Annals of Oncology Advance Access originally published online on February 1, 2007
Annals of Oncology 2007 18(3):479-484; doi:10.1093/annonc/mdl456
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© 2007 European Society for Medical Oncology
breast cancer |
Breast cancer patients' expectations in respect of the physician–patient relationship and treatment management results of a survey of 617 patients
Charité Medical University, Augustenburger Platz 1, 13353 Berlin, Germany
* Correspondence to: Dr J. Sehouli, Charité Universitätsmedizin/Campus Virchow-Klinikum, Department for Gynecology and Obstretics Augustenburger Platz 1, 13355 Berlin. Tel: +49-30-4505664373; Fax: +49-30-450564952; E-mail: sehouli{at}aol.com
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Abstract |
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 Top Abstract introductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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Background: The following study was conducted to explore patients' information needs and preferences with a special focus on doctor–patient communication.
Patients and methods: A 62-item questionnaire developed by a multidisciplinary team and validated in a phase-I study was given to breast cancer patients via the Internet (homepage) or in a hard copy version.
Results: A total of 617 patients responded, 552 on line and 65 via the hard copy questionnaire. The median age of the on-line group was 47 (21–85) and 55 (40–92) in the hard copy group. Sixty-five per cent of the patients were treated with the intention of achieving a cure and 35% of the patients had metastatic disease. The median length of the consultation communicating the information ‘You have breast cancer’ was 15 min (0–300). The most effective and patient-relevant source of information about the disease and the treatment options was consultation with the physician (84%). When asked to suggest areas for improvement, patients' most common answers were: more complementary therapies should be offered by the physician (54%); physicians should take more time to explain things (51%); and cooperation between the physicians involved in the patient's care should be improved (39%). The questions most relevant to patients were: ‘Am I getting the right therapy?’ (89%); ‘How many patients with my condition does my doctor treat?’ (46%) and ‘Can I be enrolled into a trial?’ (46%). An independent second opinion centre was desired by 94% of the respondents but only 20% knew of any such resource.
Conclusions: This study underlines the need to give patients with breast cancer the full details on treatment options and cancer management. The results provide a suitable basis for a broader interdisciplinary discussion of the patient–physician relationship and should be useful in generating hypotheses for subsequent prospective studies.
Key words: breast cancer, physician–patient relationship, internet survey
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introduction |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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Patients' needs regarding medical information and patient's expectations about doctor–patient communication become more and more relevant in the clinical day. Nevertheless, only limited data focussing on these topics exist in the literature.
Women with breast cancer, the most common malignancy in women in industrialised countries, are increasingly turning to the Internet as a source of medical information [1, 2, 3–5]. On the basis of this development, we decided to use the Internet as a vehicle to allow patients a more easy completion of the survey questions on the expectations and information needs of breast cancer patients in Germany. In this study a comparison of patients with adjuvant and metastatic breast cancer was of particular interest.
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patients and methods |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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study concept
The primary goals of this survey were to characterise expectations with regard to the physician–patient communication and treatment management, to describe patient preferences and reasons for compliance and non-compliance and to identify the need for information.
The intention was to use the data collected as a means of generating working hypotheses and as a basis for discussing possible strategies. It was not intended to develop a specific questionnaire for clinical practice.
An interdisciplinary workshop with gynaecologist (n = 5) and medical oncologists (n = 3), statisticians (n = 2), nurses (n = 2) and representatives of self-help organisation (n = 2) was carried out to define the various topics. Different studies on the topic were used as a basis for discussion [4, 6–8]. Therefore, all relevant items were fixed in a written protocol and were selected by consensus voting. The questions emerging from the workshop were worked up to a structured questionnaire containing a total of 62 items.
These questions were then tested for comprehensibility in a monocentre pilot study (at Charité University Hospital of Berlin/Campus Virchow Clinic) involving 20 patients with metastatic breast cancer. The test was conducted on the basis of semistructured interviews and feedback questionnaires under the supervision (GO) of a physician trained in interview technique. We have not used tape-recorded or video-recorded interviews. The interviewer was not involved in the patients' medical care. The average duration of an interview was 
40 min. Patients were assured at the start of the interview that their replies would be in no way detrimental to their care or clinical management. No interview item had been misunderstood or excluded from the questionnaire in the pilot study.
The questionnaire was subsequently posted on the Internet after suitable technical preparation. The questionnaire continued to be used as a hard copy version parallel to the Internet survey. In addition, a control group of 50 breast cancer patients was surveyed using an anonymous hard copy version.
Respondents were able to download the survey from the Web at www.aerzte-fragen-patientinnen.de. A link to the study was also setup on the websites of various medical associations, patient self-help groups and interest groups (see acknowledgements).
patient selection
Participation in the survey, via the Internet or using the hard copy version, was open to all patients with a diagnosis of breast cancer, whether adjuvant or metastatic. The questionnaire was in German, with the result that patients with poor German were not included. A minimum age of 18 years was defined as a criterion for inclusion.
survey procedure
The first part of the questionnaire presented the study concept and asked patients to provide basic data. The particulars requested included age, tumour status, surgical and other interventions (chemotherapy, hormone therapy, immunotherapy and radiotherapy).
Most of the questions concerned patients' expectations with regard to the physician–patient relationship. The answers to select were given in multiple choice format. Multiple replies were possible depending on the type of question. The median time taken for an Internet response was 40 min.
Written acknowledgement of the study was given by the ethics committee of the medical faculty Charité (University Hospital Berlin).
statistics
SPSS (Release 12) was used for statistical analyses and data processing.
For some questions patients were asked to rate their answer from 1 to 10 on a Likert scale. The statistical analysis of the given answers focussed primarily on a descriptive analysis. Medians and range were calculated for ordinal scale variables.
Chi-squared two-by-two tables were used to compare two independent frequency distributions. Depending on the scale quality and the question, two-tailed exact Fisher's tests or Wilcoxon tests were used to calculate P values. We have presented the exact P values to allow the reader to reach their own conclusions if an observed result is of statistical or clinical significance. Therefore, discrimination between statistical or clinical significance cannot be given. The primary objective of this survey was to identify the patient's needs and was not to develop a questionnaire. So, we have not carried out any statistical methods for validation of these questions.
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results |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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Overall, 632 patients took part in the survey from 1 October 2003 until 15 March 2004. Five hundred and sixty-seven patients responded via the Internet and 65 used the hard copy version. Fifteen of the 567 Internet respondents were excluded from the evaluation because the information provided indicated they did not have breast cancer. Hence, 552 on-line versions and 65 hard copy versions were included in the final analysis.
In 62% of the patients vocational training in the past (seamstress, bookkeeper, etc.) was documented, 33% were university graduates and 5% had no job qualifications. Only 4% of on-line respondents had no qualifications as compared with 18% of hard copy respondents. Sixty-five per cent of respondents were in an adjuvant situation at the time of the survey. Of the 35% with distant metastases, 60% had osseous, 32% hepatogenic and 22% had pulmonary metastases. Twelve per cent of the patients with metastases were diagnosed with primary metastatic breast cancer.
A total of 79% of patients had undergone chemotherapy, 56% of these therapies involved anthracycline-based polychemotherapy. Seventy-two per cent of patients had undergone radiotherapy. Sixty-five per cent of the patients had received hormonal therapy (e.g. Tamoxifen). Twelve per cent of patients with metastatic disease also reported immunotherapy (e.g. Trastuzumab). The characteristics of all patients are provided in Table 1. Of the 79% of patients on therapy at the time of the survey, 57% were receiving hormonal therapy, 28% chemotherapy, 12% immunotherapy, 10% radiotherapy and 17% were using complementary medicine.
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Sixty per cent of patients have described current clinical symptoms. The most frequent symptoms were physical weakness (62%), pain (51%), neurological symptoms (31%), skin changes (26%), shortness of breath (20%) and nausea and vomiting (19%). More patients with distant metastases had current symptoms than patients without distant metastases (77% versus 50%).
physician–patient interaction
According to the information provided by the respondents, the consultation during which patients were told, ‘You have breast cancer’ lasted a median of 15 min (range 0–300 min) (Figure 1). Consultation time data was on the basis of patients' estimation and are a subjective measure. Seventy-two per cent of the women were told the diagnosis without family or friends present; but 80% prefer a presence of family or friends when they received their diagnosis.
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Respondents rated the completeness and comprehensibility of the information provided at the consultation on a 10-item Likert scale with scores ranging from 1 to 10. Twenty-four per cent of all patients gave top scores for the completeness of information provided on their illness and therapies (median score 7). Patients without distant metastases have scored the completeness of the information with a median of 7 and in patients with distant metastases the median scores was 6.
Forty-three per cent of hard copy recipients gave top scores for completeness as opposed to 21% of on-line respondents (Figure 2).
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A similar trend emerged with regard to the comprehensibility of the explanations provided. Twenty-nine per cent of patients gave top scores for comprehensibility. The patient cohort with metastatic disease issued a median score of 7 for comprehensibility and the nonmetastatic patient cohort gave a median score of 8 (P = 0.006).
The highest score was voted for the competence of the physician (median 8.7).
Most patients felt to be involved in the treatment decision process and scored a median of 8 for this topic.
Thirty-one per cent of respondents stated that their physician addressed their questions very well, only 5% were unsatisfied. In response to the question ‘What kind of support did your doctor give when telling you "Your breast cancer is back and has spread to other parts of your body"?’, only 8% of patients stated they received excellent support (highest score) as compared with 38% who received no support at all (lowest score). The answers were not different between patients with and without distant metastasis. When asked who gave the most support in coping with the illness, 86% of respondents cited a family member/friend. The second most common response (29%) was ‘my doctor’. Nine per cent of respondents cited ‘another patient’ and ‘a self-help group’.
‘What kind of treatment counselling would you like to get from your doctor?’ The multiple choice answers were: ‘I would appreciate advice on where to go to checkup on the correctness of the choice of treatment (50%)’, ‘I would like to know how and when my condition is likely to get worse (44%)’ and ‘I would like to receive advice from two independent doctors on each step of treatment.’ Ninety-six per cent of patients would welcome information on ‘Other treatment options with all the pros and cons’ as a basis for decision making. Ninety-six per cent of patients wanted to know details of the possible side-effects and discomforts during treatment. Ninety per cent of patients wanted to understand and receive information on the mechanisms of action of the various drugs and radiotherapy.
Furthermore we asked the patients, if they want to know from the doctor details about their life expectancy. The most common response was ‘Nobody can know my probable life expectancy’ (44%). Only 29% wanted to know their exact life expectancy (adjuvant 31.2% versus metastatic 20.1%). Eighty-one per cent of patients wanted to know how and when their condition would be likely to deteriorate, including 83.9% without metastases and 72% patients with metastases.
treatment and side-effects
The women were asked about their own treatment objectives and 81% of patients in an adjuvant setting and 34% of patients in a palliative setting stated, ‘I hope for a full recovery with no more symptoms.’ Forty per cent of patients in an adjuvant setting stated, ‘I hope that no more cancer symptoms occur.’ The answer most commonly chosen by patients with metastatic cancer (49%) was ‘I hope for a decrease in tumour size.’ The second most common answer (38%) was ‘I hope that my illness will spread less quickly.’
The median score in terms of ‘How would you rate the success of the treatments you have received so far (1 worse than expected to 10 better than expected)?’ was 8 points (8 in the nonmetastatic population, 6 in patients with distant metastases).
The distress associated with surgery was with the median of 8 very low (8 from the patients without distant metastases and 7 in those with distant metastases).
Patients rated the distress resulting from side-effects with a global median score of 6. No differences between metastatic or nonmetastasic disease were seen for the following items: fatigue (3), exhaustion (3), haematological side-effects (5), alopecia (6) and damage to the heart (8). The only difference was observed for the item pain (nonmetastatic 6, metastatic 4).
Fifty-six per cent of respondents stated a patient diary allowing them to enter all laboratory values and appointments and find explanations of test results and treatments would be their most important aid to keeping track of their response to treatment. Forty-nine per cent of on-line participants chose the option of an encoded website (similar to those used for on-line banking) where they could always have access to all their test results and find behavioural recommendations. Hard copy respondents were not as interested in a website (17%); their second most preferred option (30%) was regular written communications informing them of results and outlining the next steps. Both patient groups assigned third place to ‘A form that my doctors can use to enter everything for me or that I can use to make entries.’
Twenty-five per cent of patients said they had arrived at a point where they considered giving up treatment and allowing their disease to take its course. Patients with distant metastases were more inclined to consider giving up treatment than those without (31% versus 20%, P = 0.009). Only 14% of patients, however, had actually taken the step of discontinuing a treatment (23% with distant metastases and 11% without). Both the adjuvant population and the metastatic population cited severe side-effects (54%) and lack of confidence in the treatment (32%) as the main reasons for discontinuing therapy.
When asked to rate the importance of the effectiveness and tolerability of a treatment, 87% (90% metastatic, 87% nonmetastatic) assigned a top score of 10 points for treatment efficacy. Only 41% assigned a maximum score of 10 points for the importance of tolerability (40% metastatic, 41% nonmetastatic).
Asked to rate the average prolongation of survival they would expect from a treatment that caused 30% more side-effects and discomfort than first-line therapy, 79% said ‘several years’. Only 16% accepted ‘several months’. Very few patients said that a period of ‘several weeks’ would justify a treatment with more side-effects.
Asked to propose improvements: ‘If you could improve the treatment of breast cancer in three ways, what would be the three most important improvements in your opinion?’ the respondents selected the following from the 12 options provided. The answers did not differ between the adjuvant and the palliative population.
- Doctors should offer complementary medicine as well (54%).
- Doctors should take more time explaining things (51%).
- Better cooperation among doctors (39%).
- More should be done to treat exhaustion (26%).
- The response to treatment should be told more often (26%).
- Treatment should be more effective (25%).
- Treatment should not result in hair loss (20%).
- Treatment should be shorter (13%).
- More medicines should be given to treat vomiting (11%).
- More should be done to control pain (8%).
information needs
When asked: ‘What do you think are the three most important items of information regarding your illness and its treatment?’ the following answers were given.
- Am I getting the right therapy (89%)?
- How many patients with my condition does my doctor treat (46%)?
- Can I be enrolled into a trial (46%)?
Seventy-seven per cent of patients (on-line respondents) go on the Internet to procure information as a basis for judging the quality of their treatment.
Ninety-four per cent of patients said they would welcome the opportunity to ask an independent expert whether they were receiving the best possible treatment available. Only 26%, however, said they knew of such a resource, and mentioned the hospital/the breast cancer centre, followed by Internet portals and self-help groups.
Eighty-four per cent stated that talking to the doctors treating them was the most effective and patient-friendly source of information about treatment options. On-line respondents put Internet information resources (57%) in second place, whereas brochures (23%) and self-help cancer organisations (23%) took second place in the hard copy group.
‘Which measure would you say is the best way for patients to stay informed about and participate in treatment?’ Most patients (55%) chose the following answer: ‘Full information should be provided once on the basis of a "treatment roadmap", followed by information in small gradual portions thereafter.’ The second most popular choice (50%) was ‘A qualified doctor should be appointed specially for providing information to patients and I should be able to have rapid access to this doctor if I have questions.’ Thirty-nine per cent of patients said that a person who has their confidence should always be present at sessions where information is provided. Many (27%) also said ‘Before any information session, I should be told the kind of information to ask for and why.’
psychological aspects
In response to the question ‘Which term would you associate most closely with your illness?’ most patients in an adjuvant and palliative situation said ‘fear’ (68% and 70%, respectively, P = 0.646). In patients in an adjuvant setting, the next most common reply was ‘challenge’ (58%), ‘hope’ (52%), ‘new values’ (42%) and ‘opportunity’ (39%), but also ‘death’ (36%). For patients in a palliative situation, ‘death’ took second place (59%), followed by ‘hope’ (53%), ‘challenge’ (46%), ‘new values’ (36%) and ‘opportunity’ (32%).
Asked to state what they perceived as being the main cause of their illness, the most commonly cited replies were ‘stress in the family’ (42%), stress at work (39%), genetic factors (35%) and environmental factors (33%). There were no significant differences between the adjuvant population and the metastatic population or between on-line and hard copy respondents.
The respondents feared cancer-related symptoms more than treatment-related symptoms (78% versus 22%). Asked what they feared most about their illness, most respondents—both in the adjuvant and palliative settings—said ‘fear of the disease getting worse’ (37% adjuvant, 41% palliative) and ‘fear of dying’ (26% adjuvant, 35% palliative). ‘Losing the breast/seeing my breasts change’ caused the respondents less distress in comparison (13% adjuvant, 7% palliative), likewise the fear of side-effects of therapy (10% adjuvant, 3% palliative). In response to the question ‘What do you do to help the outcome of your illness’, most of the respondents said, ‘I battle with the disease and try not to let it get the better of me’ (65% adjuvant, 76% palliative). Other frequently cited strategies were ‘I try to think positively’ (62% adjuvant, 63% palliative); ‘I live with more awareness and give myself time’ (65% adjuvant, 52% palliative); ‘I have a healthier diet than before’ (49% adjuvant, 44% palliative) and ‘I use complementary treatments as well’ (32% adjuvant, 41% palliative). ‘I follow my doctors' instructions’, said 32% of patients in an adjuvant setting and 37% of those in a palliative situation.
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discussion |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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The primary objective of this survey was to identify the patient's needs and was not to develop a questionnaire. So we have not used any statistical methods for validation of these questions. In this survey we asked patients with breast cancer about information and attitudes to various aspects of the physician–patient relationship and treatment. We do not know the time lapse between primary diagnosis and study entry. So we were not able to correlate the specific interval with the individual answers. This should be addressed in future prospective trials.
This large Internet-based survey study underlines the key role of the physician as the main point of contact for patients with breast cancer. The physician's role is essential not only as a source of information about the disease and various treatment options but also in coping with the disease.
For all the aspects concerning consultations about treatments received to date, it was striking that the hard copy respondents were considerably more satisfied with their consultations and their doctors than the on-line respondents, and patients without metastases were more satisfied than those with metastases. A selection bias cannot be ruled out, although it can also be postulated that unmet expectations for cure among patients with recurrent disease or metastasis might cause dissatisfaction. This should be studied in prospective studies.
The high demand for further information about the disease and treatment management fits in to the trend over the past number of years showing that patients with malignant disease want more counselling, information and influence on treatment management [9, 10]. A study by Jenkins et al. [11] in 2231 cancer patients showed that 87% wanted as much information as possible from their physicians. Doctors are inclined to underestimate the need for information [12].
A recently published Australian study of 126 patients with metastatic malignant disease documented that >95% of patients would appreciate comprehensive counselling about symptoms, treatment options and side-effects from their doctors [9]. Interestingly, patients of our study felt that the experienced side-effects of fatigue and exhaustion were severe r than expected. Therefore, it may be advisable to discuss these side-effects intensively with the patient before starting a therapy.
The improvement proposal most commonly described by patients is ‘The doctor should offer complementary medicine as well’ (54%), in combination with the statement ‘I use complementary therapies as well’ (32% adjuvant, 41% palliative) might be of interest in developing treatment concepts in real-life clinical situations. Patients evidently need to feel they are doing something about the disease on their own in addition to receiving conventional treatment options. A prior survey among patients with gynaecological cancers showed that a very large percentage of patients use complementary medicine or would like to do so. Patients said using complementary medicine gave them more hope for a cure and helped to take away their fear of not having done everything in their power to combat the disease [13]. Patients, in general, were prepared to choose and use a complementary treatment option under the supervision of their doctor, who is considered to be the most important and most competent point of contact. This is seen by the fact that 84% of respondents look upon consultations with their doctor as the most effective and patient-friendly source of information about treatment options.
Finally, it is important to note that the present results are primarily on the basis of patients who seek information on the Internet. The actual percentage of cancer patients who seek medical information on the Internet is unknown. The few such studies available put the rate at 10%–44% [1, 8].
In this study, the Internet was used only as a vehicle to allow patients an easier and anonymous completion of the survey questions; however, an uncritical generalization of the data to all breast cancer patients would not be legitimate. A special Internet-friendliness selection bias cannot be excluded. Interestingly, in our study Internet users seem to be less satisfied with the completeness of the information they received from the physician in comparison to the breast cancer patients who completed the hard copy questionnaire (Figure 2). This observation is probably reflecting the high motivation of Internet user to seek medical information. In concordance with a study by Helft et al. [8] in cancer patients, Internet users were significantly younger in our survey. Furthermore, socioeconomic factors (e.g. income, education) have been reported to influence the Internet access and use [8]. These factors should be analysed in prospective trials.
Our study did not disclose relevant differences between Internet users and nonusers (using hard copies) in terms of how they deal with information on their illness. Future studies should systematically investigate the impact of age on expectations and how patients deal with information on their disease. We have found no data in the literature why breast cancer patients in Germany do not use the Internet. A number of USA studies showed that lack of Internet access was the most important barrier, a factor that correlated closely with low income and a low level of education [1, 8, 14]. This is an aspect that should be investigated on the basis of further, large-scale prospective trials.
In conclusion, the key findings of this survey were:
- Breast cancer patients need more information about side-effects, clinical studies and supportive care.
- The physician is the most relevant source of information for breast cancer patients.
- Patients want to receive a second opinion about adequate therapy and treatment options.
- Breast cancer patients rated the completeness and comprehensibility of the information lower than the competence of the physician and the involvement in the treatment decision process.
- Patients are demanding complementary medicine, more time for medical explanations and better cooperation between doctors.
- Further, large international prospective studies with a cross-cultural context focussing on cancer patient's expectations and preferences in respect of physician–patient communication and treatment management should be carried out.
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Acknowledgements |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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The authors wish to thank all the women with breast cancer who took part in the survey and provided their data. This paper has only been possible through their commitment. Our thanks also go to the various institutions (OPS and ESSEX Pharma, Germany) and medical associations (DKG, BNGO, AIO, AGO) for their tremendous support. Special thanks to the North-Eastern German Society of Gynaecologic Oncology (NOGGO) for their great support. Unlimited access to the available data will be granted to all interested institutions. The original data from this study will be supplied unrestricted to all interested facilities upon request as a basis for continued debate.
Received for publication April 30, 2006. Revision received July 29, 2006. Revision received October 17, 2006. Accepted for publication October 31, 2006.
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References |
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1. Basch EM, Thaler HT, Shi W, et al. (2004) Use of information resources by patients with cancer and their companions. Cancer 100:2476–2483.[CrossRef][ISI][Medline]
2. Baker L, Wagner TH, Singer TH, et al. (2003) Use of the Internet and e-mail for health care information: results from a national survey. JAMA 289:2400–2406.
3. Engel J, Schmidt M, Schubert-Fritschle G, et al. (2000) Jahresbericht 1999 des klinisch-epidemiologischen Krebsregisters am Tumorzentrum München-Scherpunkt: Gynäkologische Tumoren. (Zuckerschwerdt, München, Germany).
4. Fogel J, Albert SM, Schnabel F, et al. (2002) Use of the Internet by women with breast cancer. J Med Internet Res 4:E9.[Medline]
5. Fox S and Fallows D. (2003) Health searches and e-mail have become more commonplace, but there is no room for improvement in searches and internet access. Pew Internet and American Life Project Online Report (16 July).
6. Chen X and Siu LL. (2001) Impact of the media and the internet on oncology: survey of cancer patients and oncologists in Canada. J Clin Oncol 19:4291–4297.
7. Detmar SB, Aaronson NK, Wever LD, et al. (2000) How are you feeling? Who wants to know? Patients' and oncologists' preferences for discussing health-related quality-of-life issues. J Clin Oncol 18:3295–3301.
8. Helft PR, Eckles RE, Johnson-Calley CS, et al. (2005) Use of the internet to obtain cancer information among cancer patients at an urban county hospital. J Clin Oncol 23:224954–4962.
9. Detmar SB, Muller MJ, Wever LD, et al. (2001) The patient–physician relationship. Patient–physician communication during outpatient palliative treatment visits: an observational study. JAMA 285:101351–1357.
10. Wallberg B, Michelson H, Nystedt M, et al. (2000) Information needs and preferences for participation in treatment decisions among Swedish breast cancer patients. Acta Oncol 39:467–476.[CrossRef][ISI][Medline]
11. Jenkins V, Fallowfield L, Saul J. (2001) Information needs of patients with cancer: results from a large study in UK cancer centres. Br J Cancer 84:48–51.[CrossRef][ISI][Medline]
12. Degner LF, Kristjanson LJ, Bowman D, et al. (1997) Information needs and decisional preferences in women with breast cancer. JAMA 277:181485–1492.[Abstract]
13. Sehouli J. (1998) Postoperative Nutzung unkonventioneller Krebstherapien (UKT) bei Patientinnen mit gynäkologischen Malignomen. Verlag für wissenschaftliche Publikationen.
14. Peterson MW and Fretz PC. (2003) Patient use of the internet for information in a lung cancer clinic. Chest 123:2452–457.
15. Hagerty RG, Butow PN, Ellis PA, et al. (2004) Cancer patient preferences for communication of prognosis in the metastatic setting. J Clin Oncol 22:91721–1730.
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