Medscape Oncology
Can the Oncologist's Attitude Affect Patient Outcomes?
Alice Goodman; William Pirl, MD, MPH Disclosures June 22, 2015
Editor's Note:
Over the past decade, much has been written about end-of-life care and about delivering bad news to cancer patients. Some of these articles and materials are written for patients and their families, while others are aimed at helping oncologists perform the difficult task of communicating with patients who have exhausted all treatment options and are facing death.
The interaction between oncologists' emotions and patients' emotions, however, is a neglected area of research, possibly because it is hard to quantify such interactions. Recently, some researchers have become interested in how oncologists and patients interact and how emotional cues influence that interaction.
At the recent 2015 annual meeting of the American Society of Clinical Oncology, investigators from Massachusetts reported on a study examining the association between oncologists' dispositional affect—their emotions and the manner in which they respond to a situation—and patients' symptoms of depression.[1] Medscape spoke with lead author William Pirl, MD, MPH, attending psychiatrist and director of psychiatric oncology at Massachusetts General Hospital, Boston, Massachusetts, about the study, what brought it about, and the dynamics of the oncologist-patient interaction.
Medscape: How did you become interested in the oncologist-patient interaction?
Oncologists and patients read each other's emotional cues in every encounter, and the emotions of one may impact the other.
Dr Pirl: One area of interest for me has been end-of-life conversations between oncologists, patients, and their families. There is scant literature about the emotional aspects of initiating discussions about stopping therapy as well as the interactions between doctors' and patients' emotions around that time.
I am interested in studying how oncologists' emotions affect the care they deliver to patients, the patient's experience of oncologist-patient encounters, and how these interactions affect medical decisions. Oncologists and patients read each other's emotional cues in every encounter, and the emotions of one may impact the other.
During a fellowship at the Radcliffe Institute, I had discussions with Jennifer Lerner, a leader in the field of how emotions affect decisions (mainly in economic areas). We identified a mutual interest in studying how oncologists' emotions affect patients and how patients' emotions affect oncologists.
One of our studies showed that increased psychological distress in patients at early-stage disease was associated with receiving more chemotherapy at the end of life.[2] This finding was the opposite of what we expected. I had assumed that patients who were distressed would receive less end-of-life care.
This study suggested that the interaction between the oncologist and the patient was more complicated than we had assumed. This led to our interest in the interaction between oncologists' mood and patients' mood. We hypothesized that in a high-emotion setting, such as metastatic cancer, oncologists' mood and patients' mood would affect medical decisions.
Medscape: Is there any published evidence about the oncologist-patient emotional interaction?
Dr Pirl: Very little has been published about this. Much of the emphasis has been on communication, not on the emotions behind the words.
A recent study tested an online intervention developed by a multidisciplinary team that is aimed at teaching patients strategies for expressing their emotional concerns to their providers and asking for support. This was a pilot study, and the intervention is now being evaluated in a randomized clinical trial.[3]
The goal of our study was to understand how the oncologist's dispositional affect—the range of feelings oncologists could experience in a given setting—might influence the care they deliver to patients, both at the end of life and early in the course of treatment. We wanted to determine whether there is a correlation between the oncologist's mood and the patient's mood.
Oncologist's Manner Affects the Patient, but to What Degree?
Medscape: Explain the study method and what you found.
Dr Pirl: Our study involved over 300 patients and 17 oncologists. As part of an ongoing trial of early palliative care, patients were assessed for depressive symptoms (using the Patient Health Questionnaire-9, PHQ9) within 8 weeks of diagnosis with metastatic cancers. Oncologists providing care for these patients completed the Positive and Negative Affect Scale (PANAS),[4] a validated measure of dispositional affect with positive and negative dimensions. Oncologists' negative affect was assessed by measuring feelings that included distressed, upset, guilty, scared, hostile, irritable, ashamed, nervous, jittery, and afraid.
Associations between patient depressive symptoms and positive and negative dispositional affect were tested with rank-sum tests and multivariate linear regressions. We found an association between the negative feelings that oncologists can have and depression in patients with newly diagnosed metastatic lung and gastrointestinal cancer. Although we found an association, we were not able to determine the directionality of this effect—that is, whether the oncologists' feelings led to the patients' depression or vice versa. We don't know from this study whether taking care of cancer patients makes oncologists depressed or whether patients' depressive mood affects oncologists.
An oncologist's affect may lead to a patient's depressive symptoms.
We found no association between oncologists' positive affect (as measured by feelings such as interested, excited, strong, enthusiastic, proud, alert, inspired, determined, attentive, active) and patients' depressive symptoms.
This study gives empiric evidence that oncologists' affect might influence patients on a clinical level. An oncologist's affect may lead to a patient's depressive symptoms.
Medscape: What is the next step in your research?
Dr Pirl: We want to explore whether oncologists' emotions are associated with patient outcomes and to demonstrate that oncologists' feelings can affect patient outcomes. If we can show this, it will bring more attention and awareness to the potential negative consequences for oncologists and patients.
Communication vs Disconnect
Medscape: Let's talk about the oncologist-patient interaction in a more general way. In your years of working with patients, what have you learned from them about the oncologist-patient interaction?
Dr Pirl: Patients are highly attuned to emotional cues related to the way the oncologist is acting: tone of voice, body language, facial expression. Patients interpret those cues as meaningful information about their own prognosis and treatment. In other words, if a doctor looks worried, that could mean the cancer is out of control. If the doctor comes into the room while the patient is waiting for test results and he is not smiling, the patient might interpret this as bad news.
Medscape: Is there ever a disconnect between the oncologist's and the patient's experience of an encounter?
Dr Pirl: Yes. This happens all the time. I have at times been surprised by the disconnect. I've seen both extremes: overinterpretation of what the oncologist said or not picking up on what the oncologist said.A patient may say, "The oncologist never told me my cancer was serious," while the oncologist has documented a discussion about the incurable nature of the cancer and the goal of therapy being to prolong life.
Or the oncologist may believe that a visit went well, but the patient views the oncologist as mean because he or she delivered bad news. A recent study showed that when bad news is delivered, patients view the oncologist as uncompassionate.[5] I've had patients say, "This doctor was so condescending. He told me I was going to die and walked out of the room." Yet, the oncologist reports a different scenario.
Medscape: Are there certain phases of treatment when emotions run high?
Dr Pirl: Times of uncertainty are difficult emotionally. These include when changes in treatment are needed, when a patient wants more information (about treatment or recurrence), and when treatment is ending and the patient is fearful about what comes next. When a patient needs something from an oncologist, the oncologist's attitude may affect the patient. These times are highly stressful for oncologists too.
One of the best things you can do for patients is to listen to their concerns.
Medscape: What are some important lessons for oncologists?
Dr Pirl: It is important to give a patient the sense that you are listening and fully focused on the patient during the encounter, even if it is brief. Make the patient feel seen and heard. At the end of the discussion, be aware of your body language. Consider leaning back in your chair and appearing relaxed while you ask whether the patient has any questions, implying that you are receptive and not rushed. Looking at a computer while talking to a patient gives the opposite impression.
In the metastatic setting, emotions may be ratcheted up. One of the best things you can do for patients is to listen to their concerns.
Medscape: What about the effect of patients' emotions on the oncologist?
Dr Pirl: The patient-oncologist interaction is clearly not a one-way street. Doctors are human. They are not robots without emotion. If a patient is angry or irritable, that can affect the oncologist and the interaction.
I would emphasize to oncologists that they need to be attuned to their feelings. If their feelings are negative, they should take a step back and think about how those feelings affect patients and how the patients' emotions affect them. Attitudes such as anger, condescension, and irritability can compromise a positive interaction.
There is a whole literature on burnout among oncologists, in part from the emotional strain of caring for cancer patients.[6] It is not surprising that there is a high rate of burnout among oncologists, but as yet, this has not been shown to affect patient outcomes. We need to determine whether burnout affects patient care and whether the effect is bi-directional. It would be valuable to develop strategies to help oncologists overcome burnout and distress.
martes, 23 de junio de 2015
www.cancer.net/blog
Inform Your Patients About Common Cancer Myths
By ASCO
June 10, 2015, Volume 6, Issue 10
Misinformation is everywhere. Direct your patients to visit www.cancer.net/blog to learn what is science fact and what is science fiction in this blog post on nine common cancer myths. Also, order ASCO Answers Fact Sheet—Myths and Facts About Cancer for your practice at www.cancer.net/estore.■
By ASCO
June 10, 2015, Volume 6, Issue 10
Misinformation is everywhere. Direct your patients to visit www.cancer.net/blog to learn what is science fact and what is science fiction in this blog post on nine common cancer myths. Also, order ASCO Answers Fact Sheet—Myths and Facts About Cancer for your practice at www.cancer.net/estore.■
Intraperitoneal Treatment in Advanced Ovarian Cancer
What Is the Future of Intraperitoneal Treatment in Advanced Ovarian Cancer?
By Robert L. Coleman, MD
June 10, 2015, Volume 6, Issue 10
Continuous interrogation into the biology of ovarian cancer and its microenvironment may hold new avenues of clinical investigation for intraperitoneal treatment.
—Robert L. Coleman, MD
An analysis of Gynecologic Oncology Group (GOG) studies recently reported in the Journal of Clinical Oncology by Tewari and colleagues and reviewed in this issue of The ASCO Post showed a survival benefit of intraperitoneal chemotherapy vs intravenous chemotherapy over long-term follow-up in women with advanced ovarian cancer.1 The findings add to the ongoing conversation on the fate of intraperitoneal treatment in this setting.
A ‘Trifecta’ of Sorts
The publication of GOG-172 in 2006 completed an intraperitoneal chemotherapy “trifecta” of sorts in demonstrating its utility as primary adjuvant therapy in women with advanced-stage ovarian cancer.2-4 Although at the time of its publication, there had been eight prospective clinical trials of intraperitoneal therapy, the three from GOG/Southwest Oncology Group (SWOG) represented the largest, with the strongest treatment effects.5 Concomitant with this latter trial’s publication came a National Cancer Institute (NCI) clinical announcement on January 4, 2006, stating that intraperitoneal therapy was “encouraged…after surgery, for women with advanced ovarian cancer.”
However, long before this landmark publication and rare NCI media release, presentations and debates at national and international conferences discussing the implications of each of these three studies (GOG-104/SWOG-8501, GOG-114, and GOG-172) had already tainted the touted benefit as bittersweet, citing excessive toxicity of the regimen, poorer patient-reported outcomes, catheter complications, and physician and patient inconvenience among the oncology community.6,7
It was noteworthy, and in some respects affirming, that the NCI announcement did not endorse a specific intraperitoneal regimen, despite heralding the results of GOG-172. This is likely due to the unique designs, endpoints, and findings of the three trials, not the least of which was that each evaluated a different intraperitoneal experimental arm. Since GOG-114 and GOG-172 compared intraperitoneal therapy with a common intravenous regimen (24-hour paclitaxel on day 1 followed by cisplatin on day 2) in a relatively contemporary ovarian cancer population, Tewari and colleagues combined the data sets and performed a long-term follow-up analysis.
As expected in this setting, the combined analysis (now with 10-year follow-up) of two individually “positive” trials was a “positive” evaluation—notably, there was an impressive 23% adjusted reduced risk of death for patients treated with intraperitoneal vs intravenous therapy. This amounted to an approximate 10.4-month survival advantage at the median between the two modalities of delivery. Few trials before or since have documented this kind of impact among this patient cohort. Progression-free survival was similarly and consistently “positive” in this analysis.
However, one of the acknowledged difficulties with intraperitoneal therapy is inconsistent delivery success throughout the intent-to-treat interval after surgery. In GOG-104, GOG-114, and GOG-172, only 58%, 71%, and 42% of intraperitoneal patients, respectively, received all six cycles of intended therapy via that route.
Although these data were/are alarming for any modality in front-line therapy, they grossly underestimated the difficulty of extrapolation to a broader medical community, particularly those outside the experienced investigators, nurses, and support staff of the cooperative group sites. Thus, it is not surprising that many clinicians considering intraperitoneal therapy as a practice standard never embraced the data and that some brave enough to try experienced significant challenges—particularly in adoption of GOG-172’s multiday/weekly strategy.
Criticisms Temper Clinical Adoption
One of the many criticisms of the “trifecta” was choice of the control arm in each of the studies. GOG-104, published the same year as GOG-111, which introduced paclitaxel in the front-line setting to poorer-prognosis patients, lacked this new agent. GOG-114 and GOG-172 used 24-hour infusion of paclitaxel and cisplatin (day 2). However, data from GOG-158, featuring paclitaxel (3-hour infusion) with carboplatin (area under the curve = 7.5) compared with the same intravenous control arm used in GOG-172, were already known and a community standard.
In addition, cross-trial evaluation (albeit statistically invalid) of the control arm in GOG-172 vs the experimental arm in GOG-158 implied “underperformance” of GOG-172’s control arm. Furthermore, at the time of GOG-172’s publication, intense interest was focused on bevacizumab (Avastin), which was serving in experimental arms of new GOG and international front-line phase III trials.8,9 This, along with an extremely provocative dose-dense, dose-intense intravenous paclitaxel phase III study by the Japanese GOG demonstrating similar efficacy results on overall survival, tempered clinical adoption of intraperitoneal therapy.10
New Light on Its Potential
Nevertheless, a series of reports like the current article by Tewari et al have cast new light on the potential for intraperitoneal therapy. First is the significant improvement in surgical standards for primary cytoreduction. At the time of initial reports on intraperitoneal therapy, the rate of complete surgical cytoreduction (R0) was 10% to 25%; R0 rates have now doubled, largely due to more aggressive surgery and advanced surgical training, globally, of gynecologic oncologists.11 Several reports, including the Tewari et al analysis, have suggested that the R0 cohort represents the subgroup most likely to benefit from intraperitoneal therapy.
Second, improvements in supportive care and alterations in the dosing/infusion schedules of the agents have dramatically improved the proportion of patients completing all six cycles of intended intraperitoneal chemotherapy.12 Although it remains a risk that alterations in dosing/schedule could impact survival efficacy, this may be countered by the ability to complete all therapy via intraperitoneal administration.
Third, understanding genomic alterations in the tumor may further clarify who should be given intraperitoneal therapy. Recently, an analysis of somatic loss of BRCA1 in patients participating in GOG-172 demonstrated a profound effect on overall survival.13 In this analysis of 393 patients (94% of GOG-172 participants), somatic loss of BRCA1 was observed in 48%. Among this cohort, the median overall survival for intraperitoneal vs intravenous therapy was 84 vs 47 months (P = .0002), amounting to a 33% reduction in the hazard for death. There was no difference between intraperitoneal and intravenous therapy among patients with normal expression of BRCA1.
Finally, histology may be important, as patients with serous cancer, the most prevalent subtype, appeared to benefit from intraperitoneal therapy, but only if six cycles could be administered.
Looking Ahead
The future of intraperitoneal therapy will likely undergo another transition, as the results of the GOG-252 (clinicaltrials.gov, NCT00951496), iPocc (NCT01506856), and NCIC-OV21 (NCT00993655) trials become available. In GOG-252, two different intraperitoneal infusion strategies are being evaluated in combination with bevacizumab against a contemporary control arm (paclitaxel, carboplatin, bevacizumab followed by bevacizumab maintenance).
The Japanese iPocc trial is comparing the same dose-dense, dose-intense paclitaxel intravenous arm as in its previous trial vs intraperitoneal carboplatin (same intravenous and intraperitoneal doses) but is allowing both optimal and suboptimal surgical cytoreduction patients to participate.
NCIC-OV21 is focusing exclusively on the neoadjuvant chemotherapy population, administering intravenous or one of two intraperitoneal regimens following interval debulking surgery planned after three to four induction cycles of intravenous platinum-based therapy.
Although each of these trials has the potential to solidify and/or broaden the potential audience for intraperitoneal therapy, they may also define it as a relic of early ovarian cancer clinical therapy. Nevertheless, continuous interrogation into the biology of ovarian cancer and its microenvironment may hold new avenues of clinical investigation for intraperitoneal treatment. ■
By Robert L. Coleman, MD
June 10, 2015, Volume 6, Issue 10
Continuous interrogation into the biology of ovarian cancer and its microenvironment may hold new avenues of clinical investigation for intraperitoneal treatment.
—Robert L. Coleman, MD
An analysis of Gynecologic Oncology Group (GOG) studies recently reported in the Journal of Clinical Oncology by Tewari and colleagues and reviewed in this issue of The ASCO Post showed a survival benefit of intraperitoneal chemotherapy vs intravenous chemotherapy over long-term follow-up in women with advanced ovarian cancer.1 The findings add to the ongoing conversation on the fate of intraperitoneal treatment in this setting.
A ‘Trifecta’ of Sorts
The publication of GOG-172 in 2006 completed an intraperitoneal chemotherapy “trifecta” of sorts in demonstrating its utility as primary adjuvant therapy in women with advanced-stage ovarian cancer.2-4 Although at the time of its publication, there had been eight prospective clinical trials of intraperitoneal therapy, the three from GOG/Southwest Oncology Group (SWOG) represented the largest, with the strongest treatment effects.5 Concomitant with this latter trial’s publication came a National Cancer Institute (NCI) clinical announcement on January 4, 2006, stating that intraperitoneal therapy was “encouraged…after surgery, for women with advanced ovarian cancer.”
However, long before this landmark publication and rare NCI media release, presentations and debates at national and international conferences discussing the implications of each of these three studies (GOG-104/SWOG-8501, GOG-114, and GOG-172) had already tainted the touted benefit as bittersweet, citing excessive toxicity of the regimen, poorer patient-reported outcomes, catheter complications, and physician and patient inconvenience among the oncology community.6,7
It was noteworthy, and in some respects affirming, that the NCI announcement did not endorse a specific intraperitoneal regimen, despite heralding the results of GOG-172. This is likely due to the unique designs, endpoints, and findings of the three trials, not the least of which was that each evaluated a different intraperitoneal experimental arm. Since GOG-114 and GOG-172 compared intraperitoneal therapy with a common intravenous regimen (24-hour paclitaxel on day 1 followed by cisplatin on day 2) in a relatively contemporary ovarian cancer population, Tewari and colleagues combined the data sets and performed a long-term follow-up analysis.
As expected in this setting, the combined analysis (now with 10-year follow-up) of two individually “positive” trials was a “positive” evaluation—notably, there was an impressive 23% adjusted reduced risk of death for patients treated with intraperitoneal vs intravenous therapy. This amounted to an approximate 10.4-month survival advantage at the median between the two modalities of delivery. Few trials before or since have documented this kind of impact among this patient cohort. Progression-free survival was similarly and consistently “positive” in this analysis.
However, one of the acknowledged difficulties with intraperitoneal therapy is inconsistent delivery success throughout the intent-to-treat interval after surgery. In GOG-104, GOG-114, and GOG-172, only 58%, 71%, and 42% of intraperitoneal patients, respectively, received all six cycles of intended therapy via that route.
Although these data were/are alarming for any modality in front-line therapy, they grossly underestimated the difficulty of extrapolation to a broader medical community, particularly those outside the experienced investigators, nurses, and support staff of the cooperative group sites. Thus, it is not surprising that many clinicians considering intraperitoneal therapy as a practice standard never embraced the data and that some brave enough to try experienced significant challenges—particularly in adoption of GOG-172’s multiday/weekly strategy.
Criticisms Temper Clinical Adoption
One of the many criticisms of the “trifecta” was choice of the control arm in each of the studies. GOG-104, published the same year as GOG-111, which introduced paclitaxel in the front-line setting to poorer-prognosis patients, lacked this new agent. GOG-114 and GOG-172 used 24-hour infusion of paclitaxel and cisplatin (day 2). However, data from GOG-158, featuring paclitaxel (3-hour infusion) with carboplatin (area under the curve = 7.5) compared with the same intravenous control arm used in GOG-172, were already known and a community standard.
In addition, cross-trial evaluation (albeit statistically invalid) of the control arm in GOG-172 vs the experimental arm in GOG-158 implied “underperformance” of GOG-172’s control arm. Furthermore, at the time of GOG-172’s publication, intense interest was focused on bevacizumab (Avastin), which was serving in experimental arms of new GOG and international front-line phase III trials.8,9 This, along with an extremely provocative dose-dense, dose-intense intravenous paclitaxel phase III study by the Japanese GOG demonstrating similar efficacy results on overall survival, tempered clinical adoption of intraperitoneal therapy.10
New Light on Its Potential
Nevertheless, a series of reports like the current article by Tewari et al have cast new light on the potential for intraperitoneal therapy. First is the significant improvement in surgical standards for primary cytoreduction. At the time of initial reports on intraperitoneal therapy, the rate of complete surgical cytoreduction (R0) was 10% to 25%; R0 rates have now doubled, largely due to more aggressive surgery and advanced surgical training, globally, of gynecologic oncologists.11 Several reports, including the Tewari et al analysis, have suggested that the R0 cohort represents the subgroup most likely to benefit from intraperitoneal therapy.
Second, improvements in supportive care and alterations in the dosing/infusion schedules of the agents have dramatically improved the proportion of patients completing all six cycles of intended intraperitoneal chemotherapy.12 Although it remains a risk that alterations in dosing/schedule could impact survival efficacy, this may be countered by the ability to complete all therapy via intraperitoneal administration.
Third, understanding genomic alterations in the tumor may further clarify who should be given intraperitoneal therapy. Recently, an analysis of somatic loss of BRCA1 in patients participating in GOG-172 demonstrated a profound effect on overall survival.13 In this analysis of 393 patients (94% of GOG-172 participants), somatic loss of BRCA1 was observed in 48%. Among this cohort, the median overall survival for intraperitoneal vs intravenous therapy was 84 vs 47 months (P = .0002), amounting to a 33% reduction in the hazard for death. There was no difference between intraperitoneal and intravenous therapy among patients with normal expression of BRCA1.
Finally, histology may be important, as patients with serous cancer, the most prevalent subtype, appeared to benefit from intraperitoneal therapy, but only if six cycles could be administered.
Looking Ahead
The future of intraperitoneal therapy will likely undergo another transition, as the results of the GOG-252 (clinicaltrials.gov, NCT00951496), iPocc (NCT01506856), and NCIC-OV21 (NCT00993655) trials become available. In GOG-252, two different intraperitoneal infusion strategies are being evaluated in combination with bevacizumab against a contemporary control arm (paclitaxel, carboplatin, bevacizumab followed by bevacizumab maintenance).
The Japanese iPocc trial is comparing the same dose-dense, dose-intense paclitaxel intravenous arm as in its previous trial vs intraperitoneal carboplatin (same intravenous and intraperitoneal doses) but is allowing both optimal and suboptimal surgical cytoreduction patients to participate.
NCIC-OV21 is focusing exclusively on the neoadjuvant chemotherapy population, administering intravenous or one of two intraperitoneal regimens following interval debulking surgery planned after three to four induction cycles of intravenous platinum-based therapy.
Although each of these trials has the potential to solidify and/or broaden the potential audience for intraperitoneal therapy, they may also define it as a relic of early ovarian cancer clinical therapy. Nevertheless, continuous interrogation into the biology of ovarian cancer and its microenvironment may hold new avenues of clinical investigation for intraperitoneal treatment. ■
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