Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians

Disparities in Access to Radiation Therapy Facilities Among American Indians/Alaska Natives and Hispanics in Washington State

PURPOSE

Racial and ethnic minorities in the state of Washington experience higher cancer mortality relative to whites. We sought to characterize differences in travel distance to radiation therapy (RT) facilities in Washington by race and ethnicity with a special focus on non-Hispanic American Indians and Alaska Natives as a contributor to limited access and cancer disparities.

METHODS AND MATERIALS

Geocoded mortality data from Washington Department of Health (2011-2018) were used to identify decedents with mortality related to all-causes, all cancers, and cancers likely requiring access to RT. This was determined from optimal RT usage estimates by diagnosis. RT facility locations were ascertained from the Directory of Radiation Therapy Centers and confirmed. Distance from decedents' address listed on death certificates to nearest RT facility was calculated. Generalized mixed models were used for statistical analysis.

RESULTS

We identified 418,754 deaths; 109,134 were cancer-related, 60,973 likely required RT. Among decedents with cancers likely requiring RT, non-Hispanic American Indians and Alaska Natives decedents would have had to travel 1.16 times (95% confidence interval [CI], 1.09-1.24) farther from their residences to reach the nearest treatment facility compared with non-Hispanic whites. This association existed in metro counties but was more pronounced in nonmetro counties (1.39 times farther; 95% CI, 1.22-1.58). In addition, Hispanics would have had to travel 1.11 times farther (95% CI, 1.06-1.16) to reach the nearest facility compared with non-Hispanic whites, primarily due to differences in urban counties. Decedents in nonmetro counties lived on average 35 miles (SD = 29) from RT centers and non-Hispanic American Indians and Alaska Natives in nonmetro counties 53 miles (SD = 38). Compared with non-Hispanic white decedents, those who were non-Hispanic black, non-Hispanic Asian, and non-Hispanic Native Hawaiian decedents lived closer to RT facilities.

CONCLUSIONS

We observed significant disparities in access to RT facilities in Washington, specifically for non-Hispanic American Indians and Alaska Natives and rural decedents. The findings call for initiatives to improve access to critical cancer treatment services for these underserved populations with known disparities in cancer deaths.

The influence of opioid-taking self-efficacy and social support on pain management satisfaction in outpatients with cancer pain

PURPOSE

The purpose of this study was to explore the correlations between patients' opioid-taking self-efficacy, social support, and their pain management satisfaction, and to evaluate the effect of social support and opioid-taking self-efficacy in explaining the variance in pain management satisfaction.

METHODS

We used a cross-sectional and correlational research design and recruited 123 cancer patients via convenience sampling. We used the following instruments: the Opioid-Taking Self-Efficacy Scale, the Inventory of Socially Supportive Behavior, and the Chinese version of the Pain Treatment Satisfaction Scale.

RESULTS

There were significant and negative correlations between opioid-taking self-efficacy and pain management satisfaction (r =  - .43, p < .001) and between social support and pain management satisfaction (r =  - .47, p < .001). Using a hierarchical regression analysis, social support and opioid-taking self-efficacy explained 17.20% and 5.20%, respectively, of the variance in pain management satisfaction.

CONCLUSIONS

The results of this study confirm the importance of social support and opioid-taking self-efficacy in influencing pain management satisfaction. We recommend that professional care providers develop relevant intervention aimed at improving patients' pain management satisfaction.

Understanding American Indian Perceptions Toward Radiation Therapy

Many American Indian (AI) and Alaska native (AN) patients do not complete guideline-concordant cancer care for the 4 most common cancers. Our aim was to better understand AI/AN attitudes toward radiation therapy (RT). Patients eligible for this survey study were AI/AN patients with cancer at the Phoenix Indian Medical Center who either received previous RT or were recommended to receive RT. An 18-item questionnaire was administered to each of the 50 participants from October 1, 2018, through February 15, 2019. Willingness to travel for RT was compared to respondent characteristics, concerns regarding RT, and obstacles to obtain RT. Duration of RT was important to 78% of patients: 24% would consider traveling 25 miles or more for a standard course, and 48% would travel that distance for a shorter course (P < .001). The top-ranked barriers to RT were transportation, cost of treatment, and insurance compatibility. The top-ranked concerns about RT were adverse effects, cost of treatment, and fear of RT. Concerns about adverse effects were associated with the radiation team's inability to explain the treatment (P = .05). Transportation concerns were significantly associated with accessibility (P = .02), communication with the RT team (P = .02), and fear of RT (P = .04). AI/AN patients are concerned about the adverse effects of RT and the logistics of treatment, particularly costs, transportation, and insurance compatibility. Use of culturally specific education and hypofractionation regimens may increase acceptance of RT for AI/AN patients with cancer, and this hypothesis will be tested in a future educational intervention-based study.

The Effect of Socioeconomic Status on Treatment and Mortality in Non-Small Cell Lung Cancer Patients

BACKGROUND

Treatment decisions for patients with non-small cell lung cancer (NSCLC) are based on patient and tumor characteristics, including socioeconomic status (SES) factors. The objective was to assess the contribution of SES factors to treatment and outcomes among patients with stage I NSCLC.

METHODS

The National Cancer Database was queried for operable patients with stage I NSCLC. Patients were divided into three treatment groups: primary resection (ie, surgery only); nonstandard treatments consisting of chemotherapy with or without radiation; and no therapy. The SES of patients who made up the treatment groups was assessed, and the 5-year survival of all groups was analyzed.

RESULTS

The cohort included 69,168 patients with stage I NSCLC. Each of these patients had between zero and five SES risk factors. The factors associated with no surgery were low income, nonwhite race, low high school graduation rate, Medicaid or no insurance, rural residence, and distance less than 12.5 miles from treatment facility. Patients with several SES risk factors have linearly increasing odds of undergoing nonstandard treatments and quadratically increasing odds of having no therapy (for patients with five factors, to odds ratio 4.7; 95% confidence interval, 3.44 to 6.30). Surgery alone was associated with significantly longer 5-year survival (71.8%) compared with nonstandard treatments (22.7%) and no therapy (21.8%; P < .001).

CONCLUSIONS

Socioeconomic status factors increase the risk of undergoing guideline discordant therapy for stage I NSCLC. As the number of SES factors increases, the odds of no therapy rises quadratically whereas the odds of nonstandard treatments rises constantly. The surgery only group had significantly longer survival than the nonstandard treatment and no therapy groups.

How do clinicians rate patient's performance status using the ECOG performance scale? A mixed-methods exploration of variability in decision-making in oncology

Background

Medical decisions made by oncology clinicians have serious implications, even when made collaboratively with the patient. Clinicians often use the Eastern Clinical Oncology Group (ECOG) performance status (PS) scores to help them make treatment-related decisions.

Methods

The current study explores the variability of the ECOG score when applied to 12 predetermined specially designed clinical case vignettes presented to a group of oncology clinicians (n = 72). The quantitative analysis included evaluation of variability of ECOG PS scores and exploration of rater and patient-related factors which may influence the final ECOG rating. In-depth interviews were conducted with oncology clinicians to ascertain factors that they felt were important while making treatment-related decisions. Basic and global themes were generated following qualitative data analysis.

Results

Quantitative results showed that there was poor agreement in ECOG rating between raters. Overall concordance with the gold standard rating ranged between 19.4% and 56.9% for the vignettes. Moreover, patients deemed to have socially desirable qualities (p < 0.004) were rated to have better PS and women patients (p < 0.004) to have worse PS. Clinicians having international work experience had increased concordance with ECOG PS rating. Qualitative results showed that ‘perceived socio-economic background of the patient’, ‘age of the patient’, ‘patient’s and family’s preferences’ and ‘past treatment response’ were the major themes highlighted by respondents that influenced the treatment-related decisions made by clinicians.

Conclusion

There is considerable variability in ECOG PS determined by clinicians. Decision-making in oncology is complex, multifactorial and is influenced by rater and patient-related factors.

Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians

OBJECTIVE

American Indian/Alaska Native (AI/AN) patients are significantly less likely than non-Hispanic whites to receive guideline-concordant cancer care. Our objective was to examine cancer treatment decision making among AI/AN patients and their providers.

METHODS

From 2011 to 2014, AI/AN cancer patients and their surgeons were identified through a hospital registry in Washington State. Patients were invited to participate in a mailed survey that queried socio-demographics, cultural affiliation, everyday perceived discrimination, and trust in providers. Both patients and surgeons were queried about decision-making quality (collaboration and satisfaction). The primary outcome was association between patient and provider assessments of decision-making quality. The secondary outcome was non-adherence to treatment.

RESULTS

Forty-nine patients (62% response rate) and 14 surgeons (37% response rate) returned surveys. Half of patients had not completed high school; 41% were living in poverty. Half of patients reported a strong tribal affiliation and most reported experiencing some form of discrimination. Patients endorsed high trust in surgeons and a high quality decision-making process; and surgeons' rated decision-making quality even more highly than patients did in every domain. Non-adherence to treatment recommendations was common (26%) and was significantly associated with lower patient-reported collaboration and satisfaction with decision making.

CONCLUSIONS

Given the importance of adherence to cancer treatment for survival, the many non-clinical reasons for non-adherence, and the currently demonstrated association between decision-making quality and adherence, it would be worthwhile to investigate how to increase AI/AN patient satisfaction with decision making and whether improving satisfaction yields improved adherence to the cancer treatment plan. Copyright © 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.