Doing the hard work of learning: oncologists' enduring impressions of a year-long communication skills training program.

PURPOSE: Few studies have examined the long-term impact of communication skills training for oncologists. We developed a year-long communication skills curriculum for medical oncology fellows with the primary goals of fostering life-long learning of patient-centered communication skills and internalization of associated attitudes and beliefs. We engaged learners through reflection, narrative methods, and action methods, thereby creating a non-threatening, team-based environment. The purpose of the current study was to determine whether learners perceived that they had acquired enduring skills, attitudes, and knowledge years after they participated. METHODS: Former fellows completed an online cross-sectional survey from June to July 2019 that included demographic information, 21 items on a numerical scale, and 3 narrative prompts. Survey items pertained to 4 domains, including skills, attitudes, confidence with specific scenarios, and overall impressions. The numerical scale ranged from "strongly agree" = 1 to "strongly disagree" = 5. RESULTS: A total of 114 fellows, including 27 teaching assistants, participated in the communication skills training over 8 years. The average time between the end of the training program and completion of the survey was 5.2 years. The response rate was 68/114 (64%). Forty-one (60%, 95% CI: 49.3-73.8) fellows agreed or strongly agreed that the curriculum profoundly impacted their practice of medicine. Forty-three (64%, 95% CI: 51.5-75.5) fellows strongly agreed or agreed that they often found themselves informally sharing lessons they learned during the series. Overall average domain scores were 1.89 (SD = 0.84) for skills, 2.16 (0.79) for attitudes, 2.05 (0.81) for confidence with specific challenges, and 2.38 (0.94) for lasting impressions. Results were significantly more favorable for teaching assistants than for others. CONCLUSION: Engaging, interactive, safe, and learner-centered communication skills training has an enduring and favorable impact on oncologists' self-perceived skills, confidence with specific challenges, and attitudes.

Integrating Storytelling into a Communication Skills Teaching Program for Medical Oncology Fellows.

Oncology training focuses primarily on biomedical content rather than psychosocial content, which is not surprising in light of the enormous volume of technical information that oncology fellows assimilate in a short time. Nonetheless, the human connection, and specifically communication skills, remains as important as ever in caring for highly vulnerable patients with cancer. We previously described a year-long communication skills curriculum for oncology fellows that consisted of monthly 1-hour seminars with role play as the predominant teaching method (Epner and Baile, Acad Med. 89:578-84, 2014). Over several years, we adapted the curriculum based on learner feedback and reflection by faculty and teaching assistants and consolidated sessions into quarterly 3-4-hour workshops. We now describe integrating stories into the curriculum as a way of building empathy and warming fellows to the arduous task of dealing with highly emotional content, such as conversations with young patients about transitioning off disease-directed therapy. Learners read and discussed published, medically themed stories; discussed their own patient care stories; and completed brief writing reflections and discussions. They then worked in small groups facilitated by faculty and upper level fellows who functioned as teaching assistants to work on applying specific skills and strategies to scenarios that they chose. Fellows completed anonymous surveys on which they rated the curriculum highly for relevance, value, organization, content, and teaching methods, including storytelling aspects. We conclude that sharing stories can help highly technical learners build reflective ability, mindfulness, and empathy, which are all critical ingredients of the art of medicine.

Managing body image difficulties of adult cancer patients: lessons from available research.

BACKGROUND: Body image is a critical psychosocial issue for patients with cancer because they often undergo significant changes to appearance and functioning. The primary purpose of this review article was to identify empirically-supported approaches to treat body image difficulties of adult cancer patients that can be incorporated into high-quality comprehensive cancer care. METHODS: An overview was provided of theoretical models of body image relevant to cancer patients, and findings were presented from published literature on body image and cancer from 2003 to 2013. These data were integrated with information from the patient-doctor communication literature to delineate a practical approach for assessing and treating body image concerns of adult cancer patients. RESULTS: Body image difficulties were found across patients with diverse cancer sites, and were most prevalent in the immediate postoperative and treatment period. Age, body mass index, and specific cancer treatments have been identified as potential risk factors for body image disturbance in cancer patients. Current evidence supports the use of time-limited cognitive-behavioral therapy interventions for addressing these difficulties. Other intervention strategies also show promise but require further study. Potential indicators of body image difficulties were identified to alert health care professionals when to refer patients for psychosocial care, and a framework was proposed for approaching conversations about body image that can be used by the oncologic treatment team. CONCLUSIONS: Body image issues affect a wide array of cancer patients. Providers can use available evidence combined with information from the health care communication literature to develop practical strategies for treating body image concerns of patients with cancer.

Managing body image difficulties of adult cancer patients.

BACKGROUND: Body image is a critical psychosocial issue for patients with cancer because they often undergo significant changes to appearance and functioning. The primary purpose of this review article was to identify empirically-supported approaches to treat body image difficulties of adult cancer patients that can be incorporated into high-quality comprehensive cancer care. METHODS: An overview was provided of theoretical models of body image relevant to cancer patients, and findings were presented from published literature on body image and cancer from 2003 to 2013. These data were integrated with information from the patient-doctor communication literature to delineate a practical approach for assessing and treating body image concerns of adult cancer patients. RESULTS: Body image difficulties were found across patients with diverse cancer sites, and were most prevalent in the immediate postoperative and treatment period. Age, body mass index, and specific cancer treatments have been identified as potential risk factors for body image disturbance in cancer patients. Current evidence supports the use of time-limited cognitive behavioral therapy interventions for addressing these difficulties. Other intervention strategies also show promise but require further study. Potential indicators of body image difficulties were identified to alert health care professionals when to refer patients for psychosocial care, and a framework was proposed for approaching conversations about body image that can be used by the oncologic treatment team. CONCLUSIONS: Body image issues affect a wide array of cancer patients. Providers can use available evidence combined with information from the health care communication literature to develop practical strategies for treating body image concerns of patients with cancer.

Difficult conversations: teaching medical oncology trainees communication skills one hour at a time.

Difficult conversations about prognosis, end of life, and goals of care arise commonly in medical oncology practice. These conversations are often highly emotional. Medical oncologists need outstanding, patient-centered communication skills to build trust and rapport with their patients and help them make well-informed decisions. Key skills include exploring patients' perspectives, responding to emotion with empathy, and maintaining mindfulness during highly charged conversations. These skills can be taught and learned. Most previously described communication skills training curricula for oncology providers involve multiday retreats, which are costly and can disrupt busy clinical schedules. Many curricula involve a variety of oncology providers, such as physicians and nurses, at various stages of their careers. The authors developed a monthly, one-hour communication skills training seminar series exclusively for physicians in their first year of medical oncology subspecialty training. The curriculum involved a variety of interactive and engaging educational methods, including sociodramatic techniques, role-play, reflective writing, and Balint-type case discussion groups. Medical oncologists in their second and third years of training served as teaching assistants and peer mentors. Learners had the opportunity to practice skills during sessions and with patients between sessions. Learners acquired important skills and found the curriculum to be clinically relevant, judging by anonymous surveys and anonymous responses on reflective writing exercises. Results from the current curriculum are preliminary but lay the foundation for enhanced and expanded communication skills training programs in the future.

"When patients and families feel abandoned".

PURPOSE: Patients with serious illness derive a sense of security by forming strong, healing relationships with their providers. These bonds are particularly strong in life-threatening illnesses, such as cancer, which carry the stigma of death and suffering. These strong relationships create expectations in patients that are not necessarily shared by their clinicians. Providers often focus on treating disease and emphasize technically excellent, "evidence-based" practice while failing to fully appreciate the power of the patient-provider relationship. In contrast, vulnerable patients expect much more than technical competence, including open and clear communication, security, continuity, and access. Patients are often left feeling abandoned when their providers do not meet their expectations, even when their care is technically sound. METHODS/RESULTS: In this paper, we describe scenarios that can lead to feelings of abandonment and discuss strategies to avoid and respond to them. CONCLUSIONS: These strategies can help us maintain healing relationships with our patients by maintaining their trust, confidence, and satisfaction. Cultivating relational aspects of medical practice requires an interchange and takes time. Experienced doctors know this and continue to do so because being present and staying with the patient during difficult times is a pillar of moral and ethical training and a fundamental attribute of a good physician.

Wooden's pyramid: building a hierarchy of skills for successful communication.

BACKGROUND: John Wooden, the legendary college basketball coach, created the "Pyramid of Success", which he constructed from 14 timeless character traits and interpersonal skills that are critical to competitive greatness. Wooden's pyramid is a powerful symbol that he and others have used for several decades as an educational tool to promote leadership and teamwork. AIM: This article proposes the "Pyramid of Relational Excellence (PRE)", patterned after Wooden's pyramid, as a mnemonic-based educational symbol for communication skills training. METHOD: Literature review, personal reflection. RESULTS: The PRE is constructed of four tiers with a total of 12 building blocks, with each successive tier built upon the one beneath it. The building blocks represent fundamental elements that are known to be critical to successful communication. CONCLUSIONS: The PRE is process oriented rather than task oriented and focuses exclusively on the face-to-face encounter. It therefore complements established communications curricula, such as the UK communication wheel and others, which are more comprehensive and task oriented. The PRE is constructed of timeless, fundamental principles. It is therefore particularly well suited for training medical students and residents.

PI3K-Akt signaling is involved in the regulation of p21(WAF/CIP) expression and androgen-independent growth in prostate cancer cells.

The purpose of this study is to investigate the role of PI3K-Akt signaling in prostate cancer cell growth and androgen receptor (AR)-mediated gene expression. Androgen-dependent LNCaP cells and their androgen-independent counterpart, LNCaP-AI cells, were used. We found that PI3K-Akt signaling is elevated in LNCaP-AI cells compared to that in LNCaP cells and is involved in androgen-independent growth. More importantly, PI3K-Akt signaling enhances AR activity and is involved in the induction of AR target genes, such as p21(WAF/CIP), a gene with anti-apoptosis activity and associated with androgen-independent growth in human prostate cancer. A receptor tyrosine kinase inhibitor also inhibits the PI3K-Akt signaling and compromises AR activity and cell growth. These findings suggest that the PI3K-Akt cell growth survival pathway and its downstream-regulated gene, p21(WAF/CIP), are targets for developing novel therapies against prostate cancer, especially those androgen-independent diseases.

Methionine restriction selectively targets thymidylate synthase in prostate cancer cells.

Tumor cells are more sensitive to methionine restriction than normal tissues, a phenomenon known as methionine auxotrophy. Previous studies showed that 5-fluorouracil and methionine restriction act synergistically against a variety of tumors. The purpose of the current studies was to determine the molecular mechanism(s) underlying this synergy. 5-Fluorouracil is known to inhibit thymidylate synthase (TS), a key enzyme that transfers a methyl group from 5,10-methylene-tetrahydrofolate to dUMP during nucleotide biosynthesis. We found that methionine restriction reduced 5,10-methylene-tetrahydrofolate levels by 75% and selectively inhibited TS activity in PC-3 human prostate cancer cells within 24hr, whereas it did not in normal prostate epithelial cells. The observed fall in TS activity was accompanied by a commensurate reduction in TS protein levels as determined by western blot analysis. In contrast, 5-fluorouracil inhibited TS activity by >90% but increased TS protein levels. This increase was abrogated by methionine restriction. Surprisingly, methionine restriction increased 3H-leucine incorporation in PC-3 cells over the first 24hr, suggesting that reduction of TS levels was not simply due to global protein synthesis inhibition. Methionine restriction also significantly reduced the ratio of dUMP to dTTP in PC-3 cells, creating an imbalanced nucleotide pool. These results suggest that synergy between methionine restriction and 5-fluorouracil is attributable to multiple factors, including depletion of reduced folates, selective inhibition of TS, and creation of an imbalanced nucleotide pool. Dietary and/or enzymatic methionine restriction combined with 5-fluoruracil has great promise as a novel treatment for advanced cancer.

Glutathione S-transferase pi is upregulated in the stromal compartment of hormone independent prostate cancer.

BACKGROUND: Glutathione S-transferase (GST) pi is a detoxifying enzyme abundant in normal prostate basal cells but only rarely expressed in prostate cancer cells. The current studies are the first to focus on GST pi in the stromal compartment of prostate tumors. METHODS: We employed immunohistochemical, immunofluorescence, and Western blot analysis to measure GST pi expression and subcellular localization in 21 primary and metastatic tumors from patients with hormone independent prostate cancer, as well as seven lymph node metastases and six prostatectomy specimens. RESULTS: GST pi was detectable in stromal cells in 17 of the 21 hormone independent prostate tumors. GST pi tissue distribution in hormone independent tumors coincided with vimentin staining, suggesting that GST pi is expressed by reactive fibroblasts and/or myofibroblasts. CONCLUSIONS: The current results suggest that prostate cancer cells induce an injury response in the stroma during progression to hormone independence, which results in GST pi expression. Stromal GST pi may contribute to chemoresistence of advanced prostate cancer.

Induction of caspase-dependent and -independent apoptosis in response to methionine restriction.

Tumor cells are more sensitive to methionine restriction than normal tissues, a phenomenon known as methionine auxotrophy. Previous studies have demonstrated that methionine restriction causes tumor cell growth arrest and eventually apoptosis. The current studies were undertaken to elucidate the molecular pathways leading to apoptosis induced by methionine restriction. We found that methionine restriction induced formation of oligonucleosomal DNA fragment and cytochrome c release from mitochondria in methionine-dependent PC3 and Hela cells. Methionine restriction also led to cleavage and activation of initiator and effector caspases in Hela cells but not PC3 cells. Furthermore, methionine restriction resulted in cleavage of BID and reduction in Bcl-2 levels in both cell lines. These data suggest that apoptosis induced by methionine restriction is mitochondria-dependent. Methionine restriction induced caspase-independent cell death in PC3 cells, whereas it stimulated caspase-dependent cell death in Hela cells. Cleavage of BID and decreased expression of Bcl-2 upon methionine deprivation may be the underlying mechanism to stimulate release of cytochrome c from mitochondria.

Nutrient intake and nutritional indexes in adults with metastatic cancer on a phase I clinical trial of dietary methionine restriction.

Animal studies have shown that dietary methionine restriction selectively inhibits growth of a variety of human tumor xenografts but has relatively few deleterious effects on normal tissues. The objectives of the present study were to determine whether enteral methionine restriction is safe and tolerable in adults with metastatic cancer and whether it reduces plasma methionine levels. Eight patients with a variety of metastatic solid tumors were enrolled in a phase I clinical trial. A commercially available methionine-free medical food served as the primary dietary protein source for all patients. Patients were prescribed diets containing 0.6-0.8 g of protein, 25-35 kcal, and 2 mg of methionine per kilogram per day. Participants remained on the experimental diet for an average of 17.3 wk (range 8-39 wk). Plasma methionine levels fell from 21.6 +/- 7.3 to 9 +/- 4 microM within 2 wk, representing a 58% decline. Serum albumin and prealbumin levels remained stable or increased. Mean energy intake increased during participation compared with baseline, and protein intake was maintained at target levels. The only side effect was weight loss of approximately 0.5% of body mass index (0.5 kg) per week. We conclude that enteral dietary methionine restriction is safe and tolerable in adults with metastatic solid tumors and results in significant reduction in plasma methionine levels.