What makes decision-making difficult for oncologists faced with critical situations? The socio-affective side of the physician-patient relationship

The aim of this qualitative study based on a Social Representations approach was to explore experienced oncologists' representations of difficult decision-making situations. In total, 22 semi-structured interviews with oncologists were conducted and analysed by performing a thematic content analysis. The thematic content analysis brought to light the main medical problem involved such as uncertainty, the lethal nature of cancer and physicians' specialties, as well as the psychosocial ones, such as patients' non-medical characteristics and the patient-physician relationships. This analysis also showed the painful tensions experienced by specialists in the context of decision-making situations when the medical arguments conflict with the psychosocial ones. These findings suggest that in order to understand more clearly the complex processes involved in difficult medical decision-making situations, studies on physicians' expertise should include the socio-affective climate involved in each patient-physician relationship.

"How do you live without a stomach?": a multiple case study examination of total gastrectomy for palliation or prophylaxis

OBJECTIVE

The number of diagnosed cases of stomach cancer in Western countries is relatively small compared to prevalence rates in Eastern populations. This disparity creates a general lack of information and understanding of the experience of patients treated for this disease in North America. Surgical removal of the stomach, also called total gastrectomy (TG), is presently the only curative treatment available to patients with stomach cancer. Considering the impact such a procedure may have, very little is known about what factors influence an individual's postsurgical quality of life (QL).

METHOD

This article reviews current literature and examines three unique case studies. Semi-structured interviews were analyzed using content analysis, a qualitative analytic approach for reporting combined subject responses.

RESULTS

Participants included one 37-year-old man with multiple polyps in his stomach and a family history of stomach cancer, one 18 year-old man with a confirmed CDH1 mutation and a family history of stomach cancer, and one 33-year-old man with confirmed metastatic gastric adenocarcinoma. Subjective patient experience was categorized into: (1) making the decision, (2) treatment impact, and (3) life after TG. Prior to surgery, all patients carefully evaluated their perceived risk compared to the treatment consequences and indicated that a certain event triggered their decision. The largest treatment impacts were learning to eat again and adjusting to the physical changes. Each patient endorsed that their experience made them appreciate and make the most of life.

SIGNIFICANCE OF RESULTS

This currently represents the only study to investigate the lived experience of TG for prophylaxis or palliation in individuals with and without genetic risk for stomach cancer. Understanding this process will allow all members of the cancer care team, and the patients themselves, to better understand the factors involved in decision making and postoperative adjustment. Fruitful avenues for future research are discussed.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.