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van Lent LGG, van der Ham M, de Jonge MJA, Gort EH, van Mil M, Hasselaar J, van der Rijt CCD, van Gurp J, van Weert JCM. Patient values in patient-provider communication about participation in early phase clinical cancer trials: a qualitative analysis before and after implementation of an online value clarification tool intervention. BMC Med Inform Decis Mak 2024; 24:32. [PMID: 38308286 PMCID: PMC10835819 DOI: 10.1186/s12911-024-02434-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 01/22/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Patients with advanced cancer who no longer have standard treatment options available may decide to participate in early phase clinical trials (i.e. experimental treatments with uncertain outcomes). Shared decision-making (SDM) models help to understand considerations that influence patients' decision. Discussion of patient values is essential to SDM, but such communication is often limited in this context and may require new interventions. The OnVaCT intervention, consisting of a preparatory online value clarification tool (OnVaCT) for patients and communication training for oncologists, was previously developed to support SDM. This study aimed to qualitatively explore associations between patient values that are discussed between patients and oncologists during consultations about potential participation in early phase clinical trials before and after implementation of the OnVaCT intervention. METHODS This study is part of a prospective multicentre nonrandomized controlled clinical trial and had a between-subjects design: pre-intervention patients received usual care, while post-intervention patients additionally received the OnVaCT. Oncologists participated in the communication training between study phases. Patients' initial consultation on potential early phase clinical trial participation was recorded and transcribed verbatim. Applying a directed approach, two independent coders analysed the transcripts using an initial codebook based on previous studies. Steps of continuous evaluation and revision were repeated until data saturation was reached. RESULTS Data saturation was reached after 32 patient-oncologist consultations (i.e. 17 pre-intervention and 15 post-intervention). The analysis revealed the values: hope, perseverance, quality or quantity of life, risk tolerance, trust in the healthcare system/professionals, autonomy, social adherence, altruism, corporeality, acceptance of one's fate, and humanity. Patients in the pre-intervention phase tended to express values briefly and spontaneously. Oncologists acknowledged the importance of patients' values, but generally only gave 'contrasting' examples of why some accept and others refuse to participate in trials. In the post-intervention phase, many oncologists referred to the OnVaCT and/or asked follow-up questions, while patients used longer phrases that combined multiple values, sometimes clearly indicating their weighing. CONCLUSIONS While all values were recognized in both study phases, our results have highlighted the different communication patterns around patient values in SDM for potential early phase clinical trial participation before and after implementation of the OnVaCT intervention. This study therefore provides a first (qualitative) indication that the OnVaCT intervention may support patients and oncologists in discussing their values. TRIAL REGISTRATION Netherlands Trial Registry: NL7335, registered on July 17, 2018.
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Affiliation(s)
- Liza G G van Lent
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands.
| | - Mirte van der Ham
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Maja J A de Jonge
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Eelke H Gort
- Department of Medical Oncology, UMC Utrecht Cancer Centre, Utrecht, the Netherlands
| | - Marjolein van Mil
- Department of Medical Oncology and Clinical Pharmacology, Antoni Van Leeuwenhoek, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jeroen Hasselaar
- Department of Pain, Anaesthesiology and Palliative Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jelle van Gurp
- Department of IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Julia C M van Weert
- Department of Communication Science, Amsterdam School of Communication Research (ASCoR) and University of Amsterdam, Amsterdam, the Netherlands
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van Gurp JLP, van Lent LGG, Stoel N, van der Rijt CCD, van Weert JCM, Hasselaar J. Accentuating patient values in shared decision-making: A mixed methods development of an online value clarification tool and communication training in the context of early phase clinical cancer trials. PATIENT EDUCATION AND COUNSELING 2024; 119:108075. [PMID: 37995489 DOI: 10.1016/j.pec.2023.108075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE In the shared decision-making (SDM) process for potential early phase clinical cancer trial participation, value clarification is highly recommended. However, exploration and discussion of patient values between patients and oncologists remains limited. This study aims to develop an SDM-supportive intervention, consisting of a preparatory online value clarification tool (OnVaCT) and a communication training. METHODS The OnVaCT intervention was developed and pilot-tested by combining theoretical notions on value clarification, with interview studies with patients and oncologists, focus groups with patient representatives and oncologists, and think aloud sessions with patients, following the Medical Research Council (MRC) framework for complex interventions. These human-centered methodologies enabled a user-centered approach at every step of the development process of the intervention. RESULTS This study shows relevant patient values and oncologists' perspectives on value exploration and discussion in daily practice. This has been combined with theoretical considerations into the creation of characters based on real-life experiences of patients in the OnVaCT, and how the tool is combined with a communication training for oncologists to improve SDM.
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Affiliation(s)
- Jelle L P van Gurp
- Department of IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Liza G G van Lent
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nicole Stoel
- Department of Pain, Anesthesiology and Palliative Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Julia C M van Weert
- Department of Communication Science, Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen Hasselaar
- Department of Pain, Anesthesiology and Palliative Care, Radboud University Medical Centre, Nijmegen, the Netherlands
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van Gurp JLP, van Lent LGG, Stoel N, van der Rijt CCD, de Jonge MJA, Pulleman SM, van Weert JCM, Hasselaar J. Core values of patients with advanced cancer considering participation in an early-phase clinical trial: a qualitative study. Support Care Cancer 2022; 30:7605-7613. [PMID: 35676342 PMCID: PMC9385761 DOI: 10.1007/s00520-022-07200-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This article identifies the core values that play a role in patients' decision-making process about participation in early-phase clinical cancer trials. METHODS Face-to-face, semi-structured serial interviews (n = 22) were performed with thirteen patients with advanced cancer recruited in two Dutch specialized cancer centers. In a cyclic qualitative analysis process, open and axial coding of the interviews finally led to an overview of the values that are woven into patients' common language about cancer and clinical trials. RESULTS Six core values were described, namely, acceptance creates room for reconsideration of values, reconciliation with one's fate, hope, autonomy, body preservation, and altruism. Previously found values in advanced cancer, such as acceptance, hope, autonomy, and altruism, were further qualified. Reconciliation with one's fate and body preservation were highlighted as new insights for early-phase clinical cancer trial literature. CONCLUSIONS This article furthers the understanding of core values that play a role in the lives and decision-making of patients with advanced cancer who explore participation in early-phase clinical cancer trials. These values do not necessarily have to be compatible with one another, making tragic choices necessary. Understanding the role of core values can contribute to professional sensitivity regarding what motivates patients' emotions, thoughts, and decisions and help patients reflect on and give words to their values and preferences. It supports mutual understanding and dialog from which patients can make decisions according to their perspectives on a good life for themselves and their fellows in the context of participation in an early-phase clinical cancer trial.
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Affiliation(s)
- Jelle L P van Gurp
- Department of IQ Healthcare, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Liza G G van Lent
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Nicole Stoel
- Department of Anaesthesiology, Pain & Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Maja J A de Jonge
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Saskia M Pulleman
- Department of Medical Oncology and Clinical Pharmacology, Antoni Van Leeuwenhoek, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Julia C M van Weert
- Department of Communication Science, Amsterdam School of Communication Research (ASCoR) and University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain & Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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Decisional Conflict after Deciding on Potential Participation in Early Phase Clinical Cancer Trials: Dependent on Global Health Status, Satisfaction with Communication, and Timing. Cancers (Basel) 2022; 14:cancers14061500. [PMID: 35326653 PMCID: PMC8946532 DOI: 10.3390/cancers14061500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 02/04/2023] Open
Abstract
When standard treatment options are not available anymore, patients with advanced cancer may participate in early phase clinical trials. Improving this complex decision-making process may improve their quality of life. Therefore, this prospective multicenter study with questionnaires untangles several contributing factors to decisional conflict (which reflects the quality of decision-making) in patients with advanced cancer who recently decided upon early phase clinical trial participation (phase I or I/II). We hypothesized that health-related quality of life, health literacy, sense of hope, satisfaction with the consultation, timing of the decision, and the decision explain decisional conflict. Mean decisional conflict in 116 patients was 30.0 (SD = 16.9). Multivariate regression analysis showed that less decisional conflict was reported by patients with better global health status (β = −0.185, p = 0.018), higher satisfaction (β = −0.246, p = 0.002), and who made the decision before (β = −0.543, p < 0.001) or within a week after the consultation (β = −0.427, p < 0.001). These variables explained 37% of the variance in decisional conflict. Healthcare professionals should realize that patients with lower global health status and who need more time to decide may require additional support. Although altering such patient intrinsic characteristics is difficult, oncologists can impact the satisfaction with the consultation. Future research should verify whether effective patient-centered communication could prevent decisional conflict.
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Laryionava K, Schildmann J, Wensing M, Wedding U, Surmann B, Woydack L, Krug K, Winkler E. Development and Evaluation of a Decision Aid to Support Patients' Participatory Decision-Making for Tumor-Specific and Palliative Therapy for Advanced Cancer: Protocol for a Pre-Post Study. JMIR Res Protoc 2021; 10:e24954. [PMID: 34533464 PMCID: PMC8486990 DOI: 10.2196/24954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background To support advanced cancer patients and their oncologists in therapeutic decisions, we aim to develop a decision aid (DA) in a multiphased, bicentric study. The DA aims to help patients to better understand risks and benefits of the available treatment options including the options of standard palliative care or cancer-specific treatment (ie, off-label drug use within an individual treatment plan). Objective This study protocol outlines the development and testing of the DA in a pre-post study targeting a heterogeneous population of advanced cancer patients. Methods In the first step, we will assess patients’ information and decisional needs as well as the views of the health care providers regarding the content and implementation of the DA. Through a scoping review, we aim to analyze specific characteristics of the decision-making process and to specify the treatment options, outcomes, and probabilities. An interdisciplinary research group of experts will develop and review the DA. In the second step, testing of the DA (design and field testing) with patients and oncologists will be conducted. As a last step, we will run a pre-post design study with 70 doctor-patient encounters to assess improvements on the primary study outcome: patients’ level of decisional conflict. In addition, the user acceptance of all involved parties will be tested. Results Interviews with cancer patients, oncologists, and health care providers (ie, nurses, nutritionists) as well as a literature review from phase I have been completed. The field testing is scheduled for April 2021 to August 2021, with the final revision scheduled for September 2021. The pre-post study of the DA and acceptance testing are scheduled to start in October 2021 and shall be finished in September 2022. Conclusions A unique feature of this study is the development of a DA for patients with different types of advanced cancer, which covers a wide range of topics relevant for patients near the end of life such as forgoing cancer-specific therapy and switching to best supportive care. Trial Registration ClinicalTrials.gov NCT04606238; https://clinicaltrials.gov/ct2/show/NCT04606238. International Registered Report Identifier (IRRID) DERR1-10.2196/24954
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Affiliation(s)
- Katsiaryna Laryionava
- Institute for History and Ethics of Medicine, Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Michael Wensing
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Ullrich Wedding
- Palliative Care, Department of Internal Medicine II, University of Jena, Jena, Germany
| | - Bastian Surmann
- Health Economics and Health Care Management, Bielefeld University, Bielefeld, Germany
| | - Lena Woydack
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Katja Krug
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Eva Winkler
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
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Borysowski J, Górski A. Ethics framework for treatment use of investigational drugs. BMC Med Ethics 2020; 21:116. [PMID: 33208140 PMCID: PMC7672838 DOI: 10.1186/s12910-020-00560-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Expanded access is the use of investigational drugs (IDs) outside of clinical trials. Generally it is performed in patients with serious and life-threatening diseases who cannot be treated satisfactorily with authorized drugs. Legal regulations of expanded access to IDs have been introduced among others in the USA, the European Union (EU), Canada and Australia. In addition, in the USA an alternative to expanded access is treatment under the Right-to-Try law. However, the treatment use of IDs is inherently associated with a number of ethically relevant problems. MAIN TEXT The objective of this article is to present a coherent framework made up of eight requirements which have to be met for any treatment use of an ID to be ethical. These include a justified need for the use of an ID, no threat to clinical development of the ID, adequate scientific evidence to support the treatment, patient's benefit as the primary goal of the use of an ID, informed decision of a patient, fair access of patients to IDs, independent review, as well as the dissemination of treatment results. CONCLUSIONS While this framework is essentially consistent with the legal regulations of expanded access of the USA, the EU, Canada and Australia, it is substantially wider in scope because it addresses some important issues that are not covered by the regulations. Overall, the framework that we developed minimizes the risks and threats, and maximizes potential benefits to each of the four key stakeholders involved in the treatment use of IDs including patients, doctors, drug manufacturers, and society at large.
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Affiliation(s)
- Jan Borysowski
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka Str. 59, 02-006, Warsaw, Poland.
- Centre for Studies on Research Integrity, Institute of Law Studies, Polish Academy of Sciences, Nowy Świat 72, 00-330, Warsaw, Poland.
| | - Andrzej Górski
- Laboratory of Bacteriophages, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Rudolfa Weigla Str. 12, 53-114, Wrocław, Poland
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Howard DA, Kanakaris NK, Giannoudis PV. Turning Adversity and Deprivation into Improvements in Medicine - The COVID Opportunity. Injury 2020; 51:785-786. [PMID: 32386659 PMCID: PMC7199680 DOI: 10.1016/j.injury.2020.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Dr Anthony Howard
- NIHR-Leeds Musculoskeletal and Biomedical Research Center, Chapel Allerton Hospital, Leeds Teaching Hospital NHS Trust, Leeds, LS7 4SA, UK,Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, LS1 3EX, UK,Corresponding Author at NIHR Clinical Lecturer in Trauma & Orthopaedics, University of Leeds, Department of Orthopaedics, Leeds General Infirmary, George Street, LS1 3EX, Tel.: +44 7769116998
| | - Nikolaos K. Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, LS1 3EX, UK
| | - Peter V. Giannoudis
- NIHR-Leeds Musculoskeletal and Biomedical Research Center, Chapel Allerton Hospital, Leeds Teaching Hospital NHS Trust, Leeds, LS7 4SA, UK,Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, LS1 3EX, UK
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