Editorial comment on “How do interventions design to improve provider-patient communication work? Illustrative applications of a framework for communication” and “The State of the Science: Informing choices across the cancer journey with public health mechanisms and decision processes”

The broad State of the Science theme From information to self-care encompassed two presentations with different focus; the first focused on patient-provider communication and the second on a public-health perspective on the cancer journey.

Dr Brundage and his coworkers from Ontario, Canada were asked to take on the daunting task of summarizing and critiquing the extensive body of knowledge related to communication and patient preferences in cancer care. rather than going through this vast and diverse literature in detail, Brundage et al. [1] dealt with this request innovatively by applying their previously developed conceptual framework of patient-provider communication to highlight both extant knowledge and remaining challenges for research and clinical application in this area. This broad framework encompasses four major features— patient and provider characteristics, with particular focus on those susceptible to change; the communication process; the goals of the communication encounter; and some aspects of the environment for the encounter. Brundage focused primarily on shared decision-making, including the use of decision-aids, but also touched upon many other aspects of patient-provider communication, using the framework as an analytic tool.

At the end of Brundage's presentation, he invited the audience to consider how other types of communication theory might enhance our knowledge and contribute to the development of relevant analytic frameworks. The workshop discussions pointed to the benefits of including knowledge derived from discourse and conversation analysis which both emphasize how patient-provider dialogues are co-created and formed interactively into a shared understanding in particular contexts. many challenges need to be addressed in moving these approaches from theoretical to applied research. Other issues which might be addressed in further developing analytic frameworks are to make them more explicit in regard to a number of areas—for example, complex communication encounters with several actors, including a variety of both patient-family constellations and health care provider constellations; multiple communication encounters and how they relate to one another; as well as specifying differences and similarities in communication encounters at different time-points along a cancer journey.

The second contribution to both the state of the science conference and this issue of Acta Oncologica is from Professor Annette Street's melbourne-based group. Street et al. [2] expands Brundage's focus on micro-communication in a dyad consisting of cancer patient and provider in an institution-based consultation, by introducing a public-health perspective. Instead of conceptualizing the cancer journey as a linear chronological trajectory for an individual, in her presentation Street used the analogy of a river, criticizing the present-day professional focus on interventions directed mid- or downstream. She instead argues the importance of ‘upstream’ cancer and palliative care research aiming not only at prophylactic measures to prevent problems, but also with a health-promoting focus. Street et al. provide numerous examples of public health strategies and interventions for cancer and palliative care in their article; in the symposium she focused particularly on three possibilities—information-sharing mechanisms, from technological innovations like web-based patient portals to human resources like registered nurses (RNs) functioning as patient navigators and/ or patient care coordinators; advance care planning as a process which can be initiated long before receiving a life threatening diagnosis; and new forms of community capacity building like life reviews, café conversations, and mass and multi-medial efforts to initiate discussion of death and dying in the general public.

While health-promoting cancer and palliative care has received more attention in recent years in the Anglo-Saxon world, these ideas remain virtually unexplored in the Nordic countries, in part due to novelty of this area and resulting lack of research evidence. Street's presentation was a springboard for the workshop discussion of communication mediums for the future, such as IT alternatives, the balance between direct and indirect patient-provider contact, and opportunities for utilizing community-based resources beyond the health care system to improve cancer care. Given the high level of computerization in Sweden, one area of particular interest for further development concerned making electronic health records more patient-accessible. The role RNs might play in this and other types of patient support became another area of lively discussion in the workshop. The varieties of different roles included in international use of umbrella terms like ‘nurse navigator’, ‘contact nurse’ or ‘care coordinator’ mean that it is difficult to tease out a robust evidence-base. Differential study of content and organization of different types of nurse navigators, contact nurses, etc might be a fruitful area for further analyses, so that research evidence about the benefits and weaknesses of such roles can provide a stronger basis for clinical development.

Street's [2] discussion about advance care planning as a public health strategy raised many issues which the workshop continued to synthesize as links between Brundage and Street's presentations. Present-day societies are dynamic and continuously undergo changes, with increasing diversity among populations and in societal values, as well as increasing diversity in individual preferences along the cancer journey. This increasing variety should be considered more systematically in future research. We need to improve our understanding of the mechanisms by which individual characteristics like gender and ethnicity are given meaning and impact on power relations and health outcomes within and outside the health care system, even in a system based on equal access such as that in Sweden.

A topic discussed both by Brundage [1] and Street [2], and continued in the workshop related to means for optimally combining professional knowledge with the knowledge and preferences of individuals seeking professional health care. There was consensus that optimal health care not only considers the views of individual patients and families, but these individuals also need access to expert knowledge to complement their perspectives. Ways this could be achieved were explored, and a discussion of how to best balance individual empowerment with the needs of a population in a publically financed health care system ensued.