Effective communication between patients and their physicians plays an integral role in shaping cancer patients' experiences and interactions with their health provider.1 The information that patients receive becomes increasingly vital to their physical and psychological well being as the US healthcare system continues to encourage engaging patients as active participants and decision-makers in their care.2-4 Cancer patients are known to seek information about their cancer, treatment, and quality-of-life issues from many sources,5, 6 including both medical and nonmedical sources.7 In this study, we focused on how patients' engagement with a fundamental source of information, their physician, affects their self-reported experience of problems associated with their cancer diagnosis among a representative sample of cancer patients in Pennsylvania.
Communicating information is important in the cancer care setting, because it may have an impact on how patients receive bad news about their diagnosis, understand new and complex material, navigate a multifaceted healthcare system, manage uncertainty, and make important treatment and lifestyle decisions.1 However, promoting patient-clinician communication does not necessarily influence patients' outcomes in positive ways. Of 21 studies that were included in a review of patient-clinician communication on health outcomes,8, 9 16 reported positive results, 4 reported nonsignificant results, and 1 was inconclusive.
On one hand, evidence suggests that patient-physician communication has positive effects not just on perceptions of the relationship but on patients' subsequent psychological and physical health outcomes as well. For example, Martinez and colleagues observed that patient-clinician information engagement (PCIE) led to improved treatment decision satisfaction and that this correlation was mediated through feeling informed.10 An earlier study by Stewart and colleagues indicated that patients who felt that common ground was achieved with their physicians were more likely to have improved health status and more efficient hospital care.8 In an experiment of a communication training program for health professionals, the training led to improved ratings by patients, fewer surgery complications, faster transfer to less intensive care levels, and shorter hospital stays.11
In contrast, other studies have reported null or negative outcomes. This meant that increased patient-clinician communication did not always lead to better health consequences. In a study among patients with breast and testicular cancers, reassurance by physicians that symptoms were not sinister yielded mixed results with regard to anxiety.12 A randomized controlled trial of a patient-centered care training program for general practice teams that treated diabetes indicated that, although patients who attended sessions with trained practiced teams reported better communication and treatment satisfaction, they did not experience improved metabolic control or diabetes-specific quality of life compared with the control group.13 Unexpectedly, the authors of that study also reported that patients with diabetes in the intervention group gained more weight at follow-up, potentially contributing to greater cardiovascular risk. In a qualitative study among cancer patients, Leydon and colleagues reported that additional information sometimes may exacerbate fear, undermine patients' hopes, and lead to more worry.14 Clearly, more research must be conducted to better understand the correlation between patient-clinician communication and disease-related outcomes.
One important effect of patient-clinician communication that requires further exploration is patient-reported outcomes related to cancer diagnosis and treatment. Patient-reported outcomes broadly encompass a diversity of measures that examine the impact of disease on patients' lives, including health-related quality of life, functional status, symptom status, overall well being, satisfaction with care, and treatment adherence.15 Patient-reported outcomes can be defined as any aspect of a patient's health status that comes directly from the individual patient with no modification or interpretation by any another observer.16 There are 3 possible correlations between patient-clinician engagement and self-reported outcomes in cancer patients. One possible effect of enhanced patient-clinician engagement is an improvement in patients' experience of cancer-related problems, perhaps because clinicians can help cancer patients and their caregivers anticipate, identify, and better manage issues such as physical symptoms and anxiety. For instance, an experiment revealed that the routine collection and use of health-related quality of life data from patients led to better subsequent quality of life and emotional functioning.17 Another possible effect is that more engagement with clinicians could lead patients to be more likely to report having symptoms. An example of this was a study in which the use of patient-reported quality of life assessments during visits led to a greater percentage of patients identifying moderate to severe problems in various health domains.18 This may be because increased engagement exacerbates patients' underlying concerns about experiencing postdiagnosis problems, as illustrated by a study in which it was observed that anxiety can be exacerbated through medical discussions.12 The third possibility is that there may be no correlation at all between patient-clinician engagement and patients' experience of cancer-related problems. In the current study, we examined the correlation between PCIE and self-reported problems related to cancer diagnosis and treatment in a population-based sample of patients with breast, prostate, or colorectal cancers.
- Top of page
- MATERIALS AND METHODS
- CONFLICT OF INTEREST DISCLOSURES
The demographic profile of the sample population approximately matched the profile of the general population of patients in Pennsylvania with the 3 cancers (colorectal, breast, and prostate cancer). The mean age of the sample population was approximately 65 years, 51% of patients were women, almost half had some college education and higher, and most were white. The mean number of cancer-related problems at baseline was 2.5 of a maximum possible score of 9 compared with the mean at Round 2, which was slightly lower at 2.1. Table 1 describes other important characteristics of the sample.
Table 1. Sample Characteristics (N=1293)
|PCIE||0.1±0.0|| ||0.0±0.0|| |
|Baseline cancer-related problem index||2.5±0.1|| ||2.3±0.1|| |
|Follow-up cancer-related problem index||2.1±0.6|| ||1.9±0.6|| |
|Age, y||65.5±0.3|| ||67.8±0.5|| |
|Women|| ||51.4|| ||51.2|
|Education|| || || || |
| ≤High school|| ||52.4|| ||51.7|
| ≥Some college|| ||47.6|| ||48.3|
|Race/ethnicity|| || || || |
| White|| ||86.2|| ||88.1|
| Black|| ||10.4|| ||8.4|
| Hispanic or other|| ||3.4|| ||3.4|
|Worry at diagnosis||3.73±0.05|| ||3.60±0.05|| |
|Nonmedical seeking||0.1±0.0|| ||0.0±0.0|| |
|Cancer type|| || || || |
| Colon|| ||31.9|| ||31.5|
| Breast|| ||34.8|| ||35|
| Prostate|| ||33.3|| ||33.5|
|Cancer stage|| || || || |
| 0|| ||9|| ||12.2|
| I|| ||20.2|| ||19.6|
| II|| ||44.7|| ||46.6|
| III|| ||13|| ||12.1|
| IV|| ||13.2|| ||9.5|
|Treatment received|| || || || |
| Surgery|| ||73.3|| ||72.7|
| Radiation therapy|| ||48.4|| ||49.3|
| Systemic therapy|| ||56.5|| ||51.7|
|Health status||3.2±0.0|| ||3.2±0.0|| |
|Frequency of physician visits||3.6±0.0|| ||3.5±0.0|| |
|Cancer experience||3.6±0.0|| ||3.7±0.0|| |
|Informed of metastatic disease|| ||14.3|| ||11.7|
The correlations between PCIE and cancer-related problems at Round 1 and Round 2 are displayed in Table 2. These correlations were highly significant for all bivariate associations between these variables. The correlation between the problem indices in Rounds 1 and 2 were strong, whereas the correlations between these variables and PCIE were medium based on the Cohen criteria.25
Table 2. Weighted Pearson Correlations Between Patient-Clinician Information Engagement and Round 1 and Round 2 Cancer-Related Problem Indices
|Variable||Round 1 Cancer-Related Problem Index||Round 2 Cancer-Related Problem Index|
|Round 1 cancer-related problem index||—||0.67a|
Table 3 provides the results from the regression models that were used to predict cancer-related problems at Round 2. Model 1 indicates that higher PCIE and more problems at Round 1 were associated with more problems at Round 2. Controlling for potential confounders in Model 2, the coefficients of PCIE and cancer-related problems at Round 1 were slightly diminished but remained statistically significant. This indicates that increased PCIE was associated with higher levels of cancer-related problems at Round 2 over and above the predicted effect of the presence of problems at baseline. Model 3 indicates a significant positive interaction between PCIE and baseline cancer-related problems. This suggests that the magnitude of effects of PCIE on patients' experience of cancer-related problems at Round 2 was contingent on the level of problems experienced in Round 1.
Table 3. Weighted Ordinary-Least-Squares Regression Analyses Predicting Round 2 Cancer-Related Problem Indexa
| ||Model 1||Model 2||Model 3|
|Round 1 cancer-related problem index||0.63d||0.02||0.56d||0.03||0.54d||0.03|
|Interaction of PCIE and Round 1 cancer-related problem index|| || || || ||0.11b||0.04|
Figure 1 displays the effects of the interaction between PCIE and cancer-related problems in Round 1 based on the coefficients from the final regression model at various levels for each variable (1 standard deviation above and below their respective means). Among the respondents who had low levels of cancer-related problems at baseline, increasing levels of PCIE were not associated with appreciable changes in the Round 2 problem index. In comparison, for respondents who had more problems at baseline, increased PCIE was associated with more cancer-related problems at follow-up.
Figure 1. The predicted Round 2 cancer-related problem index is illustrated with various levels of patient-clinician information engagement (PCIE) along with the Round 1 cancer-related problem index. Note that the predicted values were based on weighted regression coefficients from Model 3 adjusting for all control variables at their respective mean values. SD indicates standard deviation.
Download figure to PowerPoint
- Top of page
- MATERIALS AND METHODS
- CONFLICT OF INTEREST DISCLOSURES
In this study, we observed that, as patients discussed with and sought information at baseline from their physicians and other health professionals about their cancer treatment, quality of life, and other cancer-related issues, there was a tendency for patients to report experiencing more cancer-related issues the following year. This correlation was stronger among patients who had reported more cancer-related issues at baseline. On the surface, these are discouraging results—why would talking to one's physician lead to worse patient-reported outcomes? There are 3 possible reasons proposed here: increased salience, the quality or content of the discussion, and a false sense of security.
One plausible reason is that conversation with physicians leads to higher awareness of the various possible cancer-related issues a patient may experience, which may lead to more reporting of issues but not the actual experience of them. Discussing cancer-related symptoms with the physician may establish them as medical concerns worthy of attention and reporting, and the heightened awareness could lead to a lower threshold for labeling a particular issue as a problem. Although the survey items attempted to capture actual experience rather than awareness of or susceptibility to issues related to their cancer diagnoses and treatment, more objective measures of cancer-related problems and refined measures of patients' subjective perceptions of these problems would help to determine whether salience was responsible for our current findings.
Second, the measure that we used in this study was a measure of quantity rather than quality or content of the information engagement. Unclear or unsatisfactory communication can lead to worse patient-reported outcomes.26, 27 It is possible that patients who had more trouble communicating with their physicians engaged in more of it. Although quality-of-life information was included in the PCIE measure, the nature of discussions between patients and oncologists tends to focus on symptoms and treatment and less on psychological, social, and spiritual concerns,28 which also may affect patients' ability to cope with the latter concerns. However, this explanation seems to be at odds with another set of findings from the same dataset, which demonstrated that PCIE increased the feeling of being informed as well as treatment decision satisfaction.10 Without a clearer picture of the nature of the patient-clinician discussions, levels of health literacy, and patients' perceptions of the discussion within this population, it is not possible to conclude that more PCIE, regardless of its content, leads to increased experiences of cancer-related problems.
Third, more PCIE may have led to greater experience of problems through a false sense of security. Patients who talk more with their physicians may be less concerned about the problems they will face and, thus, may act less vigilantly in their self-care. This explanation may hold especially true for those patients who had more cancer-related issues at baseline, and it is consistent with the results from the interaction term tested here. These potential causal mechanisms should be tested in future studies.
The current study offers several improvements to the existing literature regarding patient-clinician communication and patient-reported outcomes: specifically, physical and psychosocial issues related to a patient's cancer diagnosis and treatment. First, it uses a representative population-based sample of patients who were diagnosed with 3 of the most prevalent cancers in Pennsylvania, as opposed to studies that typically involve convenience samples of patients in individual oncology clinics. Second, because this study was based on a longitudinal analysis, we were able to make more confident inferences about the causal direction between PCIE and cancer-related problems while controlling for potential confounders, in contrast to studies that examine cross- sectional associations. Finally, the probability sample weighting allowed for the extrapolation of findings at least to the sampling frame of cancer patients in Pennsylvania.
There are several limitations with the current study. First, the sample was composed of Pennsylvanian patients with breast, prostate, or colorectal cancers, and the results may not be generalizable to other patient populations in terms of disease or geographic location. Research among other patients should be conducted to determine whether these findings can be replicated. Second, the PCIE measure that we used captured only the extent to which patient information engagement took place for various cancer-related topics with their physician. It is possible that other measures of patient-clinician communication, such as levels of understanding and rapport, the content discussed, and the clinician's perceptions, could yield different results. Future research should incorporate the nature of the patient-physician communication from such measures. Third, the index of cancer-related problems in the current study was used to assess the self-reported presence or absence of a limited set of health and lifestyle issues. The severity and the extent to which these symptoms impacted patients' well being and lifestyles were not measured. Other dimensions of quality-of-life issues also were not measured. Therefore, additional research using patient-reported outcome measures that include other important dimensions or measures of impact on patients' well being is recommended. Fourth, there may be other potential unmeasured confounders related to the clinical status of patients at baseline. For instance, patients with baseline problems that were severe, difficult to treat or reverse, or progressed over time may be more likely to report increased PCIE and experiencing 1 of the 9 cancer-related problems at follow-up over and above their tendency to experience them during the first year after diagnosis. Although this analysis did control for certain measures of patients' clinical status at baseline (for example, stage, health status, frequency of physician visits, and subjective cancer experience), the presence and severity of problems that were difficult to resolve may not have been captured in these measured variables.
However, despite these limitations, the current study calls into question the seemingly intuitive positive effects of promoting greater patient-clinician communication in the care of cancer patients. It demonstrates that we cannot rely on the conventional wisdom that more patient engagement with physicians will lead to better long-term health outcomes, and it highlights the need to further examine the underlying causal pathways and the role of moderating factors.