Advanced Breast Cancer Patients' Perceptions of Decision Making for Palliative Chemotherapy

Guidelines versus real-world data in metastatic bladder cancer: A population-based study on first-line chemotherapy treatment patterns

BACKGROUND

For patients with metastatic bladder cancer (mBC) palliative chemotherapy is one of the main treatment options. Real-world insights into outcomes are available, but a comprehensive overview of specific treatment details like number of chemotherapy cycles received and (reasons for) adjustments is lacking.

METHODS

A population-based study was conducted, including all patients diagnosed with mBC in the Netherlands between 2016 and 2021 who started chemotherapy as initial treatment. Data on patient, tumor, and treatment characteristics, including number of cycles, adjustments and reasons for adjustments, and survival were collected from the Netherlands Cancer Registry. Treatment patterns and outcomes were analyzed descriptively. Logistic regression analysis was used to identify factors associated with receiving the full guideline-recommended treatment (4-6 cycles).

RESULTS

A total of 684 patients started first-line chemotherapy, mostly carboplatin-based (54%). Of these patients, 35% did not receive the full course of treatment. Among these patients who received <4 cycles, 24% died within one month of stopping treatment. Male sex and good performance status were independently associated with receiving the full course of treatment. Among patients who did receive a full course of treatment, half still had adjustments to their treatment schedule, which mainly included dose reductions due to side effects.

CONCLUSIONS

Among patients with mBC starting first-line chemotherapy, only a small majority received the recommended number of cycles, and treatment adjustments were common. This suggests that adhering to recommended treatment is challenging, emphasizing the importance of integrating insights on treatment discontinuation and modifications into the shared decision-making process and guideline development.

Facilitators and barriers to decision-making for hospital treatment among patients diagnosed with breast cancer in Dar es Salaam, Tanzania: A qualitative urban-based study

BACKGROUND

Breast cancer is a major public health problem in both developed and developing countries and has become the second leading cause of death among women worldwide. The mortality may be related to delayed or inappropriate treatment decision-making among the diagnosed patients. Decision-making is an important determinant for successful treatment for patients diagnosed with breast cancer. In Tanzania, there is a lack of information in the context of facilitators and barriers to treatment decision-making after a breast cancer diagnosis. This study aimed to explore facilitators and barriers to treatment decision-making among cancer patients in Tanzania.

MATERIAL AND METHODS

A descriptive qualitative design was employed to explore the facilitators and barriers to treatment decision-making at Ocean Road Cancer Institute in Dar es Salaam. A purposive sampling technique was used to recruit fourteen female patients diagnosed with breast cancer. Data were collected through in-depth, semi-structured interviews, which were audio-recorded. A thematic approach was used to analyze the data.

FINDINGS

Two major themes emerged from the study findings, namely; facilitators to treatment decision-making such as patient understanding of treatment information, and healthcare providers' support. Barriers to treatment decision-making include the cost of treatment, uncertainty about cancer treatment, and religious healing.

CONCLUSION

This study found that practising decision-making for hospital treatment remains a challenge for patients diagnosed with breast cancer. Patients' understanding of treatment information and healthcare providers' support are the main tools that can facilitate decision-making. Sensitization activities on breast cancer treatment in the community and coverage of insurance should be advocated to promote decision-making for hospital treatment.

"Hospice Care Could Be a Compassionate Choice": ChatGPT Responses to Questions About Decision Making in Advanced Cancer

Background: Patients with cancer use the internet to inform medical decision making. Objective: To examine the content of ChatGPT responses to a hypothetical patient question about decision making in advanced cancer. Design: We developed a medical advice-seeking vignette in English about a patient with metastatic melanoma. When inputting this vignette, we varied five characteristics (patient age, race, ethnicity, insurance status, and preexisting recommendation of hospice/the opinion of an adult daughter regarding the recommendation). ChatGPT responses (N = 96) were coded for mentions of: hospice care, palliative care, financial implications of treatment, second opinions, clinical trials, discussing the decision with loved ones, and discussing the decision with care providers. We conducted additional analyses to understand how ChatGPT described hospice and referenced the adult daughter. Data were analyzed using descriptive statistics and chi-square analysis. Results: Responses more frequently mentioned clinical trials for vignettes describing 45-year-old patients compared with 65- and 85-year-old patients. When vignettes mentioned a preexisting recommendation for hospice, responses more frequently mentioned seeking a second opinion and hospice care. ChatGPT's descriptions of hospice focused primarily on its ability to provide comfort and support. When vignettes referenced the daughter's opinion on the hospice recommendation, approximately one third of responses also referenced this, stating the importance of talking to her about treatment preferences and values. Conclusion: ChatGPT responses to questions about advanced cancer decision making can be heterogeneous based on demographic and clinical characteristics. Findings underscore the possible impact of this heterogeneity on treatment decision making in patients with cancer.

Associations between subjective social status and predictors of interest in genetic testing among women diagnosed with breast cancer at a young age

PURPOSE

Genetic testing for gene mutations which elevate risk for breast cancer is particularly important for women diagnosed at a young age. Differences remain in access and utilization to testing across social groups, and research on the predictors of interest in genetic testing for women diagnosed at a young age is limited.

METHODS

We examined the relationships between subjective social status (SSS) and variables previously identified as possible predictors of genetic testing, including genome sequencing knowledge, genetic worry, cancer worry, health consciousness, decision-making preferences, genetic self-efficacy, genetic-related beliefs, and subjective numeracy, among a cohort of women who were diagnosed with breast cancer at a young age.

RESULTS

In this sample (n = 1,076), those who had higher SSS had significantly higher knowledge about the limitations of genome sequencing (Odds Ratio (OR) = 1.11; 95% CI = 1.01-1.21) and significantly higher informational norms (OR = 1.93; 95% CI = 1.19-3.14) than those with lower SSS. Similarly, education (OR = 2.75; 95% CI = 1.79-4.22), health status (OR = 2.18; 95% CI = 1.44-3.31) were significant predictors among higher SSS women compared to lower SSS women in our multivariate analysis. Lower SSS women with low self-reported income (OR = 0.13; 95% CI = 0.08-0.20) had lower odds of genetic testing interest. Our results are consistent with some prior research utilizing proxy indicators for socioeconomic status, but our research adds the importance of using a multidimensional indicator such as SSS to examine cancer and genetic testing predictor outcomes.

CONCLUSION

To develop interventions to improve genetic knowledge, researchers should consider the social status and contexts of women diagnosed with breast cancer at a young age (or before 40 years old) to ensure equity in the distribution of genetic testing benefits.

Effects of Prognostic Communication Strategies on Prognostic Perceptions, Treatment Decisions and End-Of-Life Anticipation in Advanced Cancer: An Experimental Study among Analogue Patients

CONTEXT

Evidence-based guidance for oncologists on how to communicate prognosis is scarce.

OBJECTIVES

To investigate the effects of prognostic communication strategies (prognostic disclosure vs. communication of unpredictability vs. non-disclosure; standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on prognostic perceptions, treatment decision-making and end-of-life anticipation in advanced cancer.

METHODS

This experimental study used eight videos of a scripted oncological consultation, varying only in prognostic communication strategies. Cancer-naive individuals, who imagined being the depicted patient, completed surveys before and after watching one video (n = 1036).

RESULTS

Individuals generally perceived dying within 1 year as more likely after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001), and after numerical versus word-based estimates (P < 0.001). Individuals felt better informed about prognosis to decide about treatment after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001); after communication of unpredictability versus non-disclosure (P < 0.001); and after numerical versus word-based estimates (P = 0.017). Chemotherapy was more often favored after prognostic disclosure versus non-disclosure (P = 0.010), but less often after numerical versus word-based estimates (P < 0.001). Individuals felt more certain about the treatment decision after prognostic disclosure, compared to communication of unpredictability or non-disclosure (P < 0.001). Effects of different survival scenarios were absent. No effects on end-of-life anticipation were observed. Evidence for moderating individual characteristics was limited.

CONCLUSION

If and how oncologists discuss prognosis can influence how individuals perceive prognosis, which treatment they prefer, and how they feel about treatment decisions. Communicating numerical estimates may stimulate prognostic understanding and informed treatment decision-making.

The expectations of metastatic cancer patients regarding palliative chemotherapy: A Brazilian-German qualitative study

OBJECTIVE

To explore the expectations of Brazilian and German patients regarding metastatic cancer and palliative chemotherapy.

METHODS

Interviews with 48 metastatic cancer patients from Brazil and Germany were conducted. The interviews were transcribed and analyzed using the thematic analysis approach to identify common themes. The sociodemographic data were collected using an instrument developed by the authors.

RESULTS

A total of 48 patients participated in the study (58% were Brazilian and 42% were German). Of all participants, 35% were men and 65% were women. The participants' mean age was 41 years. The general idea captured from the interviewees' speech was that their diseases were curable or "while there is chemotherapy, there is life"; thus, the data analysis enabled the elaboration of the central theme, entitled "Mistaken expectations of metastatic cancer patients regarding palliative chemotherapy: While there is chemotherapy, there is life," with 5 subthemes, namely: (1) communication and expectations; (2) normal life; (3) the person behind the disease; (4) religiosity and spirituality; and (5) the fortitude to choose between continuing or discontinuing treatment.

SIGNIFICANCE OF RESULTS

Regardless of cultural aspects, patients with metastatic cancer on palliative chemotherapy tend to believe in the healing potential of treatments. Dividing expectations only into curable or incurable is insufficient, as even patients who have acknowledged the incurability of their disease expect to live, as long as they remain under treatment as if the disease did not exist.

Psychological Barriers to the Use of Opioid Analgesics for Treating Pain in Patients With Advanced Recurrent Cancer: A Multicenter Cohort Study

Background

We aimed to gain insight into psychological barriers toward initiation of strong opioid analgesic use in patients with advanced recurrent cancer.

Methods

This study included 46 patients who were prescribed with opioid analgesics for advanced recurrent cancer. The primary outcome was psychological barriers assessed using the Japanese version of the Barriers Questionnaire-II (JBQ-II). The secondary outcomes were psychological changes and pain relief one week after the induction of strong opioid analgesics.

Results

The mean age of participants was 63.6 years. Furthermore, 26.1% had an Eastern Cooperative Oncology Group (ECOG) performance status of ≥3. The mean JBQ-II total score was 1.97 (95% confidence interval: 1.75-2.19). At the initiation of opioid therapy, there was no difference in the total scores between the baseline and one week later. Nevertheless, there was a significant difference in the subscale "disease progression" score (mean 2.97 vs. 2.59, difference in means 0.38, standard error 0.16, p = 0.026). Personalized Pain Goal (PPG) was achieved in about half of the participants, and a trend toward a higher score in the subscale "harmful effects" (concern about adverse events) was observed in those who did not achieve PPG.

Conclusion

This study showed that patients with advanced recurrent cancer have psychological barriers to opioid induction. The relationship between the presence of psychological barriers before and after induction of opioid analgesics and the speed of pain improvement was determined. The results may provide fundamental information for prospective intervention studies to develop individualized education programs for patients with psychological barriers to opioids.Clinical Trial Registration Number UMIN000042443.

Barriers of and strategies for shared decision-making implementation in the care of metastatic breast cancer: A qualitative study among patients and healthcare professionals in an Asian country

BACKGROUND

Shared decision-making has been shown to improve the quality of life in metastatic breast cancer patients in high-literacy and high-resource settings. However, limited studies have examined the cultural preferences of metastatic breast cancer patients with shared decision-making implementation and the barriers encountered in an Asian setting where societal norms predominate and physician decision-making is at the forefront. This paper aims to identify (1) barriers to practising shared decision-making faced by healthcare professionals and patients and (2) strategies for implementing shared decision-making in the context of metastatic breast cancer management in Malaysia.

METHODS

We conducted a qualitative study involving 12 patients diagnosed with metastatic breast cancer, 16 healthcare professionals and 5 policymakers from surgical and oncology departments at public healthcare centres in Malaysia. Semi-structured in-depth interviews and focus group discussions were conducted. The interviews were recorded, transcribed verbatim and analysed using the thematic approach. Nvivo software was used to manage and analyse the data.

RESULTS

Five main themes emerged from the study: healthcare provider-patient communication, workforce availability, cultural and belief systems, goals of care and paternalism versus autonomy. Other strategies proposed to overcome barriers to implementing shared decision-making were training of healthcare professionals and empowering nurses to manage patients' psychosocial issues.

CONCLUSION

This study found that practising shared decision-making in the public health sector remains challenging when managing patients with metastatic breast cancer. The utilization of decision-making tools, patient empowerment and healthcare provider training may help address the system and healthcare provider-patient barriers identified in this study.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in the study design, recruitment and analysis.

Palliative chemotherapy for breast cancer: A population-based cohort study of emergency hospital admissions and place of death

OBJECTIVE

Patients with incurable breast cancer may be treated with chemotherapy to improve cancer-related symptoms, quality of life and survival. We examined the association between use of palliative chemotherapy towards the end of life in breast cancer patients and outcomes including unplanned hospital admission and place of death.

METHODS

A total of 10,966 women, treated with palliative chemotherapy for breast cancer (diagnosed 1995-2017 in England) within the 2 years prior to death (death between 2014 and 2017), were analysed. Logistic regression (outcome = emergency hospital admission in last 90 days of life yes/no; outcome = place of death hospital/other) was performed, adjusting for line of palliative chemotherapy in the last 90 days of life and patient demographics.

RESULTS

The odds of hospital admission reduced with increasing line of chemotherapy received (1st line odds ratio [OR] = 2.7, 2nd line OR = 2.1, 3rd line OR = 1.9, 4th+ line OR = 1.7; baseline chemotherapy) in last 90 days of life. A similar relationship was observed for hospital death (1st line OR = 2.4, 2nd line OR = 2.1, 3rd line OR = 1.7, 4th+ line OR = 1.5).

CONCLUSION

This study finds palliative chemotherapy towards the end of life to be associated with increased odds of unplanned hospital admissions and hospital death. These findings can be used to inform discussions between patients and healthcare professionals towards the end of life.

Anticancer Treatment Goals and Prognostic Misperceptions among Advanced Cancer Outpatients

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

Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters

PURPOSE

We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM).

METHODS

We performed content analysis of outpatient oncology encounters at two US National Cancer Institute-designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis.

RESULTS

Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation.

CONCLUSION

In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.

Dealing with Family Conflicts in Decision-making in End-of-Life Care of Advanced Cancer Patients

PURPOSE OF REVIEW

The family plays a significant role in end-of-life care and decision-making with advanced cancer patients. This non-systematic review aims to summarize the family role and possible emerging conflicts and problems related to family involvement in decisions with advanced cancer patients.

RECENT FINDINGS

Four important domains were identified: (1) discordance between patients and caregivers' understanding of prognosis and goals of care; (2) internal family conflicts; (3) cultural differences regarding the role of the family in end-of life decision-making; (4) the burden on caregivers through caring for cancer patients. Based on the findings, we formulated some implications to consider for clinical practice. We suggest to involve the family in decision-making, to ascertain patients' wish for family involvement and if necessary, taking a mediator role between patients and their caregivers; to be aware of "invisible" family influence on patients' decisions; to assess systematically family burden and needs; to provide timely information, psychological support interventions and palliative care.

Understanding the support needs of family members of people undergoing chemotherapy: A longitudinal qualitative study

PURPOSE

Capture change in family members' experiences as they look after patients during chemotherapy, and understand variability in their needs for support.

METHOD

Longitudinal digitally-recorded qualitative semi-structured interviews with family carers at the beginning, mid-point, and end of treatment. Twenty-five family members (17 women, 8 men), mean age 53, were interviewed. Fifteen participants were supporting a relative having chemotherapy with curative intent, and 10 a patient receiving palliative chemotherapy. They were recruited from two UK locations: a regional cancer centre in Southampton and a comprehensive cancer centre in London. Sixty-three interviews were conducted in total, and the data were analysed using Framework Analysis.

RESULTS

Three themes were generated from the data: Changing lives, Changing roles; Confidence in caring, and Managing uncertainty. These captured family carers' evolving needs and sense of confidence in caregiving during chemotherapy. Carers reported considerable anxiety at the outset of treatment which persisted throughout. Anxiety was underpinned by fears of disease recurrence or progression and concerns about treatment outcomes.

CONCLUSIONS

This study presents original fine-grained work that captures the changes over time in family carers' experiences of chemotherapy and their adaptation to caregiving. It provides fundamental evidence of the challenges that cancer carers face during patients' treatment; evidence that can be used as a basis for carer assessment and to build much-needed carer interventions. Oncology nurses should assess carers': ability to care; needs for information and support to prepare them for this; wellbeing over time; and, any support they may require to prevent them from becoming overburdened.

Symptom Evolution in Patients with Esophageal and Gastric Cancer Receiving Palliative Chemotherapy: A Population-Based Study

INTRODUCTION

Palliative chemotherapy (PC) is associated with a modest survival benefit in patients with incurable esophageal and gastric cancer; however, changes in symptom profile during treatment are not well described. Understanding the trajectory of symptoms during treatment may lead to improved care and facilitate shared decision making. In this study, we address this knowledge gap among all patients receiving PC in the Canadian province of Ontario.

METHODS

Patients diagnosed with incurable esophageal and gastric cancer who received PC from 2012 to 2017 were identified from the Ontario Cancer Registry. Patients with one or more recorded Edmonton Symptom Assessment System (ESAS) scores in the 12 months following cancer diagnosis were included. The ESAS includes scores from 0 to 10 in nine domains (anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and lack of well-being). Symptom severity is categorized as none-mild (≤ 3), moderate (4-6), or severe (7-10). We focused on potentially modifiable symptoms, i.e. nausea, pain, and anxiety/depression. Logistic regression was used to identify factors associated with moderate-severe ESAS scores in these domains. Among those patients with serial ESAS scores (at 8 ± 2 and 12 ± 2 weeks) receiving chemotherapy, we describe changes during treatment (decrease by ≥ 1 = improved; - 1 > 0 > 1 = unchanged; increase by ≥ 1 = deteriorated).

RESULTS

The cohort included 1900 patients who received PC, of whom 79% (1497/1900) had one or more recorded ESAS scores. In multivariate analysis, younger patients were more likely to have moderate-severe scores in nausea (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.23-2.90 [p < 0.01] in patients aged 41-50 years compared with patients aged ≥ 71 years) and pain (OR 1.88, 95% CI 1.36-2.60 [p < 0.01] in patients aged 51-60 years compared with patients aged ≥ 71 years). Compared with males, females were more likely to report moderate-severe scores in anxiety/depression (OR 1.58, 95% CI 1.21-2.08 [p < 0.01]). At 8 ± 2 weeks from PC initiation, symptom scores were unchanged in 19-42% of patients, improved in 30-51% of patients, and deteriorated in 17-35% of patients. The greatest change in symptom burden was observed for appetite (51% improvement) and anxiety/depression (35% deterioration). Similar trends were observed at 12 ± 2 weeks.

CONCLUSIONS

In this large, population-based study, we observed that younger patients were more likely to report moderate-severe symptoms in pain and nausea, and females were more likely to report moderate-severe symptoms in anxiety/depression. Anxiety/depression symptoms become increasingly problematic for a substantial proportion of patients receiving PC. Supportive care efforts to mitigate these symptoms in routine practice are needed.

How adverse events and permanent medication stoppages affect changes in patients' beliefs about oral antineoplastic agents

BACKGROUND

Patients with advanced cancer often experience adverse events related to oral antineoplastic agents (OAAs) and permanent OAA medication stoppages, yet it is unknown how these factors impact medication beliefs. Such beliefs about OAA therapy may lend insight into decisions about continued cancer treatment near the end of life.

PURPOSE

To explore relationships that adverse events and permanent OAA stoppages have on medication beliefs during the first 12 weeks following new OAA initiation.

DESIGN

A secondary data analysis from a National Cancer Institute-funded randomized controlled trial testing an intervention to promote symptom management and OAA adherence.

SETTING/SUBJECTS

Patients ≥ 21 years of age initiating a new course of OAA medication were recruited from six United States Comprehensive Cancer Centers. This analysis was based on a subset of patients with advanced disease (N = 60).

MEASUREMENTS

Beliefs about Medicine Questionnaire, Common Terminology Criteria for Adverse Events, and medical records of permanent OAA stoppages.

RESULTS

Significant decline in beliefs regarding the necessity of OAA medications existed between patients experiencing three or more adverse events and those experiencing a permanent OAA stoppage.

CONCLUSIONS

Beliefs about the necessity of OAA medication change when physicians stop OAA medication or the patient experiences three or more adverse events. Concern regarding OAA medication did not change in response to medication stoppage or adverse events for this sample. Perhaps, patients with advanced cancers may be more accepting of adverse events that occur along the treatment trajectory and are not concerned about OAA medication once it is stopped. Findings suggest the importance of physicians' discussions of adverse events and decisions to permanently stop OAA medication as a means of transitioning to a new phase of cancer care that may include palliative or hospice considerations, given that beliefs about medication necessity are changing during these threats to cancer treatment.

Palliative Chemotherapy or Radiation and Prognostic Understanding among Advanced Cancer Patients: The Role of Perceived Treatment Intent

Background: As patients' accurate understanding of their prognosis is essential for informed end-of-life planning, identifying associated factors is important. Objective: We examine if receiving palliative chemotherapy or radiation, and the perception of those treatments as curative or noncurative, is associated with prognostic understanding. Design: Cross-sectional analyses from a multisite, observational study. Setting/Subjects: Patients with advanced cancers refractory to at least one chemotherapy regimen (N = 334). Measurements: In structured interviews, patients reported whether they were receiving chemotherapy or radiation, and whether its intent was curative or not. Their responses were categorized into three groups: patients not receiving chemotherapy/radiation (no cancer treatment group); patients receiving chemotherapy/radiation and misperceiving it as curative (treatment misperception group); and patients receiving chemotherapy/radiation and accurately perceiving it as noncurative (accurate treatment perception group). Patients also reported on various aspects of their prognostic understanding (e.g., life expectancy). Results: Eighty-six percent of the sample was receiving chemotherapy or radiation; of those, 16.7% reported the purpose of treatment to be curative. The no-treatment group had higher prognostic understanding scores compared with the treatment misperception group (adjusted odds ratio [AOR] = 5.00, p < 0.001). However, the accurate treatment perception group had the highest prognostic understanding scores in comparison to the no-treatment group (AOR = 2.04, p < 0.05) and the treatment misperception group (AOR = 10.19, p < 0.001). Conclusions: Depending on patient perceptions of curative intent, receipt of palliative chemotherapy or radiation is associated with better or worse prognostic understanding. Research should examine if enhancing patients' understanding of treatment intent can improve accurate prognostic expectations.

Patient perceptions of their decision to undergo palliative chemotherapy in the Edinburgh Cancer Centre

BACKGROUND

The decision to undergo chemotherapy for incurable cancer demands informed discussions about the risks and benefits of proposed treatments. Research has shown that many patients have a poor grasp of these factors.

METHODS

An evaluation of the patient experience of palliative chemotherapy decision-making was undertaken. Patients with lung or gynaecological cancers were surveyed about their decision, what they understood about its risks and benefits, and how supported they felt.

RESULTS

A total of 29 people with lung cancer (n = 21) or gynaecological cancer (n = 8) completed questionnaires. The majority felt sure about their decision, though many were less sure of the risks and benefits of treatment. Unprompted comments revealed significant nuance, including that the decision to undergo chemotherapy may not necessarily have felt like a choice.

CONCLUSIONS

Our positive findings may reflect participant selection bias, or could represent genuine comfort in decision-making in Scottish oncology clinics. Further research is needed.

Can contemporary trials of chemotherapy for HER2-negative metastatic breast cancer detect overall survival benefit?

PURPOSE

Although several trials have demonstrated improved progression-free survival (PFS) with first-line regimens for HER2-negative metastatic breast cancer (mBC), overall survival (OS) benefit is elusive. We calculated required sample sizes to power for OS using published data from recent mBC trials.

PATIENTS AND METHODS

Randomized superiority trials of first-line chemotherapy/targeted therapy for HER2-negative mBC including >150 patients, meeting the primary efficacy objective, and published in 2000-2018 were identified. The sample sizes required to power for PFS and OS were calculated retrospectively for each trial using observed results and study/recruitment follow-up durations (α=0.05, two-sided log-rank test, 80% power), and summarized as a factor (x) relative to actual sample size.

RESULTS

Nine of 13 identified trials reported all information required for retrospective sample size calculation. Six had sample sizes larger than required to demonstrate a significant PFS benefit but all would have required larger sample sizes to demonstrate significant OS benefit with the observed results. In ten trials, the required sample size was ≥5-fold larger to power for OS than PFS.

CONCLUSION

Designing trials to test potential new treatments for HER2-negative mBC is challenging, requiring a balance of regulatory acceptability, feasibility, and realistic medical assumptions to calculate sample sizes. Powering for OS is particularly difficult in heterogeneous populations with long postprogression survival, potential crossover, heterogeneous poststudy therapy, and evolving treatment standards. Validated surrogate endpoints are critical. Ongoing trials of cancer immunotherapy (new mode of action) in triple-negative mBC (more homogeneous, shorter OS and postprogression survival, fewer treatment options) may show a new pattern.

Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India

INTRODUCTION

Desisting from disease directed treatment in the past weeks of life is a quality criterion in oncology service. Patients with advanced cancer have unrealistic expectations from chemotherapy and hold on to it as a great source of hope. Many oncologists continue futile and unnecessary treatments, instead of conveying to the patients the lack of benefit, resulting in delayed referral for palliative care (PC).

MATERIALS AND METHODS

This is a retrospective analysis of case records from June 2014 to December 2015. The primary objective was to study, how far back in time terminally ill cancer patients received definitive cancer directed therapy (DCDT). Apart from patient demographics, the diagnosis, stage, and details of DCDT, and death were captured. PC referral data were recorded. DCDT to death was taken as treatment-free interval (TFI). Analysis was performed using IBM SPSS Statistics for Windows, Version 20.

RESULTS

A total of 292 case records were evaluated. Seventy-three had inadequate treatment details. Hence, 219 records were analyzed. PC referral was done in 78.5% of patients. Only best supportive care (BSC) without any DCDT was given in 27 patients. The most common reason for BSC was a poor performance status in 92.5%. The median time from PC referral till death was 43.5 days (range: 1-518 days). Chemotherapy was the most common DCDT in 52.9% of patients. The median time from DCDT and death was 49 days (range: 0-359 days). Cervical and ovarian cancers patients had the longest TFI; shortest in unknown primary. Most patients died at home (70.4%). Patients receiving PC preferred home or hospice as place of death. Of the 80 patients given hospice care, 39 (36.5%) died in the hospice.

CONCLUSION

While DCDT needs to be started at the right time, it should also be discontinued when futile. Early involvement of the PC team, even while patients are on DCDT makes the transition smoother and more meaningful.

Ambulatory Advanced Cancer Patients' and Oncologists' Estimates of Life Expectancy Are Associated with Patient Psychological Characteristics But Not Chemotherapy Use

BACKGROUND

Patients with advanced cancer often face distressing decisions about chemotherapy. There are conflicting data on the relationships among perceived prognosis, psychological characteristics, and chemotherapy use, which impair the refinement of decision support interventions.

OBJECTIVE

Clarify the relationships among patient and oncologist estimates of life expectancy for 6 and 12 months, chemotherapy use, and patient psychological characteristics.

DESIGN

Secondary analysis of data from two cross-sectional studies.

SETTING/SUBJECTS

One hundred sixty-six patients with advanced stage cancer recruited from ambulatory cancer clinics.

MEASUREMENTS

All data were obtained at study enrollment. Patients completed the Adult Hope Scale, Hospital Anxiety and Depression Scale, and Life Orientation Test-Revised. Patients and their oncologists provided estimates of surviving beyond 6 and 12 months. Chemotherapy use was determined by chart review.

RESULTS

There were no significant associations between life-expectancy estimates and chemotherapy use nor patient anxiety, depression, hope, or optimism and chemotherapy use. Patients' life expectancy estimates for 12 months and oncologists' for 6 months were associated with higher patient anxiety and depression. Finally, both oncologist and patient estimates of life expectancy for 6 and 12 months were associated with increased levels of trait hope.

CONCLUSION

Advanced cancer patients who provide less optimistic estimates of life expectancy have increased anxiety and depression, but do not use chemotherapy more often. Increased patient trait hope is associated with more favorable oncologist estimates. These findings highlight the need for interventions to support both patients and oncologists as they clarify prognostic expectations and patients cope with the psychological distress of a limited life expectancy.

Global analysis of advanced/metastatic breast cancer: Decade report (2005-2015)

Approximately 0.5 million people worldwide die from metastatic breast cancer (mBC) every year. This manuscript provides an overview on the status of mBC in several regions of the world, highlighting the gaps in care, resources, and support available for patients with mBC. Primary research was conducted in 2015 and 2016, comprising four global qualitative and quantitative surveys of approximately 15,000 individuals in 34 countries. Secondary research was conducted using literature reviews of peer-reviewed publications, patient survey reports, and media or online articles. There have been modest improvements in mBC outcomes over the past decade. Patients are not provided with adequate information about mBC. There is a need for open discussion with patients and caregivers about realistic goals; however, physicians are not trained in communicating with patients about their disease. Maintaining patients' quality of life is a crucial goal; however, this has not improved, and in some cases, may have declined in the past decade. Public awareness and understanding of mBC is limited, with damaging consequences for patients and caregivers. Issues affecting employment remain relevant to patients with mBC and their caregivers. Globally, mBC is associated with a substantial economic burden. Relationships with caregivers are crucial to patients with mBC, and caregiver support needs are often overlooked. A strong and united global effort among healthcare professionals, including clinicians, oncologists, pharmaceutical manufacturers, payers, and policy makers, and with advocates, families, and patients, is necessary to improve the outcome and quality of life for patients with mBC.

The impact of media type on shared decision processes in third-age populations

PURPOSE

To examine the relationship between the media, through which medical information was made available (e.g. digital versus printed), and the patients' desire to play an active part in a medical decision in an SDM or an ISDM-based process. The goal of this research was to expand knowledge concerning social and personal factors that affect and explain patients' willingness to participate in the process.

METHODS

A questionnaire was distributed in this empirical study of 103 third-age participants. A theoretical model formed the basis for the study and utilized a variety of factors from technology acceptance, as well as personal and environmental influences to investigate the likelihood of subjects preferring a certain decision-making approach. The research population included men and women aged 65 or older who resided in five assisted living facilities in Israel. The sample was split randomly into 2 groups. One group used digital information and the other print. A path analysis was conducted, using Structural Equation Modelling (SEM) in AMOS SPSS, to determine the influence of the information mode of presentation on the patient's choice of the SDM or ISDM model.

RESULTS

When digital media was accessible, the information's perceived usefulness (PU) led participants to choose an ISDM-based process; this was not true with printed information. When information was available online, higher self-efficacy (SE) led participants to prefer an SDM-based process. When the information was available in print, a direct positive influence was found on the participant's choice of SDM, while a direct negative influence was found on their choice of an ISDM-based process. PU was found to be affected by external peer influences, particularly when resources were made available in print. This meant that digital resources tended to be accepted at face value more readily. Cognitive absorption had a positive effect on the research variables only when the information was available digitally. The findings suggest the use of digital information may be related to cognitive functions of older adults, since the use of digital technology and information requires more cognitive effort.

CONCLUSIONS

The study illustrates factors that make patients choose SDM or ISDM-based processes in third-age populations. In general, the results suggest that, even though a physician may attempt to place the patient in the center of the decision process, printed information does not empower the patient in the same way that digital resources do. This may have wider ramifications if the patient does not buy into the treatment plan is and becomes less motivated to be compliant with the treatment. Another key contribution of this research is to identify processes that reflect information assessment and adoptions, and the behaviors related to medical decision making, both as a model and as a process. This study suggests what health care professionals should expect to see as the transition to more digital information sources becomes the norm among the elderly population. Future research is needed to examine this model under different conditions, and to check for other variables and mechanisms perceived as mediators in the choice of SDM or ISDM processes.

The second patient? Family members of cancer patients and their role in end-of-life decision making

BACKGROUND

Family members are important companions of severely ill patients with cancer. However, studies about the desirability and difficulties of integrating relatives in the decision-making process are rare in oncology. This qualitative study explores the family role in decisions to limit treatment near the end of life from the professionals' point of view.

METHODS

Qualitative in-depth interviews were conducted with oncologists (n = 12) and nurses (n = 6) working at the Department of Hematology/Oncology at the University Hospital in Munich, Germany. The data were analyzed using a descriptive qualitative methodology and discussed from a medical ethics perspective.

RESULTS

Four major themes played a central role in the perception of the medical staff in regard to family members. (1) Family impact on patients' treatment preferences. (2) Strong family wish for further treatment. (3) Emotional distress of the family related to the involvement in end-of-life decision-making. (4) Importance of knowing family structures.

CONCLUSIONS

The important role of the family members in patients' disease process is recognized by oncologists and oncology nurses. However, this does not seem to lead to an early involvement of the family members. Developing and establishing a systematic assessment of family members' needs and wishes in order to provide a specific-tailored support should become a priority for interdisciplinary clinical research in the near future.

The will to live - breast cancer patients perceptions' of palliative chemotherapy

BACKGROUND

For women with metastatic breast cancer, late lines of chemotherapy might be beneficial but also harmful. Ongoing chemotherapy late in life increase the risk of late or absent discussions of palliative care and access to symptom relief by other options than chemotherapy. Our aim was, therefore, to investigate breast cancer patients' motives, perceptions, and experiences of late lines of palliative oncologic treatment.

MATERIAL AND METHODS

A qualitative study with semi-guided face-to-face interviews with 20 women on at least their second line of palliative chemotherapy (second-eighth line). All women had breast cancer and were 40-80 years old. The interviews were analyzed by a phenomenographical approach according to seven steps, which uses a second-order perspective, i.e., how the informants experience the world.

RESULTS

The categories that surrounded the decision to continue with palliative chemotherapy were: The decision, Personal motives and goals and The treatment. All women acknowledged that they knew they had incurable breast cancer and that the treatment goal was to slow down cancer growth. Fear of death was a strong motive for all women in addition to experience of new values of life, still they preferred the doctor to make the decision. Cancer symptoms, especially pain triggered death anxiety, whereas the patients patiently accepted similar side effects from the treatment. There were also external motives for treatment like wishes from family, friends, but also health care staff.

CONCLUSIONS

All women knew they had disseminated breast cancer, still they expressed hopes for cure, therefore, death was more of a threat than a reality of an imminent death. None of the women had perceived there was an option to stop treatment. They felt both their families and doctors expected them to continue. Death threat was their main motive for accepting treatment.

Decision aids for second-line palliative chemotherapy: a randomised phase II multicentre trial

BACKGROUND

There is increasing recognition of the delicate balance between the modest benefits of palliative chemotherapy and the burden of treatment. Decision aids (DAs) can potentially help patients with advanced cancer with these difficult treatment decisions, but providing detailed information could have an adverse impact on patients' well-being. The objective of this randomised phase II study was to evaluate the safety and efficacy of DAs for patients with advanced cancer considering second-line chemotherapy.

METHODS

Patients with advanced breast or colorectal cancer considering second-line treatment were randomly assigned to usual care (control group) or usual care plus a DA (intervention group) in a 1:2 ratio. A nurse offered a DA with information on adverse events, tumour response and survival. Outcome measures included patient-reported well-being (primary outcome: anxiety) and quality of the decision-making process and the resulting choice.

RESULTS

Of 128 patients randomised, 45 were assigned to the control group and 83 to the intervention group. Median age was 62 years (range 32-81), 63% were female, and 73% had colorectal cancer. The large majority of patients preferred treatment with chemotherapy (87%) and subsequently commenced treatment with chemotherapy (86%). No adverse impact on patients' well-being was found and nurses reported that consultations in which the DAs were offered went well. Being offered the DA was associated with stronger treatment preferences (3.0 vs. 2.5; p=0.030) and increased subjective knowledge (6.7 vs. 6.3; p=0.022). Objective knowledge, risk perception and perceived involvement were comparable between the groups.

CONCLUSIONS

DAs containing detailed risk information on second-line palliative treatment could be delivered to patients with advanced cancer without having an adverse impact on patient well-being. Surprisingly, the DAs only marginally improved the quality of the decision-making process. The effectiveness of DAs for palliative treatment decisions needs further exploration.

TRIAL REGISTRATION

Netherlands Trial Registry (NTR): NTR1113 (registered on 2 November 2007).

Determinants of Last-line Treatment in Metastatic Breast Cancer

BACKGROUND

In metastatic breast cancer (MBC) patients, the identification of factors helping clinicians in the choice between active therapy versus best supportive care is needed clinically. The aim of the present study was to identify the clinicopathologic factors that could improve the prognostic valuation of MBC patients and clinical decision-making at the end of life.

PATIENTS AND METHODS

The present study analyzed data from a retrospective series of 522 MBC patients treated at the oncology department (University Hospital of Udine) from January 2004 to June 2014. The association between clinicopathologic features and death within 30 or 90 days since last-line treatment prescription was explored. Differences between lightly (≤ 3 lines) and heavily (> 3 lines) pretreated patients and the factors affecting treatment choice were investigated.

RESULTS

The event "death" occurred in 410 patients. The median last-line survival was 100 days. The median number of therapeutic lines was 3. On multivariate analysis, worse Eastern Cooperative Oncology Group performance status was significantly associated with death within 90 and 30 days since last-line treatment prescription. Among the heavily pretreated patients, liver function impairment and evaluation by a breast cancer specialist were significantly associated with a greater and lower risk of death within 30 days, respectively. Among the lightly pretreated patients with luminal disease, age < 70 years, luminal B-like disease, and number of previous lines were associated with a greater chance of receiving chemotherapy.

CONCLUSION

In the present study, the Eastern Cooperative Oncology Group performance status was the most robust independent factor driving the last-line therapeutic choice for MBC patients. In addition, the molecular subtype and oncologist subspecialization also influenced the decision-making process.

Dying From Cancer: Communication, Empathy, and the Clinical Imagination

Medical oncologists and patients with advanced cancer struggle to discuss prognosis, goals, options, and values in a timely fashion. As a consequence, many patients die receiving aggressive treatment potentially inconsistent with their fully informed preferences and experience increased symptom burden and distress. The goals of patient - oncologist communication include exchanging information, building relationship, and engaging in shared decisions. Empathy is perhaps especially essential to effective patient - oncologist communication when the end of life is approaching. We speculate that, in addition to being a skilled response to a patient’s negative emotions, empathy is an emergent property of the relationship that allows the patient and oncologist to imagine what it will be like to navigate the transition from living with to dying from cancer; and to prepare for the transition. We propose that effective empathy: 1) requires an attentive, curious and imaginative physician; 2) acknowledges the complex and shifting goals as the end of life approaches; and 3) begins with a willingness of physicians to check in and find out what she may have misunderstood or misperceived. Empathy in end of life conversations cultivates the shared experiences necessary to co-create the new goals of care that underlie excellent end of life care.

Understanding the complexities of shared decision-making in cancer: a qualitative study of the perspectives of patients undergoing colorectal surgery

BACKGROUND

Decisions leading up to surgery are fraught with uncertainty owing to trade-offs between treatment effectiveness and quality of life. Past studies on shared decision-making (SDM) have focused on the physician-patient encounter, with little emphasis on familial and cultural factors. The literature is scarce in surgical oncology, with few studies using qualitative interviews. Our objective was to explore the complexities of SDM within the setting of colorectal cancer (CRC) surgery.

METHODS

An interdisciplinary team developed a semistructured questionnaire. Telephone interviews were conducted with CRC patients in the practice of 1 surgical oncologist. Data saturation was achieved and a descriptive thematic analysis was performed.

RESULTS

We interviewed 20 patients before achieving data saturation. Three major themes emerged. First, family was considered as a crucial adjunct to the patient-provider dyad. Second, patients identified several facilitators to SDM, including a robust social support system and a competent surgical team. Although language was a perceived barrier, there was no difference in level of involvement in care between patients who spoke English fluently and those who did not. Finally, patients perceived a lack of choice and control in decision-making, thus challenging the very notion of SDM.

CONCLUSION

Surgeons must learn to appreciate the role of family as a vital addition to the patient-provider dyad. Family engagement is crucial for CRC patients, particularly those undergoing surgical resection of late-stage disease. Surgeons must be aware of the uniqueness of decision-making in this context to empower patients and families.

Health information needs, source preferences and engagement behaviours of women with metastatic breast cancer across the care continuum: protocol for a scoping review

INTRODUCTION

The health information needs, information source preferences and engagement behaviours of women with metastatic breast cancer (mBC) depend on personal characteristics such as education level, prior knowledge, clinical complications, comorbidities and where they are in the cancer journey. A thorough understanding of the information behaviours of women living with mBC is essential to the provision of optimal care. A preliminary literature review suggests that there is little research on this topic, but that there may be lessons from a slightly broader literature. This review will identify what is known and what is not known about the health information needs, acquisition and influences of women with mBC across the care continuum. Findings will help to identify research needs and specific areas where in-depth systematic reviews may be feasible, as well as inform evidence-based interventions to address the health information needs of female patients with mBC with different demographics and characteristics and across the mBC journey.

METHODS AND ANALYSIS

A scoping review will be performed using the guidelines of Arksey and O'Malley as updated by subsequent authors to systematically search scientific and grey literature for articles in English that discuss the health information needs, source preferences, engagement styles, and associated personal and medical attributes of women ≥18 years living with mBC at different stages of the disease course. A variety of databases (including Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Excerpta Medica Database (EMBASE), Academic Search Premier, Cochrane Database of Systematic Reviews, PsycINFO, Health Source: Nursing/Academic Edition, and PQDT Open), oncology, patient advocacy and governmental websites will be searched from inception to present day. Research and non-research literature will be included; no study designs will be excluded. The six-stage Arksey and O'Malley scoping review methodological framework involves: (1) identifying the research question; (2) searching for relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results; and (6) consulting with stakeholders to inform or validate study findings (optional). Data will be extracted and analysed using a thematic chart and descriptive content analysis.

ETHICS AND DISSEMINATION

Being a secondary analysis, this research will not require ethics approval. Results will be disseminated through patient support organisations and websites and publications targeting healthcare professionals, advocates and patients.

Patients' perspectives on information from physicians during palliative chemotherapy: A qualitative study

Objective:

During the course of their disease, patients with cancer receiving palliative chemotherapy receive extensive amounts of information from physicians. The objective of our study was to describe patients' perspectives on the information they received from physicians during palliative chemotherapy with regard to their cancer diagnosis, treatments, prognosis, and future planning.

Method:

A total of 15 semistructured face-to-face interviews with patients who had incurable cancer were conducted, transcribed verbatim, and analyzed with qualitative content analysis.

Results:

Three categories were defined during the analytical process: “having a chronic disease,” “depending on chemotherapy,” and “living with an unpredictable future.”

Significance of results:

Our study demonstrated that patients undergoing palliative chemotherapy perceived that their disease was incurable and chronic, that they were dependent on chemotherapy, and that their future was uncertain. Compared with other studies, the patients in our study seemed to be more aware of their prognosis and the goals of care.

"There won't' be anything else...it's over": perceptions of women referred to palliative care only

BACKGROUND

It is not well-known how women with advanced breast and gynecological cancers cope with the transition to palliative care (PC) only, but we anticipate that this is a challenging situation for them.

OBJECTIVE

To investigate women's understanding on the reasons of anticancer treatment withdrawal, their ideas about PC, and also perceptions of the communication of bad news.

METHOD

Twenty women were interviewed by a single researcher after being informed that their antineoplastic treatment would be discontinued and they would be exclusively monitored by PC staff. The interviews were audiotaped, transcribed verbatim, and analyzed according to content analysis.

RESULTS

Three categories were identified in the participants' narratives: (1) an understanding of the meaning of PC; (2) a lack of understanding of the shift in treatment and follow-up; (3) differing perspectives about hope. The PC Unit was stigmatized as a place to die, resulting in a "place to die" subcategory. The narratives of the participants who previously had experienced PC converged on a subcategory that reveals better recognition of the importance of the PC Unit as "a place that enhances the quality of life".

CONCLUSION

The participants manifested little knowledge about PC and the forthcoming strategies for their clinical follow-up. In addition, the PC Unit was patently stigmatized as a place to die. Early referral to PC seems to be associated with a less painful therapeutic transition, based on more accurate knowledge of the importance of PC.

Shared decision making in palliative cancer care: a literature review

Background

Patients require information to make informed decisions and consent to medical treatment. Shared decision making (SDM) is a methodology that promotes a patient-centred approach to informed consent and demonstrates respect for autonomy

Purpose

The purpose of this paper is to critically review the legal and ethical issues relevant to Canadian and UK informed consent and SDM practices and how these processes relate to current palliative care practices, with a particular emphasis on radiation therapy.

Methodology

A review of the English literature from 2003 to 2013 was performed using the databases PubMed (NML), OVID Medline and Google Scholar.

Results and Conclusions

The literature identifies that palliative cancer patients desire the opportunity to be involved with decision-making discussions, which has shown to increase knowledge and result in better health-related outcomes. However, ethical and legal issues regarding the practicality of including this patient population in SDM discussions raises questions about validity of consent. For SDM to be considered a valid methodology to obtain informed consent, open and honest communication between the patient and multidisciplinary team is essential. Treatment options for palliative cancer patients are often complex and SDM allows healthcare professionals and patients to exchange information and negotiate feasible treatment options based on medical expertise and patient preferences.

Legal frameworks have defined current standards of practice for various healthcare professions, including radiation therapy. Radiation therapists, as members of the multidisciplinary team, are currently key contributors in providing information to patients regarding the radiotherapy process. Individuals working within advanced practice roles have the ability to develop skills once considered to be within medical domains and have begun to incorporate the delegated act of obtaining informed consent into practice which has shown to increase professional autonomy, accountability and improves patient-centred care.

Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer

INTRODUCTION

Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.

METHODS

More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer 'stem' cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.

RESULTS

The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.

CONCLUSIONS

With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.

Who gets genomic testing for breast cancer recurrence risk?

BACKGROUND/AIMS

Our study examined whether patient characteristics, beliefs and decision-making styles were associated with uptake of genomic testing for breast cancer recurrence risk.

METHODS

Participants were 132 early-stage breast cancer patients eligible for the Oncotype DX genomic test. We interviewed patients in 2009-2010 and obtained information from medical charts.

RESULTS

Half of the women eligible for genomic testing for breast cancer recurrence risk received it. The most common reason for not getting the test was that women's physicians did not offer it (80%). Test recipients were more likely to be unsure about receiving chemotherapy treatment compared to women who did not receive the test (p < 0.05). Women who received the test had less advanced disease pathologies, recalled a lower objective recurrence risk, perceived lower recurrence risk, and were slightly younger (all p < 0.05). Most women who described their decision-making style as active received the test (75%), whereas few women who described their style as passive received the test (12%) (p < 0.01).

CONCLUSION

In the university clinic we studied, genomic testing appeared to be more common among patients who may benefit most from the information provided by results, but confirmation in larger studies is needed.

[The importance of individual beliefs about cancer treatments for therapeutic decisions]

Interest for representations about cancer treatments and their side effects is increasing because their central role has been proved in how patients cope with illness and symptoms and how they react emotionally. Through a synthesis of the literature, this paper has two objectives: firstly, to clarify the current state of knowledge in this field, and secondly to point out the manner that bringing out these individual representations during oncological consultations contributes to preventing difficulties and treatment discontinuation and facilitates medical decision processing.

Targeted agent use in cancer patients at the end of life

CONTEXT

The use of targeted therapy at the end of life has not been well characterized.

OBJECTIVES

To determine the frequency and predictors of targeted therapy use in the last days of life.

METHODS

All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had contact with our institution within the last three months of life were included. We collected baseline demographics and data on chemotherapy and targeted agents.

RESULTS

Eight hundred sixteen patients were included: average age 62 years (range 21-97), female 48% and white 61%. The median interval between the last treatment and death was 47 (interquartile range [IQR] 21-97) days for targeted agents and 57 (IQR 26-118) days for chemotherapeutic agents. Within the last 30 days of life, 116 (14%) patients received targeted agents and 147 (18%) received chemotherapy. Regimens given in the last 30 days of life included a median of one (IQR 1-2) chemotherapeutic or targeted agent and 43 (5%) patients receiving targeted agents had concurrent chemotherapy. The most common targeted agents in the last 30 days of life were erlotinib (n = 25), bevacizumab (n = 20), rituximab (n = 11), gemtuzumab (n = 8), and temsirolimus (n = 8). On multivariate analysis, younger age (odds ratio [OR] 0.98 per year, P = 0.01), hematologic malignancy (OR = 6.1, P < 0.001), and lung malignancy (OR = 2.6, P = 0.05) were associated with increased targeted agent use in the last 30 days of life.

CONCLUSION

Targeted agents were used as often as chemotherapy at the end of life, particularly among younger patients and those with hematologic malignancies. Guidelines on targeted therapy use at the end of life are needed.

Initiating palliative care conversations: lessons from Jewish bioethics

What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding the preservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff's ethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty to inform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.

Shared decision-making in metastatic breast cancer: discrepancy between the expected prolongation of life and treatment efficacy between patients and physicians, and influencing factors

Treatment decisions in oncology are based on a balance between the efficacy of therapy and its side effects. Patients with metastases and patients with a limited prognosis are a particular challenge, since communication about the disease situation and the expected therapeutic benefit is difficult not only for patients, but also for physicians. The aim of this study was therefore to compare the benefits expected of therapy by patients and physicians. Questionnaires were sent to 9,000 breast cancer patients and to 6,938 physicians. The questionnaires described 10 cases of breast cancer in the metastatic setting. The patients and physicians were asked to state the treatment benefit they would require to decide for the therapy options chemotherapy, endocrine therapy, antibody therapy, radiotherapy, and bisphosphonates. Additionally, the participants provided data on patient and physician characteristics. Expected treatment benefits were compared between patients and physicians, and influencing factors that modified the expected benefit were identified. Patients expected much greater benefits from the therapies offered than the physicians. For all treatment modalities, about 50 % or more of patients expected more than a 12-month increase in overall survival from all therapies. Among the doctors, this proportion ranged from 7 to 30 %. Among patients, previous experience of side effects and having young children in the family were the strongest influencing factors. Among the doctors, age and level of education had a strong influence on the expected prognostic improvement to indicate a therapy option. As expectations of treatment differ greatly between patients and doctors, a structured approach to solving this conflict is required. There appear to be some indicators that might help address the problem, such as the physicians' level of training and experience and the patients' specific social circumstances.

Online exchanges among cancer patients and caregivers

Purpose

The meanings attributed to the quality of a person's illness experience result from important processes of co‐construction not only between healthcare professionals and patients but also among patients and caregivers. In the case of advanced cancer, new treatments extend patients’ lives but they raise the problem of the quality of this “renewed time”. Lay contexts of exchanges appear crucial for orienting the attribution of meaning to the time with cancer and for sharing practices to manage it. Furthermore, the internet is becoming an important space in which cancer patients meet and construct knowledge regarding their illness. The aim of this paper is to study knowledge‐ and practice‐construction among advanced cancer patients and caregivers, and to explore the suitability of online forums for analysis of these processes.

Design/methodology/approach

The paper discusses the results of a qualitative study based on one online forum for long‐term cancer patients (second relapse) and one for caregivers. The discussions explored show how patients and caregivers attribute meanings to their time with cancer. Verbatim transcripts of the discussions were analyzed according to the Interpretative Phenomenological Analysis (IPA) procedure.

Findings

The findings suggest the system of medical representations regarding health and illness should take greater account of other (lay) systems of representations and that the internet could be a valuable resource to support the development of spontaneous networks of patient and caregivers through which to organize health interventions and to involve patients and caregivers more closely in the care and cure process.

Research limitations/implications

The study examines the experiences of a particular subset of patients/caregivers who were internet‐literate and might be considered more “active” in their coping with the disease over a fairly limited time span. These potential limitations are being remedied in continuing research projects.

Practical implications

The authors’ experience with this research design suggests qualitative research may be particularly valuable in casting light on emergent phenomena such as spontaneous social networks on the internet, and in encouraging more participative forms of research engagement.

Originality/value

These findings may orient therapeutic interventions to be more closely attuned to the needs of long‐term cancer patients and their caregivers. Online forums enable participants to disclose experiences, share knowledge, and co‐construct “good practices” for illness management.

Physician, patient and family attitudes regarding information on prognosis: a Brazilian survey

BACKGROUND

Communication between physicians and patients is a fundamental aspect of cancer care, yet most physicians' perceptions are often inconsistent with the patients' stated preferences while prognostic information is the most misunderstood.

PATIENTS AND METHODS

Members of the Brazilian Society of Oncology Physicians (n=609) were identified and asked to complete a mailed questionnaire. Outpatients (n=150) and their family members (n=150), oncologists and fellows (n=55) from a public healthcare hospital and a tertiary cancer hospital in Sao Paulo were also personally invited to participate.

RESULTS

A total of 202 physicians, 150 outpatients and 150 family members were participated. The majority of patients (92%) believe they should know about their terminal stage compared with 79.2% of physicians and 74.7% of families (P=0.0003). Cancer patients were most likely to support disclosure of diagnosis and terminality (P=0.001), to consider that this disclosure was not stressful (P<0.0001) and that this knowledge would improve their quality of life (P<0.0001).

CONCLUSIONS

Cancer patients seen in these centers in Southeastern Brazil prefer to know the truth about their poor prognosis more than their physicians and families think. Further studies with larger samples of patients and physicians are necessary to show if our results are representative of all Brazilian situations.

Involvement in decision-making about treatment and ovarian cancer survivor quality of life

PURPOSE

This study sought to better understand the long-term effects on women's health related quality of life (HRQOL) of involvement in decision-making about their surgical and chemotherapeutic treatments for ovarian cancer treatment and about follow-up care after treatment.

METHODS

Using a cross-sectional survey design, a sample of 219 ovarian cancer patient/survivors from Western Washington who were between 3 months and ten years post-diagnosis were recruited via a mailed survey sent by their gynecological oncologist and interviewed about their ovarian cancer treatment, use of Complementary and Alternative Medicine (CAM), Health related quality of life, and their involvement in decision-making about their cancer treatment and follow-up care.

RESULTS

Multivariate regression analyses revealed age, but not stage of cancer to be a significant predictor of perceived involvement in decision-making about ovarian cancer treatment and follow-up. Age also predicted CAM use with older patients using herbal CAM, and younger patients using CAM activities and CAM providers (p<0.5). Controlling for demographic, disease, and treatment characteristics involvement in decision-making about surgery and follow-up care were associated with better mental health in survivorship (p<0.05). Involvement in decision-making about use of CAM and about lifestyle health changes was associated with greater vitality and better role-emotional health in survivorship (respectively; both; p<0.05).

CONCLUSIONS

As has been found in studies of breast cancer survivors, perceived involvement in decision-making about ovarian cancer treatment including surgery and follow-up care after treatment is associated with better quality of life for cancer survivors. Involvement in decision-making about the use of CAM and about changes in lifestyle health practices also appear to help survivor's emotional health related quality of life. Prospective studies are needed to determine the mechanisms by which perceived involvement in decision-making about treatment might influence survivor quality of life.

Palliative medicine and decision science: the critical need for a shared agenda to foster informed patient choice in serious illness

Assisting patients and their families in complex decision making is a foundational skill in palliative care; however, palliative care clinicians and scientists have just begun to establish an evidence base for best practice in assisting patients and families in complex decision making. Decision scientists aim to understand and clarify the concepts and techniques of shared decision making (SDM), decision support, and informed patient choice in order to ensure that patient and family perspectives shape their health care experience. Patients with serious illness and their families are faced with myriad complex decisions over the course of illness and as death approaches. If patients lose capacity, then surrogate decision makers are cast into the decision-making role. The fields of palliative care and decision science have grown in parallel. There is much to be gained in advancing the practices of complex decision making in serious illness through increased collaboration. The purpose of this article is to use a case study to highlight the broad range of difficult decisions, issues, and opportunities imposed by a life-limiting illness in order to illustrate how collaboration and a joint research agenda between palliative care and decision science researchers, theorists, and clinicians might guide best practices for patients and their families.

Shared decision-making in palliative care: a systematic mixed studies review using narrative synthesis

The aim of this study is to synthesize knowledge about the process of shared decision-making (SDM) in palliative care. Medline, EMBASE, CINAHL, PsychInfo, Web of Science were searched with core concepts: shared decisions, patient participation in decision-making, and palliative care. Titles and abstracts were screened according to inclusion criteria (original research, adult patients, Western contexts, decision-making, palliative treatment or setting), yielding 37 articles for analysis. A narrative synthesis was created using the methods of thematic analysis, conceptual mapping, and critical reflection on the synthesis process. Results demonstrate that while a majority of patients want to participate in treatment decisions to some extent, most do not achieve their preferred levels of involvement because decisions are delayed and alternative treatment options are seldom discussed. The literature regarding the process of SDM itself remains scarce in palliative care. Further research is needed in order to better understand the longitudinal, interactive, and interdisciplinary process of decision-making in palliative care.