ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 274 P U B L IC H E A LT H A N D E P ID E M IO L O G Y doI 10.11603/ijmmr.2413-6077.2022.2.13594 COMMUNICATION OF ONCOLOGICAL PATIENTS WITH ONCOLOGISTS: MAIN PROBLEMS AND PROBLEM-SOLVING STRATEGIES *V. О. Zub1, A. S. Kotuza2, O. K. Tolstanov1 1 – SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV, UKRAINE 2 – FEOFANIYA CLINICAL HOSPITAL, STATE MANAGEMENT OF AFFAIRS OF UKRAINE, KYIV, UKRAINE Background. Physician-patient сommunication is one of the main supportive care provided to oncological patients. It affects treatment outcomes, as well as the interaction of patients within the society, their family and colleagues. Furthermore, COVID-19 and military invasion of Russia into Ukraine makes the issue of improvement of physician-patient communication urgent. Objective. The aim of the study is to develop recommendations based on the analysis of denfined problems in physician-patient communication in of oncological treatment. Methods. The sociological research involved 419 patients during their inpatient treatment in the period from November 2021 to February 2022 using the EORTC QLQ-COMU26 questionnaire. Results. In the pre-war period, in Ukrainian patients with oncological diseases the worst indicators were established for “Active role of a patient” (82.00) and “Correction of misunderstandings by a specialist” (89.19). The best indicators were established for “Skills of the specialist (verbal/non-verbal)” with the score of 93.25 by a 100-point grading scale, as well as “Satisfaction with communication” – 97.04 by a 100-point grading scale. Conclusions. When developing programs for organization of oncological care, mechanisms for providing psychological care to patients through effective communication between patients and specialists regarding providing medical and psychological care must be taken into account. KEY WORDS: communication; quality of life; cancer. *Corresponding author: Valeriy Zub, Shupyk National Health- care University of Ukraine, Kyiv, Ukraine. е-mail: zub.valeriyoleksiyovych@gmail.com International Journal of Medicine and Medical Research 2022, Volume 8, Issue 2, p. 74-82 copyright © 2022, TNMU, All Rights Reserved V. О. Zub et al. Introduction Physician-patient communication is one of the main aspects of care provided to oncological patients. A number of studies have shown that communication focused on a patient can in- fluence patient’s satisfaction, decision­ma king, well-being, compliance with treatment of oncological diseases [1]. Communication focused on a patient is a cornerstone of a high-quality care [2]. Proper communication allows physician to respond better to the patients’ needs regarding infor- mation and support. For this purpose, recom- men dations for improving the communication skills of medical workers are available in many countries [3]. The effective physician-patient communication may reduce the anxiety, keep hope [4], and increase satisfaction from com- munication in patients [5]. Communication fo cused on a patient has also been developed in order to improve communication skills training of a physician [6]. These measures are aimed at involving a patient into counseling and thus increasing awareness of a physician and timely taking into account patients’ expec_ tations. The present circumstances should also be taken into account. The global crisis caused by COVID-19 outbreak in 2019 has led to unex- pected and difficult situations [7]. Physical bar­ riers and non­visitation policy had a significant impact on communication in a hospital settings. Physicians need new strategies to keep in touch with patients and their families/relatives [8, 9]. In the era of COVID-19, in order to solve the challenges for effective physician-patient com- munication for oncological patients, when physical distancing is required, different solu- tions have been suggested, particularly, video calls were introduced by using smartphones and tablets [10]. Thousands of oncological patients have suffered in connection with the war in Ukraine, as they lost the opportunity to receive treatment and were left alone with their disease. The necessary medicines are difficult to get, chemo­ therapy and radiotherapy are carried out irre- gularly, physicians are often out of the telephone reach. Moreover, cancer patients face psycho- ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 2 75 P U B L IC H E A LT H A N D E P ID E M IO L O G Y logical problems – uncertainty and the inability to plan and control their lives. Most of them have complex depressive, anxiety-depressive and phobic symptoms. Excessively expressed negative emotions (depression, anxiety, pho- bias) can cause suicidal thoughts in such patients. The oncologist-patient communication is especially difficult when it comes to information about prognosis and treatment outcomes, which is essential for achieving a shared understanding of disease state and treatment goal between patients and oncologists [11, 12]. The oncologists have frequent difficulties in assessing the patients’ information preferences [13]. In patients with advanced cancer, the prognosis information is often missing [14], and patients do not understand that the treatment provided will unlikely cure their oncological diseases [15]. The aim of the study is to develop recom- mendations based on the analysis of identified problems in physician-patient communication in patients with oncological diseases during treatment. Methods The sociological research was perfomed by surveying 419 patients during their inpatient treatment. The required number of participants was calculated according to the Glen’s method, and involved 398 individuals. Taking into account the possibility of elimination (10%), 440 questionnaires were sent proportionally to dif- ferent regions of Ukraine (Northern, Southern, Western, Eastern, Central); 419 questionnaires were received back. The inclusion criteria were the patients hospitalized with a histologically confirmed cancer diagnosis and received inpatient treat- ment. Exclusion criteria were lack of written consent to participate in the study. The research was carried out at oncological institutions in nine regions of Ukraine: Chernihiv, Zaporizhzhia, Dnipropetrovsk, Kyiv, Poltava, Khmelnytskyi, Ivano-Fran kivsk, Zakarpattia and Lviv regions. The primary data collection was performed from November 2021 till February 2022. all the patients gave written consents to participate in the trial. The average age of patients who participated in the trial was 59.62±10.33 years old. The research was conducted according to the unified protocol providing for the use of questionnaires which were designed by the European Organisation for Research and Treat- ment of Cancer (EORTC). The questionnaire included 26 questions regarding communica- tion of oncological patients with their health workers. The EORTC­QLQ­COMU26 module was composed of six scales and four separate issues [16, 17, 20]. The following scales are involved in the EORTC­QLQ­COMU26: the ability of the specialist to manage patient’s emotions (EMOT), the “specialist-patient” relationships (RELAT), the ability of the specialist to build relationships (QUAL), the active role of the patient (ACT), the skills of the specialist (verbal/non-verbal) (SKILL), the information skills of the specialist (INFO). The additional issues of EORTC­QLQ­COMU26 are the following: correction of misunderstan­ dings by the specialist (MISUN), sufficient privacy (PRIVA), taking into account patient’s preferences (PREF), satisfaction with commu- nication (SATIS). The permission to use this questionnaire from “EORTC Quality of Life Group” was re­ ceived in November 2021. The calculations were carried out according to the EORTC QLQ­COMU26 methodology [16, 17]. The results were calculated according to unified scales or individual indicators. Average score (Raw Score – RS) was presented as М±SD. Besides, all scales and individual indicators of EORTC QLQ­COMU26 questionnaire were calculated by a 100-point grading scale (SS) for easier interpretation according to the formula: SS = ((RS–1)/range)·100 Where RS – raw score, range – scale range which is determined by the difference between the maximum and minimum values of the scale. The low raw score and high score by a 100-point grading scale testified to high quality of communication with a specialist. For scales that consist of 2 or more questions, Cronbach’s alpha was calculated as an indicator of scale consistency. Results According to the findings of QLQ­COMU26 questionnaire in the patients with oncological diseases, the worst indicators were established for the “Active role of the patient” scale. The score was 82.00 by a 100-point grading scale (Table 1), RS was 3.46±0.82 (Fig. 1). This scale involved questions about sufficient opportu­ nities to communicate with a specialist (phy- sician), opportunity to ask questions freely, opportunity to show emotions. V. О. Zub et al. ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 276 P U B L IC H E A LT H A N D E P ID E M IO L O G Y According to the findings of the QLQ­ COMU26 questionnaire, a better result was established for the scale of “Information skills of the specialist”, where the score was 90.75 a 100-point grading scale. The following questions were included in this scale: whether the specialist was convinced that a patient under- stood all about the disease before providing any new information, whether the physician specified understanding by a patient the infor­ mation provided. It is quite natural that the patients with oncological diseases are often worried about their future. Thus, in the scope of this scale, the patients were asked about the specialists’ exhaustive replies to difficult ques­ tions, as well as whether these answers satisfied the patients. Generally, the sense of comp le- teness of specialists’ answers, their explanations are very important, which is also discussed in this scale. Fewer difficulties happened in the physician­ patient communication in the “Ability of the specialist to manage the patient’s emotions” scale, where the score was 91.75 by a 100-point grading scale. A cancer patient badly needs support from their family, friends, relatives, but the effort of specialist to understand the cur- rent situation of a patient is certainly important as well. In this scale there were questions regarding the specialist’s help to master pa- tient’s emotions, for example: sadness, anger, fear, anxiety, etc., and also the ability to listen when the patient demonstrated his/her emo- tions. The better result was obtained in the scale “Specialist-patient relationships”, where the score was 91.94 by a 100-point grading scale. This scale involved questions whether the specialist had spent enough time to commu- nicate, whether there was a mutual trust between the patient and specialist, whether the patient felt that they and the physician had the common understanding of the disease and its treatment. Table 1. Results of questionnaire of different QLQ-COMU26 scales in oncological patients Scale issue Directory code Score by a 100-point scale Cronbach’s Alpha Active role of the patient ACT 82.00 0.63 Information skills of the specialist INFO 90.75 0.83 Ability of the specialist to manage the patient’s emotions EMOT 91.75 0.64 Specialist-patient relationships RELAT 91.94 0.66 Ability of the specialist to build relationships QUAL 93.19 0.78 Skills of the specialist (verbal/non-verbal) SKILL 93.25 0.67 Fig. 1. Raw score of different QLQ­COMU26 scales in oncological patients. V. О. Zub et al. ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 2 77 P U B L IC H E A LT H A N D E P ID E M IO L O G Y The highest scores characterized the ability of the specialist to establish the relatioships with the patient. This issue was 93.19 by a 100-point grading scale. This scale described the attitude of the specialist to the patient: whether the physician treated the patient with respect, as an equal, whether the physician showed sincerity, whether it was easy and open to discuss the troubling problems of the patient, whether the physician took them seriously. The best indicators of the QLQ­COMU26 questionnaire were established for the “Skills of the specialist (verbal/non-verbal)” scale, where the score was 93.25 by a 100-point grading scale. This scale included the following questions: did the specialist use the language understandable to the patient (avoiding me di- cal terminology, using understandable terms), did the specialist openly answer the patient’s questions, did the specialist look at the patient during their conversation, did the specialist speak in a calm voice. It should be mentioned that in the QLQ­ COMU26 questionnaire in patients with oncolo- gical diseases, the respondents’ answers were of the same type in the “Ability of the specialist to build relationships” and “Information skills of the specialist” scales, which was shown by sufficient and high consistency, determined by Cronbach’s alpha within 0.78–0.83. For the rest of the indicators, Cronbach’s alpha was in the range of 0.63–0.67. According to the findings of QLQ­COMU26 questionnaire regarding the individual indica- tors, in the oncological patients the worst in- dica tors were in the “Correction of misunder- standings by a specialist” scale. The score was 89.19 by a 100-point grading scale (Table 2), the raw score was 3.68±0.54 (Fig. 2). This indicator included questions regarding whether the specialist explained again in another way the information which the patient had not under- stand. This indicates the problem of the physician-patient communication in this scale. One of the probable causes of such misunder- standings may be lack of time allocated per patient, vulnerable emotional state of the patient with a potentially fatal disease, and, in Table 2. Results of the QLQ-COMU26 questionnaire regarding the individual indicators of oncological patients Indicators Directory code Score by a 100-point scale Correction of misunderstandings by a specialist MISUN 89.19 Taking into account the wishes of the patient PREF 89.62 Sufficient privacy PRIVA 93.08 Satisfaction from communication SATIS 97.04 Fig. 2. Average score of individual indicators by QLQ­COMU26 in oncological patients. V. О. Zub et al. ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 278 P U B L IC H E A LT H A N D E P ID E M IO L O G Y the majority of cases, lack of medical literacy to comprehend information, which is difficult for understanding. The indicator “Taking into account the wishes of the patient” was found to be prac- tically comparable. The score was 89.62 by a 100-point grading scale. For this indicator, the patient was asked whether the specialist took into account the method of obtaining infor- mation preferred by the patient. Slightly better results were established for the indicator “Sufficient privacy”. The score was 93.08 by a 100-point grading scale. This indi- cator included the questions concerning suf- ficient privacy of the confidential conversation between the patient and specialist. The best QLQ­COMU26 questionnaire re­ sults regarding the individual indicators in oncological patients were established for the issue “Satisfaction from communication”, which was 97.04 by a 100-point grading scale. Discussion Communication is one of the most important tasks in the professional practice of a clinician, especially for those who deal with the life- threatening diseases. In this case, effective dialogue can be quite challenging, however, clinicians face this daily. In recent decades, clinical communication has been studied a lot, and, several structured approaches have been developed and suggested [8, 18, 19]. Patients with advanced oncological diseases often forget their questions during consultation with a physician, they doubt the legality of the request, indirectly express concern, feel fear of a possibly humiliating answer and physicians do not often encourage them to ask questions [21-23]. Patients may also have different needs and expectations, depending on time of the course of the disease [13, 24, 25]. Discrepancy between the perceptions of the patient and oncologist regarding the goals of treatment, duration of disease treatment can lead to medical decisions that do not meet the life goals which are very important for the patients [26]. It leads to even greater psychological stress in patients [27]. According to the findings of the QLQ­ COMU26 questionnaire for the oncological patients, the worst indicators were established for the “Active role of the patient” scale. The score was 82.00 by a 100-point grading scale which was less than the results attained by the German colleagues, where this issue was 85.0 [1]. A possible reason for a low activity of patients could be their self­absorbedness: pa­ tients are not able to talk about their problems freely, ask questions about everything con- cerning them or those they don’t completely understand. The least difficulties for the Ukrainian patients were caused by the scales with nearly comparable indicators for the “Ability of the specialist to build relationships” (93.19 points) and the “Skills of the specialist (verbal/non- verbal)” (93.25 points). These results are higher than the results obtained by the German col- leagues: the score of the “Ability of the specialist to build relationships” scale was 89.6 points, while the score of the “Skills of the specialist (verbal/non-verbal)” was 90.3 points [1]. Generally, the European patients need more sincerity and ease, openness in discussing problems during the physician-patient commu- nication. It should be taken into account that if before COVID-19 the “physicians-patient” consultations were held in person at prearranged time, during the SARS-CoV-2 pandemic communi- cation often took place usually over the phone. In this unprecedented situation often one-way communication cause a feeling of uncertainty and suffering in those who stay at home and have to wait for news [28]. It should be noted that relatives of the seriously ill patients already have the increased risk of anxiety, depression or post-traumatic stress disorder [29]. Moreover, the loss of non-verbal signals, such as eye contact and gestures complicate communication and formation of empathy between the com- munication provider and the patient. Thus, the uncertainty and experiencing psychological problems by patients make communica tion between cancer patients and physicians difficult. According to the findings of the QLQ­ COMU26 questionnaire regarding the individual indicators in oncological patients, the worst results were established for the “Correction of misunderstandings by a specialist” indicators. The score was 89.19 by a 100-point grading scale that was less than the results attained by the German colleagues, where this issue was 84.8 [1]. The best indicators for the Ukrainian pa- tients with oncological diseases in the QLQ­ COMU26 questionnaire regarding the individual indicators were established for the “Satisfaction with communication” issue, which was 97.04 that was significantly higher compared to the data of the German colleagues, where the indicator was 84.3 [1]. V. О. Zub et al. ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 2 79 P U B L IC H E A LT H A N D E P ID E M IO L O G Y An interesting and important fact should be taken into account for providing high-quality medical care is that communication with cri- tically ill patients is often three-way, rather than two-way involving not only the specialist and the patient but also family members who are often the main support, an important part of the medical team and the component of communication for the health of their relatives. A high level of depression and burden on the caregiver was registered among the patients and relatives of the hospitalised oncological patients [8, 30]. Therefore, targeted intervention in the field of physician­patient communication can improve the quality of life for both patients and their families. Family and friends can be a great support for an oncological patient. The patient can rely on a family member or a trusted friend in a similar situation for help, for example asking to accompany them to visit a physician. The presence of a supportive person is a reminder that the cancer patient is not alone and it can help them take the initiative to communicate. Generally, the inappropriate communication leads to unsatisfied patient needs for informa­ tion and support. Understanding how to im- prove the physician-patient communication is important for all involved into patient care. Conclusion The physician-patient communication is one of the main aspects of support provided to oncological patients. Effective communication of the physician and patient may reduce pa- tient’s anxiety, keep hope, increase satis faction from communication. In today’s COVID-19 pan- demic, physical barriers and no family visitation policy for patients have significantly affected the physician-patient communication for pa- tients with oncological diseases in the hospital settings, and physicians need new strategies in order to keep contact with the patients. According to the findings of the QLQ­ COMU26 questionnaire for the Ukrainian onco- logical patients, the worst indicators were established for the “Active role of the patient” scale, its score was 82.00, which was less then the results obtained by the German colleagues (85.0). The best indicators in this questionnaire were established for the issue “Skills of the specialist (verbal/non-verbal)”, the score was 93.25 by a 100-point grading scale. According to the findings of the QLQ­COMU26 ques­ tionnaire regarding the individual issues, the worst indicators were established for the “Cor- rec tion of misunderstandings by a specialist” scale. The score was 89.19 by a 100-point grading scale, which was higher the results obtained by the German colleagues (84.8 points). The best results of this questionnaire were established for the “Satisfaction with communication” scale – 97.04 by a 100-point grading scale, which was significantly higher compared to the data of the German colleagues, where the indicator was 84.3. According to the findings of the QLQ­ COMU26 questionnaire, in Ukrainian oncological patients in the pre-war period the worst indi- cators were established for the issues of “Active role of the patient” and “Correction of misun- derstandings by a specialist”. Thus, to provide a high-quality medical care it should be taken into account that commu- nication with critically ill patients is often three- way rather than two-way, where not only the specialist and the patient are involved, but fa- mily members, who are often the main support, an important part of the medical team and a significant component of communication for their relatives. When developing programs for organization of oncological care, mechanisms for providing psychological care to these pa- tients through effective communication between patients and specialists regarding providing medical and psychological care should be taken into account. During the Russia’s military invasion of Ukraine, many oncological patients had to go abroad in order to receive specialized treatment. Thus, this information can be used for better communication of the foreign physicians with the Ukrainian patients. Conflict of Interests Authors declare no conflict of interest. Author’s Contributions Valeriy Zub – conceptualization, metho- dology, formal analysis, writing – original draft, writing – reviewing and editing; Andrii Kotuza – conceptualization, methodology, investigation, writing – reviewing and editing; Oleksandr Tolstanov – conceptualization, methodology, data curation, writing – reviewing and editing. V. О. Zub et al. ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 280 P U B L IC H E A LT H A N D E P ID E M IO L O G Y References 1. Rogge AA, Helmer SM, King R, et al. Effects of training oncology physicians advising patients on complementary and integrative therapies on patient- reported outcomes: A multicenter, cluster­rando­ mized trial. Cancer. 2021;127(15):2683­2692. doi: https://doi.org/10.1002/cncr.33562 2. Levinson W. Patient­centred communication: a sophisticated procedure. BMJ Qual Saf. 2011;20(10): 823-825. doi: https://doi.org/10.1136/bmjqs­2011­000323 3. Stiefel F, Kiss A, Salmon P, Peters S, Razavi D, Cervantes A, et al. Training in communication of oncology clinicians: a position paper based on the third consensus meeting among European experts in 2018. Ann Oncol. 2018;29(10):2033­2036. doi: https://doi.org/10.1093/annonc/mdy343 4. Clayton JM, Hancock K, Parker S, Butow PN, Walder S, Carrick S, et al. Sustaining hope when communicating with terminally ill patients and their families: a systematic review. Psychooncology. 2008;17(7):641­659. doi: https://doi.org/10.1002/pon.1288 5. Sichkoriz O, Zimenkovsky A, Gutor T. Analysis of expectations and satisfaction of physicians (pro- visors)-interns in Ukraine at the stage of primary specialization – internship training. Med. perspekt. 2022;27(1):16­23. https://doi.org/10.26641/2307­0404.2022.1. 254317 6. Henselmans I, Brugel SD, de Haes HC, Wol- vetang KJ, de Vries LM, Pieterse AH, et al. Promoting shared decision making in advanced cancer: de­ КОМУНІКАЦІЯ ОНКОЛОГІЧНО ХВОРИХ ПАЦІЄНТІВ З ЛІКАРЯМИ- ОНКОЛОГАМИ: ОСНОВНІ ПРОбЛЕМИ ТА СТРАТЕГІЇ ЇХ ВИРІШЕННЯ В. О. Зуб1, А. С. Котуза2, О. К. Толстанов1 1 – НАЦІОНАЛЬНИЙ УНІВЕРСИТЕТ ОХОРОНИ ЗДОРОВ'Я УКРАЇНИ ІМЕНІ П. Л. ШУПИКА, КИЇВ, УКРАЇНА 2 – КЛІНІЧНА ЛІКАРНЯ «ФЕОФАНІЯ» ДЕРЖАВНОГО УПРАВЛІННЯ СПРАВАМИ, КИЇВ, УКРАЇНА Вступ. Комунікація “лікар-пацієнт” є одним з основних аспектів підтримки, яка надається хворим на онкологічні захворювання. Вона впливає на результати лікування, а також на взаємодію пацієнтів у суспільстві, з родиною та колегами. Крім того, поширення коронавірусної хвороби COVID-19 та військове вторгнення Росії в Україну зумовлюють необхідність покращення комунікації між лікарем та пацієнтом. Мета. Мета роботи – розробка рекомендацій на основі аналізу виявлених проблем в комунікації “лікар-пацієнт” у хворих на онкологічні захворювання під час лікування. Методи. Соціологічне дослідження проведено за участі 419 пацієнтів, на етапі їхнього стаціонарного лікування, в період з листопада 2021 року по лютий 2022 року з використанням опитувальника EORTC QLQ-COMU26 Результати. В українських пацієнтів з онкологічними захворюваннями, у довоєнний період, найгірші показники припали на шкали «Активна роль пацієнта (82.00) та “Корегування фахівцем непорозумінь” (89.19). Найкращі дані встановлено для пункту “Навички фахівця (вербальні-невербальні)”, на який припало 93.25 балів за 100-бальною шкалою та “Задоволення від комунікації” – який склав 97.04 балів за 100- бальною шкалою. Висновки. При опрацюванні програм щодо організації онкологічної допомоги повинен бути врахований механізм щодо забезпечення надання психологічної допомоги пацієнтам шляхом ефективної комунікації між пацієнтами та спеціалістами з надання медичної та психологічної допомоги. КЛЮЧОВІ СЛОВА: комунікація; якість життя; онкологія. Information about the authors Valeriy Zub – PhD, Doctoral student, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine https://orcid.org/0000­0001­9823­4216, e­mail: zub.valeriyoleksiyovych@gmail.com Andrii Kotuza – Professor, Feofaniya Clinical Hospital, State Management of Affairs of Ukraine, Kyiv, Ukraine https://orcid.org/0000­0002­1910­0197, e­mail: kotuza.andrii@gmail.com Oleksandr Tolstanov – Professor, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine https://orcid.org/0000­0002­7459­8629, e­mail: o.tolstanov@nuozu.edu.ua V. О. Zub et al. ISSN 2413-6077. IJMMR 2022 Vol. 8 Issue 2 81 P U B L IC H E A LT H A N D E P ID E M IO L O G Y velopment and piloting of a patient communication aid. Patient Educ Couns. 2019;102(5):916­923. doi: https://doi.org/10.1016/j.pec.2018.12.018 7. Sodomora, P., Gutor, L., Tryndiuk, V., Lobanova, S. Student Storytelling for Communication Skill Development Online (in the Time of COVID­19 Qua­ ran tine). 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