[Facilitators and barriers to shared decision-making in France in 2021: National survey in cancer]. / Leviers et freins à la prise de décision partagée en France en 2021 : enquête nationale auprès des patients atteints de cancer.

INTRODUCTION: Shared-decision making (SDM) combines clinical expertise of the healthcare professional with patient's knowledge, values and preferences. This survey explores from a patient perspective, the implementation, facilitators and barriers of SDM in oncology in France in 2021. PATIENTS AND METHODS: From August to October 2021, the digital platform Cancer contribution conducted an online survey relayed by 11 patient associations. RESULTS: Out of 916 responses, 727 were analyzed: 394 from patients with hematological malignancies [HM], 185 with breast cancer [BC], 93 with other solid tumors [ST] and 55 with multiple cancers [MC]. Among the participants, 47.2 % reported that they participated in a decision about their health management, with a significant variation according to the pathology (BC 43.8 %, HM 41.1 %, ST 57 %, MC 60 %, P=0.01), and regardless of age and gender. Two-thirds felt comfortable with the shared decision-making process, in relation with the time allocated and the information provided, regardless of the pathology. In addition, emotions, uncertainty and lack of information are the main reasons quoted by patients to explain their lack of ease in making a decision related to their health. CONCLUSIONS: In this survey, less than half of the patients declared that they have been enrolled in a SDM approach, this rate varying according to the type of solid tumor or hematological malignancy. This study shows that to improve the implementation of SDM in routine clinical practice in cancer, sufficient time and use of decision aids are needed.

[Tolerating uncertainty: Towards a competence-based approach]. / Faire de la tolérance à l'incertitude une compétence médicale.

Uncertainty in inherent to every aspects of medical practice. As the concept of uncertainty in healthcare is still to explore, deciphering the determinants and the roots of this uncertainty would benefit from the insights of various disciplines, such as epistemology, sociology, mathematics, or philosophy. The urgent need to improve physician's ability to cope with uncertainty, has been recently highlighted by the COVID-19 pandemic. Besides, the concept of uncertainty tolerance has been proposed, and could serve as a relevant basis for approaching uncertainty, in medical education. Thus, we propose at first to discuss the uncertainty tolerance framework from Hillen et al. Then, from an educational perspective, we outline some avenues regarding how uncertainty tolerance could be thought, in a competence-based approach, and discuss several educational activities, which have proven efficient in promoting uncertainty tolerance among medical practitioners abroad.

[The psychological impact of cancer in the medium and long term]. / L'impact psychologique du cancer à moyen et long terme.

More than one in two people recover from cancer after five years. But before claiming victory, they go through a period of remission, a time of uncertainty and convalescence during which they will have to learn to reinvest their body and their identity in order to fully take charge of their life by integrating the awareness of their fragility.

[Perinatal beliefs: Neurocognitive mechanisms and cultural specificities]. / Croyances périnatales : mécanismes neurocognitifs et spécificités culturelles.

Perinatal beliefs contribute to the experience of pregnancy and the process of parenthood. Many of these perinatal beliefs have been perpetuated and evolved over time and throughout the world, exerting their influence on the behavior of pregnant women in interaction with medical recommendations. These beliefs generally offer explanations for gravidic and puerperal phenomena, helping to reduce the uncertainty of parents faced with the biological, psychological and social transitions of pregnancy. But certain beliefs can also be harmful, and alter the maternal experience of pregnancy and postpartum. In this paper, we provide an overview of the beliefs associated with the perinatal period. We successively detail the beliefs concerning fertility, pregnancy, childbirth, and postpartum, specifying the cultural beliefs from other cultures interacting with medical recommendations. Finally, we propose a neurocognitive model of perinatal beliefs generation, and we show the need to know these beliefs to improve care in midwifery, obstetrics, and fetal medicine.

Rethinking Disease Preparedness: Incertitude and the Politics of Knowledge.

This paper argues for a rethinking of disease preparedness that puts incertitude and the politics of knowledge at the centre. Through examining the experiences of Ebola, Nipah, cholera and COVID-19 across multiple settings, the limitations of current approaches are highlighted. Conventional approaches assume a controllable, predictable future, which is responded to by a range of standard interventions. Such emergency preparedness planning approaches assume risk - where future outcomes can be predicted - and fail to address uncertainty, ambiguity and ignorance - where outcomes or their probabilities are unknown. Through examining the experiences of outbreak planning and response across the four cases, the paper argues for an approach that highlights the politics of knowledge, the constructions of time and space, the requirements for institutions and administrations and the challenges of ethics and justice. Embracing incertitude in disease preparedness responses therefore means making contextual social, political and cultural dimensions central.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

[Patient experience, epistemic authority and health challenges: the example of long COVID]. / Expérience patient, autorité épistémique et enjeux sanitaires : l'exemple du Covid long.

Since February 2020, hundreds of thousands of patients have been left with persistant symptoms after their infection. Along with their clinicians, these patients are exposed to a high degree of uncertainty and the urgent need to produce conceptual frameworks aimed at recognising, treating and validating their experience as patients suffering from new and protracted symptoms and witnessing debates as to how these symptoms should be qualified. In this respect, long covid illustrates the need to combine the collective experiential knowledge of patients and scientific knowledge for the benefit of the patients, clinicians and research.

[Clinical ethics and uncertainty: an inseparable duo for the benefit of the patient]. / Éthique clinique et incertitude : un indissociable duo au bénéfice du patient.

Clinical ethics can be conceived as thought marked by uncertainty and on uncertainty. Its difficulties must be highlighted and discussed, in order to help guide the actions of caregivers, both on a scientific and human level, for the benefit of the patient. As an intellectual and moral virtue, humility is likely to favour a high standard of reflection and action.

[Preparation, trust and uncertainty in the time of an Ebola crisis]. / Préparation, confiance et incertitude en temps de crise Ebola.

The notions of risk and crisis, which shape the management of epidemics, were studied from a social sciences perspective. An angle which provides further reflection on how teams are prepared for epidemics in hospital, by highlighting the construction of trust and uncertainty faced with the risk of infection, notably in the interdependence of the players with the measures and tools designed by experts.

[From hero to deserter, figures of the caregiver at the time of COVID-19]. / Du héros au déserteur, figures du soignant au temps de la Covid-19.

In the context of the COVID-19 pandemic, psychologists from various departments of a hospital centre in the Paris region intervened with the establishment's nursing and non-nursing staff. They gathered testimonies related to the experience of the first wave of this health crisis. They offer their interpretation of the event, which highlights the climate of uncertainty that reigned, both in its health and political dimensions.

Incertidumbre sexual en adolescentes de una escuela preparatoria pública en el sureste de México / Adolescents' sexual uncertainty attending a public senior high school in southeastern Mexico / Incerteza sexual em adolescentes de uma escola pública do sudeste do México / Incertitude sexuelle chez des adolescents d'un lycée public du sud-est du Mexique

Resumen Objetivo: Identificar la presencia de incertidumbre sexual en estudiantes de una escuela preparatoria del sureste de México. Material y Métodos: Es un estudio descriptivo y transversal, la población de interés estuvo conformada por 190 adolescentes de 15 a 18 años de una escuela preparatoria en Ciudad del Carmen, Campeche. Se aplicó una cédula de datos sociodemográficos, preguntas sobre conducta de riesgo sexual y si han recibido información sobre sexualidad, Infecciones de transmisión sexual y sobre el virus de Inmunodeficiencia Humana y el Síndrome de inmunodeficiencia adquirida, se aplicó la Escala de Incertidumbre sexual. Resultados: La mayor parte de los estudiantes, han recibido información sobre sexualidad; poco más de la mitad de los estudiantes ha recibido información sobre infecciones de transmisión sexual y sobre el virus de Inmunodeficiencia Humana y el Síndrome de inmunodeficiencia adquirida. En prevención de conductas de riesgo, cerca del 4% de los alumnos se han realizado la prueba rápida para detectar el virus de Inmunodeficiencia Humana. Respecto a la práctica de relaciones sexuales; el 31.1% respondieron que han tenido relaciones sexuales. El resultado de la diferencia de medias en incertidumbre sexual fue más elevado en los hombres (X ̅= 17.72, DE = 6.03). En relación a la conducta sexual de riesgo los hombres mostraron una diferencia significativa en comparación con la mujer con un promedio de (X ̅= 19,25, DE = 21,94). Conclusiones: Se determina que la incertidumbre sexual es un factor que ejerce influencia en la conducta de una persona y la condiciona a tomar o no medidas protectoras para su salud, como es el de evitar las conductas sexuales de riesgo, los adolescentes que tienen menos incertidumbre sexual son quienes tienen menos probabilidad de incidir en este tipo de conductas.

Abstract Objective: to identify the presence of students' sexual uncertainty attending a senior high school in southeastern Mexico. Material and Methods: a descriptive and cross-sectional study whose target population consisted of 190 adolescents aged 15 to 18 years, attending a senior high school in Ciudad del Carmen, Campeche. We applied a sociodemographic data with questions about sexual risk behavior and whether they have received information about sexuality, sexually transmitted infections, the Human Immunodeficiency Virus and the Acquired Immunodeficiency Syndrome. The Sexual Uncertainty Scale was applied. Results: most of the students have received information about sexuality; just over half of the students have information about sexually transmitted infections, the Human Immunodeficiency Virus and the Acquired Immunodeficiency Syndrome. In prevention of risk behavior, about 4% of the students have taken the rapid test for detection of human immunodeficiency virus. Regarding the sexual activity, 31.1% responded that they have had sexual intercourse. The result of the difference of the overage in sexual uncertainty was higher in men (X ̅= 17.72, SD = 6.03). In relation to risky sexual behavior, men showed a significant difference compared to women with an average of (X ̅ = 19,25, SD = 21,94). Conclusions: it is determined that sexual uncertainty is a factor that influences a person's behavior and determines whether to take health protective measures, such as avoiding risky sexual behavior. Adolescents, whose sexual uncertainty is less, are less likely to engage in this type of behavior.

Resumo Objetivo: Identificar a presença de incerteza sexual em estudantes de uma escola preparatória no sudeste do México. Material e Métodos: Trata-se de um estudo descritivo e transversal, cuja população de interesse foi composta por 190 adolescentes de 15 a 18 anos de idade de uma escola preparatória em Ciudad del Carmen, Campeche. Um cartão de dados sociodemográficos, perguntas sobre comportamento sexual de risco e se eles receberam informações sobre sexualidade, infecções sexualmente transmissíveis e sobre o vírus da Imunodeficiência Humana e a Síndrome da Imunodeficiência Adquirida foram aplicados, a Escala de Incerteza Sexual foi aplicada. Resultados: a maioria dos estudantes recebeu informações sobre sexualidade; pouco mais da metade dos estudantes recebeu informações sobre infecções sexualmente transmissíveis e sobre o vírus da imunodeficiência humana e a síndrome da imunodeficiência adquirida. Na prevenção de comportamentos de risco, cerca de 4% dos estudantes fizeram o teste rápido para detectar o vírus da Imunodeficiência Humana. Quanto à prática de relações sexuais; 31,1% responderam que tiveram relações sexuais. O resultado da diferença de médias na incerteza sexual foi maior nos homens (X ̅ = 17,72, DP = 6,03). Em relação ao comportamento sexual de risco, os homens apresentaram uma diferença significativa em comparação às mulheres com uma média de (X ̅ = 19,25, DP = 21,94). Conclusões: determina-se que a incerteza sexual é um fator que influencia o comportamento de uma pessoa e determina se deve ou não tomar medidas protetoras para sua saúde, como evitar comportamentos sexuais de risco, adolescentes que têm menos incerteza sexual são aqueles com menor probabilidade de influenciar esse tipo de comportamento.

Résumé Objectif : identifier la présence d'incertitude sexuelle chez les élèves d'un lycée dans le sud-est du Mexique. Matériel et méthodes : L'étude est descriptive et transversale. L'échantillon a été conformé par 190 adolescents de 15 à 18 ans, élèves d'un lycée de Ciudad del Carmen, Campeche. Une fiche de données sociodémographiques a été utilisée, ainsi qu'un questionnaire sur les comportements sexuels à risque et sur la réception d'informations sur la sexualité, les infections sexuellement transmissibles, et en particulier sur le virus de l'immunodéficience humaine et le syndrome d'immunodéficience acquise. De plus, l'Échelle d'Incertitude Sexuelle a été appliquée. Résultats : La plupart des élèves ont reçu des informations sur la sexualité ; un peu plus de la moitié des élèves ont reçu des informations sur les infections sexuellement transmissibles et en particulier sur le virus de l'immunodéficience humaine et le syndrome d'immunodéficience acquise. En matière de prévention de comportements à risque, environ 4 % des élèves ont passé le test rapide de dépistage du virus de l'immunodéficience humaine. 31,1% ont répondu qu'ils avaient eu des relations sexuelles. La moyenne d'incertitude sexuelle était plus élevée chez les hommes (X ̅= 17,72, DE = 6,03). En ce qui concerne le comportement sexuel à risque, les hommes ont montré une différence significative par rapport aux femmes avec une moyenne de (X ̅= 19,25, DE = 21,94). Conclusions : Il s'avère que l'incertitude sexuelle est un facteur qui influence le comportement d'une personne et l'amène à prendre ou non des mesures de protection pour sa santé, comme par exemple éviter les comportements sexuels à risque. Les adolescents qui ont moins d'incertitude sexuelle sont ceux qui sont le moins susceptibles d'adopter ce type de comportement.

[Uncertainty management and medical skills: A clinical and educational reflexion]. / Gestion de l'incertitude et compétence médicale : une réflexion clinique et pédagogique.

Uncertainty arises when information is not sufficient to predict the prognosis or the outcome following an intervention. It is omnipresent in medical daily practice, and will follow each practitioner all along his career. The communication or merely even the feeling of uncertainty is frequently perceived as a negative experience. Nevertheless, rather than a sign of weakness, feeling uncertain reflects a dynamic state of self-reassessment which should be experienced by each doctor involved in providing his patients with the best care. Furthermore, uncertainty may lead to disastrous consequences for practitioners who have not been properly prepared to it, involving the sphere of emotions (stress, anxiety, burn-out) as well as the behavioral field (misdiagnosis, excessive testing, impaired communication…). A growing number of observations, clinical or educational studies, supports the idea that learning uncertainty should be a critical prerequisite to a valuable medical practice. Through this literature review, we propose herein a conceptual glance on uncertainty. Then, we expose some sources of uncertainty in daily practice and teaching, its consequences, and the main factors that contribute to the wide variety of the individual relationship with uncertainty. We finally aim to prompt a global reflexion, falling within an uncertainty competency-based education approach, assuming that our obligation to professionalize the students necessitates making them skilled in dealing with uncertainty.

A cura em oncologia: uma ambição improvável / Cure in cancer: an improbable ambition / La guérison en cancérologie: une improbable ambition

Résumé Cet article propose une réflexion sur la notion de guérison et sur ses usages en cancérologie. Un premier point ausculte sa mise en œuvre en tant qu'ambition à la fois médicale et politique suprême de la mission fondatrice de la cancérologie française. Un deuxième axe pointe ses divers accommodements sociaux, en observant les différentes figures et mésaventures du concept confronté à l'épreuve de l'incurabilité d'un certain nombre de cancers. Enfin, une troisième partie de l'article s'intéresse aux effets de l'incertitude chronique inhérente à l'oncologie. Fondée sur des recherches empiriques inspirées par la grounded theory, par l'interactionnisme et sous l'influence revendiquée d'Anselm Strauss, cette réflexion peut être vue comme un abrégé des travaux de l'auteure, réalisés de la fin des années 1990 à nos jours, sur la cancérologie française. L'incertitude médicale et sa gestion, individuelle et collective, sont au cœur de ce travail.

Abstract This article proposes a reflection about the notion of cure and its uses in oncology. A first point examines its implementation as the utmost medical and political ambition of the founding mission of French oncology. A second axis points to its various social accommodations, observing the different figures and misadventures of the concept confronted with the test of the incurability of numerous cancers. Finally, a third part of the article focuses on the effects of the chronic uncertainty inherent in oncology. Based on empirical research made from the late 1900s to our days, inspired by grounded theory, interactionism and under the influence of Anselm Strauss, this reflection can be seen as an abstract of the author's work on French oncology. Medical uncertainty and its individual and collective management are at the core of this work.

Resumo Este artigo propõe uma reflexão sobre a noção de cura e seus usos em oncologia. Um primeiro ponto examina sua implementação como uma ambição suprema tanto médica quanto política da missão fundadora da oncologia francesa. Um segundo eixo aponta suas diversas acomodações sociais, observando as diferentes figuras e desventuras do conceito confrontado com o teste de incurabilidade de um certo número de cânceres. Finalmente, a terceira parte do artigo se centra sobre os efeitos da incerteza crônica inerente à oncologia. Com base em pesquisas empíricas inspiradas pela grounded theory, pelo interacionismo e sob a influência reivindicada de Anselm Strauss, esta reflexão pode ser vista como um resumo da obra do autor, feitas desde o final de 1900 até atualmente, sobre oncologia francesa. A incerteza médica e sua gestão, individual e coletiva, estão no centro deste trabalho.

'Thank God I'm not a Jungian'.

This article focuses less on the content of Jung's ideas than on ways in which they act as both invitation and challenge to engage with psyche. It explores the mythic framework of Jung's approach and how this can enable individuals to live in psychological and mundane worlds in which there can be no final certainties. It elaborates three particular aspects of Jung's thinking that I have found personally valuable: his generosity of vision, his insistence that individuals engage for and with themselves rather than relying on someone else's ideas, and his ponderings on the relationship between the individual and the collective. All three aspects seem to be important elements of the work of individuation.

[Why proton therapy? And how?] / Apports de la protonthérapie à la radiothérapie d'aujourd'hui, pourquoi, comment ?

Proton therapy is a radiotherapy, based on the use of protons, charged subatomic particles that stop at a given depth depending on their initial energy (pristine Bragg peak), avoiding any output beam, unlike the photons used in most of the other modalities of radiotherapy. Proton therapy has been used for 60 years, but has only become ubiquitous in the last decade because of recent major advances in particle accelerator technology. This article reviews the history of clinical implementation of protons, the nature of the technological advances that now allows its expansion at a lower cost. It also addresses the technical and physical specificities of proton therapy and the clinical situations for which proton therapy may be relevant but requires evidence. Different proton therapy techniques are possible. These are explained in terms of their clinical potential by explaining the current terminology (such as cyclotrons, synchrotrons or synchrocyclotrons, using superconducting magnets, fixed line or arm rotary with passive diffusion delivery or active by scanning) in basic words. The requirements associated with proton therapy are increased due to the precision of the depth dose deposit. The learning curve of proton therapy requires that clinical indications be prioritized according to their associated uncertainties (such as range uncertainties and movement in lung tumors). Many clinical indications potentially fall under proton therapy ultimately. Clinical strategies are explained in a paralleled manuscript.

[Can medical oncologists talk about cure to their patient after localized breast cancer treatment?] / Pouvons-nous à l'heure actuelle parler de guérison après le traitement d'un cancer du sein localisé ?

INTRODUCTION: Despite ongoing therapeutic advances in oncology, the use of the term cure in front of patients remains controversial. The word remission is often preferred in clinical practice. The purpose of this research is to explore how oncologists vary in their usage and definition of the word cure when talking to patients. METHODS: Qualitative and exploratory pilot study conducted by semi structured interviews with a group of French oncologists about a clinical vignette of localized breast cancer treated by surgery and complete adjuvant treatment. RESULTS: Thirteen oncologists participated in this study between January and March 2016. They were divided into two groups according to whether or not they use the term cure in their clinical practice. A first group of five doctors define the word cure as the lasting absence of relapse of the disease. Because of their duty of transparency and the uncertainty of post-therapeutic relapse, these five doctors tend to never use the word cure. The analysis of the second group of eight doctors, who do use of the word cure in their practice, highlighted an absence of consensus on its definition. However, all of them justify their use of it with the importance of expressing positive emotions such as hope to patients. DISCUSSION: Our findings confirm that there are divergent understandings of the concept of cure between oncologists and how they manage prognosis uncertainty. Medical language is thus influenced by scientific knowledge, but also by doctors' personal values and ways of thinking, perhaps influencing the doctor-patient relationship in turn. This exploratory study will be extended on a wider scale to explore the coexistence of other elements of diversity.

[Overmedicalization: When too much medicine harms]. / La surmédicalisation: quand trop de médecine nuit à la santé.

Overmedicalization refers to non-validated medical practices, with no clear benefits, potentially harmful and therefore unnecessarily costly. Awareness is growing with respect to this serious public health problem. Permanent expansion of diagnostic or therapeutic interventions, disease mongering, inadequate management of diagnostic uncertainty, conflict of interest or lack of commitment by physicians and patients in shared decision making. Overmedicalization is made possible by a lack of training of health professionals and users on medical decision process. Only a multidisciplinary research program, involving medical and non-medical worlds, will allow the implementation of corrective actions.

[Application of robustness test for assessment of the measurement uncertainty at the end of development phase of a chromatographic method for quantification of water-soluble vitamins]. / Application du test de robustesse pour l'évaluation de l'incertitude de mesure au terme de phase de développement d'une méthode chromatographique de quantification de cinq vitamines hydrosolubles.

OBJECTIVE: We propose in this work an efficient way to evaluate the measurement of uncertainty at the end of the development step of an analytical method, since this assessment provides an indication of the performance of the optimization process. METHOD: The estimation of the uncertainty is done through a robustness test by applying a Placquett-Burman design, investigating six parameters influencing the simultaneous chromatographic assay of five water-soluble vitamins. The estimated effects of the variation of each parameter are translated into standard uncertainty value at each concentration level. RESULTS: The values obtained of the relative uncertainty do not exceed the acceptance limit of 5%, showing that the procedure development was well done. In addition, a statistical comparison conducted to compare standard uncertainty after the development stage and those of the validation step indicates that the estimated uncertainty are equivalent. CONCLUSION: The results obtained show clearly the performance and capacity of the chromatographic method to simultaneously assay the five vitamins and suitability for use in routine application.

Incertitude, Hepatitis B, and Infant Vaccination in West and Central Africa.

This comparative study explores incertitude about hepatitis B (HBV) and its implications for childhood vaccination in Bangui, Central African Republic, and the Cascades region, Burkina Faso. Anthropological approaches to vaccination, which counter stereotypes of "ignorant" publics needing education to accept vaccination, excavate alternative ways of knowing about illness and vaccination. We build on these approaches, evaluating different kinds of incertitude (ambiguity, uncertainty, ignorance) about infancy, HBV, health protection, and vaccination. Using interviews and participant observation, we find that Bangui and Cascades publics framed their incertitude differently through stories of infancy, illness, and protection. We locate different forms of incertitude within their historical contexts to illuminate why vaccination practices differ in the Cascades region and Bangui. A more nuanced approach to incomplete knowledge, situated in political, economic, and social histories of the state and vaccination, can contribute to more appropriate global health strategies to improve HBV prevention.

[Adaptive radiation therapy for non-small cell lung cancer]. / Radiothérapie adaptative du carcinome bronchique non à petites cellules.

Anatomical changes and tumor regression during thoracic radiotherapy may alter the treatment volumes. These modifications are not taken into account into set-up or motion margins used for treatment planning. Their dosimetric impact could be significant and a better understanding of the changes occurring during the 6 to 7 weeks of treatment could be useful in order to define quantitative thresholds before a new treatment planning is needed. Margins could also be reduced in order to better spare organs at risk and perform targeted dose escalation. This review assesses the potential of morphologic and metabolic imaging during treatment for adaptive radiotherapy in non-small cell lung cancer.