Communication preferences and perceptions of cancer patient during their first medical oncology appointment

The first medical oncology appointment serves as a platform for patients to comprehend their diagnosis and prognostic implications of cancer. This study aimed to determine patients' communication preferences during their first medical oncology appointment and to assess the disparities between patients' preferences and perceptions.


| INTRODUCTION
Effective communication involving the physician, patient, and family is crucial for meeting patient needs and providing safe, high-quality, and patient-centred care. 1 Communication plays a role in regulating patients' emotions, facilitating comprehension of information, and identifying patients' perceptions and expectations. 2 the oncological setting, patients are thrust into a whirlwind of diagnostic tests, invasive procedures and complex treatments, leaving them with little opportunity to process their circumstances. 3ysical, emotional, social, and financial concerns are expected to impact individuals and their families.Indeed, discussions about patients' losses and suffering can be particularly challenging, given the number of potentially unfavourable events over time. 4Physicians often struggle to determine how much information to disclose to the patient and acknowledge a lack of expertise in delivering bad news. 57][8] The bad news perception correlates with patients' stress and anxiety levels, their ability to manage adverse information, their satisfaction with care, and their adjustment to health outcomes. 9,10Inadequate doctor-patient communication skills can lead to psychological distress, including heightened anxiety and depression, and hinder effective psychological adaptation to cancer. 113][14] For the disclosure of negative information to cancer patients about their condition, the SPIKES protocol was outlined by Baile et al. 13 This acronym denotes (i) Setting up the interview, (ii) assessing the patient's Perception, (iii) obtaining the patient's Invitation, (iv) providing Knowledge and information to the patient, (v) addressing the patient's Emotions, and (vi) Strategy and Summary. 13mited evidence exists regarding adherence to these tools and the impact of their use on patients' satisfaction.Furthermore, evidence suggests differences between doctors' and patients' preferences regarding delivering bad news. 9veral studies have aimed to deepen our understanding and evaluate, from the patient's perspective, the communication process required when receiving bad news.The Measure of Patients' Preferences questionnaire (MPP) was developed to assess patient preferences regarding Content, Facilitation, and Support. 4 The Marburg questionnaire applied the Breaking Bad News Scale, incorporating questions aligned with the six dimensions of the SPIKES protocol. 9In this study, only a minority of the interviewed cancer patients expressed satisfaction with the communication process.The SPIKES protocol did not fully address all the needs of the study population, resulting in a disparity between the information delivered and how it was conveyed, as well as patient preferences. 9yond the delivery of the diagnosis, the first medical oncology appointment represents a pivotal moment in the trajectory of the oncological disease.Typically, it is a stressful occasion during which the diagnosis and prognosis are discussed or confirmed.Many patients already possess their diagnosis but lack further information regarding the implications of cancer on their lives.Therapeutic strategies, potential side effects, and short-and long-term complications can also be addressed.Furber et al. examined how patients perceived their initial oncology consultation and how the emotional context could impact their informational requirements. 15Their findings revealed that patients' emotions and anxieties might curtail their inclination to seek more information to obviate distress.Additionally, age, sex, education, and cultural background have influenced communication preferences and truth-telling practices. 4,9,16cial support is important in addressing psychological challenges like anxiety and depression, both prevalent among cancer patients. 17It could be pertinent to identify patients at heightened risk due to psychosocial vulnerability stemming from inadequate social support.Additionally, comprehending how social factors can impact communication is crucial. 18 is essential to develop strategies to gather information and meet patients' needs according to their perspective on the first medical oncology appointment.This approach not only aids in mitigating the challenges of the appointment itself but also contributes to enhanced medical care outcomes and knowledge generation. 15is study aimed to evaluate patients' communication preferences during their first medical oncology appointment.It also assessed patients' perceptions regarding the communication elements present in their first encounter with an oncology appointment.
Additionally, it identified disparities between patients' reported perceptions and preferences in this context.

| Participants
A comprehensive survey was conducted on 169 outpatients from the Medical Oncology Department of Hospital Professor Doutor Fernando Fonseca (HFF), Portugal.All patients were 18 years or older and had received a cancer diagnosis (whether newly diagnosed, facing relapse, or experiencing disease progression).Moreover, all participants were proficient in the Portuguese language and capable of providing written informed consent.Exclusion criteria included patients with dementia or cognitive impairment. -170

| Instruments
Demographical variables such as age, sex, marital status, country of origin, qualifications and occupation were collected.Furthermore, the study encompassed the following clinical variables: tumour location, disease status, intended treatment approach, and the duration from diagnosis to the first appointment.The Hospital Anxiety and Depression Scale (HADS) was used to assess psychological morbidity and as a screening tool for anxiety and depression.It includes two subscales that individually measure depression and anxiety, each comprising 7 items rated on a 4-point severity scale. 19e Social Support Questionnaire-Short Form (SSQ6) is a 6-item measure of social support.Each item poses a question that elicits a two-part response: Part 1 asks participants to indicate the number of individuals (ranging from 0 to 9) available for support in specific circumstances, and Part 2 asks participants to rate their satisfaction (ranging from 0 "not satisfied" to 9 "fully satisfied") with these individuals.The SSQ6N indicates the perceived support index available, while the SS6QS represents the satisfaction index concerning that support. 20

| Procedure
A cross-sectional study was designed.Starting from 20th January to 20 November 2022, the research team documented all incoming requests for new medical oncology appointments.After the first appointment, the research team engaged with patients and assessed their eligibility.During this process, the researchers maintained no involvement in the patients' care.The questionnaire was delivered to the patients for completion in their homes, with a stipulated return timeframe of 3 weeks.
The Research Ethics Committee of HFF approved this study (002/2022).

| Statistical analysis
A descriptive analysis was conducted to describe the demographic and medical characteristics of the sample.A repeated measure t-test was conducted to compare the dimensions of Content, Facilitation, and Support.To compare patients' communication preferences with their perceptions during the first appointment, a paired sample t-test was carried out on the subset of items that garnered the highest ratings of "very important" above the median.An ANOVA test was used to assess differences in preferences according to sex, marital status, tumour location, disease status, treatment approach, country of origin, qualifications, occupation, and HADS scale.Pearson's correlation assessed potential associations among the three dimensions (Content, Facilitation, and Support) and variables such as age, duration from diagnosis to the first appointment, and SSQ6N and SSQ6S.All the statistical analyses were performed using the SPSS software version 27.

| RESULTS
A total of 191 questionnaires were distributed, and 169 (88.5%) were returned.Among these, 163 (96.4%) were either fully completed or had less than 10% missing answers.The remaining questionnaires had over 50% of the answers missing, rendering them unsuitable for analysis.The primary reason for non-return was the lack of psychological or emotional capacity required to complete the questionnaire.Depression and anxiety scores (assessed through HADS) and social support levels (assess through SSQ6) were measured through patient-reported outcomes.The findings show that 80.4% of the sampled individuals reported a depression score of eight or higher.
Over 50% of patients reported an anxiety score of eleven or higher, signifying the presence of severe anxiety symptoms.The averages of the two subscales SSQ6N and SSQ6S showed no statistically significant differences (p = 0.140).

| Patients' preferences concerning content, facilitation and support elements of communication
The C-FAQ items were predominantly assessed as "very important" Regarding Content, patients often rated as "very important" physicians' knowledge and honesty, along with receiving clear and comprehensible information about their condition and detailed insights into treatment options.
Within the Facilitation dimension, patients attributed the highest level of importance to the doctor's concern about the clarity and amount of information regarding cancer and treatments.Moreover, patients valued their involvement in treatment decisions and appreciated facilities such as a physical space tailored to their needs, as well as the convenience of posing questions before their next appointment.
In terms of Support, being understood and actively listened to, as well as having the doctor express concerns, were also regarded as highly important.However, fewer patients considered it "very important" to have other healthcare professionals present or to receive assistance in discussing cancer with others.

| Comparison of patients' communication preferences with perceptions
The findings in Table 3 show patients' preferences with the highest ratings alongside their perceptions during the initial medical oncology appointment.A paired-sample t-test was used to compare patients' communication preferences and perceptions.Eleven items showed significantly higher 'entirely' ratings on the preferences side.
Most of these items were related to the Content dimension (54.5%).

| Correlations between patients' preferences and demographic and medical variables
A significant and negative correlation was found between the 'time from diagnosis to first appointment' and the Support dimension (r = −0.

| DISCUSSION
This study assessed patients' perceptions of the communication elements related to Content, Facilitation, and Support dimensions that were present during their first medical oncology appointment.
Additionally, it aimed to investigate the differences between patients' perceptions and their preferences in this context.The findings indicated that the Content dimension was deemed the most important.
T A B L E 2 Percentage of responses regarding communication preferences relating to Content, Facilitation and Support.

Content
The doctor is up-to-date on research on my type of cancer 79.1 The doctor is honest about the severity of my condition 78.5 I am given information in simple, clear language 77.9 The doctor tells me the best treatment option 77.2 I feel confident about my doctor's skill 75.9 The doctor gives me as much information as possible about my cancer 74.8 I am given detailed information about the results of medical tests 74.6 The doctor explains the impact of treatment options on my daily life 73.5 The doctor talks clearly about the course of my oncological disease, according to the information he or she has 72.8 The doctor lets me know all the different treatment options 70.6

Facilitation
The doctor asks me what I want to know about my cancer 72.8 The doctor makes sure I understand everything that is said 70.2 The space where the consultation takes place is suitable for my needs 68.1 The doctor lets me know how I can contact them to ask questions or to express my concerns before the next appointment 67.5 The doctor asks what I want to know about treatment options 66.7 The doctor gives me all the information in a logical order 66.3

Support
The doctor truly listens to me 69.9 The doctor tries to understand my concerns 69.6 The doctor expresses concern for me 69.6 I can have a companion at the consultation 66.3 Note: This table only included the items ranked as "very important" above the median in terms of preferences.

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- Although both the Facilitation and Support dimensions were ranked lower, patients still considered them important, warranting thorough consideration.

| Patient's preferences regarding the content dimension
The physician's knowledge, honesty, and the provision of clear information about cancer and treatment were the most significant areas.Before the first consultation, patients lack a comprehensive understanding of their diagnosis, which explains their eagerness for information.Acquiring appropriate initial information also facilitates better adjustment of expectations throughout the trajectory of the disease. 15In a 60-item questionnaire assessing the importance and satisfaction with care, the quality of medical care and the technical competence of clinicians were reported as the greatest importance to cancer patients. 21Our findings are consistent with other studies where physicians' knowledge, clarity, and willingness to discuss treatment were deemed highly important by patients. 4,22,23

| Patient's preferences regarding the facilitation dimension
Significant results were observed for C-FAQ items related to the patient's preference to be asked by a doctor about what they wish to know about cancer and to have the assurance that they comprehend the information.Patients value the opportunity to influence the amount of information shared, which supports their sense of empowerment. 24otional status and subsequent fear of receiving negative news can influence the perception of medical terminology.Hence, the validation of comprehension is crucial, as indicated by our results.The preference for a consultation environment tailored to the patient's needs emphasises the necessity of specific conditions for effective information assimilation.The absence of these facilitation elements in other studies resulted in a less favourable communication experience. 4,22,23A B L E 3 Comparison of highest-rated patients' communication preferences with perceptions in the first medical oncology appointment.

Preferences Perception t (160) p Cohens' d M (SD) M (SD)
The doctor is up-to-date on research on my type of cancer (C) Note: A paired sample t-test was used to compare patients' communication preferences with perceptions.This analysis only included the items ranked as "very important" above the median regarding preferences.

| Patient's preferences regarding the support dimension
Patients valued the empathy demonstrated by doctors when they displayed concern for patients' emotions and attentively listened to them.Conversely, items concerning interactions with individuals beyond the doctor-patient relationship were rated as "very important" by fewer than 30% of participants.It is likely that if patients feel satisfied with the support provided by their doctor, they may not attribute as much importance to the presence of other professionals.
Additionally, patients might prefer to initially receive and understand all information privately, rather than share it immediately.
Patients with a longer duration between diagnosis and their first consultation expressed less preference for Support.This finding could be explained by the establishment of their support network, assimilation and adjustment to the information, clarifications provided by other healthcare practitioners, and the emotional regulation developed during this period. 25,26

| Patients' preferences versus perceptions
When comparing the 20 highest-rated preferences with the perceptions of their first oncology appointment, there were 11 items where perceptions were rated lower than the preferences, revealing significant discrepancies.This suggests that certain patient preferences are not being fulfilled in clinical practice, highlighting an opportunity to improve communication during the first appointment.
All aspects of communication were highly valued, irrespective of patient age, sex, marital status, tumour location, disease status, country of origin, qualifications, occupation or treatment approach.The results concerning anxiety and depression suggest that patients are distressed due to the diagnosis they are facing.More than 50% of participants reported severe anxiety symptoms, and 80.4% reported a depression score of eight or higher.Although no significant differences were found between the HADS subscales outcomes and the three communication dimensions, empathetic patient-centred care might influence patients' psychological well-being, potentially reducing their anxiety and fostering greater trust in their oncologist. 27ving social support networks in oncology is vital for managing crises and aiding patient's physical and psychological adjustment. 18wever, no significant correlations were observed between social support and communication preferences.To validate these findings, it would be important to conduct this study across various centres.

| Study limitations
This study included patients with diverse types of cancers, disease stages, treatment settings, and backgrounds.Our findings may capture the preferences of a wide spectrum of patients.Conducting a multicentric study could enhance the robustness of the results and validate their applicability across different contexts.The elevated presence of anxiety and depression might be linked to participant's reduced emotional capacity for completing the questionnaire, potentially explaining why 11.5% of participants did not return the questionnaires.
An extension of the current study could involve investigating potential variations in individual patient preferences over time.
Recording the consultation could enable a supplementary analysis and introduce insights from physicians.Future studies might also explore the possibility of separately assessing perceptions and preferences and determine whether such an approach influences the outcomes.

| Clinical implications
Understanding patients' communication preferences allows physicians to be more aware and responsive to patients' needs during a vulnerable period of their lives.There should be ongoing discussions about communication strategies, leading to the development of guidelines tailored to this context.Topics such as informing patients about the practical impact of cancer on daily life and determining their informational needs regarding treatment options could be integrated, as these expectations often go unaddressed.The promotion of communication skills training programs for healthcare teams is essential.
Given the substantial number of patients experiencing symptoms of anxiety and depression, identifying signs of pathological distress or depression becomes crucial.This recognition would enable early referrals for psychological assessment and appropriate follow-up care.

| CONCLUSIONS
VICENTE ET AL.
The C-FAQ (Communication in first oncology appointment questionnaire) was developed within this study to assess patients' communication preferences and perceptions during the first medical oncology appointment.The questionnaire comprises two sections.The first section includes 49 items to assess patients' preferences concerning a range of doctor-patient communication elements, which are derived from the MPP and Marburg Breaking Bad News Scale.The subsequent section includes 40 items, identical to those in the first part, designed to assess patients' perception of the communication elements present during their initial appointment.Participants rated items in both sections using a Likert scale ranging from 0 ('not at all') to 4 ('entirely').The items in both sections were categorised according toParker et al. (2001) into Content (the information provided and its extent; α = 0.93), Facilitation (contextual variables and setting; α = 0.92), and Support (emotional support during the interaction; α = 0.85).

Table 1
presents the demographic and medical characteristics of the participants.Participants' ages ranged from 22 to 88 years, averaging 64.5 years (SD = 12.10).The most prevalent diagnoses included gastrointestinal cancer, breast cancer, lung cancer, or other thoracic tumours.Among all patients, 89.6% received a recent cancer diagnosis.The average duration since diagnosis was 7.3 months (SD = 23.10), with 70.6% of diagnoses occurring within 3 months before their first appointment.
Patients' preferences concerning Content, Facilitation, and Support dimensions of communication were highly valued, with a greater emphasis on Content in patient preferences.Discrepancies between communication preferences and perceptions should be viewed as opportunities to enhance training in communication skills for healthcare teams, enabling them to address patient needs.Further research is needed to explore the complexities of the doctor-patient relationship and how patients' communication needs can be effectively satisfied.