Journal of Clinical Oncology

September 10, 2013

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Explicit and Reassuring Information and Palliative Cancer Care offer realistic hope. Promising not to abandon patients is one thing; however, doing so is another. Oncologists, who seem increasingly aware of the importance of nonabandonment,31,74,80 may eventually fail this task, often because the patient is referred to hospice care.31 Han and Arnold81 suggested that patients' primary physicians should not withdraw after referring to hospice care, but if it becomes necessary, they should discuss their withdrawal with patients beforehand. Several national cancer organizations82-85 advise that general practitioners should have a (continuous) role in palliative care. Others point toward the positive effects of introducing palliative care teams early on in this phase.86-88 Implementation of such initiatives might benefit patients who feel abandoned when familiar care providers are suddenly unavailable.30,74 So, although there is a need to educate future oncologists about the potential power of expressing nonabandonment,89 there is first and foremost a need to determine how this promise can best be given and kept in busy clinical daily life. This study has limitations. First, we conducted an experimental study with APs, so clinical patients in this situation might respond differently. Still, in a recent systematic review, we found that APs' perceptions are valid,47 and the perceptions of patients with and survivors of cancer versus healthy women overlapped in this study. Second, participants viewed four videos varying slightly in communication. Although we varied the order of viewing the videos, and a pilot study indicated that participants could focus on four videos, a habituation effect may have occurred for some individuals. Third, because of our recruitment methods (eg, through advocacy organizations), our sample might be biased, and less-involved women may be underrepresented. Fourth, experimental designs inherently reduce the complexity of clinical interactions, which stresses the importance of clinical follow-up studies. Last, the limited sample size of our study REFERENCES 1. Benzein E, Norberg A, Saveman BI: The meaning of the lived experience of hope in patients with cancer in palliative home care. Palliat Med 15:117-126, 2001 2. Evans WG, Tulsky JA, Back AL, et al: Communication at times of transitions: How to help patients cope with loss and re-define hope. Cancer J 12:417-424, 2006 3. Anderson WG, Alexander SC, Rodriguez KL, et al: "What concerns me is . . ." Expression of emotion by advanced cancer patients during outpatient visits. Support Care Cancer 16:803-811, 2008 4. Jeffrey D: Appropriate palliative care: When does it begin? Eur J Cancer Care (Engl) 4:122-126, 1995 5. Bensing J, Schreurs K, de Rijk A: The role of the general practitioner's affective behaviour in medical encounters. Psychol Health 11:825-838, 1996 6. Engel GL: How much longer must medicine's science be bound by a seventeenth century world view? Psychother Psychosom 57:3-16, 1992 7. Bensing JM, Dronkers J: Instrumental and affective aspects of physician behavior. Med Care 30:283-298, 1992 8. de Haes H, Bensing J: Endpoints in medical communication research, proposing a framework of functions and outcomes. Patient Educ Couns 74: 287-294, 2009 www.jco.org hampered the analysis of the influence of several background characteristics such as ethnicity. Future studies might focus on the most beneficial and feasible approach to discussing statistical information from the perspective of patients in clinical care. More research is needed on how nonabandonment can best be promised (and how that promise can be kept) in palliative care. Furthermore, studies into other types of individualized reassurance (eg, regarding pain control) would be worthwhile. Specific attention should be paid to the influence of background characteristics on communication needs and evaluations, starting with the influence of monitoring scores. In conclusion, although more research is needed to translate our findings into clinical care, the results presented once again underline the power of communication. In the current climate of personalized care, explicit and reassuring information might be beneficial for most patients, although investigating and acting on individual's specific preferences should never be neglected. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. AUTHOR CONTRIBUTIONS Conception and design: Liesbeth M. van Vliet, Nicole M. Plum, Jozien M. Bensing Collection and assembly of data: Liesbeth M. van Vliet Data analysis and interpretation: Liesbeth M. van Vliet, Elsken van der Wall, Jozien M. Bensing Manuscript writing: All authors Final approval of manuscript: All authors 9. Back AL, Anderson WG, Bunch L, et al: Communication about cancer near the end of life. Cancer 113:1897-1910, 2008 10. Innes S, Payne S: Advanced cancer patients' prognostic information preferences: A review. Palliat Med 23:29-39, 2009 11. Schapira L, Butow P, Brown R, et al: Pessimism is no poison. J Clin Oncol 28:705-707, 2010 12. Fallowfield L, Jenkins V: Communicating sad, bad, and difficult news in medicine. Lancet 363:312319, 2004 13. Hagerty RG, Butow PN, Ellis PM, et al: Communicating prognosis in cancer care: A systematic review of the literature. Ann Oncol 16:1005-1053, 2000 14. Kirk P, Kirk I, Kristjanson LJ: What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ 328:1343, 2004 15. van Vliet L, Francke A, Tomson S, et al: When cure is no option: How explicit and hopeful can information be given? A qualitative study in breast cancer. Patient Educ Couns 90:315-322, 2013 16. Hagerty RG, Butow PN, Ellis PA, et al: Cancer patient preferences for communication of prognosis in the metastatic setting. J Clin Oncol 22:1721-1730, 2004 17. Pardon K, Deschepper R, Vander Stichele R, et al: Are patients' preferences for information and participation in medical decision-making being met? Interview study with lung cancer patients. Palliat Med 25:62-70, 2011 18. Kaplowitz SA, Campo S, Chiu WT: Cancer patients' desires for communication of prognosis information. Health Commun 14:221-241, 2002 19. Barnett MM: Does it hurt to know the worst? Psychological morbidity, information preferences and understanding of prognosis in patients with advanced cancer. Psychooncology 15: 44-55, 2006 20. Clayton JM, Butow PN, Arnold RM, et al: Discussing life expectancy with terminally ill cancer patients and their carers: A qualitative study. Support Care Cancer 13:733-742, 2005 21. Rogg L, Loge JH, Aasland OG, et al: Physicians' attitudes towards disclosure of prognostic information: A survey among a representative crosssection of 1605 Norwegian physicians. Patient Educ Couns 77:242-247, 2009 22. Smith TJ, Longo DL: Talking with patients about dying. N Engl J Med 367:1651-1652, 2012 23. Leydon GM, Boulton M, Moynihan C, et al: Faith, hope, and charity: An in-depth interview study of cancer patients' information needs and information-seeking behavior. West J Med 173:2631, 2000 24. Rogg L, Aasland OG, Graugaard PK, et al: Direct communication, the unquestionable ideal? Oncologists' accounts of communication of bleak prognoses. Psychooncology 19:1221-1228, 2010 25. Lamont EB, Christakis NA: Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 134:1096-1105, 2001 © 2013 by American Society of Clinical Oncology 3247

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