process in a patient centered manner. In this sense, the model can be useful in clinical practice as well as in education.

Timing of prognostic discussions in people with advanced cancer: a systematic review

PURPOSE

Many people with cancer (patients) want to know their prognosis (a quantitative estimate of their life expectancy) but this is often not discussed or poorly communicated. The optimal timing of prognostic discussions with people with advanced cancer is highly personalised and complex. We aimed to find, organise, and summarise research regarding the timing of discussions of prognosis with people with advanced cancer.

METHODS

We conducted a systematic review of publications from databases, clinical practice guidelines, and grey literature from inception to 2023. We also searched the reference lists of systematic reviews, editorials, and clinical trial registries. Eligibility criteria included publications regarding adults with advanced cancer that reported a timepoint when a discussion of prognosis occurred or should occur.

RESULTS

We included 63 of 798 identified references; most of which were cross-sectional cohort studies with a range of 4-9105 participants. Doctors and patients agreed on several timepoints including at diagnosis of advanced cancer, when the patient asked, upon disease progression, when there were no further anti-cancer treatments, and when recommending palliative care. Most of these timepoints aligned with published guidelines and expert recommendations. Other recommended timepoints depended on the doctor's clinical judgement, such as when the patient 'needed to know' or when the patient 'seemed ready'.

CONCLUSIONS

Prognostic discussions with people with advanced cancer need to be individualised, and there are several key timepoints when doctors should attempt to initiate these conversations. These recommended timepoints can inform clinical trial design and communication training for doctors to help improve prognostic understanding.

The modified Polsby-Popper score, a novel quantitative histomorphological biomarker and its potential to predict lymph node positivity and cancer-specific survival in oral tongue squamous cell carcinoma

BACKGROUND

The significance of different histological spreading patterns of tumor tissue in oral tongue squamous cell carcinoma (TSCC) is well known. Our aim was to construct a numeric parameter on a continuous scale, that is, the modified Polsby-Popper (MPP) score, to describe the aggressiveness of tumor growth and infiltration, with the potential to analyze hematoxylin and eosin-stained whole slide images (WSIs) in an automated manner. We investigated the application of the MPP score in predicting survival and cervical lymph node metastases as well as in determining patients at risk in the context of different surgical margin scenarios.

METHODS

We developed a semiautomated image analysis pipeline to detect areas belonging to the tumor tissue compartment. Perimeter and area measurements of all detected tissue regions were derived, and a specific mathematical formula was applied to reflect the perimeter/area ratio in a comparable, observer-independent manner across digitized WSIs. We demonstrated the plausibility of the MPP score by correlating it with well-established clinicopathologic parameters. We then performed survival analysis to assess the relevance of the MPP score, with an emphasis on different surgical margin scenarios. Machine learning models were developed to assess the relevance of the MPP score in predicting survival and occult cervical nodal metastases.

RESULTS

The MPP score was associated with unfavorable tumor growth and infiltration patterns, the presence of lymph node metastases, the extracapsular spread of tumor cells, and higher tumor thickness. Higher MPP scores were associated with worse overall survival (OS) and tongue carcinoma-specific survival (TCSS), both when assessing all pT-categories and pT1-pT2 categories only; moreover, higher MPP scores were associated with a significantly worse TCSS in cases where a cancer-free surgical margin of <5 mm could be achieved on the main surgical specimen. This discriminatory capacity remained constant when examining pT1-pT2 categories only. Importantly, the MPP score could successfully define cases at risk in terms of metastatic disease in pT1-pT2 cancer where tumor thickness failed to exhibit a significant predictive value. Machine learning (ML) models incorporating the MPP score could predict the 5-year TCSS efficiently. Furthermore, we demonstrated that machine learning models that predict occult cervical lymph node involvement can benefit from including the MPP score.

CONCLUSIONS

We introduced an objective, quantifiable, and observer-independent parameter, the MPP score, representing the aggressiveness of tumor growth and infiltration in TSCC. We showed its prognostic relevance especially in pT1-pT2 category TSCC, and its possible use in ML models predicting TCSS and occult lymph node metastases.

Recasting the gold standard - part I of II: delineating healthcare options across a continuum of care

AIM

This is the first part of a two-part series on spectrum of care that encourages practitioners to embrace a non-binary approach to healthcare delivery. When care is not framed as all-or-none, either/or or best versus lesser, the provider and client can agree to diagnostic and/or treatment plans that individualize the practice of veterinary medicine. Care is tailored to the patient along a continuum of acceptable options. Care may also be intentionally incremental, with plans to reassess the patient and revise case management as needed.

RELEVANCE

Acknowledgment and ultimately acceptance that patient care journeys can be distinct, yet equitably appropriate, offers providers the flexibility to adapt case management competently and confidently to the patient based upon contextualized circumstances including client needs, wants and expectations for healthcare outcomes. Thinking outside the box to recast the historic gold standard with a continuum of care strategically offers feline practitioners a means by which they can overcome barriers to healthcare delivery.

SERIES OUTLINE

This first article introduces spectrum of care as an appropriate approach to case management and broadens its definition beyond cost of care. Part II explores communication strategies that enhance veterinary professionals' delivery of spectrum of care through open exchange of relationship-centered dialogue.

Recasting the gold standard - part II of II: communicating healthcare options along a continuum of care

SERIES OUTLINE

This is the second part of a two-part series on spectrum of care that encourages practitioners to tailor case management to the patient along a continuum of acceptable options. Part I defined the spectrum of care and broadened its approach beyond initial cost-of-care considerations. This second article introduces strategies for initiating conversations with clients about their needs, wants and expectations specific to healthcare options and case management decisions. It will explore how open inquiry, reflective listening, transparency and unconditional positive regard facilitate dialogue between providers and their clients as they collaborate on decision-making along a spectrum of care.

RELEVANCE

Contextual case management prioritizes interventions that are appropriate for both the patient and the client. To identify and explore which healthcare options represent the best fit for those impacted most by medical decisions, veterinarians need to make space for clients to feel comfortable sharing their perspectives. Clients are more likely to be engaged in decision-making when their insight is actively solicited. They have much to share with us as experts about their cat's overall health and wellness needs. Inviting clients to contribute to the consultation and being receptive to hearing what motivates their choices helps us to structure conversations around healthcare options. The ability to communicate healthcare options is as vital as the provision of healthcare, if not more so.

Accuracy of oncologists' estimates of expected survival time in advanced cancer

BACKGROUND

To evaluate the claim that oncologists overestimate expected survival time (EST) in advanced cancer.

METHODS

We pooled 7 prospective studies in which observed survival time (OST) was compared with EST (median survival in a group of similar patients estimated at baseline by the treating oncologist). We hypothesized that EST would be well calibrated (approximately 50% of EST longer than OST) and imprecise (<30% of EST within 0.67 to 1.33 of OST), and that multiples of EST would provide well-calibrated scenarios for survival time: worst-case (approximately 10% of OST <1/4 of EST), typical (approximately 50% of OST within half to double EST), and best-case (approximately 10% of OST >3 times EST). Associations between baseline characteristics and calibration of EST were assessed.

RESULTS

Characteristics of 1,211 patients: median age 66 years, male 61%, primary site lung (40%) and upper gastrointestinal (16%). The median OST was 8 months, and EST was 9 months. Oncologists' estimates of EST were well calibrated (50% longer than OST) and imprecise (28% within 0.67 to 1.33 of OST). Scenarios for survival time based on simple multiples of EST were well calibrated: 8% of patients had an OST less than 1/4 their EST (worst-case), 56% had an OST within half to double their EST (typical), and 11% had an OST greater than 3 times their EST (best-case). Calibration was independent of age, sex, and cancer type.

CONCLUSIONS

Oncologists were no more likely to overestimate survival time than to underestimate it. Simple multiples of EST provide well-calibrated estimates of worst-case, typical, and best-case scenarios for survival.

Social, Ethical and Treatment Related Problems Faced by Healthcare Workers in the Care of Head and Neck Cancer Patients: A Narrative Review from the Bioethics Consortium from India

Head and neck cancer (HNC) presents a variety of ethical difficulties for an oncologist involved in screening, diagnosis, treatment, and rehabilitation that are challenging to address, especially for those professionals/people who are not trained in medical ethics. The bioethics department has spent the last ten years compiling information and rating the seriousness of numerous niche ethical concerns and their effects on healthcare professionals practising in India. Based on these findings, the current analysis makes an effort to outline the different challenges faced by oncologists when screening, diagnosing, treating, and rehabilitating people affected with HNC, particularly in a traditional nation like India. According to the authors, this is the first overview to address these issues from an Indian viewpoint, and it represents a small effort to document a crucial but unaddressed component of cancer treatment. It is hoped that these endeavours would aid in educating upcoming healthcare professionals on how to effectively handle the difficulties.

MHAttnSurv: Multi-head attention for survival prediction using whole-slide pathology images

Whole slide images (WSI) based survival prediction has attracted increasing interest in pathology. Despite this, extracting prognostic information from WSIs remains a challenging task due to their enormous size and the scarcity of pathologist annotations. Previous studies have utilized multiple instance learning approach to combine information from several randomly sampled patches, but this approach may not be adequate as different visual patterns may contribute unequally to prognosis prediction. In this study, we introduce a multi-head attention mechanism that allows each attention head to independently explore the utility of various visual patterns on a tumor slide, thereby enabling more comprehensive information extraction from WSIs. We evaluated our approach on four cancer types from The Cancer Genome Atlas database. Our model achieved an average c-index of 0.640, outperforming three existing state-of-the-art approaches for WSI-based survival prediction on these datasets. Visualization of attention maps reveals that the attention heads synergistically focus on different morphological patterns, providing additional evidence for the effectiveness of multi-head attention in survival prediction.

Prognostic evaluation in patients with advanced cancer in the last months of life: ESMO Clinical Practice Guideline

•This ESMO Clinical Practice Guideline provides key recommendations for using prognostic estimates in advanced cancer. •The guideline covers recommendations for patients with cancer and an expected survival of months or less. •An algorithm for use of clinical predictions, prognostic factors and multivariable risk prediction models is presented. •The author group encompasses a multidisciplinary group of experts from different institutions in Europe, USA and Asia. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

Information disclosure to cancer patients in Mainland China: A meta-analysis

OBJECTIVE

This study aims to systematically examine Chinese cancer patients' and families' preferences for information disclosure to the patient, patient awareness, and predictors of patient awareness.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Web of Science, Scopus, Proquest, Taylor & Francis Online, and China National Knowledge Infrastructure were searched in April 2022 and Chinese Biomedical Literature Database in July 2022 for quantitative studies. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

A total of 22 studies were included, and the average quality score was 0.65/1. Meta-analyses showed that 89.6% and 81.8% of cancer patients wanted to know their diagnosis and prognosis, respectively. Meanwhile, 50.0% and 32.4% of families prefer diagnosis disclosure and prognosis disclosure to the patient, respectively. Significantly more patients than families favored disclosure to the patient. In reality, only 59.3% of cancer patients know their diagnosis, and 19.9% know their prognosis. For predictors, while patients' gender, cancer type (breast cancer or not), treatment method (operation or other), or complications (yes or no) do not influence diagnosis awareness, being younger, being married, having higher educational attainment, having early-stage rather than late-stage cancer, and being in a higher-grade hospital all predict better chances of knowing a diagnosis. No study explored predictors of patients' prognosis awareness. The findings did not vary according to publication time or sample size.

CONCLUSIONS

Chinese cancer patients are eager to know their diagnosis and prognosis, but families are hesitant about disclosure to the patient, and patients' awareness is low. While cultural, legal, and medical backgrounds lay the foundation for information disclosure in Mainland China, case-by-case practical factors also make a difference.

Perception of prognosis and health-related quality of life in patients with advanced cancer: results of a multicentre observational study (eQuiPe)

PURPOSE

To assess perception of prognosis in patients with advanced cancer, its association with patient's characteristics and health-related quality of life (HRQoL).

METHODS

In a multicentre observational cohort study (eQuiPe), conducted on patients with advanced cancer, perceived prognosis, coping strategies, and HRQoL were assessed. Clinical data were obtained from the Netherlands Cancer Registry. Patients with vs. without a perception of prognosis, patients who perceived their prognosis as limited (< 1 year) vs. longer (> 1 year), and patients who did not want to know their prognosis vs. those who did not know for other reasons were compared.

RESULTS

Of 1000 patients with advanced cancer, 29% perceived their prognosis as > 1 year, 13% < 1 year, and 4% non-life threatening. Thirty-six percent did not know their prognosis and another 15% did not want to know. Patients without a perception were older, lower educated, coped differently (less accepting, planning, active; more denial), and received treatment more often (p < 0.05). Global QoL was lower in patients with vs. without a perceived prognosis (66 (SD21) vs. 69 (SD19), p = 0.01), specifically in patients who perceived a limited rather than a longer prognosis (57 (SD22) vs. 70 (SD19), p < 0.01). Global QoL of patients who did not want to know their prognosis was comparable to patients who did not know for other reasons (71 (SD19) vs. 69 (SD19), p = 0.22).

CONCLUSION

More than half of the patients with advanced cancer have no perception of their prognosis. Patients with a perceived prognosis have lower HRQoL, but only in patients who perceived their prognosis as limited (< 1 year) and were probably closer to the end of life, which more likely determines their poorer HRQoL, rather than prognostic perception. Ignorance of prognosis is not associated with lower HRQoL, however, should not hamper appropriate palliative care.

Delivering Prognostic News to Older People with Chronic Disease: What Format Preference and Level of Involvement in Decision Making? A Hospital Survey

Shared decision making near end of life is a balancing act of communicating prognosis to patients and their surrogates/families and engaging them in considering value-concordant management choices. This cross-sectional survey aimed to determine the format in which older patients with chronic illnesses would prefer to receive prognostic information on their treatment options and disease progression, and their desired level of engagement in decision making. With a 60% participation rate, 139 inpatients in two hospitals and five surrogates were presented with six hypothetical scenarios with a randomly assigned sequence: verbal and written summary, graph, table, photo, video, and pamphlet. The majority (76%) of respondents chose the traditional verbal communication of prognosis by their doctor with a written summary as a reference and to share with family; the second choice was a condition-specific pamphlet (63%). Many found the graph and photo to be distressing (36% and 42%, respectively). Most (71%) wanted to know everything about their condition trajectory, and 63% chose shared decision making rather than completely autonomous or full delegation to clinicians or family. There were no gender differentials between wanting to know it all, supporting shared decision making or the preferred format for breaking news (p > 0.05). Older hospitalized patients with chronic conditions are willing to discuss end-of-life issues, learn about their prognosis, and be involved in shared decision making. Innovative formats such as graphs, videos, or photos were not welcome as part of the prognostic discussion.

Demystifying Prognosis : Understanding the Science and Art of Prognostication

The science of prognostication is emerging as a vital part of providing goal concordant patient care. Historically, modern medicine has tended to shy away from approaching prognostication as a core clinical skill, and prognosis as something to be shared directly with the patient. In recent years however, the medical field's shift towards a focus on patient autonomy and more openness in matters regarding end of life has propelled the study of prognostication into a more essential component of patient centered care. This calls for more emphasis on teaching the science of prognosis and the skill of prognostication as a core part of modern medical education. The following chapter aims to delve into the science of prognostication, explore the methods of formulating a prognosis, and discuss issues surrounding the communication of prognosis.

Examining how physician factors influence patient satisfaction during clinical consultations about cancer prognosis and pain

Objective

Patient-physician communication affects cancer patients' satisfaction, health outcomes, and reimbursement for physician services. Our objective is to use machine learning to comprehensively examine the association between patient satisfaction and physician factors in clinical consultations about cancer prognosis and pain.

Methods

We used data from audio-recorded, transcribed communications between physicians and standardized patients (SPs). We analyzed the data using logistic regression (LR) and random forests (RF).

Results

The LR models suggested that lower patient satisfaction was associated with more in-depth prognosis discussion; and higher patient satisfaction was associated with a greater extent of shared decision making, patient being black, and doctor being young. Conversely, the RF models suggested the opposite association with the same set of variables.

Conclusion

Somewhat contradicting results from distinct machine learning models suggested possible confounding factors (hidden variables) in prognosis discussion, shared decision-making, and doctor age, on the modeling of patient satisfaction. Practitioners should not make inferences with one single data-modeling method and enlarge the study cohort to help deal with population heterogeneity.

Innovation

Comparing diverse machine learning models (both parametric and non-parametric types) and carefully applying variable selection methods prior to regression modeling, can enrich the examination of physician factors in characterizing patient-physician communication outcomes.

Show me the roads and give me a road map: Development of a patient conversation tool to improve lung cancer treatment decision-making

Objective

Evidence-based decision support resources do not exist for persons with lung cancer. We sought to develop and refine a treatment decision support, or conversation tool, to improve shared decision-making (SDM).

Methods

We conducted a multi-site study among patients with stage I-IV non-small cell lung cancer (NSCLC) who completed or had ongoing lung cancer treatment using semi-structured, cognitive qualitative interviews to assess participant understanding of content. We used an integrated approach of deductive and inductive thematic analysis.

Results

Twenty-seven patients with NSCLC participated. Participants with prior cancer experiences or those with family members with prior cancer experiences reported better preparedness for cancer treatment decision-making. All participants agreed the conversation tool would be helpful to clarify their thinking about values, comparisons, and goals of treatment, and to help patients communicate more effectively with their clinicians.

Conclusion

Participants reported that the tool may empower them with confidence and agency to actively participate in cancer treatment SDM. The conversation tool was acceptable, comprehensible, and usable. Next steps will test effectiveness on patient-centered and decisional outcomes.

Innovation

A personalized conversation tool using consequence tables and core SDM components is novel in that it can encourage a tailored, conversational dynamic and includes patient-centered values along with traditional decisional outcomes.

Use of prognostic gene expression profiling tests in primary breast cancer treatment: a German real-world patient survey

Aims: In primary breast cancer, gene expression profiling tests can support adjuvant chemotherapy treatment decisions. Real-world test use in Germany was investigated in an online survey of female breast cancer patients (n = 475). Materials & methods: Relationships between three groups were examined for clinical and statistical relevance: no test indication (n = 353), test indication and tested (n = 65), and test indication but not tested (n = 57). Results: A total of 47% of participants with a test indication were not tested. Test rates increased by 23% from 2012-2018 (49%) to 2019-2021 (60%). A total of 65% of patients without testing received chemotherapy, whereas only 38% of tested patients received chemotherapy. Conclusion: The use of gene expression profiling tests correlates with a real-world chemotherapy reduction. Gene expression profiling testing may improve patient confidence in the decision for or against chemotherapy.

Oncology nurse perceptions about life expectancy discussions: a cross-sectional study exploring what patients want to know, and why doctors don't disclose

Background: Sensitive and patient-centred discussion about life expectancy has clear benefits for patients with advanced cancer and their families. The perceptions of oncology nurses about disclosure of life expectancy, and the barriers to disclosure, have rarely been explored. Objectives/Aims/Hypotheses: To examine oncology nurses' perceptions of the: (1) proportion of patients with advanced cancer who want, receive and understand estimates of life expectancy; (2) reasons why doctors may not provide estimates of life expectancy. Design: Cross-sectional survey. Methods: Australian oncology nurses who were members of a professional society or worked at a participating metropolitan cancer centre were emailed a link to an anonymous online survey. Participants provided socio-demographic characteristics and their perceptions about the proportion of patients with advanced cancer who (a) want, (b) are provided with, (c) receive and (d) understand estimates of life expectancy, as well as the reasons estimates of life expectancy may not be provided. Results: A total of 104 nurses participated. While 51% of nurses perceived that most patients (>75%) want to be provided with an estimate of their life expectancy, 63% of nurses reported that <50% of patients were provided with an estimate. Further, 85% of nurses indicated that <50% of patients understand the estimate. The most frequent reason nurses perceived doctors did not provide an estimate of life expectancy was because the doctor didn't have an accurate idea of life expectancy (80.8%). Almost one-fifth of nurses (18.3%) thought that doctors did not provide estimates because they felt it was not their responsibility to do so. Conclusions: Strategies to ensure a patient-centred approach to life expectancy discussions with patients with advanced cancer are urgently needed. Impact statement: Oncology nurses perceive that many patients with advanced cancer are not provided with an accurate estimate of their life expectancy and few understand the information provided to them.

Awareness and Utilization of Palliative Care Among Advanced Cancer Patients in Asia

CONTEXT

To date, little is known about palliative care (PC) awareness and utilization in low- and middle-income countries (LMICs) in Asia.

OBJECTIVES

This study aimed to investigate PC awareness and its predictors, utilization of PC services, and perceived utilization barriers among advanced cancer patients from select hospitals in Asian LMICs.

METHODS

This cross-sectional study analyzed data of 759 advanced cancer patients at major hospitals of four LMICs in Asia (i.e., Bangladesh, Philippines, Sri Lanka, and Vietnam). The predictors of PC awareness were investigated using multivariable logistic regression.

RESULTS

Overall PC awareness was 30.8% (n = 234). Patients with higher education (OR = 1.0; CI = 1.0,1.1), from upper-middle or high-income households (compared to low-income) (OR = 2.0; CI = 1.2,3.3), awareness of disease severity (OR = 1.5; CI = 1.0,2.2), and higher pain severity (OR = 1.1; CI = 1.0,1.2) had higher odds of PC awareness. Compared to patients who perceived themselves as being very informed about disease trajectory, those who were unsure (OR = 0.5; CI = 0.3,0.8) or uninformed (OR = 0.5; CI = 0.3,0.9) had lower odds of PC awareness. The PC utilization rate was 35.0% (n = 82) among those with PC awareness, and 47.8% (n = 66) among patients recommended PC by a healthcare professional (n = 138). The most cited PC utilization barriers were currently receiving anti-cancer treatment (n = 43; 33.9%), and having insufficient information about PC (n = 41; 32.3%).

CONCLUSION

The low awareness of PC services in these major hospitals in Asian LMICs highlights that more effort may be required to promote the awareness of PC in this region. The efforts should especially focus on those from disadvantaged groups to reduce the gap in PC awareness.

Discussing prognosis and the end of life with patients with advanced cancer or COPD: A qualitative study

Objectives

To explore patients’ experiences and recommendations for discussions about their prognosis and end of life with their physicians.

Methods

Patients with advanced cancer or advanced chronic obstructive pulmonary disease (COPD) were enrolled in qualitative interviews, which were analyzed with a phenomenological and thematic approach.

Results

During interviews with fourteen patients (median age 64 years), we identified the following themes for discussion about prognosis and the end of life: topics discussed, the timing, the setting, physician–patient relationship, responsibilities for clinicians, and recommendations. Patients preferred the physician to initiate such discussion, but wanted to decide about its continuation and content. The discussions were facilitated by an established physician–patient relationship or attendance of relatives. Patients with cancer had had discussions about prognosis at rather clear-cut moments of deterioration than patients with COPD. Patients with COPD did not consider end-of-life discussions a responsibility of the pulmonologist. Patients recommended an understandable message, involvement of relatives or other clinicians, sufficient time, and sensitive non-verbal communication.

Conclusions

Patients appreciated open, sensitive, and negotiable discussions about prognosis and the end of life.

Practice implications

Patients’ recommendations could be used for communication training. Possible differences in the need for such discussions between patients with cancer or COPD warrant further research.

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.

Training in communication and emotion handling skills for students attending medical school: Relationship with empathy, emotional intelligence, and attachment style

OBJECTIVE

To describe the Emoty-Com training, its impact on medical students' attitudes towards doctors' emotions and to explore the association between students' empathy, emotional intelligence (EI), and attachment style (AS) with post-training performance scores.

METHODS

The 16-hour Emoty-Com training was delivered to all second-year medical students of Verona and Milan (Italy) Universities. At pre-training, students filled out three questionnaires assessing empathy, AS and EI and responded to three questions on attitudes towards doctors' emotions in the doctor-patient encounter. The same three questions and a final evaluation test were proposed at post-training.

RESULTS

264 students participated in the study. The training reduced students' worry about managing emotions during doctor-patient relationships. Gender was associated with specific subscales of empathy, EI, and AS. Final performance scores were associated with students' attitudes towards emotions but not with empathy, EI, and AS.

CONCLUSION

The Emoty-Com training increased students' self-efficacy in handling their own emotions during consultations. Students' performance scores were related to their attitude towards doctors' emotions in clinical encounters.

PRACTICE IMPLICATIONS

The Emoty-Com training suggests ways to teach and evaluate emotion-handling skills for medical students. Possible links between empathy, EI, AS, and the attitudes towards doctors' emotions during the years of education are highlighted.

The Art of Counseling in the Treatment of Head and Neck Cancer: Exploratory Investigation among Perceptions of Health Professionals in Southern Italy

(1) Background: Recurrent and/or metastatic patients with head and neck squamous cell carcinoma show a poor prognosis, which has not changed significantly in 30 years. Preserving quality of life is a primary goal for this subset of patients; (2) Methods: A group of 19 physicians working in South Italy and daily involved in head and neck cancer care took an anonymous online survey aimed at revealing the level of knowledge and the application of communication techniques in daily patient care; (3) Results: Several specialists, 18 out 19 (95%), considered that patient participation in therapeutic choices is mandatory. The main obstacles to complete and reciprocate communication still consist of lack of time and staff, but also in the need for greater organization, which goes beyond the multidisciplinary strategy already used; (4) Conclusions: A greater impulse to training and updating on issues related to counseling can improve communication between the different clinicians involved in the treatment plan.

Cancer patients' experiences and preferences when receiving bad news: a qualitative study

PURPOSE

Receiving a cancer diagnosis significantly impacts patients' lives, and how the bad news is delivered influences patients' trajectory, psychosocial adjustment and openness to psycho-oncological support. We explored how patients' experiences, reactions and preferences were when receiving the news and which optimization recommendations can be made.

METHODS

We conducted an exploratory qualitative study with patients who enrolled in the new integrated cross-sectoral psycho-oncological care programme 'isPO', being enrolled 12 months post-diagnosis. Data on the main issue (i.e. perception of the moment when the diagnosis is received) were collected via telephone interviews that were fully audiotaped and transcribed. Two independent coders conducted inductive content analyses using MAXQDA.

RESULTS

Out of 38 approached patients, 23 cancer patients with 13 different tumour entities participated. They had a mean age of 54.2 (SD 16.2); n = 17 (74%) were female. Three major themes with 14 corresponding subthemes emerged: (1) patients' experiences with the bad news delivery, including setting, mode, preparation and perceived needs; (2) patients' reactions to the bad news, such as shock, fear and helplessness, disbelief and denial, anger and feeling of injustice, thankfulness and depression; and (3) patients' receiving preferences, including psycho-oncological support, addressing informational needs, needs-driven comprehensive support and a competent multidisciplinary support team.

CONCLUSIONS

The quality of bad news delivery and addressing patients' needs should be strongly considered by physicians. We recommend integrating patients' perspective on the quality management processes of breaking bad news. For providing needs-centred high-quality care, applying existing guidelines and acquiring patient-centred communication skills are central.

Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia

Introduction

Providing patient-centered care is one of the key focus areas of the Ethiopian Health Service Transformation Plan. To this end, improving health literacy of the community is critical. However, there is limited evidence about the health literacy of Ethiopians, especially among those who visit health facilities.

Objective

The aim of this study was to examine awareness of diagnosis, treatment plan and prognosis among patients at the time of their exit from public hospitals and health centers.

Methods

A cross-sectional study was conducted among 627 patients in two public hospitals and selected health centers in Addis Ababa, using a systematic random sampling technique from inpatient and outpatient departments (OPD). A total of 579 study participants had complete data and were included in this analysis. A structured, pre-tested and interview-administered questionnaire was used to collect data. We used proportions to describe the findings and logistic regression analyses to assess factors associated with awareness of diagnosis, treatment plan and prognosis.

Result

About three-fifths (61.9%) and 52.8% of the study participants knew correctly their diagnosis and treatment plan respectively. More than two-thirds, 68.4%, said that they knew about the prognosis of their illness. However, only 21 (3.6%) patient medical records had information on prognosis. Gynecologic patients had significantly lower awareness about their diagnosis and treatment plan as compared to those from a general outpatient department. Emergency patients had significantly lower awareness of their treatment plan (OR = 0.27; 95% CI: 0.11,0.68) and prognosis (OR = 0.21; 95% CI: 0.09,0.50) than new OPD patients. Patients who indicated they had a good experience at their clinical assessment had significantly lower awareness of their prognosis (OR = 0.25; 95% CI: 0.08, 0.81).

Conclusion

A significant proportion of patients didn’t know their correct diagnosis, treatment plan and prognosis. This was more pronounced among gynecologic and emergency patients. More efforts are needed to strengthen patient-provider interaction.

Prognostic disclosure in oncology - current communication models: a scoping review

BACKGROUND

Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence.

METHOD

A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020.

RESULTS

In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion.

CONCLUSION

Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.

Cancer patients' perspectives on remote monitoring at home during the COVID-19 pandemic- a qualitative study in Norway

BACKGROUND

The COVID-19 pandemic triggered an unprecedented demand for digital health technology solutions, such as remote monitoring. Previous research has focused on patients with chronic diseases, and their experiences with remote monitoring during the pandemic. Several recommendations have been presented to reduce the frequency of cancer patients' visits to oncology centers and minimizing the risk of exposure to COVID-19, such as remote monitoring. However, few studies have explored how this has influenced the healthcare services to cancer patients.

AIM

To explore cancer patients' perspectives on remote monitoring at home during the COVID-19 pandemic.

DESIGN

The study had a qualitative design, using in-depth, individual interviews.

METHODS

A total of eleven interviews were conducted with patients who received remote monitoring during the COVID-19 outbreak. Three of the interviews were conducted by telephone, and eight on a digital platform, audio recorded, and transcribed verbatime. Data were analyzed using reflexive thematic analysis as recommended by Braun & Clarke.

RESULTS

All participants were conscious about being vulnerable to infections due to having cancer and receiving cancer treatment, and the pandemic to them represented an extra burden. Most of the participants experienced that their healthcare services had changed due to the pandemic, but there was no consensus on how the services had changed. All of the participants presented remote monitoring as something «new». Whether they received remote monitoring by telephone, video consultations or more advanced solutions with the possibility to complete a questionnaire or fill in measurements, did not seem to impact their views. However, all agreed that remote monitoring could never totally replace physical consultations in hospital. Participants' views seemed to grow more positive over time, but still they emphasized both positive and negative aspects of remote monitoring solutions in cancer care.

CONCLUSION

Remote monitoring was introduced as a necessity in cancer care during the COVID-19 outbreak. This may seem as an efficient solution, allowing for patients to stay at home and avoid infection. Our results indicate that, in the case of cancer patients, it is important that healthcare personnel balance the remote monitoring solution with person-to-person contact.

Dialysis Organization Online Information on Kidney Failure Treatments: A Content Analysis Using Corpus Linguistics

Rationale & Objective

Dialysis organizations’ websites may influence patient decision making, but the websites have received almost no consideration. We investigated how/whether these websites present all kidney replacement therapy options and how the quality of life of these options is portrayed.

Study Design

Content analysis using corpus linguistics (computer-assisted language analysis).

Setting

Website content aimed at patients from the 2 major dialysis organizations’ websites, totaling 226,968 words. The analysis took place from November 12, 2020, to March 30, 2021.

Analytical Approach

We used linguistic software (AntConc) to document the frequencies of words needed to present treatment options and quality of life information.

Results

Over both sites, dialysis mentions outstripped transplantation mentions. Organization A did not appear to reference conservative kidney management. Organization B mentioned dialysis more often than conservative management, at a ratio of 34:1. Organization A did not attribute symptoms to dialysis, whereas organization B had 12 mentions of dialysis-induced symptoms out of 87 total symptom references. Both organizations framed life on dialysis optimistically, suggesting that patients can continue to engage in “work,” “sex,” or “travel”; organization A referenced sex, work, and/or travel 123 times and organization B referenced these 262 times.

Limitations

We used quantitative analysis and linked ideas with certain keywords. We did not conduct a detailed qualitative inquiry.

Conclusions

The websites emphasized dialysis as a treatment for kidney failure, and the quality of life on dialysis was framed very optimistically. Qualitative studies of treatment modalities and the quality of life on dialysis in the patient-targeted material of dialysis organizations are needed.

Los deseos de información en pacientes con cáncer avanzado

Objetivo: Comprobar los deseos de información, y las variables asociadas a ello, en los pacientes con cáncer avanzado atendidos por un Equipo de Soporte Hospitalario de Cuidados Paliativos. Método: Noventa pacientes con cáncer avanzado, fueron evaluados, mediante una entrevista estructurada sobre si tenían información sobre su enfermedad de los siguientes tipos: diagnóstico, curación, gravedad, objetivos del tratamiento y final de vida, y de su deseo de tener información en cada uno de esto cinco tipos de información. Además, se recogieron los datos sociodemográficos y clínicos, y se administraron: la Escala de Capacidad Funcional, el Índice de Comorbilidad de Charlson, y la Escala de Ansiedad y Depresión Hospitalaria. Resultados. Los resultados muestraron que la mayoría de los pacientes estaban informados del diagnóstico, y de la gravedad, pero no de los objetivos de tratamiento, la curación y el final de vida. De los pacientes no informados el 77,8% (14) deseaban conocer el diagnostico, el 60,0% (11) la gravedad, el 77,8% (35) el objetivo del tratamiento, el 76,7% (24) la curación y un 34,4% (10) el final de vida. Las variables asociadas al deseo de: a) información diagnóstica fueron: tener un cuidador principal más joven (p=,023); con pareja (p=,018), no religiosos (p=,025) y mayor número de visitas a urgencias (p=,004); b) información sobre gravedad fueron: ser joven (p=,009); con pareja (p=,04), y mejor estado ánimo (p=,009); c). Información sobre objetivos del tratamiento: ser joven (p=,001), Con pareja (p=,04), mejor estado ánimo (p=,001). d) información sobre curación: ser hombre (p=,018), con pareja (p=,04), no religiosos (p=,023). En el caso de información sobre el tiempo de vida no se encontró ninguna diferencia significativa. Conclusiones: es necesario valorar los deseos información que tienen los pacientes de forma individualizada y en las diferentes variables de información, y por ello la creación de una herramienta estandarizada en futuras investigaciones es una prioridad. La mayoría de los pacientes con cáncer avanzado están informados del diagnóstico y gravedad, pero existe un déficit de información en curación, objetivos del tratamiento y especialmente en la información del final de vida y destaca más aun, que un alto porcentaje de los pacientes no informados sí desearían recibir información, principalmente sobre los objetivos del tratamiento, sobre todo los más jóvenes, con pareja y no religiosos y con mejor estado de ánimo. Una calidad asistencial óptima en pacientes con cáncer avanzado requiere cubrir sus deseos de información.

Explaining rule of rescue obligations in healthcare allocation: allowing the patient to tell the right kind of story about their life

I consider various principles which might explain our intuitive obligation to rescue people from imminent death at great cost, even when the same resources could produce more benefit elsewhere. Our obligation to rescue is commonly explained in terms of the identifiability of the rescuee, but I reject this account. Instead, I offer two considerations which may come into play. Firstly, I explain the seeming importance of identifiability in terms of an intuitive obligation to prioritise life-extending interventions for people who face a high risk of an early death, and I explain this in turn with a fair innings-style principle which prioritises life-extending interventions for people expected to die young. However, this account is incomplete. It does not explain why we would devote the same resources to rescuing miners stuck down a mine even if they are elderly. We are averse to letting people die suddenly, or separated from friends and family. And so, secondly, I give a new account that explains this in terms of narrative considerations. We value life stories that follow certain patterns, classic patterns which are reflected in many popular myths and stories. We are particularly averse to depriving people of the opportunity to follow some such pattern as they approach death. This means allowing them to sort out their affairs, say goodbyes to family and friends, review their life, or come to terms with death itself. Such activities carry a lot of meaning as ways of closing our life story in the right way. So, for someone who has not been given much notice of their death, an extra month is worth much more than for other patients. Finally, I review the UK National Health Service's end of life premium, which gives priority to patients with short life expectancy. I suggest it falls short in terms of such considerations. For example, the NHS defines its timings in terms of how long the patient can expect to live as at the time of the treatment decision, whereas the timings should be specified in terms of time from diagnosis.