Richard Brown

Predicting the risk of chemotherapy toxicity in older patients: The Chemotherapy Risk Assessment Scale for High‐Age Patients (CRASH) score

Tools are lacking to assess the individual risk of severe toxicity from chemotherapy. Such tools would be especially useful for older patients, who vary considerably in terms of health status and functional reserve.

E-CADHERIN IMMUNOSTAINING OF BLADDER TRANSITIONAL CELL CARCINOMA, CARCINOMA IN SITU AND LYMPH NODE METASTASES WITH LONG-TERM FOLLOWUP

PURPOSEnWe analyze the expression of E-cadherin in bladder transitional cell carcinoma, areas of carcinoma in situ and lymph node metastases, and determine the value of E-cadherin immunoreactivity for predicting disease progression and survival of patients with bladder transitional cell carcinoma.nnnMATERIALS AND METHODSnThe study group consisted of 77 patients who underwent radical cystectomy. Formalin fixed paraffin sections were processed with a hot, citric acid antigen retrieval method, followed by immunostaining with anti-E-cadherin monoclonal antibody and a standard avidin biotin complex technique. E-cadherin expression was also evaluated in carcinoma in situ sections (18) and in regional lymph node metastases (17).nnnRESULTSnLoss of normal membrane E-cadherin immunoreactivity was found in 59 (77%) patients. Abnormal expression of E-cadherin was associated with muscle invasive disease (p = 0.010) and lymph node metastasis (p = 0.044). Of the 18 carcinoma in situ specimens 15 (83%) and of the 17 metastatic lymph nodes 13 (76%) had abnormal E-cadherin expression. Concordance rates of E-cadherin status in carcinoma in situ areas and metastatic lymph nodes with the primary tumors were 85% and 88%, respectively. At a median followup of 128 months, abnormal E-cadherin expression was significantly associated with disease progression (p = 0.0219) and bladder cancer specific survival (p = 0.037). E-cadherin expression and pathological stage but not grade were independent predictors of disease progression (p = 0.042, 0.047 and 0.158, respectively).nnnCONCLUSIONSnIn bladder cancer altered E-cadherin expression is associated with the degree of invasiveness, lymph node metastasis and increased risk of death from bladder cancer. Furthermore, E-cadherin status is an independent predictor of disease progression in patients treated with cystectomy for transitional cell carcinoma of the bladder.

Discussing Adjuvant Cancer Therapy

PURPOSEnTo document the adequacy of patient information in oncology consultations concerning adjuvant therapy and explore predictors of physician communication patterns, treatment decisions, patient information recall, and satisfaction.nnnPATIENTS AND METHODSnRetrospective analysis of audiotapes and verbatim transcripts of 101 initial adjuvant therapy consultations with medical and radiation oncologists was undertaken. Content analysis, data on communication patterns, treatment decisions, patient anxiety, satisfaction, and information recall were collected. Predictors of physician communication, treatment decisions, recall, and satisfaction with the consultation were identified.nnnRESULTSnThe majority of patients were well informed of their prognosis, benefits and risks of therapy, and alternative management options. Only half were asked about preferences for information or decision-making involvement. Predictors of information detail given include patient sex, age, occupation, and education. Radiation and medical oncologists express prognosis and treatment benefit using similar phrases. When offered the chance to delay decision-making, most patients do so (P <.01). Final treatment decisions appear to be influenced by the presentation of choice in treatment options by the oncologist and whether the treatment decision was made during the initial consultation (P <.01). Information recall was not influenced by communication factors. Patients receiving less detailed information had slightly higher satisfaction with the consultation (P =.03). More anxious patients tended to be less satisfied (P =.07).nnnCONCLUSIONnThe optimal way to discuss adjuvant therapy is undefined. More emphasis can be placed on soliciting patient preferences for information and decision-making involvement and tailoring both to the needs of the individual patient. Providing choice in treatment and delaying decision-making may affect the patients treatment decision.

Meeting the Decision-Making Preferences of Patients With Breast Cancer in Oncology Consultations: Impact on Decision-Related Outcomes

PURPOSEnTo investigate how involvement preferences of patients with breast cancer change during the treatment decision-making process and determine the impact of meeting patients expectations on decision-making outcomes.nnnPATIENTS AND METHODSnParticipants were 683 patients with breast cancer from 62 oncologists in five different countries recruited to an International Breast Cancer Study Group (IBCSG 33-03) project. Questionnaires elicited patients pre- and postconsultation preferences for involvement in treatment decision making and whether these were met or not. Decision-related outcomes were assessed postconsultation.nnnRESULTSnBefore the consultation, most patients preferred shared or patient-directed treatment decision making. After the consultation, 43% of patients preferences changed, and most shifted toward patient-directed decisions. The actual postconsultation decision was more likely to be made according to postconsultation rather than preconsultation preferences. Compared with patients who were less involved than they had hoped to be, patients who were as involved as they had hoped to be or were even more involved in decision making had significantly better decision-related outcomes. This was true regardless of whether preference change occurred.nnnCONCLUSIONnMany patients with early-stage breast cancer have treatment options and approach treatment decisions with a desire for decisional control, which may increase after their consultation. Patients ultimate involvement preferences were more likely to be consistent with the way the decision was actually made, suggesting that patients need to feel concordance between their preference and the actual decision. Patients who directed decisions, even if more than they hoped for, fared better on all decision-related outcomes. These results emphasize the need for oncologists to endorse and facilitate patient participation in treatment decision making.

The implementation and assessment of a comprehensive communication skills training curriculum for oncologists

Objective: The objective of this paper is to report the implementation and assessment of the Comskil Training Curriculum at Memorial Sloan‐Kettering Cancer Center.

Sharing vs. caring—The relative impact of sharing decisions versus managing emotions on patient outcomes

OBJECTIVEnTo assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.nnnMETHODSnCognitive and emotional aspects of SDM in consultations between 20 oncologists and 55 early breast cancer patients were coded using the Observing Patient Involvement (OPTION) scale and the Response to Emotional Cues and Concerns (RECC) coding system, plus blocking and facilitating behaviour scales. Patient outcomes including anxiety, decisional conflict, and satisfaction with: (i) the decision, (ii) the consultation, and (iii) doctor SDM skills, were assessed. Relationships between cognitive and emotional aspects of SDM, and patient outcomes were examined using hierarchical regression.nnnRESULTSnThe OPTION score predicted satisfaction with doctor SDM skills 2 weeks post-consultation (p=.010), and with the treatment decision 4 months post-consultation (p=.004). Emotional blocking predicted decisional conflict (p=.039), while the number of emotional cues emitted (p=.003), and the degree of empathy provided (p=.011), predicted post-consultation anxiety.nnnCONCLUSIONnCognitive and emotional aspects of SDM in oncology consultations have different effects on various patient outcomes.nnnPRACTICE IMPLICATIONSnIt is important that doctors focus on both sharing decisions and managing emotions in consultations. Communication skills training addressing both these areas may be an effective way to improve diverse patient outcomes.

Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators.

Objective: An American Psychosocial Oncology Society workgroup has developed indicators of the quality of psychosocial care that can be measured through review of medical records. The present report describes the first large‐scale use of these indicators to evaluate psychosocial care in outpatient medical oncology settings.

Shared decision making coding systems: How do they compare in the oncology context?

OBJECTIVEnThe current study aimed to evaluate three coding systems which have been used to assess shared decision making in oncology consultations (OPTION, Decision Support Analysis Tool (DSAT) and Decision Analysis System for Oncology (DAS-O)): (i) comparing their ability to identify competencies of shared decision making, and (ii) determining their ability to predict patient outcomes in a single data set.nnnMETHODnTwenty oncologists from Australia and New Zealand participated in the IBCSG Trial 33-03. The consultations of 55 women with early stage breast cancer were audio-taped, transcribed and then coded using the OPTION, DAS-O and DSAT coding systems by three different raters. Women completed the questionnaires 2 weeks and 4 months after their consultation.nnnRESULTSnDAS-O was strongly correlated with OPTION (r=0.73). DSAT was moderately correlated with DAS-O and OPTION (r<0.6). Decisional satisfaction and satisfaction with doctor SDM skills were significantly correlated with OPTION (r=0.39 and 0.42 respectively) and the latter variable was correlated with DAS-O (r=0.40). These relationships persisted in multiple linear regression analyses.nnnCONCLUSIONSnOPTION may be the most efficient and sensitive coding system for research purposes; however, DSAT appeared to document behaviours reducing decisional conflict and both DSAT and DAS-O offer more detailed feedback to doctors.nnnPRACTICE IMPLICATIONSnOptimal coding system will depend on research goals and training purposes.

Seeking informed consent to Phase I cancer clinical trials: identifying oncologists' communication strategies

Purpose: Phase I clinical trials are the gateway to effective new cancer treatments. Many physicians have difficulty when discussing Phase I clinical trials. Research demonstrates evidence of suboptimal communication. Little is known about communication strategies used by oncologists when recruiting patients for Phase I trials. We analyzed audio recorded Phase I consultations to identify oncologists communication strategies.

Barriers to therapeutic clinical trials enrollment: Differences between African-American and White cancer patients identified at the time of eligibility assessment

Background Clinical trials (CTs) are the mechanism by which research is translated into standards of care. Low recruitment among underserved and minority populations may result in inequity in access to the latest technology and treatments, compromise the generalizability, and lead to failure in identification of important positive or negative treatment effects among under-represented populations. Methods Data were collected over a 39-month period on patient eligibility for available therapeutic cancer CTs. Reasons for ineligibility and refusal were collected. The data were captured using an automated software tool for tracking eligibility pre-enrollment. We examined characteristics associated with being evaluated for a trial, and reasons for ineligibility and refusal, overall and by patient race. Results African-Americans (AAs) were more likely than Whites to be ineligible (odds ratio, (OR) = 1.26, 95% confidence interval (CI) = 1.0–1.58) and if eligible, to refuse participation (OR = 1.79, 95% CI = 1.27–2.52), even after adjusting for insurance, age, gender, study phase, and cancer type. White patients were more likely to be ineligible due to study-specific or cancer characteristics. AAs were more likely to be ineligible due to mental status or perceived noncompliance. Whites were more likely to refuse due to extra burden, due to concerns with randomization and toxicity, or because they express a positive treatment preference. AAs were more likely to refuse because they were not interested in CTs, because of family pressures, or they felt overwhelmed (NS)). Discussion This study is the first to directly compare ineligibility and refusal rates and reasons captured prospectively in AA and White cancer patients. The data are consistent with earlier studies that indicated that AA patients more often are deemed ineligible and, when eligible, more often refuse participation. However, differences in reasons for ineligibility and refusal by race have implications for a cancer center to participate in CTs appropriate for the population of patients served. On a broader scale, consideration should be given to modifying eligibility criteria and other design aspects to permit broader participation of minority and other underserved groups.