Improving Communication in Oncology
Kathleen Keefe-Cooperman, PsyD
Bayer Institute for Health Care Communication
Copyright ? 1999 The Bayer Institute for Health Care Communication West Haven, CT
We created this annotated bibliography to support the development of educational programs to help
physicians communicate more effectively with people diagnosed with cancer. We searched Medline, Psyclit, and Cancer computerized databases for articles published primarily since 1990. Our aim was to identify empiric research, literature reviews, and literature-based opinion pieces that clarified important aspects of communication at the transition from cure or control of cancer, to control of symptoms. Thus the
bibliography is not meant to reflect the entire clinician-patient communication literature, either generally or for people with cancer. We also recognized that the transition is in some ways an artifact of the medical profession not addressing “cure” and “care” equally, in the context of a longitudinal relationship. Despite this ideal, and for a variety of reasons, physicians and patients still experience this transition as a major shift in the goals and nature of treatment, and in the physician-patient relationship.
We identified and annotated 375 articles for this project. This bibliography includes the ones that make the greatest contribution to understanding the transition. The articles are organized into the following categories:
I Physician-patient communication
A) Communication skills training
B) Physician-patient relationship
C) Giving information
D) Empathy and support
E) Shared decision-making
II Oncologist stress and burnout
III Communication at the end of life: Quality of life
IV Hope and spirituality
I. PATIENT-PHYSICIAN COMMUNICATION
A. Communication skills training
Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology:
Description and preliminary outcomes of workshops on breaking bad news and managing patient
reactions to illness. Cancer. 1999;in press. Objective: To increase oncologists' confidence in breaking bad news and managing stressful patient
Design: Two half-day workshops.
Setting: University of Texas MD Anderson Cancer Center
Subjects: Twenty-seven oncology faculty of which fifteen attended the bad news workshop and
twelve the "problem situation" workshop.
Interventions: One workshop focused on breaking bad news and the other on dealing with "problem
situations." The five-hour workshops combined a didactic presentation with experiential
role-plays to enhance communication skills. The participants met as a large group for the
didactic portion and in small groups with trained facilitators for the role-plays. Measures: Self-efficacy measures were administered before and after the workshops. Additionally,
participants were mailed a follow-up workshop satisfaction questionnaire. Results: Participants expressed satisfaction with the workshop and evidenced greater confidence in
communicating bad news and managing difficult situations. Conclusions: Communication workshops, though in need of longitudinal research, may be a viable
means of providing training to oncologists.
Garg A, Buckman R, Kason Y. Teaching medical students how to break bad news. Can Med
Assoc J. 1997;156:1159-1164.
Objective: To educate medical students on how to break bad news to patients and their families in an
empathic and competent manner.
Design: Pre/Post test design.
Setting: Seven teaching hospitals affiliated with the University of Toronto since 1987.
Subjects: Out of 1260 medical students, 940 precourse and 503 postcourse questionnaires were
completed. For the final analysis, only 359 questionnaires could be used. The course was
given to all medical students in their 3rd preclinical year. Interventions: The course consisted of 2 half-day, 3-hour-long sessions given 1 or 2 weeks apart. The
course goals were to reinforce medical interviewing skills learned in the previous 2 years,
to teach advance medical interviewing skills, and to give practice in those skills while
providing individualized, constructive feedback. Students received a workbook
containing role-play and small-group exercises, and a recommended reading list. Two 30-
minute videos were produced for the class and one was shown at the beginning of each
class followed by a 15-minute discussion. The second session focused on difficult
questions and emotions.
Measures: Students were given pre- and postcourse questionnaires.
Results: Students found the course enjoyable and useful. Following the course, 92% of the
students felt they had a firm plan for giving bad news as opposed to the precourse result
of 49%. Before the course, 23% of the students felt competent as compared to 74%
following the course. Students who had witnessed role models break bad news rated them
highly and had a plan in mind for how to accomplish this task as well as a higher sense of
competence. Only 11 questionnaires showed a loss of perceived competence or strategy
or both. The precourse questionnaire showed 68% of students thought about the task of
breaking bad news often or very often.
Conclusions: Courses on teaching students communication skills can be incorporated into medical
school curricula successfully with students finding the courses enjoyable and useful.
Glimelius B, Birgegard G, Hoffman K, Kvale G, Sjoden PO. Information to and communication
with cancer patients: Improvements and psychosocial correlates in a comprehensive care program
for patients and their relatives. Patient Education and Counseling. 1995;25:171-182.
Objective: To evaluate the effect of a cancer care project on patients' and relatives' total situation. To
clarify the relationships between self-reported problems related to interactions with
medical staff and varied problems among patients and relatives. Design: Implementation of a cancer care project in which information and communication
interventions played a central role
Setting: All patients who were to receive chemotherapy at Akademiska sjukhuset, Uppsala, were
invited to participate in the project.
Subjects: One hundred and seventy-seven patients participated in the project between 3/1/87 and
4/30/89. 120 patients' relatives were also interviewed with no more than 1 relative per
patient interviewed. One month prior to the care project initiation, a preproject evaluation
was conducted on 54 patients. Subjects were similar in demographics to the other groups. Interventions: The care program was a cooperative effort between a resource group and 3 wards. All
ward personnel were involved in the project. Verbal information was supplemented with
written information. Efforts were made to increase the relatives' participation in patient
care and to improve care of the relatives by staff. An education program was conducted
with the staff. In the initial months of the program, a 1-week communication course was
held followed by regular meetings held on the wards. Communication skills practice
involved giving first information about serious disease, and general strategies for giving
Measures: A Swedish version of the Cancer Inventory of Problems Situations was used for
evaluation. Patients were interviewed at diagnosis, at regular intervals during treatment,
and after the last treatment course. Relatives were interviewed at the same time as the
patients, but separately. An additional 9 questions concerning interactions with medical
staff were administered.
Results: Scores for problems related to patient-staff interaction were low during the preproject
interview, but even lower scores were seen during the project. Strong relationships were
found between various aspects of patient- and relative-staff interactions and psychosocial
problems, although weaker relationships were found for problems relating to information
than for communication and control problems. Conclusions: Although the effects of specific interventions could not be measured, the education of
medical staff was effective in lessening problems reported by patients and relatives.
Maguire P, Faulkner A, Booth K, Elliott C, Hillier V. Helping cancer patients disclose their
concerns. Eur J Cancer. 1996;32A:78-81. Objective: To determine which behaviors promote or which hinder disclosure.
Design: Pre- and postworkshop simulated patient interviews.
Setting: A series of 3- to 5-day workshops aimed at improving physician-patient communication in
a residential setting in the UK.
Subjects: Study participants were 206 health professionals experienced in cancer care and who
completed one of the workshops.
Interventions: The participants set the workshop goals by determining which communication tasks they
most wished to be addressed and then using a videotape of a consultation for discussion
and education. Participants practiced assessing patient concerns and other tasks through
small-group role play. Another videotape session focused upon breaking collusion,
emotional survival and "unfinished business."
Measures: Participants interviewed two different simulated patients, 1 before the workshop and 1
after. Each interview was audiotaped. A rating system was developed for this study to
examine verbal communications. Two raters determined agreement by rating and
comparing 3 transcripts. Effective behaviors were hypothesized to include open directive
questions, psychologically focused questions, clarification of psychological issues,
educated guesses used in a negotiating style, and empathic statements. Inhibiting
behaviors include focusing upon physical aspects, giving advice, and offering reassurance. Results: Questions that had psychological focus, clarification of psychological aspects, and open
directive questions showed increases in disclosure of 2 and 3 fold. Leading questions and
focusing upon physical aspects hindered information getting. The use of open directive
questions and empathy was positively influenced by the workshop. Inhibitory behaviors
decreased following workshop attendance.
Conclusions: An integrated approach is needed which combines a focus on the patient's personal world
and physical aspects of cancer in order to effectively help this population. Advice- giving
and reassurance needs to be delayed until the patient's concerns are elicited and
Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians'
interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch
Intern Med. 1995;155:1877-1884.
Objective: To examine the effect of communication skills training on patients' emotional distress.
Design: A randomized, controlled field trial.
Subjects: Six hundred and forty-eight patients and 69 of their primary care physicians.
Interventions: Two communication skills courses concerning patient emotional distress that targeted
either problem-defining skills or emotion-handling skills. Measures: Physicians were randomly assigned to either a no-course control group or one of the two 8
hour communication skills courses. Office visits of the physicians were audiotaped until
five emotionally distressed and nondistressed patients were enrolled. Patients were given
the General Health Questionnaire. Physicians were audiotaped during simulated patient
visits to assess proficiency. Distressed patients were monitored via telephone 2 weeks, 3
months, and 6 months after their office visit to determine utilization of medical services
and General Health Questionnaire Scores.
Results: Trained physicians used significantly greater amounts of problem-defining skills or
emotion-handling skills with no increase in the length of the office visit. Patients of
trained physicians reported a lessening of emotional distress for up to 6 months. Conclusions: Communication skills training improved physician proficiency in reducing emotional
distress in patients without any lengthening of the office visit.
B. Physician-patient relationship
Beisecker AE. Patient power in doctor-patient communication: What do we know? Health
Description of Context: To examine research that focuses on the patient's attempts to obtain information,
to be assertive in communicating with physicians, and to be an active participant in
Topic/Scope: Variables that affect the doctor-patient relationship include: sociodemographic
characteristics of the physician and patient, attitudes of both parties, and influencing
situational factors. Patient noncompliance may represent a way for patients to assert their
independence and power. Compliance may be affected by the patient's communication
input. The exchange of information is influenced by the amount of information-seeking
behaviors evidenced during the medical encounter by the patient, or the physician's
behavior, that could discourage questions. Effective patient information-seeking behavior
can positively affect the medical outcome. Patient assertiveness has an impact as both
patient and doctor want to maintain control, autonomy, and power in the relationship.
Patient communication also involves the role of the patient in medical decision-making.
Information exchange and patient question-asking may directly influence a patient's input
in medical decisions. This may affect the patient's psychological reactions to treatment,
and his or her satisfaction levels.
Conclusions/Recommendations: A patient's assertive communication behaviors or attempts to control the
physician-patient relationship may be explained by a variety of factors. A patient's
attitude may not predict behavior, as attitudes arise from general beliefs regarding patient
rights while communication behaviors arise from a specific interaction context. Although
many patients desire information, few make attempts to elicit information from doctors.
Blanchard CG, Labrecque MS, Ruckdeschel JC, Blanchard EB. Physician behaviors, patient
perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer
patients. Cancer. 1990;65:186-192.
Objective: To examine potential predictors of patient satisfaction as related to physician behaviors.
Design: Examined physician-patient interactions using a behavioral checklist, questionnaires, and
visual analogue scales.
Setting: Three hundred and sixty-six In-patient hospital setting in NY.
Subjects: cases involving 6 oncologists and cancer patients.
Interventions: Physician-patient interaction during morning rounds.
Measures: One to two observers in clinical garb observed weekday morning rounds. The physician-
patient interaction was timed. Following rounds, the observer returned to the patient's
room. The same observers measured physician behaviors and patient responses and were
given the Physician Behavior Check List, and two visual analogue scales: one assessing
how the patient's needs were met by the physician, and the other assessing the overall
measure of the patient's involvement in the interaction. The patient also completed the 2
visual analogues and a Patient Satisfaction Questionnaire. Results: The physician spent, on average, 4.4 minutes in each patient's room, yet the patient
approximated that same time to be 8.8 minutes. Overall, patient satisfaction was high.
Patients' perceptions of behavior were found to be better predictors of patient satisfaction
than actual physician behaviors. Factors related to satisfaction were emotional support or
needs, and information needs being perceived as met. Older patients experienced greater
satisfaction. Two physician behaviors related to patient perception of prognosis:
"Identifying future tests and treatment" was related to a perceived better prognosis while
"inquires about signs and symptoms" was associated with a worse prognosis. Only 5
physician behaviors were found to occur more than 60% of the time: addressing the
individual, inquiring about the patient's overall state, inquiring about signs and symptoms
of illness, discussing tests and treatments, and touching the patient. Touching the patient
is the only behavior related to support.
Conclusions: How the patient perceives the interaction has a greater effect on satisfaction than
actual physician behaviors. Older patients express greater satisfaction. The subjects the
physicians inquired into also affect patient satisfaction.
D'Angelica M, Hirsch K, Ross H, Passik S, Brennan MF. Surgeon-patient communication in the
treatment of pancreatic cancer. Arch Surg. 1998;133:962-966.
Objective: To assess long- and short-term quality of surgeon-patient communication and to determine
the surgeon's role in emotional support of patients with pancreatic cancer (PC). Design: Survey using a combination of telephone and mail.
Setting: Urban tertiary cancer referral center.
Subjects: Forty-eight patients who had experienced a pancreatic resection for PC.
Measures: Patient satisfaction.
Results: The amount of information provided both before surgery and during the hospital stay was
rated as extremely satisfactory by patients. Physical actions found to be comforting to
patients included direct eye contact, the surgeon sitting while speaking to the patient, and
some form of physical contact.
Conclusions: Surgeons are seen as desired emotional supports by patients. Patients are ill-prepared for
long-term problems following surgery.
Delbanco TL. Enriching the doctor-patient relationship by inviting the patient's perspective.
Ann Intern Med. 1992;116:414-418.
Description of Context: Many of the problems that occur within the patient-physician relationship
involve feelings of anger and sadness related to the distancing that interferes with
appropriate interactions. This relationship can be improved by both parties first engaging
in a "patient's review," and then using survey instruments to measure each aspect of care. Topic/Scope: The patient's review focuses upon seven aspects that characterize the patient's perspective:
- values, preferences, and expressed needs of the patient
- the patient's coordination and integration of care
- communication and education needs of the patient
- the patient's physical level of comfort
- the patient's available emotional supports
- the level of involvement of family and friends
- the continuity and transition of care
The review allows the individual to be the focus of the report, and encourages the patient
and the physician to confront and express personal differences while allowing the patient
to take a more active role in his or her treatment. The review also lets the physician
ascertain the patient's fears and anxieties in order to attempt alleviation. Conclusions/ Recommendations: The patient's review should be taught in the early years of medical
school as it provides structure while allowing for an understanding of the whole person.
Patients should also be encouraged to learn this method to enhance their own personal
understanding. Survey instruments that seek patient input will promote an understanding
of how well patient needs are addressed, and how care may be improved. Addressing
these areas will promote a synergism between doctor and patient.
Fallowfield LJ. Communication skills of oncologists. Trends in Experimental and Clinical
Description of Context: Many patients are unhappy with the communication exchanges with their doctors.
The process of a cancer diagnosis, treatment, and prognosis may result in possible
emotional, relational, sexual, or occupational difficulties. Topic/Scope: Oncologists often fail to recognize even significant psychological distress. The
physician's lack of response leads to more stress for the patient. Patients do not
understand medical jargon, which, when combined with their own ideas and information
presented by the media, leads to greater confusion and resultant distress. Characteristics
of the patient, the doctor, and the system of cancer care delivery also contribute to the
problem. Due to the role of the physician in society, the patient may not be comfortable
asking the oncologist questions. The lack of information communicated to the patient
initially, combined with the number of therapeutic options, may result in long-term
adverse consequences. Five areas of communication are perceived to be most difficult for
physicians: breaking bad news, obtaining informed consent for clinical trials, speaking
with relatives, discussing treatment options, and addressing psychosocial issues.
Conclusions/Recommendations: Skills training may help address the problem, promoting basic
communication techniques such as showing respect, concern, or empathy, as well as non-
verbal and verbal caring.
Ford S, Fallowfield L, Lewis S. Can oncologists detect distress in their out-patients and how
satisfied are they with their performance during bad news consultations? Br J Cancer.
Objective: To assess the ability of oncologists to recognize distress in newly-referred out-patients
and to measure their own satisfaction with their behavior during consultations concerning
Design: Self-report measures and clinical interviews.
Setting: The medical oncology department of a London teaching hospital.
Subjects: Five senior oncologists were assessed concerning their interactions with 101 patients at
the first interview and 94 of the 101 at the second interview. Interventions: None.
Measures: Each patient had two clinical interviews, approximately 1 month apart, with the same
oncologist. Prior to the first interview, demographic information was collected. Before
both the first and second interviews, psychological functioning was determined via the
General Health Questionnaire and the Hospital Anxiety and Depression scale. At the end
of each interview, the oncologist subjectively rated his/her personal performance. The
oncologist's perceptions of patient distress were measured using 2 visual analogue scales. Results: The majority of physicians tended to under-rate patient distress. The more clinicians
perceived patients to be distressed, the less satisfied they were with the interviews. As the
oncologists usually under-rated patient distress, they were typically satisfied with the
Conclusions: Oncologists tend to under-rate rather than over-rate patient distress and would benefit
from improving their psychological assessment skills.
Goldberg R, Guadagnoli E, Silliman RA, Glicksman A. Cancer patients' concerns: Congruence
between patients and primary care physicians. J Cancer Educ. 1990;5:193-199.
Objective: To investigate similarities and differences between physician and cancer patient
perceptions of issues related to the cancer experience of the patient. Design: Survey.
Setting: Physicians and patients in Rhode Island.
Subjects: One hundred and nineteen patients and 195 physicians returned the questionnaire.
Measures: A 43-item questionnaire was developed for this study with 8 domains of concern: physical
function, social function, effects of cancer and its treatment, communication, information,
emotional support, concrete services, and health behavior. Results: The results indicate statistically significant discrepancies between physician and cancer
patient views of important issues involved in treatment. Physicians underestimated how
important patients consider knowing what will happen if the cancer recurs, knowing
whether they are cured, and knowing whether treatment will help. In the area of
communication, physicians underestimated the importance patients place on deciding
what new symptoms to bring to the doctor's attention, on comprehending what the doctor
is saying, and on being able to talk openly. Physicians and patients rated equally the
importance of general concerns about cancer epidemiology and its impact on social and
emotional functioning. However, these items were rated less important overall when
compared to communication items.
Conclusions: Primary care physicians did not understand the importance placed by patients on many
issues; thus, communication must improve to address these issues.
Lerman C, Daly M, Walsh WP. Communication between patients with breast cancer and health
care providers. Cancer. 1993;72:2612-2620. Objective: To determine the prevalence and types of deficiencies in physician-patient communication
as reported by the patient prior to postoperative therapy. Design: Used a survey methodology to identify those patients most likely to report communication
difficulties, and to evaluate the relationship between patient-reported communication
problems prior to postoperative therapy and psychological distress at the three month
follow up visit.
Setting: Fox Chase Cancer Center in Philadelphia, PA.
Subjects: The sample included 97 women diagnosed with Stage I or II breast cancer. All had
undergone primary surgical treatment for their disease, but had not begun postoperative
Measures: Demographic information was obtained from the medical records. Three coping styles
were measured: fighting spirit, assertiveness, and a need for information. Measures used
included the Fighting Spirit subscale of the Mental Adjustment to Cancer Scale, the
Rathus Assertiveness Schedule, and the Miller Behavioral Style Scale. Patient-provider
communication was evaluated using the Cancer Rehabilitation Evaluation System-
Medical Interaction Subscales (CARES). Psychological distress was determined by the
Profile of Mood States.
Results: The majority (84%) of the patients endorsed items reflective of difficulties communicating
with medical staff. Patients had difficulty comprehending provider-given information and
many patients expressed difficulties with asking questions and expressing feelings to
providers. Patients most likely to report communication problems had more distress, less
optimism, and greater feelings of hopelessness concerning the disease. Patients who
reported more communication problems prior to postoperative treatment experienced
greater psychological distress both before postoperative therapy and at the three month
follow up visit.
Conclusions: Patients who ask questions receive greater amounts of information, thus reducing
uncertainty, gaining reassurance, and receiving personalized advice. Improving physician-
patient communication aids in improving the patient's adjustment to her disease.
Communication may be enhanced through the utilization of interventions that lower
patient distress and modify coping styles.
Maguire P. Improving communication with cancer patients. Eur J Cancer 1999;35:1415-1422.
Description of Context: A review article summarizing research (Maguire's and others) in the field.
Topic/Scope: Research is summarized by key communication tasks: eliciting patient's concerns,
perceptions and feelings; breaking bad news; involving patients in treatment decisions;
obtaining informed consent; and monitoring adverse reactions. Each section ends
with a brief summary of findings. Barriers to effective communication and ways to
improve communication with patients are reviewed, with major emphasis on training
Conclusions: Physicians fail to elicit patient concerns, or block expression of concerns once asked.
This reflects lack of skills training (eg, how to move on after empathy) but also attitudes
or outcome expectancy - if I do this, bad things will happen - patient will cry, take up time,
etc. Maguire has done most of the basic research on this and finds that training needs
about 3 days of small group work and a 2-day booster 2-3 months later. His best results
have been with coaching individual physicians as they see patients, improving their self-
efficacy and outcomes expectancy with interviewing skills.