Conversations on Cancer Chemotherapy Cessation in Patients With Advanced Cancer: Qualitative Findings From a Multi-Institutional Study.

PURPOSE: As many as 20% of oncology patients receive chemotherapy in the last 14 days of their lives. This study characterized conversations between patients and cancer clinicians on chemotherapy cessation in the setting of advanced cancer. METHODS: This 3-site study captured real-time, audio-recorded interviews between oncology clinicians and patients with cancer during actual clinic visits. Audio-recordings were reviewed for discussion of chemotherapy cessation and were analyzed qualitatively. RESULTS: Among 525 recordings, 14 focused on stopping chemotherapy; 14 patients participated with 11 different clinicians. Two types of nonmutually exclusive conversation elements emerged: direct and specific elements that described an absence of effective therapeutic options and indirect elements. An example of a direct element is as follows: "…You know this is…always really tough…But I-I think that you may need more help…I think we're close to stopping chemotherapy…And hospice is really helpful to have in place…" In contrast, the second conversation element was more convoluted: "…transplant is not an option and surgery is not an option…The options…are taking a pill…It doesn't shrink the tumor…It may help you live a little longer. But I'm worried if [you] had the pill, it's still a therapy and it still has side effects. I [am] worried if I give it to you now, that you're so weak, it will make you worse." No relationship seemed apparent between conversation elements and chemotherapy cessation. CONCLUSIONS: Conversations on chemotherapy cessation are complex; multiple factors appear to drive the decision to stop.

Conversations About Financial Issues in Routine Oncology Practices: A Multicenter Study.

PURPOSE: To describe the frequency, content, dynamics, and patterns of cost conversations in academic medical oncology across tumor types. PATIENTS AND METHODS: We reviewed 529 audio recordings between May 3, 2012, to September 23, 2014, from a prospective three-site communication study in which patients at any stage of management for any solid tumor malignancy were seen in routine oncology appointments. Recordings were deidentified, transcribed, and flagged for any mention of cost. We coded encounters and used qualitative thematic analysis. RESULTS: Financial issues were discussed in 151 (28%) of 529 recordings. Conversations lasted shorter than 2 minutes on average. Patients/caregivers raised a majority of discussions (106 of 151), and 40% of cost concerns raised by patients/caregivers were not verbally acknowledged by clinicians. Social service referrals were made only six times. Themes from content analysis were related to insurance eligibility/process, work insecurity, cost of drugs, cost used as tool to influence medical decision making, health care-specific costs, and basic needs. Financial concerns influenced oncology work processes via test or medication coverage denials, creating paperwork for clinicians, potentially influencing patient involvement in trials, and leading to medication self-rationing or similar behaviors. Typically, financial concerns were associated with negative emotions. CONCLUSION: Financial issues were raised in approximately one in four academic oncology visits. These brief conversations were usually initiated by patients/caregivers, went frequently unaddressed by clinicians, and seemed to influence medical decision making and work processes and contribute to distress. Themes identified shed light on the kinds of gaps that must be addressed to help patients with cancer cope with the rising cost of care.

A Multicenter Comparison of Complementary and Alternative Medicine (CAM) Discussions in Oncology Care: The Role of Time, Patient-Centeredness, and Practice Context.

BACKGROUND: Little is known about how complementary and alternative medicine (CAM) is discussed in cancer care across varied settings in the U.S. METHODS: In two practices affiliated with one academic medical center in southern California (SoCal), and one in the upper Midwest (UM), we audio-recorded patient-clinician interactions in medical oncology outpatient practices. We counted the frequency and duration of CAM-related conversations. We coded recordings using the Roter Interaction Analysis System. We used chi-square tests for bivariate analysis of categorical variables and generalized linear models for continuous variables to examine associations between dialogue characteristics, practice setting, and population characteristics with the occurrence of CAM discussion in each setting followed by multivariate models adjusting for clinician clustering. RESULTS: Sixty-one clinicians and 529 patients participated. Sixty-two of 529 (12%) interactions included CAM discussions, with significantly more observed in the SoCal university practice than in the other settings. Visits that included CAM were on average 6 minutes longer, with CAM content lasting an average of 78 seconds. In bivariate tests of association, conversations containing CAM included more psychosocial statements from both clinicians and patients, higher patient-centeredness, more positive patient and clinician affect, and greater patient engagement. In a multivariable model including significant bivariate terms, conversations containing CAM were independently associated with higher patient-centeredness, slightly longer visits, and being at the SoCal university site. CONCLUSION: The frequency of CAM-related discussion in oncology varied substantially across sites. Visits that included CAM discussion were longer and more patient centered. IMPLICATIONS FOR PRACTICE: The Institute of Medicine and the American Society of Clinical Oncology have called for more open discussions of complementary and alternative medicine (CAM). But little is known about the role population characteristics and care contexts may play in the frequency and nature of those discussions. The present data characterizing actual conversations in practice complements a much larger literature based on patient and clinician self-report about CAM disclosure and use. It was found that CAM discussions in academic oncology visits varied significantly by practice context, that the majority were initiated by the patient, and that they may occur more when visit time exists for lifestyle, self-care, and psychosocial concerns.

Contending Worldviews in the Clinical Encounter: An Empirical Study of Complementary and Alternative Medicine Deliberations in Contemporary Medical Oncology.

OBJECTIVE: In this article, the authors characterize the different ways patients and clinicians discuss complementary and alternative medicine (CAM) during routine cancer care. METHODS: Over a period of two years, the authors audio-recorded clinical interactions between 37 medical oncology clinicians and a sample of 327 oncology patients at an academic cancer center in the Midwest United States. Recordings of conversations that included any discussion of CAM were transcribed and analyzed using a qualitative content analysis approach. RESULTS: Out of 327 conversations, CAM was mentioned and/or discussed in only 31 encounters. Communication dynamics between clinician and patient involve several factors: the condition of the patient and his or her knowledge about and experience with CAM, the clinician's knowledge and values about CAM, perceived assumptions and stereotypes about CAM, and institutional response to the integration of CAM in cancer care. CONCLUSION: Addressing the difficult and sensitive topic of CAM in cancer care requires hearing patients in a manner meaningful to them. In that sense, CAM can serve as an important marker and test case in the march toward shared decision-making and patient-centered communication generally.

Comparison of audio vs. audio + video for the rating of shared decision making in oncology using the observer OPTION5 instrument: an exploratory analysis.

BACKGROUND: How non-verbal data may influence observer-administered ratings of shared decision making is unknown. Our objective for this exploratory analysis was to determine the effect of mode of data collection (audio+video vs. audio only) on the scoring of the OPTION5 instrument, an observer rated measure of shared decision making. METHODS: We analyzed recordings of 15 encounters between cancer patients and clinicians in which a clinical decision was made. Audio+video or audio only recordings of the encounters were randomly assigned to four trained raters, who reviewed them independently. We compared the adjusted mean scores of audio+video and audio only. RESULTS: Forty-one unique decisions were identified within the 15 encounters. The mean OPTION5 score for audio+video was 17.5 (95% CI 13.5, 21.6) and for audio only was 21.8 (95% CI 17.2, 26.4) with a mean difference of 4.28 (95% CI = 0.36, 8.21; p = 0.032). CONCLUSION: A rigorous and well established measure of shared decision making performs differently when the data source is audio only. Data source may influence rating of observer administered measures of shared decision making. This potential bias needs to be confirmed as video recording to examine communication behaviors becomes more common.

Getting on the same page: Communication, patient involvement and shared understanding of "decisions" in oncology.

BACKGROUND: Patients and clinicians do not often agree on whether a decision has been made about cancer care. This could be explained by factors related to communication quality and/or the type of decision being made. METHODS: We used a self-developed coding scheme to code a random sample of 128 encounters in which patients and clinicians either agreed (n=64) or disagreed (n=64) that a cancer care decision was made and tested for associations between concordance and key communication behaviours. We also identified and characterized cancer care decisions by topic and level of patient involvement and looked for trends. RESULTS: We identified 378 cancer care decisions across 128 encounters. Explicit decisions were most commonly made about topics wherein decision control could be easily delegated to a clear and present expert (eg either the patient or the clinician). Related to this, level of patient involvement varied significantly by decision topic. Explicit decisions were rarely made in an observable way about social, non-clinical or self-management related topics, although patients and clinicians both reported having made a cancer care decision in encounters where no decisions were observed. We found no association between communication behaviours and concordance in our sample. CONCLUSIONS: What counts as a "decision" in cancer care may be constructed within disparate social roles that leave many agendas unaddressed and decisions unmade. Changing the content of conversations to encourage explicit decisions about self-management and life context-related topics may have greater value in enabling shared understanding than promoting communication behaviours among already high-performing communicators.

Shared decision making for stroke prevention in atrial fibrillation: study protocol for a randomized controlled trial.

BACKGROUND: Nonvalvular atrial fibrillation (AF) is a common ongoing health problem that places patients at risk of stroke. Whether and how a patient addresses this risk depends on each patient's goals, context, and values. Consequently, leading cardiovascular societies recommend using shared decision making (SDM) to individualize antithrombotic treatment in patients with AF. The aim of this study is to assess the extent to which the ANTICOAGULATION CHOICE conversation tool promotes high-quality SDM and influences anticoagulation uptake and adherence in patients with AF at risk of strokes. METHODS: This study protocol describes a multicenter, encounter-level, randomized trial to assess the effect of using the ANTICOAGULATION CHOICE conversation tool in the clinical encounter, compared to usual care. The participating centers include an academic hospital system, a suburban community group practice, and an urban safety net hospital, all in Minnesota, USA. Patients with ongoing nonvalvular AF at risk of strokes (CHA2DS2-VASc score ≥ 1 in men, or ≥ 2 in women) will be eligible for participation. We aim to include 999 patients and their clinicians. The primary outcome is the quality of SDM as perceived by participants, and as assessed by a post-encounter survey that ascertains (a) knowledge transfer, (b) concordance of the decision made, (c) quality of communication, and (d) satisfaction with the decision-making process. Recordings of encounters will be reviewed to assess the extent of patient involvement and how participants use the tool (fidelity). Anticoagulant use, choice of agent, and adherence will be drawn from patients' medical and pharmacy records. Strokes and bleeding events will be drawn from patient records. DISCUSSION: This study will provide a valid and precise measure of the effect of the ANTICOAGULATION CHOICE conversation tool on SDM quality and processes, and on the treatment choices and adherence to therapy among AF patients at risk of stroke. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02905032 . Registered on 9 September 2016.

Missed Opportunities: A Mixed-Methods Analysis of CAM Discussions and Practices in the Management of Pain in Oncology.

CONTEXT: Treatment of pain in cancer is a clinical priority. Many cancer patients seek and use complementary and alternative medicine (CAM) therapies. OBJECTIVES: The aim of this study was to describe the role CAM plays in oncology, clinicians' approaches to pain management and its alignment with patient preference and self-care. METHODS: We used quantitative criteria to identify patients with high, self-reported pain and reduced quality of life. For these patients, we merged quantitative and qualitative data from encounter audio recordings, patient surveys, and the medical record. RESULTS: We identified 32 patients (72% women, average age 60) experiencing significantly symptomatic pain at enrollment. Merged themes were 1) Restricted and defined roles: Oncology clinicians suggested and documented cancer-specific approaches to pain management. Patients often (17, 53%) used CAM but rarely desired to discuss it in their encounters. 2) Proactive patients in setting of neutrality: Pain management strategies were considered in 22 instances. CAM was mentioned in 4 (18%) of these discussions but only after patient initiation. Clinicians took a neutral stance. 3) Missed opportunities for person-centered CAM discussions and management: Most (88%) patients were receiving conventional pain medications at enrollment or had them added or escalated during follow-up. Some patients in pain expressed preferences for avoiding opioids. One patient reported wishing CAM would have been discussed after an encounter in which it was not. CONCLUSION: Bringing CAM discussions into the oncology encounter may facilitate a stronger patient-clinician partnership and a more open and safe understanding of pain-related CAM use.

Communication predictors and consequences of Complementary and Alternative Medicine (CAM) discussions in oncology visits.

OBJECTIVE: Cancer patients use complementary and alternative medicine (CAM), but do not routinely talk about it with their clinicians. This study describes CAM discussions in oncology visits, the communication patterns that facilitate these discussions and their association with visit satisfaction. METHODS: 327 patients (58% female; average age 61) and 37 clinicians were recorded during an oncology visit and completed post-visit questionnaires. All CAM discussions were tagged and the Roter Interaction Analysis System (RIAS) was used to code visit dialogue. RESULTS: CAM was discussed in 36 of 327 visits; discussions were brief (

Was a decision made? An assessment of patient-clinician discordance in medical oncology encounters.

BACKGROUND: Shared decision making is promoted to improve cancer care quality. Patients and clinicians may have different ideas about what constitutes a cancer care decision, which may limit the validity of self-reported measures of shared decision making. We sought to estimate the extent to which patients and clinicians agree on whether a cancer care decision was made during an outpatient encounter. METHODS: We surveyed patients and clinicians immediately after an oncology encounter at a large, tertiary medical centre and calculated agreement in response to the single-item question, 'Was a specific decision about cancer care made during the appointment today?' Answer options were 'yes' and 'no'. Participants were 315 oncology patients, with any solid tumour malignancy and at any stage of management, and their clinicians (22 staff oncologists, nine senior fellows and five nurse practitioners). RESULTS: Patients and clinicians reported having made a cancer care decision in 184 (58%) and 174 (55%) of encounters, respectively. They agreed on whether a cancer care decision was made in 213 (68%) of encounters (chance-adjusted agreement was 0.34); in 56 of the 102 discordant encounters, the patient reported making a decision while the clinician did not. We found no significant correlates with discordance. CONCLUSIONS: Patients and clinicians do not always agree on whether a cancer care decision was made. As such, measures that ask patients and/or clinicians to evaluate a decision-making process or outcome may be methodologically insufficient when they do not explicitly orient respondents towards the thing they are being asked to assess.

Listening in on difficult conversations: an observational, multi-center investigation of real-time conversations in medical oncology.

BACKGROUND: The quality of communication in medical care has been shown to influence health outcomes. Cancer patients, a highly diverse population, communicate with their clinical care team in diverse ways over the course of their care trajectory. Whether that communication happens and how effective it is may relate to a variety of factors including the type of cancer and the patient's position on the cancer care continuum. Yet, many of the routine needs of cancer patients after initial cancer treatment are often not addressed adequately. Our goal is to identify areas of strength and areas for improvement in cancer communication by investigating real-time cancer consultations in a cross section of patient-clinician interactions at diverse study sites. METHODS/DESIGN: In this paper we describe the rationale and approach for an ongoing observational study involving three institutions that will utilize quantitative and qualitative methods and employ a short-term longitudinal, prospective follow-up component to investigate decision-making, key topics, and clinician-patient-companion communication dynamics in clinical oncology. DISCUSSION: Through a comprehensive, real-time approach, we hope to provide the fundamental groundwork from which to promote improved patient-centered communication in cancer care.

Optimal control oriented to therapy for a free-boundary tumor growth model.

This paper is devoted to present and solve some optimal control problems, oriented to therapy, for a particular model of tumor growth. In the considered systems, the state is given by one or several functions that provide information on the cell population and also the tumor shape evolution and the control is a time dependent function associated to the therapy strategy (in practice, a cytotoxic drug). We first present and analyze the model (based on PDEs) and the related optimal control problems. The solutions are expected to provide the best therapy strategies for a given set of constraints (here, the cost or objective function is a measure of the number of cells at a given final time T). We also recall some mathematical techniques for solving the related optimization problems and we illustrate the behavior of the methods and the validity of the models with several numerical experiments. In view of the results, we are able to design appropriate strategies that, at least to some extent, are confirmed by real data. Finally, we present some conclusions and indications on future work.