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

Patient Perceptions of Rheumatoid Arthritis Blood Work: A Cross-Sectional Survey in the ArthritisPower Registry

OBJECTIVE

To examine how patients with rheumatoid arthritis (RA) perceive RA-related laboratory testing and the potential utility of a blood test to predict treatment response to a new RA medication.

METHODS

ArthritisPower members with RA were invited to participate in a cross-sectional survey on reasons for laboratory testing plus a choice-based conjoint analysis exercise to determine how patients value different attributes of a biomarker-based test to predict treatment response.

RESULTS

Most patients perceived that their doctors ordered laboratory tests to check for active inflammation (85.9%) or assess medication side effects (81.2%). The most commonly ordered blood tests used to monitor RA were complete blood counts, liver function tests, and those measuring C-reactive protein (CRP) and erythrocyte sedimentation rate. Patients felt CRP was most helpful in understanding their disease activity. Most worried their current RA medication would eventually stop working (91.4%) and they would waste time trying a new RA medication that may not work for them (81.7%). For patients who would require a future change in RA treatment, a majority (89.2%) reported that they would be very/extremely interested in a blood test that could help predict whether such new medication would be effective. Highly accurate test results (improving the chance RA medication will work from 50% to 85-95%) were more important to patients than low out-of-pocket cost (<$20) or minimal wait time (<7 days).

CONCLUSIONS

Patients consider RA-related blood work important for monitoring of inflammation and medication side effects. They worry about treatment effectiveness and would undergo testing to accurately predict treatment response.

Philosophy leading the way: An interdisciplinary approach to study communication of severe diagnoses

This paper explores a brand-new interdisciplinary approach applied to an enduring problem: the communication of severe diagnoses. The moment when physicians explain the diagnosis to patients and their relatives is sensitive, particularly for a disease that is rarely diagnosed early. The first part of the article is dedicated to the context of this delicate doctor-patient interaction. With this framework in mind, the paper delves into the innovative interdisciplinary methodology developed in the pilot study Communi.CARE, conducted in a hospital in Northern Italy, which focuses on the diagnosis of pancreatic ductal adenocarcinoma (PDAC). SARS-CoV-2 impact on the study development is highlighted. The study aims to explore the topic by combining different areas of expertise, including medicine, philosophy, sociology, and psychology. The contribution of philosophy is here presented as essential: it has a leading role in the conception of the study, its development, and the elaboration of results. It is shown throughout the study, from methodology to the analysis of results. Strengths and weaknesses of the methodology are discussed. In conclusion, further philosophical considerations on effective and ethical communication in this delicate context are recommended.

A systematic review of the effects of positive versus negative framing on cancer treatment decision making

OBJECTIVE

Presenting treatment outcomes positively or negatively may differently influence treatment preferences and lead to sub-optimal decision in a medical context. This review systematically organised how positive versus negative framing of treatment outcomes influenced cancer treatment decisions of cancer patients and individuals without a cancer diagnosis.

DESIGN

Three databases (PubMed, PsycInfo and Scopus) were searched for studies reporting the effects of positive versus negative framing on cancer treatment decision-making from 1981 to December 2020.

MAIN OUTCOME MEASURE

The effects of positive versus negative framing on cancer treatment preferences and the elimination of framing effect were evaluated.

RESULTS

A total of 12 studies that met inclusion criteria were reviewed. Framing effect was consistently observed in individuals without a cancer diagnosis. There was not enough evidence to suggest a robust framing effect in cancer patients. Surgery was preferred in positive framing, whereas adjuvant therapy was preferred in negative framing. Justification intervention significantly eliminated framing effect. Mixed framing failed to eliminate framing effect.

CONCLUSION

Current recommendations for presenting treatment options are based on research in cancer-screening decision-making. Knowledge of how positive versus negative framing affect cancer patients' treatment decisions is still limited. Our review highlighted the need for continued research in this area.

Experiences of 'traditional' and 'one-stop' MRI-based prostate cancer diagnostic pathways in England: a qualitative study with patients and GPs

OBJECTIVES

This study aimed to understand and explore patient and general practitioner (GP) experiences of 'traditional' and 'one-stop' prostate cancer diagnostic pathways in England.

DESIGN

Qualitative study using semi-structured interviews, analysed using inductive thematic analysis SETTING: Patients were recruited from National Health Service (NHS) Trusts in London and in Devon; GPs were recruited via National Institute for Health Research (NIHR) Clinical Research Networks. Interviews were conducted in person or via telephone.

PARTICIPANTS

Patients who had undergone a MRI scan of the prostate as part of their diagnostic work-up for possible prostate cancer, and GPs who had referred at least one patient for possible prostate cancer in the preceding 12 months.

RESULTS

22 patients (aged 47-80 years) and 10 GPs (6 female, aged 38-58 years) were interviewed. Patients described three key themes: cancer beliefs in relation to patient's attitudes towards prostate cancer;communication with their GP and specialist having a significant impact on experience of the pathway and pathway experience being influenced by appointment and test burden. GP interview themes included: the challenges of dealing with imperfect information in the current pathway; managing uncertainty in identifying patients with possible prostate cancer and sharing this uncertainty with them, and other social, cultural and personal contextual influences.

CONCLUSIONS

Patients and GPs reported a range of experiences and views of the current prostate cancer diagnostic pathways in England. Patients valued 'one-stop' pathways integrating prostate MRI and diagnostic consultations with specialists over the more traditional approach of several hospital appointments. GPs remain uncertain how best to identify patients needing referral for urgent prostate cancer testing due to the lack of accurate triage and risk assessment strategies.

Visit Linearity in Primary Care Visits for Patients with Chronic Pain on Long-term Opioid Therapy

BACKGROUND

Physicians and patients report frustration after primary care visits for chronic pain. The need to shift between multiple clinical topics to address competing demands during visits may contribute to this frustration.

OBJECTIVE

This study creates a novel measure, "visit linearity," to assess visit organization and examines whether visits that require less shifting back and forth between topics are associated with better patient and physician visit experiences. It also explores whether visit linearity differs depending on the following: (1) whether or not pain is a major topic of the visit and (2) whether or not pain is the first topic raised.

DESIGN

This study analyzed 41 video-recorded visits using inductive, qualitative analysis informed by conversation analysis. We used linear regression to evaluate associations between visit organization and post-visit measures of participant experience.

PARTICIPANTS

Patients were established adult patients planning to discuss pain management during routine primary care. Physicians were internal or family medicine residents.

MAIN MEASURES

Visit linearity, total topics, return topics, topic shifts, time per topic, visit duration, pain main topic, pain first topic, patient experience, and physician difficulty.

KEY RESULTS

Visits had a mean of 8.1 total topics (standard deviation (SD)=3.46), 14.5 topic shifts (SD=6.28), and 1.9 topic shifts per topic (SD=0.62). Less linear visits (higher topic shifts to topic ratio) were associated with greater physician visit difficulty (β=7.28, p<0.001) and worse patient experience (β= -0.62, p=0.03). Visit linearity was not significantly impacted by pain as a major or first topic raised.

CONCLUSIONS

In primary care visits for patients with chronic pain taking opioids, more linear visits were associated with better physician and patient experience. Frequent topic shifts may be disruptive. If confirmed in future research, this finding implies that reducing shifts between topics could help decrease mutual frustration related to discussions about pain.

Preparing Patients with Early Stage Prostate Cancer to Participate in Clinical Appointments Using a Shared Decision Making Training Video

Background

Rates of shared decision making (SDM) are relatively low in early stage prostate cancer decisions, as patients’ values are not well integrated into a preference-sensitive treatment decision. The study objectives were to develop a SDM training video, measure usability and satisfaction, and determine the effect of the intervention on preparing patients to participate in clinical appointments.

Methods

A randomized controlled trial was conducted to compare a plain-language decision aid (DA) to the DA plus a patient SDM training video. Patients with early stage prostate cancer completed survey measures at baseline and after reviewing the intervention materials. Survey items assessed patients’ knowledge, beliefs related to SDM, and perceived readiness/intention to participate in their upcoming clinical appointment.

Results

Of those randomized to the DA + SDM video group, most participants (91%) watched the video and 93% would recommend the video to others. Participants in the DA + SDM video group, compared to the DA-only group, reported an increased desire to participate in the decision (mean = 3.65 v. 3.39, P < 0.001), less decision urgency (mean = 2.82 v. 3.39, P < 0.001), and improved self-efficacy for communicating with physicians (mean = 4.69 v. 4.50, P = 0.05). These participants also reported increased intentions to seek a referral from a radiation oncologist (73% v. 51%, P = 0.004), to take notes (mean = 3.23 v. 2.86, P = 0.004), and to record their upcoming appointments (mean = 1.79 v. 1.43, P = 0.008).

Conclusions

A novel SDM training video was accepted by patients and changed several measures associated with SDM. This may be a scalable, cost-effective way to prepare patients with early stage prostate cancer to participate in their clinical appointments.

The Challenge of Coming Out to Providers by Gay and Bisexual Men With Prostate Cancer: Qualitative Results from the Restore Study

This study investigates the experience of communicating sexual orientation by gay, bisexual and men who have sex with men (GBM) to physicians involved in their prostate cancer care. Methodology consisted of qualitative analysis conducted on 30 in-depth interviews of GBM recruited from a national online cancer support site. Results revealed four key strategies around sexual disclosure. These ranged from explicitly outing themselves to selective or non-disclosure. Disclosures had unpredictable multiple outcomes ranging from increased trust in the patient-physician relationship to seeking alternate treatment. We concluded competent care is achieved when physicians know their patient's sexual orientation, and are trained in them.

Utilizing Digital Health to Collect Electronic Patient-Reported Outcomes in Prostate Cancer: Single-Arm Pilot Trial

BACKGROUND

Measuring patient-reported outcomes (PROs) requires an individual's perspective on their symptoms, functional status, and quality of life. Digital health enables remote electronic PRO (ePRO) assessments as a clinical decision support tool to facilitate meaningful provider interactions and personalized treatment.

OBJECTIVE

This study explored the feasibility and acceptability of collecting ePROs using validated health-related quality of life (HRQoL) questionnaires for prostate cancer.

METHODS

Using Apple ResearchKit software, the Strength Through Insight app was created with content from validated HRQoL tools 26-item Expanded Prostate Cancer Index Composite (EPIC) or EPIC for Clinical Practice and 8-item Functional Assessment of Cancer Therapy Advanced Prostate Symptom Index. In a single-arm pilot study with patients receiving prostate cancer treatment at Thomas Jefferson University Hospital and affiliates, participants were recruited, and instructed to download Strength Through Insight and complete ePROs once a week over 12 weeks. A mixed methods approach, including qualitative pre- and poststudy interviews, was used to evaluate the feasibility and acceptability of Strength Through Insight for the collection and care management of cancer treatment.

RESULTS

Thirty patients consented to the study; 1 patient failed to complete any of the questionnaires and was left out of the analysis of the intervention. Moreover, 86% (25/29) reached satisfactory questionnaire completion (defined as completion of 60% of weekly questions over 12 weeks). The lower bound of the exact one-sided 95% CI was 71%, exceeding the 70% feasibility threshold. Most participants self-identified with having a high digital literacy level (defined as the ability to use, understand, evaluate, and analyze information from multiple formats from a variety of digital sources), and only a few participants identified with having a low digital literacy level (defined as only having the ability to gather information on the Web). Interviews were thematically analyzed to reveal the following: (1) value of emotional support and wellness in cancer treatment, (2) rise of social patient advocacy in online patient communities and networks, (3) patient concerns over privacy, and (4) desire for personalized engagement tools.

CONCLUSIONS

Strength Through Insight was demonstrated as a feasible and acceptable method of data collection for ePROs. A high compliance rate confirmed the app as a reliable tool for patients with localized and advanced prostate cancer. Nearly all participants reported that using the smartphone app is easier than or equivalent to the traditional paper-and-pen approach, providing evidence of acceptability and support for the use of remote PRO monitoring. This study expands on current research involving the value of digital health, as a social and behavioral science, augmented with technology, can begin to contribute to population health management, as it shapes psychographic segmentation by demographic, socioeconomic, health condition, or behavioral factors to group patients by their distinct personalities and motivations, which influence their choices.

TRIAL REGISTRATION

ClinicalTrials.gov NC03197948; http://clinicaltrials.gov/ct2/show/NC03197948.

Review of the patient-centered communication landscape in multiple myeloma and other hematologic malignancies

OBJECTIVES

To identify factors limiting and facilitating patient-centered communication (PCC) in the United States hematology-oncology setting, with a focus on multiple myeloma (MM), given the limited attention to PCC and rapid pace of change that has taken place in this setting.

METHODS

A literature search was performed from 2007 to 2017 to identify published articles and congress abstracts related to clinician-patient communication and treatment decision-making in oncology. Search results were evaluated by year of publication and disease area. A thematic assessment was performed to identify factors limiting and promoting PCC for patients with MM and other hematologic malignancies.

RESULTS

Of the 6673 publications initially retrieved, 18 exclusively reported findings in patients with hematologic malignancies and were included in this review. We identified three critical, but modifiable, barriers to PCC in the hematologic malignancy setting, including insufficient information exchange, treatment goal misalignment, and discordant role preferences in treatment decision-making. Factors that enhanced interaction quality included educational programs for clinicians and patients.

CONCLUSIONS

Patients with MM and other hematologic malignancies experience a distinct set of challenges that may affect PCC.

PRACTICE IMPLICATIONS

Clinicians have the opportunity to improve patient care by proactively addressing the identified barriers and implementing strategies demonstrated to improve PCC.

Patient-initiated additional concerns in general surgery visits

OBJECTIVE

To understand how and when patients initiate additional concerns in general surgery visits.

METHODS

175 video-recorded visits of a general surgery practice in rural Texas were collected, coded, and analyzed using Conversation analysis.

RESULTS

Patients initiated 377 additional concerns, with 2 or more concerns raised in 80 visits, and 1 concern raised in 37 visits. Three methods of initiation were identified: fitted-to-topic (66%), fitted-to-activity (14%), and disjunctive (20%). Sixty percent of patient-initiated concerns occurred i) before the physical examination, compared to 14% after the physical exam, and ii) in pre-operative visits.

CONCLUSIONS

In contrast to the research on acute, primary care visits, patients in general surgery visits do not wait to present "door knob concerns." Instead, patients in general surgery visits are more likely to initiate concerns early in the visit. Patients most frequently find and create opportunities to introduce new concerns by fitting them to the ongoing talk or activity.

PRACTICE IMPLICATIONS

Physicians should spend more time on the physical exam, as this phase creates a unique opportunity for patients to initiate concerns.

Decision aid use during post-biopsy consultations for localized prostate cancer

BACKGROUND

Decision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patient-clinician encounters.

OBJECTIVE

To characterize the content and communicative function of high-quality DAs during diagnostic clinic visits for prostate cancer.

PARTICIPANTS

252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics.

METHODS

Qualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated.

RESULTS

Booklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physicians' explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decision-making. In regression analysis, predictors of booklet talk were fewer years of patient education (P = .027) and more time in the encounter (P = .027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk.

CONCLUSIONS

Results show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments.

A Model of Consultation in Prostate Cancer Care: Evidence From a Systematic Review

BACKGROUND

There has been an evolution of various consultation models in the literature. Men affected by prostate cancer can experience a range of unmet supportive care needs. Thus, effective consultations are paramount in the delivery of supportive care to optimize tailored self-management plans at the individual level of need.

OBJECTIVE

The aim of this study is to critically appraise existing models of consultation and make recommendations for a model of consultation within the scope of clinical practice for prostate cancer care.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement Guidelines. Electronic databases were searched using a wide range of keywords and free text items to increase the sensitivity and inclusiveness of the searches. Findings were integrated in a narrative synthesis.

RESULTS

A total of 1829 articles were retrieved and 17 papers were included. Beneficial features ranged across a number of models that included a person-centered consultation, shared management plans, and safety netting. None of the reviewed models of consultation are suitable for use in prostate cancer care because of a range of limitations and the clinical context in which models were developed. A Cancer Care Consultation Model was informed from critical appraisal of the evidence and expert clinical and service user comment.

CONCLUSION

Further research is needed to empirically test consultation models in routine clinical practice, specifically for advanced cancer specialist nurses.

IMPLICATIONS FOR PRACTICE

The Prostate Cancer Model of Consultation can be used to structure clinical consultations to target self-management care plans at the individual level of need over the cancer care continuum.

A Qualitative Investigation on Patient Empowerment in Prostate Cancer

Purpose: Men with prostate cancer often describe low levels of empowerment. eHealth interventions may represent useful tools to deliver care and education and to meet patients' needs within an empowerment framework. In order to design a platform for cancer patients' empowerment within the H2020 iManageCancer project, the perspective of the target population for the platform was assessed. The present study aims to assess the qualitative experience of prostate cancer patients during treatment in order to provide insights for clinical practice with a particular focus on the design of a web platform to promote cancer patients' empowerment.

Methods: Ten patients undergoing radiation therapy treatment took part in a semi-structured interview to explore different aspects of patient empowerment. Four main thematic areas were addressed: patient-healthcare providers' communication, decision-making, needs, and resources. A qualitative approach using thematic analysis was followed.

Results: Half of the patients reported little to no possibility to share information and questions with healthcare providers. With regards to decision-making, the role of healthcare providers was perceived as directive/informative, but half of the patients perceived to assume an active role in at least one interaction. Difficulties and needs included the choice of the specialist or of the structure after diagnosis, clinicians' support in self-management, surgical consequences, and side effects, preparation for radiation therapy. Resources included family and social support both from a practical and from an emotional perspective, coping style, and work schedule management.

Conclusions: These results suggest that relations with healthcare providers should be supported, especially immediately after diagnosis and after surgery. Support to self-management after surgery and at the beginning of radiation therapy treatment also constitutes a priority. The adoption of a personalized approach from the beginning of prostate cancer care flow may promote patient empowerment, overcoming the aforementioned needs and mobilizing resources. The social network represents an important resource that could be integrated in interventions. These considerations will be taken into account in the design of a cancer self-management platform aiming to increase patients' empowerment.

Prostate Cancer Patient Perspectives on the Use of Information in Treatment Decision-Making: A Systematic Review and Qualitative Meta-synthesis

BACKGROUND

Men with low- to intermediate-risk prostate cancer are typically asked to choose from a variety of treatment options, including active surveillance, radical prostatectomy, or brachytherapy. The Prolaris cell cycle progression test is intended to provide additional information on personal risk status to assist men with prostate cancer in their choice of treatment. To assist with assessing that new technology, this report synthesizes qualitative research on how men with prostate cancer use information to make decisions about treatment options.

METHODS

We performed a systematic review and qualitative meta-synthesis to retrieve and synthesize findings across primary qualitative studies that report on patient perspectives during prostate cancer treatment decision-making.

RESULTS

Of 8,610 titles and abstracts reviewed, 29 studies are included in this report. Most men diagnosed with prostate cancer express that their information-seeking pathway extends beyond the medical information received from their health care provider. They access other social resources to attain additional medical information, lived-experience information, and medical administrative information to help support their final treatment decision. Men value privacy, trust, honesty, control, power, organization, and open communication during interactions with their health care providers. They also emphasize the importance of gaining comfort with their treatment choice, having a chance to confirm their health care provider's recommendations (validation of treatment plan), and exercising their preferred level of independence in the treatment decision-making process.

CONCLUSIONS

Although each prostate cancer patient is unique, studies suggest that most patients seek extensive information to help inform their treatment decisions. This may happen before, during, and after the treatment choice is made. Given the amount of information patients may access, it is important that they also establish the trustworthiness of the various types and sources of information. When information conflicts, patients may be unsure about how to proceed. Open collaboration between patients and their health care providers can help patients manage and navigate their concerns so that their values and perspectives are captured in their treatment choices.

Patient and family communication during consultation visits: The effects of a decision aid for treatment decision-making for localized prostate cancer

OBJECTIVE

To analyze the effects of a decision aid on improving patients' and family members' information giving and question asking during consultations for prostate cancer treatment decision-making.

METHODS

This study is a secondary analysis of archived audio-recorded real-time consultation visits with participants from a randomized clinical trial. Participants were randomly assigned into three groups: TD-intervention targeted patient-only; TS-intervention targeted patients and family members; and control-a handout on staying healthy during treatment. We conducted content analysis using a researcher-developed communication coding system. Using SAS 9.3, we conducted Chi-square/Fisher's exact test to examine whether information giving and question asking among patients and family members varied by groups when discussing different content/topics.

RESULTS

Compared with those in the TS and control groups, significantly higher percentages of participants in the TD group demonstrated information giving in discussing topics about diagnosis, treatment options, risks and benefits, and preferences; and engaged in question asking when discussing diagnosis, watchful waiting/active surveillance, risks and benefits, and preferences for treatment impacts.

CONCLUSION

Information support and communication skills training for patients were effective in improving communication during treatment decision-making consultations.

PRACTICE IMPLICATIONS

Providing information about prostate cancer and communication skills training empower patients and their family members.

A diagnosis of chronic kidney disease: despite fears patients want to know early

Aims: We elicited input from patients on their experience getting a chronic kidney disease (CKD) diagnosis to use for optimizing current CKD education interventions. Methods: We performed structured one-on-one patient interviews. Interviews were recorded, transcribed, and coded using modified grounded theory. Participants had CKD, were not on dialysis, and were recruited from general nephrology practices. Results: 49 patients enrolled from January to October 2014. Interviews revealed four major themes: 1. Reaction to diagnosis – patients described emotional reactions and subsequent behavior changes (152 statements); 2. Timing of diagnosis – patients described how they were told about their diagnosis and expectations of when a person should be told (149 statements); 3. Mediators in diagnosis delivery – patients discussed things that helped or hindered understanding and acceptance of their diagnosis (64 statements), and 4. Perceptions of diagnosis terminology – patients discussed perceptions about diagnostic terms (e.g., “chronic kidney disease”) (91 statements). Cross-sectional study design and setting limit interpretation of causality and generalizability. Conclusions: Patients experience fear but prefer early diagnosis communication. More work is needed to define evidence-based guidelines for diagnosis messaging across the spectrum of care.

Patient Participation in Communication about Treatment Decision-Making for Localized Prostate Cancer during Consultation Visits

Objectives:

To describe the communication behaviors of patients and physicians and patient participation in communication about treatment decision-making during consultation visits for localized prostate cancer (LPCa).

Methods:

This is a secondary analysis of data from 52 men enrolled in the usual care control group of a randomized trial that focused on decision-making for newly diagnosed men with LPCa. We analyzed the patient-physician communication using the transcribed audio-recordings of real-time treatment consultations and a researcher-developed coding tool, including codes for communication behaviors (information giving, seeking, and clarifying/ verifying) and contents of clinical consultations (health histories, survival/mortality, treatment options, treatment impact, and treatment preferences). After qualitative content analysis, we categorized patient participation in communication about treatment-related clinical content, including “none” (content not discussed); “low” (patient listening only); “moderate” (patient providing information or asking questions); and “high” (patient providing information and asking questions).

Results:

Physicians mainly provided information during treatment decision consultations and patients frequently were not active participants in communication. The participation of patients with low and moderate cancer risk typically was: 1) “moderate and high” in discussing health histories; 2) “low” in discussing survival/mortality; 3) “low and moderate” in discussing treatment options; 4) “none and low” in discussing treatment impacts; and 5) “low” in discussing treatment preferences.

Conclusions:

Findings suggest opportunities for increasing patient participation in communication about treatment decision-making for LPCa during clinical consultations.