Grant Number:	1R01CA140419-01A2 Interpret this number
Primary Investigator:	Epstein, Ronald
Organization:	University Of Rochester
Project Title:	Rct of Patient, Caregiver and Physician Communication Coaching in Advanced Cancer
Fiscal Year:	2011

DESCRIPTION (provided by applicant): Crafting care that is concordant with the patient's wishes in the context of serious illness requires clear, frank and sensitive communication focused on the issues of greatest importance to the patient. We aim to test a potentially powerful intervention - targeting physicians, patients and caregivers - to improve discussions regarding prognosis and treatment choices in advanced cancer. These discussions are critical to involving patients in their care, whether or not they wish to assume responsibility for making major health care decisions. Patients who have had these discussions are less likely to be misinformed about the illness, less likely to get unwarranted aggressive care and more likely to experience improved well-being. Yet, these crucial discussions frequently do not occur. As predicted by ecological theory, individually-focused interventions - targeting clinicians or patients, or using third parties - are of limited benefit in improving communication. Our approach, informed by ecological theory, is designed to optimize communication - and patient well-being - by aligning patient, caregiver and physician communication towards common goals. In this resubmission, we respond to PA-09-122: Research on Clinical Decision Making in People with or at Risk for Life-Threatening Illness and have new Specific Aims: To determine whether a combined intervention for patients/caregivers and physicians a) improves communication regarding prognosis and treatment choices in advanced cancer (primary outcome), b) improves patient well-being and c) affects health services utilization. Design is a two-site cluster RCT of a 2- component intervention designed to improve communication about prognosis and treatment choices in advanced cancer and promote patient participation in discussions regarding their care. Oncologists (N=30) will be randomized to usual-care control or the intervention: two in-office sessions providing individual tailored feedback on their communication skills. Patients (n = 300) with advanced cancer and their caregivers will be assigned to usual-care control or the intervention: pre-visit coaching and question-prompt lists to address the same communication goals as physicians. We have piloted both components of the intervention. Main outcome measures derived from audio-recorded patient-caregiver-oncologist visits will assess a) interactive communication, including responding to patients' concerns; informing patients about treatment choices; balanced framing of prognoses; and engaging patients to participate in decisions. We will also assess b) communication 1 week following the visit and patient well-being (psychological distress, quality of life, sense of peace, and quality of death) at study entry and every 3 months using patient and caregiver surveys; and c) utilization of aggressive interventions in the last week of life and palliative care and hospice consultations following study enrollment using chart audit. Significance: The proposed study addresses critically important barriers to effective communication in the context of life-limiting illness. It is the first to test a novel communication intervention targeting physicians, patients and caregivers, and it is scalable for dissemination. PUBLIC HEALTH RELEVANCE: The proposed research tests whether a newly-developed coaching intervention for oncologists, patients with advanced cancer and their caregivers promotes communication about prognosis and treatment choices. The intervention is designed to improve communication, and result in care that respects the patient's wishes, meets patients' needs for information and emotional support, reduces psychological distress, and improves shared understanding, quality of life and sense of peace. This research has the potential to help thousands of people with advanced cancer who face a limited prognosis; they often have unanswered questions and unmet emotional needs, and are not sufficiently involved in choices regarding their care.




Patient, caregiver, and oncologist predictions of quality of life in advanced cancer: Accuracy and associations with end-of-life care and caregiver bereavement.
Authors: Hoerger M. , Gramling R. , Epstein R. , Fenton J.J. , Mohile S.G. , Kravitz R.L. , Mossman B. , Prigerson H.G. , Alonzi S. , Malhotra K. , et al. .
Source: Psycho-oncology, 2022 06; 31(6), p. 978-984.
EPub date: 2022-02-10 00:00:00.0.
PMID: 35088926
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Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review.
Authors: Duberstein P.R. , Chen M. , Hoerger M. , Epstein R.M. , Perry L.M. , Yilmaz S. , Saeed F. , Mohile S.G. , Norton S.A. .
Source: Journal Of Pain And Symptom Management, 2020 Apr; 59(4), p. 894-915.e14.
EPub date: 2019-10-19 00:00:00.0.
PMID: 31639495
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Associations of Caregiver-Oncologist Discordance in Prognostic Understanding With Caregiver-Reported Therapeutic Alliance and Anxiety.
Authors: Loh K.P. , Xu H. , Epstein R.M. , Mohile S.G. , Prigerson H.G. , Plumb S. , Ladwig S. , Kadambi S. , Wong M.L. , McHugh C. , et al. .
Source: Journal Of Pain And Symptom Management, 2020-02-13 00:00:00.0; , .
EPub date: 2020-02-13 00:00:00.0.
PMID: 32061833
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The impact of the caregiver-oncologist relationship on caregiver experiences of end-of-life care and bereavement outcomes.
Authors: An A.W. , Ladwig S. , Epstein R.M. , Prigerson H.G. , Duberstein P.R. .
Source: Supportive Care In Cancer : Official Journal Of The Multinational Association Of Supportive Care In Cancer, 2020-01-03 00:00:00.0; , .
EPub date: 2020-01-03 00:00:00.0.
PMID: 31900620
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Reply to Hope, optimism, and the importance of caregivers in end-of-life care.
Authors: Trevino K.M. , Prigerson H.G. , Epstein R.M. , Duberstein P.R. .
Source: Cancer, 2019-08-05 00:00:00.0; , .
EPub date: 2019-08-05 00:00:00.0.
PMID: 31381145
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Effects of the Values and Options in Cancer Care Communication Intervention on Personal Caregiver Experiences of Cancer Care and Bereavement Outcomes.
Authors: Duberstein P.R. , Maciejewski P.K. , Epstein R.M. , Fenton J.J. , Chapman B. , Norton S.A. , Hoerger M. , Wittink M.N. , Tancredi D.J. , Xing G. , et al. .
Source: Journal Of Palliative Medicine, 2019-06-25 00:00:00.0; , .
EPub date: 2019-06-25 00:00:00.0.
PMID: 31237459
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Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment.
Authors: Trevino K.M. , Prigerson H.G. , Shen M.J. , Tancredi D.J. , Xing G. , Hoerger M. , Epstein R.M. , Duberstein P.R. .
Source: Cancer, 2019-05-30 00:00:00.0; , .
EPub date: 2019-05-30 00:00:00.0.
PMID: 31145833
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When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer.
Authors: Rodenbach R.A. , Norton S.A. , Wittink M.N. , Mohile S. , Prigerson H.G. , Duberstein P.R. , Epstein R.M. .
Source: Patient Education And Counseling, 2019 05; 102(5), p. 909-915.
EPub date: 2018-12-12 00:00:00.0.
PMID: 30579772
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Prognostic accuracy of patients, caregivers, and oncologists in advanced cancer.
Authors: Malhotra K. , Fenton J.J. , Duberstein P.R. , Epstein R.M. , Xing G. , Tancredi D.J. , Hoerger M. , Gramling R. , Kravitz R.L. .
Source: Cancer, 2019-04-29 00:00:00.0; , .
EPub date: 2019-04-29 00:00:00.0.
PMID: 31034597
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Physician and Patient Characteristics Associated With More Intensive End-of-Life Care.
Authors: Duberstein P.R. , Kravitz R.L. , Fenton J.J. , Xing G. , Tancredi D.J. , Hoerger M. , Mohile S.G. , Norton S.A. , Prigerson H.G. , Epstein R.M. .
Source: Journal Of Pain And Symptom Management, 2019-04-18 00:00:00.0; , .
EPub date: 2019-04-18 00:00:00.0.
PMID: 31004774
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How much time is left? Associations between estimations of patient life expectancy and quality of life in patients and caregivers.
Authors: Trevino K.M. , Maciejewski P.K. , Shen M.J. , Prigerson H.G. , Mohile S. , Kamen C. , Epstein R.M. , Duberstein P. .
Source: Supportive Care In Cancer : Official Journal Of The Multinational Association Of Supportive Care In Cancer, 2018-11-01 00:00:00.0; , .
EPub date: 2018-11-01 00:00:00.0.
PMID: 30387051
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Patients' Hopes for Advanced Cancer Treatment.
Authors: DeMartini J. , Fenton J.J. , Epstein R. , Duberstein P. , Cipri C. , Tancredi D. , Xing G. , Kaesberg P. , Kravitz R.L. .
Source: Journal Of Pain And Symptom Management, 2018-09-24 00:00:00.0; , .
EPub date: 2018-09-24 00:00:00.0.
PMID: 30261227
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Family caregiver descriptions of stopping chemotherapy and end-of-life transitions.
Authors: Norton S.A. , Wittink M.N. , Duberstein P.R. , Prigerson H.G. , Stanek S. , Epstein R.M. .
Source: Supportive Care In Cancer : Official Journal Of The Multinational Association Of Supportive Care In Cancer, 2018-07-28 00:00:00.0; , .
EPub date: 2018-07-28 00:00:00.0.
PMID: 30056528
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Communication about geriatric assessment domains in advanced cancer settings: "Missed opportunities".
Authors: Lowenstein L.M. , Volk R.J. , Street R. , Flannery M. , Magnuson A. , Epstein R. , Mohile S.G. .
Source: Journal Of Geriatric Oncology, 2018-06-05 00:00:00.0; , .
EPub date: 2018-06-05 00:00:00.0.
PMID: 29884597
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The ecology of patient and caregiver participation in consultations involving advanced cancer.
Authors: Freytag J. , Street R.L. , Xing G. , Duberstein P.R. , Fiscella K. , Tancredi D.J. , Fenton J.J. , Kravitz R.L. , Epstein R.M. .
Source: Psycho-oncology, 2018-03-25 00:00:00.0; , .
EPub date: 2018-03-25 00:00:00.0.
PMID: 29575388
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Preference for Palliative Care in Cancer Patients: Are Men and Women Alike?
Authors: Saeed F. , Hoerger M. , Norton S.A. , Guancial E. , Epstein R.M. , Duberstein P.R. .
Source: Journal Of Pain And Symptom Management, 2018-03-23 00:00:00.0; , .
EPub date: 2018-03-23 00:00:00.0.
PMID: 29581034
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Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study.
Authors: Fenton J.J. , Duberstein P.R. , Kravitz R.L. , Xing G. , Tancredi D.J. , Fiscella K. , Mohile S. , Epstein R.M. .
Source: Journal Of Clinical Oncology : Official Journal Of The American Society Of Clinical Oncology, 2018-01-20 00:00:00.0; 36(3), p. 225-230.
EPub date: 2017-11-17 00:00:00.0.
PMID: 29148892
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Promoting End-of-Life Discussions in Advanced Cancer: Effects of Patient Coaching and Question Prompt Lists.
Authors: Rodenbach R.A. , Brandes K. , Fiscella K. , Kravitz R.L. , Butow P.N. , Walczak A. , Duberstein P.R. , Sullivan P. , Hoh B. , Xing G. , et al. .
Source: Journal Of Clinical Oncology : Official Journal Of The American Society Of Clinical Oncology, 2017-03-10 00:00:00.0; 35(8), p. 842-851.
EPub date: 2017-01-30 00:00:00.0.
PMID: 28135140
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Effect Of A Patient-centered Communication Intervention On Oncologist-patient Communication, Quality Of Life, And Health Care Utilization In Advanced Cancer: The Voice Randomized Clinical Trial
Authors: Epstein R.M. , Duberstein P.R. , Fenton J.J. , Fiscella K. , Hoerger M. , Tancredi D.J. , Xing G. , Gramling R. , Mohile S. , Franks P. , et al. .
Source: Jama Oncology, 2017-01-01 00:00:00.0; 3(1), p. 92-100.
PMID: 27612178
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Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer.
Authors: Gramling R. , Fiscella K. , Xing G. , Hoerger M. , Duberstein P. , Plumb S. , Mohile S. , Fenton J.J. , Tancredi D.J. , Kravitz R.L. , et al. .
Source: Jama Oncology, 2016-11-01 00:00:00.0; 2(11), p. 1421-1426.
PMID: 27415765
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Eloquent silences: A musical and lexical analysis of conversation between oncologists and their patients.
Authors: Bartels J. , Rodenbach R. , Ciesinski K. , Gramling R. , Fiscella K. , Epstein R. .
Source: Patient Education And Counseling, 2016 10; 99(10), p. 1584-94.
EPub date: 2016-04-20 00:00:00.0.
PMID: 27156659
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Relationships between personal attitudes about death and communication with terminally ill patients: How oncology clinicians grapple with mortality.
Authors: Rodenbach R.A. , Rodenbach K.E. , Tejani M.A. , Epstein R.M. .
Source: Patient Education And Counseling, 2016 Mar; 99(3), p. 356-363.
EPub date: 2015-10-23 00:00:00.0.
PMID: 26519993
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In search of compassion: a new taxonomy of compassionate physician behaviours.
Authors: Cameron R.A. , Mazer B.L. , DeLuca J.M. , Mohile S.G. , Epstein R.M. .
Source: Health Expectations : An International Journal Of Public Participation In Health Care And Health Policy, 2015 Oct; 18(5), p. 1672-85.
PMID: 24305037
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"Speaking-for" and "speaking-as": pseudo-surrogacy in physician-patient-companion medical encounters about advanced cancer.
Authors: Mazer B.L. , Cameron R.A. , DeLuca J.M. , Mohile S.G. , Epstein R.M. .
Source: Patient Education And Counseling, 2014 Jul; 96(1), p. 36-42.
PMID: 24862913
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Discussing prognosis and end-of-life care in the final year of life: a randomised controlled trial of a nurse-led communication support programme for patients and caregivers.
Authors: Walczak A. , Butow P.N. , Clayton J.M. , Tattersall M.H. , Davidson P.M. , Young J. , Epstein R.M. .
Source: Bmj Open, 2014-06-26 00:00:00.0; 4(6), p. e005745.
EPub date: 2014-06-26 00:00:00.0.
PMID: 24969786
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Single-patient (n-of-1) trials: a pragmatic clinical decision methodology for patient-centered comparative effectiveness research.
Authors: Duan N. , Kravitz R.L. , Schmid C.H. .
Source: Journal Of Clinical Epidemiology, 2013 Aug; 66(8 Suppl), p. S21-8.
PMID: 23849149
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Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers.
Authors: Hoerger M. , Epstein R.M. , Winters P.C. , Fiscella K. , Duberstein P.R. , Gramling R. , Butow P.N. , Mohile S.G. , Kaesberg P.R. , Tang W. , et al. .
Source: Bmc Cancer, 2013-04-09 00:00:00.0; 13, p. 188.
EPub date: 2013-04-09 00:00:00.0.
PMID: 23570278
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Media, messages, and medication: strategies to reconcile what patients hear, what they want, and what they need from medications.
Authors: Kravitz R.L. , Bell R.A. .
Source: Bmc Medical Informatics And Decision Making, 2013; 13 Suppl 3, p. S5.
PMID: 24565216
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