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JAMA Network Open Jun 2021Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month...
IMPORTANCE
Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month before death, despite most patients desiring information earlier.
OBJECTIVE
To describe successful navigation and missed opportunities for EOL discussions (eg, advance care planning, palliative care, discontinuation of disease-directed treatment, hospice care, and after-death wishes) between oncologists and outpatients with advanced cancer.
DESIGN, SETTING, AND PARTICIPANTS
This study is a secondary qualitative analysis of outpatient visits audio-recorded between November 2010 and September 2014 for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. The study was conducted at 2 US academic medical centers. Participants included medical, gynecological, and radiation oncologists and patients with stage IV malignant neoplasm, whom oncologists characterized as being ones whom they "…would not be surprised if they were admitted to an intensive care unit or died within one year." Data were analyzed between January 2018 and August 2020.
EXPOSURES
The parent study randomized participants to oncologist- and patient-directed interventions to facilitate discussion of emotions. Encounters were sampled across preintervention and postintervention periods and all 4 treatment conditions.
MAIN OUTCOMES AND MEASURES
Secondary qualitative analysis was done of patient-oncologist dyads with 3 consecutive visits for EOL discussions, and a random sample of 7 to 8 dyads from 4 trial groups was analyzed for missed opportunities.
RESULTS
The full sample included 141 patients (54 women [38.3%]) and 39 oncologists (8 women [19.5%]) (mean [SD] age for both patients and oncologists, 56.3 [10.0] years). Of 423 encounters, only 21 (5%) included EOL discussions. Oncologists reevaluated treatment options in response to patients' concerns, honored patients as experts on their goals, or used anticipatory guidance to frame treatment reevaluation. In the random sample of 31 dyads and 93 encounters, 35 (38%) included at least 1 missed opportunity. Oncologists responded inadequately to patient concerns over disease progression or dying, used optimistic future talk to address patient concerns, or expressed concern over treatment discontinuation. Only 4 of 23 oncologists (17.4%) had both an EOL discussion and a missed opportunity.
CONCLUSIONS AND RELEVANCE
Opportunities for EOL discussions were rarely realized, whereas missed opportunities were more common, a trend that mirrored oncologists' treatment style. There remains a need to address oncologists' sensitivity to EOL discussions, to avoid unnecessary EOL treatment.
Topics: Adult; Advance Care Planning; Aged; Aged, 80 and over; Communication; Female; Humans; Male; Middle Aged; Neoplasms; Oncologists; Patient Care Planning; Patients; Physician-Patient Relations; Qualitative Research; Terminal Care; United States
PubMed: 34110395
DOI: 10.1001/jamanetworkopen.2021.13193 -
JCO Oncology Practice Jun 2021Financial distress (FD) among older adults with cancer is not well studied. We sought to characterize prevalence and factors associated with FD among older adults with...
PURPOSE
Financial distress (FD) among older adults with cancer is not well studied. We sought to characterize prevalence and factors associated with FD among older adults with cancer and the association of FD with geriatric assessment (GA) -identified deficits.
PATIENTS AND METHODS
We included adults age ≥ 60 years with cancer in the University of Alabama at Birmingham Cancer and Aging Resilience Evaluation Registry who underwent GA during initial consultation with a medical oncologist before starting systemic therapy. We captured FD using a single-item question: "Do you have to pay for more medical care than you can afford?" We built multivariable models to study the impact of sociodemographic/clinical factors on FD as well as the association of FD with GA impairments.
RESULTS
We identified 447 older adults with a median age of 69 years; 60% were men, 75% were White, and colorectal (26%) and pancreatic (19%) cancers were the most common. Overall, 27% (n = 121) reported having FD. Factors associated with FD included being Black (v White; odds ratio [OR], 2.26; 95% CI, 1.35 to 3.81; .002), being disabled/unemployed (v employed; OR, 2.60; 95% CI, 1.17 to 5.76; = .019), and having an advanced degree ( less than high school; OR, 0.13; 95% CI, 0.03 to 0.65; = .012). Patients with FD were more likely to report several GA impairments, including depression (OR, 2.10; 95% CI, 1.06 to 4.18; = .034) and impaired health-related quality of life in physical (β = -2.82; = .014) and mental health domains (β = -3.31; = .002).
CONCLUSION
More than a quarter of older adults with cancer reported FD at the time of initial presentation to an oncologist. Several demographic factors and GA impairments were associated with FD.
Topics: Aged; Cross-Sectional Studies; Geriatric Assessment; Humans; Male; Middle Aged; Neoplasms; Oncologists; Quality of Life
PubMed: 33125296
DOI: 10.1200/OP.20.00601 -
Cancer Reports (Hoboken, N.J.) Apr 2021In India, caregivers are an integral part of the illness experience, especially in cancer, to the extent that they can become proxy decision-makers for the patient.... (Review)
Review
BACKGROUND
In India, caregivers are an integral part of the illness experience, especially in cancer, to the extent that they can become proxy decision-makers for the patient. Further, owing to acute resource constraints in the Indian healthcare system, it may be difficult for oncologists to assess and elicit questions from each patient/caregiver. Consequently, there is a need to address these unique aspects of oncology care in India to improve patient outcomes and understanding of their illness and treatment. This can be achieved through a Question Prompt List (QPL), a checklist used by care recipients during medical consultations.
RECENT FINDINGS
This narrative review will first introduce research on the development and effectiveness of the QPL, and then it will highlight current gaps in oncology care in India and explore how the QPL may aid in closing these gaps. A literature search of the empirical research focused on the development, feasibility and acceptability of the QPL in oncology settings was conducted. The final review included 40 articles pertaining to QPL research. Additionally, psycho-oncology research in India centered on information needs and experiences was reviewed. Current Indian psycho-oncology research reports patients' want to be actively involved in their cancer care and a need for more illness information. However, a high demand on physicians' resources and the family caregivers' interference can be barriers to meeting patients' information/communication needs. International research demonstrates that a QPL helps structure and decrease consultation time, improves patient satisfaction with care, and improves the quality of communication during medical encounters.
CONCLUSION
QPLs for Indian patients and caregivers may focus on the scope of medical consultations to address patient needs while influencing the course and content of the patient-caregiver-physician interactions. Further, it can address the resource constraints in Indian oncology care settings, thus reducing the physician's burden.
Topics: Caregivers; Checklist; Communication; Humans; India; Medical Oncology; Oncologists; Patient Participation; Patient Satisfaction; Physician-Patient Relations; Psychology; Referral and Consultation
PubMed: 33295152
DOI: 10.1002/cnr2.1316 -
Journal of Pain and Symptom Management Jul 2020Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and... (Randomized Controlled Trial)
Randomized Controlled Trial
CONTEXT
Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes.
OBJECTIVES
We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death.
METHODS
We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety.
RESULTS
We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02).
CONCLUSION
A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment.
Topics: Adult; Anxiety; Anxiety Disorders; Caregivers; Child, Preschool; Humans; New York; Oncologists; Prognosis; Prospective Studies; Quality of Life; Therapeutic Alliance
PubMed: 32061833
DOI: 10.1016/j.jpainsymman.2020.02.005 -
Cancer Jul 2021Unsolicited patient complaints (UPCs) about physician practices are nonrandomly associated with malpractice claims and clinical quality. The authors evaluated the...
BACKGROUND
Unsolicited patient complaints (UPCs) about physician practices are nonrandomly associated with malpractice claims and clinical quality. The authors evaluated the distributions and types of UPCs associated with oncologists by specialty and assessed oncologist characteristics associated with UPCs.
METHODS
This retrospective study reviewed UPCs associated with US radiation oncologists (ROs), medical oncologists (MOs), and surgical oncologists (SOs) from 35 health care systems from 2015 to 2018. Average total UPCs were compared by specialty in addition to sex, medical school graduation year, degree, medical school location, residency location, practice setting, and practice region. For continuous variables, linear regression was used to test for an association with total complaints.
RESULTS
The study included 1576 physicians: 318 ROs, 1020 MOs, and 238 SOs. The average number of UPCs per physician was different and depended on the oncologic specialty: ROs had significantly fewer complaints (1.28; 95% confidence interval [CI], 1.02-1.54) than MOs (3.81; 95% CI, 3.52-4.10) and SOs (6.89; 95% CI, 5.99-7.79; P < .0001). In a multivariable analysis, oncologic specialty, recency of graduation, and academic practice were predictive of higher total UPCs (P < .05). UPCs described concerns with care and treatment (42.8%), communication (26.4%), accessibility (17.5%), concern for patient (10.3%), and billing (2.9%).
CONCLUSIONS
ROs had significantly fewer complaints than MOs and SOs and may have a lower risk of malpractice claims as a group. In addition to oncologic specialty, a more recent year of medical school graduation and working at an academic center were independent risk factors for UPCs. Further research is needed to clarify the reasons underlying these associations and to identify interventions that decrease UPCs and associated risks.
LAY SUMMARY
This study of 1576 oncologists found that radiation oncologists had significantly fewer complaints than medical oncologists, who in turn had significantly fewer complaints than surgical oncologists. Other characteristics associated with more patient complaints included recency of medical school graduation and practice in an academic setting. Oncologists' patient complaints provide information that may have practical applications for patient safety and risk management. Understanding and addressing the characteristics that increase the risk for complaints could improve patients' experiences and outcomes.
Topics: Communication; Humans; Malpractice; Oncologists; Radiation Oncologists; Retrospective Studies; Risk Factors
PubMed: 33724453
DOI: 10.1002/cncr.33513 -
JAMA Network Open Mar 2022The functional status and physical performance of older adults with cancer are underassessed and undertreated despite the high prevalence of impaired functional status... (Randomized Controlled Trial)
Randomized Controlled Trial
Association of Oncologist-Patient Communication With Functional Status and Physical Performance in Older Adults: A Secondary Analysis of a Cluster Randomized Clinical Trial.
IMPORTANCE
The functional status and physical performance of older adults with cancer are underassessed and undertreated despite the high prevalence of impaired functional status and physical performance in this population and their associations with chemotherapy-induced toxic effects and mortality.
OBJECTIVE
To examine the association between providing oncologists with a geriatric assessment (GA) summary with recommendations and having oncologist-patient conversations about functional and physical performance.
DESIGN, SETTING, AND PARTICIPANTS
Data for this secondary analysis were collected from October 29, 2014, to April 28, 2017, for a national cluster randomized clinical trial conducted by the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program evaluating the effect of a GA intervention on patient satisfaction with communication about aging-related concerns. There were 17 practice clusters in the intervention group and 14 in the usual care group. All 541 participants underwent a GA including standardized functional and physical performance measures and had 1 clinical encounter audio-recorded, transcribed, and blindly coded to categorize conversations by GA domain. Participants were aged 70 years or older, with a stage III or IV solid tumor or lymphoma with palliative treatment intent, and impairment in 1 or more GA domain. Statistical analysis was performed from August 18, 2020, to January 10, 2022.
INTERVENTIONS
Oncologist practices randomized to the intervention received a GA summary and validated recommendations for each patient prior to the audio-recorded clinical encounter.
MAIN OUTCOMES AND MEASURES
The primary analysis of this clinical trial assessed the effect of the intervention on patient satisfaction with oncologist communication about aging-related concerns. This secondary analysis assessed the post hoc hypothesis that the intervention would be associated with an increase in the proportion of patients having conversations with their oncologists and receiving oncologist recommendations specific to functional and physical performance concerns.
RESULTS
A total of 541 patients (276 men [51%]; mean [SD] age, 77.5 [5.2] years [range, 70-96 years]) were analyzed at baseline. Excluding 13 patients without audio recordings, 86% of patients (95% CI, 78%-91%) in the intervention group vs 59% of patients (95% CI, 47%-69%; P < .001) receiving usual care had conversations about functional or physical performance. Conversations were more frequently initiated by oncologists in the intervention group (84%; 95% CI, 77%-90%) than oncologists in the usual care group (58%; 95% CI, 45%-70%; P < .001). Oncologists in the intervention group were more likely to address patients' concerns (43%; 95% CI, 33%-53%) than oncologists in the usual care group (17%; 95% CI, 10%-26%; P < .001).
CONCLUSIONS AND RELEVANCE
In this secondary analysis of a cluster randomized clinical trial, providing oncologists with a GA summary was associated with an increase in the number of oncologist-patient conversations about functional and physical performance-related concerns with recommendations to address these concerns. These findings support the use of the GA summary and recommendations as important tools in caring for older adults with advanced cancer and functional or physical impairments.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02107443.
Topics: Aged; Communication; Functional Status; Geriatric Assessment; Humans; Male; Oncologists; Physical Functional Performance
PubMed: 35302628
DOI: 10.1001/jamanetworkopen.2022.3039 -
Cancer Research and Treatment Jul 2021Particle therapy is a promising and evolving modality of radiotherapy that can be used to treat tumors that are radioresistant to conventional photon beam radiotherapy.... (Review)
Review
Particle therapy is a promising and evolving modality of radiotherapy that can be used to treat tumors that are radioresistant to conventional photon beam radiotherapy. It has unique biological and physical advantages compared with conventional radiotherapy. The characteristic feature of particle therapy is the "Bragg peak," a steep and localized peak of dose, that enables precise delivery of the radiation dose to the tumor while effectively sparing normal organs. Especially, the charged particles (e.g., proton, helium, carbon) cause a high rate of energy loss along the track, thereby leading to high biological effectiveness, which makes particle therapy attractive. Using this property, the particle beam induces more severe DNA double-strand breaks than the photon beam, which is less influenced by the oxygen level. This review describes the general biological and physical aspects of particle therapy for oncologists, including non-radiation oncologists and beginners in the field.
Topics: Heavy Ion Radiotherapy; Humans; Neoplasms; Neutrons; Oncologists; Radiation Oncology
PubMed: 34139805
DOI: 10.4143/crt.2021.066 -
Seminars in Hematology Oct 2017Twitter use by physicians, including those in the hematology-oncology field, is increasing. This microblogging platform provides a means to communicate and collaborate... (Review)
Review
Twitter use by physicians, including those in the hematology-oncology field, is increasing. This microblogging platform provides a means to communicate and collaborate on a global scale. For the oncology professional, an active Twitter presence provides opportunities for continuing medical education, patient engagement and education, personal branding, and reputation management. However, because Twitter is an open, public forum, potential risks such as patient privacy violations, personal information disclosures, professionalism lapses, and time management need to be considered and managed. The authors have summarized the benefits and risks of Twitter use by the hematology-oncology physician. In addition, strategies to maximize benefit and minimize risk are discussed, and resources for additional learning are provided.
Topics: Hematology; Humans; Oncologists; Risk Assessment; Social Media; Telemedicine
PubMed: 29153081
DOI: 10.1053/j.seminhematol.2017.08.001 -
ESMO Open Feb 2022The European Society for Medical Oncology (ESMO) 2021 conference provided a high number of randomized phase III trial reports, many of which were claimed to be practice... (Review)
Review
BACKGROUND
The European Society for Medical Oncology (ESMO) 2021 conference provided a high number of randomized phase III trial reports, many of which were claimed to be practice changing. Given the short time available for conference presentations, results and conclusions tend to have greatest priority with less time remaining for study background and study methodology.
PURPOSE
On behalf of the ESMO Practicing Oncologists Working Group, 11 potentially practice-changing reports were selected and screened for three main questions: (i) Did the investigators provide sufficient details with regard to Patients and Methods to make the results comprehensible? (ii) Were there any reasons to consider bias? (iii) To which extent did the results presented translate to clinical benefit?
RESULTS
In 2 out of 11 trials, the study design presented differed considerably from the study design described at ClinicalTrials.gov. Allocation concealment was not carried out in 6 out of 11 trials. In none of the trials reporting progression-free survival was informative censoring considered an issue. In none of the trials reporting overall survival was desirable crossover considered an issue. Defined trial outcome measures depicted at ClinicalTrials.gov, which could boost or weaken the ESMO-Magnitude of Clinical Benefit Scale score, were often lacking in the presentation. Study success was claimed in a heterogeneous manner, which was often not clearly linked to overall clinical benefit.
CONCLUSION
ESMO conference presentations can inform the scientific community and catalyze further research but cannot replace the full papers in peer-reviewed journals, which are needed to estimate the thoroughness of the results, the overall impact on clinical benefit and the consequences for future treatment guidelines.
Topics: Clinical Trials, Phase III as Topic; Humans; Medical Oncology; Neoplasms; Oncologists; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic; Research Design
PubMed: 35051788
DOI: 10.1016/j.esmoop.2021.100376 -
BMJ Open Aug 2022The increasing incidence of cancer, coupled with improved survivorship, has increased demand for cancer follow-up care and the need to find alternative models of care....
BACKGROUND
The increasing incidence of cancer, coupled with improved survivorship, has increased demand for cancer follow-up care and the need to find alternative models of care. Shared cancer follow-up care in general practice is a safe option in terms of quality of life and cancer recurrence; however, there are barriers to translating this into practice. This review aimed to identify factors that influence the translation of shared cancer follow-up care into clinical practice.
METHODS
Systematic review. Seven electronic databases: MEDLINE, Science Citation Index, Academic Search Complete, CINAHL, APA Psychinfo, Health Source: Nursing/Academic Edition and Psychology and Behavioural Sciences Collection, were searched for published papers between January 1999 and December 2021. The narrative review included papers if they were available in full-text, English, peer-reviewed and focused on shared cancer follow-up care.
RESULTS
Thirty-eight papers were included in the final review. Five main themes emerged: (1) reciprocal clinical information sharing is needed between oncologists and general practitioners, and needs to be timely and relevant; (2) responsibility of care should be shared with the oncologist overseeing care; (3) general practitioners skills and knowledge to provide cancer follow-up care; (4) need for clinical management guidelines and rapid referral to support general practitioners to provide shared follow-up care and (5) continuity of care and satisfaction of care is vital for shared care.
CONCLUSION
The acceptability of shared cancer follow-up care is increasing. Several barriers still exist to translating this into practice. Work is required to develop a shared-care model that can support general practitioners, while the oncologist can oversee the care and implement two-way communication between general and oncologists' clinics. The move towards integrating electronic healthcare records and web-based platforms for information exchange provides a promise to the timely exchange of information.
PROSPERO REGISTRATION NUMBER
CRD42020191538.
Topics: Aftercare; General Practitioners; Humans; Neoplasms; Oncologists; Quality of Life
PubMed: 36038175
DOI: 10.1136/bmjopen-2021-055460