Perceived Barriers to Goals of Care Discussions With Patients With Advanced Cancer and Their Families in the Ambulatory Setting: A Multicenter Survey of Oncologists.

BACKGROUND: Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting. METHODS: A previously published survey to assess barriers to GOC discussions among clinicians on inpatient medical wards was modified for the ambulatory oncology setting and distributed to oncologists from 12 centers in Ontario, Canada. Physicians were asked to rank the importance of various barriers to having GOC discussions (1 = extremely unimportant to 7 = extremely important). RESULTS: Questionnaires were completed by 30 (24%) of 127 physicians. Respondents perceived patient- and family-related factors as the most important barriers to GOC discussions. Of these, patient difficulty accepting prognosis or desire for aggressive treatment were perceived as most important. Patients' inflated expectation of treatment benefit was also considered an important barrier to discontinuing active cancer-directed therapy. While physician barriers were ranked lower than patient-related factors, clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Patient's refusal for referral was the most highly rated barrier to early palliative care referral. Most respondents were nonetheless very or extremely willing to initiate (90%) or lead (87%) GOC discussions. CONCLUSION: Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.

A single-institution experience of salvage therapy for patients with early and locally advanced breast cancer who progress during neoadjuvant chemotherapy.

PURPOSE: Progression during neoadjuvant chemotherapy (NAT) for early and locally advanced breast cancer is generally uncommon. However, these patients tend to do poorly, and salvage therapy (ST) use is variable and often not well defined. We aimed to establish the characteristics and outcomes of breast cancer (BC) patients progressing on NAT, report the patterns of institutional ST usage, and identify predictors of ST failure. METHODS: A retrospective review was conducted using the "Biomatrix" institutional database. Fisher's exact test was used to study the association between baseline characteristics and progression after ST. Survival outcomes were estimated using Kaplan-Meier. Disease-Free Survival 1 (DFS1) and DFS2 represent the time between diagnosis and first progression, and the first and second progression, respectively. The log-rank test was used to compare survival outcomes between different ST types. RESULTS: Thirty patients out of 413 (7.2%) progressed on primary NAT, with a median follow-up of 28.52 months (13.77-46.97) and a mean age of 57 years (standard deviation: 12). The two most frequently used ST modalities were surgery (43%) and radiation with concurrent cisplatin chemotherapy (CT/RT) (40%). Eighty percent of the patients made it to subsequent surgery and among those, 11 (69%) were initially not operable and their tumors were rendered surgically removable after ST. The initial tumor stage and grade, and the presence of lymphovascular invasion predicted progression after ST (p = 0.02, p = 0.03 and p = 0.01, respectively). Median DFS1, DFS2, and overall survival were 4.4 months (95% CI 3.6-5.7), 14.8 months (95% CI 2.37-NR), and 39.5 months (95% CI 22.73-NR), respectively. No difference in survival outcomes based on ST type was seen. CONCLUSION: In this evaluated cohort and despite potential poorer outcomes, patients progressing on NAT responded well to ST, became operable, and had promising survival outcomes. Appropriate selection of ST is crucial, and can help improve outcomes in such patients.

Patient, staff, and clinician perspectives on implementing electronic communications in an interdisciplinary rural family health practice.

Aim To conduct an environmental scan of a rural primary care clinic to assess the feasibility of implementing an e-communications system between patients and clinic staff. BACKGROUND: Increasing demands on healthcare require greater efficiencies in communications and services, particularly in rural areas. E-communications may improve clinic efficiency and delivery of healthcare but raises concerns about patient privacy and data security. METHODS: We conducted an environmental scan at one family health team clinic, a high-volume interdisciplinary primary care practice in rural southwestern Ontario, Canada, to determine the feasibility of implementing an e-communications system between its patients and staff. A total of 28 qualitative interviews were conducted (with six physicians, four phone nurses, four physicians' nurses, five receptionists, one business office attendant, five patients, and three pharmacists who provide care to the clinic's patients) along with quantitative surveys of 131 clinic patients. Findings Patients reported using the internet regularly for multiple purposes. Patients indicated they would use email to communicate with their family doctor for prescription refills (65% of respondents), appointment booking (63%), obtaining lab results (60%), and education (50%). Clinic staff expressed concerns about patient confidentiality and data security, the timeliness, complexity and responsibility of responses, and increased workload. CONCLUSION: Clinic staff members are willing to use an e-communications system but clear guidelines are needed for successful adoption and to maintain privacy of patient health data. E-communications might improve access to and quality of care in rural primary care practices.

Oral Anticancer Medication Adherence, Toxicity Reporting, and Counseling: A Study Comparing Health Care Providers and Patients.

PURPOSE: Oral anticancer medications (OACMs) have created new treatment opportunities, but also challenges for patients and practitioners. We aimed to compare health care provider (HCP) and patient perceptions on OACM adherence, toxicity reporting, and patient educational needs. METHODS: An online survey for HCPs and paper survey for patients were analyzed using descriptive statistics. Bivariate analysis using the χ(2) test was used for some questions. RESULTS: There were 169 HCP and 143 patient responses; 91% of patients reported taking their OACMs as prescribed more than 75% of the time, but only 40% of HCPs believed their patients were as adherent; 97% of HCPs believed patients reported their adverse effects some or most of the time; 61% of patients reported toxicities sometimes, often, or very often, but 30% never or rarely reported; 66% of HCPs believed patients did not report toxicity because of fear of treatment interruption, compared with 2% of patients. HCPs (53%) and patients (62%) both believed adverse effect tolerance was a common reason not to report. Most HCPs (70%) believed patients reported adverse effects first to a nurse. Patients seemed to report equally to nurses (42%) and oncologists (38%). Both HCPs and patients favored paper-based educational materials and call-back programs. CONCLUSION: This study highlights disparities in patient and HCP perceptions of OACM adherence principles and toxicity reporting. Opportunities for improved patient education are identified, particularly around reporting significant toxicities. Different HCPs may benefit from complimentary counseling tools to encompass the entire spectrum of patient needs and provider practice.