Improving health staff’s communication and assessment skills of psychosocial morbidity and quality of life in cancer patients: a study in Southern European countries. Agreement SI2.307317 (2000CVGG2-026) European Commission – University of Ferrara) Coordinator Center Ferrara Itaky, Participating Centers, Lisbon Portugal, Barcelona Spain

Background. Psychiatric lierature in oncology has demonstrated a 25-35% prevalence of emotional disorders (e.g. anxiety and depression) among cancer patients. In spite of the negative consequences of psychosocial morbidity secondary to cancer, only a minority of patients with psychopathological symptoms are correctly identified by oncologists. Training models have been shown to increase doctors' confidence in their skills and their ability to address the patient's needs. No data are available about these areas in Southern European countries, such as Italy, Spain and Portugal, where the doctor-patient relationship is still a problem. Aims. The aims of the study were: (i) to examine the rate of psychosocial morbidity in a series of cancer outpatients with a good performance status and its relationship with coping, level of concerns and ability to talk with family members about their illness; (ii) to examine the concordance (agreement) between patients and their doctors in rating specific area of quality of life; (iii) to develop and apply in the cancer centers participating in the study a training model for doctors addressing the recognition of emotional problems in cancer patients; (iv) to examine the efficacy of the training model both on the doctor subjective level and the doctor-patient rating of quality of life. Methods. A series of cancer outpatients were evaluated as regards their mental status through a psychiatric interview (WHO-ICD-10), psychological morbidity (Hospital Anxiety Depression scale-HAD), coping strategies (Mini-Mental Adjustment to Cancer scale-Mini-MAC), concerns about illness (Cancer Worries Inventory- CWI), and ability to talk with their family (Openness scale). Doctors and a subgroup of patients completed also, independently, a Visual Analogue Scale (VAS) relative to quality of life issues (e.g. mood, well-being, physical symptoms, maladaptive coping, level of distress). Doctors were asked to complete a questionnaire (Confidence Questionnaire-CQ) about their own confidence in dealing with emotions of cancer patients. A training model specifically aimed at improving doctors’ knowledge and ability to rate psychological problems (depression, anxiety, adjustment disorders) was developed and applied to those who participated in the patients’ assessment phase (VAS), The efficacy of the training was examined by re-administering the CQ to doctors after the training and by re-examining the doctor-patient concordance in rating quality of life (VAS). Results. Three-hundred and thirteen cancer patients from Italy, Spain, Portugal and Switzerland participated in the study, with regard to assessment of psychosocial morbidity. A 30.4% (n=95) prevalence of ICD-10 psychiatric diagnoses were found (especially adjustment disorders, n=67, 21.4%. On the HAD, 54 subjects (17.3%) and 28 (8.9%) proved to be cases for anxiety and depression, and a further 17.6% (n=55) and 15.3% (n=48) had sub-threshold symptoms for anxiety and depression, respectively. “Caseness” was related to high scores on the CWI, low scores on the Openness, high scores on the Hopelessness and Anxious Preoccupations sub-scales of the Mini-MAC. Concordance between doctors (n=39) and patients on quality of life domains was within a 27-43% range. Levels of doctors’ confidence in their ability to deal with emotions in cancer patients were in the mild range. A training model (video-clips, slide-kits, simulated cases, exercises in small groups) addressing psychopathology secondary to cancer was developed and applied to doctors (n=30). Satisfaction with the training model was high. At the follow-up, doctors’ confidence in their own skills significantly improved among doctors who had completed the assessment, training and post-training assessment. A slight, but insignificant trend in improvement of doctor-patient concordance about quality of life issues was observed (range 33-51%) in a second post-workshop assessment of new patients (n=67). Discussion. The project confirmed the high level of psychosocial morbidity in cancer patients belonging to a specific cultural context: Southern Europe. It also indicated the role of cancer-related worries and maladaptive coping in psychosocial morbidity and the importance of openness about cancer problems in favouring adjustment. The low capacity of doctors to rate their patients’ quality of life, especially psychological domains, was confirmed. A specifically developed short training model to be applied in clinical oncology showed its worth in improving doctors’ confidence in their skills but only moderately on the objective ratings of psychological issues in cancer patients. Improvement of the training model and diffusion of didactic experiences in cancer settings, starting form the results presented here is an important area which merits further exploration.