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Mathews J, Merchant S, Galica J, Palmer MJ, O'Donnell J, Koven R, Booth C, Brundage M. Measuring prognostic awareness in patients with advanced cancer: a scoping review and interpretive synthesis of the impact of hope. J Natl Cancer Inst 2024; 116:506-517. [PMID: 38134429 DOI: 10.1093/jnci/djad267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Assessment of prognostic awareness (PA) in patients with advanced cancer is challenging because patient responses often indicate their hopes. The objectives of this scoping review were to summarize studies that measured PA in patients with advanced cancer and to synthesize data about how PA was measured and whether hope was incorporated into the measurement. METHODS MEDLINE and Embase databases were searched from inception to December 14, 2021. Data regarding the impact of hope on assessment of PA were extracted when studies reported on patients' beliefs about prognosis and patients' beliefs about their doctor's opinion about prognosis. An interpretive synthesis approach was used to analyze the data and to generate a theory regarding the incorporation of hope into the assessment of PA. RESULTS In total, 52 studies representing 23 766 patients were included. Most were conducted in high-income countries and measured PA based on the goal of treatment (curable vs incurable). Five studies incorporated hope into the assessment of PA and reported that among patients who responded that their treatment goal was a cure, an average of 30% also acknowledged that their doctors were treating them with palliative intent. Interpretive synthesis of the evidence generated a trinary conceptualization of PA patients who are aware and accepting of their prognosis; aware and not accepting; and truly unaware. Each of these groups will benefit from different types of interventions to support their evolving PA. CONCLUSION The trinary conceptualization of PA may promote understanding of the impact of hope in the assessment of PA and guide future research.
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Affiliation(s)
- Jean Mathews
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Shaila Merchant
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
- Division of General Surgery and Surgical Oncology, Queen's University, Kingston, ON, Canada
| | - Jacqueline Galica
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
- School of Nursing, Queen's University, Kingston, ON, Canada
| | - Michael J Palmer
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Jennifer O'Donnell
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Rachel Koven
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Christopher Booth
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Michael Brundage
- Department of Oncology, Queen's University, Kingston, ON, Canada
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Košir U, van de Wal D, Husson O, Zablith N, Turcotte RE. Patient-physician agreement on function and pain is associated with long-term outcomes in sarcoma: findings from a longitudinal study. J Cancer Surviv 2023:10.1007/s11764-023-01473-3. [PMID: 37847463 DOI: 10.1007/s11764-023-01473-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/21/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE We aimed to describe the level of agreement between patients and physicians on the ratings of daily functioning and pain in a cohort of sarcoma patients and assess how (dis)agreement and its change over time predicted patient-reported outcomes in survivorship. METHOD We performed secondary analysis of longitudinal data from a sarcoma-specialty clinic in Montreal, Canada. Demographics, clinical characteristics and patient-physician agreement were summarized descriptively. Linear mixed models were used to assess the effects of time, baseline agreement, change in agreement over time, interaction of time and change in agreement and 12-month daily functioning, quality of life, and fatigue. RESULTS Data were available for 806 patients (57.7% male, x̄ = 53.3 years) who completed at least one questionnaire. Patient-physician disagreement was common on the level of function (43.4%) and pain (45.7%). Baseline physician-patient agreement was associated with better 12-month outcomes. Improvement in agreement on function over time was significantly associated with daily functioning (F(2, 212) = 3.18, p = 0.043) and quality of life (F(2, 212) = 3.17, p < 0.044). The pattern was similar though less pronounced for the agreement on pain. CONCLUSIONS Our study offers novel insights into the importance of patient-physician agreement and communication's role in long-term patient-reported outcomes in sarcoma. IMPLICATIONS FOR CANCER SURVIVORS The results emphasize the importance of mutual understanding of symptoms and patients' needs and suggest that further consultation in cases of discordance of ratings and opinions might be beneficial for optimal survivorship.
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Affiliation(s)
- Urška Košir
- Division of Orthopedic Surgery, McGill University Health Centre (MUHC), Montreal, QC, Canada.
- Department of Experimental Psychology, University of Oxford, Oxford, UK.
| | - Deborah van de Wal
- Medical Oncology Department, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Husson
- Medical Oncology Department, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nadine Zablith
- Division of Orthopedic Surgery, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Robert E Turcotte
- Division of Orthopedic Surgery, McGill University Health Centre (MUHC), Montreal, QC, Canada
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Ray EM, Teal RW, Carda-Auten J, Coffman E, Sanoff HK. Qualitative evaluation of barriers and facilitators to hepatocellular carcinoma care in North Carolina. PLoS One 2023; 18:e0287338. [PMID: 37347754 PMCID: PMC10287003 DOI: 10.1371/journal.pone.0287338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Many patients with hepatocellular carcinoma (HCC) never receive cancer-directed therapy. In order to tailor interventions to increase access to appropriate therapy, we sought to understand the barriers and facilitators to HCC care. METHODS Patients with recently diagnosed HCC were identified through the University of North Carolina (UNC) HCC clinic or local hospital cancer registrars (rapid case ascertainment, RCA). Two qualitative researchers conducted in-depth, semi-structured interviews. Interviews were audiotaped, transcribed, and coded. RESULTS Nineteen interviews were conducted (10 UNC, 9 RCA). Key facilitators of care were: physician knowledge; effective communication regarding test results, plan of care, and prognosis; social support; and financial support. Barriers included: lack of transportation; cost of care; provider lack of knowledge about HCC; delays in scheduling; or poor communication with the medical team. Participants suggested better coordination of appointments and having a primary contact within the healthcare team. LIMITATIONS We primarily captured the perspectives of those HCC patients who, despite the challenges they describe, were ultimately able to receive HCC care. CONCLUSIONS This study identifies key facilitators and barriers to accessing care for HCC in North Carolina. Use of the RCA system to identify patients from a variety of settings, treated and untreated, enabled us to capture a broad range of perspectives. Reducing barriers through improving communication and care coordination, assisting with out-of-pocket costs, and engaging caregivers and other medical providers may improve access. This study should serve as the basis for tailored interventions aimed at improving access to appropriate, life-prolonging care for patients with HCC.
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Affiliation(s)
- Emily M Ray
- Department of Medicine, Division of Oncology, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Randall W Teal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Jessica Carda-Auten
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Erin Coffman
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Hanna K Sanoff
- Department of Medicine, Division of Oncology, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
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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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Blume ED, Kirsch R, Cousino MK, Walter JK, Steiner JM, Miller TA, Machado D, Peyton C, Bacha E, Morell E. Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000114. [PMID: 36633003 PMCID: PMC10472747 DOI: 10.1161/hcq.0000000000000114] [Citation(s) in RCA: 5] [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] [Indexed: 01/13/2023]
Abstract
AIM This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease. METHODS A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.
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Gibbons S, Sinclair CT. Demystifying Prognosis : Understanding the Science and Art of Prognostication. Cancer Treat Res 2023; 187:53-71. [PMID: 37851219 DOI: 10.1007/978-3-031-29923-0_5] [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: 10/19/2023]
Abstract
The science of prognostication is emerging as a vital part of providing goal concordant patient care. Historically, modern medicine has tended to shy away from approaching prognostication as a core clinical skill, and prognosis as something to be shared directly with the patient. In recent years however, the medical field's shift towards a focus on patient autonomy and more openness in matters regarding end of life has propelled the study of prognostication into a more essential component of patient centered care. This calls for more emphasis on teaching the science of prognosis and the skill of prognostication as a core part of modern medical education. The following chapter aims to delve into the science of prognostication, explore the methods of formulating a prognosis, and discuss issues surrounding the communication of prognosis.
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Affiliation(s)
- Shauna Gibbons
- Division of Palliative Medicine, University of Kansas Health System, 4000 Cambridge St, Kansas City, KS, USA.
| | - Christian T Sinclair
- Division of Palliative Medicine, University of Kansas Health System, 4000 Cambridge St, Kansas City, KS, USA
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Chou WYS, Falisi AL, Castro K, Ferrer RA, Gaysynsky A, Huang GC, Mollica MA, Peterson EB, Kent EE. Cancer clinical trial providers' perspectives on communicating goals of care: A key informant study. PEC INNOVATION 2022; 1:100041. [PMID: 37213723 PMCID: PMC10194320 DOI: 10.1016/j.pecinn.2022.100041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/15/2022] [Accepted: 04/16/2022] [Indexed: 05/23/2023]
Abstract
Objectives There has been limited research to date exploring provider communication in the context of cancer clinical trials. To elucidate multidisciplinary care providers' experiences, this qualitative study sought to understand their perspectives and communication patterns around goals of care discussions with patients enrolled in cancer clinical trials. Methods Semi-structured key informant interviews were conducted with a purposive sample of physicians, nurse practitioners, social workers, chaplains, nurses, and administrative staff in a cancer research hospital (N=19). Data were analyzed and interpreted using thematic analysis. Results Providers hold varied perspectives on goals of care in cancer clinical trials, highlighting the tension and potential for misalignment between scientific and clinical (patient-centered) goals. Inherent institutional hierarchies may impede some team members from initiating goal discussions. Care transitions (e.g., stopping treatment or initiating hospice) offer critical opportunities for goals of care discussions. Conclusion Conflicting perspectives among team members, perceptions of provider roles, and communication patterns could help explain some of the communication challenges previously documented in advanced cancer and clinical trial care. Innovation This qualitative study contributes to the literature on healthcare team communication in the clinical trial context and highlights tangible opportunities to better leverage providers' diverse experience and improve patient-centered care.
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Affiliation(s)
- Wen-Ying Sylvia Chou
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
- Corresponding author at: Health Communication and Informatics Research Branch, National Cancer Institute, 9609 Medical Center Dr. 3E614, MSC – 9761, Rockville, MD 20850, USA.
| | - Angela L. Falisi
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Kathleen Castro
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Rebecca A. Ferrer
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Anna Gaysynsky
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
- ICF, 530 Gaither Road, Rockville, MD 20850, USA
| | - Grace C. Huang
- Westat, 1600 Research Boulevard, Rockville, MD 20850, USA
| | - Michelle A. Mollica
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Emily B. Peterson
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Erin E. Kent
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
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Nipp RD. Palliative and Supportive Care for Individuals with Pancreatic Adenocarcinoma. Hematol Oncol Clin North Am 2022; 36:1053-1061. [PMID: 36154784 DOI: 10.1016/j.hoc.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Individuals with pancreatic adenocarcinoma experience a complex constellation of palliative and supportive care needs. Notably, when caring for patients with pancreatic adenocarcinoma, clinicians must carefully assess and address these individuals' palliative and supportive care needs, as these can have important implications related to their treatment experience and care outcomes. Importantly, prior research has consistently demonstrated the benefits of palliative and supportive care interventions for patients with cancer to help address symptom burden, illness understanding, coping mechanisms, and informed decision making. However, much of this research did not specifically tailor the interventions to the unique concerns of a pancreatic cancer population. Thus, an urgent need exists to design and conduct rigorous research with the goal of enhancing care delivery and outcomes for the highly symptomatic population of individuals with pancreatic adenocarcinoma.
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Affiliation(s)
- Ryan D Nipp
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, 800 Northeast 10th Street, Oklahoma City, OK 73104, USA.
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Huepenbecker SP, Zhang X, Morgan MA, Haggerty AF. A prospective cross-sectional survey comparing patient and provider expectations regarding ovarian cancer prognosis. Gynecol Oncol Rep 2022; 42:101042. [PMID: 35874551 PMCID: PMC9303825 DOI: 10.1016/j.gore.2022.101042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 12/01/2022] Open
Abstract
Providers believe prognostic discussions are important for ovarian cancer patients. Providers report having prognostic conversations more often than patients. Ovarian cancer patients and providers have different expectations surrounding treatment, remission, and survival. Age, marital status, religion, and cancer stage may affect patient perceptions of ovarian cancer prognosis.
Introduction There is limited data comparing patient and physician expectations regarding ovarian cancer prognosis. Our primary objective was to compare physician and patient estimates of survival to 6 months, 1 year, and 5 years; secondary objectives included comparing provider and patient responses on the likelihood of requiring future treatments and categorizing patient and provider preferences regarding communication about prognosis. Methods A prospective cross-sectional survey was delivered to 10 gynecologic oncology providers and 50 adult ovarian cancer patients from November 2015-April 2016 at one institution. Descriptive statistics were used to categorize survey answers and compare survey answers between patients and providers; multivariable logistic regression evaluated patient survey responses. Results All providers (100%) believed treating providers should discuss prognosis and 90% reported having prognostic conversations with patients, compared to 63%, 37%, and 4% of patients who reported discussing prognosis, living wills/advance directives, and palliative care/hospice services, respectively, with their provider. Compared to their provider, patients gave significantly lower estimations of requiring any future therapy (mean score 84.6 vs 74, p <.001) and future chemotherapy (mean score 84.1 vs 69.8, p <.001) and significantly higher estimations of requiring future surgery (mean score 23.3 vs 40, p <.001), achieving remission (mean score 33.5 vs 47.5, p =.009), survival to 1 year (mean score 77.1 vs 86.4, p =.002), and survival to 5 years (mean score 40.5 vs 61.3, p <.001). Conclusions Although gynecologic oncology providers believe it is important to discuss prognosis and end-of-life care, there are gaps in communication, knowledge, and expectations between providers and ovarian cancer patients.
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Affiliation(s)
- Sarah P. Huepenbecker
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Corresponding author.
| | - Xiaochen Zhang
- Center for Research on Reproduction and Women’s Health, University of Pennsylvania, 3440 Market St, Philadelphia, PA 19104, USA
| | - Mark A. Morgan
- Division of Gynecologic Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Ashley F. Haggerty
- Division of Gynecologic Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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Petrillo LA, Shimer SE, Zhou AZ, Sommer RK, Feldman JE, Hsu KE, Greer JA, Traeger LN, Temel JS. Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study. Cancer 2022; 128:3120-3128. [PMID: 35731234 DOI: 10.1002/cncr.34369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer. METHODS This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication. RESULTS Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making. CONCLUSIONS Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.
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Affiliation(s)
- Laura A Petrillo
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sophia E Shimer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashley Z Zhou
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert K Sommer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kelly E Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kiuchi K, Hasegawa K, Watanabe M, Motegi E, Kosaka N, Fukasawa I. Clinical indicators useful in decision-making about palliative chemotherapy for end-of-life ovarian cancer patients. Arch Gynecol Obstet 2021; 305:425-430. [PMID: 34347151 DOI: 10.1007/s00404-021-06162-z] [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: 05/14/2020] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Chemotherapy for end-of-life ovarian cancer patients is a complex and delicate problem. We evaluated whether active palliative chemotherapy is beneficial for such patients using inflammatory parameters, nutritional indicators, and the PPI (Palliative Prognostic Index), which predicts short-term prognosis. METHODS Thirty-six patients among 49 patients who died from ovarian cancer from 2014 to 2019 at our hospital were enrolled, whom clinical and laboratory data just before starting their final chemotherapy regimen could be obtained. Associations between the time from last chemotherapy to death and the following parameters were investigated: age, performance status, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio, Modified Glasgow Prognostic Score (mGPS), Prognostic Nutritional Index (PNI) score, and PPI score. RESULTS The median age was 57 (range 19-80) years. The median time from last chemotherapy to death was 45.5 (range 11-110) days. Eight patients (22%) died within 30 days of their last chemotherapy regimen. In univariate analysis, median survival time was significantly shorter in patients with higher NLR, mGPS 2, and higher PPI values; NLR (≥ median vs. < median): 32 (range 11-80) days vs. 54 (range 35-110) days, p = 0.008; mGPS (2 vs. 0-1): 42 (range 11-80) days vs. 96 (range 49-110) days, p = 0.012; and PPI score (≥ median vs. < median): 38 (range 11-74) days vs. 60 (range 18-110) days, p = 0.005. However, in multivariate analysis, no factors were identified as independent prognostic factors for survival. CONCLUSION Parameters, such as NLR, mGPS, and PPI score, may be indicators for discontinuation of palliative chemotherapy, and may be useful for maximizing end-of-life care for ovarian cancer patients.
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Affiliation(s)
- Kaori Kiuchi
- Department of Obstetrics and Gynecology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Kiyoshi Hasegawa
- Department of Obstetrics and Gynecology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan. .,Department of Obstetrics and Gynecology, Inuyama Chuo General Hospital, 6 Futakotsuka Goroumaru, Inuyama, Aichi, 484-8511, Japan.
| | - Mariko Watanabe
- Department of Obstetrics and Gynecology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Emi Motegi
- Department of Obstetrics and Gynecology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Nobuaki Kosaka
- Department of Obstetrics and Gynecology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Ichio Fukasawa
- Department of Obstetrics and Gynecology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
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Gelfman LP, Mather H, McKendrick K, Wong AY, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Non-Concordance between Patient and Clinician Estimates of Prognosis in Advanced Heart Failure. J Card Fail 2021; 27:700-705. [PMID: 34088381 PMCID: PMC8186811 DOI: 10.1016/j.cardfail.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Despite efforts to enhance serious illness communication, patients with advanced heart failure (HF) lack prognostic understanding. OBJECTIVES To determine rate of concordance between HF patients' estimation of their prognosis and their physician's estimate of the patient's prognosis, and to compare patient characteristics associated with concordance. DESIGN Cross-sectional analysis of a cluster randomized controlled trial with 24-month follow-up and analysis completed on 09/01/2020. Patients were enrolled in inpatient and outpatient settings between September 2011 to February 2016 and data collection continued until the last quarter of 2017. SETTING Six teaching hospitals in the U.S. PARTICIPANTS Patients with advanced HF and implantable cardioverter defibrillators (ICDs) at high risk of death. Of 537 patients in the parent study, 407 had complete data for this analysis. INTERVENTION A multi-component communication intervention on conversations between HF clinicians and their patients regarding ICD deactivation and advance care planning. MAIN OUTCOME(S) AND MEASURE(S) Patient self-report of prognosis and physician response to the "surprise question" of 12-month prognosis. Patient-physician prognostic concordance (PPPC) measured in percentage agreement and kappa. Bivariate analyses of characteristics of patients with and without PPPC. RESULTS Among 407 patients (mean age 62.1 years, 29.5% female, 42.4% non-white), 300 (73.7%) dyads had non-PPPC; of which 252 (84.0%) reported a prognosis >1 year when their physician estimated <1 year. Only 107 (26.3%) had PPPC with prognosis of ≤ 1 year (n=20 patients) or > 1 year (n=87 patients); (Κ = -0.20, p = 1.0). Of those with physician estimated prognosis of < 1 year, non-PPPC was more likely among patients with lower symptom burden- number and severity (both p ≤.001), without completed advance directive (p=.001). Among those with physician prognosis estimate > 1 year, no patient characteristic was associated with PPPC or non-PPPC. CONCLUSIONS AND RELEVANCE Non-PPPC between HF patients and their physicians is high. HF patients are more optimistic than clinicians in estimating life expectancy. These data demonstrate there are opportunities to improve the quality of prognosis disclosure between patients with advanced HF and their physicians. Interventions to improve PPPC might include serious illness communication training.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, AZ
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine
| | - Hannah I Lipman
- Hackensack Meridian Health, Hackensack, NJ; Hackensack Meridian School of Medicine
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center; Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, AL
| | - Sean P Pinney
- Division of Cardiology, UChicago Medicine, Chicago, IL
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
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13
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van der Velden NCA, van der Kleij MBA, Lehmann V, Smets EMA, Stouthard JML, Henselmans I, Hillen MA. Communication about Prognosis during Patient-Initiated Second Opinion Consultations in Advanced Cancer Care: An Observational Qualitative Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115694. [PMID: 34073341 PMCID: PMC8199300 DOI: 10.3390/ijerph18115694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022]
Abstract
Prognostic communication is essential for patients with advanced cancer to enable informed medical decision-making and end-of-life planning. Discussing prognosis is challenging, and might be especially complex for oncologists conducting a second opinion (SO). Survival data are often lacking, and consulting oncologists need to consider previously conveyed information and patients’ relationship with the referring oncologist. We qualitatively investigated how advanced cancer patients and consulting oncologists discuss prognosis during audio-recorded SO consultations (N = 60), including prognostic information received from the referring oncologist. Our results show that patients regularly expressed implicit cues to discuss prognosis or posed explicit questions tentatively. Consulting oncologists were mostly unresponsive to patients’ cues and cautious to prognosticate. They also seemed cautious when patients brought up the referring oncologist. Consulting oncologists checked which prognostic information patients had received from the referring oncologist, before estimating prognosis. They agreed with the first opinion or rectified discrepancies carefully. Altogether, this study exposes missed opportunities for open prognostic discussions in SOs. Consulting oncologists could explicitly explore patients’ information preferences and perceptions of prognosis. If desired, they can provide tailored, independent information to optimise patients’ prognostic awareness and informed medical decision-making. They may additionally support patients in dealing with prognosis and the uncertainties associated with it.
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Affiliation(s)
- N. C. A. van der Velden
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
- Correspondence:
| | - M. B. A. van der Kleij
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
| | - V. Lehmann
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - E. M. A. Smets
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - J. M. L. Stouthard
- Department of Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands;
| | - I. Henselmans
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - M. A. Hillen
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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Jabbarian LJ, Rietjens JAC, Mols F, Oude Groeniger J, van der Heide A, Korfage IJ. Untangling the relationship between negative illness perceptions and worse quality of life in patients with advanced cancer-a study from the population-based PROFILES registry. Support Care Cancer 2021; 29:6411-6419. [PMID: 33891204 PMCID: PMC8464557 DOI: 10.1007/s00520-021-06179-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/24/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Quality of life (QoL) is an important yet complex outcome of care in patients with advanced cancer. QoL is associated with physical and psychosocial symptoms and with patients' illness perceptions (IPs). IPs are modifiable cognitive constructs developed to make sense of one's illness. It is unclear how IPs influence patients' QoL. A better understanding of this relationship can inform and direct high quality care aimed at improving patients' QoL. We therefore investigated the mediating role of anxiety and depression in the association of IPs with QoL. METHODS Data from 377 patients with advanced cancer were used from the PROFILES registry. Patients completed measures on IPs (BIPQ), QoL (EORTC QLQ-C30), and symptoms of anxiety and depression (HADS). Mediation analyses were conducted to decompose the total effect of IPs on QoL into a direct effect and indirect effect. RESULTS All IPs but one ("Comprehensibility") were negatively associated with QoL (p<0.001); patients with more negative IPs tended to have worse QoL. The effect was strongest for patients who felt that their illness affected their life more severely ("Consequences"), patients who were more concerned about their illness ("Concern"), and patients who thought that their illness strongly affected them emotionally ("Emotions"). Anxiety mediated 41-87% and depression mediated 39-69% of the total effect of patients' IPs on QoL. CONCLUSION Negative IPs are associated with worse QoL. Anxiety and depression mediate this association. Targeting symptoms of anxiety and depression, through the modification of IPs, has the potential to improve QoL of patients with advanced cancer.
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Affiliation(s)
- Lea J Jabbarian
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Floortje Mols
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands.,Netherlands Comprehensive Cancer Organisation (IKNL), Netherlands Cancer Registry, Eindhoven, the Netherlands
| | - Joost Oude Groeniger
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
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15
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Abstract
PURPOSE OF REVIEW Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy. RECENT FINDINGS First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.
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Affiliation(s)
- Sophie Lelorain
- Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000, Lille, France.
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16
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van den Broek-Altenburg E, Gramling R, Gothard K, Kroesen M, Chorus C. Using natural language processing to explore heterogeneity in moral terminology in palliative care consultations. BMC Palliat Care 2021; 20:23. [PMID: 33494745 PMCID: PMC7836473 DOI: 10.1186/s12904-021-00716-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/15/2021] [Indexed: 11/22/2022] Open
Abstract
Background High quality serious illness communication requires good understanding of patients’ values and beliefs for their treatment at end of life. Natural Language Processing (NLP) offers a reliable and scalable method for measuring and analyzing value- and belief-related features of conversations in the natural clinical setting. We use a validated NLP corpus and a series of statistical analyses to capture and explain conversation features that characterize the complex domain of moral values and beliefs. The objective of this study was to examine the frequency, distribution and clustering of morality lexicon expressed by patients during palliative care consultation using the Moral Foundations NLP Dictionary. Methods We used text data from 231 audio-recorded and transcribed inpatient PC consultations and data from baseline and follow-up patient questionnaires at two large academic medical centers in the United States. With these data, we identified different moral expressions in patients using text mining techniques. We used latent class analysis to explore if there were qualitatively different underlying patterns in the PC patient population. We used Poisson regressions to analyze if individual patient characteristics, EOL preferences, religion and spiritual beliefs were associated with use of moral terminology. Results We found two latent classes: a class in which patients did not use many expressions of morality in their PC consultations and one in which patients did. Age, race (white), education, spiritual needs, and whether a patient was affiliated with Christianity or another religion were all associated with membership of the first class. Gender, financial security and preference for longevity-focused over comfort focused treatment near EOL did not affect class membership. Conclusions This study is among the first to use text data from a real-world situation to extract information regarding individual foundations of morality. It is the first to test empirically if individual moral expressions are associated with individual characteristics, attitudes and emotions.
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Affiliation(s)
| | - Robert Gramling
- University of Vermont, Robert Larner, M.D. College of Medicine, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Kelly Gothard
- University of Vermont, Robert Larner, M.D. College of Medicine, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Maarten Kroesen
- Delft University of Technology, Stevinweg 1, Delft, CB, 2628, The Netherlands
| | - Caspar Chorus
- Delft University of Technology, Stevinweg 1, Delft, CB, 2628, The Netherlands
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17
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Gal R, Oostinga D, Wessels H, Verlaan JJ, Charest-Morin R, Fisher CG, Verkooijen HM, Versteeg AL. Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies. BMC Cancer 2020; 20:1212. [PMID: 33298017 PMCID: PMC7724808 DOI: 10.1186/s12885-020-07683-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/23/2020] [Indexed: 02/08/2023] Open
Abstract
Background Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care. Methods A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients’ pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality. Results The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates. Conclusions Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes. Trial registration PROSPERO registration number: CRD42020145151. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-020-07683-7.
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Affiliation(s)
- R Gal
- Division of Imaging and Cancer, University Medical Center Utrecht, University of Utrecht, Heideberglaan 100, 3584, CG, Utrecht, the Netherlands.
| | - D Oostinga
- Department of Orthopaedic Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - H Wessels
- Department of Corporate Communications, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J Verlaan
- Department of Orthopaedic Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - R Charest-Morin
- Department of Orthopaedics, Division of Spine, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - C G Fisher
- Department of Orthopaedics, Division of Spine, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - H M Verkooijen
- Division of Imaging and Cancer, University Medical Center Utrecht, University of Utrecht, Heideberglaan 100, 3584, CG, Utrecht, the Netherlands
| | - A L Versteeg
- Division of Imaging and Cancer, University Medical Center Utrecht, University of Utrecht, Heideberglaan 100, 3584, CG, Utrecht, the Netherlands
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18
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Hoesseini A, Offerman MPJ, van de Wall-Neecke BJ, Sewnaik A, Wieringa MH, Baatenburg de Jong RJ. Physicians' clinical prediction of survival in head and neck cancer patients in the palliative phase. BMC Palliat Care 2020; 19:176. [PMID: 33234115 PMCID: PMC7687732 DOI: 10.1186/s12904-020-00682-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/09/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The prognosis of patients with incurable head and neck cancer (HNC) is a relevant topic. The mean survival of these patients is 5 months but may vary from weeks to more than 3 years. Discussing the prognosis early in the disease trajectory enables patients to make well-considered end-of-life choices, and contributes to a better quality of life and death. However, physicians often are reluctant to discuss prognosis, partly because of the concern to be inaccurate. This study investigated the accuracy of physicians' clinical prediction of survival of palliative HNC patients. METHODS This study was part of a prospective cohort study in a tertiary cancer center. Patients with incurable HNC diagnosed between 2008 and 2011 (n = 191), and their treating physician were included. Analyses were conducted between July 2018 and February 2019. Patients' survival was clinically predicted by their physician ≤3 weeks after disclosure of the palliative diagnosis. The clinical prediction of survival in weeks (CPS) was based on physicians' clinical assessment of the patient during the outpatient visits. More than 25% difference between the actual survival (AS) and the CPS was regarded as a prediction error. In addition, when the difference between the AS and CPS was 2 weeks or less, this was always considered as correct. RESULTS In 59% (n = 112) of cases survival was overestimated. These patients lived shorter than predicted by their physician (median AS 6 weeks, median CPS 20 weeks). In 18% (n = 35) of the cases survival was correctly predicted. The remaining 23% was underestimated (median AS 35 weeks, median CPS 20 weeks). Besides the differences in AS and CPS, no other significant differences were found between the three groups. There was worse accuracy when predicting survival closer to death: out of the 66 patients who survived 6 weeks or shorter, survival was correctly predicted in only eight (12%). CONCLUSION Physicians tend to overestimate the survival of palliative HNC patients. This optimism can result in suboptimal use of palliative and end-of-life care. The future development of a prognostic model that provides more accurate estimates, could help physicians with personalized prognostic counseling.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Bojou J van de Wall-Neecke
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Marjan H Wieringa
- Department of Education and Research, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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19
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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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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. PURPOSE To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. METHOD Walker and Avant's approach to concept analysis. FINDINGS End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). DISCUSSION Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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Ciria-Suarez L, Jimenez-Fonseca P, Hernández R, Rogado J, Calderon C. Estimation of Risk of Recurrence and Toxicity Among Oncologists and Patients With Resected Breast Cancer: A Quantitative Study. Front Psychol 2020; 11:540083. [PMID: 33192784 PMCID: PMC7653019 DOI: 10.3389/fpsyg.2020.540083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Shared decision-making regarding adjuvant systemic therapy in breast cancer is based on both properly conveying information about the prognosis of the disease and the benefits and risks of adjuvant treatment, as well as the patient's ability to understand this information. This work proposed to analyze oncologists' and patients' perceptions of the risk of recurrence with and without chemotherapy and toxicity, and the factors influencing said impressions. This was a prospective, cross-sectional, multicenter study that involved 281 breast cancer patients and 23 oncologists. Prognosis (risk of recurrence with and without chemotherapy and risk of severe toxicity with chemotherapy) and shared decision making (SDM) questionnaires were completed by all participants; breast cancer patients also filled out the 18-item Brief Symptom Inventory (BSI-18). Oncologists' prediction of risk of relapse without and with chemotherapy (30.4 and 13.3%) and risk of severe toxicity (9.8%) were more optimistic than those of breast cancer patients (78.6, 29.6, and 61%, respectively). The greater the severity, the higher the risk of relapse according to the oncologists (p = 0.001); not so for the patients. Older physicians and more experienced ones predicted lower risk of relapse with and without chemotherapy and less severe toxicity than younger doctors and those with less experience (p < 0.001). Oncologists' SDM and their prediction of risk of relapsing with chemotherapy correlated negatively with patients' SDM and their prediction of risk of severe toxicity (p < 0.01). There is a positive correlation between psychological distress (BSI-18) and prognosis of risk of recurrence with chemotherapy in breast cancer patients (p < 0.001). These results stress the importance of improving doctor-patient communication in SDM. In breast cancer patients undergoing treatment with curative intent, expectations of being cured would increase and treatment-related anxiety would decrease by enhancing doctor-patient communication to coincide more with respect to risk of relapse and toxicity, thereby enhancing patients' quality of life.
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Affiliation(s)
- Laura Ciria-Suarez
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | - Paula Jimenez-Fonseca
- Department of Medical Oncology, Central University Hospital of Asturias, Oviedo, Spain
| | - Raquel Hernández
- Department of Medical Oncology, Canary University Hospital, Santa Cruz de Tenerife, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Infanta Leonor University Hospital, Madrid, Spain
| | - Caterina Calderon
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain
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22
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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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23
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Gray TF, Forst D, Nipp RD, Greer JA, Temel JS, El-Jawahri A. Prognostic Awareness in Caregivers of Patients with Incurable Cancer. J Palliat Med 2020; 24:561-569. [PMID: 32996821 DOI: 10.1089/jpm.2020.0236] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Little is known about how patients with incurable cancer and caregivers differ in their prognostic awareness, and the relationship between caregiver prognostic awareness and their psychological distress. Objective: To investigate prognostic awareness in caregivers of patients with incurable cancer and prognostic discordance in patient-caregiver dyads and its association with psychological distress. Design: This is a cross-sectional study. Setting/Subjects: In total, subjects were 390 caregivers of adults with incurable lung, gastrointestinal, and brain cancers at a cancer center in the northeastern United States. Measurements: The Prognosis and Treatment Perceptions Questionnaire was used to assess prognostic awareness and Hospital Anxiety and Depression Scale to assess psychological distress. Results: In total, 39.7% (n = 147/370) and 17.3% (n = 64/370) caregivers reported clinically significant anxiety and depression symptoms. And 53.7% of caregivers reported the patients' cancer as "curable" and 44.1% reported the cancer was "not terminal." Caregivers' report of curability was not associated with their anxiety (odds ratio [OR] = 0.99, p = 0.93) or depression (OR = 1.05, p = 0.32) symptoms. Among 42.5% (124/292) and 26.0% (76/292) of dyads (n = 292), both patients and their caregivers agreed in their perception of the cancer as curable and incurable, respectively. In 19.9% of dyads (n = 58), patients reported their cancer as curable, while their caregivers reported it as incurable. In 11.6% of dyads (n = 34), patients reported the cancer as incurable while caregivers reported it as curable. Conclusions: More than half of caregivers have misperceptions about the patients' likelihood of cure, and one-third of patient-caregiver dyads have discordant perceptions. Supportive care interventions may facilitate conversations and enhance prognostic understanding in patients with incurable cancer and their caregivers.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Forst
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Joseph A Greer
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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24
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Perceptions of time spent pursuing cancer care among patients, caregivers, and oncology professionals. Support Care Cancer 2020; 29:2493-2500. [PMID: 32935204 DOI: 10.1007/s00520-020-05763-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Patients with cancer spend significant time receiving treatment and recovering from side effects. Little is known about how patients and their caregivers perceive time spent receiving cancer treatment and how this impacts health-related quality of life (HRQoL). Our study aims to characterize perceptions of time invested in receiving cancer therapy as experienced by patients, caregivers, and oncology professionals. METHODS We conducted semi-structured interviews with patients undergoing treatment for advanced lung cancer and melanoma, their informal caregivers, and oncology professionals (physicians, nurses, social workers, and chaplains). Participants received and provided care at a tertiary cancer center. Interviews were audiorecorded and transcribed verbatim. Transcripts were analyzed qualitatively using predominantly inductive coding to identify themes relating to time perception and cancer care. RESULTS We interviewed 29 participants (11 patients, 7 informal caregivers, and 11 oncology professionals) and found they consistently differentiated between time remaining in life ("existential time") and time required to manage cancer treatment and symptoms ("chronological time"). Patients and caregivers reported distress around the mechanics of oncologic care that interrupted their daily lives (hobbies, activities). Participants described the impact of time invested in cancer care on dimensions of quality of life, ranging from minimal to substantial negative impact. CONCLUSIONS We found that the time spent undergoing cancer treatment affects well-being and often prevents patients and caregivers from participating in meaningful activities. The investment of personal time undergoing cancer therapy for patients with advanced solid tumors merits further study and can enhance communication between patients, caregivers, and their oncologists.
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25
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Elfgen C, Montagna G, Schmid SM, Bierbauer W, Güth U. Metastatic Breast Cancer as a Chronic Disease: Evidence-Based Data on a Theoretical Concept. Breast Care (Basel) 2020; 15:281-288. [PMID: 32774223 DOI: 10.1159/000502636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background We challenge the concept of metastatic breast cancer (MBC) as a chronic disease. Methods We analyzed an unselected cohort of 367 patients who were diagnosed with MBC over a 22-year period (1990-2011). Results In order to create a "chronic disease subgroup", we separated those patients from the entire cohort in whom systemic therapy was not applied after the diagnosis of MBC (n = 53; 14.4%). Three hundred fourteen patients (85.6%) comprised the "chronic disease subgroup". The vast majority of those patients (89.8%) died of progressive disease after a median metastatic disease survival (MDS) of 25 months. Twenty patients (6.4%) died of non-MBC-related causes (MDS 38.5 months). Approximately 1 in 4 patients (26.8%) died within the first year after the MBC diagnosis. The 3- and 5-year MDS rates were 35.4 and 16.2%, respectively. Only 12 patients (3.8%) were exceptional survivors (MDS >10 years). Conclusion The term "chronic disease" might be appropriate in selected MBC cases, bringing MBC into alignment with "classical" chronic diseases such as diabetes and hypertension. However, most cases display fundamental differences with regard to temporal progression and above all the case fatality rate. More than 90% of patients in the "chronic disease subgroup" died of the disease with a MDS of 2-3 years (even those who underwent systemic palliative therapies). Doctors and patients might understand the term "chronic disease" differently. The term must be used sparingly and explained carefully in order to create a common level of communication based on a shared understanding which avoids awakening false hopes and fostering misleading expectations.
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Affiliation(s)
- Constanze Elfgen
- Department of Breast Surgery, Brust-Zentrum Zürich, Zurich, Switzerland.,Department of Senology, Institute of Gynecology and Obstetrics, University of Witten-Herdecke, Witten, Germany
| | - Giacomo Montagna
- Breast Center, University Hospital Basel, Basel, Switzerland.,Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland
| | - Seraina Margaretha Schmid
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland.,Breast Center St. Gallen, Spital Grabs, Grabs, Switzerland
| | - Walter Bierbauer
- Department of Psychology, Applied Social and Health Psychology, University of Zurich, Zurich, Switzerland
| | - Uwe Güth
- Department of Breast Surgery, Brust-Zentrum Zürich, Zurich, Switzerland.,Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland
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26
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Loh KP, Xu H, Epstein RM, Mohile SG, Prigerson HG, Plumb S, Ladwig S, Kadambi S, Wong ML, McHugh C, An A, Trevino K, Saeed F, Duberstein PR. Associations of Caregiver-Oncologist Discordance in Prognostic Understanding With Caregiver-Reported Therapeutic Alliance and Anxiety. J Pain Symptom Manage 2020; 60:20-27. [PMID: 32061833 PMCID: PMC7311277 DOI: 10.1016/j.jpainsymman.2020.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 01/28/2023]
Abstract
CONTEXT Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes. OBJECTIVES We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death. METHODS We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety. RESULTS We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02). CONCLUSION A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment.
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Affiliation(s)
- Kah Poh Loh
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Huiwen Xu
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ronald M Epstein
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya G Mohile
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA; Cornell Center for Research on End-of-Life Care, New York, New York, USA
| | - Sandra Plumb
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Susan Ladwig
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sindhuja Kadambi
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Melisa L Wong
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California, USA
| | - Colin McHugh
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Amy An
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kelly Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Fahad Saeed
- Department of Medicine, Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
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27
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Rangabashyam MS, Lee SY, Tan SY, Mueller S, Sultana R, Ho J, Skanthakumar T, Tan NC, Tan HK, Soo KC, Iyer NG. Adherence of head and neck squamous cell carcinoma patients to tumor board recommendations. Cancer Med 2020; 9:5124-5133. [PMID: 32472749 PMCID: PMC7367636 DOI: 10.1002/cam4.3097] [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: 02/16/2020] [Accepted: 04/15/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Multidisciplinary team (MDT) meetings or tumor boards (TBs) are fundamental components of cancer treatment. Although their primary function is improved outcomes, this aspect is often underreported. The main objective of this study was to analyze the outcomes of patients with head and neck squamous cell carcinoma (HNSCC) discussed at TBs, and to compare the effect of adherence and nonadherence to recommended treatment plans on outcomes. METHODS Retrospective data analysis was conducted of HNSCC patients those who were adherent and nonadherent to TB therapy recommendations during 2008-2009 at a comprehensive cancer center. Fisher's exact test and t test were used for group-wise comparison, and Kaplan-Meier and logistic regression models, for survival analysis and determination of the contributing factors to nonadherence. RESULTS Comprehensive Treatment plans were recommended by TBs in 293 HNSCC patients with curative intent. Seventy-two patients were excluded based on the selection criteria. Among the remaining 221 patients, 172 (77.9%) were adherent to TB recommendations, while 49 (22.1%) failed to comply. Patient (n = 36; 73.5%), clinician (n = 2; 4.1%), and disease-related (n = 11; 22.4%) factors were significant contributors to nonadherence. Mean (±standard deviation (SD)) survival time was 55.6 ± 2.32 and 29.1 ± 4 months in the adherent and nonadherent groups, (P < .0001, respectively). Multivariate analyses showed that gender, ethnicity, higher T-stage, and multimodal treatment were associated with nonadherence. CONCLUSION Adherence to TB recommendations improved overall survival, reflecting the importance of interdisciplinary expertise in contemporary cancer treatment. Early identification and intervention is crucial in "at risk" patients to prevent subsequent drop-out from optimal cancer care.
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Affiliation(s)
- Mahalakshmi S Rangabashyam
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore
| | - Shi Yan Lee
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore
| | - Sher Yin Tan
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore
| | - Stefan Mueller
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Johnatton Ho
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore
| | | | - Ngian Chye Tan
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore.,Duke-NUS Medical School, Singapore
| | - Hiang Khoon Tan
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore.,Duke-NUS Medical School, Singapore
| | - Khee Chee Soo
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - N Gopalakrishna Iyer
- Department of Head & Neck Surgery, National Cancer Centre Singapore, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore.,Duke-NUS Medical School, Singapore
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28
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Sisk BA, Dobrozsi S, Mack JW. Teamwork in prognostic communication: Addressing bottlenecks and barriers. Pediatr Blood Cancer 2020; 67:e28192. [PMID: 31965719 PMCID: PMC7096274 DOI: 10.1002/pbc.28192] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/16/2019] [Accepted: 01/09/2020] [Indexed: 11/09/2022]
Abstract
Prognostic communication is essential to family-centered care in pediatric oncology. Yet, prognostic communication from the medical team to the family is often absent or incomplete. In our experience, many clinical groups view prognostic disclosure as the responsibility of the patient's primary oncologist, and nurses are often excluded from these conversations. This current individual-based model of prognostic disclosure lacks redundancy and creates a communication bottleneck. We propose that clinical groups should address prognostic communication with a multidisciplinary team-based approach that incorporates three critical components: shared team mental models, distribution and redundancy in role assignment, and high fidelity monitoring of communication milestones.
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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
| | - Sarah Dobrozsi
- Division of Hematology and Oncology, Department of Pediatrics, Medical College of Wisconsin/Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - 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
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29
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The Effect of Prognostic Communication on Patient Outcomes in Palliative Cancer Care: a Systematic Review. Curr Treat Options Oncol 2020; 21:40. [PMID: 32328821 PMCID: PMC7181418 DOI: 10.1007/s11864-020-00742-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND While prognostic information is considered important for treatment decision-making, physicians struggle to communicate prognosis to advanced cancer patients. This systematic review aimed to offer up-to-date, evidence-based guidance on prognostic communication in palliative oncology. METHODS PubMed and PsycInfo were searched until September 2019 for literature on the association between prognostic disclosure (strategies) and patient outcomes in palliative cancer care, and its moderators. Methodological quality was reported. RESULTS Eighteen studies were included. Concerning prognostic disclosure, results revealed a positive association with patients' prognostic awareness. Findings showed no or positive associations between prognostic disclosure and the physician-patient relationship or the discussion of care preferences. Evidence for an association with the documentation of care preferences or physical outcomes was lacking. Findings on the emotional consequences of prognostic disclosure were multifaceted. Concerning disclosure strategies, affective communication seemingly reduced patients' physiological arousal and improved perceived physician's support. Affective and explicit communication showed no or beneficial effects on patients' psychological well-being and satisfaction. Communicating multiple survival scenarios improved prognostic understanding. Physicians displaying expertise, positivity and collaboration fostered hope. Evidence on demographic, clinical and personality factors moderating the effect of prognostic communication was weak. CONCLUSION If preferred by patients, physicians could disclose prognosis using sensible strategies. The combination of explicit and affective communication, multiple survival scenarios and expert, positive, collaborative behaviour likely benefits most patients. Still, more evidence is needed, and tailoring communication to individual patients is warranted. IMPLICATIONS Future research should examine the effect of prognostic communication on psychological well-being over time and treatment decision-making, and focus on individualising care.
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30
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Loh KP, Soto Pérez de Celis E, Duberstein PR, Culakova E, Epstein RM, Xu H, Kadambi S, Flannery M, Magnuson A, McHugh C, Trevino KM, Tuch G, Ramsdale E, Yousefi-Nooraie R, Sedenquist M, Liu JJ, Melnyk N, Geer J, Mohile SG. Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer. Cancer 2020; 127:149-159. [PMID: 33036063 PMCID: PMC7736110 DOI: 10.1002/cncr.33259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 07/06/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes. METHODS For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method. RESULTS Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008). CONCLUSIONS Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes.
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Affiliation(s)
- Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Enrique Soto Pérez de Celis
- Department of Geriatrics, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Eva Culakova
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Ronald M Epstein
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Family Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Psychiatry, University of Rochester Medical Center, Rochester, New York.,Department of Medicine, Palliative Care, University of Rochester Medical Center, Rochester, New York
| | - Huiwen Xu
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Surgery, Cancer Control, University of Rochester Medical Center, Rochester, New York
| | - Sindhuja Kadambi
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Marie Flannery
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Allison Magnuson
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Colin McHugh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gina Tuch
- Department of Aged Care, Alfred Health, Melbourne, Victoria, Australia
| | - Erika Ramsdale
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Margaret Sedenquist
- SCOREboard Advisory Group, University of Rochester Medical Center, Rochester, New York
| | - Jane Jijun Liu
- Heartland National Cancer Institute Community Oncology Research Program (NCORP), Decatur, Illinois
| | | | - Jodi Geer
- Metro-Minnesota NCORP, St Paul, Minnesota
| | - Supriya G Mohile
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
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Loh KP, Xu H, Back A, Duberstein PR, Gupta Mohile S, Epstein R, McHugh C, Klepin HD, Abel G, Lee SJ, El-Jawahri A, LeBlanc TW. Patient-hematologist discordance in perceived chance of cure in hematologic malignancies: A multicenter study. Cancer 2019; 126:1306-1314. [PMID: 31809566 DOI: 10.1002/cncr.32656] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/29/2019] [Accepted: 11/07/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Ensuring that patients with hematologic malignancies have an accurate understanding of their likelihood of cure is important for informed decision making. In a multicenter, longitudinal study, the authors examined discordance in patients' perception of their chance of cure versus that of their hematologists, whether patient-hematologist discordance changed after a consultation with a hematologist, and factors associated with persistent discordance. METHODS Before and after consultation with a hematologist, patients were asked about their perceived chance of cure (options were <10%, 10%-19%, and up to 90%-100% in 10% increments, and "do not wish to answer"). Hematologists were asked the same question after consultation. Discordance was defined as a difference in response by 2 levels. The McNemar test was used to compare changes in patient-hematologist prognostic discordance from before to after consultation. A generalized linear mixed model was used to examine associations between factors and postconsultation discordance, adjusting for clustering at the hematologist level. RESULTS A total of 209 patients and 46 hematologists from 4 sites were included in the current study. Before consultation, approximately 61% of dyads were discordant, which improved to 50% after consultation (P < .01). On multivariate analysis, lower educational level (<college vs postgraduate: odds ratio [OR], 2.24; 95% CI, 1.02-4.92), higher social support-affection subscale score (1-unit change in score: OR, 1.15; 95% CI, 1.00-1.32), and discordance before consultation (OR, 6.17; 95% CI, 2.99-12.72) were found to be significantly associated with discordance after consultation. CONCLUSIONS Patient-hematologist concordance in prognostic understanding appears to improve after a hematology consultation, but approximately one-half of patients' views of their prognoses were found to remain discordant with those of their hematologists. Interventions are needed to improve prognostic understanding among patients with hematologic malignancies.
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Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Anthony Back
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Supriya Gupta Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Ronald Epstein
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Palliative Care Program, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Colin McHugh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Heidi D Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina
| | - Gregory Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Areej El-Jawahri
- Department of Hematology-Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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32
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Douglas SL, Daly BJ, Meropol NJ, Lipson AR. Patient-physician discordance in goals of care for patients with advanced cancer. ACTA ACUST UNITED AC 2019; 26:370-379. [PMID: 31896935 DOI: 10.3747/co.26.5431] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background Shared decision-making at end of life (eol) requires discussions about goals of care and prioritization of length of life compared with quality of life. The purpose of the present study was to describe patient and oncologist discordance with respect to goals of care and to explore possible predictors of discordance. Methods Patients with metastatic cancer and their oncologists completed an interview at study enrolment and every 3 months thereafter until the death of the patient or the end of the study period (15 months). All interviewees used a 100-point visual analog scale to represent their current goals of care, with quality of life (scored as 0) and survival (scored as 100) serving as anchors. Discordance was defined as an absolute difference between patient and oncologist goals of care of 40 points or more. Results The study enrolled 378 patients and 11 oncologists. At baseline, 24% discordance was observed, and for patients who survived, discordance was 24% at their last interview. For patients who died, discordance was 28% at the last interview before death, with discordance having been 70% at enrolment. Dissatisfaction with eol care was reported by 23% of the caregivers for patients with discordance at baseline and by 8% of the caregivers for patients who had no discordance (p = 0.049; ϕ = 0.20). Conclusions The data indicate the presence of significant ongoing oncologist-patient discordance with respect to goals of care. Early use of a simple visual analog scale to assess goals of care can inform the oncologist about the patient's goals and lead to delivery of care that is aligned with patient goals.
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Affiliation(s)
- S L Douglas
- Case Comprehensive Cancer Center, Cleveland, OH.,Case Western Reserve University, Cleveland, OH
| | - B J Daly
- Flatiron Health, an independent subsidiary of the Roche Group, New York, NY, U.S.A.,Case Comprehensive Cancer Center, Cleveland, OH.,Case Western Reserve University, Cleveland, OH
| | - N J Meropol
- Case Comprehensive Cancer Center, Cleveland, OH.,Case Western Reserve University, Cleveland, OH.,University Hospitals Cleveland Medical Center, Cleveland, OH.,Flatiron Health, an independent subsidiary of the Roche Group, New York, NY, U.S.A
| | - A R Lipson
- Case Comprehensive Cancer Center, Cleveland, OH
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Association of illness understanding with advance care planning and end-of-life care preferences for advanced cancer patients and their family members. Support Care Cancer 2019; 28:2959-2967. [DOI: 10.1007/s00520-019-05174-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
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George LS, Balboni TA, Maciejewski PK, Epstein AS, Prigerson HG. "My doctor says the cancer is worse, but I believe in miracles"-When religious belief in miracles diminishes the impact of news of cancer progression on change in prognostic understanding. Cancer 2019; 126:832-839. [PMID: 31658374 DOI: 10.1002/cncr.32575] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/23/2019] [Accepted: 09/14/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND News of cancer progression is critical to setting accurate prognostic understanding, which guides patients' treatment decision making. This study examines whether religious belief in miracles modifies the effect of receiving news of cancer progression on change in prognostic understanding. METHODS In a multisite, prospective cohort study, 158 patients with advanced cancer, whom oncologists expected to die within 6 months, were assessed before and after the visit at which scan results were discussed. Before the visit, religious belief in miracles was assessed; after the visit, patients indicated what scan results they had received (cancer was worse vs cancer was stable, better, or other). Before and after the visit, prognostic understanding was assessed, and a change score was computed. RESULTS Approximately 78% of the participants (n = 123) reported at least some belief in miracles, with almost half (n = 73) endorsing the strongest possible belief. A significant interaction effect emerged between receiving news of cancer progression and belief in miracles in predicting change in prognostic understanding (b = -0.18, P = .04). Receiving news of cancer progression was associated with improvement in the accuracy of prognostic understanding among patients with weak belief in miracles (b = 0.67, P = .007); however, among patients with moderate to strong belief in miracles, news of cancer progression was unrelated to change in prognostic understanding (b = 0.08, P = .64). CONCLUSIONS Religious belief in miracles was highly prevalent and diminished the impact of receiving news of cancer progression on prognostic understanding. Assessing patients' beliefs in miracles may help to optimize the effectiveness of "bad news" scan result discussions.
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Affiliation(s)
- Login S George
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tracy A Balboni
- Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul K Maciejewski
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Deparment of Radiology, Weill Cornell Medicine, New York, New York
| | - Andrew S Epstein
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
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Dover LL, Dulaney CR, Williams CP, Fiveash JB, Jackson BE, Warren PP, Kvale EA, Boggs DH, Rocque GB. Hospice care, cancer-directed therapy, and Medicare expenditures among older patients dying with malignant brain tumors. Neuro Oncol 2019; 20:986-993. [PMID: 29156054 DOI: 10.1093/neuonc/nox220] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background End-of-life care for older adults with malignant brain tumors is poorly understood. The purpose of this study is to quantify end-of-life utilization of hospice care, cancer-directed therapy, and associated Medicare expenditures among older adults with malignant brain tumors. Methods This retrospective cohort study included deceased Medicare beneficiaries age ≥65 with primary malignant brain tumor (PMBT) or secondary MBT (SMBT) receiving care within a southeastern cancer community network including academic and community hospitals from 2012-2015. Utilization of hospice and cancer-directed therapy and total Medicare expenditures in the last 30 days of life were calculated using generalized linear and mixed effect models, respectively. Results Late (1-3 days prior to death) or no hospice care was received by 24% of PMBT (n = 383) and 32% of SMBT (n = 940) patients. SMBT patients received late hospice care more frequently than PMBT patients (10% vs 5%, P = 0.002). Cancer-directed therapy was administered to 18% of patients with PMBT versus 25% with SMBT (P = 0.003). Nonwhite race, male sex, and receipt of any hospital-based care in the final 30 days of life were associated with increased risk of late or no hospice care. The average decrease in Medicare expenditures associated with hospice utilization for patients with PMBT was $-12,138 (95% CI: $-18,065 to $-6210) and with SMBT was $-1,508 (95% CI: $-3,613 to $598). Conclusions Receiving late or no hospice care was common among older patients with malignant brain tumors and was significantly associated with increased total Medicare expenditures for patients with PMBT.
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Affiliation(s)
- Laura L Dover
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Caleb R Dulaney
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Courtney P Williams
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bradford E Jackson
- Center for Outcomes Research, John Peter Smith Hospital Health Network, Fort Worth, Texas
| | - Paula P Warren
- Department of Neurology, Division of Neuro-Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth A Kvale
- Department of Medicine, Division of Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Birmingham VA Medical Center, Birmingham Alabama
| | - D Hunter Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gabrielle B Rocque
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Medicine, Division of Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Duckworth KE, Morrell R, Russell GB, Powell B, Canzona M, Lichiello S, Riffle O, Tolbert A, McQuellon R. Goals and Adverse Effects: Rate of Concordance Between Patients and Providers. J Oncol Pract 2019; 15:e798-e806. [PMID: 31356148 DOI: 10.1200/jop.19.00015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Adequate understanding of the goals and adverse effects of cancer treatment has important implications for patients' decision making, expectations, and mood. This study sought to identify the degree to which patients and clinicians agreed upon the goals and adverse effects of treatment (ie, concordance). METHODS Patients completed a demographic questionnaire, the National Comprehensive Cancer Network Distress Thermometer, the Medical Outcomes Study Social Support Survey, the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-General questionnaire, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being questionnaire, and a 13-item questionnaire about the goals and adverse effects of treatment. Providers completed a 12-item questionnaire. RESULTS One hundred patients (51 female) and 34 providers participated (questionnaire return rate mean difference, 5 days; SD, 16 days). Patient and provider dyads agreed 61% of the time regarding the intent of treatment. In cases of nonagreement, 36% of patients reported more optimistic therapy goals compared to providers. Patients and providers agreed 69% of the time regarding the patient's acknowledgement and understanding of adverse effects. Patients who reported an understanding of likely adverse effects endorsed significantly lower distress scores (mean, 2.5) than those who endorsed not understanding associated adverse effects (mean, 4.1; P = .008). CONCLUSION Timely data capturing of patient-provider dyadic ratings is feasible. A significant discrepancy exists between a substantial percentage of patients' and providers' views of the intent and adverse effects of treatment. Patients were almost always more optimistic about the intent of treatment. Higher rates of distress were noted in cases of discordance. Providers may benefit from conversational feedback from patients as well as other integrated feedback systems to inform them about patient understanding.
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Affiliation(s)
| | | | | | - Bayard Powell
- Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | | | - Olivia Riffle
- The University of North Carolina at Charlotte, Charlotte, NC
| | - Aimee Tolbert
- Wake Forest Baptist Medical Center, Winston-Salem, NC
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Loh KP, Mohile SG, Lund JL, Epstein R, Lei L, Culakova E, McHugh C, Wells M, Gilmore N, Mohamed MR, Kamen C, Aarne V, Conlin A, Bearden J, Onitilo A, Wittink M, Dale W, Hurria A, Duberstein P. Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists. Oncologist 2019; 24:e292-e302. [PMID: 31015317 PMCID: PMC6656513 DOI: 10.1634/theoncologist.2018-0890] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/11/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Ensuring older patients with advanced cancer and their oncologists have similar beliefs about curability is important. We investigated discordance in beliefs about curability in patient-oncologist and caregiver-oncologist dyads. MATERIALS AND METHODS We used baseline data from a cluster randomized trial assessing whether geriatric assessment improves communication and quality of life in older patients with advanced cancer and their caregivers. Patients were aged ≥70 years with incurable cancer from community oncology practices. Patients, caregivers, and oncologists were asked: "What do you believe are the chances the cancer will go away and never come back with treatment?" Options were 100%, >50%, 50/50, <50%, and 0% (5-point scale). Discordance in beliefs about curability was defined as any difference in scale scores (≥3 points were severe). We used multivariate logistic regressions to describe correlates of discordance. RESULTS Discordance was present in 60% (15% severe) of the 336 patient-oncologist dyads and 52% (16% severe) of the 245 caregiver-oncologist dyads. Discordance was less common in patient-oncologist dyads when oncologists practiced longer (adjusted odds ratio [AOR] 0.90, 95% confidence interval [CI] 0.84-0.97) and more common in non-Hispanic white patients (AOR 5.77, CI 1.90-17.50) and when patients had lung (AOR 1.95, CI 1.29-2.94) or gastrointestinal (AOR 1.55, CI 1.09-2.21) compared with breast cancer. Severe discordance was more common when patients were non-Hispanic white, had lower income, and had impaired social support. Caregiver-oncologist discordance was more common when caregivers were non-Hispanic white (AOR 3.32, CI 1.01-10.94) and reported lower physical health (AOR 0.88, CI 0.78-1.00). Severe discordance was more common when caregivers had lower income and lower anxiety level. CONCLUSION Discordance in beliefs about curability is common, occasionally severe, and correlated with patient, caregiver, and oncologist characteristics. IMPLICATIONS FOR PRACTICE Ensuring older patients with advanced cancer and their caregivers have similar beliefs about curability as the oncologist is important. This study investigated discordance in beliefs about curability in patient-oncologist (PO) and caregiver-oncologist (CO) dyads. It found that discordance was present in 60% (15% severe) of PO dyads and 52% (16% severe) of CO dyads, raising serious questions about the process by which patients consent to treatment. This study supports the need for interventions targeted at the oncologist, patient, caregiver, and societal levels to improve the delivery of prognostic information and patients'/caregivers' understanding and acceptance of prognosis.
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Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Jennifer L Lund
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald Epstein
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
- Department of Psychiatry, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
- Department of Family Medicine, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
- Department of Medicine, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
| | - Lianlian Lei
- Department of Public Health Services, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Eva Culakova
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Colin McHugh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Megan Wells
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Nikesha Gilmore
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Mostafa R Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Charles Kamen
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Valerie Aarne
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Alison Conlin
- Pacific Cancer Research Consortium NCORP, Seattle, Washington, USA
| | - James Bearden
- Southeast Clinical Oncology Research Consortium NCORP, Winston-Salem, North Carolina, USA
| | | | - Marsha Wittink
- Department of Psychiatry, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
| | - William Dale
- City of Hope National Medical Center, Duarte, California, USA
| | - Arti Hurria
- City of Hope National Medical Center, Duarte, California, USA
| | - Paul Duberstein
- Department of Psychiatry, Palliative Care, University of Rochester Medical Center, Rochester, New York, USA
- Rutgers School of Public Health, Piscataway, New Jersey, USA
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Trevino KM, Prigerson HG, Shen MJ, Tancredi DJ, Xing G, Hoerger M, Epstein RM, Duberstein PR. Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment. Cancer 2019; 125:3259-3265. [PMID: 31145833 PMCID: PMC6717015 DOI: 10.1002/cncr.32188] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment. METHODS The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale. RESULTS Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life. CONCLUSIONS Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions.
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Affiliation(s)
- Kelly M Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Department of Medicine, New York Presbyterian Hospital, New York, New York
| | - Megan Johnson Shen
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Department of Medicine, New York Presbyterian Hospital, New York, New York
| | - Daniel J Tancredi
- Department of Pediatrics, University of California at Davis, Davis, California
| | - Guibo Xing
- Department of Pediatrics, University of California at Davis, Davis, California
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Paul R Duberstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, New Jersey
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39
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Dover LL, Dulaney CR, Fiveash JB, Williams CP, Jackson BE, Warren P, Rocque GB. Hospital-Based End-of-Life Care and Costs for Older Patients With Malignant Brain Tumors. JAMA Oncol 2019; 3:1581-1582. [PMID: 28655028 DOI: 10.1001/jamaoncol.2017.1624] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laura L Dover
- Department of Radiation Oncology, University of Alabama at Birmingham
| | - Caleb R Dulaney
- Department of Radiation Oncology, University of Alabama at Birmingham
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham
| | - Courtney P Williams
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham
| | - Bradford E Jackson
- Department of Biostatistics and Epidemiology, University of North Texas Health Sciences Center, Fort Worth
| | - Paula Warren
- Division of Neuro-oncology, Department of Neurology, University of Alabama at Birmingham
| | - Gabrielle B Rocque
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham
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40
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Rodenbach RA, Norton SA, Wittink MN, Mohile S, Prigerson HG, Duberstein PR, Epstein RM. When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:909-915. [PMID: 30579772 PMCID: PMC6491225 DOI: 10.1016/j.pec.2018.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/23/2018] [Accepted: 12/12/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions. METHODS Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life. RESULTS Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude. CONCLUSION Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life. PRACTICE IMPLICATIONS Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care.
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Affiliation(s)
- Rachel A Rodenbach
- University of Pittsburgh Medical Center, 3459 5th Ave, Pittsburgh, PA, 15213, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA.
| | - Sally A Norton
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Marsha N Wittink
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Supriya Mohile
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Holly G Prigerson
- Weill Cornell Medicine, 413 E 69th St, New York City, NY, 10021, USA
| | - Paul R Duberstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA; Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Ronald M Epstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA
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Saeed F, Sardar MA, Davison SN, Murad H, Duberstein PR, Quill TE. Patients' perspectives on dialysis decision-making and end-of-life care
. Clin Nephrol 2019; 91:294-300. [PMID: 30663974 PMCID: PMC6595398 DOI: 10.5414/cn109608] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 04/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Few studies have explored dialysis patients' perspectives on dialysis decision-making and end-of-life-care (EoLC) preferences. We surveyed a racially diverse cohort of maintenance dialysis patients in the Cleveland, OH, USA, metropolitan area. MATERIALS AND METHODS In this cross-sectional study, we administered a 41-item questionnaire to 450 adult chronic dialysis patients. Items assessed patients' knowledge of their kidney disease as well as their attitudes toward chronic kidney disease (CKD) treatment issues and EoLC issues. RESULTS The cohort included 67% Blacks, 27% Caucasians, 2.8% Hispanics, and 2.4% others. The response rate was 94% (423/450). Most patients considered it essential to obtain detailed information about their medical condition (80.6%) and prognosis (78.3%). Nearly 19% of respondents regretted their decision to start dialysis. 41% of patients would prefer treatment(s) aimed at relieving pain rather than prolonging life (30.5%), but a majority would want to be resuscitated (55.3%). Only 8.4% reported having a designated healthcare proxy, and 35.7% reported completing a living will. A significant percentage of patients wished to discuss their quality of life (71%), psychosocial and spiritual concerns (50.4%), and end-of-life issues (38%) with their nephrologist. CONCLUSION Most dialysis patients wish to have more frequent discussions about their disease, prognosis, and EoLC planning. Findings from this study can inform the design of future interventions.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology
- Division of Palliative Care University of Rochester School of Medicine and Dentistry, Rochester
| | | | - Sara N. Davison
- Division of Nephrology & Immunology, University of Alberta, Edmonton, Alberta, Canada, and
| | - Haris Murad
- Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Paul R. Duberstein
- Division of Palliative Care University of Rochester School of Medicine and Dentistry, Rochester
- Department of Psychiatry, and Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Timothy Edward Quill
- Division of Palliative Care University of Rochester School of Medicine and Dentistry, Rochester
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Wong A, Billett A, Milne D. Balancing the Hype with Reality: What Do Patients with Advanced Melanoma Consider When Making the Decision to Have Immunotherapy? Oncologist 2019; 24:e1190-e1196. [PMID: 31015314 DOI: 10.1634/theoncologist.2018-0820] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/19/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Immunotherapy has resulted in unprecedented improvements in survival and maintained quality of life for many patients with advanced melanoma. However, durable responses are observed in only a minority of patients, and severe treatment side effects are experienced by 5%-30%. There are no reliable tests that can differentiate between patients who are likely to respond to immunotherapy and those who will not. Hence, new challenges have arisen as clinicians try to facilitate patients in their decision-making regarding immunotherapy. Furthermore, little is known about the real-world patients' experience and understanding of immunotherapy outside the clinical trial setting. Here, we explore the perspectives of patients undergoing immunotherapy for melanoma and focus on factors that influenced their treatment decision-making. MATERIALS AND METHODS Twenty-three in-depth semistructured interviews were conducted with patients receiving pembrolizumab for stage IV melanoma at an Australian public cancer hospital. Patients were recruited at a range of time points after commencing therapy, and their experience of treatment was explored. Interviews were audio recorded, transcribed verbatim, coded, and analyzed thematically. RESULTS Immunotherapy is viewed as a symbol of hope, with high-profile anecdotes reinforcing this perception. Only a minority of patients expressed a good understanding of the likely efficacy and potential treatment side effects. Patients are reliant on their clinicians' recommendation regarding immunotherapy treatment decisions. CONCLUSION Novel treatments such as immunotherapy provide significant hope for patients. This may influence their preference for immunotherapy over and above the usual considerations of the trade-off between efficacy and toxicity. Careful counsel and individualized patient resources may further facilitate treatment decision-making. IMPLICATIONS FOR PRACTICE This study highlighted some of the misconceptions held by patients that need to be addressed when discussing the possibility of receiving treatment with immunotherapy for advanced melanoma. Patients placed a lot of importance on high-profile anecdotes rather than truly understanding likely outcomes of treatment based on personal circumstances. The majority of patients had a poor understanding of the potential side effects and long-term implications of treatment with immunotherapy. Careful counsel is required in order to facilitate informed decision-making about treatment and to ensure possible side effects are known and appreciated. Further research is needed to develop tools to aid decision-making in everyday clinical practice.
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Affiliation(s)
- Annie Wong
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - Alex Billett
- Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - Donna Milne
- Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- Melanoma and Skin Unit, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
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Loh KP, Mohile SG, Epstein RM, McHugh C, Flannery M, Culakova E, Lei L, Wells M, Gilmore N, Babu D, Whitehead MI, Dale W, Hurria A, Wittink M, Magnuson A, Conlin A, Thomas M, Berenberg J, Duberstein PR. Willingness to bear adversity and beliefs about the curability of advanced cancer in older adults. Cancer 2019; 125:2506-2513. [PMID: 30920646 DOI: 10.1002/cncr.32074] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/07/2019] [Accepted: 02/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown. METHODS Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50, <50%, 0%, and uncertain. The willingness to bear adversity in exchange for longevity was assessed by asking patients to consider trade-offs between survival and 2 clinical outcomes that varied in abstractness: 1) maintaining quality of life (QOL; an abstract outcome); and 2) specific treatment-related toxicities (eg, nausea/vomiting, worsening memory). Logistic regression was used to assess the independent associations between willingness to bear adversity and ACC. RESULTS Of the 524 patients aged 70 to 96 years, approximately 5.3% reported that there was a 100% chance that their cancer would be cured (ACC). ACC was not found to be significantly associated with willingness to bear treatment-related toxicities, but was more common among patients who were willing to trade QOL for survival (adjusted odds ratio, 4.08; 95% CI, 1.17-14.26). CONCLUSIONS Patients who were more willing to bear adversity in the form of an abstract state, namely decreased QOL, were more likely to demonstrate ACC. Although conversations regarding prognosis should be conducted with all patients, those who are willing to trade QOL for survival may especially benefit from conversations that focus on values and emotions.
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Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Ronald M Epstein
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Division of Palliative Care, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Colin McHugh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Marie Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eva Culakova
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Lianlian Lei
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Megan Wells
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Dilip Babu
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Mary I Whitehead
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - William Dale
- Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Arti Hurria
- Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Marsha Wittink
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Allison Magnuson
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alison Conlin
- Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program (NCORP), Seattle, Washington
| | - Melanie Thomas
- Southeast Clinical Oncology Research Consortium (SCOR), Winston-Salem, North Carolina
| | - Jeffrey Berenberg
- Hawaii Minority Underserved National Cancer Institute Community Oncology Research Program (MU-NCORP), Honolulu, Hawaii
| | - Paul R Duberstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Social and Behavioral Health Sciences, Rutgers School of Public Health, New Brunswick, New Jersey
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Bergerot CD, Bergerot PG, Philip EJ, Hsu JA, Dizman N, Vaishampayan U, Dorff T, Pal SK. Perception of cure among patients with metastatic genitourinary cancer initiating immunotherapy. J Immunother Cancer 2019; 7:71. [PMID: 30867071 PMCID: PMC6416952 DOI: 10.1186/s40425-019-0557-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/04/2019] [Indexed: 12/14/2022] Open
Abstract
Background Despite the advent of checkpoint inhibitors (CPIs) for advanced genitourinary (GU) cancers, existing studies suggest that durable complete responses are observed in fewer than 10% of patients. This study sought to evaluate the association between expectations of cure reported by patients with advanced GU cancers initiating immunotherapy and quality of life (QOL), anxiety and depression. Patient and methods A single-institution, cross-sectional survey study was conducted with patients preparing to receive CPIs for treatment of metastatic renal cell carcinoma (RCC), urothelial cancer (UC) and prostate cancer (PC). Patients were assessed prior to initiation of immunotherapy for expectations of cure (divided into four quartiles), quality of life (QOL; Functional Assessment of Chronic Illness Therapy-General [FACT-G]), and symptoms of anxiety and depression (PROMIS). Results Sixty patients were enrolled, with metastatic RCC, UC and PC comprising 63, 28 and 8% of the study population, respectively. Median age of the cohort was 65 (range, 31–91), and 68% were male; 33% received CPI in the first-line setting. Despite extensive counseling from oncologists regarding potential clinical outcomes with immunotherapy, a substantial proportion of patients (23%) harbored inaccurate expectations regarding the potential benefit of immunotherapy. Importantly, patients with accurate expectations of cure reported lower anxiety scores using the PROMIS-Anxiety inventory. No significant differences were found between expectations of cure and quality of life or depression, using the FACT-G and PROMIS-Depression inventories, respectively. Conclusion The current study found that a considerable proportion of patients with advanced GU cancers harbor inaccurate expectations concerning the potential benefit of immunotherapy. These results suggest that more effective counselling may mitigate patient anxiety, and potentially promote treatment satisfaction and adherence.
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Affiliation(s)
- Cristiane Decat Bergerot
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Paulo Gustavo Bergerot
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Errol J Philip
- University of California San Francisco, San Francisco, CA, USA
| | - Jo Ann Hsu
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Nazli Dizman
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Ulka Vaishampayan
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI, USA
| | - Tanya Dorff
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Sumanta Kumar Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA.
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Trevino KM, Maciejewski PK, Shen MJ, Prigerson HG, Mohile S, Kamen C, Epstein RM, Duberstein P. How much time is left? Associations between estimations of patient life expectancy and quality of life in patients and caregivers. Support Care Cancer 2018; 27:2487-2496. [PMID: 30387051 PMCID: PMC6494724 DOI: 10.1007/s00520-018-4533-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/26/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE It is unclear whether life-expectancy estimates of patients with advanced cancer and their caregivers are associated with patient existential, social, or emotional quality of life (QOL) or caregiver emotional QOL. METHODS Patients with advanced cancer and their caregivers (n = 162 dyads) reported estimates of the chance the patient would live for 2 years or more from 0% (most pessimistic) to 100% (most optimistic). They also completed self-report measures of QOL. RESULTS Adjusting for sociodemographic confounds and multiple comparisons, more pessimistic caregiver and patient life-expectancy estimates were associated with worse caregiver emotional QOL and worse patient existential QOL. Discrepancies between patient and caregiver estimates were not associated with patient or caregiver QOL. CONCLUSIONS Pessimistic life-expectancy estimates are associated with worse existential QOL in patients and worse emotional QOL in caregivers. Prospective research to establish causal relationships is needed, and interventions to address the relationship between beliefs about life expectancy and existential and emotional QOL should be considered. Providing these interventions to patients and caregivers receiving information on life expectancy may mitigate the negative impact of life-expectancy information on patient existential quality of life.
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Affiliation(s)
- Kelly M Trevino
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA.
| | - Paul K Maciejewski
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA
| | - Megan Johnson Shen
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA
| | - Holly G Prigerson
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA
| | - Supriya Mohile
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Charles Kamen
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Ronald M Epstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Paul Duberstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
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Ilowite MF, Al-Sayegh H, Ma C, Dussel V, Rosenberg AR, Feudtner C, Kang TI, Wolfe J, Bona K. The relationship between household income and patient-reported symptom distress and quality of life in children with advanced cancer: A report from the PediQUEST study. Cancer 2018; 124:3934-3941. [PMID: 30216416 DOI: 10.1002/cncr.31668] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/15/2018] [Accepted: 06/11/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Children with advanced cancer experience high symptom distress, which negatively impacts their health-related quality of life (HRQOL). To the authors' knowledge, the relationship between income and symptom distress and HRQOL is not well described. METHODS The Pediatric Quality of Life and Symptoms Technology (PediQUEST) multisite clinical trial evaluated an electronic patient-reported outcome system to describe symptom distress and HRQOL in children with advanced cancer via repeated surveys. The authors performed a secondary analysis of PediQUEST data for those children with available parent-reported household income (dichotomized at 200% of the Federal Poverty Level and categorized as low income [<$50,000/year] or high income [≥$50,000/year]). The prevalence of the 5 most commonly reported physical and psychological symptoms was compared between groups. Multivariable generalized estimating equation models were used to test the association between household income and symptom distress and HRQOL. RESULTS A total of 78 children were included in the analyses: 56 (72%) in the high-income group and 22 (28%) in the low-income group. Low-income children were more likely to report pain than high-income children (64% vs 42%; P=.02). In multivariable models, children from low-income families demonstrated a uniform trend toward higher total (βlow-high =3.1; 95% confidence interval [95% CI], -0.08 to 6.2 [P=.06]), physical (β=3.8; 95% CI, -0.4 to 8.0 [P=.09]), and psychological (β=3.46; 95% CI, -1.91 to 8.84 [P=.21]) symptom distress compared with children from high-income families. Low income was associated with a uniform trend toward lower total (β=-7.9; 95% CI, -14.8, to -1.1 [P=.03]), physical (β=-11.2; 95% CI, -21.2 to -1.2 [P=.04]), emotional (β=-5.8; 95% CI, -13.6 to 2.0 [P=.15]), social (β=-2.52; 95% CI, -9.27 to 4.24 [P=.47]), and school (β=-9.8; 95% CI, -17.8 to -1.8 [P=.03]) HRQOL. CONCLUSIONS In this cohort of children with advanced cancer, children from low-income families were found to experience higher symptom burden and worse QOL.
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Affiliation(s)
- Maya F Ilowite
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Clement Ma
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Veronica Dussel
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Center for Research and Implementation in Palliative Care, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Abby R Rosenberg
- Seattle Children's Hospital Cancer and Blood Disorders Center, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tammy I Kang
- Section of Palliative Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Joanne Wolfe
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kira Bona
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
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Peterson EB, Chou WYS, Falisi A, Ferrer R, Mollica MA. The role of medical social workers in cancer clinical trial teams: A group case study of multidisciplinary perspectives. SOCIAL WORK IN HEALTH CARE 2018; 57:688-704. [PMID: 29856290 DOI: 10.1080/00981389.2018.1477899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Social workers collaborate with a wide range of healthcare providers in clinical trial teams, yet their roles may not always be understood or supported by team members. It is currently unknown how social workers and multidisciplinary team members perceive social workers' roles in the clinical trial context. METHODS Using a group case-study approach, social workers, core medical team members, and allied healthcare workers (n = 19) completed in-depth interviews to discuss the roles of social workers in a cancer clinical trial setting. FINDINGS Social workers discussed their role as primarily patient-centered, perceiving themselves to be a counselor, patient advocate, and conduit. They also described areas of perceived limited role contribution. Other members of the multidisciplinary teams viewed the roles of social workers to be focused on being a conduit and coordinator. DISCUSSION We found discordance in the way that social workers and their team members view the roles of social workers in clinical trials. Our data suggest that structural and interpersonal barriers may prevent social workers from working to the full extent of their license in a clinical trial context. Implications, future research, and suggestions for interventions to more fully integrate social workers into clinical trial settings are discussed.
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Affiliation(s)
- Emily B Peterson
- a Division of Cancer Control and Population Sciences , National Cancer Institute , Rockville , MD , USA
| | - Wen-Ying Sylvia Chou
- a Division of Cancer Control and Population Sciences , National Cancer Institute , Rockville , MD , USA
| | - Angela Falisi
- a Division of Cancer Control and Population Sciences , National Cancer Institute , Rockville , MD , USA
| | - Rebecca Ferrer
- a Division of Cancer Control and Population Sciences , National Cancer Institute , Rockville , MD , USA
| | - Michelle A Mollica
- a Division of Cancer Control and Population Sciences , National Cancer Institute , Rockville , MD , USA
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Agarwal R, Epstein AS. Advance Care Planning and End-of-Life Decision Making for Patients with Cancer. Semin Oncol Nurs 2018; 34:316-326. [PMID: 30100366 DOI: 10.1016/j.soncn.2018.06.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To highlight the importance, challenges, and evolution of advance care planning for patients with cancer. DATA SOURCES Peer-reviewed journal articles and clinical guidelines. CONCLUSION Advance care planning is fundamental to support the personhood of patients with advanced cancer. Patients must be encouraged by physicians and nurses to articulate what matters and provides meaning to them as they live, cope, and receive treatment for their cancer. IMPLICATIONS FOR NURSING PRACTICE Nurses can facilitate advance care planning and primary palliative care, to support patients and families to make informed and value-concordant decisions regarding cancer and end-of-life treatments.
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Mackenzie LJ, Carey ML, Suzuki E, Sanson-Fisher RW, Asada H, Ogura M, D’Este C, Yoshimura M, Toi M. Agreement between patients' and radiation oncologists' cancer diagnosis and prognosis perceptions: A cross sectional study in Japan. PLoS One 2018; 13:e0198437. [PMID: 29883453 PMCID: PMC5993258 DOI: 10.1371/journal.pone.0198437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 05/18/2018] [Indexed: 12/01/2022] Open
Abstract
This study assessed agreement between radiation oncologist- and cancer patient-reported perceptions about cancer diagnosis, time since diagnosis, treatment purpose, and whether life expectancy had been discussed; and described preferences for prognosis discussions. Adult cancer patients receiving radiotherapy at a Japanese hospital were invited to complete a touchscreen tablet survey. Patient survey responses were linked and comparisons made with a survey completed by their radiation oncologist. Among 146 cancer patient-oncologist dyads, there was almost perfect agreement on cancer diagnosis (ĸ = 0.88, 95% CI: 0.82–0.94), substantial agreement on time since diagnosis (ĸ = 0.70, 95% CI: 0.57–0.83) and moderate agreement on whether treatment goal was curative or palliative (ĸ = 0.44, 95% CI: 0.28–0.57; all p’s < 0.0001). Agreement about whether a life expectancy discussion had occurred was less than expected by chance (κ = -0.06, p = 0.9). Radiation oncologists reported that they had spoken to over two thirds of patients about this, whilst less than one third of patients stated that this discussion had occurred with their radiation oncologist. Over half of the patients who had not discussed life expectancy wanted to. Patients had variable preferences for whether they (80%), their radiation oncologist (78%) or their partner/family (52%) should decide whether they discuss their life expectancy. Although patient self-reported information about diagnosis and time since diagnosis appears to be reasonably accurate (compared with clinician-reported information), limitations of self-reported data about prognostic discussions were highlighted by poor agreement between patient- and clinician-reported information about whether prognostic discussions have occurred. Additional support is needed to improve prognosis communication and understanding in radiation oncology settings.
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Affiliation(s)
- Lisa Jane Mackenzie
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Graduate School of Medicine, Kyoto University Hospital, Kyoto, Japan
- * E-mail:
| | - Mariko Leanne Carey
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Eiji Suzuki
- Breast Surgery, Kyoto University Hospital, Kyoto, Japan
| | | | - Hiromi Asada
- Department of Nursing, Kyoto University Hospital, Kyoto, Japan
| | - Masakazu Ogura
- Department of Radiation Oncology and Image Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Catherine D’Este
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Acton, Australian Capital Territory, Australia
| | - Michio Yoshimura
- Department of Radiation Oncology and Image Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Masakazu Toi
- Breast Surgery, Kyoto University Hospital, Kyoto, Japan
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Gyawali B, Niraula S. Cancer treatment in the last 6 months of life: when inaction can outperform action. Ecancermedicalscience 2018; 12:826. [PMID: 29743946 PMCID: PMC5931812 DOI: 10.3332/ecancer.2018.826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Indexed: 11/14/2022] Open
Abstract
When an investigational anticancer drug is being tested, demonstration of improvement in overall survival (OS) will generally lead to regulatory approval. However, the value that improvement in OS adds to patients’ lives is guided largely by the context of the improvement and accompanying trade-offs. For example, when a patient’s life expectancy is less than 6 months, many oncologists will not embark on any active cancer treatments. However, multiple new anticancer drugs have been approved recently after being tested in end-stage cancer patients and demonstrating median OS in the experimental arm close to 6 months. Such practice, particularly when the treatment is also accompanied by serious toxicities and cost, can undermine a peaceful life-death transition. In this commentary, we review regulatory approvals in the last 5 years and the ethical considerations involved in testing active cancer treatment in terminal cancer patients.
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Affiliation(s)
- Bishal Gyawali
- Program on Regulation, Therapeutics and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Saroj Niraula
- Department of Medical Oncology and Hematology, University of Manitoba and Cancer Care Manitoba, Winnipeg R2H 2A6, Canada
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