The Pursuit of Positive Impacts: Translating Longitudinal Cancer Studies into Successful Health Communication Interventions

Over a decade ago, in the 100th issue of Health Communication (Volume 25, issues 6-7); 2010), 30 "impact" articles addressed how our collective research findings had been translated to make a positive difference for persons across diverse communities. It is laudable to develop projects helping others to enhance their awareness about healthy living, refine practical communication skills to promote behavioral change, and rely on findings to enact important practices and policies giving priority to how well and long we live in contemporary society. As a preview, however, an article entitled "Why is it so difficult to talk about impact?" raised a series of inherent challenges faced whenever we conduct our research to advance basic knowledge by pursuing meaningful translation opportunities. These efforts are constrained in various ways: A lack of motivation, ability, and training to envision and implement protocols beneficial for the public good; the need to procure adequate resources (e.g., time and money) for sustaining longitudinal investigations; dealing with misconceptions that "applied" communication research has less value than "basic" studies; and creating and managing cross-disciplinary collaborations necessary to achieve project goals. When designing interventions to change others' lives in meaningful ways, attention must also be given to balancing community outreach while avoiding unnecessary self-promotion and imposition of social scientific priorities.

Communication About Negative and Uncertain Results: Interactional Dilemmas During a Genetic Telehealth Consult

This case study focuses on a video telehealth consult to discuss genetic testing results. Participants include a Genetic Counselor (GC) and a Patient (P) previously diagnosed with ovarian cancer who is currently undergoing chemotherapy treatments. Utilizing conversation analysis (CA), attention is first given to a series of interactional dilemmas as GC delivers and P responds to negative, uncertain, and complex test results. Specific findings address practices employed by GC to structure the encounter and establish authority, impacts on P's participation and understandings, recurring and at times problematic orientations to "negative" findings, and inherent ambiguities faced by GC and P when attempting to discern good and bad news. Close examination of these moments provides a unique opportunity to identify, describe, and explain genetic counseling as a co-produced, interactional achievement. These findings are then integrated with patient's post-counseling survey (susceptibility, anxiety, uncertainty, fear, and hope), including reported experiences which broaden understandings of the interactional environment. Specific recommendations are raised for improving counseling skills, enhancing patients' understandings, and building therapeutic alliances addressing both patients' emotional circumstances and the complexities of genetic test results.

Enacting Woundedness and Compassionate Care for Recurrent Metastatic Breast Cancer

This analysis integrates Arthur Frank's timeless revelations about woundedness within the communication context of an oncology interview. A Patient whose life is threatened by recurrent metastatic breast cancer claims personal knowledge and visibly demonstrates impacts from illness experiences. Conversation Analysis (CA) was conducted on a video recorded and transcribed case study involving a Patient, her husband, and co-present oncologists. By focusing on narratives as talk-in-interaction, grounded exemplars are provided of primary interactional achievements: How woundedness gets displayed and responded to with empathy and compassionate witnessing; Patient's flooding out with emotion and potential embarrassment; attempting to regain control and resume talking about her condition; and the serial organization of crying and laughter when managing noticeably delicate moments. In this interview, woundedness is not discounted or dismissed but recognized as legitimate suffering meriting shared commiseration. Understanding how to enact humane and communicatively competent skills during emotionally uncertain moments can enhance medical education.

Defining Moments, Revisited

'Defining moments' are revealed by weaving three strands together in this essay. First, by reenacting stories as 'tell-aboutables,' 'defining moments' are achieved through participants' methods for drawing attention to significant events. Occasioned reconstructions are designed by speakers as timely and worthy to be heard, responded to, and appreciated by recipients. In turn, 'defining moments' of shared existence emerge through next stories, serial orderings of storytelling achievements exposing (in Goffman's terms) less about people and their moments than moments and their people. Second, numerous examples are provided of how stories about cancer comprise altogether routine everyday life activities for patients, family members, and providers. 'Defining moments' can and do become radically re-defined when landscapes of wellness give way to progressive entanglements and forfeitures of sickness. When 'health' comes into play, it is not uncommon for priorities to be given less to self-promotion (e.g. blaming and boasting), and more to efforts designed to optimize mental, emotional, spiritual, and physical well-being. Third, personal stories about 'defining moments' are shared from my long-term investigations of family cancer and patient-oncologist interactions. A vibrant reflexivity is cultivated when we recognize that, and how, our basic research can be successfully translated to advance the public good.

Managing “Stable” Cancer News

This study focuses on oncology interviews with returning patients who have been diagnosed with cancer, are undergoing various treatment regimens, and have been informed by doctors of their current “stable” medical condition. Conversation analysis was conducted on 112 video recorded and transcribed oncology interviews involving 30 doctors. In 44 of 112 (39 percent) interviews, doctors announced stable as good cancer news. In response, patients rarely affirm stable as good news for them. Nonreponses and minimal responses lacking enthusiasm occurred in one third of instances, and in the majority of interactions, patients resisted and questioned impacts of the need to endure ongoing treatments yet reduced possibilities for cancer shrinkage or remission. These interactional disjunctures reflect epistemic dilemmas for doctors seeking to provide quality care and especially for patients who must simultaneously manage good and bad news. Findings extend ongoing research and theoretical development that address the social psychological burdens inherent in disappointment, medical diagnosis, and prognosis. A focus on how patients and doctors manage stable cancer reveals recurring tensions between patients’ lay experiences with illness and how doctors give biomedical priority to controlling cancer.

A White Family's Oral Storytelling About Cancer Generates More Favorable Evaluations From Black American Audiences

One proposition of Entertainment Education (EE) suggests that actors communicating messages should be ethnically and culturally homogenous with targeted audiences. The present study challenges this assumption by investigating audience evaluations of When Cancer Calls... (WCC), a unique 80-minute theatrical production based on actual phone conversations between family members dealing with a loved one's cancer diagnosis, treatment, and eventual death. In WCC, the family is White and all interactions are drawn verbatim from 61 recorded phone calls made over 13 months. This study addresses whether authentic family storytelling about cancer minimizes differences between the White family in WCC, diverse Persons of Color (POC), and specifically how WCC resonates with Black Americans' cancer experiences. Data collected (n=483) from audiences in four U.S. cities confirmed overall positive audience reactions to viewings of WCC. Blacks were significantly more likely to evaluate WCC favorably than Whites or other POC. Rooted in the prominence of oral communication traditions, these findings confirm the power of family storytelling as a vehicle for designing health communication campaigns for Black American audiences. For example, when Blacks were forbidden to learn how to read and write during American slavery, family storytelling was a powerful tool for preserving history, sharing news, resisting racism in hostile environments, and sustaining resilience necessary for survival. These WCC findings provide innovative strategies for facilitating communication among cancer patients and family members, especially Black Americans who are deeply affected and face ongoing challenges talking about cancer.

Patient-Initiated Pain Expressions: Interactional Asymmetries and Consequences for Cancer Care

Only minimal attention has been given to analyzing interactional moments when patients and providers talk about "pain" in general consultations and primary care, and no attention has focused on how pain gets managed during oncology interviews. Conversation analysis (CA) is used to examine a sampling of instances drawn from a collection of 146 pain instances across 65 video recorded and transcribed clinical encounters in a comprehensive cancer clinic. Specific attention is drawn to how pain descriptions are not static but malleable as cancer patients upgrade, downgrade, and produce combined orientations when making their experiences available to oncologists. In response, it is shown that doctors acknowledge patients' descriptions, but do not elaborate nor affiliate with, important pain disclosures. Three interactional environments are closely examined: 1) Reporting and responding to past pain/hurt incidents; 2) Doctor's missing assessments in response to good news announcements about patients' minimal pain; and 3) Patient-initiated pain responses to doctors' questions. These empirical findings confirm identified patterns of interactional asymmetries comprising pain events in UK consultations and USA primary care. Close examination of these social actions provides basic knowledge about how pain communication reframes historical understandings of individuals' pain experiences. Implications for future research are identified, and a protocol is described for how clinical practice and medical education can be improved by refining understandings of pain communication to promote increased sensitivities and more personalized responses to pain expressions.

"Tiny Tiny Little Nothings": Minimization and Reassurance in the Face of Cancer

Drawing from a sub-sample of video recorded and transcribed oncology interviews, Conversation Analysis is used to examine moments when cancer is portrayed as absent or minimally present but not dangerously invasive. Though cancer patients and their doctors invest considerable efforts pursuing life-affirming and hopeful possibilities advancing the quality of living and healing outcomes, little is known about how"good news" and thus hopeful social actions get organized. An interactional practice is identified for depicting tumor sizes as small or shrinking - a displayed preference to tumors that are large, growing, and spreading (i.e., metastasizing). By relying on gestural depictions (e.g., pinched fingers and open hands), in precise unison with paired lexical affiliates (e.g., tiny, little, nothing), it is shown how patients seek to justify their wellness and doctors offer reassurance by demonstrating that tumor sizes are minimally threatening. These interactional practices provide a needed balance to deathly cancer stereotypes, criticisms of health-care bureaucracies as inhumane, and overreliance on biomedical authority enacted during clinical encounters. A need exists to verify the existence of a benign social order in the midst of cancer care, actions designed to address malignant diagnoses by curtailing uncontrolled cancer growth.

Making Cancer Visible: Unmasking Patients' Subjective Experiences

The Face of Cancer, an article and patient's painting published nearly 15 years ago, has contributed in significant ways to a body of research focusing on communication during oncology interviews. Impacts from this painting helped to create a sensitivity for analyzing naturally occurring video recordings, including moments when patients' subjective experiences are raised and responded to. Analysis begins with how a melanoma patient's facial expression bears striking resemblance to the painting, vocal and other visible social actions (e.g., gaze, gesture), and how patient's story about a friend's metastatic cancer reveals her primal fears and hopes about cancer. Actions displayed by other patients (breast, testicular, abdominal, and leukemia) are also examined to unmask how their faces and bodies make cancer visible, doctors' responses, and the complexities of how patients' stressful stories get constructed. Implications are raised for improving patient-provider relationships by offering more personalized care. Understanding how patients display their concerns and emotions, through spoken and embodied actions, enhances discernment about how best to provide tailored and supportive responses to patients' life-world experiences especially, but not exclusively, when dealing with the stresses and angst of cancer.

The Transformative Power of Authentic Conversations About Cancer

Entertainment-education (E-E) assumes that actors performing content should be ethnically and culturally homogeneous with targeted audiences. The present study challenges this basic E-E assumption. Findings are presented from audience members who viewed When Cancer Calls… This theatrical production was constructed from verbatim transcriptions of naturally occurring telephone conversations between White family members as they communicated about and through their cancer journey. Non-White audience members were significantly more likely than White audience members to (a) regard the performance as authentic, (b) find it would influence "people like me," and (c) recommend the production to others. These findings suggest that all people must rely on communication when facing health challenges together. Such interactions that are fundamental to family membership are thus primal for the human social condition, regardless of differences in race and ethnicity. These findings also suggest innovative approaches to E-E health interventions that may contradict traditional market segmentation theories based on cultural differences and the principle of homophily.

Laughter, Humor, and Cancer: Delicate Moments and Poignant Interactional Circumstances

Conversation analysis is employed to examine transcribed excerpts drawn from a subsample of 75 naturally occurring and video recorded interviews between cancer patients and 30 doctors. Close examination is provided of how cancer patients initiate, and doctors respond, to laughter and humor during oncology interviews. Interactions demonstrate that communication about the disease "cancer" shares qualities similar to other medical areas (e.g., primary care): the tendency for patients to initiate laughter or humor to address troubling and challenging circumstances; and that during moments when patients address personal matters, doctors are not invited and do not reciprocate with shared laughter and humor. Prominent in talk about cancer are various precarious circumstances, awkward and delicate moments mirroring the lived experiences of cancer patients (e.g., when patients attempt to minimize fears, justify that they are well when threatened with sickness, claim normality in the midst of chronic conditions, and take stances that weight loss and gain are not problematic). These examples provide a compelling case that routine cancer care involves many poignant situations managed through laughter and humor. Implications are raised for how quality care might be improved through grounded understandings of laughter, humor, and cancer.

The Conversations About Cancer (CAC) Project-Phase II: National findings from viewing When Cancer Calls…and implications for Entertainment-Education (E-E)

OBJECTIVE

We address cancer communication by creating and assessing the impacts of a theatrical production, When Cancer Calls…(WCC…), anchored in conversations from the first natural history of a patient and family members talking through cancer on the telephone.

METHODS

A national study was conducted using a multi-site and randomized controlled trial. An 80-minute video was produced to assess viewing impacts across cancer patients, survivors, and family members. Comparisons were made with a control video on cancer nutrition and diet. Pretest-posttest sample size was 1006, and 669 participants completed a 30-day follow-up impacts assessment.

RESULTS

All five family and communication indices increased significantly for WCC…. When compared to the placebo, average pretest-posttest change scores were higher for self-efficacy (775%), family fabric (665%), outside support (189%), and family communication (97%). One month following viewings, WCC…participants reported 30% more conversations about cancer among patients and family members about cancer.

CONCLUSION

A new genre of Entertainment-Education (E-E) was created that triggers positive reactions from audience members. Managing delicate and often complex communication about the trials, tribulations, hopes, and triumphs of cancer journeys is fundamentally important for everyday living.

PRACTICE IMPLICATIONS

Unique opportunities exist to make WCC… available to national and global audiences, create tailored curricula, and integrate these viewings into educational programs for patients, family members, and care-provider teams across diverse health, corporate, and governmental systems.

Fears, Uncertainties, and Hopes: Patient-Initiated Actions and Doctors' Responses During Oncology Interviews

New cancer patients frequently raise concerns about fears, uncertainties, and hopes during oncology interviews. This study sought to understand when and how patients raise their concerns, how doctors responded to these patient-initiated actions, and implications for communication satisfaction. A subsampling of video recorded and transcribed encounters was investigated involving 44 new patients and 14 oncologists. Patients completed pre/post self-report measures about fears, uncertainties, and hopes as well as postevaluations of interview satisfaction. Conversation analysis was used to initially identify pairs of patient-initiated and doctor-responsive actions. A coding scheme was subsequently developed, and two independent coding teams, comprised of two coders each, reliably identified patient-initiated and doctor-responsive social actions. Interactional findings reveal that new cancer patients initiate actions much more frequently than previous research had identified, concerns are usually raised indirectly, and with minimal emotion. Doctors tend to respond to these concerns immediately, but with even less affect, and rarely partner with patients. From pre/post results, it was determined that the higher patients' reported fears, the higher their postvisit fears and lower their satisfaction. Patients with high uncertainty were highly proactive (e.g., asked more questions), yet reported even greater uncertainties after encounters. Hopeful patients also exited interviews with high hopes. Overall, new patients were very satisfied: oncology interviews significantly decreased patients' fears and uncertainties, while increasing hopes. Discussion raises key issues for improving communication and managing quality cancer care.

"Having an ovary this big is not normal": physicians' use of normal to assess wellness and sickness during oncology interviews

During oncology interviews, physicians and patients routinely employ the term normal to describe patients' condition and overall health status. Surprisingly prevalent but little understood, normal is recruited to achieve an array of social actions comprising a primal aspect of patient-provider interactions: determining, assessing, and treating patients' health status as well and/or sick. Utilizing conversation analysis (CA) to examine a collection of 136 normal references across 61 oncology interviews, this article draws from a subsample of 101 instances to examine how physicians use normal to perform four specific sets of social actions: (a) invoking normal as a preferred range, (b) utilizing normal as evidence that does not explicitly label patients' conditions, (c) treating the absence of normal as indicative of sickness, and (d) providing reassurance to patients in the presence of normal and not normal circumstances. Special attention is given to how oncologists make the case for wellness and/or sickness by identifying patients as normal or not normal/abnormal. Future research is needed to understand how patients employ normal to characterize their symptoms and negotiate health status, to explore how or if alternative orientations to normal are based on gender and/or varying ethnicities, and to develop a more precise understanding of alternative practices for describing and categorizing test results (e.g., common/uncommon).

The Conversations About Cancer (CAC) project: assessing feasibility and audience impacts from viewing The Cancer Play

Basic communication research has identified a major social problem: communicating about cancer from diagnosis through death of a loved one. Over the past decade, an award-winning investigation into how family members talk through cancer on the telephone, based on a corpus of 61 phone calls over a period of 13 months, has been transformed into a theatrical production entitled The Cancer Play. All dialogue in the play is drawn from naturally occurring (transcribed) interactions between family members as they navigate their way through the trials, tribulations, hopes, and triumphs of a cancer journey. This dramatic performance explicitly acknowledges the power of the arts as an exceptional learning tool for extending empirical research, exploring ordinary family life, and exposing the often taken-for-granted conceptions of health and illness. In this study, a Phase I STTR project funded by the National Cancer Institute (NCI), we assess the feasibility of educating and impacting cancer patients, family members, and medical professionals who viewed the play as a live performance and through DVD screenings. Pre- and postperformance questionnaires were administered to solicit audience feedback. Pre-post change scores demonstrate overwhelming and positive impacts for changing opinions about the perceived importance, and attributed significance, of family communication in the midst of cancer. Paired-sample t-tests were conducted on five factor-analyzed indices/indicators-two indices of opinions about cancer and family communication, two indices measuring the importance of key communication activities, and the self-efficacy indicator-and all factors improved significantly (<.001). Informal talkback sessions were also held following the viewings, and selected audience members participated in focus groups. Talkback and focus-group sessions generated equally strong, support responses. Implications of the Phase I study are being applied in Phase II, a currently funded effort to disseminate the play nationally and to more rigorously test its impact on diverse audiences. Future directions for advancing research, education, and training across diverse academic and health care professions are discussed.

Patients' efforts to justify wellness in a comprehensive cancer clinic

Conversation analysis (CA) is employed to examine oncology interviews within a comprehensive cancer clinic. Data are drawn from a sampling of 75 video-recorded and transcribed encounters involving 30 oncologists. During history-taking, by expanding answers to doctor's questions designed to solicit "yes/no" responses, patients manage constraints on interaction by initiating and pursuing distinct courses of action. One prominent set of nonconforming actions involves how cancer patients "justify wellness" and contest doctors' orientations to sickness. In response, doctors treat patients' expansions as dispreferred (e.g., through lack of acknowledgment or topic shift) because they do not conform with questions designed to solicit minimal answers. Patients initiate "justifying wellness" by invoking epistemic knowledge, using extreme language to optimize medical histories, emphasizing and bolstering wellness claims, and reporting healthy lifestyles. As a resource for managing vulnerability in the face of cancer, and for advancing resilient stances toward health and healing, patients attempt to counter the likelihood, severity, and overall threat of cancer. These and related actions ward off otherwise troubling diagnoses and, directly or indirectly, make the case for minimal or even dismissing the need for ongoing cancer care. Implications are raised for recalibrating "sick role" and "well role" activities as practical achievements, distributions of yes/no questions and expanded answers, a benign theory of social order in cancer clinics, the importance of responding to patients' wellness efforts, and the need for a more refined understanding of moments when hurting patients report, demonstrate, and seek treatment for various cancer-related problems.

Disclosing and responding to cancer “fears” during oncology interviews

Video-excerpts from routine oncology interviews are examined to reveal how patients demonstrate and doctors respond to "fears" about cancer. Vocally and visually, embodied impacts of dealing with dreaded consequences of cancer are apparent when addressing both good and potentially bad cancer news. Even a "brush" with cancer can promote negative and ongoing impacts provoking unresolved illness dilemmas. We reveal how, in the midst of extending answers and initiating concerns, patients exhibit trepidations when volunteering narrative information about their medical history and experience of symptoms. In response, doctors are shown to acknowledge yet exhibit minimal receptiveness to patients' lifeworld disclosures and demonstrations (e.g., redirecting attention away from patients' concerns by offering "textbook" symptoms and related pursuits of biomedical agendas). Discussion focuses on interactional criteria for identifying "fears", patients' lay orientations to medical visits, and implications for refining educational workshops for oncologists.

Between dad and son: initiating, delivering, and assimilating bad cancer news

The opening moments of a phone call reveal how a father informs his son, for the 1st time, that his mom's tumor is malignant. An extended phone opening reveals how delaying talk about the mom's condition allows for important interactional work: Displaying resistance to announce the bad news directly, projecting and anticipating the valence of forthcoming news prior to its announcement, and delicately sharing ownership of a serious health condition at the outset of a family cancer journey. Enacting a biomedical demeanor, replete with technical language and withholdings of emotional and personal reactions, subsequent delivery and reception of the bad news is managed stoically-a normalized resource employed by consequential figures when managing and coping with dreaded news events. By closely examining how family members talk through cancer on the telephone, the scope of health communication research is extended beyond clinical settings into home environments, progress is made on the noticeable absence of interactional studies in psycho-oncology, and diverse implications arise for understanding how lay persons diagnose and manage illness dilemmas.

Revealing moments: formulating understandings of adverse experiences in a health appraisal interview

Analysis of a health appraisal interview reveals how an interviewer employs formulations to organize talk about a patient's medical history. When selected reportings by patient are paraphrased, a three-part formulations cycle is initiated: (1) interviewer's formulated understandings, (2) patient's confirmation, and (3) topic shift by interviewer. The reenactment of this interactional pattern promotes increasing attention to patient's adverse experiences as "root problems" underlying adult health status (e.g. molestation, obesity, depression). Creating an environment for patient's emergent disclosures is facilitated by displaying non-judgmental sensitivity to patient's stated concerns, soliciting alignment to particular reconstructions and avoidance of moving the interview forward prematurely and to issues not grounded in patient's illness circumstances. The identification and utilization of communication techniques for attending to patient's bio-psycho-social history is critical for refining understandings of empathic interviewing, enhancing diagnosis and treatment (e.g. referrals), decreasing patients' utilization of health care systems, and ultimately reducing costs for quality medical care.