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Oncology

Perspectives on Oncology-Specific Language During the Coronavirus Disease 2019 PandemicA Qualitative Study

Educational Objective
To understand how oncologists can communicate during challenging situations and during a pandemic

1 Credit CME

JAMA Oncology

Published Online: August 6, 2020

Brief Report

Article Information and Disclosures

Laila A. Gharzai, MD, LLM^1,2;

Kenneth Resnicow, PhD^3,4;

Lawrence C. An, MD^4,5;

Reshma Jagsi, MD, DPhil^1,2

Author Affiliations

¹Department of Radiation Oncology, University of Michigan, Ann Arbor
²Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
³Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
⁴Center for Health Communications Research, University of Michigan, Ann Arbor
⁵Department of Internal Medicine, University of Michigan, Ann Arbor

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Key Points

Question How can oncologists communicate with patients in challenging situations during the coronavirus disease 2019 pandemic?

Findings In this qualitative study of 8 physicians and 48 patients with cancer, the physicians identified 8 oncology-specific scenarios in which communication with patients had been challenging, and the patients provided their reactions to each scenario. These physician and patient insights, along with principles identified through literature review by health communication experts, were synthesized for application to the clinical scenarios.

Meaning This study suggests that communication needs in cancer care can be identified to inform the development of a practical, evidence-based communication guide that fulfills the need of patients and oncologists.

Abstract

Importance The novel coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the US health care system, causing an influx of patients who require resources. Many oncologists are having challenging conversations with their patients about how the COVID-19 pandemic is affecting cancer care and may desire evidence-based communication guidance.

Objectives To identify the clinical scenarios that pose communication challenges, understand patient reactions to these scenarios, and develop a communication guide with sample responses.

Design, Setting, and Participants This qualitative study that was conducted at a single Midwestern academic medical center invited physicians to respond to a brief semistructured interview by email or telephone and then disseminated an anonymous online survey among patients with cancer. Oncology-specific, COVID-19–related clinical scenarios were identified by the physicians, and potential reactions to these scenarios were gleaned from the patient responses to the survey. Health communication experts were invited to participate in the iterative development of a communication guide, comprising 3 essential communication principles and strategies and informed by insights from physicians and patients. This study was conducted from March 25, 2020, to April 2, 2020.

Interventions Expert review, interviews, and surveys assessing challenging situations specific to cancer management during the COVID-19 pandemic.

Main Outcomes and Measures Oncology-specific, COVID-19–related clinical scenarios from physician interviews; responses to each scenario from patient surveys; and applicable communication principles from health communication expert literature review.

Results Of the 8 physicians who participated in interviews, 4 were men (50%) and 4 were women (50%). These physicians represented the following disciplines: internal medicine (n = 1), hematology/oncology (n = 2), radiation oncology (n = 3), and surgical oncology (n = 2). Their disease site specialization included cancers of the breast, head and neck, melanoma, and gastrointestinal and genitourinary tracts. A total of 48 patients with cancer completed the online survey; no demographic information was collected from the patients. The physicians identified 8 oncology-specific, COVID-19–related scenarios in which communication might be challenging: (1) worse outcomes from COVID-19, (2) delay in cancer screening, (3) delay in diagnostic workup, (4) delay in initiation of treatment, (5) offer of nonstandard treatment, (6) treatment breaks, (7) delay in follow-up imaging or care, and (8) inability to be admitted into the hospital for management. Potential patient reactions to each of these scenarios were compiled from survey responses. For most scenarios, patient reactions involved anger, fear, and anxiety (eg, “I’m scared”; “This isn’t fair. I am upset.”). These emotional patient responses informed the selection of the 3 general communication principles, which suggested language and strategies that physicians can use to respond to patients.

Conclusions and Relevance In this qualitative study, physicians and patients identified communication needs used by health communication experts to inform the development of a practical, evidence-based communication guide for oncology care during the COVID-19 pandemic.

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Article Information

Accepted for Publication: June 2, 2020.

Corresponding Author: Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, 1500 E Medical Center Dr, UHB2C490, SPC 5010, Ann Arbor, MI 48109 (rjagsi@med.umich.edu).

Published Online: August 6, 2020. doi:10.1001/jamaoncol.2020.2980

Author Contributions: Dr Gharzai had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Gharzai, An.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Gharzai, An, Jagsi.

Administrative, technical, or material support: Gharzai, Resnicow, An.

Supervision: Gharzai, An, Jagsi.

Conflict of Interest Disclosures: Dr Jagsi reported receiving grants from the National Institutes of Health, Doris Duke Foundation, Komen Foundation, Blue Cross Blue Shield of Michigan, and Genentech; grants and personal fees from the Greenwall Foundation; personal fees from Amgen, Vizient, Sherinian and Hasso, and Dressman, Benziger, Lavelle outside the submitted work; and stock options for service as an advisor for RJ Equity Quotient. No other disclosures were reported.

Additional Contributions: Anthony Back, MD, University of Washington, and staff of VitalTalk, Seattle, Washington, provided invaluable guidance to clinicians having challenging coronavirus disease 2019 conversations and inspired the development of this guide for patients with cancer. The following people assisted in the development of this oncology-specific guide: Christine Veenstra, MD, Department of Medical Oncology, University of Michigan; Sarah Hawley, PhD, MPH, Department of Internal Medicine, University of Michigan; Diane Egleston, MPH, Center for Health Communications Research, University of Michigan; Colleen Sullivan Leh, BFA, Center for Health Communications Research, University of Michigan; Elizabeth Hershey, MS, Center for Health Communications Research, University of Michigan; Nicole Fawcett, BA, Director of Communications, University of Michigan Rogel Cancer Center; Theodore S. Lawrence, MD, PhD, Department of Radiation Oncology, University of Michigan; David Smith, MD, Department of Medical Oncology, University of Michigan; Keith Casper, MD, Department of Otolaryngology, University of Michigan; Michael S. Sabel, MD, Department of Surgery, University of Michigan; Donna Murphy, LMSW, Patient and Family Support Services Program, University of Michigan; Michele Heisler, MD, MPA, Department of Internal Medicine, University of Michigan; Marsha Benz, MPH, MA, University Health Services, University of Michigan; Molly White, MPH, Office of Patient Experience, University of Michigan; Delwyn Catley, PhD, Department of Pediatrics, Children's Mercy Kansas City; Kathy Goggin, PhD, Department of Pediatrics, Children's Mercy Kansas City; and Geoffrey Williams, MD, PhD, Department of Internal Medicine, University of Rochester. These individuals received no additional compensation, outside of their usual salary, for their contributions.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.