Step by step development of clinical care pathways for older cancer patients: Necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.     

The Role of General Practitioners in Cancer Care: A Mixed Method Design

The aims of this study were to identify the current role of general practitioners (GP) and the unmet needs of cancer patients in primary care. First, we conducted individual interviews with 10 cancer patients. Next, we developed a questionnaire, which was distributed among cancer patients across Estonia. Altogether, 113 questionnaires were returned. We observed that while the patients were satisfied with their GP’s work, they mostly preferred to discuss cancer-related problems with oncologists. The role of GPs in regard to other diseases was perceived as very important, also patients found it relevant to consult all investigations with their primary health care physician. The main problems experienced by the patients were a lack of proper accessible information about their disease and its inadequate presentation by doctors, as well as problems with coordination between primary and secondary health care providers. In conclusion, we can say that even treatment of cancer is centralised to oncology clinics, patients also contact their GPs during cancer care. Therefore, GPs should be aware of patients’ general health and comorbid medical problems. Better communication between primary and secondary health care doctors as well as more integration of GPs in cancer care is needed.     

Assessing the impact of late treatment effects in cervical cancer: an exploratory study of women's sexuality

Cancer survivorship has become a major issue due to people living longer with the effects of cancer treatment. A key issue in this area are the 'iatrogenic effects' of cancer treatments and their adverse impact on the quality of long-term patient survival. This paper considers the late physical effects of treatment for cervical cancer, in particular psychosocial problems associated with sexuality. The aim of this paper was to explore women's sexuality following treatment for cervical cancer. A qualitative phenomenological design was used to explore the lived experiences of a purposive sample of 13 women 2-3 years after treatment, using in-depth interviewing. The findings demonstrate that cancer treatment can result in a number of late physical effects, including bladder and bowel dysfunction. Moreover, the physical problems led to sexual difficulties experienced several years after treatment. Concerns were expressed by patients about perceived psychosexual difficulties encountered as a result of treatment. In conclusion, the study raises issues associated with the management of late treatment effects and its impact on sexuality. The findings underline the need for effective communication of possible iatrogenic effects of treatment during follow-up care and a need for research to consider the advice and information that women require about long-term treatment effects.     

Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop

The Institute of Medicine's National Cancer Policy Forum recently convened a workshop on patient-centered cancer treatment planning, with the aim of raising awareness about this important but often overlooked aspect of cancer treatment. A primary goal of patient-centered treatment planning is to engage patients and their families in meaningful, thorough interactions with their health care providers to develop an accurate, well-conceived treatment plan, using all available medical information appropriately while also considering the medical, social, and cultural needs and desires of the patient and family. A cancer treatment plan can be shared among the patient, family, and care team in order to facilitate care coordination and provide a roadmap to help patients navigate the path of cancer treatment. There are numerous obstacles to achieving patient-centered cancer treatment planning in practice. Some of these challenges stem from the patient and include patients' lack of assertiveness, health literacy, and numeracy, and their emotional state and concurrent illnesses. Others are a result of physician limitations, such as a lack of time to explain complex information and a lack of tools to facilitate treatment planning, as well as insensitivity to patients' informational, cultural, and emotional needs. Potential solutions to address these obstacles include better training of health care providers and patients in optimal communication and shared decision making, and greater use of support services and tools such as patient navigation and electronic health records. Other options include greater use of quality metrics and reimbursement for the time it takes to develop, discuss, and document a treatment plan.     

Present status and future perspectives of the regional referral clinical pathway of cancer in Kumamoto

Preparation of a system of community cooperation clinical pathway is called for by The Basic Act on Anti-Cancer Measures and The Basic Plans for National Cancer Strategy. Designated cancer care hospitals should play a very important role in constructing a local communication system among hospitals, clinics and nursing homes. In order to cooperate for seamless care of cancer, a notebook for patients with cancer has been made in Kumamoto by launching the Kumamoto Prefecture Regional Cooperation Conference of cancer management with the assistance of Kumamoto Prefectural government and the designated cancer care hospitals. This notebook consists of case information, treatment history, treatment goals, time schedule for cancer treatment, harmful phenomena due to cancer chemotherapy and counterplans for such side effects. This notebook will serve to improve comprehension and the attitude not only of patients, but also of co-medicals to cancer status and treatment. A physician approach and medical system are needed so that each patient can receive cooperative cancer treatment and care between hospitals and clinics.     

Information Communication Technology: New Approach for Rural Cancer Care Improvement

Cancer control aims to reduce the incidence, morbidity, and mortality of cancer and to improve the qualityof life of cancer patients. For rural populations this presents particular problems. This article covers challengesof oncology care in rural areas and solutions via applying information communication technology with specialtytelemedicine for overcoming problems in prevention, early diagnosis, treatment, and palliative care. In addition,telecommunications infrastructures and frameworks for implementation of telemedicine are decribed.     

Examining ethical dilemmas as obstacles to hospice and palliative care for advanced cancer patients

Oncologists deal almost exclusively with patients with serious and life-threatening diseases, many who are terminally ill. While hospice care remains an ideal model of care for cancer patients with life-ending disease, many obstacles are present in the clinical setting that either impede or prevent the otherwise appropriate referral of patients eligible for this type of end-of-life care. These obstacles are best viewed as ethical dilemmas for oncology clinicians, as they often challenge or obscure a clinician's perceptions about what is in the best interests of their advanced cancer patients. These dilemmas include: Issues surrounding prognosis determination and communication, Concerns about effectively communicating a terminal prognosis while still allowing patients and families to maintain hope, Conflicts of interests for involved clinicians and, Potential problems of the current reimbursement mechanisms for hospice which may be inadequate to meet the needs of all dying cancer patients. For oncologists caring for advanced cancer patients, it is essential that they have a working knowledge regarding these ethical issues, and overt dilemmas, present in end-of-life cancer care in order that they might better appreciate how, and when, to initiate palliative and hospice care for as many of their patients as possible.     

Communication and information: the experience of radiotherapy patients

The purpose of this study was to explore patients' own accounts of their experiences of having cancer and undergoing radiotherapy treatment. The respondents were suffering from either cancer of the head and neck or lung region. The methodology was qualitative and the method used to collect data was semi-structured, audio-taped interviews. Overall the study reflected a high degree of satisfaction with care. However, it did highlight some problems regarding insufficient information about the side-effects of treatment. It was also apparent that difficulties existed in satisfying individual requirements for information about treatment options and prognosis. Data which characterized another level of communication emphasized how health professionals' demeanour and statements of understanding can assist patients in coping with the challenge of having cancer. By providing in-depth feedback about patients' experiences of serious illness, it is concluded that this type of research can contribute to enhancing patient care.     

Experiences of cancer patients in Poland throughout diagnosis and treatment

Previous studies have failed to explain why the mortality rate of cancer patients is higher in Poland than other countries in the European Union. We aimed to evaluate the health care system in Poland during the diagnosis and treatment of cancer. In this multicentre study, 125 cancer patients treated at 15 centres across Poland participated in focus group interviews in 2014. We identified and assessed crucial elements that affect a patients' experience from the early onset of symptoms, through to diagnosis and treatment. We found that the majority of patients were dissatisfied with the length of time taken to diagnose cancer. Throughout diagnosis, treatment and follow‐up, patients reported a lack of communication from health care professionals. While dealings with oncologists and medical staff were viewed favourably, patients felt the cancer centres were not well organised. Patients recommended that having one doctor in charge of an individual's treatment and follow‐up would improve patient care and well‐being. A late cancer diagnosis may be contributing to the high mortality rate observed in Poland. In the future, new policies should be developed to reduce the time to cancer diagnosis, increase communication with health care professionals and improve the organisation of cancer care for patients.     

Health literacy and cancer communication

Health literacy is increasingly recognized as a critical factor affecting communication across the continuum of cancer care. We reviewed research on health literacy and examined its impact on cancer outcomes and communication. According to the National Adult Literacy Survey (NALS), considered the most accurate portrait of literacy in our society, about one in five American adults may lack the necessary literacy skills to function adequately in our society. As patients, such individuals are at a disadvantage in their capacity to obtain, process, and understand cancer information and services needed to make appropriate health care decisions. Patients with poor health literacy have a complex array of difficulties with written and oral communication that may limit their understanding of cancer screening and of symptoms of cancer, adversely affecting their stage at diagnosis. In addition, these barriers impair communication and discussion about risks and benefits of treatment options, and patient understanding of informed consent for routine procedures and clinical trials. More research is needed to identify successful methods for educating and communicating with patients who have limited health literacy. Based on our own experience, we offer practical communication aids that can help bridge the cancer communication gap.     

Effective communication skills are the key to good cancer care

Communication within oncology is a core clinical skill but one in which few oncologists or specialist cancer nurses have received much formal training. Inadequate communication may cause much distress for patients and their families, who often want considerably more information than is usually provided. Many patients leave consultations unsure about the diagnosis and prognosis, confused about the meaning of--and need for--further diagnostic tests, unclear about the management plan and uncertain about the true therapeutic intent of treatment. Additionally, communication difficulties may impede the recruitment of patients to clinical trials, delaying the introduction of efficacious new treatments into clinics. Lack of effective communication between specialists and departments can also cause confusion and a loss of confidence amongst the team. Oncologists themselves acknowledge that insufficient training in communication and management skills is a major factor contributing to their own stress, lack of job satisfaction and emotional burnout. Consequently, over the past few years there have been several initiatives aimed at improving basic communication skills training for healthcare professionals in the cancer field. In this paper, some of the issues that influence communication within an oncology setting, and ultimately affect patient care, are discussed.     

Communication Competencies of Oncology Nurses in Malaysia

This paper reports on part of a large study to identify competencies of oncology nurses in Malaysia. It focuseson oncology nurses’ communications-related competency. As an important cancer care team member, oncologynurses need to communicate effectively with cancer patients. Literature shows that poor communication canmake patients feel anxious, uncertain and generally not satisfied with their nurses’ care. This paper deliberateson the importance of effective communication by oncology nurses in the context of a public hospital. Four focusgroup discussions were used in this study with 17 oncology/cancer care nurses from Malaysian public hospitals.The main inclusion criterion was that the nurses had to have undergone a post-basic course in oncology, or havework experience as a cancer care nurse. The findings indicated that nurses do communicate with their patients,patients’ families and doctors to provide information about the disease, cancer treatment, disease recurrence andside effects. Nurses should have good communication skills in order to build relationships as well as to providequality services to their patients. The paper concludes by recommending how oncology nursing competenciescan be improved.     

Communication and the patient/physician relationship: a phenomenological inquiry

All interaction between patient and medical team is mediated through communication. In working with advanced cancer patients, troubled communication between the patient and healthcare team is sometimes evident. The current study examined the perspective of seven advanced cancer patients on this communication. The patients were under the care of an urban cancer research center, and each had expressed, at least once, a desire for hastened death. Using a phenomenological form of inquiry, serial, "in-depth semistructured" interviews were conducted (mean = 3; range = 2-6) at a place convenient to the patient. The interviews were audiotaped, transcribed, coded, and organized into themes. The study findings suggest that the most important aspects of communication between the advanced cancer patient and medical team at an urban cancer research center are the extreme vulnerability of the patient to both style and content of the communication; the extreme sensitivity of the communication itself, because it concerns issues vital to the patient; and the complexity of the communication, encompassing and expressing both verbal and non-verbal messages, as well as intended and unintended messages. Conflict inherent in almost all communication between patient and medical team involved disagreement about goals of care and the participants' perception of not being treated with respect. Harm caused to the participant by communication missteps included loss of hope, a sense of abandonment, and diminished feelings of personal dignity and worth. The findings may not be representative of advanced cancer patients being cared for in a different treatment setting.     

Threatened fertility: A longitudinal study exploring experiences of fertility and having children after cancer treatment

Infertility is a recognised potential sequel of cancer treatment which impacts negatively on the quality of survival. The aim of this study was to explore how men and women experience the threat of infertility by cancer treatment and individuals’ thoughts about having children after cancer during the first 2 years following diagnosis. Nine women and seven men (aged 24–41) participated in two interviews in this longitudinal interview study, after the initiation of cancer treatment and 2 years thereafter. The interviews focused on participants’ thoughts and feelings about threatened fertility and having children. The interviews were analysed with qualitative content analysis with a particular focus on identifying experiences over time. The Traits–Desires–Intentions model was used to reflect upon the study findings. The analysis resulted in the identification of four themes: Continue calmly on chosen path, Abandoning plans for children, Avoiding the subject of fertility and Struggling towards life goals. The results emphasise the need to offer individualised fertility‐related treatment communication and counselling, both at the time of cancer diagnosis and also in connection with follow‐up care. Appropriate fertility‐related communication should be included in young cancer patients’ survivor care plans.     

Cancer patient satisfaction with care

A diagnosis of cancer places considerable stress on patients and requires them to make major adjustments in many areas of their lives. As a consequence, considerable demands are placed on health care providers to satisfy the complex care needs of cancer patients. Currently, there is little available information to indicate the extent to which cancer patients are satisfied with the quality of care they receive. The present study assessed the perceptions of 232 ambulatory cancer patients about the importance of and satisfaction with the following aspects of care: doctors technical competence and interpersonal and communication skills, accessibility and continuity of care, hospital and clinic care, nonmedical care, family care, and finances. The results indicate that all 60 questionnaire items used were considered to reflect important aspects of care, but that greater importance was given to the technical quality of medical care, the interpersonal and communication skills of doctors, and the accessibility of care. Most patients were satisfied with the opportunities provided to discuss their needs with doctors, the interpersonal support of doctors, and the technical competence of doctors. However, few patients were satisfied with the provision of information concerning their disease, treatment, and symptom control and the provision of care in the home and to family and friends.     

Oncologists’ perspectives on post‐cancer treatment communication and care coordination with primary care physicians

Post‐treatment cancer care is often fragmented and of suboptimal quality. We explored factors that may affect cancer survivors’ post‐treatment care coordination, including oncologists’ use of electronic technologies such as e‐mail and integrated electronic health records (EHRs) to communicate with primary care physicians (PCPs). We used data from a survey (357 respondents; participation rate 52.9%) conducted in 2012–2013 among medical oncologists caring for patients in a large US study of cancer care delivery and outcomes. Oncologists reported their frequency and mode of communication with PCPs, and role in providing post‐treatment care. Seventy‐five per cent said that they directly communicated with PCPs about post‐treatment status and care recommendations for all/most patients. Among those directly communicating with PCPs, 70% always/usually used written correspondence, while 36% always/usually used integrated EHRs; telephone and e‐mail were less used. Eighty per cent reported co‐managing with PCPs at least one post‐treatment general medical care need. In multivariate‐adjusted analyses, neither communication mode nor intensity were associated with co‐managing survivors’ care. Oncologists’ reliance on written correspondence to communicate with PCPs may be a barrier to care coordination. We discuss new research directions for enhancing communication and care coordination between oncologists and PCPs, and to better meet the needs of cancer survivors post‐treatment.     

Key issues in death at home

After our facility was first opened, we provided terminal care for one patient with terminal stomach cancer. In this case palliative care, so important in terminal care, and care for the family was insufficient, and in the end we had to abandon the process assuring the kind of death the patient wished for at home. Learning from this experience, we have provided terminal care to about 150 patients based on each patient's outlook on life and view of life and death. These patients have included terminal cancer patients and patients informed of their cancer who chose to coexist with the cancer and live together with their families. At home, the words and facial expressions of the patients and their families are clear expressions of their humanity. At times, such, feelings are also directed frankly and unaffectedly toward us, the visiting nursing staff. When considering the early case in which we were unable to continue home care, we could see various problems: on the part of the medical staff including primary physician and nurses, the welfare service, the patient and family, and neighboring informal social resources. These included problems in informing the patient of his cancer and his remaining days. In home treatment of patients with terminal cancer, death at home assisted by a physician from the same medical facility is not emotionally all it might appear to be. Nurses, for example, do not provide religious comfort; therefore, they can not provide home hospice services. Or so it is said. However, in supporting community home care, there is an exchange between humans and the communication of genuine feelings; thus, the nurturing of warm care makes possible the kind of death the person wishes. In fact, we can not deny that that is the path we are taking. In the present report, we explore the issues that make home terminal care possible from the viewpoint of visiting nurses.