Interventions aiming to improve advance care planning uptake in oncology: a scoping review of recent randomized controlled trials

PURPOSE OF REVIEW

The evidence regarding the effectiveness of interventions aiming to improve ACP uptake appears mixed. The purpose of this scoping review is to summarize findings from recent RCTs assessing the efficacy of interventions designed to increase ACP uptake in cancer care.

RECENT FINDINGS

The PubMed database was searched for studies published between 2021 and 2023. Ten RCTs were identified that evaluated a wide range of interventions aimed at encouraging or facilitating ACP communication among patients with advanced cancer, caregivers, and HCPs. Three RCTs developed ACP facilitation tools for patients and sometimes caregivers. Six RCTs involved integrating trained ACP facilitators into patient care, and one RCT used nudges to encourage oncologists trained in ACP discussions to initiate discussions with patients at highest risk of short-term mortality. Most of the reviewed interventions were based on previously tested intervention approaches or tools.

SUMMARY

The key effects identified in this review are the facilitation of ACP discussions among patients, caregivers, and HCPs, and the documentation of patient preferences in the medical record. The direct involvement of facilitators in ACP document drafting and inclusion in patient files, as well as interventions prompting end-of-life discussions, contributed to this effect.

Advance care planning in oncology: a scoping review and some recommendations

PURPOSE OF REVIEW

Cancer patients' communication with their relatives and healthcare professionals (HCPs) is essential for advance care planning (ACP). The purpose of this scoping review was to synthesize recent research findings about factors enabling cancer patients', their relatives', and physicians' communication about ACP, and to propose recommendations for future ACP implementation in cancer care.

RECENT FINDINGS

This review confirmed the importance of aspects of the cancer care context (i.e., culture) as ACP uptake-predisposing and -enabling factors. It highlighted the difficulty of determining who should initiate ACP discussion, with which patients and at what time-points. It also highlighted a lack of consideration for socioemotional processes in the study of ACP uptake despite evidence that cancer patients', relatives' and physicians' discomforts that arise from communication about end-of-life and the wish to safeguard each other are main obstacles to ACP implementation.

SUMMARY

Based on these recent findings, we propose an ACP communication model, developed with the consideration of factors reported to influence ACP uptake and communication in healthcare, and integrating socioemotional processes. The testing of the model may yield suggestions for innovative interventions that can support communication about ACP and promote a better uptake in clinical practice.

Improving emotion regulation in breast cancer patients in the early survivorship period: Efficacy of a brief ecologically boosted group intervention

PURPOSE

This study reports the short- and mid-term benefits of an eight-session emotion and self-regulation group intervention ecologically boosted through daily app-based prompts. The intervention was designed for breast cancer patients in the early survivorship period meeting criteria for clinical levels of psychological symptoms.

METHODS

Patients were randomly assigned to the immediate intervention arm (n = 61; intervention received immediately) or to the delayed intervention arm (n = 59; intervention received 5 months later). Psychological symptoms, including anxiety, depressive symptoms, emotional distress, fear of cancer recurrence (FCR), worry, and intrusive thoughts were assessed through questionnaires. Emotion regulation was assessed in a dynamic emotion regulation task and in everyday life. Assessments were completed at baseline (T1), 5 months (T2) and 10 months (T3) later.

RESULTS

Treated patients reported lower levels of worry and intrusive thoughts. They improved their ability to down-regulate the intensity of their negative emotions when exposed to cancer-related triggers in the dynamic emotion regulation task. They reported fewer and less intense negative emotions and more positive emotions in their everyday life. Benefits were maintained 5 months later, except for positive emotions in everyday life.

CONCLUSIONS

The results showed that focusing on emotion regulation is a relevant approach in the treatment of psychological symptoms for breast cancer patients in the early survivorship period meeting criteria for clinical levels of psychological symptoms. The intervention led to changes in patients' dynamic and everyday life emotion regulation. Consolidation sessions may be needed to sustain benefits in positive emotions and to increase the effect sizes.

A randomized controlled trial assessing behavioral, cognitive, emotional and physiological changes resulting from a communication skills training in physicians caring for cancer patients

OBJECTIVE

This randomized study assesses behavioral, cognitive, emotional and physiological changes resulting from a communication skills training (CST) for physicians caring for cancer patients.

METHODS

Medical specialists (N = 90) were randomly assigned in groups to complete a manualized 30-h CST or to a waiting list. Assessments included behavioral (communication skills), cognitive (self-efficacy, sense of mastery), emotional (perceived stress) and physiological (heart rate) measures. Assessments were made at baseline (both groups), after CST program (training group), and four months after (waiting list group). All assessments were conducted before, during, and after a complex communication task with an advanced-stage cancer simulated patient (SP).

RESULTS

Trained physicians had higher levels of communication skills (from RR=1.32; p = .003 to RR=41.33; p < .001), self-efficacy (F=9.3; p = .003), sense of mastery (F=167.9; p < .001) and heart rate during the SP encounter (from F=7.4; p = .008 to F=4; p = .050) and same levels of perceived stress (F=3.1; p = .080).

CONCLUSION

A learner-centered, skills-focused and practice-oriented manualized 30-h CST induced multilevel changes indicating physician engagement in a learning process.

PRACTICE IMPLICATIONS

Trainers should consider the CST multilevel benefits (behavioral, cognitive, emotional and physiological) before, during and after a complex communication simulated task as an innovative way to assess the efficacy of a communication skills learning process.

Early together: A randomized phase III study of early palliative care in metastatic uveal melanoma (MUM)

TPS9598

Background: Uveal melanoma is a rare cancer. Up to 50% of patients (pts) develop metastasis, mainly hepatic. Overall survival in metastatic pts is 12 months (mo), contrasting with a good overall condition until death. To evaluate the impact of integrating early palliative care on patient needs and self-efficacy, we designed a comparative randomized trial in MUM pts. Methods: 162 pts will be randomized (1:2) between the control and the experimental groups in two French centres (Institut Curie-Paris and Centre Antoine Lacassagne-Nice). In the control group, palliative care is introduced according to international guidelines. In the experimental group, it is added earlier, concomitant to the announcement of metastases by the medical oncologist. The main objective is to assess if early supportive care impacts on patient psychological needs at 6 mo, versus standard of care, based on the SCNS-SF34 questionnaire. Secondary objectives include patient’s other needs at 6 and 12 mo, quality of life (QLQ-C30), progression-free and overall survival, and partners’ needs (SCNS-P&C). MUM pts, suitable for a treatment with no curative intent, ECOG PS 0-1, with no physical or biological sign of disease, and capable of filling questionnaires are eligible. Questionnaires are completed by all pts at each oncological visit (baseline, 3, 6, 9 and 12 mo). Supportive care visits take place every 6 weeks if needed and address patient’s information needs, disease and treatment understanding, social and psychological status, symptoms, and partners’ involvement. Prognostic uncertainty and disease seriousness in the absence of symptom is addressed depending on pts’ expressed needs. Medical oncologists and supportive care physicians from both centres attend communication skill training provided by an expert during the study. Analyses: SCNS-SF34 psychological needs scale scores at 6-mo will be compared with a Student’s t-test, in an ITT analysis. For 10 points mean score difference expected between groups (within standard deviation of 20 points) and a two-sided type 1 error of 5%, inclusion of 54 pts (control group) and 108 pts (experimental group) provides the study 85% of power. The planned inclusion period is 3 years, pts will be followed for one year, for a total study duration of 4 years. From July 2020 to January 2022, 63 pts have been enrolled in the trial; 2 pts declined. Five pts were removed early from the study: one for consent retrieval, 4 for early death due to metastasis. COVID-19 delayed enrollment for 5 months. We plan to complete the study Q4 2023 and to analyze the data Q4 2024. Clinical trial information: NCT04728113. [Table: see text]

How does physicians' decisional conflict influence their ability to address treatment outcomes in a decision-making encounter with an advanced-stage cancer simulated patient? A descriptive study

OBJECTIVES

This descriptive study assesses how physicians' decisional conflict influences their ability to address treatment outcomes (TOs) in a decision-making encounter with an advanced-stage cancer simulated patient (SP).

METHODS

Physicians (N = 138) performed a decision-making encounter with the SP trained to ask for TOs information. The physicians' decisional conflict regarding patients' cancer treatments in general was assessed with the General Decisional Conflict Scale (Gen-DCS). The physicians' decisional conflict regarding the SP's cancer treatments was assessed with the Specific Decisional Conflict Scale (Spe-DCS). Physicians' ability to address TOs during the encounter was assessed with an interaction analysis system: the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP). Weekly time spent with cancer patients was assessed with a questionnaire.

RESULTS

Physicians' Spe-DCS (β = -.21 ; p = .014) and weekly time spent with cancer patients (β = .22 ; p = .008) predicted the number of TOs addressed during the encounter. Spe-DCS scores predicted nearly all MD.POP dimensions (r = -.18 ; p = .040 to r = -.30 to p < .001) whereas Gen-DCS scores predicted nearly none MD.POP dimensions.

CONCLUSION

Physicians' specific decisional conflict interferes with their ability to address TOs in a decision-making encounter with an advanced-stage cancer SP.

PRACTICE IMPLICATIONS

Physicians should be trained to address TOs according to patient preferences, despite their own decisional conflict.

Decisional conflict of physicians during the decision-making process for a simulated advanced-stage cancer patient: an international longitudinal study with German and Belgian physicians

BACKGROUND

Decision making with advanced cancer patients is often associated with decisional conflict regarding treatment outcomes. This longitudinal multicenter study investigated German physicians' course of decisional conflict during the decision-making process for a Simulated advanced-stage cancer Patient (SP). Results were compared to a matched sample of Belgian physicians.

METHODS

German physicians' (n = 30) decisional conflict was assessed with the Decisional Conflict Scale (DCS) at baseline (t1) and after the four steps of a decision-making process: after reviewing the SP chart (t2), after viewing an assessment video interview with the SP (t3), after reviewing the team recommendations (t4), and after conducting the patient-physician decision-making interview (t5). The results were compared to those of a Belgian matched sample (n = 30).

RESULTS

Decisional conflict of German physicians decreased during the Decision-Making process (M = 53.5, SD = 11.6 at t2 to M = 37.8, SD = 9.6 at t5, p < 0.001). This was similar to the pattern in the Belgian sample (M = 53.5, SD = 12.5 at t2 to M = 34.1, SD = 10.9 at t5, p < 0.001). There was no significant difference between the two groups for Decisional conflict end scores (p = 0.171). At the end of the Decision-making process, in both groups, still 43.3% of the physicians among each group (n = 13) reported a high Decisional Conflict (DCS > 37.5).

CONCLUSIONS

Physicians' decisional conflict decreases during the decision-making process for an advanced cancer SP, though it remains at a high level. Culture, language and different health care systems have no influence on this process. The results emphasize the influence of psychosocial factors. We conclude that this issue should be considered more intensively in future research and in clinical care.

Development of the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP) during medical encounters

OBJECTIVE

Our first objective was to develop the Multi-Dimensional analysis of Patient Outcome Predictions (MD.POP), an interaction analysis system that assesses how HCPs discuss precisely and exclusively patient outcomes during medical encounters. The second objective was to study its interrater reliability.

METHOD

The MD.POP was developed by consensus meetings. Forty simulated medical encounters between physicians and an actress portraying a patient were analysed. Interrater reliability analysis was conducted on 20 of those simulated encounters.

RESULTS

The MD.POP includes six dimensions: object, framing, value, domain, probability and form of POP. The coding method includes four steps: 1) transcription of the encounter, 2) POP identification, 3) POP dimension coding and 4) POP scoring. Descriptive analyses show that the MD.POP is able to describe verbal expressions addressing the patient's outcomes. Statistical analyses show excellent interrater reliability (Cohen's Kappa ranging from 0.92 to 0.94).

CONCLUSION

The MD.POP is a reliable interaction analysis system that assesses how HCPs discuss patient medical, psychological or social outcomes during medical encounters.

PRACTICAL IMPLICATION

The MD.POP provides a measure for researchers to study how HCPs communicate with patients about potential outcomes. Results of such studies will allow to provide recommendations to improve HCP's communication about patients' outcomes.

Predictors of physicians' communication performance in a decision-making encounter with a simulated advanced-stage cancer patient: A longitudinal study

OBJECTIVES

Physicians' characteristics that influence their communication performance (CP) in decision-making encounters have been rarely studied. In this longitudinal study, predictors of physicians' CP were investigated with a simulated advanced-stage cancer patient.

METHODS

Physicians (n=85) performed a decision-making encounter with a simulated patient (SP). Their CP was calculated by analyzing encounter transcripts with validated interaction analysis systems. Potential specific psychological predictors were physicians' empathy towards the SP (Jefferson Scale of Physician Empathy, JSPE) and their decisional conflict about the treatment (Decisional Conflict Scale, DCS). Potential general psychological predictors were physicians' empathy towards cancer patients (JSPE), their decisional conflict about cancer patients' treatments (DCS), and their affective reactions to uncertainty (Physicians' Reactions to Uncertainty, PRU).

RESULTS

Physicians' CP was predicted by their decisional conflict about the SP's treatment (DCS) (β=0.41; p< 0.001) and their affective reactions to uncertainty regarding cancer treatments (PRU) (β=-0.31; p=0.003).

CONCLUSION

During encounters with advanced-stage cancer patients, physicians' awareness of uncertainty about which treatments to consider may facilitate their communication performance, whereas physicians' affective reactions to uncertainty may inhibit their performance.

PRACTICE IMPLICATIONS

Physicians' decisional conflict and reactions to uncertainty should be addressed in communication skills training programs.

Communication about uncertainty and hope: A randomized controlled trial assessing the efficacy of a communication skills training program for physicians caring for cancer patients

Background

Although previous studies have reported the efficacy of communication skills training (CST) programs, specific training addressing communication about uncertainty and hope in oncology has not yet been studied. This paper describes the study protocol of a randomized controlled trial assessing the efficacy of a CST program aimed at improving physician ability to communicate about uncertainty and hope in encounters with cancer patients.

Methods/design

Physician participants will be randomly assigned in groups (n = 3/group) to a 30-h CST program (experimental group) or to a waiting list (control group). The training program will include learner-centered, skills-focused, practice-oriented techniques. Training efficacy is assessed in the context of an encounter with a simulated advanced stage cancer patient at baseline and after the CST for the experimental group, and after four months for the waiting-list group. Efficacy assessments will include communicational, psychological and physiological measures. Group-by-time effects will be analyzed using a generalized estimating equation (GEE). A power analysis indicated that a sample size of 60 (30 experimental and 30 control) participants will be sufficient to detect effects.

Discussion

The current study will aid in the development of effective CST programs to improve physician ability to communicate about uncertainty and hope in encounters with cancer patients.

Trial registration

US Clinical Trials Register NCT02836197.

Adherence to geriatric assessment (GA)-based recommendations in older patients (pts) with cancer

10010

Background: In the general older population, GA-guided treatment plans improve overall survival, quality of life and functional status. In geriatric oncology, studies mainly focused on screening and assessment but not on geriatric interventions and follow-up. The aim of this study was to investigate the adherence to recommendations and subsequent interventions based on GA results in older pts with cancer. Methods: A prospective Belgian multicenter (n = 22) cohort study included pts ≥70 years with a malignant tumor when an oncological treatment decision had to be made. Pts with an abnormal G8 (≤14/17) underwent GA and were included in this study. Recommendations for interventions were formulated based on GA results. At follow-up adherence to GA-based recommendations was documented. Results: From 11-2012 till 2-2015, G8 screening was performed in 8451 pts. 5838 pts with an abnormal G8 were included in the study. Geriatric recommendations were given in 79.2% of pts with a median of 2/pt (range 0-10), most frequently consultation of a dietician (73%) for malnutrition, a social worker (54.8%) for social and functional status problems and a geriatrician (42.1%) for general geriatric problems. Follow-up data were available for 4167 pts. In the group of pts where recommendations were given, at least one intervention was performed in 69% with a median of 1/pt (range 0-6), most frequently dietician (43.4%), social worker (26.1%) and geriatrician (22.6%). A total of 7569 actions were undertaken for a total of 5725 geriatric recommendations. Recommendations were most frequently adhered to for malnutrition, social status and functional status problems. The most frequent actions undertaken were nutritional support and supplements, extended home care and psychological support. Conclusions: This large scale Belgian study focusses on the adherence to GA based interventions in older pts with cancer and contributes to the optimization of care for these pts. We identified the domains for which geriatric interventions are most frequently recommended and adhered to and which health care professionals and referrals are essential in the multidisciplinary approach of older pts with cancer.

Cognitive compensatory processes of older, clinically fit patients with hematologic malignancies undergoing chemotherapy: A longitudinal cohort study

OBJECTIVE

Despite the well-known negative impacts of cancer and anticancer therapies on cognitive performance, little is known about the cognitive compensatory processes of older patients with cancer. This study was designed to investigate the cognitive compensatory processes of older, clinically fit patients with hematologic malignancies undergoing chemotherapy.

METHODS

We assessed 89 consecutive patients (age ≥ 65 y) without severe cognitive impairment and 89 age-, sex-, and education level-matched healthy controls. Cognitive compensatory processes were investigated by (1) comparing cognitive performance of patients and healthy controls in novel (first exposure to cognitive tasks) and non-novel (second exposure to the same cognitive tasks) contexts, and (2) assessing psychological factors that may facilitate or inhibit cognitive performance, such as motivation, psychological distress, and perceived cognitive performance. We assessed cognitive performance with the Trail-Making, Digit Span and FCSR-IR tests, psychological distress with the Hospital Anxiety and Depression Scale, and perceived cognitive performance with the FACT-Cog questionnaire.

RESULTS

In novel and non-novel contexts, average cognitive performances of healthy controls were higher than those of patients and were associated with motivation. Cognitive performance of patients was not associated with investigated psychological factors in the novel context but was associated with motivation and psychological distress in the non-novel context.

CONCLUSIONS

Older, clinically fit patients with hematologic malignancies undergoing chemotherapy demonstrated lower cognitive compensatory processes compared to healthy controls. Reducing distress and increasing motivation may improve cognitive compensatory processes of patients in non-novel contexts.

Development of the LaComm 1.0, A French medical communication analysis software: A study assessing its sensitivity to change

OBJECTIVE

To test and compare the sensitivity to change of a communication analysis software, the LaComm 1.0, to the CRCWEM's using data from a randomized study assessing the efficacy of a communication skills training program designed for nurses.

METHODS

The program assessment included the recording of two-person simulated interviews at baseline and after training or 3 months later. Interview transcripts were analyzed using the CRCWEM and the LaComm 1.0 tools.

RESULTS

One hundred and nine oncology nurses (mainly graduated or certified) were included in the study. The CRCWEM detected 5 changes out of 13 expected changes (38%) (e.g., more open directive questions after training) and the LaComm 1.0, 4 changes out of 7 expected changes (57%) (e.g., more empathic statements after training). For open directive question, the effect sizes of the group-by-time changes were slightly different between tools (CRCWEM: Cohen's d=0.97; LaComm 1.0: Cohen's d=0.67).

CONCLUSIONS

This study shows that the LaComm 1.0 is sensitive to change.

PRACTICE IMPLICATIONS

The LaComm 1.0 is a valid method to assess training effectiveness in French. The use of the Lacomm 1.0 in future French communication skills training programs will allow comparisons of studies.

Vulnerabilities in Older Patients when Cancer Treatment is Initiated: Does a Cognitive Impairment Impact the Two-Year Survival?

Introduction

Dementia is a known predictor of shorter survival times in older cancer patients. However, no empirical evidence is available to determine how much a cognitive impairment shortens survival in older patients when cancer treatment is initiated.

Purpose

To longitudinally investigate how much a cognitive impairment detected at the initiation of cancer treatment influences survival of older patients during a two-year follow-up duration and to compare the predictive value of a cognitive impairment on patients survival with the predictive value of other vulnerabilities associated with older age.

Methods

Three hundred and fifty-seven consecutive patients (≥65 years old) admitted for breast, prostate, or colorectal cancer surgeries were prospectively recruited. A cognitive impairment was assessed with the Montreal Cognitive Assessment (MoCA<26). Socio-demographic, disease-related, and geriatric vulnerabilities were assessed using validated tools. Univariate and subsequent multivariate Cox proportional hazards models stratified for diagnosis (breast/prostate cancer versus colorectal cancer) and disease status (metastatic versus non-metastatic) were used.

Results

A cognitive impairment was detected in 46% (n = 163) of patients. Survival was significantly influenced by a cognitive impairment (HR = 6.13; 95% confidence interval [CI] = 2.07–18.09; p = 0.001), a loss in instrumental autonomy (IADL ≤7) (HR = 3.06; 95% CI = 1.31–7.11; p = 0.009) and fatigue (Mob-T<5) (HR = 5.98; 95% CI = 2.47–14.44; p <0.001).

Conclusions

During the two years following cancer treatment initiation, older patients with a cognitive impairment were up to six times more likely to die than patients without. Older patients should be screened for cognitive impairments at cancer treatment initiation to enable interventions to reduce morbidity and mortality. Further studies should address processes underlying the relationship between cognitive impairments and an increased risk of dying in older cancer patients.

Predictors of physicians' satisfaction with their management of uncertainty during a decision-making encounter with a simulated advanced stage cancer patient

OBJECTIVES

To optimize their training, predictors of physicians' satisfaction with their management of uncertainty should be examined. This study investigated these predictors by using a simulated advanced stage cancer patient.

METHODS

Physicians (n=85) rated their satisfaction with their management of uncertainty (Visual Analog Scale-100mm) after a decision-making encounter. Communication predictors were examined with the: Observing Patient Involvement scale (OPTION), Multidimensional analysis of Patient Outcome Predictions (MD.POP) and Communication Content Analysis Software (LaComm). Psychological predictors were assessed with the: Intolerance of Uncertainty Inventory (IUI), Physicians' Reactions to Uncertainty scale (PRU), Decisional Conflict Scale (DCS), and Jefferson Scale of Physician Empathy (JSPE).

RESULTS

Physicians' satisfaction (mean=67mm; standard deviation=17mm) was not predicted by their communication, but by their anxiety due to uncertainty (PRU) (β=-.42; p=<.001) and their perceived empathy (JSPE) (β=.26; p=.009). These variables accounted for 25% of variance in physicians' satisfaction.

CONCLUSIONS

Physicians' satisfaction with their management of uncertainty was not affected by their communication performance, but by their psychological characteristics.

PRACTICE IMPLICATIONS

Training programs should increase physicians' awareness regarding the communication performance required in decision-making encounters under conditions of uncertainty.

Is it possible to improve communication around radiotherapy delivery: A randomized study to assess the efficacy of team training?

BACKGROUND AND PURPOSE

The aim of this study was to assess the efficacy of a 38-h communication skills training program designed for multidisciplinary radiotherapy teams.

MATERIALS AND METHODS

Four radiotherapy teams were randomly assigned to a training program or to a waiting list. Assessments were scheduled at baseline (T1) and then after the training was completed or four months later (T2), respectively. Communication around radiotherapy delivery was assessed based on audio recordings of the first and last radiotherapy sessions in order to assess team members' communication skills and the expression of concerns by breast cancer patients (analyzed with content analysis software LaComm).

RESULTS

198 radiotherapy sessions were recorded. During the first radiotherapy sessions, members of the trained teams exhibited more assessment skills (p=0.048), provided more setting information (p<0.001), and used more social words (p=0.019) compared to the members of the untrained teams. During the last radiotherapy session, members of the trained teams used more assessment skills (p=0.004) and patients interacting with members of the trained teams expressed more sadness words (p=0.023).

CONCLUSION

Training of multidisciplinary teams has the potential to transfer skills that affect the short exchanges that take place around radiotherapy delivery.

Factors associated with self-perceived burden to the primary caregiver in older patients with hematologic malignancies: an exploratory study

OBJECTIVE

Although cancer patients frequently experience self-perceived burden to others, this perception has not been enough studied. The aim of this study was to investigate the prevalence of self-perceived burden to the primary caregiver (SPB-PC) and associated factors in an older patient population with hematologic malignancies at the time of chemotherapy initiation.

METHODS

In total, 166 consecutive patients with hematologic malignancies aged ≥65 years were recruited at the time of chemotherapy initiation. Patients' SPB-PC was assessed using a 100-mm visual analogue scale (VAS). Characteristics potentially associated with SPB-PC, including sociodemographic and medical characteristics, physical functioning status (Karnofsky performance score, activities of daily living (ADL)/instrumental ADL), symptoms (fatigue, pain, nausea, quality of life), psychological distress (Hospital Anxiety and Depression Scale (HADS)), perceived cognitive function (Functional Assessment of Cancer Therapy Cognitive (FACT-Cog) Scale), and patients'/primary caregivers' personal relationship characteristics (family tie, support), were assessed.

RESULTS

Thirty-five percent of patients reported moderate to severe SPB-PC (VAS ≥ 50 mm). Patients' SPB-PC was associated with lower Karnofsky performance (β = -0.135, p = 0.058) and ADL (β = -0.148, p = 0.037) scores, and higher HADS (β = 0.283, p < 0.001) and FACT-Cog perceived cognitive impairments subscale (β = 0.211, p = 0.004) scores. The proportion of explained variance was 23.5%.

CONCLUSIONS

Health care professionals should be aware that about one third of older cancer patients experience moderate to severe SPB-PC at the time of chemotherapy initiation. They should adapt their support of patients who report such a feeling. Copyright © 2016 John Wiley & Sons, Ltd.

A Belgian Survey on Geriatric Assessment in Oncology Focusing on Large-Scale Implementation and Related Barriers and Facilitators

OBJECTIVES

The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate.

RESULTS

Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration.

CONCLUSION

Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.

Identification of clinical parameters predictive of one-year survival using two geriatric tools in clinically fit older patients with hematological malignancies: Major impact of cognition

BACKGROUND

Little is known about the reliability of G8 screening tool and the prognostic value of clinical parameters within the Comprehensive Geriatric Assessment (CGA) in clinically fit older patients with hematological malignancies.

MATERIALS AND METHODS

This study was performed to assess the reliability of G8 as a screening tool and to determine the predictive value of CGA items in terms of 1-year overall survival (OS). G8 and CGA were proposed to 107 consecutive patients (65-89 years) with hematological malignancies assessed by their physicians as clinically fit, meaning not exhibiting geriatric syndromes and/or irreversible comorbidities significantly impairing their daily function, and thus able to receive chemotherapy.

RESULTS

Out of 107 patients, 90 patients were evaluable and completed both scales; 72% and 80% were defined as "vulnerable" when evaluated with G8 (≤ 14.5) or CGA (≥ 2 impairments) respectively. The area under ROC-curve of G8 compared to CGA was 0.749±0.051. Neither G8 nor CGA total scores were predictive of 1-year OS. However, age (HR=1.105, 95% CI: 1.016-1.202; p=0.019), diagnosis (HR=5.208, 95% CI: 1.895-14.310; p=0.001) and cognitive status (HR=3.260, 95% CI: 1.043-10.194; p=0.042) were predictive of OS.

CONCLUSIONS

We conclude that in our selected hematological patients: 1) the G8 score does not help selecting patients for CGA, 2) the G8 and CGA total scores do not predict OS, and 3) in addition to the age and disease itself, cognitive impairment appears to be a powerful prognostic factor.

Transfer of Communication Skills to the Workplace: Impact of a 38-Hour Communication Skills Training Program Designed for Radiotherapy Teams

Purpose

This study assessed the efficacy of a 38-hour communication skills training program designed to train a multidisciplinary radiotherapy team.

Methods

Four radiotherapy teams were randomly assigned to a training program or a waiting list. Assessments were scheduled at baseline and after training for the training group and at baseline and 4 months later for the waiting list group. Assessments included an audio recording of a radiotherapy planning session to assess team members' communication skills and expression of concerns of patients with breast cancer (analyzed with content analysis software) and an adapted European Organisation for Research and Treatment of Cancer satisfaction with care questionnaire completed by patients at the end of radiotherapy.

Results

Two hundred thirty-seven radiotherapy planning sessions were recorded. Compared with members of the untrained teams, members of the trained teams acquired, over time, more assessment skills (P = .003) and more supportive skills (P = .050) and provided more setting information (P = .010). Over time, patients interacting with members of the trained teams asked more open questions (P = .022), expressed more emotional words (P = .025), and exhibited a higher satisfaction level regarding nurses' interventions (P = .028).

Conclusion

The 38-hour training program facilitated transfer of team member learned communication skills to the clinical practice and improved patients' satisfaction with care.

The effect of communication skills training on residents' physiological arousal in a breaking bad news simulated task

OBJECTIVE

Breaking bad news (BBN) is a complex task which involves dealing cognitively with different relevant dimensions and a challenging task which involves dealing with intense emotional contents. No study however has yet assessed in a randomized controlled trial design the effect of a communication skills training on residents' physiological arousal during a BBN task.

METHODS

Residents' physiological arousal was measured, in a randomized controlled trial design, by heart rate and salivary cortisol before, during and after a BBN simulated task.

RESULTS

Ninety-eight residents were included. MANOVA showed significant group-by-time effects. Trained residents' mean heart rate levels remained elevated after training and cortisol areas under the curve increased after training compared to untrained residents.

CONCLUSION

Communication skills training has an effect on residents' physiological arousal. Residents' self-efficacy and communication skills improvements in a BBN simulated task are associated with an elevated physiological arousal, which becomes proportional to the complexity of the task and reflects a better engagement and performance.

PRACTICE IMPLICATIONS

Residents should be informed that, to perform a task, they need to engage in the task with a physiological arousal proportional to the complexity of this task. Communication skills training should be adapted.

Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study

BACKGROUND

To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions.

PATIENTS AND METHODS

Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above.

RESULTS

One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%).

CONCLUSION

Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment.

Desire for formal psychological support among caregivers of patients with cancer: prevalence and implications for screening their needs

OBJECTIVE

To investigate the prevalence of desire for formal psychological support of primary caregivers of patients with cancer and to identify caregivers' and patients' socio-demographic and psychological characteristics as well as patients' disease-related characteristics associated with this desire.

METHODS

This is a multicenter, cross-sectional study assessing desire for formal psychological support among consecutive primary caregivers of patients with cancer. Patients and caregivers completed the Hospital Anxiety and Depression Scale and reported their desire for formal psychological support.

RESULTS

Two-hundred and eighty-two patient-caregiver dyads were assessed. Forty percent of patients had breast cancer, 16% had a hematologic cancer, 12% had a gastrointestinal cancer, and 32% had another solid tumor. Nineteen percent of caregivers reported desiring formal support, and 54% experienced moderate to high levels of distress. Regression analysis showed that caregivers' desire for formal support was negatively associated with caregivers' age (Exp(B) = 0.95; p < 0.001) and education levels (Exp(B) = 0.35; p = 0.032) and positively with caregivers' level of distress (Exp(B) = 1.08; p < 0.001) and with patients' desire for formal psychological support (Exp(B) = 2.54; p = 0.008). These variables only predicted 25% of caregivers who desire formal support.

CONCLUSIONS

One out of five caregivers desires formal psychological support although one out of two caregivers experiences significant levels of distress. The weak association between caregivers' desire for formal support and distress emphasizes the need to implement systematic screenings of both their distress and their desire for formal psychological support in oncology.

How much is residents' distress detection performance during a clinical round related to their characteristics?

OBJECTIVE

The aim of this study was to investigate residents' characteristics associated with their performance in detecting patients' distress (detection performance).

METHODS

Residents' detection performance was assessed in a clinical round. A mean detection performance score was calculated for each resident by comparing residents' rating of patients' distress (VAS) with patients' reported distress (HADS). Residents' characteristics include general (socio-demographic, professional and psychological), detection (self-efficacy, attitudes and outcome expectancies) and performance characteristics (communication skills (LaComm), psychological arousal (STAI) and physiological arousal (heart rate and blood pressure) in a highly emotional and complex simulated interview task).

RESULTS

Ninety-four residents and 442 inpatients were included. 30% of the variance in residents' detection performance was related to residents' performance characteristics: anxiety level (p=.040) and mean arterial blood pressure (p=.019) before the task; empathy (p=.027) and mean heart rate (p=.043) during the task; mean arterial blood pressure changes (p=.012) during the assessment procedure.

CONCLUSION

Residents' detection performance is partly related to their performance characteristics. Psychological and physiological arousals are key characteristics--beside empathic skills--that need to be considered in models designed to determine detection performance.

PRACTICE IMPLICATIONS

Future interventions designed to improve residents' detection performance should focus notably on their performance characteristics.

The Ways of Coping Checklist (WCC): validation in French-speaking cancer patients

We explore the psychometric properties of the French version of the Ways of Coping Checklist Revised (WCC-R) for a cancer patient sample. The WCC-R was completed by 622 patients and 464 completed the State-Trait Anxiety Inventory (STAI). A confirmatory factor analysis (CFA) on the original factor structure did not fit the data. The sample was randomly divided into two subsamples. Exploratory factor analysis was conducted on one subsample and revealed three factors: 'Seeking social support', 'Problem focused-coping' and 'Self-blame and avoidance', including 21 items. A CFA confirmed this structure in the second subgroup. These scales correlated with the anxiety scores.

Transfer of communication skills to the workplace during clinical rounds: impact of a program for residents

BACKGROUND AND PURPOSE

Communication with patients is a core clinical skill in medicine that can be acquired through communication skills training. Meanwhile, the importance of transfer of communication skills to the workplace has not been sufficiently studied. This study aims to assess the efficacy of a 40-hour training program designed to improve patients' satisfaction and residents' communication skills during their daily clinical rounds.

METHODS

Residents were randomly assigned to the training program or to a waiting list. Patients' satisfaction was assessed with a visual analog scale after each visit. Transfer of residents' communication skills was assessed in audiotaped actual inpatient visits during a half-day clinical round. Transcripted audiotapes were analyzed using content analysis software (LaComm). Training effects were tested with Mann-Whitney tests and generalized linear Poisson regression models.

RESULTS

Eighty-eight residents were included. First, patients interacting with trained residents reported a higher satisfaction with residents' communication (Median=92) compared to patients interacting with untrained residents (Median=88) (p=.046). Second, trained residents used more assessment utterances (Relative Risk (RR)=1.17; 95% Confidence intervals (95%CI)=1.02-1.34; p=.023). Third, transfer was also observed when residents' training attendance was considered: residents' use of assessment utterances (RR=1.01; 95%CI=1.01-1.02; p=.018) and supportive utterances (RR=0.99; 95%CI=0.98-1.00; p=.042) (respectively 1.15 (RR), 1.08-1.23 (95%CI), p<.001 for empathy and 0.95 (RR), 0.92-0.99 (95%CI), p=.012 for reassurance) was proportional to the number of hours of training attendance.

CONCLUSION

The training program improved patients' satisfaction and allowed the transfer of residents' communication skills learning to the workplace. Transfer was directly related to training attendance but remained limited. Future studies should therefore focus on the improvement of the efficacy of communication skills training in order to ensure a more important training effect size on transfer.

Efficacy of a communication and stress management training on medical residents' self-efficacy, stress to communicate and burnout: a randomized controlled study

This is a longitudinal randomized controlled study investigating the efficacy of a communication and stress management skills training programme on medical residents' self-efficacy to communicate and to manage stress in interviews, stress to communicate in interviews, and burnout. Ninety-six medical residents participated. Results showed a statistically significant increase in self-efficacy and decrease in stress to communicate. No changes were noted in burnout. Results of this training may encourage its compulsory organization in the medical curriculum. Further research is required to examine whether a programme associating person-directed and organization-directed interventions could have an impact on residents' burnout.

Insight on variables leading to burnout in cancer physicians

Although communication skills training programs have been recommended to reduce physicians' burnout, few studies have investigated their efficacy. This study assessed the impact of two training programs on cancer physicians' burnout. Especially, it identified some variables leading to burnout in order to develop effective interventions. Burnout was assessed with the Maslach Burnout Inventory. No statistically significant impact of training programs on burnout was observed. The amount of clinical workload and the overuse of some facilitative communication skills were associated with cancer physicians' burnout. The content of such programs must be redefined to reduce burnout.

Predictors and correlates of burnout in residents working with cancer patients

There are few studies which have investigated variables associated with the development of burnout among residents working with cancer patients. The aim of this study is to identify variables leading to residents' burnout in order to develop effective interventions. Burnout was assessed with Maslach Burnout Inventory. Person- (i.e., emotional-focused coping) and work-related (i.e., changes in lack of organizational support index) variables explain 28% of the variance in changes in emotional exhaustion. Training programs may be improved by adding specific modules for residents, about problem-focused coping in interviewing patients, and for supervisors, about effective team management.

Impact of life-threatening risk information on the evolution of patients' anxiety and risk recall: the specific context of informed consent for experimental stem cell transplant

OBJECTIVE

This study examines risk recall and evolution of patients' anxiety after transmission of life-threatening risk information in an informed consent procedure for experimental HSCT.

METHODS

Informed consent interviews were audio-recorded and transcribed. Patient risk recall was obtained through comparing information provided in the interview to information recalled by patients following the interview. The evolution of patients' anxiety was assessed through comparing patients' post- to patients' pre-interview anxiety using the STAI-State. Physicians' communication skills and risk framing were analyzed.

RESULTS

Twenty patients were included. Patients recalled on average 4 risks (S.D.=1.6) out of 9 different risks transmitted (S.D.=2) which corresponds to a recall rate of 44% (S.D.=15.5). Patients' anxiety remained on average stable (Mean=0.4; S.D.=9.1). Linear regression analysis showed that risk recall was predicted positively by the number of risks transmitted (B=.30; P=.032) and by patients' problem-focused coping (B=.21; P=.008). The evolution of anxiety was predicted positively by the number of times benefits were transmitted (B=.83; P=.003) and negatively by the level of anxiety before the interview (B=-.50; P=.001).

CONCLUSION

Results show the limits of patients' risk recall in the context of informed consent for a life-threatening procedure.

PRACTICE IMPLICATIONS

This study highlights the necessity to develop strategies allowing tailoring of risk transmission to every patient's needs.

Factors that influence cancer patients' and relatives' anxiety following a three-person medical consultation: impact of a communication skills training program for physicians

BACKGROUND

No study has yet assessed the impact of physicians' skills acquisition after a communication skills training program on changes in patients' and relatives' anxiety following a three-person medical consultation. This study aimed at comparing, in a randomized study, the impact, on patients' and relatives' anxiety, of a basic communication skills training program and the same program consolidated by consolidation workshops and at investigating physicians' communication variables associated with patients' and relatives' anxiety.

METHODS

Consultations with a cancer patient and a relative were recorded and analyzed by the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' anxiety were assessed with the State-Trait Anxiety Inventory-State.

RESULTS

No statistically significant change over time and between groups was observed. Mixed-effects modeling of changes in patients' and relatives' anxiety showed that decreases in both patients' and relatives' anxiety were linked with patients' and relatives' self-reported distress (p = 0.031 and 0.005), and that increases in both patients' and relatives' anxiety were linked with physicians' breaking bad news (p = 0.028 and 0.005).

CONCLUSION

No impact of the training program was observed. Results indicate the need to further study communication skills which may help reduce patients' and relatives' anxiety especially when breaking bad news.

Factors influencing physicians' detection of cancer patients' and relatives' distress: can a communication skills training program improve physicians' detection?

PURPOSE

This study aimed to assess the impact on physicians' detection of patients' and relatives' distress of six 3-h consolidation workshops (CW) following a 2.5-day communication skills basic training (BT) program and to investigate factors associated with detection of distress.

METHODS

Physicians, after BT, were randomized to CW or to a waiting list. Physicians' detection of patients' and relatives' distress was measured through differences between physicians' ratings of patients' and relatives' distress (VAS) and patients' and relatives' self-reported distress (HADS). Communication skills were analysed according to the CRCWEM.

RESULTS

Mixed-effects modelling of physicians' detection of patients' distress showed a positive group by time effect in favour of physicians in the CW group. Detection of patients' distress was associated negatively with patients' distress, positively with physicians' concurrent use of psychological assessment and supportive skills, and negatively with general assessment skills. Mixed-effects modelling of physicians' detection of relatives' distress showed no significant group by time effect. Detection of relatives' distress was associated negatively with relatives' distress and with general assessment skills.

CONCLUSION

CW following a 2.5-day BT are needed to improve physicians' detection of patients' distress in three-person interviews. Results indicate the need to further improve physicians' detection of relatives' distress.

Physicians are different when they learn communication skills: influence of the locus of control

PURPOSE

Although it is widely recognised that educational interventions may be more effective for people with an 'internal' Locus of Control (who believe that life outcomes are controlled by their own characteristics or actions) compared to people with an 'external' Locus of Control (who believe that life outcomes are controlled by external forces such as luck, fate or others), no study has yet assessed the influence of physicians' Locus of Control (LOC) on communication skills learning. This study aims to test the hypothesis that, in a communication skills training program, physicians with an 'internal' LOC would demonstrate communication skills acquisition to a greater degree than those with an 'external' LOC.

METHODS

A non-randomised longitudinal intervention study was conducted between January 1999 and April 2001. Sixty-seven volunteer physicians from private and institutional practice in Belgium participated in a learner-centred, skills-focused, practice-oriented communication skills training program. Communication skills changes were assessed in 2 standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower third of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance.

RESULTS

In the two-person and three-person interviews, changes in the use of open directive questions were more important among physicians with an "internal" LOC compared with changes observed among physicians with an 'external' LOC (P=0.066 and P=0.004, respectively). In the three-person interview, changes in the use of directive questions, assessing functions and moderate feelings stated explicitly were more important among physicians with an 'internal' LOC compared with changes observed among physicians with an 'external' LOC (P= 0.001; P=0.002 and P=0.011 respectively).

CONCLUSION

This study shows that physicians' LOC is a psychological characteristic that could influence the efficacy of a communication skills training program. This evidence supports the idea that a psychological characteristic such as 'internal' LOC may facilitate communication skills acquisition through physicians' belief that communication with patients may be controlled by physicians themselves.

Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians

BACKGROUND

No study has yet assessed the impact of physicians' skills acquisition after a communication skills training programme on the evolution of patients' anxiety following a medical consultation. This study aimed to compare the impact, on patients' anxiety, of a basic communication skills training programme (BT) and the same programme consolidated by consolidation workshops (CW), and to investigate physicians' communication variables associated with patients' anxiety.

PATIENTS AND METHODS

Physicians, after attending the BT, were randomly assigned to CW or to a waiting list. The control group was not a non-intervention group. Consultations with a cancer patient were recorded. Patients' anxiety was assessed with the State Trait Anxiety Inventory before and after a consultation. Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual.

RESULTS

No statistically significant change over time and between groups was observed. Mixed-effects modelling showed that a decrease in patients' anxiety was linked with screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' distress (P < 0.001). An increase in anxiety was linked with breaking bad news (P = 0.050) and with supportive skills (P = 0.013). No impact of the training programme was observed.

CONCLUSIONS

This study shows the influence of some communication skills on the evolution of patients' anxiety. Physicians should be aware of these influences.

[Stakes, aims and specificities of the physician-patient communication in cancer care: state of the art and perspectives]

The physician-patient relationship has three main stakes : creating a high-quality inter-personal relationship, exchanging information and decision-making. The achievement of these stakes implies that the physician and the patient are able to reach specific communicational objectives. The aim of this paper is to review the characteristics of care as regards cancer patients that could prevent the physician from reaching these stakes and objectives. Moreover, two future perspectives in this field are exposed : the study of factors that influence the communication process when a cancer patient is accompanied by one of his or her relative in a medical interview and the study of personal characteristics of physicians that can predict their ability to communicate in cancer care. On the basis of this triple review, proposals aimed to improve physician-patient communication in cancer care are exposed.

Teaching communication and stress management skills to junior physicians dealing with cancer patients: a Belgian Interuniversity Curriculum

BACKGROUND

Ineffective physicians' communication skills have detrimental consequences for patients and their relatives, such as insufficient detection of psychological disturbances, dissatisfaction with care, poor compliance, and increased risks of litigation for malpractice. These ineffective communication skills also contribute to everyday stress, lack of job satisfaction, and burnout among physicians. Literature shows that communication skills training programs may significantly improve physicians' key communication skills, contributing to improvements in patients' satisfaction with care and physicians' professional satisfaction. This paper describes a Belgian Interuniversity Curriculum (BIC) theoretical roots, principles, and techniques developed for junior physicians specializing in various disciplines dealing with cancer patients.

CURRICULUM DESCRIPTION

The 40-h training focuses on two domains: stress management skills and communication skills with cancer patients and their relatives. The teaching method is learner-centered and includes a cognitive, behavioral, and affective approach. The cognitive approach aims to improve physicians' knowledge and skills on the two domains cited. The behavioral approach offers learners the opportunity to practice these appropriate skills through practical exercises and role plays. The affective approach allows participants to express attitudes and feelings that communicating about difficult issues evoke. Such an intensive course seems to be necessary to facilitate the transfer of learned skills in clinical practice.

CONCLUSIONS

The BIC is the first attempt to bring together a stress management training course and a communication training course that could lead not only to communication skills improvements but also to burnout prevention.

Communication skills training in cancer care: where are we and where are we going?

PURPOSE OF REVIEW

This review gives an overview of recent developments in the field of communication skills training programs designed for cancer health care professionals.

RECENT FINDINGS

The Web of Knowledge was searched for empirical papers published between January 2002 and February 2005. Twenty-two papers were included in the review describing 13 different studies. Four studies were randomised trials using a pretest-posttest comparison design. As regards participant-based outcomes, studies showed improvements in terms of participant satisfaction with course, reported improvements in communication skills, increased knowledge and confidence, and changes in attitudes and beliefs. Results in terms of participants' level of stress and burnout were inconsistent across studies. Improvements were observed as regards the use of taught skills following training. Three studies using an utterance-by-utterance analysis system reported improvements in physicians' use of assessment skills or supportive skills. One study observed improvements in terms of decision-making skills. No change was observed as regards physicians' detection of patient distress. As regards patient-based outcomes, only two of four studies reported improvements in terms of patient satisfaction with and perception of interviews.

SUMMARY

Results of this review confirm the usefulness of learner-centred, skills-focused, and practise-oriented communication skills training programs organised in small groups of a maximum 6 participants and lasting at least 20 hours. Such communication skills training programs may therefore be recommended to health care professionals treating cancer patients and their families.