Behind closed doors: systematic analysis of breast cancer consultation communication and predictors of satisfaction with communication

Beyond Physical Well-being: Exploring Demographic Variances in Psychosocial Well-being before Breast Reconstruction

A patient's preoperative satisfaction with their breasts and baseline psychosocial, sexual, and physical well-being are important considerations when planning breast reconstruction. We sought to elucidate variances in preoperative responses among patients undergoing postmastectomy breast reconstruction.

Methods

Preoperative BREAST-Q responses and demographic data, including race, generation, median household incomeinstitutional review board and body mass index (BMI) were collected from breast cancer patients scheduled for mastectomy. Associations between demographic group and survey response were analyzed by chi-square or independent t-tests.

Results

In total, 646 of 826 patients identified had complete data and were included in the final analysis. Patients in BMI group 1 (16-24.9) were more likely to report feeling "very satisfied" with how they looked unclothed compared with patients in other BMI groups (P = 0.031). Conversely, patients in groups 3 and 4 (35+), reported lower satisfaction (P = 0.037) and felt less attractive without clothes (P = 0.034). Asian women were less likely to feel attractive (P = 0.007), and Black patients were less likely to feel of equal worth to other women (P < 0.001). Finally, patients were less likely to report confidence in social settings if they were Black (P < 0.001), Asian (P < 0.001), from the millennial generation (P = 0.017), or living in zip codes with median household income less than $55,000 (P = 0.042).

Conclusions

Breast cancer patients' feelings toward their natural breasts vary widely between demographic groups. Understanding baseline psychosocial factors in this population is key to informing preoperative discussions and interpreting postoperative satisfaction.

Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction

BACKGROUND

Psychological factors are broadly understood to contribute to overall health, but their contribution to wound healing is less well defined. Limited data exist on the association of preoperative psychological factors such as body image and postoperative complications. The present study analyzed the association between preoperative body image factors and postoperative complications following breast reconstruction.

METHODS

This was a prospective cohort study of 302 breast cancer patients undergoing breast reconstruction from 2011 to 2015. All patients completed the BREAST-Q; demographics, surgical details, and postoperative complications were recorded. The association of body image factors by means of the BREAST-Q and postoperative complications was analyzed.

RESULTS

On univariate analysis, patients who reported lower preoperative satisfaction with how they appeared in the mirror unclothed, or felt less self-confident or attractive, were significantly more likely to develop an infection postoperatively. Preoperative satisfaction scores were not associated with complications when analyzed in a multivariate fashion. On binomial logistic regression analysis, after controlling for age, body mass index, reconstruction technique, and use of radiotherapy, patients who reported less preoperative satisfaction with how comfortably bras fit or how they appeared in a mirror unclothed were at an increased risk for delayed wound healing.

CONCLUSIONS

Patients with lower preoperative body satisfaction were found to have an increased incidence of infections and delayed wound healing. Although postoperative outcomes are multifactorial, the data suggest that baseline psychological factors such as body image may play a role in postoperative outcomes. Broader use of prehabilitative therapies, targeted at psychosocial factors, may warrant further investigation to optimize postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Prognostic disclosure in cancer care: a systematic literature review

Background:

Collusion in cancer care is the diplomatic concealment of information between a triad of the health care professional (HCP), patient, and caregiver. Free and expressive communication is determined by multiple factors, which establishes a healthy balance between ‘patient-centric’ and ‘family-centric’ decision making. The lack of a universal approach to prognostic disclosure techniques emphasizes the need for a systematic review of contemporary practice.

Methods:

A systematic review of the literature was conducted till June 2020 using themes based on cancer, communication, prognostic disclosure, and collusion by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:

Fifty-three studies involving 10,569 subjects were studied for their utility on prognostic disclosure using different communication methods and interfaces. Twenty-three studies used a face-to-face interview with subjects while in-person telephonic interviews were conducted in two studies, 16 studies implicated semi-structured questionnaires, and 6 studies mentioned the development of a new technique/tool for disclosure. The duration of a session for prognosis-disclosure ranged from 22 min to 1 h. The involvement of palliative care specialists and mental health professionals was limited during the disclosure of the prognosis.

Conclusion:

The findings of the review indicate that patients in cancer care are aware of their diagnosis and to a certain extent of prognosis despite nondisclosure by their family members and treating teams. This review emphasizes the assessment of ‘disclosure wishes’ among patients and caregivers in separate interviews rather than simply relying on one specific method of interviewing. The nonconfrontational approach and training among HCPs are of utmost importance to build therapeutic resilience among the treating team involved in cancer care. Since many factors such as family wishes, cultural dissonance, medical model, and patient perception could become barriers to prognostic disclosure, there is a need to develop a universal approach to prognostic disclosure and handling associated collusion.

Psychosocial and Clinical Predictors of Patient Satisfaction with Cancer Care

Purpose

Patient satisfaction with healthcare was recognized as an indispensable component of healthcare quality assurance programs for decades. Limited research has explored psychosocial variables impacting patient satisfaction with cancer care. The objective of our study was to identify the level of patient satisfaction with cancer care in Riyadh, Saudi Arabia and determine the psychosocial and clinical predictors of patient satisfaction.

Methods

A cross-sectional observational study was carried out in 2018–2019 with patients with cancer at the Outpatient Oncology Clinic at King Saud University Medical City in Riyadh, Saudi Arabia. The questionnaire contained a visual analog scale (VAS) of satisfaction with cancer care, a VAS of satisfaction with social support, the Patient Health Questionnaire-9 Depression scale, and the Generalized Anxiety Disorder 7-item scale.

Results

Out of the 400 patients approached, 280 agreed to participate in the study. Of the 280 patients participating in the study, 65% were satisfied with cancer care. Higher satisfaction was associated with being non-Saudi, being employed, having fewer household residents (≤4), being satisfied with social support, not receiving radiotherapy, and receiving hormonal or biological therapy. Having anxiety or depression was also associated with lower satisfaction. After adjustment for sociodemographic and clinical characteristics, being satisfied with social support, having ≤ 4 household residents, receiving hormonal therapy, and receiving biological therapy rather than radiotherapy were all independent predictors of higher satisfaction with cancer care.

Conclusion

This study found an inadequate level of patient satisfaction with cancer care. Higher levels of satisfaction were associated with being satisfied with social support, using biological and hormonal therapy, while lower satisfaction was associated with a larger number of household residents (>4), depression, anxiety and using radiotherapy.

Prevalence of collusion in cancer communications: A meta-analysis

INTRODUCTION

Collusion is the non-disclosure of information about diagnosis or prognosis, frequently encountered in cancer care and palliative services. Unraveling collusion is a skill and differences among communication techniques by Health Care Workers have maintained the process of non-disclosure to patients and caregivers. Identifying the prevalence of collusion in cancer care is required to improve the existing strategies across the world.

METHODS

A systematic review of the literature from 1991 to 2020 in the English language was conducted with the protocol registration on PROSPERO ID (CRD 42021249216.) to identify the pooled prevalence of collusion.

RESULTS

By using random effect model, the pooled prevalence estimate among patients for the diagnostic and prognostic collusion was 24.15, (95% CI [17.09; 32.96], Tou2 = 1.0801, I²  = 97.9%, Cochran's Q = 1058.22, df = 21, p-value < 0.001) and 37.92, (95% CI [22.46; 56.30], Tou2 = 1.9641, I²  = 98.6%, Cochran's Q = 944.26, df = 13, p-value < 0.001) respectively. There was no difference across subgroups with different types of setting for the interview, WHO regions and trend over the years.

CONCLUSIONS

Substantial prevalence of collusion goes unnoticed in cancer care. A meaningful understanding of such a large prevalence requires inquiry into the existing communication paradigm in cancer care across the world. The findings also question the need of formulating uniform interview techniques and structured assessment tools or questionnaires in cancer care to improve the disclosure rates.

Employment status and information needs of patients with breast cancer: a multicentre cross-sectional study of first oncology consultations

OBJECTIVES

To investigate the early information needs of women with a recent diagnosis of breast cancer (BC) according to their employment status.

DESIGN

Cross-sectional.

SETTING

Secondary-care patients attending three outpatient oncology clinics in northern Italy.

PARTICIPANTS

377 women with a recent diagnosis of early-stage, non-metastatic BC aged 18-75 were recruited. Of them, 164 were employed, 103 non-employed and 110 retired.

OUTCOME MEASURES

The first consultation visit with an oncologist was audio-recorded and analysed for the number and type of questions asked. Linear regression models considering consultations' and patients' characteristics as confounding variables were applied.

RESULTS

Employed patients asked significantly more questions than non-employed and retired patients (17 vs 13 and 14; F=6.04; p<0.01). When age and education were included in the statistical model, the significance of employment status was rearranged among all the variables and was no more significant (b=1.2, p=0.44). Employed women asked more questions concerning disease prognosis (0.7 vs 0.4 and 0.6; F=3.5; p=0.03), prevention (1.4 vs 0.6 and 0.7; F=10.7; p<0.01), illness management (7.2 vs 6 and 5.4; F=3.8; p=0.02) and social functioning (37% vs 18% and 20%; χ²=14.3; p<0.01) compared with the other two groups. Finally, they attended more frequently the consultation alone (37% vs 18% and 25%; χ²=10.90, p<0.01), were younger (50 vs 58 and 67 years; F=63.8; p<0.01) and with a higher level of education (77% vs 27% and 45%; χ²=68.2; p<0.01).

CONCLUSIONS

Employment status is related to the type of questions asked during the first consultation. Also, it interrelates with other patients' characteristics like age and education in determining the number of questions asked. Patients' characteristics including employment status could be considered in tailoring work and social-related information provided during the first oncological consultation. Future studies could explore potential differences in information needs according to the different kinds of work.

Using a quality of life (QoL)-monitor: preliminary results of a randomized trial in Dutch patients with early breast cancer

Purpose

The diagnosis and treatment of cancer negatively affect patients’ physical, functional and psychological wellbeing. Patients’ needs for care cannot be addressed unless they are recognized by healthcare providers (HCPs). The use of quality of life (QoL) assessments with feedback to HCPs might facilitate the identification and discussion of QoL-topics.

Methods

113 patients with stage I–IIIB breast cancer treated with chemotherapy were included in this randomized controlled trial. Patients were randomly allocated to receive either usual care, or usual care with an intervention consisting of a QoL-monitor assessing QoL, distress and care needs before every chemotherapy cycle visit. Patients completed questionnaires regarding QoL, illness perceptions, self-efficacy, and satisfaction with communication. From the 2nd visit onwards, patients in the intervention arm and their HCPs received a copy of the QoL overview and results were shown in patients’ medical files. Audio-recordings and patients’ self-reports were used to investigate effects on communication, patient management and patient-wellbeing. A composite score for communication was calculated by summing the number of QoL-topics discussed during each consultation.

Results

Use of the QoL-monitor resulted in a higher communication score (0.7 topics increase per visit, p = 0.04), especially regarding the disease-specific and psychosocial issues (p < 0.01). There were no differences in patient management, QoL, illness perceptions or distress. Patients in the experimental arm (n = 60) had higher scores on satisfaction with communication (p < 0.05).

Conclusions

Use of a QoL-monitor during chemotherapy in patients with early breast cancer might result in a more frequent discussion of QoL-topics, associated with high levels of patients’ satisfaction.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02549-8) contains supplementary material, which is available to authorized users.

Improving Communication in Breast Cancer Treatment Consultation: Use of a Computer Test of Health Numeracy

Background: Communication of statistics and probability is challenging in the cancer care setting. The objectives of this study are to evaluate a novel approach to cancer communication through the use of a computer assessment of patient health numeracy. Methods: We conducted a pilot study of the Computer Adapted Test of Numeracy Understanding in Medicine Instrument (CAT-NUMi) before the cancer treatment consultation for women with stage 0-3 breast cancer. Patient outcomes included the interpersonal processes of care (IPC) and the decisional conflict scale. We evaluated clinician use of numeric information in the cancer consultation and assessed feasibility outcomes from the clinician and patient perspective. Results: Patient participants (n = 50) had a median (interquartile range) age of 51 years (46-61), 70% were English speaking, and 30% Spanish speaking. Decisional conflict was low with a mean (standard deviation [SD]) decisional conflict score of 17.4 (12.3). The lack of clarity score (range 1-5) on the IPC was low (mean, SD),1.70 (0.71), indicating clear communication. Clinicians more often used percentages in communicating prognosis among those with higher numeracy scores (median, range): high (2, 0-8), medium (1, 0-7), and low (0, 0-8); p = 0.04. The patient experience of taking the CAT-NUMi was rated as very good or excellent by 65%, fair by 33%, and poor by 2% of patients. Conclusion: Screening for health numeracy with a short computer-based test may be a feasible strategy to optimize clear communication in the cancer treatment consultation. Further studies are needed to evaluate this strategy across cancer treatment clinical settings and populations.

Breaking Bad News: A contextual model for Pakistan

Objectives:

The purpose of the study was to identify the sequence of violence that ensues after breaking bad news and develop a contextual model of breaking bad news and develop a model contextual for Pakistan.

Methods:

A qualitative exploratory study was conducted using Six FGDs and 14 IDIs with healthcare providers working in the emergency and the obstetrics and gynecology departments of tertiary care hospitals of Karachi, Pakistan. Data was transcribed and analyzed to identify emerging themes and subthemes using thematic content analysis.

Results:

Impatience or lack of tolerance, lack of respect towards healthcare providers, unrealistic expectations from healthcare facility or healthcare staff were identified as main reasons that provoked violence after breaking bad news. A conceptual five step model was developed to guide communication of bad news by the health care providers. On initial testing the model was found to be effective in de-escalation of violence.

Conclusion:

Communication of bad news requires application of specific approaches to deal with contextual challenges for reducing violence against healthcare.

How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis

BACKGROUND

In this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians' awareness of patients' problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes.

RESULTS

PROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit.

CONCLUSIONS

This paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making.

Addressing the Social Needs of Hypertensive Patients: The Role of Patient-Provider Communication as a Predictor of Medication Adherence

BACKGROUND

Poor medication adherence is a pervasive problem in patients with hypertension. Despite research documenting an association between patient-provider communication and medication adherence, there are no empirical data on how the informational and relational aspects of communication affect patient's actual medication-taking behaviors. The aim of this study was to evaluate the impact of patient-provider communication on medication adherence among a sample of primary care providers and their black and white hypertensive patients.

METHODS AND RESULTS

Cohort study included 92 hypertensive patients and 27 providers in 3 safety-net primary care practices in New York City. Patient-provider encounters were audiotaped at baseline and coded using the Medical Interaction Process System. Medication adherence data were collected continuously during the 3-month study with an electronic monitoring device. The majority of patients were black, 58% women, and most were seeing the same provider for at least 1 year. Approximately half of providers were white (56%), 67% women, and have been in practice for an average of 5.8 years. Fifty-eight percent of patients exhibited poor adherence to prescribed antihypertensive medications. Three categories of patient-provider communication predicted poor medication adherence: lower patient centeredness (odds ratio: 3.08; 95% confidence interval: 1.04-9.12), less discussion about patients' sociodemographic circumstances (living situation, relationship with partner; odds ratio: 6.03; 95% confidence interval: 2.15-17), and about their antihypertensive medications (odds ratio: 6.48; 95% confidence interval: 1.83-23.0). The effect of having less discussion about patients' sociodemographic circumstances on medication adherence was heightened in black patients (odds ratio: 8.01; 95% confidence interval: 2.80-22.9).

CONCLUSIONS

The odds of poor medication adherence are greater when patient-provider interactions are low in patient centeredness and do not address patients' sociodemographic circumstances or their medication regimen.

Factors predicting patient satisfaction in women with advanced breast cancer: a prospective study

Background

The present study (1) examined patient satisfaction with care over the first year following the diagnosis of advanced breast cancer and (2) tested if unmet health system and information needs, physical symptom distress, and psychological distress predicted patient satisfaction.

Methods

Prospective study of 213 Chinese women with advanced breast cancer assessed while awaiting or receiving initial chemotherapy (baseline), then again at 1.5-, 3-, 6-, and 12-months post-baseline. Health system and information unmet (HSI) needs, psychological distress, physical symptom distress, and patient satisfaction were assessed at baseline; patient satisfaction was reassessed at each follow-up assessment. Latent growth curve analysis assessed changes in patient satisfaction over the 12 months follow-up; hierarchical multiple regression analysis tested if baseline health system information needs, physical symptom distress, anxiety and depression predicted patient satisfaction at one-year post-baseline.

Results

The level of patient satisfaction was high and did not change significantly over time. Only HSI needs (β = − 0.27, p < 0.005) significantly associated with baseline patient satisfaction. Patient satisfaction at one-year post-baseline was predicted by HSI needs (β = − 0.26, p < 0.005), Anxiety (β = 0.23, p < 0.05) and Depression (β = − 0.28, p < 0.005), adjusting for the effect of baseline patient satisfaction (β = 0.22, p < 0.005).

Conclusions

Unmet health information needs and greater depressive symptoms at initial treatment phased predicted subsequent poorer patient satisfaction. This highlights a need to reinforce the importance of patient-centered care model in managing advanced breast cancer.

Measuring recall of medical information in non-English-speaking people with cancer: A methodology

BACKGROUND

Many patients who require an interpreter have difficulty remembering information from their medical consultations. Memory aids such as consultation audio-recordings may be of benefit to these patients. However, there is no established means of measuring patients' memory of medical information.

OBJECTIVES

This study aimed to develop a method for eliciting and coding recall of medical information in non-English-speaking patients.

DESIGN

This method, called Patient-Interpreter-Clinician coding (PICcode), was developed in the context of a phase II trial conducted in two outpatient oncology clinics in Melbourne, Australia, and was refined iteratively through consultation with an expert panel and piloting. Between-coder differences in early versions of the coding system were resolved through discussion and consensus resulting in refinements to PICcode.

RESULTS

The final version of PICcode involved transcribing, translating and coding of audio-recorded consultations and semi-structured interviews (SSI). The SSIs were designed to elicit patients' free-recall of medical information. Every unit of medical information in the consultation was identified and categorized in a coding tree. SSIs were coded to identify the extent to which information was recalled from the consultation.

DISCUSSION

The iterative changes involved in developing PICcode assisted in clarifying precise details of the process and produced a widely applicable coding system. PICcode is the most comprehensively described method of determining the amount of information that patients who use an interpreter recall from their medical consultations. PICcode can be adapted for English-speaking patients and other healthcare populations.

Coping Well with Advanced Cancer: A Serial Qualitative Interview Study with Patients and Family Carers

OBJECTIVES

To understand successful strategies used by people to cope well when living with advanced cancer; to explore how professionals can support effective coping strategies; to understand how to support development of effective coping strategies for patients and family carers.

DESIGN

Qualitative serial (4-12 week intervals) interview study with people with advanced cancer and their informal carers followed by focus groups. The iterative design had a novel focus on positive coping strategies. Interview analysis focused on patients and carers as individuals and pairs, exploring multiple dimensions of their coping experiences. Focus group analysis explored strategies for intervention development.

PARTICIPANTS

26 people with advanced (stage 3-4) breast, prostate, lung or colorectal cancer, or in receipt of palliative care, and 24 paired nominated informal/family carers.

SETTING

Participants recruited through outpatient clinics at two tertiary cancer centres in Merseyside and Manchester, UK, between June 2012 and July 2013.

RESULTS

45 patient and 41 carer interviews were conducted plus 4 focus groups (16 participants). People with advanced cancer and their informal/family carers develop coping strategies which enable effective management of psychological wellbeing. People draw from pre-diagnosis coping strategies, but these develop through responding to the experience of living with advanced cancer. Strategies include being realistic, indulgence, support, and learning from others, which enabled participants to regain a sense of wellbeing after emotional challenge. Learning from peers emerged as particularly important in promoting psychological wellbeing through the development of effective 'everyday', non-clinical coping strategies.

CONCLUSIONS

Our findings challenge current models of providing psychological support for those with advanced cancer which focus on professional intervention. It is important to recognise, enable and support peoples' own resources and coping strategies. Peer support may have potential, and could be a patient-centred, cost effective way of managing the needs of a growing population of those living with advanced cancer.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis

BACKGROUND

While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent.

OBJECTIVE

To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting.

METHODS

Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis.

RESULTS

The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter.

CONCLUSIONS

This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.

Patient communication pattern scale: psychometric characteristics

BACKGROUND

In western societies, a shared decision-making model for doctor-patient relationships calling for open and collaborative communication is recommended. Research focuses mainly on the doctor's communication patterns, while research on patient communication patterns is rare. The purpose of this study was to develop a tool for evaluating patient's communication patterns - the Patient Communication Pattern Scale (PCPS).

METHODS

Interviews based on structured questionnaires were conducted with 251 cancer patients. In addition to the 14-item PCPS, the questionnaire included questions regarding education, religiosity and desirability of control in general and over one's own health in particular, for validating the scale.

RESULTS

The PCPS was found to be a valid and reliable tool for evaluating patients' communication patterns. Confirmatory factor analysis supported the PCPS designed structure of five facets: (1) Information, (2) Clarification, (3) Initiation, (4) Preferences and (5) Emotions.

CONCLUSION

The PCPS is a reliable scale for evaluating patient communication patterns. The use of this scale can assist in promoting related research and in developing interventions for enhancing open and collaborative doctor-patient communication.

How does a physician's accurate understanding of a cancer patient's unmet needs contribute to patient perception of physician empathy?

OBJECTIVE

Unmet supportive care needs of patients decrease patient perception of physician empathy (PE). We explored whether the accurate physician understanding of a given patient's unmet needs (AU), could buffer the adverse effect of these unmet needs on PE.

METHODS

In a cross-sectional design, 28 physicians and 201 metastatic cancer patients independently assessed the unmet supportive care needs of patients. AU was calculated as the sum of items for which physicians correctly rated the level of patient needs. PE and covariates were assessed using self-reported questionnaires. Multilevel analyses were carried out.

RESULTS

AU did not directly affect PE but acted as a moderator. When patients were highly expressive and when physicians perceived poor rapport with the patient, a high AU moderated the adverse effect of patient unmet needs on PE.

CONCLUSION

Physician AU has the power to protect the doctor-patient relationship in spite of high patient unmet needs, but only in certain conditions.

PRACTICE IMPLICATIONS

Physicians should be encouraged toward AU but warned that high rapport and patient low emotional expression may impede an accurate reading of patients. In this latter case, they should request a formal assessment of their patients' needs.

Surgical pathology and the patient: a systematic review evaluating the primary audience of pathology reports

The pathology report is a critical document that helps guide the management of patients with cancer. More and more patients read their reports, intending to participate in decisions about their care. However, a substantial subset of patients may lack the ability to comprehend this often technical and complex document. We hypothesized that most literature on pathology reports discusses reports from the perspective of other physicians and not from the perspective of patients. An expert panel of physicians developed a list of search criteria, which we used to identify articles on PubMed, MEDLINE, Cochrane Reviews, and Google Scholar databases. Two reviewers independently evaluated all articles to identify for detailed review those that met search criteria. We identified the primary audience of the selected articles and the degree to which these articles addressed clarity of communication of pathology reports with patients. Of 801 articles identified in our search, 25 involved the formatting of pathology reports for clarity of communication. Recurrent themes in proposed improvements in reports included content standardization, variation in terminology, clarity of communication, and quality improvement. No articles discussed patients as their target audience. No study evaluated the health literacy level required of patients to comprehend pathology reports. In summary, there is a scarcity of patient-centered approaches to improve pathology reports. The literature on pathology reports does not include patients as a target audience. Limited resources are available to help patients comprehend their reports. Efforts to improve patient-centered communication are desirable to address this overlooked aspect of patient care.

Does the use of shared decision-making consultation behaviors increase treatment decision-making satisfaction among Chinese women facing decision for breast cancer surgery?

OBJECTIVE

To assess the extent to which breast surgical consultations used shared decision making (SDM), identify factors associated with use of SDM, and assess if using SDM increases decision-making satisfaction.

METHODS

Two hundred and eighty-three video-recorded diagnostic-treatment decision consultations between breast surgeons and women with breast cancer were assessed using the Decision Analysis System for Oncology (DAS-O) coding system designed for assessing SDM behaviors. Women completed a questionnaire at pre-consultation, one-week post-consultation and one-month post-surgery. Patient outcomes included decision conflict, patient satisfaction with medical consultation, and decision regret.

RESULTS

Overall, the level of SDM behaviors was low. The extent of SDM behavior within consultation was related to greater consultation duration (p<0.001), more than one treatment being offered (p<0.001), and fewer questions raised by patients/companions (p<0.05). While use of SDM consultation did not influence post-consultation decision conflict, it increased satisfaction with information given and explained, patients' feelings of trust and confidence in their surgeons, and reduced post-surgical decision regret.

CONCLUSION

These breast surgical consultations mostly adopted informed treatment decision-making approaches. Using SDM improved patient consultation and decision satisfaction.

PRACTICE IMPLICATIONS

The study findings highlight a need to reinforce the importance of SDM in consultations among breast surgeons.

Barriers Against Psychosocial Communication: Oncologists' Perceptions

Purpose

To explore oncologists' psychosocial attitudes and beliefs and their perceptions regarding barriers against psychosocial communication.

Methods

A questionnaire was distributed to oncologists in Sweden (n = 537). Questions covered demography, the Physician Psychosocial Beliefs Scale (PPBS), and barriers against psychosocial communication. Stepwise multiple regression was used to determine what factors contribute the most to the PPBS score and the total number of barriers and barriers affecting clinical practice, respectively. Spearman rank-order correlation was used to determine correlation between PPBS score and number of barriers.

Results

Questionnaire response rate was 64%. Mean PPBS value was 85.5 (range, 49 to 123; SD, 13.0). Most oncologists (93%) perceived one or more barriers in communicating psychosocial aspects with patients. On average, five different communication barriers were perceived, of which most were perceived to affect clinical practice. These barriers included insufficient consultation time, lack of resources for taking care of problems discovered, and lack of methods to evaluate patients' psychosocial health in clinical practice. There was a positive correlation (rs = 0.490; P < .001) between the PPBS score and the number of perceived barriers (ie, less psychosocially oriented oncologists perceived more barriers). Oncologists with supplementary education with a psychosocial focus perceived fewer barriers/barriers affecting clinical practice (P < .001 and P = .001, respectively) and were more psychosocially oriented (P = .001).

Conclusion

Oncologists perceive many different barriers affecting psychosocial communication in clinical practice. Interventions aiming to improve psychosocial communication must therefore be multifaceted and individualized to clinics and individual oncologists. It is important to minimize barriers to facilitate optimal care and treatment of patients with cancer.

Is communication guidance mistaken? Qualitative study of parent-oncologist communication in childhood cancer

BACKGROUND

Guidance encourages oncologists to engage patients and relatives in discussing the emotions that accompany cancer diagnosis and treatment. We investigated the perspectives of parents of children with leukaemia on the role of paediatric oncologists in such discussion.

METHODS

Qualitative study comprising 33 audio-recorded parent-oncologist consultations and semi-structured interviews with 67 parents during the year following diagnosis.

RESULTS

Consultations soon after the diagnosis were largely devoid of overt discussion of parental emotion. Interviewed parents did not describe a need for such discussion. They spoke of being comforted by oncologists' clinical focus, by the biomedical information they provided and by their calmness and constancy. When we explicitly asked parents 1 year later about the oncologists' role in emotional support, they overwhelmingly told us that they did not want to discuss their feelings with oncologists. They wanted to preserve the oncologists' focus on their child's clinical care, deprecated anything that diverted from this and spoke of the value of boundaries in the parent-oncologist relationship.

CONCLUSION

Parents were usually comforted by oncologists, but this was not achieved in the way suggested by communication guidance. Communication guidance would benefit from an enhanced understanding of how emotional support is experienced by those who rely on it.

Young breast cancer patients' involvement in treatment decisions: the major role played by decision-making about surgery

OBJECTIVE

The objective of this study is to investigate young breast cancer patients' preferred and actual involvement in decision-making about surgery, chemotherapy, and adjuvant endocrine therapy (AET).

METHODS

A total of 442 women aged 18-40 years at the time of the diagnosis participated in the region-wide ELIPPSE40 cohort study (southeastern France). Logistic regression analyses were performed on various factors possibly affecting patients' preferred and perceived involvement in the decisions about their cancer treatment.

RESULTS

The women's mean age was 36.8 years at enrollment. Preference for a fully passive role in decision-making was stated by 20.7% of them. It was favored by regular breast surveillance (p = 0.04) and positive experience of being informed about cancer diagnosis (p = 0.02). Patients' preferences were independently associated with their reported involvement in decision-making about surgery (p = 0.01). A fully passive role in decision-making about chemotherapy and AET was more likely to be reported by patients who perceived their involvement in decision-making about surgery as having been fully passive (adjusted odds ratio = 4.8, CI95% [2.7-8.7], and adjusted odds ratio = 9.8, CI95% [3.3-29.2], respectively). This study shows a significant relationship between the use of antidepressants and involvement in decision-making about surgery, and confirms the relationship between impaired quality of life (in the psychological domain) and a fully passive role in decisions about cancer treatment.

CONCLUSIONS

Patients' involvement in decision-making about chemotherapy and AET was strongly influenced by their experience of decision-making about surgery, regardless of their tumor stage and history of breast or ovarian cancer. When decisions are being made about surgery, special attention should be paid to facilitating breast cancer patients' involvement in the decision-making.

Different perspectives on communication quality and emotional functioning during routine oncology consultations

OBJECTIVE

To determine quality of communication in routine oncology consultations from patient, physician, and observer perspectives, and to determine agreement of emotional function content in consultations from these three perspectives.

METHODS

In total, 69 consultations were included. Perceived quality of communication and whether or not emotional functioning had been discussed was evaluated with patient- and physician-reported questionnaires. Observer perspective was evaluated by content analysis of audio records of the consultations. Agreement between perspectives was analyzed and means compared using linear mixed models.

RESULTS

The patients' ratings of communication quality differed significantly from those of both the physician and observer. Observer and physician scores did not differ significantly. Physicians rated emotional functioning as discussed more often than was reported from patient and observer perspectives.

CONCLUSION

The patients' view of the quality of communication differed from that of the physician and observer. Whether emotional functioning was discussed or not was also perceived differently by patients, physicians, and observer.

PRACTICE IMPLICATIONS

The underpinnings and implications of these results need to be further explored regarding how to move toward a higher degree of shared understanding, where different perspectives are more in alignment, and how to develop more valid methods for evaluating communication.

Cancer patients' evaluation of communication: a report from the population-based study 'The Cancer Patient's World'

PURPOSE

The aims of this study were to assess how communication with health care staff is perceived by Danish cancer patients and to characterise those patients who report problems in communication.

METHODS

In a cross-sectional survey, a nationally representative sample of 2,202 cancer patients who had been in contact with a hospital department during the past year was invited to respond to a questionnaire. Communication with doctors and nurses was assessed separately as were their abilities as listeners, doctors' use of an understandable language, timing of the information, duration of consultations, and whether doctors criticised other doctors.

RESULTS

A total of 1,490 cancer patients responded to the questionnaire. Of these, 24 % reported one or more problems with the areas of communication measured. The problem most frequently reported (by 12 %) was not having sufficient time for consultations. More patients reported problems with doctors' communication and abilities as listeners than with nurses' skills in these areas. There was a general pattern that younger patients and those sampled in Copenhagen reported the highest degree of dissatisfaction with the communication. Those exposed to a high number of different treatment modalities were at especially high risk of experiencing problems.

CONCLUSIONS

A high proportion of patients reported one or more problems in the communication. However, the number reporting each of the specific problems was remarkably low. Special focus should be given to patients exposed to several treatment modalities and their communicative needs.

Predictors and outcomes of feeling of insufficient consultation time in cancer care in Korea: results of a nationwide multicenter survey

BACKGROUND

Shared decision making and an integrative approach is expected to result in better outcomes, but might require more time. While ensuring that sufficient consultation time is essential to quality cancer care, it is not clear whether cancer patients feel that the amount of consultation time with their oncologists is sufficient.

METHODS

Data were collected from 2,556 cancer patients on their perceived and preferred consultation time, and included potential predictors, such as socio-demographics, clinical, behavioral, and quality-of-life factors, as well as potential outcomes, including unmet patient needs, trust in doctor, and satisfaction. The feeling of insufficient consultation time was defined as the perception that consultation time is less than the preferred consultation time; multivariate analyses were used for identification of predictors and comparison of outcomes.

RESULTS

Overall, 37.1% felt that consultation time was less than preferred. Younger age, female sex, higher education level, having national health insurance, having been diagnosed with less common cancers, and having anxiety/depression were significantly associated with feelings of insufficient consultation time. Subjects with a feeling of insufficient consultation time reported higher current needs for information, physical symptoms, and psychological problems. They also reported less trust in their physician, lower overall satisfaction, and lower intention to continue treatment at the current cancer center.

CONCLUSION

This study illustrated that high-quality cancer care, characterized by shared decision making and an integrative approach, seems to be related to sufficient consultation time that meets the individual's subjective needs, and measures should be taken to ensure sufficient consultation time.

Comparing doctors' and nurses' accounts of how they provide emotional care for parents of children with acute lymphoblastic leukaemia

OBJECTIVE

Despite the emphasis that communication skills training (CST) programmes place on attending to the emotional care of patients, evidence suggests that practitioners neglect this aspect of patient care. We describe and compare doctors' and nurses' accounts of managing the emotional care of parents of children with leukaemia, with the overall objective of examining how their accounts might inform training and policy.

METHODS

Audio-recorded qualitative interviews with 30 doctors and nurses working in six UK paediatric oncology and haematology treatment centres were analysed interpretatively, drawing on the constant comparative method.

RESULTS

Doctors' and nurses' descriptions of managing emotional care differed markedly. Doctors described reassuring parents through their ongoing clinical care of the child and by explaining the potentially curative nature of treatment. Doctors did not think they could reassure parents by eliciting and explicitly discussing parents' fears. In contrast, nurses relied on psychological skills and explicit discussion of parents' emotions to provide reassurance. Both doctors and nurses relied on each other to ensure that parents' emotional needs were met by the multidisciplinary team rather than by individual practitioners.

CONCLUSION

Nurses' accounts of providing emotional care resembled the emphasis on explicit emotional talk in CST. However, doctors' accounts indicated that they provided emotional care in ways that diverged markedly from expectations in CST but that were more consistent with their biomedical and authoritative role in patient care. These findings may have implications for CST in future revisions of guidelines, but work is first needed to explore parents' perspectives on emotional care.

Satisfaction with follow-up consultations among younger adults treated for cancer: the role of quality of life and psychological variables

OBJECTIVE

Given increased survival rates and treatment-related late effects, follow-up for cancer survivors is increasingly recommended. However, information about adverse events (e.g. possibility of late effects) may be distressing for the cancer survivor and lead to poor clinic attendance. Survivor satisfaction with appointments and the information provided are important. The Monitoring Process Model provides a theoretical framework to understand how survivors cope with threatening information, and consequences for follow-up care. Our aims were to describe satisfaction with routine follow-up and association between monitoring/blunting and satisfaction with care.

METHODS

Three hundred and forty-nine patients [aged 18-45 years with a history of haematological, germ cell, breast or childhood cancer, >5 years from diagnosis without relapse (>2 years for germ cell survivors) and with a follow-up appointment during the study period] were identified from hospital databases. Participants completed questionnaires before (T1) and after a routine appointment (T2).

RESULTS

Two hundred and seventy-nine (79.9%) questionnaires were completed at T1 and 198 (56.7%) at T2. Clinic satisfaction was higher with shorter waiting time, longer consultation and more topics discussed, but not associated with monitoring. High monitors reported more psychological problems, more importance of clinic attendance and greater value of support groups and professional counselling.

CONCLUSIONS

Satisfaction with follow-up is high among young adult cancer survivors. Follow-up was rated more highly by higher monitors, supporting previous findings that monitors seek out health care information. Provision of additional support services might increase satisfaction among survivors with psychological and social problems.