Tanina Foster

Discussing Bad News in the Outpatient Oncology Clinic: Rethinking Current Communication Guidelines

Aware that his pancreatic cancer had metastasized to his liver, Mr B and his adult son and daughter traveled several hundred miles to see an oncologist at a regional comprehensive cancer center. As the oncologist explained the treatment options, Mr B and his family occasionally interrupted with questions, statements, or expressions of emotion. During the interaction, Mr B and his family learned that surgery was not a treatment option, as they had hoped. They also learned that Mr B was not eligible for any clinical trials. The only available option was chemotherapy, but it carried the potential for severe adverse effects, had less than a 10% chance of shrinking the tumor, and had no chance of “melting the tumor away.” In response to one of the son’s questions, the oncologist said that complementary or alternative medicines were not available at this center. As part of his response to the daughter’s question about the urgency of a treatment decision, the oncologist mentioned that the cancer had been in Mr B’s body for a number of years. Mr B and both of his children asked several questions about this piece of information, indicating their surprise and dismay. Mr B shook his head and exclaimed, “And I go to the doctor all the time!” As the discussion concluded, the oncologist provided details about how chemotherapy might be delivered and repeated that there was no urgency to the decision.

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

OBJECTIVE Communication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists. METHODS Participants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication. RESULTS The intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found. CONCLUSION This QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes. PRACTICE IMPLICATIONS This QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.

An Analysis of Race-related Attitudes and Beliefs in Black Cancer Patients: Implications for Health Care Disparities.

Abstract:This research concerned relationships among Black cancer patients’ health care attitudes and behaviors (e.g., adherence, decisional control preferences,) and their race-related attitudes and beliefs shaped by (a) general life experiences (i.e., perceived discrimination, racial identity) and (b) experiences interacting with health care systems (i.e., physician mistrust, suspicion about medical care). Perceived discrimination, racial identity, and medical suspicion correlated weakly with one another; mistrust and suspicion correlated only moderately. Race-related attitudes and beliefs were associated with health care attitudes and behavior, but patterns of association varied. Physician mistrust and medical suspicion each independently correlated with adherence and decisional control preferences, but discrimination only correlated with control preferences. Associations among patients’ different racial attitudes/beliefs are more complex than previously assumed. Interventions that target patient attitudes/beliefs and health care disparities might be more productive if they focus on mistrust or suspicion specific to health care providers/systems and their correlates identified in this study.

Comparing thin slices of verbal communication behavior of varying number and duration

OBJECTIVE The aim of this study was to assess the accuracy of thin slices to characterize the verbal communication behavior of counselors and patients engaged in Motivational Interviewing sessions relative to fully coded sessions. METHODS Four thin slice samples that varied in number (four versus six slices) and duration (one- versus two-minutes) were extracted from a previously coded dataset. In the parent study, an observational code scheme was used to characterize specific counselor and patient verbal communication behaviors. For the current study, we compared the frequency of communication codes and the correlations among the full dataset and each thin slice sample. RESULTS Both the proportion of communication codes and strength of the correlation demonstrated the highest degree of accuracy when a greater number (i.e., six versus four) and duration (i.e., two- versus one-minute) of slices were extracted. CONCLUSION These results suggest that thin slice sampling may be a useful and accurate strategy to reduce coding burden when coding specific verbal communication behaviors within clinical encounters. PRACTICE IMPLICATIONS We suggest researchers interested in using thin slice sampling in their own work conduct preliminary research to determine the number and duration of thin slices required to accurately characterize the behaviors of interest.

Abstract A13: Randomized trial of a Question Prompt List to increase patient active participation during racially discordant oncology interactions

Purpose: Communication during racially discordant oncology interactions (i.e., Black patient, non-Black physician) is often of poorer quality than during similar interactions with White patients, and may contribute to racial disparities in cancer treatment. Question Prompt Lists (QPL) have been shown to increase patient active participation in clinical interactions and to influence related outcomes, but have never been tested in racially discordant oncology interactions. This study evaluated the acceptability and effectiveness of a QPL designed to increase patient active participation and related outcomes during clinical interactions in which Black patients discussed medical treatment for breast, colon, or lung cancer with non-Black oncologists. Participants and Methods: Eighteen non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, MI completed baseline measures. Patients were then randomly assigned to one of three arms: 1) usual care; 2) receiving a QPL specifically designed for this study in the form of a booklet (QPL-only); 3) receiving the QPL booklet plus the assistance of a communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Trained observers assessed patient active participation using two measures: a frequency count of active participation communication behaviors (i.e., questions, assertions, and statements of concern) and a global rating scale of seven items indicating active participation (e.g., “The patient asked the doctor a lot of questions”). Observers also rated oncologist patient-centered communication using a 14-item global scale with three subscales (i.e., informativeness, supportiveness, relationship-building). Following interactions, patients rated oncologist patient-centeredness; shared decision-making; trust in their oncologist; and difficulty understanding and remembering what was discussed during the conversation with their oncologist. Intervention arm patients also used a 3-point scale to provide their perceptions of the intervention. Analyses included multi-level regression models, with patients nested within oncologists. Results: Patients in both intervention arms viewed the QPL booklet favorably (M=2.80; SD=.23). Patients in the QPL-plus-Coach arm also viewed the coaching favorably (M=2.83; SD=.29). Interaction length did not significantly differ across arms. Patients in the QPL-only arm participated more actively than patients in the usual care or QPL-plus-coach arm (frequency count: p=.02; global scale p=.06). The intervention had no significant effect on other outcomes. Conclusion: Findings suggest a QPL in the form of a booklet may be an acceptable and effective intervention to increase active participation in oncology interactions among Black patients. Future research should investigate whether the addition of a physician-focused intervention might produce additional benefits, such as better oncologist communication and increased patient trust. Research examining the influence of patient and oncologist characteristics, including race-related attitudes, on patient active participation and related outcomes in racially discordant oncology interactions may inform future interventions to improve the quality of communication and care for Black patients with cancer. Citation Format: Susan Eggly, Lauren Hamel, Terrance L. Albrecht, Tanina Foster, Robert Chapman, Louis A. Penner. Randomized trial of a Question Prompt List to increase patient active participation during racially discordant oncology interactions. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A13.

Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials

BackgroundCancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients’ decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial.Methods/designData collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients’ understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes.DiscussionPACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers.Trial registrationClinical Trials.gov registration number: NCT02906241 (September 8, 2016).

Abstract B09: Partnering around cancer clinical trials: Preliminary report of an intervention to improve patient-physician communication and clinical trial enrollment of Black and White men with prostate cancer

Background: Few patients, especially racial/ethnic minorities, enroll in clinical trials (CTs) in the United States, in part due to factors related to patient-physician interactions. We describe a theory-based patient intervention to improve communication and enrollment of Black and White men in prostate cancer CTs. We also report on preliminary baseline data comparing Black and White participants9 demographic and social characteristics and their willingness to discuss a CT with a physician. Method: A team of communication scientists, psychologists, and clinicians collaborated to create a theory-based, patient-focused intervention. Theories included the common ingroup identity model, which suggests people from different social groups can better achieve goals when they see themselves as members of the same team, and patient-centered communication, which suggests that patient active participation improves clinical communication. The intervention is in the form of a booklet given to patients prior to meeting with their oncologist. The booklet includes a) encouragement to view the patient and physician as a team and participate actively in clinical interactions, and b) 33 questions about participating in a CT. Preliminary data from one data collection site (Detroit, Michigan) include 72 Black (n=40) and White (n=32) men with prostate cancer who completed baseline measures assessing age; education; income; breadwinner status; marital status; health literacy; perceived economic burden (e.g., how difficult is it for you to live on your total household income right now?); general trust in physicians; group-based medical mistrust (including three subscales--suspicion, perceived racial health care disparities, and perceived health care provider support); and willingness to discuss a CT with a physician. Chi-square and independent samples t-tests were conducted to determine racial differences. Results: Black patients were younger (p=.04), had less education (p=.006) and lower annual incomes (p Discussion: Black and White patients differed in many demographic and social characteristics. Both groups indicated they were very willing to discuss a CT with their physician, although Whites were significantly more willing. This finding suggests the intervention may be especially beneficial for Black patients, who are disproportionately under-represented in CTs. Next steps involve analysis of the effect of the intervention and addition of a physician-focused intervention. Citation Format: Lauren M. Hamel, Louis A. Penner, Elisabeth Heath, Dina Lansey, Michael Carducci, Terrance L. Albrecht, Ellen Barton, Mark Manning, Tanina Foster, Mark Wojda, Susan Eggly. Partnering around cancer clinical trials: Preliminary report of an intervention to improve patient-physician communication and clinical trial enrollment of Black and White men with prostate cancer [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B09.

Abstract A84: Perceived Social Support Moderates the Associations between Race-Based Medical Suspicion and Perceptions of Cancer Treatment

Background: Decades of research have demonstrated the salutary effects of higher perceived social support on thoughts and feelings about one9s health. Separate work has shown that Black patients with higher race-based medical suspicion have more negative perceptions of their healthcare. Prior studies have not systematically investigated the extent to which perceived social support is related to medical suspicion in Black cancer populations. Purpose: We specifically explored whether larger social network size and higher social support satisfaction moderated negative perceptions and feelings typically experienced by Black patients scoring high on suspicion. Methods: 114 Black cancer patients reported their social support and suspicion at a baseline session. One week later, they interacted with their oncologist about initial treatment options during a clinic visit. Following the interaction, patients reported their uncertainty regarding the recommended treatment, perceived difficulty completing treatment, and distress. Results: Moderation results showed that larger social network size was related to less uncertainty and less perceived difficulty completing treatment for Black patients low in suspicion. However, larger social network size failed to reduce uncertainty and perceived difficulty and exacerbated distress for Black patients high in suspicion. Social support satisfaction moderated only the relation between medical suspicion and perceived difficulty. Conclusions: Social support is associated with distinct cancer treatment perceptions for Black cancer patients as a function of patients9 suspicion, which may be explained by entrenchment in a social network that reinforces negative personal biases. Citation Format: Sarah C. E. Stanton, Louis A. Penner, Susan Eggly, Felicity W. K. Harper, Lauren M. Hamel, Tanina Foster, Michael S. Simon, Ellen Barton, Robert A. Chapman, Terrance L. Albrecht. Perceived Social Support Moderates the Associations between Race-Based Medical Suspicion and Perceptions of Cancer Treatment. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A84.