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Explored factors influencing patient satisfaction with and utilization of information booklets. Patients (N=36) rated five booklets, and strongly preferred one with a grade-eight reading level. The relationship of preference and recall was investigated. No difference between those who seek or avoid information was found. Additional findings are reported. (Author/EMK)

Objectives: Many oncology health professionals (HPs) report communicating with carers as complex; and receive limited carer-relevant training. We developed an online HP education program for supporting and managing carer involvement (eTRIO). We aimed to assess whether HPs' self-efficacy in carer communication, knowledge, and decision-making preferences improve following eTRIO. Satisfaction and implementation potential were assessed., Methods: This type 1 hybrid effectiveness-implementation study used a pre-post single arm intervention design. HPs completed baseline measures, the eTRIO online module, and measures at 1- and 12-weeks post-intervention. Measures included: self-efficacy in carer communication (13-items), applied knowledge (7-items), preference for carer involvement in decisions (1-item). Fifteen of participants completed feedback interviews which underwent thematic analysis. User analytics were collected and analysed., Results: Fifty-six HPs completed baseline measures, 42 completed post- and follow-up measures. At baseline mean self-efficacy score was 88. HPs showed a statistically significant increase in self-efficacy post-intervention (mean = 105.8, CI [12.99, 20.47]), maintained at 12-weeks (mean = 101.1, CI [8.00, 15.72]). There were no changes in knowledge or decision-making preferences. Program engagement and satisfaction were high, 86.7% participants rated eTRIO as very/extremely helpful., Conclusions and Practice Implications: eTRIO provided HPs with confidence to effectively engage with carers and manage complex situations such as family dominance. These gains are noteworthy, as conflict with families/carers contributes to HP burnout., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Objective: Research on family communication of germline genome sequencing (GS) results (versus of genetic results after targeted genetic testing) is still emerging, yet potentially complex results increase the importance of communicating risk to relatives. Promoting equity by ensuring patients have sufficient health literacy to interpret results is important in this context. This study aimed to identify cancer patients' perceived importance of result disclosure, predictors of perceptions, and perspectives on family communication., Methods: This explanatory-sequential, cross-sectional mixed-methods study involved participants (n = 246) completing a questionnaire and (n = 20) a semi-structured interview. Ordinal logistic regressions determined associations between potential predictors and perceived importance of result disclosure. Interview transcripts were analysed thematically using a constant-comparative approach., Results: More participants intended disclosing to nuclear (77.4%) than to extended family (42.7%). More than half (59.3%) felt results were family information; 62.7% believed it was important to disclose results to family members. Nuclear and extended family communication scores and education level were significantly positively associated with perceived importance of disclosure (p < 0.05). Six qualitative themes were identified: i) Responsibility to inform, ii) Choice, iii) Autonomy, iv) Family Communication, v) Significance of results, and vi) Health professional role., Conclusion: Low health literacy and family conflict can complicate communication of GS results. Patients seek clear, interpretable information in a format they can easily communicate., Practice Implications: Healthcare professionals can facilitate discussion of GS results by offering written information, encouraging disclosure, exploring existing family dynamics and communication patterns, and offering strategies to improve family communication. Centralised genetic communication offices and chatbots can also be helpful., Competing Interests: Declaration of Competing Interest BM has a remunerated consultant role with the company Astrazeneca with respect to an unrelated project. The other authors declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: People living with multimorbidity often rely on the support of informal family carers, yet challenges frequently arise when carers of people with multimorbidity (PwM) interact with health professionals (HPs) and healthcare systems. This study aimed to provide insights into the experiences and challenges involved in working with carers of PwM, from HPs' perspectives., Methods: Twenty-one HPs (11 doctors, 5 nurses and 5 allied health professionals) from varying specialities participated in semi-structured interviews. Interviews were transcribed and qualitatively analysed using thematic analysis., Results: Five themes were identified: carer involvement makes multimorbidity easier to manage, differing views on HP's responsibilities to carers, multimorbidity makes management harder for HPs, strategies to support carers of PwM, and multimorbidity is one aspect of complexity., Conclusions: HPs recognise unique needs of carers of PwM, yet perceive challenges addressing these needs and supporting this commonly overlooked group., Practice Implications: The unmet needs of carers of PwM that HPs identified in this study suggest pathways for future improvements and interventions, including HP education and training, and appropriate referral pathways for carers of PwM to access supportive services. Underpinning these findings is the need for greater recognition and respect for the critical work of family carers in healthcare., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: The Concerns about Late Effects in Oncology (CLEO) questionnaire was developed to measure concerns cancer survivors may have about late effects. The current study sought to assess the Concerns about Late Effects in Oncology's (CLEO) psychometric properties - factor structure, construct validity, discriminatory power, and internal consistency., Methods: 147 breast cancer survivors completed a survey. Factor structure was determined by exploratory factor analysis (EFA). Construct validity was assessed against fear of cancer recurrence, anxiety, depression, quality of life, and neuroticism. Discriminatory power was assessed against participants' age and clinical characteristics., Results: The EFA confirmed a 4-factor structure; health professionals' support, psychological impacts, adapting, and daily functional impacts. There was only partial support for construct validity and discriminatory power. The CLEO demonstrated excellent internal consistency, with an overall Cronbach's α = 0.87 (health professionals' support: α = 0.89, psychological impacts: α = 0.93, adapting: α = 0.82, and daily functional impacts: α = 0.89)., Conclusion: The findings suggest further development of the CLEO should focus on the psychological and functional impacts of late effects., Practice Implications: Use of the CLEO may enhance communication about the impact of late effects, ensuring earlier identification and management of late effects in this population., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Competing interests The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: To explore Indian cancer patients' and their primary family caregivers' (PFC) experiences and expectations of treatment-related communication with their physician while undergoing radiation therapy., Methods: Participants, comprising patient-PFC dyads (n = 32), patients only (n = 33) and PFC only (n = 7), were recruited from one hospital in Mumbai, India. Semi-structured interviews explored participants' perceived role in cancer-related decision-making, diagnosis and prognosis communication experiences with the physician, communication expectations of their treating physician, and information needs. Interviews were audio-recorded, transcribed verbatim, and analysed using the framework approach., Results: Main themes included: (i) patients' passive role in treatment communication, (ii) family as an integral part of the medical consultation, and (iii) dyads' expectations and beliefs about the role of the physician., Conclusion: Indian cancer patients played a passive role in treatment decision-making while physicians were seen as primary medical decision-makers. Further, PFCs provided the final consent for the treatment plan and acted as a mediator/moderator between the patient-physician., Practice Implications: These findings suggest the need for (i) interventions such as question prompt lists that may improve patient activation and caregiver preparedness, and (ii) triadic communication training interventions for optimal communication between the three stakeholders (i.e., patient, physician and PFC)., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Cancer patients, carers and oncology health professionals have been impacted by the COVID-19 pandemic in many ways, but their experiences and psychosocial responses to the pandemic are still being explored. This study aimed to document the experience of Australians living with cancer, family carers, and Oncology health professionals (HPs) when COVID-19 first emerged., Methods: In this qualitative study, participants (cancer patients currently receiving treatment, family carers and HPs) completed a semi-structured interview exploring their experiences of COVID-19 and the impact it had on cancer care. Participants also completed the Hospital Anxiety and Depression Scale (patients) and the Depression, Anxiety and Stress Scale (carers and HPs) to assess emotional morbidity. Thematic analysis was undertaken on qualitative data., Results: 32 patients, 16 carers and 29 HPs participated. Qualitative analysis yielded three shared themes: fear and death anxiety, isolation, and uncertainty. For HPs, uncertainty incorporated the potential for moral distress and work-stress. Patients and carers scoring high on anxiety/depression measures were more likely to have advanced disease, expressed greater death anxiety, talked about taking more extreme precautionary measures, and felt more impacted by isolation., Conclusion: Cancer and COVID-19 can have compounding psychological impacts on all those receiving or giving care., Practice Implications: Screening for distress in patients, and burnout in HPs, is recommended. Increased compassionate access and provision of creative alternatives to face-to-face support are warrented., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: To understand advanced cancer patients' experience of uncertainty when receiving comprehensive tumor genomic profiling (CTGP) results, and their perceptions of how healthcare provider (HCP) communication impacts uncertainty., Methods: Thirty-seven semi-structured interviews with advanced cancer patients were conducted within two weeks of patients receiving CTGP results. Transcripts were thematically analyzed, using an inductive approach., Results: We identified three themes that illustrate patient experience of uncertainties when receiving CTGP results: 1. Type and degree of uncertainty fluctuates along with changing illness circumstances and the nature of the CTGP results; 2. HCPs' co-ordination of care and communication shapes uncertainty, with immediate, clearer and simpler information promoting certainty; and 3. Patients felt that communicating results to reduce relatives' uncertainty is important, with patients choosing the time and process for achieving this and desiring HCPs support., Conclusion: Oncology patients are confronted with an array of uncertainties. Clear, simple communication from HCPs about results and their implications, and support to manage uncertainty, will be of benefit., Practice Implications: If CTGP is to become routine clinical practice, clear communication will be crucial in reducing uncertainty. Awareness of potential uncertainties experienced by patients when receiving results, will assist HCPs to address uncertainties, reduce uncertainty where possible, and offer targeted support to patients struggling with uncertainty., Competing Interests: Declaration of Competing Interest BM has a remunerated consultant role with the company Astrazeneca with respect to an unrelated project. The other authors declare no conflicts of interest., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Given the stressful and emotional nature of cancer, challenging interactions between nurses, patients, and family frequently occur. Nurses are rarely equipped with strategies to avoid or de-escalate stressful situations with carers, which can include displays of conflict, anger, or dominance. A brief online education module (TRIO-Conflict) was developed to provide nurses with management strategies to use in situations of conflict. This study aimed to assess the feasibility, acceptability, and potential efficacy of TRIO-Conflict., Methods: Nurses were recruited through an Australian breast cancer organisation (McGrath Foundation). Participants completed pre/post module measures of attitudes towards carers, confidence in their skills to effectively navigate challenging interactions with carers, and applied knowledge of management strategies. Data were analysed using Wilcoxon signed-rank tests. Qualitative feedback was analysed using content analysis., Results: 52 nurses completed pre-/post- measures, with 4 semi-structured interviews conducted. Significant improvements in attitudes towards carers (p = .010) and confidence in one's own ability to manage challenging interactions with carers (p < .001) were found, but not knowledge of strategies. Most nurses found TRIO-Conflict very/extremely helpful (87%) and were satisfied with content (94%) and usability (93%)., Conclusion: TRIO-Conflict utilised evidence-based learning techniques (provision of example phrases, video vignettes, reflective exercises) to improve nurses attitudes and confidence., Practice Implications: TRIO-Conflict is a brief, targeted, clinically relevant, and easily accessible online training programme which could be widely disseminated to oncology nurses., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: This study explored family communication about undertaking genomic sequencing, and intentions to communicate pertinent heritable results to family members., Methods: Semi-structured interviews were conducted with cancer patients (n = 53) and their relatives (n = 20) who underwent germline genome sequencing or molecular tumor testing. Interviews were audio-recorded, transcribed and analyzed using thematic analysis., Results: Key themes relevant to family communication about undertaking sequencing included: perceiving family member interest, delaying discussion until results were received, having shared capacity to understand and cope, and having open communication in the family. Intended communication subsequent to receiving results was affected by: disease severity, risk management options, degree of closeness in the family, sense of responsibility, and potential adverse impacts on family. Resource and support needs varied based on the complexity of test results, health professionals' availability, and disease severity. Unique subthemes were identified for specific subgroups., Conclusion: Current findings support the need to assess the impact and resource needs specific to each clinical application of genomic sequencing., Practice Implications: Increasingly sophisticated and complex clinical genomic sequencing warrants development of family-centered interventions and resources to facilitate preference-sensitive communication about genomic sequencing, including disseminating relevant information to family members., Competing Interests: Declaration of Competing Interest BM has a remunerated consultant role with the company AstraZeneca with respect to an unrelated project. The other authors declare no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Patients want to discuss spirituality more with their doctors but feel disempowered. Question prompt lists (QPLs) assist conversations. This study assessed the impact of a QPL on spirituality discussions in Palliative Care (PC)., Methods: This was a sub-study of a trial in which PC patients were randomised to either receive a QPL prior to a consultation or not, to see whether its provision influenced advanced cancer patients'/caregivers' questions and discussion of topics relevant to end-of-life care during consultations with a PC physician. Consultations were recorded and transcribed. Transcriptions were analysed to examine the frequency and content of spirituality discussions. We conducted logistic regression to investigate the impact of the QPL and other predictors., Results: 174 patients participated. Spirituality was discussed in half the consultations. Patients receiving a QPL discussed spirituality 1.38 times more than controls. This finding did not reach statistical significance. First PC consultation and being asked about their concerns by the doctor were significant predictors of a spiritual discussion., Conclusion: Patients are more likely to discuss spirituality in their first PC consultation, and when their doctor asks them about their concerns., Practice Implications: Doctors caring for patients at the end of life should routinely raise spiritual issues., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To document the effect of a cancer specific question prompt list (QPL) on patients question asking and shared decision-making (SDM), and to evaluate the combined effect of the QPL and consultation audio recording (CAR) on patient outcomes., Method: This exploratory study compared two groups of patients receiving either a QPL or combined QPL/CAR, to a control group. Measurements included number/types of questions asked, and physician SDM behavior (OPTION score). Questionnaire data included anxiety/depression and quality of life (QoL)., Results: A total of 93 patients participated (31 Control, 30 QPL and 32 Combined). Patients in the intervention groups asked more questions concerning prognosis (p < .0001), the disease (p = .006) and quality of treatment (p < .001) than patients in the control group, but no impact was found on the OPTION score. An increase in mean consultation length was observed in the intervention groups compared to the control group (44 vs. 36 min; p = .028). Patients rated both interventions positively., Conclusion: Provision of the QPL facilitates patients to ask a broader range of questions, but does not increase physician SDM behavior., Practical Implementation: The combination of QPL and CAR seems feasible and should be tested in an implementation study following the disease trajectory., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Family caregivers regularly attend medical consultations and are often involved in decision-making; however, there are few practical strategies to guide effective communication for the clinician-patient-family trio. We aimed to develop and evaluate the first comprehensive guidelines for oncology physicians and nurses, on how to positively and effectively involve family caregivers of adult patients in consultations and patient care (TRIO Guidelines-1) and how to manage challenging interactions with family caregivers (TRIO Guidelines-2)., Methods: The TRIO Guidelines were based on a comprehensive literature review and input from an expert advisory group (n = 10). They underwent two rounds of formal evaluation via an online Delphi consensus process involving international experts (n = 35), and a subset were piloted with 24 breast cancer clinicians in a workshop format., Results: TRIO Guidelines-1 incorporate strategies and sub-strategies on facilitating collaborative and effective family involvement (6 topics). Example wording, behaviours, and level of evidence are provided throughout. All 24 clinicians rated the guidelines as helpful after the pilot workshop., Conclusion: These guidelines will be a useful educational tool for clinicians and medical/nursing students., Practice Implications: By equipping clinicians with strategies to facilitate effective and collaborative family engagement, the TRIO Guidelines have the potential to transform communication in clinical practice., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Family caregivers can, at times, add complexity to clinical encounters. Difficult family caregivers and dynamics may: derail consultation communication, reduce patient autonomy, and compromise effective clinical care. A paucity of practical strategies guiding effective clinician-family communication exists. This study aimed to develop and evaluate the first comprehensive, evidence-based guidelines (the TRIO guidelines) for oncology physicians and nurses to better manage several complex/challenging situations involving family members., Methods: TRIO Guidelines were based on a comprehensive review of literature, relevant guidelines, and feedback from an expert advisory group (n = 10). Draft guidelines underwent two rounds of evaluation via an online Delphi consensus process involving international experts (n = 35)., Results: Guidelines incorporate topic areas, strategies, and sub-strategies on managing challenging family involvement (7 topics). Example wording, behaviours and level of evidence are provided., Conclusion: Challenging triadic interactions require skillful navigation, and the TRIO Guidelines provide clear, specific, and evidence-based strategies for clinicians to utilise in these potentially stressful encounters. Training based on these guidelines may improve both patient care and clinician confidence., Practice Implications: Implementation of these guidelines into medical/nursing curricula and as a component of continuing professional development programs will likely be highly beneficial., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Family caregivers are regularly involved in cancer consultations and treatment decision-making (DM). Yet there is limited conceptual description of caregiver influence/involvement in DM. To address this, an empirically-grounded conceptual framework of triadic DM (TRIO Framework) and corresponding graphical aid (TRIO Triangle) were developed., Methods: Jabareen's model for conceptual framework development informed multiple phases of development/validation, incorporation of empirical research and theory, and iterative revisions by an expert advisory group., Results: Findings coalesced into six empirically-grounded conceptual insights: i) Caregiver influence over a decision is variable amongst different groups; ii) Caregiver influence is variable within the one triad over time; iii) Caregivers are involved in various ways in the wider DM process; iv) DM is not only amongst three, but can occur among wider social networks; v) Many factors may affect the form and extent of caregiver involvement in DM; vi) Caregiver influence over, and involvement in, DM is linked to their everyday involvement in illness care/management., Conclusion: The TRIO Framework/Triangle may serve as a useful guide for future empirical, ethical and/or theoretical work., Practice Implications: This Framework can deepen clinicians's and researcher's understanding of the diverse and varying scope of caregiver involvement and influence in DM., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Decision-making in ductal carcinoma in situ (DCIS) is complex due to the heterogeneity of the disease. This study aimed to understand women's experience of making treatment decisions for DCIS, their information and support needs, and factors that influenced decisions., Methods: We searched six electronic databases, conference proceedings, and key authors. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Thematic analysis was used to combine and summarise findings., Results: We identified six themes and 28 subthemes from 18 studies. Women with DCIS have knowledge deficits about DCIS, experience anxiety related to information given at diagnosis and the complexity of decision-making, and have misconceptions regarding risks and outcomes of treatment. Women's decisions are influenced by their understanding of risk, the clinical features of their DCIS, and the benefits and harms of treatment options. Women are dissatisfied with the decisional support available., Conclusions: Informed and shared decision-making in this complex decision setting requires clear communication of information specific to DCIS and individual's, as well as decision support for patients and clinicians., Practice Implications: This approach would educate patients and clinicians, and assist clinicians in supporting patients to an evidence-based treatment plan that aligns with individual values and pReferences., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Question prompt lists (QPLs) and consultation audio-recordings (CARs) are two communication strategies that can assist cancer patients in understanding and recalling information. We aimed to explore clinician and organisational barriers and facilitators to implementing QPLs and CARs into usual care., Methods: Semi-structured interviews with twenty clinicians and senior hospital administrators, recruited from four hospitals. Interviews were recorded, transcribed verbatim and thematic descriptive analysis was utilised., Results: CARs and QPLs are to some degree already being initiated by patients but not embedded in usual care. Systematic use should be driven by patient preference. Successful implementation will depend on minimal burden to clinical environments and feedback about patient use. CARs concerns included: medico-legal issues, ability of the CAR to be shared beyond the consultation, and recording and storage logistics within existing medical record systems. QPLs issues included: applicability of the QPLs, ensuring patients who might benefit from QPL's are able to access them, and limited use when there are other existing communication strategies., Conclusions: While CARs and QPLs are beneficial for patients, there are important individual, system and medico-legal considerations regarding usual care., Practice Implications: Identifying and addressing practical implications of CARs and QPLs prior to clinical implementation is essential., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: Little is known about how family are involved in cancer treatment decision-making. This study aimed to qualitatively explore Australian oncology clinicians', patients', and family members' attitudes towards, and experiences of, family involvement in decision-making., Methods: Semi-structured interviews were conducted with 30 cancer patients, 33 family members, 10 oncology nurses and 11 oncologists. Framework analysis methods were used., Results: Three main themes were uncovered: (i) how family are involved in the decision-making process: specific behaviours of family across 5 (extended) decision-making stages; (ii) attitudes towards family involvement in the decision-making process: balancing patient authority with the rights of the family; and (iii) factors influencing family involvement: patient, family, cultural, relationship, and decision., Conclusion: This study highlighted many specific behaviours of family throughout the decision-making process, the complex participant attitudes toward retaining patient authority whilst including the family, and insight into influencing factors. These findings will inform a conceptual framework describing family involvement in decision-making., Practice Implications: Clinicians could ascertain participant preferences and remain open to the varying forms of family involvement in decision-making. Given the important role of family in the decision-making process, family inclusive consultation strategies are needed., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: Most women diagnosed with unilateral breast cancer without BRCA1 or BRCA2 mutations are at low risk of contralateral breast cancer. Contralateral Prophylactic Mastectomy (CPM) decreases the relative risk of contralateral breast cancer, but may not increase life expectancy; yet international uptake is increasing. This study applied protection motivation theory (PMT) to determine factors associated with women's intentions to undergo CPM., Methods: Three hundred eighty-eight women previously diagnosed with unilateral breast cancer and of negative or unknown BRCA1 or BRCA2 status were recruited from an advocacy group's research database. Participants completed measures of PMT constructs based on a common hypothetical CPM decision-making scenario., Results: PMT constructs explained 16% of variance in intentions to undergo CPM. Response efficacy (CPM's advantages) and response costs (CPM's disadvantages) were unique individual predictors of intentions., Conclusion: Decision-making appears driven by considerations of the psychological, cosmetic and emotional advantages and disadvantages of CPM. Overestimations of threat to life from contralateral breast cancer and survival benefit from CPM also appear influential factors., Practice Implications: Patients require balanced and medically accurate information regarding the pros and cons of CPM, survival rates, and recurrence risks to ensure realistic and informed decision-making.

Objective: The aim of this systematic literature review was to ascertain the patient perspective regarding the role of the doctor in the discussion of spirituality., Methods: We conducted a systematic search in ten databases from inception to January 2015. Eligible papers reported on original research including patient reports of discussion of spirituality in a medical consultation. Papers were separated into qualitative and quantitative for the purposes of analysis and quality appraisal with QualSyst. Papers were merged for the final synthesis., Results: 54 studies comprising 12,327 patients were included. In the majority of studies over half the sample thought it was appropriate for the doctor to enquire about spiritual needs in at least some circumstances (range 2.1-100%, median 70.5%), but patient preferences were not straightforward., Conclusion: While a majority of patients express interest in discussion of religion and spirituality in medical consultations, there is a mismatch in perception between patients and doctors regarding what constitutes this discussion and therefore whether it has taken place., Practice Implications: This review demonstrated that many patients have a strong interest in discussing spirituality in the medical consultation. Doctors should endeavor to identify which patients would welcome such conversations., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To explore treatment decision-making experiences of Australian migrants with cancer from Arabic, Chinese, or Greek backgrounds and their relatives., Methods: 73 patients and 18 caregivers from cancer support groups and oncology clinics participated in either a focus group (n=14) or semi-structured interview (n=21) conducted in the participant's own language. Participant treatment decision-making preferences were discussed as part of patients' overall treatment experience and a thematic analysis conducted., Results: Four main themes emerged from the data: (1) perceived role of the patient in decision-making; (2) access to information and the impact of language; (3) cultural influences (4) family involvement. The majority of participants experienced passive involvement during treatment consultations, but expressed a desire for greater involvement. Language rather than culture was a greater obstacle to active participation. Difficulty communicating effectively in English was the most significant barrier to participation in treatment decisions. To overcome language challenges, participants actively sought information from alternative sources., Conclusion: This study provides new insights into the influence of language and culture on the treatment decision-making experiences of migrants with cancer and their families within the Australian cancer care system., Practice Implications: To reduce health disparities doctors need to address language difficulties and be aware of cultural differences., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Objective: Selective estrogen receptor modulators (SERMs) reduce breast cancer risk by 38%. However, uptake is low and the reasons are not well understood. This study applied protection motivation theory (PMT) to determine factors associated with intention to take SERMs., Methods: Women at increased risk of breast cancer (N=107), recruited from two familial cancer clinics in Australia, completed a questionnaire containing measures of PMT constructs. Hierarchical multiple linear regression analysis was used to analyze the data., Results: Forty-five percent of women said they would be likely or very likely to take SERMs in the future. PMT components accounted for 40% of variance in intention to take SERMs. Perceived vulnerability, severity and response efficacy appeared the most influential in women's decisions to take or not take SERMs., Conclusion: Many women are interested in SERMs as a risk management option. Accurate risk estimation and an understanding of the benefits of SERMs are critical to women's decision making., Practice Implications: Health professionals need to explore women's perceptions of their risk and its consequences, as well as providing clear evidence-based information about the efficacy of SERMs. Exploring the source and strength of beliefs about SERMs may allow more effective, tailored counseling., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Telephone-based supportive care presents a potentially highly accessible means of addressing unmet supportive care needs for people with cancer. Identification of behaviours that facilitate communication is essential for development of training for telephone-based supportive care. The aim of this study was to describe communication behaviours within supportive care telephone calls in two contexts (1) a telephone outreach intervention and (2) cancer helpline calls, to identify potential areas for further training., Methods: 50 recorded calls were analysed using two standardised coding systems: the RIAS and Verona-CoDES-C., Results: Mean call length was 21 min (304 utterances) for nurse-outreach calls and 23 min (355 utterances) for helpline calls. Closed questioning, verbal attentiveness and giving information/counselling were the most common communication behaviours identified. Emotional cues were most commonly responded to through non-explicit back-channelling, exploration of content or provision of reassurance or advice., Conclusions: This study confirmed the need to address the manner in which questions are framed to maximise patient disclosure. Responding to patent emotional cues was highlighted as an area for future training focus., Practice Implications: Communication skills training that addresses each of these tasks is likely to improve the effectiveness of telephone-based delivery of supportive care., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To systematically review quantitative and qualitative studies exploring physician-adult patient-adult companion (triadic) communication and/or decision-making within all medical encounters., Methods: Studies were identified via database searches and reference lists. One author assessed eligibility of studies, verified by two co-authors. Data were extracted by one author and cross-checked for accuracy. Two authors assessed the quality of included articles using standardized criteria., Results: Of the 8409 titles identified, 52 studies were included. Summary statements and tables were developed for each of five identified themes. Results indicated companions regularly attended consultations, were frequently perceived as helpful, and assumed a variety of roles. However, their involvement often raised challenges. Patients with increased need were more often accompanied. Some companion behaviours were felt to be more helpful (e.g. informational support) and less helpful (e.g. dominating/demanding behaviours), and preferences for involvement varied widely., Conclusion: Triadic communication in medical encounters can be helpful but challenging. Based on analysis of included studies, preliminary strategies for health professionals are proposed., Practice Implications: Preliminary strategies for health professionals include (i) encourage/involve companions, (ii) highlight helpful companion behaviours, (iii) clarify and agree upon role preferences of patient/companions. Future studies should develop and evaluate specific strategies for optimizing triadic consultations., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: A Question Prompt List (QPL) is a proven, simple intervention to aid patients to be active participants in consultations with their physicians by asking questions. We aimed to further develop and test the efficacy of a targeted QPL for clinical trials (QPL-CT)., Methods: Breast, Lung and Genitourinary cancer patients who were facing a discussion about a therapeutic clinical trial completed short pre- and post-consultation questionnaires and used the QPL-CT in their discussions with their oncologists., Results: 30 participants were recruited from 6 oncologists. All QPL-CT questions were selected by at least one-third of participants. Participants mostly wanted and asked questions about personal trial benefit. Oncologists provided information about personal benefit to varying degrees, thus patients did not ask some questions. Patients were still left with some unasked and unanswered questions., Conclusion: The QPL-CT has potential as a simple, inexpensive intervention to aid such communication. Further investigation is needed to demonstrate the efficacy of the QPL-CT in improving cancer patient outcomes., Practice Implications: These preliminary finding suggest that important areas of clinical trials are overlooked in clinical consultations. The QPL-CT may be an effective method to encourage oncologists to endorse patient question asking about clinical trials and prompt patient questions., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: Immigrants report challenges communicating with their health team. This study compared oncology consultations of immigrants with and without interpreters vs Anglo-Australian patients., Methods: Patients with newly diagnosed incurable cancer who had immigrated from Arabic, Chinese or Greek speaking countries or were Anglo-Australian, and family members, were recruited from 10 medical oncologists in 9 hospitals. Two consultations from each patient were audio-taped, transcribed, translated into English and coded., Results: Seventy-eight patients (47 immigrant and 31 Anglo-Australian) and 115 family members (77 immigrant and 38 Anglo Australian) participated in 141 audio-taped consultations. Doctors spoke less to immigrants with interpreters than to Anglo-Australians (1443 vs. 2246 words, p=0.0001), spent proportionally less time on cancer related issues (p=0.005) and summarising and informing (p≤0.003) and more time on other medical issues (p=0.0008) and directly advising (p=0.0008). Immigrants with interpreters gave more high intensity cues (10.4 vs 7.4). Twenty percent of cues were not interpreted. Doctors tended to delay responses to or ignore more immigrant than Anglo-Australian cues (13% vs 5%, p=0.06)., Conclusions: Immigrant cancer patients with interpreters experience different interactions with their doctors than Anglo-Australians, which may compromise their well-being and decisions., Practice Implications: Guidelines and proven training programmes are needed to improve communication with immigrant patients, particularly those with interpreters., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: Question Prompt Lists (QPLs) have demonstrated significant promise in facilitating communication in general, surgical and palliative oncology settings yet have not been tested in the oncology clinical trial setting. We aimed to develop a targeted QPL for Clinical Trials (QPL-CT)., Methods: Breast, lung, and genitourinary cancer patients who either had (trial experienced) or had not (trial naive) participated in a clinical trial joined focus groups to help develop and explore the acceptability of a QPL-CT. Clinicians also participated in separated focus groups. Focus groups were audio-recorded and transcribed. We explored patients' trial information needs and views about the utility of the QPL-CT., Results: Patients focused on four trial information needs: understanding foundational information, conflict of interest issues and financial implications of trial participation. Of note, experienced patients need to personalize foundational information., Conclusion: Patient information needs varied considerably and were influenced by trial experience. Patients valued the QPL-CT as an aid to gathering new trial information and ensuring that their information needs were met., Practice Implications: Physicians need to carefully elicit patient information needs and tailor trial information to meet these needs. The QPL-CT, may be of great benefit during clinical trial discussions., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: This study aimed to explore the impact of nurse responses to patients' and family members' emotional cues and concerns during the chemotherapy education consultation., Methods: 51 cancer patients and 13 nurses participated in this study. Nurse-delivered chemotherapy education sessions were audio-recorded, and patients completed the EORTC QLQ-C30 V3.0 questionnaire before the education. The audio records were transcribed and coded., Results: Patients expressed their emotions more than family members, but patients' cues decreased when family were present. Patients with lower emotional wellbeing (greater psychological distress) prior to the consultation did not express more cues/concerns. Nurses responded to patients' and families' cues equally in a cue-facilitative fashion. Facilitative responses were associated with decreased patients' cues., Conclusion: Family presence appears to hinder patients' cues/concerns. Nurses' PS responses were associated with less cues/concerns by patients., Practice Implication: The current study challenges the common assumption that a higher number of cues is indicative of effective consultation, and indicates the influence of family in patients' cues/concerns., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes., Methods: Cognitive and emotional aspects of SDM in consultations between 20 oncologists and 55 early breast cancer patients were coded using the Observing Patient Involvement (OPTION) scale and the Response to Emotional Cues and Concerns (RECC) coding system, plus blocking and facilitating behaviour scales. Patient outcomes including anxiety, decisional conflict, and satisfaction with: (i) the decision, (ii) the consultation, and (iii) doctor SDM skills, were assessed. Relationships between cognitive and emotional aspects of SDM, and patient outcomes were examined using hierarchical regression., Results: The OPTION score predicted satisfaction with doctor SDM skills 2 weeks post-consultation (p=.010), and with the treatment decision 4 months post-consultation (p=.004). Emotional blocking predicted decisional conflict (p=.039), while the number of emotional cues emitted (p=.003), and the degree of empathy provided (p=.011), predicted post-consultation anxiety., Conclusion: Cognitive and emotional aspects of SDM in oncology consultations have different effects on various patient outcomes., Practice Implications: It is important that doctors focus on both sharing decisions and managing emotions in consultations. Communication skills training addressing both these areas may be an effective way to improve diverse patient outcomes., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: The current study aimed to evaluate three coding systems which have been used to assess shared decision making in oncology consultations (OPTION, Decision Support Analysis Tool (DSAT) and Decision Analysis System for Oncology (DAS-O)): (i) comparing their ability to identify competencies of shared decision making, and (ii) determining their ability to predict patient outcomes in a single data set., Method: Twenty oncologists from Australia and New Zealand participated in the IBCSG Trial 33-03. The consultations of 55 women with early stage breast cancer were audio-taped, transcribed and then coded using the OPTION, DAS-O and DSAT coding systems by three different raters. Women completed the questionnaires 2 weeks and 4 months after their consultation., Results: DAS-O was strongly correlated with OPTION (r=0.73). DSAT was moderately correlated with DAS-O and OPTION (r<0.6). Decisional satisfaction and satisfaction with doctor SDM skills were significantly correlated with OPTION (r=0.39 and 0.42 respectively) and the latter variable was correlated with DAS-O (r=0.40). These relationships persisted in multiple linear regression analyses., Conclusions: OPTION may be the most efficient and sensitive coding system for research purposes; however, DSAT appeared to document behaviours reducing decisional conflict and both DSAT and DAS-O offer more detailed feedback to doctors., Practice Implications: Optimal coding system will depend on research goals and training purposes., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate whether a consultation skills training (CST) program with oncologists and trainees would improve skills in detecting and responding to patient distress, thereby improving their patients' emotional functioning and reducing psychological distress., Methods: Randomized-controlled trial with 29 medical and radiation oncologists from Australia randomized to CST group (n=15) or usual-care group (n=14). The CST consisted of a 1.5-day face-to-face workshop incorporating presentation of principles, a DVD modelling ideal behaviour and role-play practice, and four 1.5h monthly video-conferences. At the CST conclusion, patients of participating doctors were recruited (n=192 in CST group, n=183 in usual-care group), completing telephone surveys at baseline, 1 week and 3 months to assess quality of life, anxiety, depression and unmet psychosocial needs., Results: Despite high patient functioning at baseline, anxiety significantly improved at 1-week follow-up in the CST group, compared to the control group. There were no statistically significant differences in emotional functioning, depression or unmet supportive care need between the groups., Conclusion: Consistent trends for greater improvements were observed in intervention compared to control group patients, suggesting the CST program deserves wider evaluation., Practice Implications: Video-conferencing after a short training course may be an effective strategy for delivering CST.

Objective: To ascertain the feasibility of implementing three decision support tools (DSTs) for people with rectal cancer within the surgical consultation., Methods: Twenty colorectal surgeons participated in a focus group or individual interviews. Colorectal surgeons were also asked to complete a self-administered questionnaire., Results: All surgeons responded encouragingly to the concept of DSTs. However, for every positive statement an accompanying caveat was made and these were either a criticism of each tool or a barrier to their implementation. Surgeons stated DSTs should be used by patients and surgeons together (80%). The majority (70-75%) thought each tool was 'useful' or 'extremely useful'. However, there were strong views that in their current form the DSTs would not feasible to be used within the surgical consultation. Time restraints, personal and clinical characteristics of the patient, the content of each tool, the potential negative impact on the doctor-patient relationship were noted as real barriers to their implementation., Conclusion: Surgeons have identified a number of barriers that may limit implementation of DSTs into routine clinical practice., Practice Implications: Feasibility and implementation studies have the potential to provide important information to help guide development, evaluation and implementation of DSTs.

Objective: This randomized controlled trial aimed to evaluate a decision aid for women with multiple sclerosis deciding whether to start or enlarge their families., Method: Decision aid materials were mailed to participants, and their response materials returned by mail. One-hundred and ninety-four women with MS agreed to participate and were randomized to receive the DA or not. Participants completed questionnaires measuring decisional-conflict, self-efficacy, knowledge, depression and anxiety as well as their views regarding having children pre- and post-intervention., Results: Women who received the DA had a significant decrease in decisional-conflict, increase in self-efficacy and knowledge of MS and pregnancy and more certainty in their choice than those in the control group. There were no adverse effects on depression or anxiety and women's decisions were not biased in either direction., Conclusion: The DA is a useful tool that can be used by women with MS contemplating motherhood., Practice Implications: This DA is used as a resource by the MS Society illustrating how DAs may help with lifestyle choices complicated by illness. It represents a tool adaptable to suit other illnesses where reproductive decision-making may be compromised and should be of interest to health-care professionals who are consulted by women with family-planning concerns.

Objective: Statistical health risk information has proved notoriously confusing and difficult to understand. While past research indicates that presenting risk information in a frequency format is superior to relative risk and probability formats, the optimal characteristics of frequency formats are still unclear. The aim of this study is to determine the features of 1000 person frequency diagrams (pictographs) which result in the greatest speed and accuracy of graphical perception., Methods: Participants estimated the difference in chance of survival when taking or not taking Drug A, on a pictograph format, varying by mode (one-graph/two-graph), direction (vertical/horizontal), and shading (shaded/unshaded), and their preferences for the different formats. Their understanding of different components of the 1000 person diagram was assessed. Responses were timed and scored for accuracy., Results: Horizontal pictographs were perceived faster and more accurately than vertical formats. Two-graph pictographs were perceived faster than one-graph formats. Shading reduced response time in two-graph formats, but increased response times in one-graph formats. Shaded and one-graph pictographs were preferred., Conclusions: As shading and one-graph formats were preferred, further clarification as to why shading negatively impacts on response times in the one-graph format is warranted., Practice Implications: Horizontal pictographs are optimal.

Cancode is a computerized interaction analysis system developed for cancer consultations. This paper assesses its reliability and validity, and compares the use of audio versus video tape; by assessing 30 consultations between an actor and 10 oncologists. Weighted Kappa inter- and intra-rater scores ranged from 0.5 to 1.0 and 0.58-1.0, respectively, and use of video tape did not alter verbal coding. Factor analysis of verbal codes revealed two factors, 'verbal control' and 'verbal support'. Verbal and non-verbal doctor behavior differed by patient type ('verbal support' P = 0.007, 'verbal control' P = 0.004, 'Responsiveness' P = 0.000, and 'Immediacy' P = 0.000). Inter-doctor variation was noted for 'verbal support' (P = 0.000) and 'Relaxation' (P = 0.000). 'Responsiveness' was negatively correlated with 'verbal support' (-0.58) and 'verbal control' (-0.65). Cancode is reliable, valid and sensitive to doctors behavioral changes. For a more passive patient, the doctor may switch from a 'cure' to 'care' oriented consult, responding to psycho-social instead of informational needs.