Measurement equivalence of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Medicare survey items between Whites and Asians.

PURPOSE: Asians report worse experiences with care than Whites. This could be due to true differences in care received, expectations about care, or survey response styles. We examined responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Medicare survey items by Whites and Asians, controlling for underlying level on the CAHPS constructs. METHODS: We conducted multiple group analyses to evaluate measurement equivalence of CAHPS Medicare survey data between White and Asian Medicare beneficiaries for CAHPS reporting composites (communication with personal doctor, access to care, plan customer service) and global ratings of care using pooled data from 2007 to 2011. Responses were obtained from 1,326,410 non-Hispanic Whites and 40,672 non-Hispanic Asians (hereafter referred to as Whites and Asians). The median age for Whites was 70, with 24 % 80 or older, and 70 for Asians, with 23 % 80 or older. Fifty-eight percent of Whites and 56 % of Asians were female. RESULTS: A model without group-specific estimates fit the data as well as a model that included 12 group-specific estimates (7 factor loadings, 3 measured variable errors, and 2 item intercepts): Comparative Fit Index = 0.947 and 0.948; root-mean-square error of approximation = 0.052 and 0.052, respectively). Differences in latent CAHPS score means between Whites and Hispanics estimated from the two models were similar, differing by 0.053 SD or less. CONCLUSIONS: This study provides support for measurement equivalence of the CAHPS Medicare survey composites (communication, access, customer service) and global ratings between White and Asian respondents, supporting comparisons of care experiences between the two groups.

The rationale for patient-reported outcomes surveillance in cancer and a reproducible method for achieving it.

Patient-reported outcomes (PROs) measure quality of life, symptoms, patient functioning, and patient perceptions of care; they are essential for gaining a full understanding of cancer care and the impact of cancer on people's lives. Repeatedly captured facility-level and/or population-level PROs (PRO surveillance) could play an important role in quality monitoring and improvement, benchmarking, advocacy, policy making, and research. This article describes the rationale for PRO surveillance and the methods of the Patient Reported Outcomes Symptoms and Side Effects Study (PROSSES), which is the first PRO study to use the American College of Surgeons Commission on Cancer's Rapid Quality Reporting System to identify patients and manage study data flow. The American Cancer Society, the National Cancer Institute, the Commission on Cancer, and RTI International collaborated on PROSSES. PROSSES was conducted at 17 cancer programs that participated in the National Cancer Institute Community Cancer Centers Program among patients diagnosed with locoregional breast or colon cancer. The methods piloted in PROSSES were successful as demonstrated by high eligibility (93%) and response (61%) rates. Differences in clinical and demographic characteristics between respondents and nonrespondents were mostly negligible, with the exception that non-white individuals were somewhat less likely to respond. These methods were consistent across cancer centers and reproducible over time. If repeated and expanded, they could provide PRO surveillance data from patients with cancer on a national scale.

Improving the quality of survivorship for older adults with cancer.

In May 2015, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging through a U13 grant, convened a conference to identify research priorities to help design and implement intervention studies to improve the quality of life and survivorship of older, frailer adults with cancer. Conference attendees included researchers with multidisciplinary expertise and advocates. It was concluded that future intervention trials for older adults with cancer should: 1) rigorously test interventions to prevent the decline of or improve health status, especially interventions focused on optimizing physical performance, nutritional status, and cognition while undergoing cancer treatment; 2) use standardized care plans based on geriatric assessment findings to guide targeted interventions; and 3) incorporate the principles of geriatrics into survivorship care plans. Also highlighted was the need to integrate the expertise of interdisciplinary team members into geriatric oncology research, improve funding mechanisms to support geriatric oncology research, and disseminate high-impact results to the research and clinical community. In conjunction with the 2 prior U13 meetings, this conference provided the framework for future research to improve the evidence base for the clinical care of older adults with cancer. Cancer 2016;122:2459-68. © 2016 American Cancer Society.

Cancer-Related Information Seeking Among Cancer Survivors: Trends Over a Decade (2003-2013).

The demonstrated benefits of information seeking for cancer patients, coupled with increases in information availability, underscore the importance of monitoring patient information seeking experiences over time. We compared information seeking among cancer survivors to those with a family history of cancer and those with no history of cancer. We identified characteristics associated with greater information seeking among cancer survivors, key sources of cancer-related information, and changes in information source use over time. Data from five iterations of the Health Information National Trends Survey (HINTS) spanning 2003 to 2013 were merged and analyzed. Frequencies, cross-tabulations, multivariate logistic regression, and multinomial regression analyses were conducted. All data were weighted to provide representative estimates of the adult US population. Cancer information seeking was reported most frequently by cancer survivors (69.8 %). The percentage of cancer survivors who reported information seeking increased from 66.8 % in 2003 to 80.8 % in 2013. Cancer information seeking was independently associated with age, education, and income; seeking was less likely among older adults, those with less education, and those with lower incomes. Compared to respondents in 2003, those in 2005 (odds ratio (OR) = 0.40, 95 % confidence interval (CI) = 0.24-0.65) and 2008 (OR = .43, 95 % CI = 0.26-0.70) were about half as likely to use the Internet as the first source of cancer information compared to a healthcare provider. Despite overall increases in cancer information seeking and access to health information from a variety of sources, healthcare providers remain a key source of health information for cancer survivors.

Cancer survivors' disclosure of complementary health approaches to physicians: the role of patient-centered communication.

BACKGROUND: Cancer survivors' disclosure of complementary health approaches (CHAs) to their follow-up care physicians is necessary to ensure the safe and optimal use of such approaches. Rates of disclosure of CHAs are variable and may be facilitated by patient-centered communication. METHODS: This cross-sectional study conducted in 2003-2004 examined a population-based sample of leukemia, colorectal, and bladder cancer survivors (n=623) who were 2 to 5 years after their diagnosis. A subset of participants who reported using CHAs (n=196) was analyzed with multivariate logistic regression to examine the association between patients' perceptions of their physician's patient-centered communication (ie, information exchange, affective behavior, knowledge of patients as persons) and patients' disclosure of CHA use to their physician with adjustments for physician, patient, and patient-physician relationship factors. RESULTS: Thirty-one percent of the full sample used CHAs, and 47.6% of CHA users disclosed their use to their physicians. Disclosure was significantly associated with patient-centered communication even with adjustments for hypothesized covariates (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.09-1.71). Perceived physician knowledge of the patient as a person (OR, 1.28; 95% CI, 1.10-1.48) and information exchange (OR, 1.27; 95% CI, 1.02-1.60) were the aspects of patient-centered communication that contributed to this association. The main reason for nondisclosure assessed in the survey was that survivors did not think that it was important to discuss CHAs (67.0%). A majority of physicians encouraged continued use of CHAs when they were disclosed (64.8%). CONCLUSIONS: Results support the idea that improving the overall patient centeredness of cancer follow-up care and improving the disclosure of CHA use are potentially synergistic clinical goals.

The role of families in decisions regarding cancer treatments.

BACKGROUND: Shared decision-making is an important component of patient-centered care and is associated with improved outcomes. To the authors' knowledge, little is known concerning the extent and predictors of the involvement of a patient's family in decisions regarding cancer treatments. METHODS: The Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is a large, multiregional, prospective cohort study of the cancer care and outcomes of patients with lung and colorectal cancer. Participants reported the roles of their families in decision-making regarding treatment. Multinomial logistic regression was used to assess patient factors associated with family roles in decisions. RESULTS: Among 5284 patients, 80 (1.5%) reported family-controlled decisions, with the highest adjusted rates (12.8%) noted among non-English-speaking Asians. Among the 5204 remaining patients, 49.4% reported equally sharing decisions with family, 22.1% reported some family input, and 28.5% reported little family input. In adjusted analyses, patients who were married, female, older, and insured more often reported equally shared decisions with family (all P <.001). Adjusted family involvement varied by race/ethnicity and language, with Chinese-speaking Asian (59.8%) and Spanish-speaking Hispanic (54.8%) patients equally sharing decisions with family more often than white individuals (47.6%). Veterans Affairs patients were least likely to report sharing decisions with family, even after adjustment for marital status and social support (P <.001). CONCLUSIONS: The majority of patients with newly diagnosed lung or colorectal cancer involve family members in treatment decisions. Non-English-speaking Asians and Hispanics rely significantly on family. Further studies are needed to determine the impact of family involvement in treatment decisions on outcomes; until then, physicians should consider eliciting patients' preferences for family involvement.

Unveiling SEER-CAHPS®: a new data resource for quality of care research.

BACKGROUND: Since 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care. OBJECTIVE: To describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI's Surveillance, Epidemiology and End Results (SEER) data. DESIGN: This is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients' global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973-2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002-2011) for fee-for-service beneficiaries on utilization and costs of care. PARTICIPANTS: In total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort. MAIN MEASURES: The data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys. KEY RESULTS: Sizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage. CONCLUSIONS: SEER-CAHPS is a valuable resource for information about Medicare beneficiaries' experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

The Relation Between Having a Usual Source of Care and Ratings of Care Quality: Does Patient-Centered Communication Play a Role?

Having a usual source of health care has been consistently associated with greater use of preventive services, decreased use of emergency services, and with patients' ratings of quality and satisfaction with care. Ongoing patient-provider relationships may be, in part, fostered by patient-centered communication. Growing evidence demonstrates that positive patient-centered communication improves adherence to treatment recommendations, management of chronic disease, quality of life, and disease-related outcomes. We aimed to determine how patient-centered communication between patients and physicians might mediate the relation between having a source of usual care and ratings of health care quality. We analyzed data from Cycle 1 of the fourth iteration of the Health Information National Trends Survey. Data were collected through mailed questionnaire in October 2011 through February 2012 (N = 3,959). Overall, individuals with a usual source of care reported more patient-centered communication experiences and had higher ratings of quality of care. Parameter estimates for each pathway in the mediation model were estimated through regression analysis. Results confirm the importance of patient-centered communication in shaping patients' perceptions of the quality of their care, accounting for a significant portion of the observed relation between having a usual source of care and ratings of quality.

The importance of symptom surveillance during follow-up care of leukemia, bladder, and colorectal cancer survivors.

PURPOSE: We examined cancer survivors' experience of bothersome symptoms, association of symptom bother with health-related quality of life (HRQOL), survivors' perception of symptom care, and their symptom-related information needs. METHODS: Using self-report survey measures, survivors of leukemia, bladder, or colorectal cancer who were 2-5 years post-diagnosis and received follow-up care in the past year (N = 623) provided information about the presence of bothersome symptoms, symptom-related information needs, adequacy of symptom-related care, and their physical and mental HRQOL. Multivariable statistical analyses were conducted to identify correlates of symptom bother, inadequate care, and symptom information needs and to examine the association between symptom bother and HRQOL. RESULTS: Twenty-eight percent of the 606 respondents experienced symptom bother in the past year (46 % of leukemia, 24 % of bladder, and 26 % of colorectal cancer survivors). Younger survivors, those of Hispanic ethnicity, with low income, those with recurrent cancer, and chemotherapy recipients were more likely to report symptom bother (all p < 0.05). Symptom bother was associated with lower physical and mental HRQOL (p < 0.001). While 92 % of survivors with symptoms discussed them with their follow-up care physician, 52 % of these reported receiving inadequate symptom care. Survivors reporting inadequate symptom care were 2.5 times as likely to identify symptom information needs compared to those who received adequate care (p < 0.05). CONCLUSIONS: One in four cancer survivors report symptoms 2-5 years post-diagnosis, and only half of these survivors receive adequate care to address those symptoms. Research that refines and tests symptom care interventions for this population is warranted.

Role of oncologists and primary care physicians in providing follow-up care to non-Hodgkin lymphoma survivors within 5 years of diagnosis: a population-based study.

PURPOSE: The growing population of non-Hodgkin lymphoma (NHL) survivors living longer with high physical and psychological treatment burden, in combination with the projected shortage of medical professionals, necessitates redesigning cancer follow-up care. This study examined follow-up care patterns, factors associated with follow-up care, and attitudes towards follow-up care among NHL survivors. METHODS: We surveyed survivors of aggressive NHL 2 to 5 years post-diagnosis (N = 363) using a population-based sample from the Los Angeles County Surveillance Epidemiology and End Results registry. RESULTS: Most survivors (82 %) received cancer-related follow-up care in the past year from an oncologist. History of recurrence, more comorbidities, more symptoms, and a shorter survivor-oncologist relationship were associated with high-frequency care with the oncologist [(≥5 visits in the past year), p < 0.05]. Many survivors followed up by oncologists (71 %) also saw a primary care provider (PCP) and 47 % also saw both a PCP and other specialists. Factors associated with seeing a PCP in addition to an oncologist included more symptoms, more health information needs, no history of recurrence, perceived excellent quality of cancer follow-up care, and fewer visits with the oncologist (p < 0.05). Survivors generally reported high reassurance from, and low negative anticipation towards, follow-up care. CONCLUSIONS: The high proportion of NHL survivors receiving care from multiple physicians, and the sizable proportion (∼30 %) who have not recently seen a PCP, suggests that coordinating care across specialties is critical to ensure comprehensive, non-duplicative care. Understanding factors associated with cancer-related follow-up is a first step towards more effective, efficient, patient-centered care.

Health-related quality of life among survivors of aggressive non-Hodgkin lymphoma.

BACKGROUND: Non-Hodgkin lymphoma (NHL) is the fifth most common cancer among men and women. Patients with aggressive NHL receive intense medical treatments that can significantly compromise health-related quality of life (HRQOL). However, knowledge of HRQOL and its correlates among survivors of aggressive NHL is limited. METHODS: Self-reported data on HRQOL (physical and mental function, anxiety, depression, and fatigue) were analyzed for 319 survivors of aggressive NHL. Survivors 2 to 5 years postdiagnosis were selected from the Los Angeles County Cancer Registry. Bivariate and multivariable methods were used to assess the influence of sociodemographic, clinical, and cognitive health-appraisal factors on survivors' HRQOL. RESULTS: After accounting for other covariates, marital status was associated with all HRQOL outcomes (P < .05). Younger survivors reported worse mental function and higher levels of depression, anxiety, and fatigue (P < .01). Survivors who had more comorbid conditions or lacked private health insurance reported worse physical and mental function and higher levels of depression and fatigue (P < .05). Survivors who experienced a recurrence reported worse physical function and higher levels of depression and fatigue (P < .05). With the exception of a nonsignificant association between perceived control and physical function, greater perceptions of personal control and health competence were associated significantly with more positive HRQOL outcomes (P < .01). CONCLUSIONS: The current results indicated that survivors of aggressive NHL who are younger, are unmarried, lack private insurance, or experience greater illness burden may be at risk for poorer HRQOL. Cognitive health-appraisal factors were strongly related to HRQOL, suggesting potential benefits of interventions focused on these mutable factors for this population.

Patients' and family members' views on patient-centered communication during cancer care.

OBJECTIVES: To explore patients' and family members' views on communication during cancer care and to identify those aspects of clinician-patient communication which were most important to patients and family members. METHODS: We conducted a secondary data analysis of qualitative data from 137 patients with cancer and family members of patients with cancer. We used a modified version of the constant comparative method and coding paradigm of grounded theory. RESULTS: Patients want sensitive, caring clinicians who provide information that they need, when they need it, in a way that they can understand; who listen and respond to questions and concerns, and who attempt to understand the patient's experience. Effective information exchange and a positive interpersonal relationship with the clinician were of fundamental importance to patients and family members. These were interrelated; for instance, failure to provide information a patient needed could damage the relationship, whereas excellent listening could foster the relationship. Information exchange and relationship were also integral to decision-making, managing uncertainty, responding to emotions, and self-management. Clinicians who were responsive to patients' needs beyond the immediate medical encounter were valued. CONCLUSIONS: The complexity of cancer care today suggests that efforts to improve communication must be multilevel, acknowledging and addressing patient, clinician, organizational and policy barriers, and facilitators. Measurement tools are needed to assess cancer patients' and family members' experiences with communication over the course of cancer care to provide meaningful, actionable feedback to those seeking to optimize their effectiveness in communicating with patients with cancer.

Complementary and alternative medicine use among newly diagnosed prostate cancer patients.

PURPOSE: We surveyed prostate cancer patients about complementary and alternative medicine (CAM) use and evaluated patient factors that correlated with CAM use 6 months following diagnosis. METHODS: The Prostate CAncer Therapy Selection study was a prospective, observational multi-site study of men's treatment decision-making process after a diagnosis of local stage prostate cancer. Recruitment occurred in community urology practices in Washington State, hospital-based urology clinics affiliated with the University of Southern California, and Kaiser Permanente in Northern California. Eligible study participants included men over age 21 diagnosed with local stage prostate cancer between May 1, 2005 and December 31, 2006. RESULTS: Fifty-two percent of survey respondents (379) reported using one or more types of CAM. Of the patients, 51% used one CAM method, 26% used two methods, and 23% used three or more methods. The most commonly reported category was mind-body therapies (65%). Only 43% of patients discussed their CAM use with a health professional; of those, 20% informed their primary care physician and 30% told the doctor managing their prostate cancer care. Less than half thought the CAM they used was "very helpful", but a majority thought it was somewhat helpful for their condition. CONCLUSIONS: Further research is needed to characterize the goals prostate cancer patients have for CAM, whether the treatments met those goals, and how this translates into the perceived helpfulness of these therapies. The implications of patients not discussing CAM use with health professionals at the time of prostate cancer treatment need further studies.

Unanticipated and underappreciated outcomes during management of local stage prostate cancer: a prospective survey.

PURPOSE: Due to the complexity of factors that must be considered when choosing a therapy for prostate cancer, we hypothesized that many men will find that certain factors such as side effects gain or lose importance after therapy relative to their expectations before therapy. MATERIALS AND METHODS: We conducted a prospective survey of men deciding on a therapy for local stage prostate cancer in 3 geographic regions. Men were asked to rate the importance of 11 personal factors before starting therapy and again 6 months after therapy. RESULTS: Among 448 eligible men completing the most common treatment options, overall satisfaction with treatment choice was high across all therapies. While most men changed rankings of importance in at least 1 of the 11 factors, the majority of pre-post evaluations were highly consistent. In adjusted analyses the 2 factors that emerged as significantly underappreciated for all major prostate cancer treatments were 1) the impact of treatment on usual daily activities, and 2) the recommendations of friends and relatives who were affected with prostate cancer. CONCLUSIONS: Initial patient expectations of the importance of the majority of factors related to prostate cancer treatment are generally accurate. Better counseling may improve the accuracy of patient expectations of the personal burden of treatment, and their evaluation of the advice of affected friends and relatives.

Perceived risk, trust and health-related quality of life among cancer survivors.

BACKGROUND: To design effective interventions that improve cancer survivors' health-related quality of life (HRQoL), it is necessary to understand how HRQoL is related to cancer cognitions and interpersonal/social factors. PURPOSE: This study investigated whether perceived risk of recurrence is associated with HRQoL and whether trust in the follow-up care physician moderates the perceived risk/HRQoL relationship. METHOD: A cross-sectional survey of cancer survivors (N = 408). RESULTS: Higher perceived risk was associated with worse mental and physical HRQoL. Higher trust was associated with better mental (but not physical) HRQoL. The inverse association between perceived risk and mental HRQoL was eliminated among those with high trust in their physicians. Trust did not moderate the perceived risk/physical HRQoL relationship. CONCLUSIONS: Addressing survivors' perceived risk of recurrence and improving the provider-patient relationship may enhance interventions to improve mental HRQoL among cancer survivors. However, the causal relationships among the constructs should be explicated.

Providing health messages to Hispanics/Latinos: understanding the importance of language, trust in health information sources, and media use.

Health communication is critical to promoting healthy lifestyles and preventing unhealthy behaviors. However, populations may differ in terms of their trust in and use of health information sources, including mass media, the Internet, and interpersonal channels. We used the 2005 Health Information National Trends Survey (HINTS) to test the hypothesis that Hispanics who are less comfortable speaking English would differ from Hispanics who are comfortable speaking English with respect to trust in health information sources and media use. Hispanics/Latinos comprised 9% of the 2005 HINTS sample (n = 496). Respondents not born in the United States regardless of race/ethnicity and all Hispanics were asked, "How comfortable do you feel speaking English?" Responses of "completely," "very," or "native speaker" were combined into "comfortable speaking English": all other responses were categorized as "less comfortable speaking English." Those comfortable speaking English reported higher trust for health information from newspapers (p < .05), magazines (p < .05), and the Internet (p < .01) compared with those less comfortable speaking English. They also reported more media exposure: daily hours listening to the radio and watching television (both p < .05) and days per week reading newspapers (p < .05). Hispanics comfortable speaking English reported much higher levels of Internet use (54% versus 14%, p < .0001). Hispanics who are not comfortable speaking English may be difficult to reach, not only because of language barriers and lower trust in media, but also because they report relatively little use of various media channels. These findings have important implications for health communications toward non-native speakers of English in general and Hispanics in particular.

Perceived helpfulness of physicians' communication behavior and breast cancer patients' level of trust over time.

OBJECTIVE: We evaluated the association between physicians' communication behavior and breast cancer patients' trust in their physicians. DESIGN: Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis. PARTICIPANTS: Newly diagnosed breast cancer patients (N = 246). MEASUREMENTS: We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients' trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients' trust. RESULTS: At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged. CONCLUSIONS: Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis.

Follow-up care delivery among colorectal cancer survivors most often seen by primary and subspecialty care physicians.

BACKGROUND: The Institute of Medicine has identified patients as a key source of information for assessing the quality of care. OBJECTIVE: To evaluate the association of physician specialty with the content and quality of follow-up cancer care. DESIGN AND PARTICIPANTS: Three hundred three colorectal cancer (CRC) survivors in Northern California were surveyed 2-5 years post-diagnosis. MEASUREMENTS: Specialty of physician seen most often [primary care physician (PCP), oncologist, surgeon, or gastroenterologist]; other physician specialties seen; patient characteristics; content of visits; patient-centered quality of follow-up care (communication, coordination, nursing, and staff interactions). MAIN RESULTS: A minority (16%) of CRC survivors reported that the doctor they most often saw for follow-up cancer care was a PCP, while 60% saw an oncologist. Many CRC survivors (40%) saw >1 physician for follow-up cancer care. Survivors most often seen by PCPs were more likely to have three or more medical comorbidities (70% vs. 51%, p = 0.012) than survivors seen by subspecialty physicians. Survivors seen by PCPs were less likely to report seeing a doctor for medical tests and more likely to report discussing disease prevention (82% vs. 64%, p = 0.012) or diet (70% vs. 48%, p = 0.005) with their doctor. There were no significant specialty differences in patient-centered quality of follow-up cancer care. CONCLUSIONS: Cancer survivors' assessment of the quality of care was similar across specialties, while the content of follow-up cancer care varied by physician specialty. These findings provide important information about the potential value of primary care and the need for coordination when delivering care to CRC survivors.

Importance of patient-centered care in enhancing patient well-being: a cancer survivor's perspective.

In this narrative article, the author, a long-term cancer survivor, reflects on his personal interactions with the healthcare system over a period of 14 years in order to highlight the importance of delivering patient-centered care. He makes a case for why quality of care assessments are incomplete if they focus on clinical indicators of quality alone and exclude systematic assessment of the patient-centered aspects of care from the patient's perspective. The important role played by patient-centered care in reducing patient suffering and enhancing well-being is underscored in this commentary.

How does communication heal? Pathways linking clinician-patient communication to health outcomes.

OBJECTIVE: Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient's anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. CONCLUSION: Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway. PRACTICE IMPLICATIONS: Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.