Overcoming communication challenges in integrative supportive cancer care: The integrative physician, the psycho-oncologist, and the patient

Complementary Therapies in Medicine 29 (2016) 9–15

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Overcoming communication challenges in integrative supportive cancer care: The integrative physician, the psycho-oncologist, and the patient Eran Ben-Arye (MD) (Director) a,b,c,∗,1 , Efrat Shavit (MSW) d , Haya Wiental (MSW) d , Elad Schiff (MD) e,f , Olga Agour (MSW) a,d , Noah Samuels (MD) g a

Integrative Oncology Program, The Oncology Service, Lin Medical Center, Clalit Health Services, Haifa and Western Galilee District, Israel Complementary and Traditional Medicine Unit, Department of Family Medicine, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel c Clalit Health Services, Haifa and Western Galilee District, Israel d Social-Work Service, The Oncology Service and Lin Medical center, Clalit Health Services, Haifa and Western Galilee District, Israel e Department of Internal Medicine, Bnai-Zion Hospital, Haifa, Israel f The Department for Complementary/Integrative Medicine, Law and Ethics, The International Center for Health, Law and Ethics, Haifa University, Israel g Tal Center for Integrative Medicine, Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel b

a r t i c l e

i n f o

Article history: Received 13 May 2015 Received in revised form 5 June 2016 Accepted 2 September 2016 Available online 4 September 2016 Keywords: Communication Supportive care Multi-disciplinary team Psycho-oncology Complementary medicine

a b s t r a c t Background: Complementary/integrative medicine (CIM) services are increasingly being integrated into conventional supportive cancer care, presenting a number of challenges to communication between healthcare professionals (HCPs). The purpose of the present study was to explore the impact of the communication between integrative physicians (IPs) trained in CIM and social workers (SWs) working as psycho-oncologists in the same oncology setting. We examine whether IP-SW communication correlates with the number of patient-SW sessions, as provided within the oncology department. Methods: SW-IP communication, defined as a summary of the IP consultation sent to the patient’s SW, was compared to SW-patient communication, defined as the number of psycho-oncology treatment sessions. Results: Of 344 patients referred by their oncology HCP for IP consultation, 91 were referred by an SW and 253 by an oncologist or nurse. IP-to-SW summaries were provided for 150 patients referred by a non-SW HCP (43.6%), and for 91 of SW-referred patients (26.5%). In all, 32 patients referred to the IP had no psycho-oncology interaction with an SW; 58 only one meeting; and 254 with ≥2 interactions, with 119 having >6 sessions. SW-patient interactions were greater with higher rates of IP-SW communication, for both patients referred by an SW (79.1%) and those referred by a non-SW HCP (77.3%) when compared to patients for whom no summary was provided (64.1%; p = 0.02). Conclusion: A greater level of IP-SW communication, measured by the provision of an IP summary to the patient’s SW, was found to correlate with a higher rate of SW-patient interactions. The use of a structured two-way referral-summary between IPs and SWs has the potential to advance the SW-patient psycho-oncology interaction, within an integrative supportive cancer care setting. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Most research being published today on the multifaceted subject of communication in supportive cancer care focuses on the

∗ Corresponding author at: Integrative Oncology Program, The Oncology Service and Lin Medical Center, Clalit Health Services, Haifa and Western Galilee District, Israel. E-mail address: [email protected] (E. Ben-Arye). 1 Address: Lin Medical Center, The Oncology Service, 35 Rothschild St., Haifa, Israel. http://dx.doi.org/10.1016/j.ctim.2016.09.001 0965-2299/© 2016 Elsevier Ltd. All rights reserved.

role of patient-provider interactions. These include issues such as the breaking of bad news, the discontinuation of cancer treatment, reaching and informed decision, and addressing patients’ concerns and well-being.1–5 In their systematic review on the subject, Lelorain et al. found that better patient-provider communication and empathy among healthcare providers (HCPs) can lead to a reduction in patients’ levels of distress and an increase in satisfaction with their care.6 As for the treatment of the disease itself, researchers and clinicians are advocating a collaborative inter-disciplinary approach.7 Nevertheless, research in this field has been limited to the examination of the impact of communi-

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cation between oncology healthcare providers and patients, with respect to patients’ concerns, quality of life (QOL) and adherence to the treatment regimen. Oskay-Ozcelik et al. found that cancer care in today’s world is characterized by a multi-disciplinary approach, which in itself can become a source of distress for many patients. Indeed, many patients express a lack of confidence in the care they are receiving, citing a lack of cooperation between the various healthcare providers involved.8 The presence of complementary/integrative medicine (CIM) services, which are being integrated into standard practice within leading oncology centers. The CIM services are gradually emerging throughout industrialized nations, and provide treatment modalities such as acupuncture, mind-body and manual/touch modalities (e.g. reflexology, shiatsu, tuina) as well as dietary supplement consultation.9,10 The accepted terms for CIM have recently been discussed by the Society for Integrative Oncology, defining Integrative Medicine as “the use of evidence-based complementary practices in coordination with evidence-based conventional care”.11 The term Integrative Oncology is defined as “the use of complementary and integrative therapies in collaboration with conventional oncology care”. Integrative oncology presents a number of challenges to the multidisciplinary approach needed in treating patients with cancer. This includes addressing the communication between oncology HCPs such as oncologists, nurse oncologists and psychooncologists, and CIM practitioners.12 Many of the core concepts of CIM are based on the principles of evidence-based medicine, as well as a bio-psycho-social −spiritual, patient-centered approach which addresses the patients’ affinity to cultural-related traditional medicine. This approach should be conducted within a non-judgmental environment, in order to promote patient-health care provider communication.13–15 However, in contrast with the current status of psycho-oncology, the integration of CIM practice within mainstream supportive cancer care is still a new concept. Nevertheless, these two approaches share many aspects of patient care and the promotion of wellness. With this in mind, researchers have begun to compare the efficacy of the two approaches for outcomes such as the relief of emotional distress during cancer treatment.16 Studies are being conducted which are comparing CIM with psychotherapeutic interventions, this by researchers from the field of behavioral and mental health science.17 To the best of our knowledgae, no studies have been published to date which examine the interaction between integrative physicians (IPs) with dual training in CIM and supportive cancer care, and psycho-oncology social workers (SWs) who are working together in the oncology setting. Research into the collaborative and multidisciplinary CIM model of care is needed, since IPs and SWs often see patients with the same indications for referral to their respective services (e.g. emotionl and other bio-psycho-social-spiritual concerns). The present study set out to examine the IP-SW relationship, focusing on the communicative process between them, as reflected in the exchange of summary letters by IPs following their CIM consultation, and SWs co-providing psycho-oncology treatments to the same group of patients. The study also examined the correlation between IP-SW communication and the number of patient-SW sessions, as provided within the oncology setting.

2. Methods 2.1. Study site and participants The study took place at the Clalit Oncology Service (COS) of the Haifa and Western-Galilee district of the Clalit Healthcare Organization, between July 2009 and December 2012. The COS contains five professional sectors (oncologists, nurse oncologists, SWs, sec-

retaries, and CIM practitioners), all of which collaborate as part of a multi-disciplinary team, fostering continuity of care and promoting case management for patients. In 2008, the Integrative Oncology Program (IOP) was established within the COS with the goal of improving quality-of-life (QOL) outcomes among patients receiving adjuvant and palliative chemotherapy. The IOP team is comprised of integrative physicians (IPs) who are MD physicians with CIM training; oncology nurses with extensive training in the field of CIM; spiritual support therapists; a music therapist; traditional Chinese medicine practitioners; an occupational therapist; a physiotherapist; and a nutritional consultant. The role of the IPs in the oncology setting is to assess patients’ expectations, concerns and well-being. Patients are referred to the consultation by their oncology HCP using a set list of indications, during which a patient-centered CIM treatment plan is designed, with the goal of reducing the side effects of treatment and improving quality of life and function. The COS psycho-oncology team is comprised of nine SWs, all trained in psycho-oncology. One of the COS psycho-oncologists has additional CIM training in mind-body medicine, and works for 4 h each week as part of the IOP team. The role of the SW is to provide patients with guidance regarding social benefits, as well as emotional support through psycho-oncology interventions (e.g. psychotherapy). The psycho-oncology service at the COS plays an integral role in the multidisciplinary care of patients with cancer. Patient care begins with the initial diagnosis of the disease, and continues throughout treatment regimens and survivorship, or end-of-life care. Patients and their families first meet with a member of the psycho-oncology team, with the goal of reaching an understanding regarding the resources available and expectations from the treatment process. Psycho-oncology interactions are geared at helping patients cope with their disease, as well as with the side effects of the anti-cancer treatment. Family members are frequently included in this process, and many are themselves treated as well, in order to help them cope. 2.2. Study design The present research was designed as a prospective registry protocol-based study. Patients’ QOL-related concerns were assessed at three time intervals: at the initial IP consultation, and at 6- and 12-weeks follow-up visits. Quantitative assessment was conducted using the Measure Yourself Concerns and Wellbeing (MYCAW)18 and the Edmonton Symptom Assessment Scale (ESAS) questionnaires.19 The registry protocol documents aspects of IPHCP communication, which include the referring HCP’s occupation; the indications for referral; and the provision of a letter summarizing the treatment plan to the referring HCP and to the patient’s family physician. Referral of patients to the IP consultation requires that the referring oncology HCP provide a structured referral letter specifying at least one clinical indication. HCPs are given a pre-defined list which includes symptoms such as fatigue, gastro-intestinal symptoms, pain and neuropathy, as well as emotional or spiritual concerns, hematological toxicities, dyspnea, gynecology-urinary symptoms, and other QOL-related issues. HCPs who may refer patients to the IP include oncologists, oncology nurses and psycho-oncology SWs working at the COS. During the initial IP assessment, the patient’s prior experience and current expectations regarding the outcomes of the CIM therapeutic process are examined. During the consultation, the IP provides patients with an opportunity to present their narratives regarding their illness, as well as express their concerns regarding QOL-related issues. Toward the end of the consultation, treatment goals are outlined and a preliminary treatment plan is tailored to the patient’s outlook, as well as to the level of evidence regarding the efficacy and safety (e.g., potential interactions with

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Analysis of referral source and IP-SW communication Referrals generated by SW (n=91)

Referrals generated by non- SW (n=253)

HCP referrals to IP consultation

IP consultation with IP summary Group A (n=103) Referrer: non-SW IP summary to SW: No

Group B (n=150) Referrer: non-SW IP summary to SW: Yes

Group C (n=91) Referrer: SW IP summary to SW: Yes

(n=344) Group I (n=32)

Group II (n=58)

Group III (n=254)

Interaction with SW:

Interaction with SW:

Interaction with SW:

None

1 session

≥ 2 sessions

Analysis of number of patient-SW sessions Fig. 1. Core study procedures and patient recruitment study plan.

chemotherapy) of each treatment option. A structured letter summarizing the IP consultation is entered into the patient’s medical file, and then sent via internal mail to the referring oncology HCP. Once the treatment plan has been established, patients undergo a series of CIM treatments which are provided by the IP and other IOP team members. The CIM modalities offered include the following: advice on nutrition and the use of dietary or herbal supplements; acupuncture and manual modalities; Anthroposophic medicine; mind-body medicine treatments (e.g., relaxation, guided imagery, music therapy); and spiritual counseling. CIM treatment schedules range from one session per week to once every 3 weeks. At each subsequent treatment, patients and CIM practitioners discuss the outcomes of the previous encounter, with the practitioner modifying the treatment accordingly. The COS provides conventional oncology treatments to approximately 1000 new patients each year, and the psycho-oncology service offers consultations to each new patient. The psychooncology SWs sit with each patient for an initial visit lasting approximately 50 min, which focuses primarily on the patient’s social benefits. Psycho-therapeutic interventions may follow, usually entailing between 1 and 6 sessions. In some cases, especially where there is prolonged illness, the therapeutic intervention may continue indefinitely, depending on the needs and wishes of the patient. The goals of the intervention are to help patients cope emotionally with their disease, and to help them overcome the severe side effects of the anti-cancer treatments. While all HCPs at the COS are able to refer their patients to the IP consultation, oncologists and nurses are more likely to refer newlydiagnosed patients who have been admitted for chemotherapy. This is due to the order of events in the COS, with the first visit taking place in the oncologists’ office, followed by a nurse intake and only then a preliminary meeting with the psycho-oncology SW.

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further divided into groups: C1, where the SW-IP interaction was bi-directional, as described; and C2, where the interaction was bidirectional and where an SW with CIM training was involved in the CIM treatment as well. The SW-patient interaction was defined according to the number of therapeutic sessions attended by the patient. The number of SW-patient interactions was established based on the COS patients’ medical records, which were searched independently by three of the authors (ES, HW, OA). While this parameter may not reflect the depth of the therapeutic alliance, it provides an objective measure of the communicative and thus therapeutic interaction between patients and the SWs responsible for their care. Using this outcome, patients were grouped into the following categories: Group I, no SW-patient interaction documented; Group II, only 1 treatment session recorded; and Group III, with 2 or more sessions. In a sub-set analysis, group III was divided into group IIIa (2–6 sessions) and group IIIb (>6 sessions). 2.4. Data analysis Sample power calculation was conducted using Win Epi scope 2, with 95% confidence interval and power of 80%. The sample size was determined based on the assumption that at least 90 participants in each group (patients referred to the IP consultation by an SW, vs. those referred by a non-SW) would have a 15% difference in the chance that the IP would return a summary of the CIM consultation to the referring SW. Data were evaluated using the SPSS software program (version 18; SPSS Inc., Chicago, IL). Pearson’s chi-square test and Fisher’s exact test were used to detect any differences in the prevalence of categorical variables and demographic data between the groups. In addition, a t-test was performed to determine any variation in continuous variables, when normality was assumed. In cases of non-normal distribution, the Mann-Whitney U test was employed. Differences between groups’ categories were performed using ANOVA and post-hoc tests. Somers’d test was used to measure the association and relationship between variables in groups A-C and groups I–III. An adjusted ␣ for pair-wise comparisons was conducted. P values of less than 0.05 were considered to be of statistical significance. 2.5. Ethical considerations The Ethics (Helsinki) Committee at the Carmel Medical Center, Haifa, Israel, approved the study protocol. Participation in the study was voluntary. Information collected from patients and participating SW’s was gathered in an anonymous fashion, following informed consent. The study protocol was registered in the NIH protocol registration system (ClinicalTrials.gov) and designated as NCT01860365. 3. Results

2.3. Outcome measures

3.1. Psycho-oncology social worker-integrative physician communication

The patient registry was searched for all referrals of patients to an IP consultation, and for the return of a written summary by the IP to the referring oncology HCP (Fig. 1). SW-IP communication was defined according to the referral-response interaction between the two practitioners, with three possibilities: Group A, patients referred by an HCP other than an SW, and for whom no IP summary was provided; Group B, patients referred by a non-SW HCP, but for whom an IP summary of the consultation was sent to the patient’s SW; and Group C, patients who were referred by and for whom an IP summary was sent to the SW. In a subset analysis, group C was

A total of 344 patients were referred by an oncology HCP to the IP for CM consultation. Of these, 103 were referred by a non-SW HCP, and no summary of the consultation was sent by the IP to the patient’s SW (29.9%, group A); 150 were referred by a non-SW HCP, yet an IP summary was sent by to the treating SW (43.6%, group B); and 91 were referred by and a summary of the consultation was sent by the IP to the patient’s SW (26.5%, group C). In this last group, 40 patients were being treated by an SW with CIM training who was employed by both the psycho-oncology and IOP services (group C2).

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Table 1 Comparison of demographic, treatment, and cancer-related variables between Group A–C‡ based on SW-IP communication via a structure referral. Characteristic

Group AN = 103n (%)

Group BN = 150n (%)

Group CN = 91n (%)

P value

Age [Mean in years ± SD (median)]

64.71 ± 11.96 (65)

60.27 ± 12.63 (61)

62.55 ± 12.80 (64)

0.022 between group A:B

Sex: Male Female

33 (32.0) 70 (68.0)

25 (16.7) 125 (83.3)

26 (28.6) 65 (71.4)

0.006 between group A:B

Residential location* : Haifa Suburbs Periphery

41 (39.8) 43 (41.7) 19 (18.4)

61 (40.7) 47 (31.3) 42 (28.0)

32 (35.2) 41 (45.1) 18 (19.8)

0.15

Cancer sites: Breast Gynecological Gastro-intestinal Prostate Lung

33 (33) 24 (24) 25 (25) 11 (11) 7 (7)

69 (44) 29 (20) 26 (18) 12 (8) 7 (5)

39 (43) 12 (13) 27 (30) 8 (9) 4 (4)

0.15

Cancer recurrence: Yes No

22 (21.4) 81 (78.6)

25 (16.7) 125 (83.3)

35 (38.5) 56 (61.5)

<0.0001 between group B:C

Evidence for advanced cancer: Yes No

51 (49.5) 52 (50.5)

63 (42.0) 87 (58.0)

46 (50.5) 49 (49.5)

0.33

Chemotherapy setting: Neo-Adjuvant & Adjuvant Palliative & Curative

67 (66.3) 34 (33.7)

97 (66.0) 50 (34.0)

54 (59.3) 37 (40.7)

0.51

Cancer-related complementary medicine use: Yes No

54 (52.9) 48 (47.1)

76 (50.7) 74 (49.3)

43 (47.8) 47 (50.6)

0.77

SD = standard deviation. Data analysis was performed by t-test, Fisher’s exact test, and Pearson Chi-square test, as needed. Data are limited to the number of respondents who reported this information. * In relation to residential distance from Haifa: suburbs – up to 20 km from Haifa; periphery -beyond 20 km from Haifa. ‡ (Group A = no communication; B = unidirectional from IP to SW; C = bidirectional SW-IP).

The demographic characteristics of the patient groups, in accordance with the degree of the SW-IP interaction, are presented in Table 1. Patients in all three groups were receiving similar chemotherapy regimens in an adjuvant, neo-adjuvant or palliative framework. All participants had comparable rates of advanced vs. localized disease, and reported a similar prevalence of prior use of complementary medicine for cancer-related outcomes. Patients in group B, however, were younger and had a higher female-to-male ratio when compared to group A (p = 0.22 and 0.006, respectively), and lower rates of cancer recurrence when compared to group C (p < 0.0001).

3.2. Psycho-oncologist-patient communication Of the 344 patients referred to the IP for CIM consultation (Fig. 1), 32 had no documented interaction with an SW (9.3%, group I); 58 had only one such meeting (16.8%, group II); and 254 had at least 2 interactions with an SW (73.8%, group III), of which 119 had more than 6 interactions (sub-group IIIb, 34.6% of the cohort). The demographic and medical characteristics of the patients, in accordance with the rates of SW-patient interaction, are presented in Table 2. Patients in all four groups had similar characteristics with respect to gender and the distance of residence from the oncology service. All were undergoing similar chemotherapy regimens – whether adjuvant, neo-adjuvant or palliative – and reported similar rates of prior use of complementary medicine for cancer-related outcomes. However, patients in group I had a higher prevalence of metastatic disease when compared to the other two groups (p < 0.0001), and of cancer recurrence when compared with group II (p = 0.005).

Fig. 2. Patients’ leading concerns (% of patients in each group).

3.3. SW-IP communication and patients’ concerns The three clustered groupings, divided according to the correlation between IP-SW communication and patients’ concerns (as assessed by the IP), are presented in Fig. 2. Patients in group C (SWreferred, IP summary provided) expressed significantly greater emotional concerns than those in group A (non-SW referred, no IP summary provided; 63.7% vs. 39.8%, p = 0.001). At the same time, no significant difference was found between these two groups with respect to gastro-intestinal concerns (e.g. mouth sores, constipation, nausea, etc.; p = 0.44), fatigue (p = 0.072), or pain/neuropathy (p = 0.99). Nor was any difference found between the 4 groups of SW-patient interaction groups (I–III) vis-a-vis patients’ concerns

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Table 2 Comparison of demographic, treatment, and cancer-related variables between Groups I–III‡ categorized, according to the level of SW-patient interaction. Characteristic

Group I N = 32 n (%)

Group IIN = 58n (%)

Group III

N = 254

P value

Sub-group IIIan = 135(%)

Sub-groupIIIbn = 119(%) 60.03 ± 10.66 (60)

0.014 between groups I:IIIb

Age [Mean in years ± SD (median)]

68.19 ± 12.49 (71.5)

61.85 ± 13.46 (61)

63.04 ± 13.50

Sex: Male Female

9 (28.1) 23 (71.9)

18 (31.0) 40 (69.0)

29 (21.5) 106 (78.5)

28 (23.5) 91 (76.5)

0.55

Residence distance: Haifa* Suburbs Periphery

13 (40.6) 12 (37.5) 7 (21.9)

26 (44.8) 18 (31.0) 14 (24.1)

54 (40.0) 47 (34.8) 34 (25.2)

42 (35.3) 53 (44.5) 24 (20.2)

0.70

Cancer sites: Breast Gynecological Gastro-intestinal Prostate Lung

8 (27) 6 (20) 7 (23) 6 (20) 3 (10)

20 (34.5) 11 (18.9) 19 (32.7) 5 (8.6) 4 (6.8)

63 (47.7) 26 (19.7) 26 (19.7) 12 (9.0) 5 (3.8)

50 (43.9) 22 (19.3) 27 (23.7) 9 (7.8) 6 (5.3)

0.46

Cancer recurrence: Yes No

14 (43.8) 18 (56.3)

9 (15.5) 49 (84.5)

33 (24.4) 102 (75.6)

27 (22.7) 92 (77.3)

0.0049 between groups I:II

Evidence for advanced cancer: Yes No

24 (75.0) 8 (25.0)

25 (43.1) 33 (56.9)

56 (41.5) 79 (58.5)

55 (46.2) 64 (53.8)

<0.0001 between I to other groups

Chemotherapy setting: Neo-Adjuvant/Adjuvant Palliative & Curative

14 (43.8) 18 (56.3)

37 (64.9) 20 (35.1)

86 (64.2) 48 (35.8)

81 (69.2) 36 (30.8)

0.07

Cancer-related complementary medicine use: Yes 20 (62.5) No 12 (37.5)

22 (37.9) 36 (62.1)

68 (50.7) 66 (49.3)

63 (52.9) 56 (47.1)

0.13

(65)

SD = standard deviation. Data analysis was performed by t-test, Fisher’s exact test, and Pearson Chi-square test, as needed. Data are limited to the number of respondents who reported this information. * In relation to residential distance from Haifa: suburbs – up to 20 km from Haifa; periphery -beyond 20 km from Haifa. ‡ Group I: no SW-patient interaction; Group II: one session; Group IIIa: 2–6 sessions; Group IIIb: >6 sessions.

regarding gastro-intestinal symptoms (p = 0.99), fatigue (p = 0.09), pain/neuropathy (p = 0.67) or emotional concerns (p = 0.15). 3.4. Correlation between SW-IP communication and SW-patient interactions The relationship between SW-IP communication and SWpatient interaction was tested by comparing groups A-C with groups I–III. A further sub-analysis of the four SW-IP groups (A, B, C1, and C2) was also conducted, comparing the four SW-patient groups (I, II, IIIa, IIIb), with the findings presented in Table 3. A Somers’d measure of association between the four SW-IP groups and the four SW- patient groups yielded a value of 0.114 (p = 0.013). Analysis of the 3 main SW-IP and SW-patient groups showed that patients in groups B and C had a higher frequency of ≥2 SW-patient interactions when compared to patients in group A (A:B:C, 64.1% vs. 77.3% vs. 79.1%, p = 0.02). 4. Discussion The interaction between psycho-oncology social workers, integrative physicians and cancer patients is complex. Both of these healthcare professionals deal with aspects of patients’ emotional and spiritual concerns, as well as with QOL-related outcomes, whether physical or emotional. In the present study we found a high level of communication between IPs and psycho-oncology SWs working within an oncology service, where both provide supportive care to cancer patients. Our findings show that the majority of patients presented to the IP with a structured referral from their

SW, and only 30% had no SW-IP interaction whatsoever. This interaction is not to be taken for granted. Both patients and health care providers may view the two domains as overlapping, particularly with respect to the treatment of patients’ emotional and spiritual concerns. Both integrative medicine and psycho-oncology address similar QoL-related outcomes and symptom management. Both aim to relieve patient anxiety, depression, insomnia and other bio-physical symptoms such as chemotherapy-related fatigue and nausea, which are invariably accompanied by a significant emotional component. To the best of our knowledge, this is the first study which examines the relationship between psycho-oncology SWs and IPs who are working together in a clinical integrative oncology setting. There is a large body of published evidence supporting the use of CIM treatment modalities in cancer care. Many of these therapies have been found to be of benefit, such as with relaxation and guided imagery20 ; mindfulness-based21 and stress management interventions22 ; and yoga.23 All of these modalities can be found in various therapeutic frameworks of psycho-oncology care programs. In the present study, we focused our attention on a specific population of patients who had been referred by their oncologist, nurse oncologist, or psycho-oncology SW to an IP consultation and subsequent CIM intervention. We set out to explore any association between SW-IP communication and SW-patient interactions, and found that many of the patients’ demographic and disease-related characteristics and concerns were not related to the degree of SWIP communication. At the same time, we observed that patients in the group with a higher level of SW-IP communication had a greater

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Table 3 Correlation between IP-SW communication and SW-patient interaction. Psycho-oncologist/Patient:Psycho-oncologist/IP

Group A Group B Group C Total

Gr. C1 Gr. C2

Group In (%)

11 (10.7) 14 (9.3) 4 (7.8) 3 (7.5) 32 (9.3)

Group IIn (%)

Group III n (%)

Gr. IIIa n (%)

Gr. IIIb n (%)

26 (25.2) 20 (13.3) 7 (13.7) 5 (12.5) 58 (16.9)

39 (37.9) 59 (39.3) 22 (43.1) 15 (37.5) 135 (39.2%)

Total

27 (26.2) 57 (38.0) 18 (35.3) 17 (42.5) 119(34.6)

103 150 51 40 344

Group A–C correspond to: A = no communication; B = unidirectional from IP to SW; C = bidirectional SW-IP; sub-groups C: C1 bi-directional communication; C2 = bi-directional communication and integrative treatment provided by dually-trained SW. Groups I–III correspond to: Group I: no meeting; Group II: one session; Group III: 2 and more sessions; Sub groups III: IIIa: 2–6 sessions IIIb: >6 sessions.

degree of emotional concerns, when compared with the patient group with no SW-IP interaction. It is possible that the presence of emotional concerns may have encouraged the study SWs to refer their patients to the IP, or else that the IPs identified these concerns and recognized the need to communicate with the SW responsible for the patients’ care. The relatively low number of referrals to the IP consultation generated by SWs, when compared to referrals by oncologists and nurse oncologists, most probably does not reflect a reduced interest in or reluctance to refer to CIM treatments. It is more likely the result of the fact that the psycho-oncologist is the last healthcare professional to be seen by a newly-diagnosed cancer patient at the COS. Whatever the explanation may be, we suggest that the association between patients’ emotional concerns and greater SW-IP communication indicates a significant collaborative relationship between these two healthcare professionals. Moreover, we observed an association between the level of SW-IP communication and the SW-patient interaction. This was shown in the C2 subgroup, in which patients were treated by an SW with training in CIM who works in both the psycho-oncology and the integrative medicine service. It is possible that this group experienced a more intense SW-patient interaction, as reflected by a higher degree of SW-IP communication. It is also possible that better communication between SWs and IPs may improve, if only indirectly, the SW-patient interaction. In additional to these findings, we found that none of the leading patient concerns (including emotional) correlated with the degree of the SW-patient interaction, as measured by the number of meetings which took place between the two. Patients in group I, in which no interaction took place, had a significantly higher prevalence of metastatic disease and cancer recurrence. While it is probable that patients with more advanced disease could probably benefit the most from a psycho-oncology intervention, it is also likely that the lack of SW involvement in this group was patient-related. Patients with more severe illness may need to focus more on survival and “concrete” issues such as pain management, and may thus be less willing to discuss emotional issues with an SW. The lesser degree of involvement by psycho-oncology SWs in the treatment of severely ill patients may also be practitioner-dependent, reflecting the challenges in treating this patient population. Finally, patients in the group with the greatest SW-IP communication were those with a higher rate of cancer recurrence, suggesting that SW-IP communication may be related to the intensity of the treatment regimen. Further research is needed in order to corroborate and better understand these findings. The present study has a number of limitations which need to be addressed in future studies of this kind. Firstly, the study population which was investigated may not reflect other groups of patients. The study took place in a unique therapeutic environment: an oncology service in which both psych-oncology care and complementary medicine are provided, without charge. There were also a relatively low number of referrals to the IP consultation gener-

ated by SWs, when compared to oncologists and nurse oncologists. Finally, there is the possibility of a selection bias regarding the referral process to the IP consultation, since only those patients receiving chemotherapy, supportive or palliative care were eligible. Future research will need to explore other patient populations with additional demographic and cancer-related parameters. Qualitative research methodology should be incorporated in this research, in order to better understand IP-SW communication patterns, while highlighting those areas in which IP-SW collaboration may lead to a synergistic therapeutic effect. In conclusion, our findings suggest a correlation between the level of SW-IP communication and SW-patient interactions, as administered within a supportive cancer care setting integrating psycho-oncology with CIM. Further studies are needed in order to support the potential for a synergistic effect occurring between psycho-oncology SWs and IPs trained in complementary medicine. This would provide a better understanding regarding the treatment of patients within an integrative setting, in which both modalities are provided as an integral part of patients’ supportive care. Exploring health care practitioners’ communication within a multi-disciplinary team may provide a better understanding of the practitioner-patient interaction. Our findings, which indicate a possible correlation between IP-SW communication and SWpatient interaction patterns in an integrative oncology setting may be relevant for other clinical care settings as well, with practical implications enhancing practitioner-practitioner communication. Conflict of interest The authors state that there are neither actual nor potential conflicts of interest, including any financial, personal or other relationships with other people or organizations whatsoever. Funding This work was not supported by grants. Disclosure The authors have declared no conflicts of interest. References 1. Wuensch A, Tang L, Goelz T, et al. Breaking bad news in China–the dilemma of patients’ autonomy and traditional norms. A first communication skills training for Chinese oncologists and caretakers. Psychooncology. 2013;22(5):1192–1195. 2. Sheppard VB, Adams IF, Lamdan R, et al. The role of patient-provider communication for black women making decisions about breast cancer treatment. Psychooncology. 2011;20(12):1309–1316. 3. Brown R, Bylund CL, Siminoff LA, et al. Seeking informed consent to Phase I cancer clinical trials: identifying oncologists’ communication strategies. Psychooncology. 2011;20(4):361–368.

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