Caring for an Individual with Chronic Lymphocytic Leukemia (CLL): Understanding Family Caregivers' Perceptions of Social Support, Caregiver Burden, and Unmet Support Needs

Family caregivers (FCs) of a patient with chronic lymphocytic leukemia (CLL) can encounter unpredictable challenges and care demands. They can experience high levels of burden, a loss of self-care, and poor quality of life. Their receipt of social support and ability to communicate with clinicians may impact their burden. FCs would benefit from educational resources that teach them communication skills central to their ability to obtain the support they need-support that is imperative to reducing burden. To better target psychosocial educational interventions focused on social support and communication skills, we aimed to explore the relationship between social support, sources of support, and burden; the relationship between FCs' clinical communication and their perceptions of support and burden; and any unmet support needs. A total of 575 CLL FCs completed an online survey of validated scales about social support, burden, and clinical communication, as well as an open-ended item in which they reported any unmet support needs. Statistical analyses showed that FCs who perceived they were more supported reported less burden, and female FCs reported more burden than males. Support from family, friends, and professionals collectively contributed to FCs' support. FCs who perceived they had stronger communication skills with their loved one's clinicians reported more social support. FCs identified six areas of unmet support needs: financial, emotional, informational, instrumental, peer, and communication support. Collectively, findings show that increased social support can reduce FCs' burden and qualitative findings provide a roadmap of social support domains to target that could potentially improve the caregiving experience.

Clinician feedback using a shared decision-making tool for the evaluation of patients with thyroid nodules-an observational study

BACKGROUND

We pilot-tested an encounter conversation aid to support shared decision making (SDM) between patients with thyroid nodules and their clinicians.

OBJECTIVE

Characterize the clinician feedback after providing care to patients with thyroid nodules using a tool to promote SDM conversations during the clinical encounter, and evaluate how clinicians used the tool during the visit.

METHODS

Mixed method study in two academic centers in the U.S., including adult patients presenting for evaluation of thyroid nodules and their clinicians. We thematically analyzed interviews with clinicians after they used the SDM tool in at least three visits to characterize their feedback. Additionally, investigators evaluated visits recordings to determine the extent to which clinicians engaged patients in the decision-making process (OPTION score, scale 0 to 100, higher levels indicating higher involvement), the tool's components used (fidelity), and encounter duration. Using a post-visit survey, we evaluated the extent to which clinicians felt the tool was easy to use, helpful, and supportive of the patient-clinician collaboration.

RESULTS

Thirteen clinicians participated in the study and used the SDM tool in the care of 53 patients. Clinicians thought the tool was well-organized and beneficial to patients and clinicians. Clinicians noticed a change in their routine with the use of the conversation aid and suggested it needed to be more flexible to better support varying conversations. The median OPTION score was 34, the fidelity of use 75%, and the median visit duration 17 min. In most encounters, clinicians agreed or strongly agreed the tool was easy to use (86%), helpful (65%), and supported collaboration (62%).

CONCLUSION

Clinicians were able to use a SDM tool in the care of patients with thyroid nodules. Although they wished it were more flexible, they found on the whole that its use in the clinical encounter was beneficial to patients and clinicians.

Living with a blood cancer in later life: The complex challenges and related support needs of adults aged 75 and older

OBJECTIVES

This study investigated the challenges and support needs of adults aged 75 and older during and after treatment for a blood cancer to aid targeted supportive resource development.

METHODS

Adults aged 75 and older with a blood cancer participated in in-depth, semi-structured interviews about challenges and unmet support needs. Participants recruited through The Leukemia & Lymphoma Society were (1) in treatment or previously in treatment for a blood cancer at age 75 or older and (2) living in the United States or its territories. A thematic analysis was conducted with findings compared between 2 groups: (1) chronic -living with a chronic blood cancer; (2) acute -living with an acute blood cancer or both an acute and chronic blood cancer.

RESULTS

Participants (n = 50) ranged from 75 to 91 years old. Both groups described similar experiences and identified 5 challenges and support needs: (1) socioemotional impact, (2) activities of daily living and instrumental activities of daily living (ADLs/iADLs), (3) uncertainty management, (4) treatment-related stressors, and (5) COVID-19-related strain. Properties for these themes illustrate challenges and support needs, with some differences between groups. For instance, those living with a chronic blood cancer highlighted financial strain with treatment-related stressors, while those with an acute blood cancer focused more on iADLs.

SIGNIFICANCE OF RESULTS

Findings inform an agenda for targeted resource development for older adults with a blood cancer nearing the end of the life span. Results demonstrate the need for supportive services and family communication interventions to help patients manage iADLs and navigate socioemotional needs and challenges.

Thyroid Cancer Risk Communication in Patients with Thyroid Nodules

The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.

Young Adult Caregiving Daughters and Diagnosed Mothers Navigating Breast Cancer Together: Open and Avoidant Communication and Psychosocial Outcomes

For many diagnosed mothers and their daughters, breast cancer is a shared experience. However, they struggle to talk about cancer. This is particularly true when the daughter is in adolescence or young adulthood, as they tend to be more avoidant, which is associated with poorer biopsychosocial outcomes. When daughters are their mother's caregivers, daughters' burden and distress are heightened. Young adult caregiving daughters (YACDs) are the second most common family caregiver and encounter more distress and burden than other caregiver types. Yet, YACDs and their diagnosed mothers receive no guidance on how to talk about cancer. Thirty-nine mother/YACD pairs participated in an online survey to identify challenging topics and strategies for talking about cancer, and to explore associations between openness/avoidance and psychosocial outcomes. YACDs and mothers reported the same challenging topics (death, treatment-related issues, negative emotions, relational challenges, YACDs' disease risk) but differed on why they avoided the topic. YACDs and mothers identified the same helpful approaches to navigate conversations (openness, staying positive, third-party involvement, avoidance). Avoidance was correlated with more distress whereas openness was correlated with better psychosocial outcomes. These results provide a psychosocial map for a mother-YACD communication skills intervention, which is key to promoting healthy outcomes.

Adult-Child Caregivers' Family Communication Experiences after an Older Parent's Blood Cancer Diagnosis: A Survey Exploring Their Openness, Avoidance, and Social Support

Adult-child caregivers of an aging parent living with a blood cancer describe struggling to communicate with one another and within the family system. They may avoid critical care conversations, which may impede care and their ability to receive social support. We examined what approaches adult-child caregivers of a parent diagnosed with a blood cancer use to enhance their family communication, the topics they find most challenging to discuss, and the roles of openness and support. We used qualitative and quantitative approaches to analyze data from a larger online survey study. In partnership with the Leukemia & Lymphoma Society, we recruited 121 adult-child caregivers. Responses to one open-ended item were analyzed to capture strategies used to enhance communication with their parent and family. They reported utilizing digital communication modalities, prioritizing frequent communication, engaging in openness, establishing boundaries, kinkeeping, and enacting support. Within the quantitative data, we further explored two of these themes (openness and support) and their relationships to other variables using t-tests and regression analysis. Adult-child caregivers and diagnosed parents avoid talking about mortality and negative feelings. Openness in the family about cancer was linked to caregivers' perceptions of receiving social support. Findings demonstrate that cultivating openness between midlife adult children and diagnosed parents may enhance opportunities to receive support.

Adult sibling-related experiences while caring for a parent diagnosed with a blood cancer

INTRODUCTION

An older parent's blood cancer diagnosis impacts the entire family system, including adult siblings, an often overlooked subsystem of the family. Yet, adult siblings are typically involved in their parents' care needs. We explored sibling-related experiences adult child caregivers identify while caring for a parent diagnosed with a blood cancer to capture information useful for caregiving intervention development.

METHOD

Fifteen adult child caregivers with at least 1 sibling participated in an in-depth, semistructured interview. Participants were 87% white and 80% daughters. A majority of caregivers were in midlife (M age = 44), with parents diagnosed between age 56 and 90. A thematic analysis was conducted on transcripts using the constant comparative method.

RESULTS

Caregivers described 3 types of sibling-related experiences that centered on (a) caregiving responsibilities (e.g., sharing/not sharing tasks; challenging feelings about lack of involvement); (b) expectations about the caregiver role (e.g., gender, family status, and birth order expectations); and (c) coping together and apart (e.g., receiving information together, enhanced relationships, divergent maladaptive coping).

DISCUSSION

Findings illustrate how a parent's blood cancer diagnosis can enhance the sibling bond and family system as well as contribute to tension, particularly regarding the experiences of not sharing caregiving tasks or having divergent approaches to coping. Findings also provide insight into areas in which supportive interventions or resources are needed (e.g., helping siblings talk about caregiving involvement) to promote healthy family functioning after a blood cancer diagnosis. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient feedback receiving care using a shared decision making tool for thyroid nodule evaluation-an observational study

PURPOSE

To characterize the feedback of patients with thyroid nodules receiving care using a shared decision making (SDM) tool designed to improve conversations with their clinicians related to diagnostic options (e.g. thyroid biopsy, ultrasound surveillance).

METHODS

Investigators qualitatively analyzed post-encounter interviews with patients to characterize their feedback of a SDM tool used during their clinical visits. Additionally, investigators counted instances of diagnostic choice awareness and of patients' expression of a diagnostic management preference in recordings of clinical encounters of adult patients presenting for evaluation of thyroid nodules in which the SDM tool was used.

RESULTS

In total, 53 patients (42 (79%) women); median age 62 years were enrolled and had consultations supported by the SDM tool. Patients were favorable about the design of the SDM tool and its ability to convey information about options and support patient-clinician interactions. Patients identified opportunities to improve the tool through adding more content and improve its use in practice through training of clinicians in its use. There was evidence of diagnostic choice awareness in 52 (98%) of these visits and patients expressed a diagnostic management preference in 40 (76%).

CONCLUSION

User centered design including feedback from patients and real life observation supports the use of the SDM tool to facilitate collaboration between patients and clinicians.

Understanding the Impact of COVID-19 on Chronic Lymphocytic Leukemia (CLL) Caregiving and Related Resource Needs

Chronic lymphocytic leukemia (CLL) caregivers play a central role in disease management-a role that has been heightened during the COVID-19 pandemic given the healthcare system's reliance on frontline family caregivers and CLL patients' increased risk of infection and mortality. Using a mixed-method design, we investigated the impact of the pandemic on CLL caregivers (Aim 1) and their perceived resource needs (Aim 2): 575 CLL caregivers responded to an online survey; 12 spousal CLL caregivers were interviewed. Two open-ended survey items were thematically analyzed and compared with interview findings. Aim 1 results showed that two years into the pandemic, CLL caregivers continue to struggle with coping with distress, living in isolation, and losing in-person care opportunities. Caregivers described experiencing increasing caregiving burden, realizing the vaccine may not work or didn't work for their loved one with CLL, feeling cautiously hopeful about EVUSHELD, and dealing with unsupportive/skeptical individuals. Aim 2 results indicate that CLL caregivers needed reliable, ongoing information about COVID-19 risk, information about and access to vaccination, safety/precautionary measures, and monoclonal infusions. Findings illustrate ongoing challenges facing CLL caregivers and provide an agenda to better support the caregivers of this vulnerable population during the COVID-19 pandemic.

Patients' Perspectives of Factors That Influence Pharmacogenetic Testing Uptake: Enhancing Patient Counseling and Results Dissemination

Patient preferences for pharmacogenetic (PGx) counseling, testing and results dissemination are not well-established, especially in medically underserved Black and Latino populations. The aim of this study was to capture the preferences of Black and Latino patients who received PGx testing to ascertain: (1) factors enhancing their willingness to do testing and (2) preferences for the dissemination of results. Using the constant comparative method, we thematically analyzed interviews with 13 patients from medically underserved populations who had undergone PGx testing. The findings describe participants wanting better medication options, receiving a clear explanation about the testing, valuing or having an interest in science or medicine and having misconceptions about testing results as factors affecting one's willingness to undergo PGx testing. Additionally, patients confirmed preferring receiving results of PGx testing in a sharable format and described the significance of discussing results in a clinical appointment. The findings provide insight into what Black and Latino patients may prefer in terms of clinical implementation of PGx testing. These results can be utilized for tailoring future implementation of PGx testing and informing best pre- and post-test patient counseling and education practices.

PSAT245 Feasibility of introducing a conversation aid for patients with thyroid nodules in clinical practice: Understanding the clinician experience

Background

To support the collaboration between patients with thyroid nodules and their clinician, we developed a Thyroid NOdule conversation aid (TNOC). TNOC includes a representation of thyroid cancer risk, alternative management options, and a print-out summary for patients. In a pilot study, the use of TNOC was associated with improvement in the quality of diagnostic conversations.

Research question: The aim of this study was to evaluate the feasibility of introducing TNOC into clinical encounters and understand clinicians’ experience with its use.

Methods

Prospective study conducted in two academic centers in the U.S. We included adult patients with thyroid nodules and their clinicians (endocrinologists and ear, nose, and throat specialists (ENT)). The feasibility of introducing TNOC was evaluated by the fidelity to which TNOC was used (12 item checklist of included components, such as: thyroid cancer risk presentation, management options) and the duration of clinical visits, evaluated through video recordings. Clinicians completed a post-visit survey to evaluate how helpful and easy to use TNOC was and the degree to which it supported collaboration with their patients. A qualitative analysis of semi-structured interviews was conducted after clinicians used TNOC in at least three visits. The interview guide was developed following constructs included in the Consolidated Framework for Implementation Research. Analysis was conducted using the constant comparative method.

Results

Twelve clinicians (9 endocrinologists and 3 ENT) were included and used TNOC with 53 patients. Most patients were women (N -42, 79%) with a median age of 62 years (Interquartile range, 53-70). The median size of the thyroid nodules was 2.3 cm (Interquartile range, 1.3, 3.0). The median clinical visit duration was 17 minutes (Interquartile range 10,28). The median fidelity score was 75% (interquartile range 58, 75), with thyroid cancer risk presentation being the most commonly used item (98%) and the printable summary the least used (15%). Clinicians agreed or strongly agreed that TNOC was helpful (N=34, 65%), easy to use (N=44, 85%), and supported collaboration with patients (N= 32, 62%).

In the qualitative analysis, clinicians reported that TNOC was organized and covered commonly discussed topics. Moreover, the use of TNOC could support the clinical interaction and be beneficial for patients by assuring the patient perspective was considered, creating space for questions, and improving how information was presented. Yet, the perceived benefit of using TNOC was expected to be different depending on the expertise of the clinician, as experts might benefit less. Clinicians highlighted the importance of familiarity with TNOC to ease its use and suggested modifications: additional visual content, improved navigation to support dynamic use and providing patient access before/after the visit.

Interpretation: Using TNOC to support thyroid nodule management conversations was feasible, helpful, easy to use, and supportive of patient-clinician collaboration.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT246 Decision Making for Patients with Thyroid Nodules: Understanding the Patient's Experience

Background

We recently developed a Thyroid NOdule conversation aid (TNOC), a conversation tool that supports communication about management options between patients with thyroid nodules and their clinicians. TNOC uses an interactive electronic interface to support conversations about thyroid cancer risk in patients with thyroid nodules and management options. In a pilot study, the use of TNOC in the clinical encounter was associated with improvement in the quality of diagnostic conversations.

Research question: The aim of the study was to evaluate the patient's experience when receiving care using TNOC.

Methods

Prospective study conducted in two academic centers in the U.S. We included adult patients presenting for the evaluation of thyroid nodules and using TNOC in the encounters with their clinicians. Patients that were hyperthyroid, pregnant or had records of previous biopsy were excluded. Patient demographics and clinical features were obtained through electronic health record review. We conducted post-visit semi-structured interviews to assess patients’ experiences using TNOC. The semi-structured interview was developed following constructs included in the Consolidated Framework for Implementation Research. Qualitative analysis was conducted following the constant comparative method to identify emerging themes related to the patient experiences using TNOC. After an initial group of themes were identified, a final set of themes was derived based on prevalence and salience, following an iterative process by two coders.

Results

53 patients were enrolled in the study and 49 completed the post-visit interview. Most patients were women (N -42, 79%) and white (N-47, 89%) with a median age of 62 years (Interquartile range, 53-70). The median size of the thyroid nodules was 2.3 cm (Interquartile range, 1.3, 3.0) and 45% were ACR-TIRADS 4 or 5 (N-24). Most nodules were found incidentally (N-37, 70%).

In the qualitative assessment, the layman terms included in TNOC, the structured, step-wise and visual presentation of information were considered positively by patients. The language, visuals, and structure of TNOC supported knowledge transfer about thyroid nodules and their management options, helping them better understand their situation. Patients felt they worked together with their clinician by going through the conversation aid, making them feel comfortable asking questions. However, patients reported that the clinician's familiarity with TNOC and the learning needs of patients could affect the perceived benefit of the conversation aid. Patients suggested including more information and visuals in TNOC and providing access before/after the visit.

Interpretation: Patients found that the use of TNOC in medical encounters was helpful to understand information, treatment options, and working with their clinicians. This information supports the implementation of TNOC in practice to support decision-making.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Development and pilot testing of a conversation aid to support the evaluation of patients with thyroid nodules

OBJECTIVE

To support patient-centred care and the collaboration of patients and clinicians, we developed and pilot tested a conversation aid for patients with thyroid nodules.

DESIGN, PATIENT AND MEASUREMENTS

We developed a web-based Thyroid NOdule Conversation aid (TNOC) following a human-centred design. A proof of concept observational pre-post study was conducted (TNOC vs. usual care [UC]) to assess the impact of TNOC on the quality of conversations. Data sources included recordings of clinical visits, post-encounter surveys and review of electronic health records. Summary statistics and group comparisons are reported.

RESULTS

Sixty-five patients were analysed (32 in the UC and 33 in the TNOC cohort). Most patients were women (89%) with a median age of 57 years and were incidentally found to have a thyroid nodule (62%). Most thyroid nodules were at low risk for thyroid cancer (71%) and the median size was 1.4 cm. At baseline, the groups were similar except for higher numeracy in the TNOC cohort. The use of TNOC was associated with increased involvement of patients in the decision-making process, clinician satisfaction and discussion of relevant topics for decision making. In addition, decreased decisional conflict and fewer thyroid biopsies as the next management step were noted in the TNOC cohort. No differences in terms of knowledge transfer, length of consultation, thyroid cancer risk perception or concern for thyroid cancer diagnosis were found.

CONCLUSION

In this pilot observational study, using TNOC in clinical practice was feasible and seemed to help the collaboration of patients and clinicians.