Giving Information Systematically and Transparently in Lung and GI Cancer Phase 1

Despite exciting recent advances in cancer treatments, there still, ultimately, comes a time when advanced disease progresses, and patients can reliably be expected to have months, not years, left to live. For patients with metastatic cancers studied in the investigator's Coping with Cancer NCI R01s, this comes after progression on 1st- or 2nd-line therapy -- be it chemo-, immune-, or targeted therapy. Prior studies conducted by the investigator have found that oncologists can reliably predict when patients have only months to live (e.g., remarkable agreement between oncologist estimates of months to live shared with patients and patients' actual survival of months). By contrast, patients appear largely unaware of their prognosis. For example, 5% of patients a median of 5 months from death, accurately understood they had incurable, late/end-stage, terminal cancer, and likely only months to live. Dying cancer patients appear to lack the prognostic understanding needed to make informed choices.

Patients who grasp that they are dying (e.g., the 8.6% who "get the gist" that they likely have months to live), relative to those who do not, have been shown to have: a) higher rates of advance care planning (ACP), b) receive less burdensome, unbeneficial care (e.g., fewer intensive care unit, ICU, stays, less cardiopulmonary resuscitation, CPR), and c) more value-consistent care. The investigator has found that patient prognostic understanding is improved by oncologist discussions of life-expectancy, but despite 71% of patients wanting to discuss prognosis with their oncologists (83% adult cancer patients thought prognostic information was extremely/very important), only 17.6% of cancer patients within months of death reported that they had discussed prognosis with their oncologist. Not only do oncologists appear to discuss prognosis less than patients want them to, but even when prognostic discussions do occur, the investigator has found that some approaches (e.g., matter-of-fact) are more effective than others (e.g., vague) for promoting patients' prognostic understanding. Thus, prior work identifies a need to improve communication to promote patient prognostic understanding in a way that oncologists will likely learn, accept, use, and possibly implement more broadly in clinical practice.

To address this need, the investigator 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 the patient heard. Unlike traditional emphasis on numerical or medical details, the Oncolo-GIST approach is based on Reyna's Fuzzy-Trace Theory of decision-making, which emphasizes the need for an understanding of the bottom-line gist of a situation. The Oncolo-GIST approach distills prognostic discussions to clear communication of end-of-life (EoL) decision-making essentials (e.g., life-expectancy). 3 specific aims of the Oncolo-GIST approach will be tested in 2 phases:

Phase 1 will consist of two parts: 1) An interview of key stakeholders/key informants regarding Oncolo-GIST Version 1.0 in order to inform refinements to produce Oncolo-GIST Version 2.0. 2) An open trial of Oncolo-GIST Version 1.0 to inform refinements to produce Oncolo-GIST Version 2.0.

Phase 2 will involve a cluster randomized trial of Oncolo-GIST Version 2.0 on 50 patients with metastatic cancers worse on at least 1 line of therapy (chemo-, immune-, targeted), whose oncologists do not expect to survive 12 months. Patients will be assessed in the week prior to their scheduled scan, within 1 week of the clinic visit in which progressive scan results are discussed, and then 2 and 4 months later to explore intervention effects on primary and secondary outcomes, respectively. Oncologists will be assessed in the week following that same clinic visit to obtain their impressions of the discussion of prognosis and the patient's prognostic understanding.

In the phase one stakeholder interviews the investigator aims to obtain feedback on Oncolo-GIST Version 1.0 from stakeholders/key informants on an early draft of the Oncolo-GIST manual and proposed approach using a version of the Delphi method in which the investigator will interview bereaved family caregivers of advanced cancer patients (n=10) and oncology clinicians who care for patients with advanced gastrointestinal (GI) and thoracic (lung) cancers (n=10).

The Delphi method involves gathering opinions from "experts" (i.e., key informants/stakeholders), keeping feedback anonymous, and circulating it back to experts until consensus is reached. Two feedback rounds will occur in Phase 1. The investigator will recruit 10 bereaved caregivers (e.g., family/friends such as widows) of patients who died in the past year with primary diagnoses of GI or lung cancers, and 10 oncology clinicians (oncologists, palliative care physicians, nurses, nurse practitioners, social workers and psychologists) who care for patients with metastatic GI and lung cancers to obtain their feedback on the Oncolo-GIST Version 1.0 manual and procedures. Consenting subjects will be provided a copy of the Oncolo-GIST 4-step manual and a survey to obtain structured feedback on content, format, and language, which they will be asked to return within 4-6 weeks. Responses will be reviewed and compiled and returned to experts for additional feedback on the revised manual. A 30-60-minute follow-up telephone or video-conferenced interview of experts will be conducted by study staff within the following 2 weeks to identify important themes that may be clinically useful to incorporate into the Oncolo-GIST 2.0 intervention. Interviews will be audio-recorded, transcribed, and kept confidential. The investigator has successfully employed these procedures in a prior study, the EMPOWER intervention, with cancer patient caregivers (CA218313).

In the phase 1 open trial the investigator aims to determine feasibility and acceptability of Oncolo-GIST Version 1.0 in a trial of 10 advanced cancer patients to gather information of the feasibility and acceptability of the intervention to patients and oncologists and to inform refinements that will result in Version 2.0.

We will consent the 8 available oncologists identified by Drs. Shah and Saxena in the GI and lung cancer clinics at Weill Cornell Medicine (WCM). The PI will assign a number to each of the 8 oncologists and provide these numbers to the study statistician who will then randomly assign 4 of the numbers to training in the Oncolo-GIST intervention and the other 4 to usual care. Ten patients who meet the eligibility criteria will receive care from 1 of the 4 oncologists trained in the intervention. Phase 1 expert data will be reviewed and summarized, indicating strengths and weaknesses of the intervention and recommended modifications. Phase 1 open trial data will be cleaned, collated, and analyzed. Feasibility of patient recruitment and retention and oncologists' ability to apply the technique will be evaluated. Acceptability will be assessed among oncologists randomized to the intervention and their patients. The quantitative and qualitative data will inform refinements to the study design and intervention procedures that will result in Oncolo-GIST Version 2.0. A summary document will identify the main thematic issues raised in gathering of the Phase 1 data and will explain how they will (or why they will not) be addressed in revisions to the intervention. The 4 oncologists trained in Version 1.0 will receive additional instruction to be compliant with Version 2.0.

The details for Phase 2 are enumerated in a separate record marked "Giving Information Systematically and Transparently in Lung and GI Cancer Phase 2" (Oncolo-GIST P2), under NCT ID# NCT04179305.