Prevalence and Predictors of Physician-Patient Discordance in Prognostic Perceptions in Advanced Cancer

BACKGROUND: Discordance between physicians' and patients' prognostic perceptions in advanced cancer care threatens informed medical decision-making and end-of-life preparation, yet this phenomenon is poorly understood. We sought to: (1) describe the extent and direction of prognostic discordance, patients' prognostic information preferences in cases of prognostic discordance, and physicians' awareness of prognostic discordance; and (2) examine which patient, physician, and caregiver factors predict prognostic discordance. MATERIALS AND METHODS: Oncologists and advanced cancer patients (median survival ≤12 months; n = 515) from 7 Dutch hospitals completed structured surveys in a cross-sectional study. Prognostic discordance was operationalized by comparing physicians' and patients' perceptions of the likelihood of cure, 2-year mortality risk, and 1-year mortality risk. RESULTS: Prognostic discordance occurred in 20% (likelihood of cure), 24%, and 35% (2-year and 1-year mortality risk) of physician-patient dyads, most often involving patients with more optimistic perceptions than their physician. Among patients demonstrating prognostic discordance, the proportion who preferred not knowing prognosis varied from 7% (likelihood of cure) to 37% (1-year mortality risk), and 45% (2-year mortality risk). Agreement between physician-perceived and observed prognostic discordance or concordance was poor (kappa = 0.186). Prognostic discordance was associated with several patient factors (stronger fighting spirit, self-reported absence of prognostic discussions, an information source other than the healthcare provider), and greater physician-reported uncertainty about prognosis. CONCLUSION: Up to one-third of the patients perceive prognosis discordantly from their physician, among whom a substantial proportion prefers not knowing prognosis. Most physicians lack awareness of prognostic discordance, raising the need to explore patients' prognostic information preferences and perceptions, and to tailor prognostic communication

Potential Adverse Outcomes of Shared Decision Making about Palliative Cancer Treatment: A Secondary Analysis of a Randomized Trial

Background: While shared decision making (SDM) is advocated for ethical reasons and beneficial outcomes, SDM might also negatively affect patients with incurable cancer. The current study explored whether SDM, and an oncologist training in SDM, are associated with adverse outcomes (i.e., patient anxiety, tension, helplessness/hopelessness, decisional uncertainty, and reduced fighting spirit). Design: A secondary analysis of a randomized clinical trial investigating the effects of SDM interventions in the context of advanced cancer. The relations between observed SDM (OPTION12), specific SDM elements (4SDM), oncologist SDM training, and adverse outcomes were analyzed. We modeled adverse outcomes as a multivariate phenomenon, followed by univariate regressions if significant. Results: In total, 194 patients consulted by 31 oncologists were included. In a multivariate analysis, observed SDM and adverse outcomes were significantly related. More specifically, more observed SDM in the consultation was related to patients reporting more tension (P = 0.002) and more decisional uncertainty (P = 0.004) at 1 wk after the consultation. The SDM element “informing about the options” was especially found to be related to adverse outcomes, specifically to more helplessness/hopelessness (P = 0.002) and more tension (P = 0.016) at 1 wk after the consultation. Whether the patient consulted an oncologist who had received SDM training or not was not significantly related to adverse outcomes. No relations with long-term adverse outcomes were found. Conclusions: It is important for oncologists to realize that for some patients, SDM may temporarily be associated with negative emotions. Further research is needed to untangle which, when, and how adverse outcomes might occur and whether and how burden may be minimized for patients. Observed shared decision making was related to more tension and uncertainty postconsultation in advanced cancer patients However, training oncologists in SDM did not affect adverse outcomes. Further research is needed to untangle which, when, and how adverse outcomes might occur and how burden may be minimized

Psychological well-being and perceived control after a breast cancer diagnosis

De diagnose borstkanker en de daaropvolgende behandelingen kunnen negatieve emoties zoals angst en somberheid teweegbrengen. Kennis over het verloop in dergelijke klachten en over factoren die de kans op psychische problemen vergroten, geeft richting aan de psychosociale zorg voor borstkankerpatiënten. Dit proefschrift beschrijft de resultaten van een onderzoek waarin vrouwen werden gevolgd gedurende de verschillende fases in het eerste jaar na de diagnose. Het onderzoek richtte zich op individuele verschillen in het verloop van psychische klachten, op verschillen tussen negatieve emoties en op de voorspellende rol van waargenomen controle. Hoewel vrouwen opvallend veerkrachtig bleken, doorliep niet iedereen het traject na diagnose zonder problemen. Vooral kort na diagnose werden angst en algemene psychische klachten gerapporteerd; depressieve symptomen waren niet veelvoorkomend. Veel vrouwen hadden weinig klachten of herstelden zich na de afronding van de behandeling, terwijl een kleine groep pas na de behandeling of in elke fase problemen ondervond. Vrouwen met een sterk gevoel van controle over het leven rapporteerden relatief weinig psychische klachten. Zij dachten positief over de situatie en de eigen vaardigheden om met de ziekte om te gaan en zij bleven betrokken bij hun sociale leven. Vooral vrouwen met een stressbestendige persoonlijkheid hadden het gevoel zelf invloed te hebben op de genezing van de ziekte. Zelfs na teleurstellend nieuws resulteerde een geloof in de eigen invloed niet in psychische problemen. Naast deze centrale bevindingen rapporteert het proefschrift over de invloed van wachttijden op het emotioneel welbevinden en over de validiteit van een vragenlijst gericht op de persoonlijk stijl in de omgang met problemen.

Enhancing patient participation in oncology consultations: a best evidence synthesis of patient-targeted interventions

Because of the complexity of cancer consultations, the contribution of patients is often limited. This systematic review examined the characteristics and effectiveness of patient-targeted interventions that aim to enhance cancer patients' participation in the consultation. Relevant studies were selected by a search of databases until mid-2010 (Pubmed, PsycINFO and CINAHL), citations in relevant reviews as well as backward/forward citations. A Best Evidence Synthesis was performed, taking into account the quality of studies. A total of 52 publications were included, describing 46 studies and 30 unique interventions. One-third was delivered through either written or multimedia material, two-thirds face to face. Most originated from English-speaking countries. Half targeted heterogeneous cancer populations, one-third targeted women with breast cancer. Half focussed on initial treatment-planning consultations. Overall, there was evidence for an effect on observed patient participation. There was no evidence for an effect on patient or doctor satisfaction and insufficient evidence for an effect on psychological well-being, physical well-being and consultation duration. The findings turned out to be largely independent of study quality. Effect of the interventions could only be demonstrated for immediate outcomes, that is, behaviour observed in the consultation. Implications for future research are discussed, including attention for gaps in the literature as well as the choice of outcome measure

The adaptive role of perceived control before and after cancer diagnosis: A prospective study

Cancer is generally considered a low-control situation. Stability of perceptions of control before and after cancer was examined, as well as the adaptive value of maintenance versus relinquishment of control in the psychological adjustment to cancer. This study, conducted in the northern Netherlands, was carried out in a prospective design with four assessment points (one pre-morbid and three post-morbid assessments) involving semi-structured interviews and self-report questionnaires. Ninety-nine newly diagnosed cancer patients all aged over 57 years completed all four assessment points. We found that perceptions of control declined before and after disease, possibly as a consequence of the diagnosis of cancer. Further, maintenance of control after cancer diagnosis was related to lower levels of psychological distress 6 and 12 months after diagnosis. These results suggest that maintenance of perceptions of control is beneficial to the psychological adjustment to cance