New Breast Cancer Approaches: Integration, Communication

Institution: University of California, San Francisco
Investigator(s): Leah Karliner, M.D. -
Award Cycle: 2005 (Cycle 11) Grant #: 11IB-0020 Award: $150,000
Award Type: IDEA
Research Priorities
Community Impact of Breast Cancer>Health Policy and Health Services: better serving women's needs

Initial Award Abstract (2005)
Introduction: Researchers are continually developing new approaches to care for women with breast cancer. Many of these approaches may involve complicated technology, important medication choices, or genetic information about an individual woman's cancer. Doctors treating women with breast cancer must find ways to understand these new approaches and integrate them into their medical practice. Because these approaches are often technical in nature, it may be difficult for doctors to communicate well with their patients about new tests and treatments. Communication is a particular challenge in California where there is a wide range of cultures and languages, and where many breast cancer patients may not speak English very well.

Hypotheses: The central hypothesis of this research study is that breast cancer patients' access to new tests and treatments and doctor's communication with women about those new treatments can be improved through techniques designed to help doctors integrate new approaches into medical practice, and communicate with women about the new approaches. To do this, however, we must first understand the decision-making processes that doctors go through when there is new information available that is relevant to their patients. We must also understand what challenges doctors have communicating new information to their patients in general about new information, and any particular communication challenges they face when talking with women who do not speak English well.

Methodology: In this study we will first interview eight breast cancer doctors about their past experiences learning about and integrating into practice new tests and treatments for women with early-stage breast cancer, as well as about the challenges they have encountered communicating with breast cancer patients about this new information. Next we will use the information from the interviews to design a survey questionnaire to send to breast cancer doctors across California. The purpose of the survey will be two-fold: 1) to better understand the decision-making processes that doctors go through when they are deciding whether or not to incorporate new tests and treatments into their care of women with early-stage breast cancer; and 2) to better understand the communication challenges doctors face when talking with women in general about new tests and treatments, and specific communication challenges they encounter when treating women who do not speak English well.

Innovative elements: There are two novel aspects to this project. The first is that no one has yet studied the connection between breast cancer doctors' integration of new tests and treatments into practice and their communication with patients about those new tests and treatments. The second is that no one has tried to understand the specific difficulties that may arise when breast cancer doctors need to communicate with patients who don't speak English about new tests and treatments. The goal of this project is to understand and make connections between breast cancer doctors' integration of new tests and treatments and their communication with patients, particularly with those who do not speak English well.

Advocacy involvement: This project fits well with the National Breast Cancer Coalitions' Quality Care Initiative. Their initiative has six overlapping core values: Access, Information, Choice, Respect, Accountability, and Improvement. Our study seeks to: 1) improve access to new breast cancer tests and treatments by understanding how doctors integrate new information into practice; 2) improve communication of information about new tests and treatments with patients; thus 3) allowing women, including women who don't speak English well, more choice in their treatment. Quality communication requires doctors to respect their individual patients, and leads to accountability.

Final Report (2008)
Both timely integration of proven new information into practice, and quality communication with patients about that new information are fundamental to the provision of equal access for all women to advances in early-stage breast cancer care. Therefore, this projectís purpose was to gain an understanding of the steps of incorporation breast surgeons and oncologists use when confronted with new approaches to care, how they communicate about that new approach with patients, and how that communication is impacted by language barriers.

We interviewed 7 key informant surgeons and oncologists; these interviews formed the basis of our physician survey. We mailed surveys to a randomly selected sample of 1251 surgeons and oncologists throughout California. 321 completed our survey, 99 refused, 615 were found to be ineligible, and 216 were non-respondents, for a participation rate of 51%. Participants were from a wide geographical range and from many different practice settings, with the majority being in solo or group private practice.

We faced the challenge of encouraging participation by very busy practicing clinicians. In addition, we had the challenge of our contact database (AMA Masterfile) not specifying whether physicians were engaged in the care of breast cancer patients. To overcome these challenges, we sent two survey mailings, with a reminder postcard in-between, a participation incentive of a Borderís gift card, and then followed up by calling and faxing our non-respondents. In addition, we conducted extensive web searches to clarify whether non-respondents were currently in clinical practice in California.

We found that, when first starting to use a new approach to breast cancer care, the majority of physicians were most excited about having additional choices to offer patients, offering the most up to date advances, and learning something new. The majority of physicians were most concerned about the unknown long-term adverse effects of the new approach. However, surgeons were more likely than oncologists to be concerned about their skills in the new area; while oncologists were more likely than surgeons to be concerned about the expense/cost of the new approach, and about causing immediate harm. Fewer than half of physicians reported that they always tell patients how many times they have done/used a new technique or treatment; however, surgeons were more likely than oncologists to report always telling patients.

When asked to choose the three situations which they found most challenging when caring for a patient with breast cancer, the majority chose: 1) when a patient has pre-formed ideas about acceptable and unacceptable treatments; 2) when a patient wants under-treatment that is not standard of care; and 3) helping the patient understand how population-based statistics apply to her. Language barriers have a significant impact on how physicians approach conversations about treatment with their breast cancer patients. While they report that they are generally no less likely either to present the patient with a full spectrum of treatment options or to offer a new approach or treatment, approximately half strongly agree/agree that they tend to be more directive in their treatment recommendations and to simplify their discussion of risks and benefits, and a majority worry that the patient may not ask all of the questions she has at the time of the visit.

We would like to use our data on physician experiences and concerns communicating across language barriers to create a best-practices communication tool to distribute to breast cancer physicians across California to support them in their communication needs and enhance the quality of care they provide to all of their patients about treatment, prognosis, and new approaches.

Symposium Abstract (2007)
Background: Breast cancer doctors face the ongoing task of both incorporating new approaches to care into their practice and communicating about these approaches with their patients.

Objective: To assess the specific challenges surgeons and medical oncologists encounter when communicating with their breast cancer patients about prognosis, treatment and new options of care.

Methods: We mailed surveys to a representative sample of physicians (1250; 661 surgeons, 588 medical oncologists), randomly selected from the American Medical Assosciation Physician Masterfile.

Preliminary Data: To date, 254 physicians have responded. Of these, 119 (47%) were surgeons, 135 (53%) medical oncologists; 191 (76%) were men; 169 (67%) were in solo/group private practice; 188 (74%) were graduates of medical schools. In general, physicians found communicating with breast cancer patients most challenging when the woman has preformed ideas about what is acceptable or unacceptable treatment (80%), desires under-treatment (52%), or has trouble understanding how population-based statistics apply to her (49%). More respondents found it difficult to discuss treatment options and prognosis with women when they were non-English speaking than when they either had a low level of education or were from a different culture than the physician. When considering a new approach/technique in breast cancer care, both surgeons and medical oncologists were most excited about being able to offer their patients additional choices (82%) and the most up to date advances (79%). Surgeons and medical oncologists were equally and most frequently concerned about the potential unknown long-term side effects of the new approach/technique (72%).

Conclusions/Implications: Our preliminary results suggest that both surgeons and oncologists are excited about new approaches/techniques to care, but they are also worried about how implementation of these in their practice may lead to unknown long-term harm. Breast cancer physicians experience communication challenges in discussing treatment and prognosis, particularly when the patient enters the encounter with pre-existing ideas about limits to her treatment. Lastly, language barriers present a particular challenge for physicians. The results lay the foundation for the development of specific communication interventions which will most assist physicians in communicating with their breast cancer patients.

Language barriers and patient-centered breast cancer care.
Periodical:Patient Education and Counseling
Index Medicus: Patient Educ Couns
Authors: Karliner LS, Hwang ES, Nickleach D, Kaplan CP
Yr: 2010 Vol: Aug 2010 Nbr: Abs: Pg:ePub