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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- 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
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- 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
| | - Susan D. Block
- 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
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2
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Odai-Afotey A, Lederman RI, Ko NY, Gagnon H, Fikre T, Gundersen DA, Revette AC, Hershman DL, Crew KD, Keating NL, Freedman RA. Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors. Breast Cancer Res Treat 2023; 200:127-137. [PMID: 37178432 PMCID: PMC10182756 DOI: 10.1007/s10549-023-06960-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors. METHODS During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity. RESULTS The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed. CONCLUSION In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.
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Affiliation(s)
- Ashley Odai-Afotey
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ruth I Lederman
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Naomi Y Ko
- Section of Hematology and Medical Oncology, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Tsion Fikre
- Section of Hematology and Medical Oncology, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anna C Revette
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Dawn L Hershman
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
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3
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Ramanadhan S, Salvia M, Hanby E, Revette AC, Rivard MK, Scout NFN, Applegate J, Gordon B, Machado A, Lunn MR, Obedin-Maliver J, Potter J, Chen JT, Tan ASL. "We're always an afterthought"- Designing tobacco control campaigns for dissemination with and to LGBTQ +-serving community organizations: a thematic analysis. Cancer Causes Control 2023:10.1007/s10552-023-01706-x. [PMID: 37160611 DOI: 10.1007/s10552-023-01706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 04/18/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE Evidence-based health communication campaigns can support tobacco control and address tobacco-related inequities among lesbian, gay, bisexual, transgender, and queer (LGBTQ +) populations. Community organizations focused on LGBTQ + health (e.g., nonprofits, community centers, and community health centers) can be prime channels for delivering evidence-based health communication campaigns. However, it is unclear how to balance the goals of a) designing campaigns to support broad adoption/uptake and b) adaptation addressing the needs of diverse communities and contexts. As part of an effort to support "designing for dissemination," we explored the key challenges and opportunities staff and leaders of LGBTQ + -serving community organizations encounter when adopting or adapting evidence-based health communication campaigns. METHODS A team of researchers and advisory committee members conducted this study, many of whom have lived, research, and/or practice experience with LGBTQ + health. We interviewed 22 staff members and leaders of community organizations serving LGBTQ + populations in the US in early 2021. We used a team-based, reflexive thematic analysis approach. RESULTS The findings highlight the challenges of attempting to use health communication campaigns misaligned with the assets and needs of organizations and community members. The three major themes identified were as follows: (1) available evidence-based health communication campaigns typically do not sufficiently center LGBTQ + communities, (2) negotiation regarding campaign utilization places additional burden on practitioners who have to act as "gatekeepers," and (3) processes of using health communication campaigns often conflict with organizational efforts to engage community members in adoption and adaptation activities. CONCLUSIONS We offer a set of considerations to support collaborative design and dissemination of health communication campaigns to organizations serving LGBTQ + communities: (1) develop campaigns with and for LGBTQ + populations, (2) attend to the broader structural forces impacting campaign recipients, (3) support in-house testing and adaptations, and (4) increase access to granular data for community organizations.
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Affiliation(s)
| | - Meg Salvia
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elaine Hanby
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | - Bob Gordon
- California LGBT Tobacco Education Partnership, San Francisco, CA, USA
| | | | | | | | - Jennifer Potter
- Fenway Health, Boston, MA, USA
- Harvard Medical School, Boston, USA
| | - Jarvis T Chen
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andy S L Tan
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
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4
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Clancy DD, Revette AC, Bahl NE, Ho KT, Manor B, Testa MA, Dieli-Conwright CM, Hshieh T, Driver JA, Abel GA, DuMontier C. Benefits and Barriers of Technology for Home Function and Mobility Assessment: Perspectives of Older Patients With Blood Cancers, Caregivers, and Clinicians. JCO Clin Cancer Inform 2023; 7:e2200171. [PMID: 37098230 PMCID: PMC10281405 DOI: 10.1200/cci.22.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 04/27/2023] Open
Abstract
PURPOSE Advances in digital health technology can overcome barriers to measurement of function and mobility for older adults with blood cancers, but little is known about how older adults perceive such technology for use in their homes. METHODS To characterize potential benefits and barriers associated with using technology for home functional assessment, we conducted three semistructured focus groups (FGs) in January 2022. Eligible patients came from the Older Adult Hematologic Malignancies Program at Dana-Farber Cancer Institute (DFCI), which includes adults 73 years and older enrolled during their initial consult with their oncologist. Eligible caregivers were 18 years and older and identified by enrolled patients as their primary caregiver. Eligible clinicians were practicing DFCI hematologic oncologists, nurse practitioners, or physician assistants with ≥2 years of clinical experience. A qualitative researcher led thematic analysis of FG transcripts to identify key themes. RESULTS Twenty-three participants attended the three FGs: eight patients, seven caregivers, and eight oncology clinicians. All participants valued function and mobility assessments and felt that technology could overcome barriers to their measurement. We identified three themes related to potential benefits: making it easier for oncology teams to consider function and mobility; providing standardized, objective data; and facilitating longitudinal data. We also identified four themes related to barriers to home functional assessment: concerns related to privacy and confidentiality, burden of measuring additional patient data, challenges in operating new technology, and concerns related to data improving care. CONCLUSION These data suggest that specific concerns raised by older patients, caregivers, and oncology clinicians must be addressed to improve acceptability and uptake of technology used to measure function and mobility in the home.
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Affiliation(s)
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
- Harvard School of Public Health, Boston, MA
| | | | | | - Bradley Manor
- Harvard Medical School, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA
| | | | | | - Tammy Hshieh
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA
- Brigham and Women's Hospital, Boston, MA
| | - Jane A. Driver
- Harvard School of Public Health, Boston, MA
- Brigham and Women's Hospital, Boston, MA
- Geriatric Research, Education and Clinical Center and Geriatrics and Extended Care, VA Boston Healthcare System, Boston, MA
| | - Gregory A. Abel
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
| | - Clark DuMontier
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
- Geriatric Research, Education and Clinical Center and Geriatrics and Extended Care, VA Boston Healthcare System, Boston, MA
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5
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Merz A, Stevens SE, Das PJ, Avery M, Revette AC, Wolfe J, Feraco AM. Adaptation of the Day100 Talk communication intervention for Spanish-speaking families of children with cancer. Pediatr Blood Cancer 2023; 70:e30101. [PMID: 36546398 DOI: 10.1002/pbc.30101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/07/2022] [Accepted: 10/22/2022] [Indexed: 12/24/2022]
Abstract
The Day100 Talk (Day100) bridges communication gaps between parents and clinicians early in pediatric cancer care through an interprofessional family conference facilitated by structured tools. We aimed to understand communication challenges and facilitators and to adapt Day100 for Spanish-speaking parents. We interviewed Spanish-speaking parents with limited English proficiency, Spanish-English medical interpreters, and clinicians to gather communication experiences and adapt Day100. Results showed that communication difficulties were precipitated by linguistic and cultural differences, nonvisual technologies, and limited spontaneous communication. Interpreters enhanced communication as linguistic and cultural brokers. Nonverbal cues also facilitated communication. Participants offered recommendations to adapt Day100 for future study.
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Affiliation(s)
- Alexandra Merz
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sarah E Stevens
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - P Jeet Das
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,University of Michigan Medical School, University of Michigan, Ann Arbor, USA
| | - Madeline Avery
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela M Feraco
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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6
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Greenzang KA, Scavotto ML, Revette AC, Schlegel SF, Silverman LB, Mack JW. "There's no playbook for when your kid has cancer": Desired elements of an electronic resource to support pediatric cancer communication. Pediatr Blood Cancer 2023; 70:e30198. [PMID: 36602023 PMCID: PMC10375908 DOI: 10.1002/pbc.30198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL), the most common childhood malignancy, has a relatively favorable long-term prognosis. Yet the complexity of treatment and the emotionality of the diagnosis leave families feeling unprepared for many aspects of therapy. This qualitative study aimed to identify desired elements and format of a communication resource to support patients and families facing a diagnosis of ALL. METHODS Semi-structured interviews of 12 parents of children receiving ALL treatment, 10 parents of survivors of ALL, and eight adolescent and young adult (AYA) survivors of ALL were conducted between February and June 2021. The interviews focused on communication experiences throughout treatment and identified domains to be addressed in a resource in development. RESULTS All participants supported the development of an interactive, electronic health (eHealth) resource to help navigate ALL treatment. They felt a website would be helpful in addressing information gaps and mitigating pervasive feelings of overwhelm. Participants specifically sought: (a) information resources to address feelings of cognitive overload; (b) practical tips to help navigate logistical challenges; (c) clear depictions of treatment choices and trajectories to facilitate decision-making; and (d) additional psychosocial resources and support. Two overarching themes that families felt should be interwoven throughout the eHealth resource were connections with other patients/families and extra support at transitions between phases of treatment. CONCLUSIONS A new diagnosis of ALL and its treatment are extremely overwhelming. Patients and families unanimously supported an eHealth resource to provide additional information and connect them with emotional support, starting at diagnosis and extending throughout treatment.
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Affiliation(s)
- Katie A Greenzang
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Madison L Scavotto
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anna C Revette
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sarah F Schlegel
- Division of Pediatric Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,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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7
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Fenton ATHR, Fletcher KM, Kizildag D, Borstelmann NA, Kessler D, Cronin C, Revette AC, Wright AA, Frank E, Enzinger AC. Cancer Caregivers' Prognostic and End-of-Life Communication Needs and Experiences and their Impact. J Pain Symptom Manage 2023; 65:16-25. [PMID: 36198337 PMCID: PMC9790036 DOI: 10.1016/j.jpainsymman.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Family caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers' communication experiences or the impact of these experiences on patients and caregivers at EOL. OBJECTIVES Investigate cancer caregivers' communication experiences and potential impact on patient and caregiver outcomes. METHODS Semistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes. RESULTS Caregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating-often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers' and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers' abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement. CONCLUSION Caregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients' communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.
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Affiliation(s)
| | | | - Deniz Kizildag
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | - Anna C Revette
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alexi A Wright
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
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8
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Chen JJ, Roldan CS, Nichipor AN, Balboni TA, Krishnan MS, Revette AC, Chen AB, Hertan LM. Prognostic Understanding and Goals of Palliative Radiotherapy: A Qualitative Study. J Pain Symptom Manage 2022; 64:567-576. [PMID: 36007684 DOI: 10.1016/j.jpainsymman.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT There is a paucity of data describing patients' expectations of goals of palliative radiotherapy (RT) and overall prognosis. OBJECTIVES To explore patients' perceptions of and preferences for communication surrounding goals of palliative RT and cancer prognosis. METHODS We conducted a qualitative study utilizing semi-structured interviews with seventeen patients with either bone or lung metastases receiving their first course of palliative RT at a comprehensive cancer center. All patient interviews were recorded, transcribed verbatim, and thematically analyzed. RESULTS Themes of goals of palliative RT centered on either restoration, such as through improving quality of life or minimizing pain, or on a desire to combat cancer by eliminating tumor. While most patients perceived that palliative RT would palliate symptoms but not cure their cancer, some patients believed that the goal of palliative RT was to cure. Themes that emerged surrounding patients' understanding of prognosis and what lies ahead included uncertainty and apprehension about the future, a focus on additional treatment, and confronting mortality. Most patients preferred to receive information about goals of treatment and prognosis from their doctors, including radiation oncologists, rather than other members of the medical team. Patients also expressed a desire for written patient education materials on palliative RT. CONCLUSION Unclear perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive cancer treatments. Patients desire prognostic information from their doctors, including radiation oncologists, who are important contributors to goals of care discussions and may improve patient understanding and well-being by using restorative rather than combat-oriented language.
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Affiliation(s)
- Jie Jane Chen
- Department of Radiation Oncology (J.J.C.), University of San Francisco, San Francisco, California, USA
| | - Claudia S Roldan
- Northwestern Feinberg School of Medicine (C.S.R.), Chicago, Illinois, USA
| | - Alexandra N Nichipor
- Psychosocial Oncology and Palliative Care (A.N.N.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Radiation Oncology (T.A.B., M.S.K.), Dana-Farber Cancer Institute/ Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Monica S Krishnan
- Department of Radiation Oncology (T.A.B., M.S.K.), Dana-Farber Cancer Institute/ Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Anna C Revette
- Survey and Data Management Core (A.C.R.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Aileen B Chen
- Department of Radiation Oncology (A.B.C.), MD Anderson Cancer Center, Houston, Texas, USA
| | - Lauren M Hertan
- Department of Radiation Oncology (L.M.H.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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9
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Freedman RA, Ko NY, Lederman RI, Gagnon H, Fikre T, Gundersen DA, Revette AC, Odai-Afotey A, Kantor O, Hershman DL, Crew KD, Keating NL. Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors. Breast Cancer Res Treat 2022; 196:623-633. [PMID: 36220997 PMCID: PMC9552717 DOI: 10.1007/s10549-022-06752-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/18/2022] [Indexed: 12/02/2022]
Abstract
Purpose The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care. Methods We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt. Results During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination. Conclusions Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06752-8.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
| | - Naomi Y Ko
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Ruth I Lederman
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tsion Fikre
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anna C Revette
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Olga Kantor
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Dawn L Hershman
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Nancy L Keating
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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10
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Morris SE, Revette AC, Brandoff DE, Leiter RE, Sannes TS, Thomas JD. Caring for People We Know: An Unrecognized Risk for Burnout? J Palliat Med 2022; 26:472-480. [PMID: 36194065 DOI: 10.1089/jpm.2022.0331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: As the field of palliative care continues to grow, many clinicians will care for patients with whom they have personal connections. Breaching the boundary between a clinician's personal and professional life is potentially an unrecognized risk for burnout. Objective: We explored the challenges of caring for patients personally known to clinicians and the types of support needed, with a view to developing preliminary practice guidelines. Design: Focus groups. Setting/Subjects: Thirteen psychosocial oncology and palliative care clinicians who care for adult patients participated in one of two focus groups. Six participants were physicians, four were nurse practitioner/registered nurse/physician assistant (NP/RN/PAs), and three were psychosocial clinicians. Measurement: Using NVivo 12, we analyzed focus group transcripts from clinicians about their experiences caring for patients they know personally, the impact of such experiences, and the type of support and guidelines that could benefit clinicians in these unique situations. Results: Navigating boundaries and managing the psychological impact on the clinician, including fear of negative evaluation, increased anxiety and emotional exhaustion were the most challenging aspects of providing such care. Suggested guidelines include an early team meeting, a buddy system, a conversation guide to address the dual relationship, and embedded psychological support and mentorship. Conclusions: Feedback from clinicians identified preliminary guidelines that incorporate tools palliative care teams can use to improve support for clinicians caring for patients with whom they have a personal connection. These tools address the psychosocial aspects of care and have the potential to help clinicians feel a greater sense of control in these often, challenging and emotionally taxing situations.
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Affiliation(s)
- Sue E Morris
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Douglas E Brandoff
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy S Sannes
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jane deLima Thomas
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
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11
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Warner ET, Revette AC, Lormil B, Booz NA, Vora KB, Haas J, Moy B. Underrepresented minority clinical trial participation: Perspectives of the research care team and patients. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
93 Background: Clinical trials (CT) are important treatment options for patients with cancer, yet enrollment rates among underrepresented minority (URM) patients remain suboptimal. Oncology care teams need to assess barriers and facilitators of CT participation and identify practices and resources to better support patients. As part of a larger mixed-methods project, we elicited perspectives on improving URM CT enrollment from oncology research care teams and patients. Methods: We conducted four 60-minute focus groups with 12 oncology physicians, 12 research nurses, and nine clinical research coordinators, and semi-structured interviews with nine URM CT patients at a large academic medical center between January and December 2021. Results: Thematic analysis of the focus groups and interviews identified multiple barriers and potential resources and supports at the patient, healthcare team, institutional, and trial design levels. Barriers included difficulty ensuring patient understanding and informed consent, especially among patients with low health literacy and limited-English proficiency, complex logistical and financial demands of CT participation for patients, and the lack of multidisciplinary oncology care team collaboration. Collectively, these barriers undermined communication, trust, and the quality of patients’ relationships with the care team, all affecting CT participation. Suggested resources and practices included proactive needs assessments for all patients with early engagement of social workers, providing a liaison or navigator for each patient, services and support to reduce patient out of pocket costs, expansion of non-English materials availability and increased used of interpreters, increased training and diversity for all care team roles, and simplifying CT requirements by streamlining informed consent documents, eliminating unnecessary CT-related appointments, and broadening eligibility criteria. Conclusions: Findings suggest that changes in clinical trial design, care team coordination, and early assessment and monitoring of patients’ needs and experiences may help reduce access barriers and increase enrollment of URM patients into cancer CTs.
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Affiliation(s)
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | - Beverly Moy
- Massachusessets General Hospital, Boston, MA
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12
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Minami CA, Bryan AF, Freedman RA, Revette AC, Schonberg MA, King TA, Mittendorf EA. Assessment of Oncologists' Perspectives on Omission of Sentinel Lymph Node Biopsy in Women 70 Years and Older With Early-Stage Hormone Receptor-Positive Breast Cancer. JAMA Netw Open 2022; 5:e2228524. [PMID: 36001314 PMCID: PMC9403774 DOI: 10.1001/jamanetworkopen.2022.28524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/06/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Randomized clinical trial data have demonstrated that omission of surgical axillary evaluation does not affect overall survival in women 70 years and older with early-stage (clinical tumor category 1 [cT1] with node-negative [N0] disease) hormone receptor (HR)-positive and erb-B2 receptor tyrosine kinase 2 (ERBB2; formerly HER2)-negative breast cancer. Therefore, the Choosing Wisely initiative has recommended against routine use of sentinel lymph node biopsy (SLNB) in this population; however, retrospective data have revealed that more than 80% of patients eligible for SLNB omission still undergo the procedure. Multidisciplinary factors involved in these patterns remain unclear. Objective To describe surgical, medical, and radiation oncologists' perspectives on omission of SLNB in women 70 years and older with cT1N0 HR-positive, ERBB2-negative breast cancer. Design, Setting, and Participants This qualitative study used in-depth semi-structured interviews to explore the factors involved in oncologists' perspectives on providing care to older women who were eligible for SLNB omission. Purposive snowball sampling was used to recruit a sample of surgical, medical, and radiation oncologists representing a wide range of practice types and number of years in practice in the US and Canada. A total of 29 oncologists who finished training and were actively treating patients with breast cancer were interviewed. Interviews were conducted between March 1, 2020, and January 17, 2021. Main Outcomes and Measures Recordings from semi-structured interviews were transcribed and deidentified. Thematic analysis was used to identify emergent themes. Results Among 29 physicians (16 women [55.2%] and 13 men [44.8%]) who participated in interviews, 16 were surgical oncologists, 6 were medical oncologists, and 7 were radiation oncologists. Data on race and ethnicity were not collected. Participants had a range of experience (median [range] years in practice, 12.0 [0.5-30.0]) and practice types (14 academic [48.3%], 7 community [24.1%], and 8 hybrid [27.6%]). Interviews revealed that the decision to omit SLNB was based on nuanced patient- and disease-level factors. Wide variation was observed in oncologists' perspectives on SLNB omission recommendations and supporting data. In addition, participants' statements suggested that the multidisciplinary nature of cancer care may increase oncologists' anxiety regarding SLNB omission. Conclusions and Relevance In this study, findings from interviews revealed that oncologists' perspectives may have implications for the largely unsuccessful deimplementation of SLNB in women 70 years and older with cT1N0 HR-positive, ERBB2-negative breast cancer. Interventions aimed at educating physicians, improving patient-physician communication, and facilitating preoperative multidisciplinary conversations may help to successfully decrease SLNB rates in this patient population.
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Affiliation(s)
- Christina A. Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
| | - Ava F. Bryan
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Rachel A. Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna C. Revette
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mara A. Schonberg
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tari A. King
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
| | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
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13
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Freedman RA, Revette AC, Gagnon H, Perilla-Glen A, Kokoski M, Hussein SO, Leone E, Hixon N, Lovato R, Loeser W, Lin NU, Minami CA, Canin B, LeStage B, Faggen M, Poorvu PD, McKenna J, Ruddy KJ, Keating NL, Schonberg MA. Acceptability of a companion patient guide to support expert consensus guidelines on surveillance mammography in older breast cancer survivors. Breast Cancer Res Treat 2022; 195:141-152. [PMID: 35908120 PMCID: PMC9362353 DOI: 10.1007/s10549-022-06676-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/04/2022] [Indexed: 11/04/2022]
Abstract
Purpose To support shared decision-making, patient-facing resources are needed to complement recently published guidelines on approaches for surveillance mammography in breast cancer survivors aged ≥ 75 or with < 10-year life expectancy. We created a patient guide to facilitate discussions about surveillance mammography in older breast cancer survivors. Methods The “Are Mammograms Still Right for Me?” guide estimates future ipsilateral and contralateral breast (in-breast) cancer risks, general health, and the potential benefits/harms of mammography, with prompts for discussion. We conducted in-clinic acceptability testing of the guide by survivors and their clinicians at a National Cancer Institute-designated comprehensive cancer center, including two community practices. Patients and clinicians received the guide ahead of a clinic visit and surveyed patients (pre-/post-visit) and clinicians (post-visit). Acceptability was defined as ≥ 75% of patients and clinicians reporting that the guide (a) should be recommended to others, (b) is clear, (c) is helpful, and (d) contains a suitable amount of information. We also elicited feedback on usability and mammography intentions. Results We enrolled 45 patients and their 21 clinicians. Among those responding in post-visit surveys, 33/37 (89%) patients and 15/16 (94%) clinicians would recommend the guide to others; 33/37 (89%) patients and 15/16 (94%) clinicians felt everything/most things were clear. All other pre-specified acceptability criteria were met. Most patients reported strong intentions for mammography (100% pre-visit, 98% post-visit). Conclusion Oncology clinicians and older breast cancer survivors found a guide to inform mammography decision-making acceptable and clear. A multisite clinical trial is needed to assess the guide’s impact mammography utilization. Trial registration: ClinicalTrials.gov-NCT03865654, posted March 7, 2019. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06676-3.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Anna C Revette
- Survey and Qualitative Methods Core for Qualitative and Quantitative Research, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Adriana Perilla-Glen
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Molly Kokoski
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Saida O Hussein
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Erin Leone
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nicole Hixon
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Rebeka Lovato
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Wendy Loeser
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Barbara LeStage
- Dana-Farber Cancer Institute, Boston, MA, USA.,Alliance for Clinical Trials in Oncology, Boston, MA, USA
| | - Meredith Faggen
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Philip D Poorvu
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Jennifer McKenna
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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14
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Jacobson JO, Zerillo JA, Mulvey T, Stuver SO, Revette AC. Development of a taxonomy for characterising medical oncology-related patient safety and quality incidents: a novel approach. BMJ Open Qual 2022; 11:bmjoq-2022-001828. [PMID: 35793864 PMCID: PMC9260784 DOI: 10.1136/bmjoq-2022-001828] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/10/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Joseph O Jacobson
- Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica Ann Zerillo
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Therese Mulvey
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sherri O Stuver
- Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Anna C Revette
- Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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15
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Doolin JW, Haakenstad E, Neville BA, Lipsitz SR, Zhang S, Cleveland J, Hiruy S, Hassett MJ, Revette AC, Schrag D, Basch E, McCleary NJ. A phase II feasibility study of electronic patient reported outcomes (ePROs) for oral cancer directed therapies (OCDT). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e13509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e13509 Background: Patients receiving oral cancer directed therapy (OCDT) may be at greater risk of toxicity and non-adherence than those on intravenous treatments. Electronic patient reported outcomes (ePROs) have the potential to mitigate those risks by alerting clinicians to patient status between visits, prompting earlier intervention. Best practices for ePROs implementation are not yet defined. We sought to demonstrate the feasibility of ePROs between visits for patients receiving OCDT both without and with asynchronous nursing triage calls for severe symptoms. Methods: In this Phase II feasibility study, patients were prospectively enrolled into two arms. In the first arm, “passive management” (Arm 1) patients were sent weekly ePROs with 15 symptoms, graded 0 (none) to 3 (severe), through the electronic patient portal (ePP). Responses were available for review by clinicians via the electronic medical record (EMR). In the second arm, “active management” (Arm 2) patients received the same weekly ePROs. If a patient responded with a severe symptom, a nurse would call within one business day to triage the concern. The primary outcome was 30-day feasibility, defined as a patient responding to 50% or more of ePROs sent during this period. Secondary outcomes included feasibility at 60- and 90-days, unplanned healthcare utilization (urgent care, ED visit or hospitalization), and nursing calls. At the time the Arm 2 was enrolling, a language-concordant interface for the EMR and ePP became available. The study was amended to include primarily Spanish speaking patients with a language concordant ePROs survey. Results: 100 patients were enrolled, 50 per arm. 10 patients who primarily spoke Spanish were included in Arm 2; the remaining 90 patients were fluent in English. 96 patients were eligible for evaluation of 30-day feasibility, 92 for 60-day, and 86 for 90-day. The 30-day feasibility by arm was 57% in Arm 1 and 45% in Arm 2 (p = 0.26). The 30-day feasibility in the Spanish language subgroup of the Arm 2 was 56%. Nursing calls in the first 30-days were 101 in Arm 1 and 109 in Arm 2. Multivariable regression for predictors of responding to 50% or more of ePROs in days 0-30 did not identify statistically significant correlates of feasibility. Conclusions: ePROs administered via an ePP were feasible the first 30 days on oral cancer directed treatment. Adding nurse triage calls between visits and a language concordant process for primarily Spanish speaking patients were feasible. Larger studies are needed to determine which factors truly impact use of the program and, most importantly, adherence and quality of life.[Table: see text]
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Affiliation(s)
- Jim W Doolin
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | - Stuart R. Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
| | | | - Ethan Basch
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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16
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Odai-Afotey A, Lederman R, Ko NY, Gagnon H, Hershman DL, Crew KD, Keating NL, Gundersen DA, Revette AC, Freedman RA. Financial distress, health literacy, numeracy, and treatment receipt by race/ethnicity amongst breast cancer survivors. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18554 Background: Low-income and minority women are less likely to receive breast cancer treatments and have higher mortality rates compared with other women.We examined economic hardship, health literacy, and numeracy by race/ethnicity and whether these factors were associated with differences in receipt of recommended treatment. Methods: We conducted a telephone survey in 2018-2020 of adult women diagnosed with stage I-III breast cancer between 2013-2016 at three centers in Boston and New York. We asked women about treatment receipt and factors contributing to decision-making. We used X2 and Fischer exact tests to examine associations between economic distress, health literacy/numeracy, and treatment receipt by race/ethnicity. Results: Among 326 respondents (AAPOR cooperation rate 63-80% across sites), 55% were Non-Hispanic (NH) White, 23% were NH Black, and 14% Hispanic; 15% were Medicaid-insured. Due to item non-response, sample sizes ranged from 294-315 per question. A substantial proportion of women, and particularly Black and Hispanic women, reported economic distress, worse finances over time, and low literacy/numeracy (Table). Overall, 7% (n = 22) did not initiate at least one recommended treatment. Although we observed no differences in treatment by race/ethnicity (p = 0.70), those not initiating recommended treatment(s) reported more worry about paying large medical bills (52% vs. 27%) and covering visit costs (27 vs. 10%); p < .05 for both. Conclusions: In a diverse sample of breast cancer survivors, financial distress was common, particularly for non-White participants; non-White women also had lower literacy/numeracy. Although we observed some associations of these factors (but not race/ethnicity) with less receipt of recommended treatments, because few women declined treatments, understanding the scope of impact is limited. However, our results highlight the importance of up-front and longer-term assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures on financial distress and the focus on health literacy/numeracy among a diverse population.[Table: see text]
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Affiliation(s)
| | | | - Naomi Y Ko
- Boston University Medical Center, Boston, MA
| | | | - Dawn L. Hershman
- Columbia University College of Physicians and Surgeons, New York, NY
| | | | | | | | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
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17
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Rosenberg SM, Gierisch JM, Revette AC, Lowenstein CL, Frank ES, Collyar DE, Lynch T, Thompson AM, Partridge AH, Hwang ES. "Is it cancer or not?" A qualitative exploration of survivor concerns surrounding the diagnosis and treatment of ductal carcinoma in situ. Cancer 2022; 128:1676-1683. [PMID: 35191017 PMCID: PMC9274613 DOI: 10.1002/cncr.34126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/15/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Of the nearly 50,000 women in the United States who undergo treatment for ductal carcinoma in situ (DCIS) annually, many may not benefit from treatment. To better understand the impact of a DCIS diagnosis, patients self-identified as having had DCIS were engaged regarding their experience. METHODS In July 2014, a web-based survey was administered through the Susan Love Army of Women breast cancer listserv. The survey included open-ended questions designed to assess patients' perspectives about DCIS diagnosis and treatment. Deductive and inductive codes were applied to the responses; common themes were summarized. RESULTS Among the 1832 women included in the analytic sample, the median age at diagnosis was 60 years. Four primary themes were identified: 1) uncertainty surrounding a DCIS diagnosis, 2) uncertainty about DCIS treatment, 3) concern about treatment side effects, and 4) concern about recurrence and/or developing invasive breast cancer. When diagnosed, participants were often uncertain about whether they had cancer or not and whether they should be considered a "survivor." Uncertainty about treatment manifested as questioning the appropriateness of the amount of treatment received. Participants expressed concern about the "cancer spreading" or becoming invasive and that they were not necessarily "doing enough" to prevent recurrence. CONCLUSIONS In a large, national sample, participants with a history of DCIS reported confusion and concern about the diagnosis and treatment, which caused worry and significant uncertainty. Developing strategies to improve patient and provider communications regarding the nature of DCIS and acknowledging gaps in the current knowledge of management options should be a priority.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer M Gierisch
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Carol L Lowenstein
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth S Frank
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Thomas Lynch
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Alastair M Thompson
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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18
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Rubin BR, Chung M, Hasdianda MA, Gray TF, Aaronson EL, Dundin A, Egorova NA, Revette AC, Berry D, Ouchi K. Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Nurses. J Palliat Med 2022; 25:650-655. [PMID: 35100041 PMCID: PMC8982111 DOI: 10.1089/jpm.2021.0398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.
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Affiliation(s)
- Batsheva R Rubin
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Chung
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mohammad Adrian Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew Dundin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha A Egorova
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, Washington, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
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Minami CA, Bryan AF, Revette AC, Freedman RA, King TA, Mittendorf EA. Oncologists’ perspectives on omission of sentinel lymph node biopsy in women >70 years with early-stage hormone receptor-positive breast cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.48] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
48 Background: Trial data show that omission of surgical axillary staging does not affect overall survival in women >70 with cT1N0 hormone receptor-positive (HR+) breast cancer, and the Society of Surgical Oncology’s Choosing Wisely recommendations advise against routine use of sentinel lymph node biopsy (SLNB) in patients with early-stage HR+ cancers. Despite this, almost 80% of women eligible for omission still undergo SLNB. We sought to explore oncologists’ perspectives of omission of SLNB in this patient population. Methods: We conducted an exploratory qualitative study using semi-structured telephone interviews with surgical, medical, and radiation breast oncologists throughout North America from 3/2020 to 1/2021. Purposive snowball sampling ensured a range of practice types. Interviews were transcribed and a team trained in qualitative analysis undertook thematic analysis guided by grounded theory to identify emergent themes. Results: Participants included sixteen surgical, six medical, and seven radiation oncologists (55% female) (Table). Overall, while oncologists in all fields expressed acceptance regarding SLNB omission in certain women >70 with cT1N0 HR+ disease, many viewed it as a complex choice based on patient comorbidities, chronologic age, patient preferences, and disease factors. Although patients’ physiologic age and life expectancy were also important decisional factors, almost all participants assessed these subjectively despite knowing that validated tools existed. Most surgeons perceived the data backing the Choosing Wisely recommendation as weak, although knowledge of specific supporting studies was low. While all participants agreed that SLNB omission does not affect survival, several radiation oncologists expressed anxiety about resultant increased regional recurrence risk. In the absence of known nodal status, medical and radiation oncologists stated they were more likely to order additional imaging, rely on OncotypeDX scores to make systemic therapy decisions, add high tangents, and be reluctant to offer partial breast irradiation. Conclusions: While surgeons are aware of the Choosing Wisely recommendation, high SLNB rates in patients eligible for omission may be driven by perceptions of the quality of the supporting data and differing ideas regarding appropriate candidacy for omission. There are downstream effects of SLNB omission on medical and radiation oncology treatment decision making and surgeons should engage in multidisciplinary discussion prior to surgery.[Table: see text]
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Affiliation(s)
- Christina Ahn Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Breast Oncology Program, Dana Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Ava F. Bryan
- Department of Surgery, University of Chicago, Chicago, IL
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
| | - Rachel A. Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Tari A. King
- Division of Breast Surgery, Department of Surgery, BWH, Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
| | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, BWH, Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
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20
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Chen JJ, Roldan CS, Nichipor AN, Balboni TA, Krishnan MS, Revette AC, Hertan LM, Chen AB. Patient-Provider Communication, Decision-Making, and Psychosocial Burdens in Palliative Radiotherapy: A Qualitative Study on Patients' Perspectives. J Pain Symptom Manage 2021; 62:512-522. [PMID: 33556491 DOI: 10.1016/j.jpainsymman.2021.01.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 12/25/2022]
Abstract
CONTEXT Patient-provider communication impacts how patients with cancer make decisions about treatment. OBJECTIVES To examine patient perceptions of discussions, decision-making, and psychosocial burdens related to receiving palliative radiotherapy (RT), in order to inform best practices for communication about palliative RT. METHODS We conducted an exploratory qualitative study using oral questionnaires and semi-structured interviews. Seventeen patients receiving their first course of palliative RT for lung or bone metastases at a comprehensive cancer center were interviewed. Patient interviews were transcribed verbatim and thematically analyzed using NVivo software. RESULTS Themes that impacted patients' decisions to initiate RT included a desire to minimize pain, optimism about what RT could provide for the future, perception of having "no other choice," disappointment about cancer progression, and unfamiliarity with RT. Most patients preferred shared decision-making regarding RT initiation and reported patient empowerment, effective communication, and team collaboration as contributing to shared decision-making. Most patients preferred their physicians to make decisions about RT treatment intensity and described trust in their physicians, institutional reputation, and RT expertise as motivators for this preference. Patients who possessed a proactive decisional mindset about initiating RT as opposed to having "no other choice" were less likely to report experiencing psychosocial burdens. CONCLUSION Most patients prefer shared decision-making regarding RT initiation but prefer their radiation oncologists to make decisions regarding treatment intensity. Communication that empowers patients in their desired level of engagement for RT decision-making may help patients make informed decisions, contribute toward a proactive decisional mindset, and reduce their perception of psychosocial burdens.
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Affiliation(s)
- Jie Jane Chen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Claudia S Roldan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Alexandra N Nichipor
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tracy A Balboni
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Monica S Krishnan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lauren M Hertan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aileen B Chen
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
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21
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Ramanadhan S, Revette AC, Lee RM, Aveling EL. Pragmatic approaches to analyzing qualitative data for implementation science: an introduction. Implement Sci Commun 2021; 2:70. [PMID: 34187595 PMCID: PMC8243847 DOI: 10.1186/s43058-021-00174-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
Qualitative methods are critical for implementation science as they generate opportunities to examine complexity and include a diversity of perspectives. However, it can be a challenge to identify the approach that will provide the best fit for achieving a given set of practice-driven research needs. After all, implementation scientists must find a balance between speed and rigor, reliance on existing frameworks and new discoveries, and inclusion of insider and outsider perspectives. This paper offers guidance on taking a pragmatic approach to analysis, which entails strategically combining and borrowing from established qualitative approaches to meet a study's needs, typically with guidance from an existing framework and with explicit research and practice change goals.Section 1 offers a series of practical questions to guide the development of a pragmatic analytic approach. These include examining the balance of inductive and deductive procedures, the extent to which insider or outsider perspectives are privileged, study requirements related to data and products that support scientific advancement and practice change, and strategic resource allocation. This is followed by an introduction to three approaches commonly considered for implementation science projects: grounded theory, framework analysis, and interpretive phenomenological analysis, highlighting core analytic procedures that may be borrowed for a pragmatic approach. Section 2 addresses opportunities to ensure and communicate rigor of pragmatic analytic approaches. Section 3 provides an illustrative example from the team's work, highlighting how a pragmatic analytic approach was designed and executed and the diversity of research and practice products generated.As qualitative inquiry gains prominence in implementation science, it is critical to take advantage of qualitative methods' diversity and flexibility. This paper furthers the conversation regarding how to strategically mix and match components of established qualitative approaches to meet the analytic needs of implementation science projects, thereby supporting high-impact research and improved opportunities to create practice change.
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Affiliation(s)
- Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA.
| | - Anna C Revette
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Rebekka M Lee
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Emma L Aveling
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
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22
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Freedman RA, Minami CA, Winer EP, Morrow M, Smith AK, Walter LC, Sedrak MS, Gagnon H, Perilla-Glen A, Wildiers H, Wildes TM, Lichtman SM, Loh KP, Brain EGC, Ganschow PS, Hunt KK, Mayer DK, Ruddy KJ, Jagsi R, Lin NU, Canin B, LeStage BK, Revette AC, Schonberg MA, Keating NL. Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement. JAMA Oncol 2021; 7:609-615. [PMID: 33507222 DOI: 10.1001/jamaoncol.2020.7582] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited. Objective To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older. Evidence After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized. Findings The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue. Conclusions and Relevance It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Adriana Perilla-Glen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hans Wildiers
- Department of General Medical Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Tanya M Wildes
- Division of Medical Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Pamela S Ganschow
- Department of Medicine, Rush University Medical College and Cook County Health, Chicago, Illinois
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Reshma Jagsi
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor.,Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Barbara K LeStage
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Alliance for Clinical Trials in Oncology, Boston, Massachusetts
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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23
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Feraco AM, McCarthy SR, Revette AC, Stevens SE, Das PJ, Al-Sayegh H, Ma C, Tulsky JA, Wolfe J. Feasibility and acceptability of the "Day 100 Talk": An interdisciplinary communication intervention during the first six months of childhood cancer treatment. Cancer 2020; 127:1134-1145. [PMID: 33320337 DOI: 10.1002/cncr.33362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Communication gaps arise early in the childhood cancer trajectory and may persist. The authors conducted a pilot study of the feasibility and acceptability of a communication intervention, the Day 100 Talk (D100). D100 involves an interprofessional family conference during initial months of treatment between oncologists, psychosocial clinicians, and parents, facilitated by a 3-part conversation tool. METHODS The authors enrolled English-speaking parents of children with nonrelapsed, nonprogressive cancer who were receiving continuity care from enrolled pediatric oncologists and psychosocial clinicians at a single site. The a priori feasibility threshold was 60% parent completion of the D100 intervention. Surveys from parents and professionals and debrief interviews with professionals assessed D100 acceptability. RESULTS Thirty-seven parents (77%) and 38 oncology professionals (67%) enrolled. Twenty of 33 evaluable parents (61%) participated in a D100 family conference. Most commonly, parents did not complete the D100 intervention because of scheduling difficulties related to clinical team constraints. All 17 parents who completed a post-D100 survey agreed or strongly agreed that D100 participation was helpful. In debrief interviews, professionals identified D100 benefits, namely, stepping back to the big picture and getting on the same page, and barriers related to logistical challenges and professionals' anticipatory dread. CONCLUSIONS The D100 intervention pilot demonstrates high acceptability among parents of children with cancer. Despite meeting the prespecified feasibility threshold, findings highlight important barriers to D100 dissemination, namely, perceived burdens on professionals. Potential strategies to reduce burden may include using virtual visit platforms, incorporating D100 elements across multiple visits, or prioritizing intervention delivery to parents with the greatest need for enhanced communication.
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Affiliation(s)
- Angela M Feraco
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah R McCarthy
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah E Stevens
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - P Jeet Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Biostatistics Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Clement Ma
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Biostatistics Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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24
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Gooding HC, Brown CA, Revette AC, Vaccarino V, Liu J, Patterson S, Stamoulis C, de Ferranti SD. Young Women's Perceptions of Heart Disease Risk. J Adolesc Health 2020; 67:708-713. [PMID: 32622924 PMCID: PMC7606261 DOI: 10.1016/j.jadohealth.2020.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/02/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Heart disease is the number one cause of death in women. Little is known about how adolescent and young adult women perceive their risk of heart disease. METHODS We conducted eight online, semistructured focus groups with 35 young women aged 15-24 years recruited from two primary care practices in Boston, MA. Focus group discussion topics built upon data from a larger sample of women who completed the American Heart Association Women's Health Study survey. Topics included health concerns salient to young women, perceived susceptibility to heart disease, and barriers to heart-healthy behaviors. We used qualitative coding and thematic analyses to synthesize data. RESULTS Participants were surprised to learn that heart disease is the leading cause of death in women. Young women discussed age ("I feel like those are things I associate with older people like 40"), gender ("I usually hear more about men suffering from heart problems than women"), and social norms ("we're so pressured just to grow up and [be] more focused on pregnancies or depression or our weight") as reasons for their low perceived risk for heart disease. Participants noted several barriers to adopting heart-healthy behaviors including stress, lack of time, and low perceived risk. "We just don't have time to worry about hearts. Especially if our hearts aren't bothering us to begin with and we can't see it." CONCLUSIONS Perceptions of age, gender, and social norms contribute to low heart disease awareness among young women, which in turn may limit heart-healthy behaviors.
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Affiliation(s)
- Holly C Gooding
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
| | - Courtney A Brown
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Anna C Revette
- Division of Population Sciences, Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Viola Vaccarino
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Jingyi Liu
- Department of Medicine, Stanford Healthcare, Stanford, California
| | - Sierra Patterson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Catherine Stamoulis
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Abstract
Background The American Heart Association Go Red for Women campaign has improved awareness of cardiovascular disease (CVD) among adult women aged 25 years and older. Little is known about awareness among younger women. Methods and Results We assessed awareness of CVD and prevention efforts among 331 young women aged 15 to 24 years using the American Heart Association National Women's Health Study survey. We compared responses from this cohort to the 2012 American Heart Association online survey of 1227 women aged 25 years and older. Only 33 (10.0%) young women correctly identified CVD as the leading cause of death in women. This was significantly lower than awareness among all adult women in 2012 (785 [64.0%]) and among women aged 25 to 34 years (90 of 168 [53.6%]) (P<0.01 for both). Many young women in the current study (144 [43.5%]) said they were not at all informed about CVD; most worried little (130 [39.2%]) or not at all (126 [38%]) about CVD. Young women did report engaging in behaviors known to reduce risk of CVD, although not considering oneself at risk was cited as the number one barrier to engaging in prevention behaviors. Conclusions Young women are largely unaware of CVD as the leading cause of death for women. Given that most young women are not worried about CVD and their 10‐year risk for CVD events is low, campaigns to promote heart‐healthy behaviors among younger women should underscore the benefits of these preventive behaviors to current health in addition to reductions in lifetime risk of CVD.
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Affiliation(s)
- Holly C Gooding
- 1 Division of Adolescent/Young Adult Medicine Boston Children's Hospital Boston MA.,2 Department of Pediatrics Harvard Medical School Boston MA
| | - Courtney A Brown
- 1 Division of Adolescent/Young Adult Medicine Boston Children's Hospital Boston MA
| | - Jingyi Liu
- 2 Department of Pediatrics Harvard Medical School Boston MA
| | - Anna C Revette
- 3 Survey and Data Management Core Division of Population Sciences Dana-Farber Cancer Institute Boston MA
| | - Catherine Stamoulis
- 1 Division of Adolescent/Young Adult Medicine Boston Children's Hospital Boston MA.,2 Department of Pediatrics Harvard Medical School Boston MA
| | - Sarah D de Ferranti
- 2 Department of Pediatrics Harvard Medical School Boston MA.,4 Department of Cardiology Boston Children's Hospital Boston MA
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Abstract
Phenomenon: Learning to assume ownership of patient care is a critical objective of medical training. However, little is known about how ownership is best defined and measured or about its value to trainees. The authors aimed to define ownership and elucidate the significance of developing ownership skills over the course of pediatric residency training. Approach: Focus groups and phone interviews were held with pediatric residency program directors (N = 18) and pediatric residents (N = 14). Focus groups and interviews were audio-recorded, transcribed verbatim, and qualitatively analyzed using thematic analysis. Findings: Program directors and residents characterized ownership as essential to good patient care. Ownership was defined as including personal responsibility, a connection to patients/families, and follow-up and follow-through. For many, ownership was most conspicuous in its absence. Respondents found meaning in their work when exerting ownership and lack of ownership was linked to burnout and frustration. Ownership was recognized as a critical skill that requires development during training to form a professional identity, avoid burnout, become an independent practitioner and function as an integral member of medical teams. Insights: Pediatric residents and faculty considered ownership a cornerstone of patient care and critical to forming a professional identity. The defining characteristics of patient care ownership-personal responsibility, connections with patients and families, and continuity of care-can be used to develop an instrument to assess trainee development of ownership. These findings reinforce the value of ownership in graduate medical education and support creating curricular interventions to foster ownership.
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Affiliation(s)
- Katie A Greenzang
- a Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute , Boston , Massachusetts , USA
- b Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School , Boston , Massachusetts , USA
| | - Anna C Revette
- c Survey and Data Management Core, Dana-Farber Cancer Institute , Boston , Massachusetts , USA
| | - Jennifer C Kesselheim
- a Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute , Boston , Massachusetts , USA
- b Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School , Boston , Massachusetts , USA
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27
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Ouchi K, George N, Revette AC, Hasdianda MA, Fellion L, Reust A, Powell LH, Sudore R, Schuur JD, Schonberg MA, Bernstein E, Tulsky JA, Block SD. Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department. J Palliat Med 2018; 22:267-273. [PMID: 30418094 DOI: 10.1089/jpm.2018.0360] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting. OBJECTIVE To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED. DESIGN Prospective intervention development study. SETTING In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate. MEASUREMENTS Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning. RESULTS We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care. CONCLUSION An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.
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Affiliation(s)
- Kei Ouchi
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Naomi George
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Anna C Revette
- 5 Survey and Data Management Core for Qualitative and Quantitative Research, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Mohammad Adrian Hasdianda
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Lauren Fellion
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Audrey Reust
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Lynda H Powell
- 6 Department of Preventive Medicine, Rush Medical College , Chicago, Illinois
| | - Rebecca Sudore
- 7 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Jeremiah D Schuur
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Mara A Schonberg
- 8 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Edward Bernstein
- 9 The Brief Negotiated Interview Active Referral to Treatment Institute, Boston University School of Public Health , Boston, Massachusetts.,10 Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts
| | - James A Tulsky
- 4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Susan D Block
- 3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,10 Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts.,11 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,12 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts
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Freedman RA, Revette AC, Hershman DL, Silva K, Sporn NJ, Gagne JJ, Kouri EM, Keating NL. Understanding Breast Cancer Knowledge and Barriers to Treatment Adherence: A Qualitative Study Among Breast Cancer Survivors. Biores Open Access 2017; 6:159-168. [PMID: 29282433 PMCID: PMC5743034 DOI: 10.1089/biores.2017.0028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Disparities in breast cancer treatment receipt are common and multifactorial. Data are limited on how knowledge about one's breast cancer and understanding treatment rationales may impact treatment completion. In this qualitative analysis, we explored barriers to care with a focus on knowledge. We conducted 18 in-depth interviews with women from diverse socioeconomic backgrounds who were treated at Dana-Farber Cancer Institute (n = 12; Boston, MA) and Columbia University Medical Center (n = 6; New York, NY) and had undergone neo/adjuvant breast cancer treatment within the prior 3 years. Interviews focused on treatments received, adherence, barriers experienced, and questions related to breast cancer knowledge and treatment rationales. We analyzed transcribed interview recordings in N'Vivo using a two-stage coding process that allowed for both preconfigured and emergent themes. Answers for breast cancer knowledge were confirmed using medical records. In our analysis, over one-third of women reported incomplete therapy, including never initiating treatment, stopping treatment prematurely, or missing/delaying treatments due to logistical reasons (childcare, transportation) or patient preferences. Others reported treatment modifications because of provider recommendations. Nearly all women were able to accurately describe the rationale for recommended treatments. Among 17 women for whom medical records were available, women correctly reported 18–71% of their tumor characteristics; incorrect reporting was not consistently associated with treatment incompletion. In conclusion, logistical issues and patient preferences were the main reasons for incomplete therapy in our study. Understanding of treatment rationale was high, but breast cancer knowledge was variable. Further assessment of how knowledge may impact cancer care is warranted.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Kathryn Silva
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nora J Sporn
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Joshua J Gagne
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elena M Kouri
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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