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Winters KL, Byrd CT. Caregiver Predictions of Their 3- to 6-Year-Old Child Who Stutters' Communication Attitude. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:2086-2105. [PMID: 38889195 PMCID: PMC11253804 DOI: 10.1044/2024_jslhr-23-00662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 03/11/2024] [Accepted: 04/24/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Caregivers share critical insight during their child's stuttering evaluation; yet, there have been no empirical studies evaluating whether caregivers provide similar accounts of their 3- to 6-year-old child's communication attitude compared to their child's self-report. This study examined caregiver- and child-reported communication attitude and assessed potential moderators of more comparable caregiver and child ratings (i.e., caregiver confidence, caregiver-child conflict, observer-rated stuttering severity). METHOD One hundred thirteen children who stutter ages 3 through 6 years and a primary caregiver were recruited from clinical settings across the United States. Children completed the Communication Attitude Test for Preschool and Kindergarten Children Who Stutter (KiddyCAT) and three speaking samples, which were recorded to assess observer-rated stuttering severity using the Stuttering Severity Instrument-Fourth Edition. Caregivers predicted their child's communication attitude (C-KiddyCAT) and provided a confidence rating for their prediction. Caregivers also rated caregiver-child conflict using the Child-Parent Relationship Scale-Short Form (CPRS-SF). Multiple regression was used to (a) evaluate whether caregiver C-KiddyCAT scores predicted child KiddyCAT scores and (b) assess potential moderators of the relationship between C-KiddyCAT and KiddyCAT scores. RESULTS Caregiver ratings of their child's communication attitude (C-KiddyCAT) predicted child communication attitude ratings (KiddyCAT). A significant interaction between caregiver-child conflict (CPRS-SF) and caregiver ratings of their child's communication attitude (C-KiddyCAT) suggested caregiver-child conflict changed the underlying relationship between C-KiddyCAT and KiddyCAT scores, such that low conflict resulted in more similar C-KiddyCAT and KiddyCAT scores. Neither caregiver confidence nor observer-rated stuttering severity influenced the relationship between C-KiddyCAT and KiddyCAT scores. CONCLUSIONS Although many caregivers predicted communication attitude ratings that closely aligned with their child's report, some caregiver-child dyads provided divergent ratings. Clinicians should interpret caregiver predictions of their child's communication attitude within the context of their full evaluation and the caregiver-child relationship. Assessing both self-reported communication attitude and caregiver predictions of their child's communication attitude provides a meaningful starting point to counseling caregivers about cognitive components of stuttering for preschool- and kindergarten-age children who stutter.
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Affiliation(s)
- Katie L. Winters
- Department of Communication Sciences and Disorders, University of Cincinnati, OH
| | - Courtney T. Byrd
- Department of Speech, Language, and Hearing Sciences, The University of Texas at Austin
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Ouyang N, Feder SL, Baker JN, Knobf MT. Prognostic Communication Between Parents and Clinicians in Pediatric Oncology: An Integrative Review. Am J Hosp Palliat Care 2024; 41:545-557. [PMID: 37309610 DOI: 10.1177/10499091231183107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Background: Prognostic communication between clinicians and parents in pediatric oncology is complex. However, no review has exclusively examined research on prognostic communication in pediatric oncology. In this review, we synthesize the evidence on prognostic communication in pediatric oncology and provide recommendations for future research. Methods: We conducted an integrative review searching six databases for studies on prognostic communication in pediatric oncology as of August 2022. We applied descriptive and narrative approaches to data analysis. Results: Fourteen quantitative and five qualitative studies were included. All studies were conducted in Western developed countries. In total, 804 parents of 770 children with cancer were included. Across studies, parents were predominately female, Non-Hispanic White, and had high school or higher levels of education. Most parents reported that prognostic communication was initiated in the first year after their children's diagnosis. High-quality prognostic communication was positively associated with trust and hope and negatively associated with parental distress and decisional regret. In qualitative studies, parents suggested that prognostic communication should be open, ongoing, and delivered with sensitivity. Most studies were of moderate quality. The main gaps included inconsistent definitions of prognostic communication, and a lack of comprehensive and validated measurements, high-quality longitudinal studies, and diverse settings and participants. Conclusions: Clinicians should initiate high-quality prognostic communication early on in clinical practice. Future research should consider conducting high-quality longitudinal studies, developing prognostic communication definitions and measurements, and conducting studies across settings with diverse populations.
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Affiliation(s)
- Na Ouyang
- School of Nursing, Yale University, Orange, CT, USA
| | - Shelli L Feder
- School of Nursing, Yale University, Orange, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - M Tish Knobf
- School of Nursing, Yale University, Orange, CT, USA
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Kaye EC, Smith J, Zhou Y, Bagatell R, Baker JN, Cohn SL, Diller LR, Glade Bender JL, Granger MM, Marachelian A, Park JR, Rosenberg AR, Shusterman S, Twist CJ, Mack JW. Factors influencing parents' choice of palliative treatment goals for children with relapsed or refractory neuroblastoma: A multi-site longitudinal survey study. Cancer 2024; 130:1101-1111. [PMID: 38100619 PMCID: PMC10939929 DOI: 10.1002/cncr.35149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Many parents of children with advanced cancer report curative goals and continue intensive therapies that can compound symptoms and suffering. Factors that influence parents to choose palliation as the primary treatment goal are not well understood. The objective of this study was to examine experiences impacting parents' report of palliative goals adjusted for time. The authors hypothesized that awareness of poor prognosis, recall of oncologists' prognostic disclosure, intensive treatments, and burdensome symptoms and suffering would influence palliative goal-setting. METHODS The authors collected prospective, longitudinal surveys from parents of children with relapsed/refractory neuroblastoma at nine pediatric cancer centers across the United States, beginning at relapse and continuing every 3 months for 18 months or until death. Hypothesized covariates were examined for possible associations with parental report of palliative goals. Generalized linear mixed models were used to evaluate factors associated with parents' report of palliative goals at different time points. RESULTS A total of 96 parents completed surveys. Parents were more likely to report a primary goal of palliation when they recalled communication about prognosis by their child's oncologist (odds ratio [OR], 52.48; p = .010). Treatment intensity and previous ineffective therapeutic regimens were not associated with parents' report of palliative goals adjusted for time. A parent who reported new suffering for their child was less likely to report palliative goals (OR, 0.13; p = .008). CONCLUSIONS Parents of children with poor prognosis cancer may not report palliative goals spontaneously in the setting of treatment-related suffering. Prognostic communication, however, does influence palliative goal-setting. Evidence-based interventions are needed to encourage timely, person-centered prognostic disclosure in the setting of advanced pediatric cancer. PLAIN LANGUAGE SUMMARY Many parents of children with poor-prognosis cancer continue to pursue curative treatments that may worsen symptoms and suffering. Little is known about which factors influence parents to choose palliative care as their child's main treatment goal. To explore this question, we asked parents of children with advanced neuroblastoma across the United States to complete multiple surveys over time. We found that the intensity of treatment, number of treatments, and suffering from treatment did not influence parents to choose palliative goals. However, when parents remembered their child's oncologist talking about prognosis, they were more likely to choose palliative goals of care.
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Affiliation(s)
- Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Jesse Smith
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN
| | - Yiwang Zhou
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin N. Baker
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Susan L. Cohn
- Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL
| | - Lisa R. Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
| | - Julia L. Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M. Meaghan Granger
- Hematology and Oncology Center, Cook Children’s Hospital, Fort Worth, TX
| | - Araz Marachelian
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Julie R. Park
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
- Department of Pediatric Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Abby R. Rosenberg
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
- Department of Pediatric Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Psychosocial Oncology and Palliative Care, Division of Pediatric Palliative Care; Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
| | - Clare J. Twist
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jennifer W. Mack
- Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Population Sciences’ Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA, USA
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Dai B, Xiao C, Wang Y, Li T, Duan Y, Jiang Y, Shi L, Hong X, Geng W, Hu J, Cao J, Wei J. Development and psychometric validation of the hospitalized patients' expectations for treatment scale-clinician version. Front Psychiatry 2024; 14:1325013. [PMID: 38283892 PMCID: PMC10811258 DOI: 10.3389/fpsyt.2023.1325013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024] Open
Abstract
Objective Patient safety management systems in general hospitals require a comprehensive tool for assessing the expectations of inpatients across different wards. This study aimed to develop and psychometrically validate a new scale, the hospitalized patients' expectations for treatment scale-clinician version (HOPE-C), to meet this requirement. Methods We interviewed 35 experts and 10 inpatients while developing the HOPE-C scale. The scale was initially designed with three dimensions: clinicians' expectations regarding doctor-patient communication, clinicians' expectations regarding treatment outcome, and clinicians' expectations regarding disease management. We recruited 200 inpatients from a general hospital in China. At the same time, 51 clinicians were assigned to the enrolled patients who completed the HOPE-C to examine the reliability, validity, and psychometric characteristics of the questionnaire. We applied item analysis, assessed construct validity, evaluated internal consistency, and conducted a test-retest reliability analysis over 7 days. Results Both exploratory and confirmatory analyses supported a 2-dimensional structure, comprising doctor-patient communication expectations and treatment outcome expectations, with favorable model fit parameters (root mean square residual [RMR] = 0.042, root mean square error of approximation [RMSEA] = 0.049, comparative fit index [CFI] = 0.989, Tucker-Lewis index [TLI] = 0.984). Item analysis demonstrated appropriate item design (r = 0.744-0.961). The scale exhibited strong internal consistency, with Cronbach's α values of 0.884, 0.816, and 0.840 for the overall scale, the doctor-patient communication expectation subscale, and the treatment outcome expectation subscale, respectively. The 7-day test-retest reliability was 0.996 (p < 0.001). Conclusion Our findings suggest that the HOPE-C is a reliable and valid assessment tool for measuring the expectations of inpatients in general hospitals. It effectively identifies patients' expectations concerning doctor-patient communication and treatment outcomes.
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Affiliation(s)
- Bindong Dai
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunfeng Xiao
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yufei Wang
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- 4+4 Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Li
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanping Duan
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinan Jiang
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lili Shi
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xia Hong
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqi Geng
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaojiao Hu
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinya Cao
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wei
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Bernstein SM, Barks MC, Ubel PA, Weinfurt K, Barlet MH, Farley S, Jiao MG, Bansal S, Fisher K, Lemmon ME. Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions. J Pediatr 2023; 263:113677. [PMID: 37611734 PMCID: PMC10841319 DOI: 10.1016/j.jpeds.2023.113677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/09/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions. STUDY DESIGN In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm. RESULTS Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%). CONCLUSIONS Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.
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Affiliation(s)
- Sarah M Bernstein
- University of Utah School of Medicine, Salt Lake City, UT; Duke University Medical Center, Durham, NC.
| | - Mary C Barks
- Duke Margolis Center for Health Policy, Durham, NC
| | | | | | | | | | - Megan G Jiao
- Duke Margolis Center for Health Policy, Durham, NC
| | | | | | - Monica E Lemmon
- Duke University Medical Center, Durham, NC; Duke Margolis Center for Health Policy, Durham, NC
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Carmona-Bayonas A, Rodriguez-Gonzalez A, García-García T, Velasco-Durantez V, Hernández-San Gil R, Cruz-Castellanos P, Fernandez-Montes A, Castillo-Trujillo A, Ballester I, Rogado J, Calderon C, Jimenez-Fonseca P. Can Oncologists Prompt Patient Prognostic Awareness to Enhance Decision-Making? Data From the NEOetic Study. Oncologist 2023; 28:986-995. [PMID: 37185783 PMCID: PMC10628594 DOI: 10.1093/oncolo/oyad100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/21/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Anti-neoplastic therapy improves the prognosis for advanced cancer, albeit it is not curative. An ethical dilemma that often arises during patients' first appointment with the oncologist is to give them only the prognostic information they can tolerate, even at the cost of compromising preference-based decision-making, versus giving them full information to force prompt prognostic awareness, at the risk of causing psychological harm. METHODS We recruited 550 participants with advanced cancer. After the appointment, patients and clinicians completed several questionnaires about preferences, expectations, prognostic awareness, hope, psychological symptoms, and other treatment-related aspects. The aim was to characterize the prevalence, explanatory factors, and consequences of inaccurate prognostic awareness and interest in therapy. RESULTS Inaccurate prognostic awareness affected 74%, conditioned by the administration of vague information without alluding to death (odds ratio [OR] 2.54; 95% CI, 1.47-4.37, adjusted P = .006). A full 68% agreed to low-efficacy therapies. Ethical and psychological factors oriented first-line decision-making, in a trade-off in which some lose quality of life and mood, for others to gain autonomy. Imprecise prognostic awareness was associated with greater interest in low-efficacy treatments (OR 2.27; 95% CI, 1.31-3.84; adjusted P = .017), whereas realistic understanding increased anxiety (OR 1.63; 95% CI, 1.01-2.65; adjusted P = 0.038), depression (OR 1.96; 95% CI, 1.23-3.11; adjusted P = .020), and diminished quality of life (OR 0.47; 95% CI, 0.29-0.75; adjusted P = .011). CONCLUSION In the age of immunotherapy and targeted therapies, many appear not to understand that antineoplastic therapy is not curative. Within the mix of inputs that comprise inaccurate prognostic awareness, many psychosocial factors are as relevant as the physicians' disclosure of information. Thus, the desire for better decision-making can actually harm the patient.
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Affiliation(s)
- Alberto Carmona-Bayonas
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, UMU, IMIB, Murcia, Spain
| | - Adán Rodriguez-Gonzalez
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Faculty of Medicine, University of Oviedo, Oviedo, Spain
| | - Teresa García-García
- Department of Medical Oncology, Hospital General Universitario Santa Lucia, Cartagena, Spain
| | - Verónica Velasco-Durantez
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Oviedo, Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | | | | | - Ana Fernandez-Montes
- Department of Medical Oncology, Complejo Hospitalario Universitario de Ourense, Orense, Spain
| | - Alfredo Castillo-Trujillo
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Faculty of Medicine, University of Oviedo, Oviedo, Spain
| | - Inmaculada Ballester
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, UMU, IMIB, Murcia, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Caterina Calderon
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology. University of Barcelona, Spain
| | - Paula Jimenez-Fonseca
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Faculty of Medicine, University of Oviedo, Oviedo, Spain
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Greenzang KA, Scavotto ML, Revette AC, Schlegel SF, Silverman LB, Mack JW. "There's no playbook for when your kid has cancer": Desired elements of an electronic resource to support pediatric cancer communication. Pediatr Blood Cancer 2023; 70:e30198. [PMID: 36602023 PMCID: PMC10375908 DOI: 10.1002/pbc.30198] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL), the most common childhood malignancy, has a relatively favorable long-term prognosis. Yet the complexity of treatment and the emotionality of the diagnosis leave families feeling unprepared for many aspects of therapy. This qualitative study aimed to identify desired elements and format of a communication resource to support patients and families facing a diagnosis of ALL. METHODS Semi-structured interviews of 12 parents of children receiving ALL treatment, 10 parents of survivors of ALL, and eight adolescent and young adult (AYA) survivors of ALL were conducted between February and June 2021. The interviews focused on communication experiences throughout treatment and identified domains to be addressed in a resource in development. RESULTS All participants supported the development of an interactive, electronic health (eHealth) resource to help navigate ALL treatment. They felt a website would be helpful in addressing information gaps and mitigating pervasive feelings of overwhelm. Participants specifically sought: (a) information resources to address feelings of cognitive overload; (b) practical tips to help navigate logistical challenges; (c) clear depictions of treatment choices and trajectories to facilitate decision-making; and (d) additional psychosocial resources and support. Two overarching themes that families felt should be interwoven throughout the eHealth resource were connections with other patients/families and extra support at transitions between phases of treatment. CONCLUSIONS A new diagnosis of ALL and its treatment are extremely overwhelming. Patients and families unanimously supported an eHealth resource to provide additional information and connect them with emotional support, starting at diagnosis and extending throughout treatment.
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Affiliation(s)
- Katie A Greenzang
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Madison L Scavotto
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anna C Revette
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sarah F Schlegel
- Division of Pediatric Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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8
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Porter AS, Woods C, Stall M, Baker JN, Mack JW, Kaye EC. Mismatch between Pediatric Oncologists' Private and Parent-Facing Prognostic Communication: Communication Patterns Used to Soften Prognostic Disclosure. J Palliat Med 2023; 26:210-219. [PMID: 35976087 DOI: 10.1089/jpm.2022.0265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Purpose: Most parents of children with cancer desire honest prognostic communication, yet oncologists often avoid clear prognostic disclosure. This study explored differences between oncologists' private assessments of prognosis and their prognostic communication with patients and parents. Patients and Methods: In this prospective, longitudinal, mixed-methods study, we audio-recorded serial disease reevaluation conversations between children with advancing cancer, parents, and primary oncologists and separately surveyed and interviewed oncologists at disease progression time points. At time points when oncologists privately described curability as ≤10%, content analysis was used to compare prognostic language in recorded dialogue with private responses about prognosis. Results: Of 33 enrolled patient-parent dyads, 17 patients with high-risk cancer under the care of 6 primary oncologists experienced disease progression during the study period. In 95% of oncologist interviews at disease progression time points, oncologists either predicted curability to be ≤10% or incurable. In most interviews (82%), oncologists stated unequivocally that chances of cure were ≤10%, yet did not communicate these low odds during recorded discussions at the same time point. Analysis revealed three distinct communication patterns through which oncologists softened prognostic disclosure to patients and families: (1) space-holding for hope of cure: statements acknowledging difficult prognosis yet leaving room for possibility of cure; (2) vague warning: statements implying that cancer may progress without offering specifics; and (3) data without interpretation: statements describing disease progression findings in detail without explaining what this meant for the patient's future life or survival. Conclusion: Pediatric oncologists often temper their assessment of poor prognosis when speaking with patients and families. Future work should explore serious conversation guides and other clinical interventions aimed at encouraging person-centered prognostic disclosure for patients with advancing cancer and their families.
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Affiliation(s)
- Amy S Porter
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Cameka Woods
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melanie Stall
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Porter AS, Chow E, Woods C, Lemmon ME, Baker JN, Mack JW, Kaye EC. Navigating prognostic communication when children with poor-prognosis cancer experience prolonged disease stability. Pediatr Blood Cancer 2023; 70:e29920. [PMID: 36000929 DOI: 10.1002/pbc.29920] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Most pediatric patients and families want clear prognostic information across the illness course. Yet when children with poor-prognosis cancer experience prolonged disease stability, uncertainty can make communication particularly challenging. In this study, we aimed to (i) assess how frequently oncologists communicate about prognosis when high-risk cancer does not progress, and (ii) describe prognostic communication patterns in the context of disease stability. PATIENTS AND METHODS In this prospective, longitudinal, mixed-methods study, we audio-recorded serial disease re-evaluation conversations between children with poor-prognosis cancer, their families, and their primary oncologists. For this secondary analysis, we conducted content analysis across serial conversations among 16 patient-parent-oncologist triads for whom the patient's disease remained stable over the 24-month study period. RESULTS Prognostic communication was absent in >50% of recorded conversations. Overall, it comprised only 4% of dialog time, nearly 90% of which was dialog about prognostic uncertainty; discussion of curability occurred infrequently. Three distinct patterns for prognostic communication emerged: (a) "Don't know" statements, avoiding or deferring prognostication; (b) "Worry" statements, preparing families for possible future disease progression; and (c) relief-caveat statements, celebrating disease stability while balancing positivity with caution. CONCLUSIONS Oncologists seldom talked about prognosis with high-risk patients during periods of disease stability; yet when they did, they used thoughtful and effective strategies to prepare families for possible future disease progression. Further research is needed to better understand if, how, and when patients and families with stable disease who are high risk for future disease progression prefer to receive information about prognosis.
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Affiliation(s)
- Amy S Porter
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Emma Chow
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Rhodes College, Memphis, Tennessee, USA
| | - Cameka Woods
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Monica E Lemmon
- Department of Pediatrics, Duke Children's Health Center, Durham, North Carolina, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Porter AS, Woods C, Stall M, Velrajan S, Baker JN, Mack JW, Kaye EC. Oncologist approaches to communicating uncertain disease status in pediatric cancer: a qualitative study. BMC Cancer 2022; 22:1109. [PMCID: PMC9620648 DOI: 10.1186/s12885-022-10190-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 09/28/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Most patients with cancer and their caregivers desire honest, clear prognostic communication, yet oncologists often disclose prognosis inconsistently. Prognostic communication becomes even more challenging when disease progression is unclear or equivocal. Presently, oncologist approaches for discussing uncertain disease findings are poorly understood. Methods In this prospective, longitudinal study, we audio-recorded serial disease reevaluation conversations between children with high-risk cancer, their families, and their primary oncologists over 24 months and conducted content analysis at recorded timepoints when oncologists categorized disease progression as equivocal. Results Of the 265 medical discussions recorded across the illness course for 33 patient-parent dyads, a total of 40 recorded discussions took place at equivocal timepoints, comprising > 500 min of medical dialogue. Prognosis talk encompassed < 3% of dialogue and was absent in nearly half of equivocal discussions (17/40, 42.5%). Curability statements were identified in only two conversations. Inductive content analysis of dialogue revealed four distinct patterns for communicating equivocal disease status: (1) up-front reassurance, (2) softening the message, (3) describing possible disease progression without interpretation, (4) expressing uncertainty without discussing the bigger picture. Conclusion Oncologists rarely discuss prognosis with children with high-risk cancer and their families at timepoints when disease progression is not definitive. Formal guidance is needed to better support oncologists in navigating uncertainty while sharing honest, person- and family-centered information about prognosis. Supplementary information The online version contains supplementary material available at 10.1186/s12885-022-10190-6.
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Affiliation(s)
- Amy S. Porter
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA
| | - Cameka Woods
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA
| | - Melanie Stall
- grid.267313.20000 0000 9482 7121The University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | - Justin N. Baker
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA
| | - Jennifer W. Mack
- grid.65499.370000 0001 2106 9910Dana-Farber Cancer Institute, Boston, MA USA ,grid.2515.30000 0004 0378 8438Boston Children’s Hospital, Boston, MA USA
| | - Erica C. Kaye
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA ,grid.240871.80000 0001 0224 711XDivision of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop 1121, 38105 Memphis, TN USA
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11
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Madrigal VN, Hill DL, Shults J, Feudtner C. Trust in Physicians, Anxiety and Depression, and Decision-Making Preferences among Parents of Children with Serious Illness. J Palliat Med 2022; 25:428-436. [PMID: 34516933 PMCID: PMC8968833 DOI: 10.1089/jpm.2021.0063] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: To assess parental decision-making preferences when caring for a child with serious illness and to evaluate for an association between preferences and parental trust in physicians, and potential modification of this association by parental anxiety or depression. Methods: We analyzed cross-sectional data from 200 parents of 158 children in the United States who had life-threatening illnesses and whose attending physicians thought that the parents would have to make major medical decision in the next 12 to 24 months. Parents completed measures of decision-making preferences, trust in physicians, anxiety, and depression. Results: Higher reported levels of trust were associated with lower preferences for autonomous decision making (Spearman correlation = -0.24; 95% confidence interval [CI] = -0.36 to -0.01; p < 0.008). Among parents with higher levels of trust, increasing anxiety scores were associated with decreasing preference for autonomy, whereas among parents with lower levels of trust, increasing anxiety scores showed an increasing preference for autonomy (regression coefficient = -0.01; 95% CI = -0.02 to -0.001; p ≤ 0.03). Conclusions: Decreasing trust in physicians is associated with a higher preference for autonomous decision making. Parents who have higher levels of anxiety exhibit this association more strongly. Decision support for parents of children with serious illness should use strategies to respect parental decision-making preferences, address potential distrust, and provide mental health support to parents who are anxious or depressed.
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Affiliation(s)
- Vanessa N. Madrigal
- Division Critical Care Medicine, Department of Pediatrics, George Washington University, Washington, DC, USA.,Pediatric Ethics Program, Children's National Hospital, Washington, DC, USA
| | - Douglas L. Hill
- Department of Medical Ethics, Roberts Center for Pediatric Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Department of Biostatistics, Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Medical Ethics, Roberts Center for Pediatric Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Address correspondence to: Chris Feudtner, MD, PhD, MPH, Department of Medical Ethics, Roberts Center for Pediatric Research, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, USA
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12
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Carpenter K, Scavotto M, McGovern A, Ma C, Kenney LB, Mack JW, Greenzang KA. Early parental knowledge of late effect risks in children with cancer. Pediatr Blood Cancer 2022; 69:e29473. [PMID: 34842331 PMCID: PMC11284957 DOI: 10.1002/pbc.29473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/24/2021] [Accepted: 11/01/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND/OBJECTIVES Despite the pervasiveness of late effects in childhood cancer survivors, many parents feel inadequately informed about their child's risks. We assessed early parental knowledge of risks of late effects and predictors of increased knowledge. DESIGN/METHODS Parents of children receiving cancer treatment at Dana-Farber/Boston Children's Cancer and Blood Disorders Center were surveyed about their knowledge of their child's likelihood of eight late effects. Individual risk for each late effect (yes/no) was assessed using the Children's Oncology Group's Long-Term Follow-Up Guidelines v5 as a reference. Descriptive statistics were used to summarize knowledge scores; ordinal logistic regression was used to identify predictors of higher knowledge. RESULTS Of 96 parent participants, 11 (11.46%) correctly identified all of their child's risks for the eight late effects. Five of eight was the median number of correctly identified late effect risks. Among 21 parents whose children were at risk for ototoxicity, 95% correctly identified this risk. Conversely, parents of at-risk children were less knowledgeable about risks of secondary malignancy (63% correct identification, of N = 94 at risk), cardiac toxicity (61%; N = 71), neurocognitive impairment (56%; N = 63), and infertility (28%; N = 61). Ordinal logistic regression analysis identified no significant differences in parental knowledge of late effect risks by any factors evaluated. CONCLUSIONS Gaps in parental knowledge of potential late effects of childhood cancer treatment emerge early in a child's care, and parents are more knowledgeable about some late effects, such as ototoxicity, than others, such as infertility. As no child- or parent-specific factors were associated with increased knowledge of late effect risks, interventions must be applied broadly.
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Affiliation(s)
- Kendall Carpenter
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Madison Scavotto
- Division of Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alana McGovern
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Clement Ma
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public HealthUniversity of Toronto, Toronto, Ontario, Canada
| | - Lisa B. Kenney
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Jennifer W. Mack
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Katie A. Greenzang
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts, USA
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13
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Abstract
Purpose of Review To present new findings in order to aid in the provision of high-quality symptom management and psychosocial care for adolescents and young adults with advanced cancer at the end of life. Recent Findings Behavioral health providers support patients by teaching them symptom control skills, building legacies, and making meaning of their lives. Integration of cultural values is essential for comprehensive assessment and decision-making. Effective management of physiological symptoms and psychological distress begins with accurate communication about prognosis and goals of care that focus on patient preferences and priorities. Oncology teams promote quality of life and the successful management of fatigue, pain, decreased mobility, poor appetite, and dyspnea with the early inclusion of palliative care. Summary While provision of end-of-life care in a young person with cancer presents challenges, multidisciplinary teams can effectively accompany patients in this journey by prioritizing patient and family preferences to promote quality of life.
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14
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Sisk BA, Harvey K, Friedrich AB, Antes AL, Yaeger LH, Mack JW, DuBois J. Multilevel barriers and facilitators of communication in pediatric oncology: A systematic review. Pediatr Blood Cancer 2022; 69:e29405. [PMID: 34662485 PMCID: PMC8875310 DOI: 10.1002/pbc.29405] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 01/03/2023]
Abstract
Multiple factors can facilitate or impede the fulfillment of communication functions in pediatric cancer. In this systematic review, we evaluated 109 studies from the preceding 20 years that presented qualitative or quantitative evidence of barriers or facilitators to communication in pediatric cancer. Using a multilevel framework developed in our prior study, we then analyzed and categorized the levels of barriers and facilitators identified in included studies. The vast majority of studies focused on individual-level barriers, rather than team, organization/system, collaborating hospital, community, or policy-level barriers. Future studies should explore the full range of factors that affect communication.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri.,Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kieandra Harvey
- Brown School of Social Work, Washington University School of Medicine, St. Louis, Missouri
| | - Annie B. Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, Missouri
| | - Alison L. Antes
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer W. Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts; and Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| | - James DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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15
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Marcus KL, Kao PC, Ma C, Wolfe J, DeCourcey DD. Symptoms and Suffering at End of Life for Children With Complex Chronic Conditions. J Pain Symptom Manage 2022; 63:88-97. [PMID: 34311060 DOI: 10.1016/j.jpainsymman.2021.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/22/2021] [Accepted: 07/16/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT Children with cancer and cardiac disease suffer with high symptom burden at end of life (EOL). Little is known about the EOL experience for children with other complex chronic conditions (CCCs). OBJECTIVES To evaluate symptoms and suffering at EOL for children with noncancer, noncardiac CCCs as well as parental distress related to child suffering. METHODS This study is a secondary data analysis of a cross-sectional, single-center survey of bereaved parents of children with CCCs who died between 2006 to 2015. The primary outcome was parent-reported child suffering in the final two days of life. RESULTS Among 211 eligible parents contacted for participation, 114 completed the survey, and 99 had complete primary outcome data (participation rate 47%). Most children had congenital/chromosomal (42%) or progressive central nervous system (22%) conditions. Twenty-eight percent of parents reported high child suffering in the final two days of life. Parents reported that pain and difficulty breathing caused the greatest suffering for children and distress among themselves. Some parents also reported distress related to uncertainty about child suffering. Parents were less likely to report high child suffering if they were confident in knowing what to expect when their child was dying (AOR 0.20; 95% CI 0.07-0.60) or felt prepared for medical problems at EOL (AOR 0.12; 95% CI 0.04-0.42). CONCLUSION Nearly one-third of parents of children with CCCs report high suffering in their child's final days of life. Parent preparedness was associated with lower perceived child suffering. Future research should target symptoms contributing to parent and child distress and assess whether enhancing parent preparedness reduces perceived child suffering.
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Affiliation(s)
- Katherine L Marcus
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Pei-Chi Kao
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Danielle D DeCourcey
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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16
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Greenzang KA, Kelly CA, Al-Sayegh H, Ma C, Mack JW. Thinking ahead: Parents' worries about late effects of childhood cancer treatment. Pediatr Blood Cancer 2021; 68:e29335. [PMID: 34520114 PMCID: PMC8541904 DOI: 10.1002/pbc.29335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many childhood cancersurvivors experience at least one late effect of treatment, and both late effects and persistent cancer-related worry can negatively impact quality of life in survivorship. Little is known about the prevalence or impact of parental worry about late effects early in treatment. This study evaluated parental perceived likelihood, impact, and worry about late effects of childhood cancer. PROCEDURE We surveyed 96 parents of pediatric cancer patients at Dana-Farber/Boston Children's Cancer and Blood Disorders Center within a year of diagnosis. Parents were asked about their experiences with late effects communication, general worry about late effects, and specific late effect worries. RESULTS Most (96%) parents valued information about late effects, and 93% considered late effects in their treatment decision-making. Yet, 24% could not recall receiving any information about late effects, and only 51% felt well prepared for potential late effects. Though only 20% of parents considered their child at high risk of experiencing late effects, 61% were extremely/very worried about late effects. Those who felt their child was at high risk of experiencing late effects were more likely to worry (OR = 4.7, P = 0.02). CONCLUSIONS Many parents feel inadequately informed about late effects of cancer treatment, and only one-fifth of parents consider late effects to be likely for their child. However, a majority of parents worry about late effects, including ones they think their child is unlikely to experience. Although some worry is anticipated, disproportionate worry may be mitigated by addressing both educational shortfalls and emotional concerns.
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Affiliation(s)
- Katie A. Greenzang
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts;,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts;,Division of Pediatric Hematology/Oncology, Boston Children’s Hospital;,Department of Pediatrics, Boston Children’s Hospital;,Harvard Medical School, Harvard University
| | - Colleen A. Kelly
- Department of Pediatrics, Boston Children’s Hospital;,Harvard Medical School, Harvard University,Boston University School of Medicine, and Boston Medical Center
| | - Hasan Al-Sayegh
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts;,Division of Pediatric Hematology/Oncology, Boston Children’s Hospital
| | - Clement Ma
- Centre for Addiction and Mental Health, Toronto, Canada,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts;,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts;,Division of Pediatric Hematology/Oncology, Boston Children’s Hospital;,Department of Pediatrics, Boston Children’s Hospital;,Harvard Medical School, Harvard University
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17
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Graetz DE, Rivas SE, Wang H, Vedaraju Y, Fuentes AL, Caceres-Serrano A, Antillon-Klussmann F, Devidas M, Metzger ML, Rodriguez-Galindo C, Mack JW. Communication Priorities and Experiences of Caregivers of Children With Cancer in Guatemala. JCO Glob Oncol 2021; 7:1529-1536. [PMID: 34748391 PMCID: PMC8577673 DOI: 10.1200/go.21.00232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although > 90% of children with cancer live in low- and middle-income countries, little is known about communication priorities and experiences of families in these settings. We examined communication priorities and the quality of information exchange for Guatemalan caregivers of children with cancer during diagnostic communication. METHODS A cross-sectional survey including items used in pediatric communication studies from high-income countries and novel questions was verbally administered to 100 caregivers of children with cancer in Guatemala. RESULTS Guatemalan caregivers prioritized communication functions of exchanging information (99%), fostering healing relationships (98%), decision making (97%), enabling self-management (96%), and managing uncertainty (94%) over responding to emotions (66%) and cultural awareness (48%). Almost all caregivers wanted as many details as possible about their child's diagnosis and treatment (96%), likelihood of cure (99%), and late effects (97%). Only 67% were always given the information they needed without asking for it, and most caregivers sometimes (56%) or always (18%) had questions they wanted to discuss but did not. Approximately half of the caregivers (54%) correctly identified their child's diagnosis, primary site, disease extent (localized v metastatic), proposed treatment length, and treatment intent (curative v palliative). Caregivers of children with leukemia were more likely to correctly identify all attributes than those whose children had solid tumors (P < .001). CONCLUSION Caregivers in Guatemala prioritize many of the same aspects of diagnostic communication as parents in the United States, and experience similar challenges. Shared communication values offer potential for adaptation of communication interventions across settings with varying resources and diverse cultures. Communication priorities and experiences of caregivers of children with cancer in Guatemala similar to those in US.![]()
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Affiliation(s)
| | | | - Huiqi Wang
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | | | | | - Jennifer W Mack
- Dana Farber Cancer Institute/Boston Children's Hospital, Boston, MA
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18
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Mack JW, Jaung T, Uno H, Brackett J. Parent and Clinician Perspectives on Challenging Parent-Clinician Relationships in Pediatric Oncology. JAMA Netw Open 2021; 4:e2132138. [PMID: 34787658 PMCID: PMC8600390 DOI: 10.1001/jamanetworkopen.2021.32138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Parents of children with cancer value strong therapeutic relationships with oncology clinicians, but not every relationship is positive. OBJECTIVE To identify the prevalence of challenging parent-clinician relationships in pediatric oncology and factors associated with these challenges from parent and clinician perspectives. DESIGN, SETTING, AND PARTICIPANTS This survey was conducted among parents and oncology clinicians of children with cancer within 3 months of diagnosis from November 2015 to July 2019 at Dana-Farber Cancer Institute/Boston Children's Hospital and Texas Children's Hospital. Participants were 400 parents of children with cancer and 80 clinicians (ie, oncology physicians and nurse practitioners). Parents completed surveys about relationships with 1 to 2 primary oncology clinicians; clinicians completed surveys about relationships with parents. Data were analyzed from July 2020 to August 2021. EXPOSURES At least 3 previous clinical visits between parent and clinician. MAIN OUTCOMES AND MEASURES The Relationship Challenges Scale Parent Version and Clinician Version were developed and used to measure threats to the therapeutic alliance. For the Relationship Challenges Scale-Parent version, relationships were considered challenging if a parent responded to any single question in the 2 lowest of 4 possible categories. For the Relationship Challenges Scale-Clinician version, challenges were considered to be present if a clinician reported responses in the 3 lowest of 6 possible response categories to any question. RESULTS Among 400 parents, there were 298 [74.5%] women, 25 Asian individuals (6.3%), 28 Black individuals (7.0%), 97 Hispanic individuals (24.3%), 223 White individuals (55.8%), and 10 individuals (2.4%) with other race or ethnicity; race and ethnicity data were missing for 17 (4.3%) individuals. Among 80 clinicians, there were 57 (71.3%) women, 38 attending physicians (47.5%), 32 fellows (40.0%), and 10 nurse practitioners (12.5%). Parents identified 676 unique relationships with clinicians, and clinician reports were available for 338 relationships. Among 338 relationships with paired parent and clinician surveys, 81 relationships (24.0%) were considered challenging by parents, 127 relationships (37.6%) were considered challenging by clinicians, and 33 relationships (9.8%) were considered challenging by parent and clinician. Parents with Asian or other race or ethnicity (odds ratio [OR] vs White parents, 3.62; 95% CI, 1.59-8.26) or who had lower educational attainment (OR for ≤high school vs >high school, 3.03; 95% CI, 1.56-5.90) were more likely to experience relationships as challenging. Clinicians used a variety of strategies more frequently in 127 relationships in which they perceived challenges vs 211 relationships in which they did not perceive challenges, such as holding regular family meetings (22 relationships [17.3%] vs 13 relationships [6.2%]; P = .009) and offering extra time and attention (66 relationships [52%] vs 60 relationships [28.4%]; P < .001). However, these strategies were not used with increased frequency when parents experienced relationships as challenging vs when parents did not experience this. CONCLUSIONS AND RELEVANCE This survey study found that nearly one-quarter of parents of children with cancer reported challenges in the therapeutic relationship with their oncologist and that clinicians used strategies to improve relationships more frequently when they experienced the relationship as challenging. These findings suggest that new strategies are needed to improve experiences for parents and to help clinicians recognize and attend to parents whose experiences are suboptimal.
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Affiliation(s)
- Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| | - Tim Jaung
- Division of Population Sciences Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Julienne Brackett
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, Texas Children’s Hospital, Houston
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19
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Rost M, Mihailov E. In the name of the family? Against parents' refusal to disclose prognostic information to children. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:421-432. [PMID: 33847853 PMCID: PMC8349339 DOI: 10.1007/s11019-021-10017-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2021] [Indexed: 06/12/2023]
Abstract
Parents frequently attempt to shield their children from distressing prognostic information. Pediatric oncology providers sometimes follow parental request for non-disclosure of prognostic information to children, invoking what we call the stability of the family argument. They believe that if they inform the child about terminal prognosis despite parental wishes, cohesion and family structure will be severely hampered. In this paper, we argue against parental request for non-disclosure. Firstly, we present the stability of the family argument in more detail. We, then, set out the (conceptual, legal, systemic) entitativity of the family and the kind of value the stability of the family argument assumes, before we set on to critically evaluate the argument. Our analysis shows that disclosure of prognostic information to children does not necessarily destabilize the family to a greater extent than non-disclosure. In fact, a systemic perspective suggests that mediated disclosure is more likely to result in a (long-term) stability of the family than non-disclosure. It is in the interest of the family to resist the initial aversive reaction to delivering bad news. In the final part, we draw a set of recommendations on how to facilitate decision-making in face of parental request for non-disclosure.
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Affiliation(s)
- Michael Rost
- Institute for Biomedical Ethics, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland.
| | - Emilian Mihailov
- Institute for Biomedical Ethics, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland
- Research Centre in Applied Ethics, Faculty of Philosophy, University of Bucharest, Bucharest, Romania
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20
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De Abreu Lourenco R, McCarthy MC, McMillan LJ, Sullivan M, Gillam L. Understanding decisions to participate in genomic medicine in children's cancer care: A comparison of what influences parents, health care providers, and the general community. Pediatr Blood Cancer 2021; 68:e29101. [PMID: 34089211 DOI: 10.1002/pbc.29101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/28/2021] [Accepted: 04/21/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The emerging role of genomically guided precision medicine in pediatric cancer care presents significant clinical, practical, and ethical challenges. We investigated the factors that influence decision-making in genomic medicine from the perspective of different stakeholders in the context of difficult-to-treat childhood cancer. METHODS Health care providers (HCPs), parents of childhood cancer survivors, and general community members completed an online discrete choice experiment survey. Respondents considered whether to recommend (HCPs) or choose (parents/community) a genomically guided approach to pediatric cancer treatment. Respondents completed eight choice questions varying by survival benefit, prognosis, likelihood of finding a target, quality of life (QoL), HCP/parent preference, need for biopsy, cost, and who pays. Data were analyzed using a probability regression model, with findings expressed as relative importance, stated importance, and marginal willingness to pay (mWTP). RESULTS One hundred twenty-six HCPs, 130 parents, and 531 community members participated. The probability of recommending/choosing genomically guided treatment increased significantly with better prognosis, survival benefit, improvements in QoL, and decision-making partner support. It decreased with increasing costs and if parents paid for treatment. HCPs were more responsive to all factors but were most influenced by survival outcomes, and parents and community members by QoL. In contrast to these forced choice preference results, HCPs stated they were most influenced by QoL and community members by survival. CONCLUSION Our findings support the primacy of QoL in genomic decision-making, with some differences across stakeholders in the other factors influencing decision-making. These findings emphasize the need for high-quality information giving and communication to support genomic medicine choices.
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Affiliation(s)
- Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Haymarket, New South Wales, Australia
| | - Maria C McCarthy
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Laura J McMillan
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Michael Sullivan
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Lyn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.,Department of Bioethics, Royal Children's Hospital, Parkville, Victoria, Australia
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21
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Hiratsuka Y, Oishi T, Miyashita M, Morita T, Mack JW, Sato Y, Takahashi M, Komine K, Saijo K, Ishioka C, Inoue A. Factors related to specialized palliative care use and aggressive care at end of life in Japanese patients with advanced solid cancers: a cohort study. Support Care Cancer 2021; 29:7805-7813. [PMID: 34169330 DOI: 10.1007/s00520-021-06364-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE This study aimed to (1) describe characteristics of aggressive care at the end of life (EOL) and (2) identify factors associated with specialized palliative care use (SPC) and aggressive care at the EOL among Japanese patients with advanced cancer. METHODS This single-center, follow-up cohort study involved patients with advanced cancer who received chemotherapy at Tohoku University Hospital. Patients were surveyed at enrollment, and we followed clinical events for 5 years from enrollment in the study. We performed multivariate logistic regression analysis to identify independent factors related to SPC use and chemotherapy in the last month before death. RESULTS We analyzed a total of 135 patients enrolled between January 2015 and January 2016. No patients were admitted to the intensive care unit, and few received resuscitation or ventilation. We identified no factors significantly associated with SPC use. Meanwhile, younger age (20-59 years, odds ratio [OR] 4.10; 95% confidence interval [CI] 1.30-12.91; p = 0.02) and no receipt of SPC (OR 4.32; 95% CI 1.07-17.37; p = 0.04) were associated with chemotherapy in the last month before death. CONCLUSION Younger age and a lack of SPC were associated with chemotherapy at the EOL in patients with advanced cancer in Japan. These findings suggest that Japanese patients with advanced cancer may benefit from access to SPC.
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Affiliation(s)
- Yusuke Hiratsuka
- Department of Palliative Medicine, Takeda General Hospital, Aizu Wakamatsu, Japan.,Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Takayuki Oishi
- Department of Clinical Oncology, Tohoku University School of Medicine, Sendai, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8575, Japan.
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Jennifer W Mack
- Department of Pediatric Oncology and Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yuko Sato
- Department of Clinical Oncology, Tohoku University School of Medicine, Sendai, Japan
| | - Masahiro Takahashi
- Department of Clinical Oncology, Tohoku University School of Medicine, Sendai, Japan
| | - Keigo Komine
- Department of Medical Oncology, Tohoku University Hospital, Sendai, Japan
| | - Ken Saijo
- Department of Clinical Oncology, Tohoku University School of Medicine, Sendai, Japan
| | - Chikashi Ishioka
- Department of Clinical Oncology, Tohoku University School of Medicine, Sendai, Japan
| | - Akira Inoue
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
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22
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Kaye EC, Stall M, Woods C, Velrajan S, Gattas M, Lemmon M, Baker JN, Mack JW. Prognostic Communication Between Oncologists and Parents of Children With Advanced Cancer. Pediatrics 2021; 147:peds.2020-044503. [PMID: 33952691 PMCID: PMC8503785 DOI: 10.1542/peds.2020-044503] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Parents of children with cancer perceive deficits in quality of prognostic communication. How oncologists disclose information about disease progression and incurability and how prognostic communication impacts parental understanding of prognosis are poorly understood. In this study, we aimed to (1) characterize communication strategies used by pediatric oncologists to share prognostic information across a child's advancing illness course and (2) explore relationships between different communication approaches and concordance of oncologist-parent prognostic understanding. METHODS In this prospective, longitudinal, mixed-methods study, serial disease reevaluation conversations were audio recorded across an advancing illness course for children with cancer and their families. Surveys and interviews also were conducted with oncologists and caregivers at specific time points targeting disease progression. RESULTS Seventeen children experienced advancing illness on study, resulting in 141 recordings (40 hours). Fewer than 4% of recorded dialogue constituted prognostic communication, with most codes (77%) occurring during discussions about frank disease progression. Most recordings at study entry contained little or no prognosis communication dialogue, and oncologists rated curability lower than parents across all dyads. Parent-oncologist discordance typically was preceded by conversations without incurability statements; ultimately, concordance was achieved in most cases after the oncologist made direct statements about incurability. Content analysis revealed 3 distinct patterns (absent, deferred, and seed planting) describing the provision of prognostic communication across an advancing pediatric cancer course. CONCLUSIONS When oncologists provided direct statements about incurability, prognostic understanding appeared to improve. Further research is needed to determine optimal timing for prognostic disclosure in alignment with patient and family preferences.
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Affiliation(s)
- Erica C. Kaye
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Melanie Stall
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cameka Woods
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Melanie Gattas
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Monica Lemmon
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Jennifer W. Mack
- Dana-Farber Cancer Institute, Boston, Massachusetts,Boston Children’s Hospital, Boston, Massachusetts
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23
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Sisk BA, Schulz G. Moving Toward a Basic Science of Prognostic Communication. Pediatrics 2021; 147:peds.2021-050208. [PMID: 33952690 DOI: 10.1542/peds.2021-050208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Ginny Schulz
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
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24
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Terrasson J, Brédart A, El Mellah L, Doz F, Seigneur É, Dolbeault S. [Emotions Associated with Breaking Bad News in Pediatric Oncology and Parents-Pediatrician Communication: A Status Report]. Bull Cancer 2021; 108:399-414. [PMID: 33707034 DOI: 10.1016/j.bulcan.2020.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/28/2022]
Abstract
This literature review aims to explain how the emotions aroused by the announcement of bad news in pediatric oncology affect communication between parents and pediatric oncologists. In the first part, we summarize the parents' expectations regarding communication with the pediatrician at this critical time in their child's care. Then, in a second part, we specify the influence that the emotions of pediatric oncologists and parents during these announcements can have on parent-pediatrician communication. In this context, the emotions and defense mechanisms of pediatric oncologists, parental distress as expressed by parents and as perceived or feared by pediatricians, are discussed. For this synthesis, we have endeavoured to select studies including both mothers and fathers. On the basis of the observations carried out in this review, we conclude by suggesting avenues for the practical implications and for future research. The continuation of research including both parents appears necessary to allow for a closer adaptation of the reactions and needs of each parent, particularly at key moments in the child's care, such as the announcement of bad news. Encouraging exchanges on the emotions felt within the medical and care team, particularly with the department psychologist, could be an opportunity for pediatricians to question their experience of the announcement of bad news and could promote the circulation of emotions in the parent-pediatrician relationship and communication.
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Affiliation(s)
- Johanna Terrasson
- Unité de Psycho-Oncologie, Institut Curie, PSL Université Paris, 75005 Paris, France.
| | - Anne Brédart
- Unité de Psycho-Oncologie, Institut Curie, PSL Université Paris, 75005 Paris, France; Laboratoire Psychopathologie et Processus de Santé, Université de Paris, 92100 Boulogne-Billancourt, France
| | - Leïla El Mellah
- Unité de Psycho-Oncologie, Institut Curie, PSL Université Paris, 75005 Paris, France
| | - François Doz
- Centre SIREDO - Soins, Innovation, Recherche, en oncologie de l'Enfant, de l'aDOlescent et de l'adulte jeune, Institut Curie, 75005 Paris, France; Université de Paris, 12, rue de l'École de Médecine, 75006 Paris, France; UMR 144 CNRS, Institut Curie, 75005 Paris, France
| | - Étienne Seigneur
- Unité de Psycho-Oncologie, Institut Curie, PSL Université Paris, 75005 Paris, France; Centre SIREDO - Soins, Innovation, Recherche, en oncologie de l'Enfant, de l'aDOlescent et de l'adulte jeune, Institut Curie, 75005 Paris, France
| | - Sylvie Dolbeault
- Unité de Psycho-Oncologie, Institut Curie, PSL Université Paris, 75005 Paris, France; Centre de recherche en Épidémiologie et Santé des Populations (CESP), Inserm, U1018, Université Paris-Sud, 94807 Villejuif, France
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25
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Levine DR, Cuviello A, Nelson C, Lu Z, Mandrell BN, Baker JN. Hope-Colored Glasses: Perceptions of Prognosis Among Pediatric Oncology Patients and Their Parents. JCO Oncol Pract 2021; 17:e730-e739. [PMID: 33661701 DOI: 10.1200/op.20.00762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer patients' belief about prognosis can heavily influence medical decision making and goals of care. It is known that parents of children with cancer tend to be optimistic regarding their child's prognosis; however, little is known about pediatric patients' prognostic beliefs, how physicians' prognostic communication is perceived, and how these perceptions are compared with actual prognoses. PATIENTS AND METHODS An original survey was administered to 100 pediatric oncology patients, age 10-18 years, and their parents from 2013 to 2015, at St Jude Children's Research Hospital. Patients were eligible for inclusion if they had an oncologic diagnosis, were between 1 month and 1 year from diagnosis, and were English speaking. Survey responses regarding perceived prognosis were compared with actual prognoses as determined from the medical record review and published literature. Analysis included descriptive statistics and association tests. RESULTS Nearly half of participants (patients = 48.9%, parents = 50.5%) displayed prognostic optimism as compared with the determined objective estimate of curative potential. The majority of both patients (78%) and parents (85%) reported belief in a very high chance of cure, although fewer reported that their physician communicated a very high chance for cure (patients = 57%, parents = 70%), and only 43% were determined to have a very high probability of cure. Significant differences were noted in prognostic optimism by cancer type (P < .0001); patients with solid tumor were more often optimistic (n = 25, 83.3% optimistic; n = 5, 16.7% accurate), and patients with lymphoma were most often accurate (n = 2, 8.7% optimistic; n = 21, 91.3% accurate). CONCLUSION Pediatric oncology patients and parents tend to be optimistic about their chance of cure, as compared to both perceived prognostic communication from physicians and objective estimated prognosis. Understanding the nature of prognostic optimism among patients with cancer and caregivers may empower clinicians to guide realistic decision making while supporting hope.
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Affiliation(s)
- Deena R Levine
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Andrea Cuviello
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Catherine Nelson
- Department of Pediatrics, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Belinda N Mandrell
- Division of Nursing Research, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
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26
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Nayak B, Moon JY, Kim M, Fischhoff B, Haward MF. Optimism bias in understanding neonatal prognoses. J Perinatol 2021; 41:445-452. [PMID: 32778685 DOI: 10.1038/s41372-020-00773-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Discrepancies between physician and parent neonatal prognostic expectations are common. Optimism bias is a possible explanation. STUDY DESIGN Parents interpreted hypothetical neonatal prognoses in an online survey. RESULTS Good prognoses tended to be interpreted accurately, while poor prognoses were interpreted as less than the stated value. One-third of participants consistently overstated survival for the three lowest prognoses, compared to the sample as a whole. Three significant predictors of such optimistic interpretations were single-parent status (OR 0.39; 95% CI 0.2-0.75; p = 0.005), African-American descent (OR 3.78; 95% CI 1.63-8.98; p = 0.002) and the belief that physicians misrepresented prognoses (OR 3.11; 95% CI 1.47-6.65; p = 0.003). Participants' explanations echoed research on optimism bias in clinical and decision science studies. CONCLUSION Participants accepted positive prognoses for critically ill neonates, but reinterpreted negative ones as being unduly pessimistic demonstrating optimism bias.
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Affiliation(s)
- Babina Nayak
- Harlem Hospital Medical Center, Columbia University, New York, NY, USA.,Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jee-Young Moon
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy and Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.
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27
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Emerson ND, Bursch B. Ethical Issues in Providing End-of-Life Cancer Care for Transitional-Aged Youth. J Clin Psychol Med Settings 2021; 28:781-788. [PMID: 33598787 DOI: 10.1007/s10880-021-09764-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
The aim of the study is to examine the salient ethical factors that arise in caring for transitional-aged cancer patients at the end of life (EOL). This article reviews significant clinical, ethical, and legal considerations relevant to psychologists working in oncology. Transitional-aged youth (TAY, ages 16-24) with cancer face a number of challenges when navigating treatment options at the EOL. Changes in treatment roadmaps, lapses in effective provider-patient communication, disagreements with parents, and developmental and disease-based changes in capacity all become salient in palliative care. Psychologists should be aware that both physician and patient factors influence the types of treatments proposed as well as the extent of EOL discussions. Psychologists are urged to bear in mind the ethical principles of respect for people's rights and dignity and nonmaleficence to best aid families and multidisciplinary teams navigate this difficult time and promote quality of life and the patient's wishes.
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Affiliation(s)
- Natacha D Emerson
- UCLA Department of Psychiatry, David Geffen School of Medicine, 760 Westwood Plaza, UCLA Semel 48-241, Los Angeles, CA, 90024-1759, USA.
| | - Brenda Bursch
- UCLA Department of Psychiatry, David Geffen School of Medicine, 760 Westwood Plaza, UCLA Semel 48-241, Los Angeles, CA, 90024-1759, USA.,UCLA Department of Pediatrics, David Geffen School of Medicine, 760 Westwood Plaza, UCLA Semel 48-241, Los Angeles, CA, 90024-1759, USA
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28
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Morell E, Miller MK, Lu M, Friedman KG, Breitbart RE, Reichman JR, McDermott J, Sleeper LA, Blume ED. Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease. J Am Heart Assoc 2021; 10:e018488. [PMID: 33442989 PMCID: PMC7955315 DOI: 10.1161/jaha.120.018488] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision‐making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease. Methods and Results A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1‐year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1–5), 39% had single‐ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis “extremely well” or “well,” 28% of physicians thought parents understood the prognosis only “a little,” “somewhat,” or “not at all.” Better parent‐reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4–21.7, P=0.02). There was poor parent–physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy. Conclusions Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent‐reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient‐reported outcomes, parent education, and physician communication tools may be beneficial.
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Affiliation(s)
- Emily Morell
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles Los Angeles CA
| | | | - Minmin Lu
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | | | | | - Julie McDermott
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Lynn A Sleeper
- Department of Cardiology Boston Children's Hospital Boston MA
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29
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Hui D, Mo L, Paiva CE. The Importance of Prognostication: Impact of Prognostic Predictions, Disclosures, Awareness, and Acceptance on Patient Outcomes. Curr Treat Options Oncol 2021; 22:12. [PMID: 33432524 DOI: 10.1007/s11864-020-00810-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 02/05/2023]
Abstract
OPINION STATEMENT In the advanced cancer setting, patients, families, and clinicians are often confronted with an uncertain future regarding treatment outcomes and survival. Greater certainty on what to expect can enhance decision-making for many personal and healthcare issues. Although 70-90% of patients with advanced cancer desire open and honest prognostic disclosure, a small proportion do not want to know. Approximately half of patients with advanced cancer have an inaccurate understanding of their illness, which could negatively impact their decision-making. In this review, we use a conceptual framework to highlight 5 key steps along the prognostic continuum, including (1) prognostic formulation, (2) prognostic disclosure, (3) prognostic awareness, (4) prognostic acceptance, and (5) prognosis-based decision-making. We shall summarize the impact of prognostic predictions, disclosure, awareness, and acceptance on various patient and caregiver outcomes, such as hope, trust, anxiety, depression, chemotherapy use, and care planning. Based on where the patient is at along the prognostic continuum, we propose 5 different subgroups (avoidance: "I don't want to know"; discordant, "I never wanted to know"; anxious, "I don't know what's happening"; concerned, "I don't like this"; acceptance, "I know how to plan ahead"). Although prognostication is not necessarily a linear process, recognizing where the patient is at cognitively and emotionally along the prognostic continuum may allow clinicians to provide personalized interventions, such as specialist palliative care and psychology referral, towards personalizing prognostic disclosure, enhancing prognostic awareness, increasing prognostic acceptance, and supporting decision-making and, ultimately, improving patient outcomes.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414 - 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Li Mo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414 - 1515 Holcombe Blvd, Houston, TX, 77030, USA.,The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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30
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Feraco AM, McCarthy SR, Revette AC, Stevens SE, Das PJ, Al-Sayegh H, Ma C, Tulsky JA, Wolfe J. Feasibility and acceptability of the "Day 100 Talk": An interdisciplinary communication intervention during the first six months of childhood cancer treatment. Cancer 2020; 127:1134-1145. [PMID: 33320337 DOI: 10.1002/cncr.33362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Communication gaps arise early in the childhood cancer trajectory and may persist. The authors conducted a pilot study of the feasibility and acceptability of a communication intervention, the Day 100 Talk (D100). D100 involves an interprofessional family conference during initial months of treatment between oncologists, psychosocial clinicians, and parents, facilitated by a 3-part conversation tool. METHODS The authors enrolled English-speaking parents of children with nonrelapsed, nonprogressive cancer who were receiving continuity care from enrolled pediatric oncologists and psychosocial clinicians at a single site. The a priori feasibility threshold was 60% parent completion of the D100 intervention. Surveys from parents and professionals and debrief interviews with professionals assessed D100 acceptability. RESULTS Thirty-seven parents (77%) and 38 oncology professionals (67%) enrolled. Twenty of 33 evaluable parents (61%) participated in a D100 family conference. Most commonly, parents did not complete the D100 intervention because of scheduling difficulties related to clinical team constraints. All 17 parents who completed a post-D100 survey agreed or strongly agreed that D100 participation was helpful. In debrief interviews, professionals identified D100 benefits, namely, stepping back to the big picture and getting on the same page, and barriers related to logistical challenges and professionals' anticipatory dread. CONCLUSIONS The D100 intervention pilot demonstrates high acceptability among parents of children with cancer. Despite meeting the prespecified feasibility threshold, findings highlight important barriers to D100 dissemination, namely, perceived burdens on professionals. Potential strategies to reduce burden may include using virtual visit platforms, incorporating D100 elements across multiple visits, or prioritizing intervention delivery to parents with the greatest need for enhanced communication.
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Affiliation(s)
- Angela M Feraco
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah R McCarthy
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah E Stevens
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - P Jeet Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Biostatistics Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Clement Ma
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Biostatistics Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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31
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Porter KA, O'Neill C, Drake E, Parker S, Escolar ML, Montgomery S, Moon W, Worrall C, Peay HL. Parent Experiences of Sanfilippo Syndrome Impact and Unmet Treatment Needs: A Qualitative Assessment. Neurol Ther 2020; 10:197-212. [PMID: 33263924 PMCID: PMC8139994 DOI: 10.1007/s40120-020-00226-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/19/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Sanfilippo syndrome (MPS III) is a rare, degenerative condition characterized by symptoms impacting cognitive ability, mobility, behavior, and quality of life. Currently there are no approved therapies for this severe life-limiting disease. Integrating patient and caregiver experience data into drug development and regulatory decision-making has become a priority of the Food and Drug Administration and rare disease patient communities. Methods This study assesses parents’ perceptions of their child’s Sanfilippo syndrome disease-related symptoms using a research approach that is consistent with the Center for Drug Evaluation and Research (CDER) guidance. This study was initiated by the Cure Sanfilippo Foundation, and all steps in the research process were informed by a multidisciplinary advisory committee, with an objective of informing biopharmaceutical companies and regulatory agencies. We explored caregiver burden, symptoms with greatest impact, and meaningful but unmet treatment needs. Data were collected from 25 parents through three focus groups and a questionnaire. Transcripts were coded and analyzed using inductive thematic analysis, and descriptive analysis of quantitative data was conducted. Results Participating parents’ children ranged in age from 4 to 36 years. Participants endorsed high caregiving burden across all stages of the disease. Analysis revealed multiple domains of unmet need that impact child and family quality of life, including cognitive-behavioral challenges in communication, relationships, behavior, anxiety, and child safety; and physical health symptoms including sleep, pain, and mobility. Participants reported placing high value on incremental benefits targeting those symptoms, and on a treatment that would slow or stop symptom progression. Conclusion Even modest treatment benefits for Sanfilippo syndrome were shown to be highly valued. Despite high caregiver burden, most parents expressed a willingness to “try anything,” including treatments with potentially high risk profiles, to maintain their child’s current state. Electronic supplementary material The online version of this article (10.1007/s40120-020-00226-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katherine Ackerman Porter
- Center for Genomics, Bioinformatics, and Translational Research, RTI International, Research Triangle Park, NC, USA.
| | | | - Elise Drake
- Cure Sanfilippo Foundation, Columbia, SC, USA
| | - Samantha Parker
- Patient and Policy Affairs, Lysogene, Neuilly sur Seine, France
| | - Maria L Escolar
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | | | - William Moon
- Cure Sanfilippo Foundation Parent Advocates, Columbia, SC, USA
| | - Carolyn Worrall
- Cure Sanfilippo Foundation Parent Advocates, Columbia, SC, USA
| | - Holly L Peay
- Center for Genomics, Bioinformatics, and Translational Research, RTI International, Research Triangle Park, NC, USA
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32
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Expectations and perception of cancer treatment goals in previously untreated patients. The EXPECT trial. Support Care Cancer 2020; 29:3585-3592. [PMID: 33159221 PMCID: PMC8163685 DOI: 10.1007/s00520-020-05826-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022]
Abstract
Purpose Misconceptions regarding activity and toxicity of therapeutic interventions are common among cancer patients. There is little knowledge about the factors that contribute to a more realistic perception by patients. Methods This pilot study was designed as a prospective questionnaire survey and included 101 therapy-naïve patients treated at the Division of Oncology, Medical University of Vienna. After obtaining written informed consent, patients’ expectations about treatment aims, side effects and the satisfaction with their oncologic consultation were interrogated before the first treatment cycle by questionnaires. Results Of 101 patients, 53 (53%) were female and 67/101 (66%) were treated with curative attempt in an adjuvant or neo-adjuvant setting. The most common diagnoses were lung cancer (31%) and breast cancer (30%). Although 92% of patients were satisfied with the information given by their oncologist, palliative patients were more likely to declare that not everything was explained in an intelligible manner (p = 0.01). Patients with a first language other than German stated more often that their physician did not listen carefully enough (p = 0.02). Of 30 patients, 26 (87%) receiving chemotherapy with palliative intent believed that their disease was curable. Concerning adverse events, female patients anticipated more frequently hair loss (p = 0.003) and changes in taste (p = 0.001) compared to men. Patients under curative treatment were more likely to expect weight loss (p = 0.02) and lack of appetite (p = 0.01) compared to patients with palliative treatment intent. Conclusion In conclusion, cancer patients were satisfied with the patient-doctor communication. This prospective study aggregated patients’ concerns on side effects and the perception of therapeutic goals in therapy-naïve patients. Of note, the majority of patients treated in the palliative setting expected their treatment to cure the disease. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-020-05826-x.
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Mack JW, Kang TI. Care experiences that foster trust between parents and physicians of children with cancer. Pediatr Blood Cancer 2020; 67:e28399. [PMID: 32827346 DOI: 10.1002/pbc.28399] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/09/2020] [Accepted: 04/23/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Trust is a core aspect of the patient-physician relationship, especially in cancer care. We sought to examine parents' experiences with trust over the first year after a child's cancer diagnosis. PROCEDURE We conducted a prospective, questionnaire-based longitudinal cohort study of parents and physicians of children with cancer at two academic pediatric hospitals. We evaluated trust among 166 parents of children with cancer over the first year after diagnosis. Surveys were administered after diagnosis, at 4 months, and at 12 months after diagnosis. RESULTS Seventy-one percent of parents trusted the child's oncologist "completely" at baseline, as did 79% at 4 months and 77% at 12 months. At baseline, high-quality physician communication (OR 4.11 [1.78-9.51], P = .001) and information (OR 2.82 [1.29-6.16], P = .01) were associated with trust, after adjustment for parent gender, race/ethnicity, and education. Parents were less likely to trust the physician completely at 12 months if the child had experienced cancer relapse or progression (OR 0.28 [0.10-0.81], P = .02). In a mixed linear model adjusted for parent gender, race/ethnicity, education, and clustering by physician, trust was associated with high-quality communication (OR 3.40 [1.61-7.20], P = .001) and receipt of high-quality information (OR 2.48 [1.18-5.21], P = .02), and inversely associated with relapse or progression (OR 0.39 [0.17-0.92], P = 0.03); trust increased over time (P < .0001). CONCLUSIONS Most parents form trusting relationships with their children's oncologists. Physicians can foster trust through patient-centered communication and provision of high-quality information about a child's cancer. Poor outcomes such as relapse are a threat to trust.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Tammy I Kang
- Section of Pediatric Palliative Care, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Mack JW, Uno H, Twist CJ, Bagatell R, Rosenberg AR, Marachelian A, Granger MM, Glade Bender J, Baker JN, Park JR, Cohn SL, Fernandez JH, Diller LR, Shusterman S. Racial and Ethnic Differences in Communication and Care for Children With Advanced Cancer. J Pain Symptom Manage 2020; 60:782-789. [PMID: 32360991 PMCID: PMC7523916 DOI: 10.1016/j.jpainsymman.2020.04.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Racial and ethnic disparities in end-of-life care are well documented among adults with advanced cancer. OBJECTIVES To examine the extent to which communication and care differ by race and ethnicity among children with advanced cancer. METHODS We conducted a prospective cohort study at nine pediatric cancer centers enrolling 95 parents (42% racial/ethnic minorities) of children with poor prognosis cancer (relapsed/refractory high-risk neuroblastoma). Parents were surveyed about whether prognosis was discussed; likelihood of cure; intent of current treatment; and primary goal of care. Medical records were used to identify high-intensity medical care since the most recent recurrence. Logistic regression evaluated differences between white non-Hispanic and minority (black, Hispanic, and Asian/other race) parents. RESULTS About 26% of parents recognized the child's low likelihood of cure. Minority parents were less likely to recognize the poor prognosis (odds ratio [OR] = 0.19; 95% CI = 0.06-0.63; P = 0.006) and the fact that current treatment was unlikely to offer cure (OR = 0.07; 95% CI = 0.02-0.27; P < 0.0001). Children of minority parents were more likely to experience high-intensity medical care (OR = 3.01; 95% CI = 1.29-7.02; P = 0.01). After adjustment for understanding of prognosis, race/ethnicity was no longer associated with high-intensity medical care (adjusted odds ratio = 2.14; 95% CI = 0.84-5.46; P = 0.11), although power to detect an association was limited. CONCLUSION Parental understanding of prognosis is limited across racial and ethnic groups; racial and ethnic minorities are disproportionately affected. Perhaps as a result, minority children experience higher rates of high-intensity medical care. Work to improve prognostic understanding should include focused work to meet needs of minority populations.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Clare J Twist
- Roswell Park Cancer Institute Buffalo, New York, New York, USA
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abby R Rosenberg
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Pediatric Bioethics/Palliative Care, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Araz Marachelian
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - M Meaghan Granger
- Hematology and Oncology Center, Cook Children's Hospital, Fort Worth, Texas, USA
| | - Julia Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Julie R Park
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Susan L Cohn
- Department of Pediatrics, Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA
| | - Jorge H Fernandez
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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Sisk BA, Fasciano K, Block SD, Mack JW. Impact of cancer on school, work, and financial independence among adolescents and young adults. Cancer 2020; 126:4400-4406. [PMID: 32658324 DOI: 10.1002/cncr.33081] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND For adolescents and young adults (AYAs), the diagnosis of cancer can impede social development, especially with respect to education, employment, and financial independence. However, there are limited quantitative data on the extent and trajectory of life disruptions during cancer treatment for AYA patients. METHODS This was a longitudinal, prospective, questionnaire-based cohort study of 145 AYA patients with cancer aged 15 to 29 years who were treated at a large academic cancer center. Questionnaires were administered shortly after diagnosis and 4 and 12 months after diagnosis. RESULTS Although half of the participants lived with their parents 6 months before diagnosis, 61% lived with their parents after diagnosis (P = .0002 vs 6 months before diagnosis), with a similar proportion reported to be living with their parents 4 months after diagnosis (61%; P = .001) and 55% doing so 12 months after diagnosis (P = .07). Before diagnosis, 38% of the patients were not attending school. After diagnosis, that proportion rose to 61% (P < .0001), with a similar proportion 4 months after diagnosis (61%; P < .0001); 54% were not in school at 12 months (P = .001). Patients experienced similar decrements in employment (30% not working before diagnosis vs 49% not working after diagnosis; P < .0001) and financial independence (37% with complete financial independence before diagnosis vs 31% after diagnosis; P = .02). Overall, 65% of the patients (94 of 145) had not returned to their precancer baseline in at least 1 of these 4 social domains by 12 months after diagnosis. CONCLUSIONS For many AYA patients, cancer leads to less engagement with school and work activities and decreased financial independence from parents. Clinicians should engage in early and ongoing discussions with patients about the potential impact of cancer on their lives.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Karen Fasciano
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susan D Block
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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Sisk BA, Friedrich A, Blazin LJ, Baker JN, Mack JW, DuBois J. Communication in Pediatric Oncology: A Qualitative Study. Pediatrics 2020; 146:peds.2020-1193. [PMID: 32820068 PMCID: PMC7461134 DOI: 10.1542/peds.2020-1193] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND When children are seriously ill, parents rely on communication with their clinicians. However, in previous research, researchers have not defined how this communication should function in pediatric oncology. We aimed to identify these communication functions from parental perspectives. METHODS Semistructured interviews with 78 parents of children with cancer from 3 academic medical centers at 1 of 3 time points: treatment, survivorship, or bereavement. We analyzed interview transcripts using inductive and deductive coding. RESULTS We identified 8 distinct functions of communication in pediatric oncology. Six of these functions are similar to previous findings from adult oncology: (1) building relationships, (2) exchanging information, (3) enabling family self-management, (4) making decisions, (5) managing uncertainty, and (6) responding to emotions. We also identified 2 functions not previously described in the adult literature: (7) providing validation and (8) supporting hope. Supporting hope manifested as emphasizing the positives, avoiding false hopes, demonstrating the intent to cure, and redirecting toward hope beyond survival. Validation manifested as reinforcing "good parenting" beliefs, empowering parents as partners and advocates, and validating concerns. Although all functions seemed to interact, building relationships appeared to provide a relational context in which all other interpersonal communication occurred. CONCLUSIONS Parent interviews provided evidence for 8 distinct communication functions in pediatric oncology. Clinicians can use this framework to better understand and fulfill the communication needs of parents whose children have serious illness. Future work should be focused on measuring whether clinical teams are fulfilling these functions in various settings and developing interventions targeting these functions.
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Affiliation(s)
- Bryan A. Sisk
- Division of Hematology and Oncology, Department of
Pediatrics and
| | - Annie Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint
Louis University, St Louis, Missouri
| | - Lindsay J. Blazin
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, Tennessee
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care
and,Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, Tennessee
| | - Jennifer W. Mack
- Division of Population Sciences, McGraw Patterson
Center for Population Sciences and Department of Pediatric Oncology, Dana-Farber
Cancer Institute, Boston, Massachusetts; and,Division of Hematology/Oncology, Boston
Children’s Hospital, Boston, Massachusetts
| | - James DuBois
- Division of General Medical Sciences, Department of
Medicine, School of Medicine, Washington University in St Louis, St Louis,
Missouri
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Breaking Serious News. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Greenzang KA, Fasciano KM, Block SD, Mack JW. Early information needs of adolescents and young adults about late effects of cancer treatment. Cancer 2020; 126:3281-3288. [PMID: 32365227 DOI: 10.1002/cncr.32932] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adolescent and young adult (AYA) cancer survivors have high risks of late effects. Little is known about the late-effect information needs of AYAs early in treatment or their role in treatment decision making. This study evaluated the importance, quality, and implications of information about late effects in AYAs recently diagnosed with cancer. METHODS This study surveyed 201 AYAs with cancer who were 15 to 29 years old and were treated at the Dana-Farber Cancer Institute (Boston, Massachusetts). Patients were approached within 6 weeks of their diagnosis and were asked about their late-effect and infertility information needs, treatment decision making, and communication outcomes. RESULTS Forty-five percent of the participants were female; 88% were white. Most AYAs (87% [173 of 200]) considered information about the risks of late effects to be extremely or very important; 80% (159 of 200) valued information about infertility. Many were distressed by information about late effects (53% [105 of 200]) and infertility (45% [89 of 200]); those who considered late-effect information distressing were more likely to value this information (P < .0001). Consideration of late effects (41% [82 of 201]) and infertility (36% [72 of 201]) greatly influenced many patients' treatment decision making. Although 92% of the patients (184 of 199) reported receiving high-quality information about the diagnosis, 57% (113 of 199; P < .0001) and 65% (130 of 199; P < .0001) felt that they had received high-quality information about late effects and infertility, respectively. CONCLUSIONS Most AYAs with cancer value early information about the risks of late effects and infertility, yet many patients felt that they had not received high-quality information about these topics. The development of age-appropriate late-effect communication strategies that recognize high AYA distress may help to address the gap between desired information and perceived information quality.
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Affiliation(s)
- Katie A Greenzang
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Karen M Fasciano
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan D Block
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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Greenzang KA, Al-Sayegh H, Ma C, Najafzadeh M, Wittenberg E, Mack JW. Parental Considerations Regarding Cure and Late Effects for Children With Cancer. Pediatrics 2020; 145:peds.2019-3552. [PMID: 32284427 PMCID: PMC7193979 DOI: 10.1542/peds.2019-3552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND More than 80% of children with cancer become long-term survivors, yet most survivors experience late effects of treatment. Little is known about how parents and physicians consider late-effects risks against a potential survival benefit when making treatment decisions. METHODS We used a discrete choice experiment to assess the importance of late effects on treatment decision-making and acceptable trade-offs between late-effects risks and survival benefit. We surveyed 95 parents of children with cancer and 41 physicians at Dana-Farber/Boston Children's Cancer and Blood Disorders Center to assess preferences for 5 late effects of treatment: neurocognitive impairment, infertility, cardiac toxicity, second malignancies, and impaired growth and development. RESULTS Each late effect had a statistically significant association with treatment choice, as did survival benefit (P < .001). Avoidance of severe cognitive impairment was the most important treatment consideration to parents and physicians. Parents also valued cure and decreased risk of second malignancies; physician decision-making was driven by avoidance of second malignancies and infertility. Both parents and physicians accepted a high risk of infertility (parents, a 137% increased risk; physicians, an 80% increased risk) in exchange for a 10% greater chance of cure. CONCLUSIONS Avoidance of severe neurocognitive impairment was the predominant driver of parent and physician treatment preferences, even over an increased chance of cure. This highlights the importance of exploring parental late-effects priorities when discussing treatment options.
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Affiliation(s)
- Katie A. Greenzang
- Division of Population Sciences and,Department of Pediatric Oncology, Dana-Farber Cancer
Institute, Boston, Massachusetts;,Division of Pediatric Hematology/Oncology, Boston
Children’s Hospital, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Department of Pediatric Oncology, Dana-Farber Cancer
Institute, Boston, Massachusetts;,Division of Pediatric Hematology/Oncology, Boston
Children’s Hospital, Boston, Massachusetts
| | | | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and
Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts;
and
| | - Eve Wittenberg
- Center for Health Decision Science, Harvard T.H. Chan
School of Public Health, Harvard University, Boston, Massachusetts
| | - Jennifer W. Mack
- Division of Population Sciences and,Department of Pediatric Oncology, Dana-Farber Cancer
Institute, Boston, Massachusetts;,Division of Pediatric Hematology/Oncology, Boston
Children’s Hospital, Boston, Massachusetts
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Parent Perspectives of Receiving Early Information About Palliative and End-of-Life Care Options From Their Child's Pediatric Providers. Cancer Nurs 2020; 42:E22-E30. [PMID: 29620556 DOI: 10.1097/ncc.0000000000000589] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Parents of children diagnosed with cancer may experience decision regret about cancer treatment decisions and dissatisfaction with the perceived clarity in information received from their child's providers. OBJECTIVE The aim of this study was to describe parental perspectives about receiving an early palliative care and end-of-life (PC/EOL) communication intervention titled "Communication Plan: Early through End of Life Intervention" (COMPLETE) from an interprofessional team of physician and registered nurse providers. METHODS Ten parents participated in semistructured interviews after receiving the COMPLETE intervention. The COMPLETE intervention included 3 sessions delivered shortly after diagnosis and at the next 2 cancer treatment evaluations. Sessions of COMPLETE focused on early PC/EOL care discussions at diagnosis and after tumor response evaluations with their child's providers. RESULTS Results included 2 theme categories: (1) COMPLETE nurtures realistic hope and meaningful dialogue by parents connecting with healthcare providers as a dyad, and (2) benefits of COMPLETE helped parents to make informed decisions. In addition, there were offered suggestions to improve COMPLETE. CONCLUSION The COMPLETE intervention provided a unique mechanism to foster early discussions about PC/EOL options between parents and an interprofessional team during the first 6 months of the child's cancer treatment. Future study is needed using a randomized clinical control-group design to evaluate COMPLETE with a large sample of parents. IMPLICATIONS FOR PRACTICE Findings provide promising evidence of parents' preference and receptivity to receive early information about PC/EOL care options for a child with a brain tumor with a poor prognosis. The COMPLETE intervention provided a mechanism to help encourage parental consideration of realistic hoped-for goals for their child's condition and care.
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Pinquart M. Featured Article: Depressive Symptoms in Parents of Children With Chronic Health Conditions: A Meta-Analysis. J Pediatr Psychol 2020; 44:139-149. [PMID: 30346613 DOI: 10.1093/jpepsy/jsy075] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/25/2018] [Indexed: 11/12/2022] Open
Abstract
Objective Caring for children with chronic health conditions is associated with stressors that may impair mental health. The goal of our meta-analysis was to analyze depressive symptoms among parents who care for a child or adolescent with chronic physical disease and/or sensory disability and/or physical disability compared with parents of healthy children or test norms. Methods A systematic search through electronic databases identified 460 relevant studies that were included in a random-effects meta-analysis. Results Parents of children with chronic conditions showed small to moderate elevations of depressive symptoms compared with parents of healthy/nondisabled children and test norms (g = .46 SD units). Twelve studies using structured clinical interviews provided a weighted mean depression rate of 20.9%. The highest elevations were found among parents of young people with neuromuscular disorders, cancer, and cerebral palsy. Elevations of depressive symptoms were greater in cases with shorter durations of the chronic condition, in mothers compared with fathers, and in parents from economically less developed countries rather than developed countries. Conclusions Parents of children with chronic conditions, particularly parents of children with neuromuscular disorders, cancer, and cerebral palsy, should be screened for depression and receive psychosocial services aimed at reducing these symptoms, if needed.
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Perez GK, Salsman JM, Fladeboe K, Kirchhoff AC, Park ER, Rosenberg AR. Taboo Topics in Adolescent and Young Adult Oncology: Strategies for Managing Challenging but Important Conversations Central to Adolescent and Young Adult Cancer Survivorship. Am Soc Clin Oncol Educ Book 2020; 40:1-15. [PMID: 32324424 PMCID: PMC7328818 DOI: 10.1200/edbk_279787] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Research on adolescents and young adults (AYAs) with cancer has flourished over the past decade, underscoring the unique medical and psychosocial needs of this vulnerable group. A cancer diagnosis during adolescence and young adulthood intersects with the developmental trajectory of AYAs, derailing critical physical, social, and emotional development. AYAs face these abrupt life changes needing age-appropriate information and resources to offset these challenges. Greater attention is needed to address AYA-specific concerns on reproductive and sexual health, financial security and independence, emotional well-being, social support, and end-of-life care. If these unique needs are unaddressed, this can adversely affect AYAs' health care engagement and overall quality of life, increasing their risk for cancer-related morbidity and early mortality. In particular, health care decisions made during treatment have important implications for AYA patients' future health. Oncology clinicians are well positioned to address AYA patients' concerns by anticipating and addressing the challenges this age group is likely to face. In this paper, we explore several core topics that affect AYAs' quality of life and that can be challenging to address. Starting from the moment of diagnosis, through cancer treatment and post-treatment survivorship, and into end of life, each section highlights critical developmental-centric life domains that are affected by the cancer experience. Specifically, we discuss resources, tools, and strategies to navigate these challenging conversations. Taking a risk-reduction approach that invites two-way communication and facilitates referral to age-appropriate resources would help destigmatize these experiences and, in turn, would support the provision of compassionate and effective age-concordant care to this vulnerable group.
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Affiliation(s)
- Giselle K. Perez
- Harvard Medical School/Massachusetts General Hospital, Boston, MA
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA
| | - John M. Salsman
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kaitlyn Fladeboe
- Seattle Children’s Research Institute, University of Washington, Seattle, WA
| | - Anne C. Kirchhoff
- Huntsman Cancer Institute and Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Elyse R. Park
- Harvard Medical School/Massachusetts General Hospital, Boston, MA
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA
| | - Abby R. Rosenberg
- Seattle Children’s Research Institute, University of Washington, Seattle, WA
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Isack A, Santana VM, Russo C, Klosky JL, Fasciano K, Block SD, Mack JW. Communication Regarding Therapeutic Clinical Trial Enrollment Between Oncologists and Adolescents and Young Adults with Cancer. J Adolesc Young Adult Oncol 2020; 9:608-612. [PMID: 32101064 DOI: 10.1089/jayao.2019.0107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Adolescent and young adult (AYA) cancer patients enroll in therapeutic clinical trials at low rates. Prior study has focused on trial availability; this research attempts to elucidate the role of communication in individual decision-making. We surveyed 193 AYA patients and reviewed medical records of informed consent discussions. Twenty percent (38/193) of patients were offered trials, 58% (22/38) enrolled. Many were unable to correctly identify whether they were offered trials or enrolled, including 27% (6/22) of patients on clinical trials who believed that they were not. Efforts to improve communication have potential to enhance informed decision-making in this vulnerable population.
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Affiliation(s)
- Asisa Isack
- The Division of Population Sciences' Center for Outcomes and Policy Research, Boston, Massachusetts, USA
| | - Victor M Santana
- Departments of Oncology and Clinical Trials Administration, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Carolyn Russo
- Departments of Oncology and Clinical Trials Administration, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - James L Klosky
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Karen Fasciano
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan D Block
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jennifer W Mack
- The Division of Population Sciences' Center for Outcomes and Policy Research, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Children's Hospital Boston, Massachusetts, USA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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McCarthy MC, De Abreu Lourenco R, McMillan LJ, Meshcheriakova E, Cao A, Gillam L. Finding Out What Matters in Decision-Making Related to Genomics and Personalized Medicine in Pediatric Oncology: Developing Attributes to Include in a Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:347-361. [DOI: 10.1007/s40271-020-00411-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Wiener L, Tager J, Mack J, Battles H, Bedoya SZ, Gerhardt CA. Helping parents prepare for their child's end of life: A retrospective survey of cancer-bereaved parents. Pediatr Blood Cancer 2020; 67:e27993. [PMID: 31595653 PMCID: PMC8330433 DOI: 10.1002/pbc.27993] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Most parents vividly recall the weeks, days, and moments preceding their child's death for years to come. Dissatisfaction with communication about their child's condition and lack of guidance can contribute to stress prior to a child's death. Based on findings from a study assessing the degree of preparation bereaved parents received and our collective clinical experience, the authors provide suggestions on end-of-life communication and guidance for parents. METHODS Caregivers of a child who died from cancer were invited to complete a 46-item survey through a closed social media (Facebook) group ("Parents who lost children to cancer"). In four months' time, 131 bereaved caregivers completed the survey. Results were analyzed using descriptive statistics, chi-square analyses, and a thematic content analysis framework. The mean age of the child at the time of death was 12. RESULTS Approximately 40% of the parents in this study felt unprepared for both the medical problems their child faced and how to respond to their child's emotional needs; fewer than 10% felt very prepared for either. Parents were more likely to feel unprepared when perceived suffering was high, highlighting the critical importance of communication and support from the healthcare team as an adjunct to optimal symptom control. CONCLUSIONS Through quantitative and open-ended responses, this study identified specific medical and emotional issues about which parents wanted greater preparation. Future research to evaluate guidance strategies to reduce parental suffering prior to the child's death is needed.
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Affiliation(s)
- Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Julia Tager
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
- University of Massachusetts Amherst, Amherst, Massachusetts
| | | | - Haven Battles
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Sima Zadeh Bedoya
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Cynthia A. Gerhardt
- Center for Biobehavioral Health, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
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Walter JK, Hill DL, DiDomenico C, Parikh S, Feudtner C. A conceptual model of barriers and facilitators to primary clinical teams requesting pediatric palliative care consultation based upon a narrative review. BMC Palliat Care 2019; 18:116. [PMID: 31864331 PMCID: PMC6925857 DOI: 10.1186/s12904-019-0504-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/09/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite evidence that referral to pediatric palliative care reduces suffering and improves quality of life for patients and families, many clinicians delay referral until the end of life. The purpose of this article is to provide a conceptual model for why clinical teams delay discussing palliative care with parents. DISCUSSION Building on a prior model of parent regoaling and relevant research literature, we argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to a plan that includes palliative aspects, resulting in a subspecialty palliative care referral. Like patients and families, clinicians and clinical teams may recognize that a seriously ill patient would benefit from palliative care and shift from a restorative mindset to a palliative approach. We call this transition "clinician regoaling". Clinicians may experience inhibitors and facilitators to this transition at both the individual and team level which influence the clinicians' willingness to consult subspecialty palliative care. The 8 inhibitors to team level regoaling include: 1) team challenges due to hierarchy, 2) avoidance of criticizing colleagues, 3) structural communication challenges, 4) group norms in favor of restorative goals, 5) diffusion of responsibility, 6) inhibited expression of sorrow, 7) lack of social support, 8) reinforcement of labeling and conflict. The 6 facilitators of team regoaling include: 1) processes to build a shared mental model, 2) mutual trust to encourage dissent, 3) anticipating conflict and team problem solving, 4) processes for reevaluation of goals, 5) sharing serious news as a team, 6) team flexibility. CONCLUSIONS Recognizing potential team level inhibitors to transitioning to palliative care can help clinicians develop strategies for making the transition more effectively when appropriate.
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Affiliation(s)
- Jennifer K. Walter
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Douglas L. Hill
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Concetta DiDomenico
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Shefali Parikh
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Chris Feudtner
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
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Gittzus JA, Fasciano KM, Block SD, Mack JW. Peace of mind among adolescents and young adults with cancer. Psychooncology 2019; 29:572-578. [PMID: 31825157 DOI: 10.1002/pon.5309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/18/2019] [Accepted: 11/28/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Adolescents and young adults (AYAs) with cancer have high rates of psychological distress and unmet support needs. Peace of mind is an important construct among older cancer patients and parents of children with cancer but has not been explored in AYAs. We sought to evaluate the extent to which AYAs with cancer experience peace of mind and to identify factors associated with greater peace of mind. METHODS We surveyed 193 AYAs with cancer aged 15 to 29 years within 12 weeks of diagnosis; 137 patients completed the same measures again 4 and 12 months after diagnosis. Patients were asked to report peace of mind, measured using items from the Functional Assessment of Chronic Illness, Spiritual Well-being scale (FACIT-Sp); anxiety and depression, using the Hospital Anxiety and Depression Scale (HADS); and experiences surrounding medical communication and decision making. RESULTS Mean scores for peace of mind were 3.59 at diagnosis (range 1-5, standard deviation 0.84), with similar scores at 4 (3.53, P = .34) and 12 (3.59, P = .94) months. In a multivariable model adjusted for age and gender, patients who reported receiving high-quality information about their cancer had greater peace of mind at diagnosis (β = .25, P = .03), whereas those who reported holding a passive role in treatment decision making (β = -.47, P < .0001) or who had anxiety (β = -.64, P = .0003) or depression (β = -.51, P = .04) had lower peace of mind. CONCLUSION Peace of mind did not improve significantly over time for AYAs with cancer. While high-quality communication may be associated with heightened peace of mind, further study is needed to clarify relationships between peace of mind and other psychological variables.
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Affiliation(s)
- Jordan A Gittzus
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Karen M Fasciano
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan D Block
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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Mack JW, Cronin AM, Uno H, Shusterman S, Twist CJ, Bagatell R, Rosenberg A, Marachelian A, Granger MM, Glade Bender J, Baker JN, Park J, Cohn SL, Levine A, Taddei S, Diller LR. Unrealistic parental expectations for cure in poor-prognosis childhood cancer. Cancer 2019; 126:416-424. [PMID: 31584705 DOI: 10.1002/cncr.32553] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/10/2019] [Accepted: 08/10/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Many parents of children with advanced cancer pursue curative goals when cure is no longer possible. To the authors' knowledge, no pediatric studies to date have prospectively evaluated prognosis communication or influences on decision making in poor-prognosis childhood cancer. METHODS The authors conducted a prospective cohort study at 9 pediatric cancer centers that enrolled 95 parents of children with recurrent or refractory, high-risk neuroblastoma (63% of those who were approached), a condition for which cure rarely is achieved. Parents were surveyed regarding the child's likelihood of cure; their primary goal of care; the child's symptoms, suffering, and quality of life; and regret concerning the last treatment decision. Medical records identified care and treatment decisions. RESULTS Only 26% of parents recognized that the chance of cure was <25%. When asked to choose a single most important goal of care, approximately 72% chose cure, 10% chose longer life, and 18% chose quality of life. Parents were more likely to prioritize quality of life when they recognized the child's poor prognosis (P = .002). Approximately 41% of parents expressed regret about the most recent treatment decision. Parents were more likely to experience regret if the child had received higher intensity medical care (odds ratio [OR], 3.14; 95% CI, 1.31-7.51), experienced suffering with limited benefit from the most recent treatment (OR, 4.78; 95% CI, 1.16-19.72), or experienced suffering from symptoms (OR, 2.91; 95% CI, 1.18-7.16). CONCLUSIONS Parents of children with poor-prognosis cancer frequently make decisions based on unrealistic expectations. New strategies for effective prognosis communication are needed.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Angel M Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Clare J Twist
- Pediatric Experimental Therapeutics, Department of Pediatric Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Rochelle Bagatell
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Abby Rosenberg
- Department of Pediatric Hematology/Oncology, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Araz Marachelian
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - M Meaghan Granger
- Hematology and Oncology Center, Cook Children's Medical Center, Fort Worth, Texas
| | - Julia Glade Bender
- Department of Pediatric Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Julie Park
- Department of Pediatric Hematology/Oncology, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Susan L Cohn
- Department of Pediatrics, Comer Children's Hospital, University of Chicago, Chicago, Illinois
| | - Alyssa Levine
- Emory University School of Medicine, Atlanta, Georgia
| | - Sarah Taddei
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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Sisk BA, Fasciano K, Block SD, Mack JW. Longitudinal prognostic communication needs of adolescents and young adults with cancer. Cancer 2019; 126:400-407. [PMID: 31568584 DOI: 10.1002/cncr.32533] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/09/2019] [Accepted: 08/26/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although the majority of adolescent and young adult (AYA) patients with cancer desire prognostic information, to the authors' knowledge little is known regarding how preferences for prognostic communication change over time. METHODS The current study was a longitudinal, prospective, questionnaire-based cohort study of 136 AYA patients with cancer who were aged 15 to 29 years and who were treated at a large academic cancer center. Previously published scales were administered at the time of diagnosis and at 4 months and 12 months after diagnosis. RESULTS The majority of patients reported that prognostic information was very/extremely important at the time of diagnosis (85%), at 4 months (96%; P = .002 compared with baseline), and at 12 months (81%; P = .02 compared with baseline). Few patients reported that prognostic knowledge was very/extremely upsetting at baseline (7%), at 4 months (9%; P = .44 compared with baseline), or at 12 months (11%; P = .27 compared with baseline). The majority of patients were satisfied with the amount of prognostic information received throughout the year after diagnosis (81%, 86%, and 81%, respectively, at the time of diagnosis, at 4 months, and at 12 months). This percentage did not change between the time of diagnosis and 4 months (P = .16) or between diagnosis and 12 months (P = 1.00). In multivariable analysis, satisfaction with prognostic information received was associated with patient report of high-quality communication (odds ratio, 2.67; 95% CI, 1.38-5.17) and having a >75% chance of cure (odds ratio, 2.39; 95% CI, 1.24-4.61) after adjustment for patient age category, race/ethnicity, and time point of administration. CONCLUSIONS The majority of AYA patients with cancer were satisfied with prognostic disclosure over time, but a sizeable minority wanted additional information. Desire for prognostic information increased over time. Clinicians should return to prognostic discussions over time to support AYA patients with cancer.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Karen Fasciano
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susan D Block
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer W Mack
- Department of Pediatric Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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Graetz D, Fasciano K, Rodriguez-Galindo C, Block SD, Mack JW. Things that matter: Adolescent and young adult patients' priorities during cancer care. Pediatr Blood Cancer 2019; 66:e27883. [PMID: 31207103 DOI: 10.1002/pbc.27883] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adolescents and young adults (AYAs) experience cancer while balancing emerging identity and life goals. We investigated AYAs' priorities during cancer, including psychosocial concerns, cure-directed therapy, and potential late effects. METHODS We surveyed 203 cancer patients aged 15-29 treated at Dana-Farber Cancer Institute, Boston, Massachusetts, and their oncologists. Patients were approached and rated the importance of aspects of treatment, outcomes, and life during therapy. Response options were "extremely," "very," "somewhat," "a little important," or "not at all important." Ratings of "extremely" or "very important" were used as indicators of strong priorities. RESULTS Patients' three most frequent priorities were cure (97%), being good to the people they care about (95%), and having supportive people around them (94%). Most prioritized being with family (90%), returning to school/work (89%), maintaining relationships with friends (88%), and feeling normal (85%). Fewer prioritized minimizing long-term (78%) and acute side effects (68%) and fertility (59%). Many participants (88%) said that cure influenced their decisions "a great deal," while fewer were influenced by side effects (32%), fertility (36%), or relationships (16%). Most patients (85%) thought their oncologist understood what was most important to them when treatment started. CONCLUSION Nearly all AYA cancer patients prioritize cure, while maintaining social relationships and a sense of normalcy. These priorities influence decisions they make about treatment to differing degrees, with cure influencing decision-making for most patients. Although the priority of cure is well established, recognizing other AYA priorities allows providers to optimally support these patients from the time of diagnosis.
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Affiliation(s)
- Dylan Graetz
- St. Jude Children's Research Hospital, Departments of Hematology and Oncology, Memphis, Tennessee
| | - Karen Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos Rodriguez-Galindo
- St. Jude Children's Research Hospital, Department of Oncology and Global Pediatric Medicine, Memphis, Tennessee
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Departments of Psychiatry and Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer W Mack
- Dana Farber Cancer Institute/Boston Children's Hospital, Department of Pediatric Oncology and Division of Population Sciences, Boston, Massachusetts
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