Despite recent advances in cancer treatments, there still comes a time when the disease progresses, and patients can reliably be expected to have months, but not years, left to live. Although oncologists can reliably predict when patients have months to live, and 71% of advanced cancer patients report wanting prognostic information (with 83% deeming it extremely important), only 17.6% of patients a median of 5 months from death reported a prognostic discussion with their oncologist. Moreover, only 5% of these patients had accurate prognostic understanding. Not only does informed, patient-centered, shared decision-making rely on patients' having a basic understanding of their prognosis, but patients' prognostic understanding has been linked to significantly better end-of-life outcomes (e.g., less burdensome, unbeneficial care; more palliative and value- consistent care). Our prior work thus highlights the need for a communication technique that will prove acceptable to oncologists and that promotes patients' prognostic understanding. To address this need, we developed the ?Giving Information Simply &Transparently? (GIST), Oncolo-GIST intervention -- a manualized oncologist communication intervention that simplifies how to impart prognostic information by focusing on 4 basic steps: 1) Giving scan information, 2) Informing prognosis, 3) Strategizing sensitively, and 4) Transparently asking what patients heard.
3 specific aims of the Oncolo-GIST approach will be tested:
U Specific Aim #1 :U will obtain feedback on Oncolo-GIST Version 1.0 from stakeholders/key informants (n=10 bereaved caregivers; n=10 oncology clinicians) using a modified Delphi approach.
U Specific Aim #2 :U will determine feasibility and acceptability of Oncolo-GIST Version 1.0 in an open trial of 10 advanced cancer patients.
U Specific Aim #3 :U will determine whether patients (n=25) meeting with an oncologist randomly assigned to training in Oncolo-GIST Version 2.0 are more likely than patients receiving usual care (n=25) to have better prognostic understanding (e.g., report they likely have months to live), our Uprimary outcomeU. Potential effects on patient: a) engagement in ACP, b) quality of life, receipt of: c) intensive care, d) palliative care, e) value-consistent end-of-life care, and oncologist-reported: f) satisfaction with prognostic discussions and g) therapeutic alliance with patients, will be explored. Results will lead to refinements in the Oncolo-GIST intervention, suggest its clinical feasibility and acceptability, and whether the Oncolo-GIST intervention promotes patients' prognostic understanding and hypothesized downstream effects (e.g., less intensive, more palliative care, better patient quality of life). Positive results will support the future testing of the Oncolo- GIST intervention in a multi-site R01 RCT of advanced cancer patients and suggest the potential broader applicability of this gist approach to informed end-of-life decision-making.

Public Health Relevance

Project Relevance Although oncologists can reliably predict when their advanced cancer patients have months to live, and the vast majority of patients state that they want this prognostic information and find it very important to their end- of-life decision-making, very few patients report discussing prognosis with their oncologist, and even fewer advanced cancer patients have been shown to have accurate prognostic understanding. We propose to refine and pilot ?Giving Information Simply and Transparently? (GIST), the Oncolo-GIST intervention, which we expect will provide oncologists with a streamlined, potentially effective method of communicating with advanced cancer patients to promote patients' prognostic understanding (e.g., grasp that they likely have months, not years, to live) and the positive outcomes (e.g., more engagement in advance care planning, palliative and value-consistent end-of-life care, better therapeutic alliances with oncologists) expected to follow from improved oncologist communication and enhanced prognostic understanding.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Exploratory/Developmental Grants (R21)
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Behavioral Medicine, Interventions and Outcomes Study Section (BMIO)
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Kehl, Karen
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Weill Medical College of Cornell University
Internal Medicine/Medicine
Schools of Medicine
New York
United States
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