Collaborating in the formulation of treatment goals with the patient, listening and not interrupting, making eye contact, and earning trust and respect—these are all known ways that oncologists can strengthen a patient-physician alliance. Now, a new study suggests that by developing a strong patient-physician alliance, oncologists can increase treatment adherence in young adult patients with advanced cancer.
The researchers, from Dana-Farber Cancer Institute's Center for Psychosocial Epidemiology and Outcomes Research, found that younger cancer patients who develop a strong alliance with their health care providers say they are more willing to adhere to treatment plans, and in fact report that they are more adherent. The study is published in the May 1 issue of the Journal of Clinical Oncology (2013;31:1683-1689)
This is important, the researchers say, because younger adults with cancer have lower levels of treatment adherence relative to patients with cancer in other age groups.
In the study of 95 patients age 20 to 40 (mean 33 years) with advanced cancer, the patient-physician alliance was signi?cantly and positively associated with greater willingness to adhere to treatment and greater adherence to oral medication.
Oncologists don't want to be therapists, “but they should appreciate that the way they interact with, and the way their relationship is perceived by their patients, particularly their young adult cancer patients, has an enormous impact on the patient's psychosocial well-being and willingness to adhere to treatment,” the study's senior author, Holly G. Prigerson, PhD, Director of the Center and Professor of Psychiatry at Harvard Medical School, said in a telephone interview.
Young adults with cancer can feel more alienated from their friends and families than older adults do, she noted. While people their own age are involved in jobs and marriage and are starting out in life, cancer patients are facing a life-threatening illness that can be isolating. That may heighten the importance of this social relationship with the physician.
First author Kelly M. Trevino, PhD, Instructor in Psychiatry at Brigham and Women's Hospital Department of Psychiatry, defined the patient-physician alliance as a collaborative bond, a feeling of mutual understanding, trust, respect, and caring.
She said that having a health care provider who understands their particular needs is ranked by young adults and adolescents as their second most important health care need—right after development of treatments for cancers diagnosed in adolescents and young adults.
Trevino said these data do not yet point to specific actions oncologists should take, but that it is known that providers who use direct communication and are positive and nonjudgmental are seen as having a stronger alliance with patients.
“Oncologists who want to foster a therapeutic alliance with their patients should strive to listen attentively to their concerns, convey respect, offer empathic support, and promote trust in working toward shared goals of care,” the article notes (Karen Fasciano, PsyD, is also a coauthor).
Summing up, the researchers concluded: “Development of guidelines and skills-based training for oncologists, young adults, and their families that foster a strong alliance may improve the psychosocial functioning of young adult patients with cancer, improve their treatment adherence, and promote the positive outcomes that follow from better mental health and treatment adherence.”
Confirmation of Importance of Communication
Asked for a comment about the paper for this article, Bradley J. Zebrack, PhD, Associate Professor of Social Work at the University of Michigan, said the study shows that communication is important because it is associated with clinical and patient outcomes: “It is another piece of data that suggests that communication between the patient and doctor is associated with adherence to therapy and higher probability of completing therapy.”
He said the study is especially relevant because improvements in survival for young adults and teens have not been as strong as those in pediatric and adult cancer patients. “Granted, survival is very high already, but we want to see more improvement in survival rates, and we are not quite sure why that isn't happening in adolescents adults. This paper says it may be a behavioral aspect, and suggests that improving the relationship will also improve adherence.”
Zebrack said it is intuitive that patients who complete their therapy would have better survival outcomes than those who don't. Oncologists can strengthen the alliance by engaging patients in their own care, with the idea that “we're going to be partners in your care.”
The researchers acknowledge that adherence in the study was assessed by only one question in the self-reported questionnaire, and that more objective means would be more helpful. Also, the study focused only on oral treatment.
Zebrack said these limitations are the same as with any cross-sectional study, in that the findings suggest causation but do not definitely prove it. “We need studies that are longitudinal and prospective to make more definitive inferences about what factors contribute to what outcomes,” he said.
Adolescent Patients Can Look Like Adults, Act Like Kids
Anyone who has raised an adolescent or worked with one knows how frustrating they can be, sometimes acting so mature and at other times seeming completely irresponsible.
Having an adolescent cancer patient can be that much more trying, with the added worry that being irresponsible can mean noncompliance with therapy.
“Adolescence is a time of cognitive, physical, and emotional growth, and sometimes communicating with them is very challenging, said Bradley J. Zebrack, PhD, Associate Professor at the University of Michigan School of Social Work.
Oncologists should recognize this developmental state and be prepared when the otherwise articulate young adult acts emotionally immature. “At times, teen will do something very irresponsible—skip a chemotherapy session—and when asked why, they'll answer, ‘I don't know.’ And in fact, they may not know why, because some portions of their brain just aren't fully developed yet.”
The strategy for working with teens is to find ways to engage them in their own care, to convince them that undergoing therapy is something they're doing for themselves, he said.
“When they go home and their parents harp on them to take their pills, they ignore their parents, and that's sometimes more due to resistance to their parents. But if you can engage them in an alliance, tell them ‘we're going to be partners in your care’ and express a positive, nonjudgmental partnership, and then you can explain there are things you will do as a doctor but there are other things they have to do as a patient.”