Physicians' communication with a cancer patient and a relative: a randomized study assessing the efficacy of consolidation workshops

BACKGROUND: Although patients with cancer are often accompanied by a relative during medical interviews, to the authors' knowledge little is known regarding the efficacy of communication skills training programs on physicians' communication skills in this context. The objective of the current study was to assess the efficacy of 6 consolidation workshops, 3 hours in length, that were conducted after a 2.5-day basic training program. METHODS: After attending the basic training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual interviews that were recorded on an audio tape at baseline, after consolidation workshops for the consolidation-workshops group, and 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' perceptions of and satisfaction with physicians' communication performance were assessed using a 15-item questionnaire. RESULTS: Sixty-two physicians completed the training program. Compared with physicians who participated to the basic training program, when addressing the patient, physicians who were randomized to the consolidation workshops used more open, open directive, and screening questions (P = 0.011 in simulated patient interviews and P = 0.005 in actual patient interviews) and elicited and clarified psychologic concerns more often (P = 0.006 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the relative, physicians who were randomized to the consolidation workshops gave less premature information (P = 0.032 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the patient and the relative simultaneously, physicians who were randomized to the consolidation workshops used more empathy, educated guesses, alerting to reality, confronting, negotiating, and summarizing (P = 0.003 in simulated patient interviews and P = 0.024 in actual patient interviews). Patients, but not relatives, who interacted with physicians in the consolidation-workshops group were more satisfied globally with the interviews (P = 0.022). CONCLUSIONS: Six 3-hour consolidation workshops resulted in improved communication skills addressed to patients and to relatives. The current results showed that the transfer of skills addressing relatives' concerns remained limited and that consolidation workshops should focus even more systematically on the practice of three-person interviews.     

Factors that influence physicians' detection of distress in patients with cancer: can a communication skills training program improve physicians' detection?

BACKGROUND: No study to date has assessed the impact of skills acquisition after a communication skills training program on physicians' ability to detect distress in patients with cancer. METHODS: First, the authors used a randomized design to assess the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by 2 communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. Then, contextual, patient, and communication variables or factors associated with physicians' detection of patients' distress were investigated. After they attended the basic communication skills training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Interviews with a cancer patient were recorded before training, after consolidation workshops for the group that attended consolidation workshops, and approximately 5 months after basic training for the group that attended basic training without the consolidation workshops. Patient distress was recorded with the Hospital Anxiety and Depression Scale before the interviews. Physicians rated their patients' distress on a visual analog scale after the interviews. Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. Communication skills were analyzed according to the Cancer Research Campaign Workshop Evaluation Manual. RESULTS: Fifty-eight physicians were evaluable. Repeated-measures analysis of variance showed no statistically significant changes over time and between groups in physicians' ability to assess patient distress. Mixed-effects modeling showed that physicians' detection of patients' distress was associated negatively with patients' educational level (P = 0.042) and with patients' self-reported distress (P < 0.000). Mixed-effects modeling also showed that physicians' detection of patient distress was associated positively with physicians breaking bad news (P = 0.022) and using assessment skills (P = 0.015) and supportive skills (P = 0.045). CONCLUSIONS: Contrary to what was expected, no change was observed in physicians' ability to detect distress in patients with cancer after a communication skills training programs, regardless of whether physicians attended the basic training program or the basic training program followed by the consolidation workshops. The results indicated a need for further improvements in physicians' detection skills through specific training modules, including theoretical information about factors that interfere with physicians' detection and through role-playing exercises that focus on assessment and supportive skills that facilitate detection.     

How to optimize physicians' communication skills in cancer care: results of a randomized study assessing the usefulness of posttraining consolidation workshops.

PURPOSE: Although there is wide recognition of the usefulness of improving physicians' communication skills, no studies have yet assessed the efficacy of post-training consolidation workshops. This study aims to assess the efficacy of six 3-hour consolidation workshops conducted after a 2.5-day basic training program. METHODS: Physicians, after attending the basic training program, were randomly assigned to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual patient interviews that were audiotaped at baseline and after consolidation workshops for the consolidation-workshop group, and approximately 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' perceptions of communication skills improvement were assessed using a 14-item questionnaire. RESULTS: Sixty-three physicians completed the training program. Communication skills improved significantly more in the consolidation-workshop group compared with the waiting-list group. In simulated interviews, group-by-time repeated measures analysis of variance showed a significant increase in open and open directive questions (P =.014) and utterances alerting patients to reality (P =.049), as well as a significant decrease in premature reassurance (P =.042). In actual patient interviews, results revealed a significant increase in acknowledgements (P =.022) and empathic statements (P =.009), in educated guesses (P =.041), and in negotiations (P =.008). Patients interacting with physicians who benefited from consolidation workshops reported higher scores concerning their physicians' understanding of their disease (P =.004). CONCLUSION: Consolidation workshops further improve a communication skills training program's efficacy and facilitate the transfer of acquired skills to clinical practice.     

Look Good Feel Better workshops: A “big lift” for women with cancer

Background. Look Good Feel Better (LGFB) aims to help women manage appearance-related side effects of cancer and its treatment. In this pilot study, we assessed the impact of LGFB workshops on self-image, social interactions, perceived social support, and anxiety. Methods. We administered scales preworkshop and postworkshop participation. We conducted semistructured telephone interviews following attendance. Results. Statistically and qualitatively, subjects experienced significant improvement in self-image, social interaction, and anxiety. Participant anxiety decreased, but greater social support was anticipated than actually obtained. Conclusions. LGFB workshops increase self-image, improve social interactions, and reduce anxiety.     

Factors that influence cancer patients' and relatives' anxiety following a three-person medical consultation: impact of a communication skills training program for physicians

Background: No study has yet assessed the impact of physicians' skills acquisition after a communication skills training program on changes in patients' and relatives' anxiety following a three‐person medical consultation. This study aimed at comparing, in a randomized study, the impact, on patients' and relatives' anxiety, of a basic communication skills training program and the same program consolidated by consolidation workshops and at investigating physicians' communication variables associated with patients' and relatives' anxiety. Methods: Consultations with a cancer patient and a relative were recorded and analyzed by the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' anxiety were assessed with the State‐Trait Anxiety Inventory—State. Results: No statistically significant change over time and between groups was observed. Mixed‐effects modeling of changes in patients' and relatives' anxiety showed that decreases in both patients' and relatives' anxiety were linked with patients' and relatives' self‐reported distress (p = 0.031 and 0.005), and that increases in both patients' and relatives' anxiety were linked with physicians' breaking bad news (p = 0.028 and 0.005). Conclusion: No impact of the training program was observed. Results indicate the need to further study communication skills which may help reduce patients' and relatives' anxiety especially when breaking bad news. Copyright © 2007 John Wiley & Sons, Ltd.     

Teaching Advance Care Planning to Medical Students with a Computer-Based Decision Aid

Discussing end-of-life decisions with cancer patients is a crucial skill for physicians. This article reports findings from a pilot study evaluating the effectiveness of a computer-based decision aid for teaching medical students about advance care planning. Second-year medical students at a single medical school were randomized to use a standard advance directive or a computer-based decision aid to help patients with advance care planning. Students' knowledge, skills, and satisfaction were measured by self-report; their performance was rated by patients. 121/133 (91%) of students participated. The Decision-Aid Group (n = 60) outperformed the Standard Group (n = 61) in terms of students′ knowledge (p < 0.01), confidence in helping patients with advance care planning (p < 0.01), knowledge of what matters to patients (p = 0.05), and satisfaction with their learning experience (p < 0.01). Likewise, patients in the Decision Aid Group were more satisfied with the advance care planning method (p < 0.01) and with several aspects of student performance. Use of a computer-based decision aid may be an effective way to teach medical students how to discuss advance care planning with cancer patients.     

Communication training in oncology: results of intensive communication workshops for Italian oncologists

LENZI R., BAILE W.F., COSTANTINI A., GRASSI L. & PARKER P.A. (2010) European Journal of Cancer Care 20 , 196–203 Communication training in oncology: results of intensive communication workshops for Italian oncologists The primary aim of this study was to evaluate the efficacy of a 3‐day communication course model for senior Italian oncologists. The course, initially designed for US oncologists, was modified to address specific educational areas expected to be relevant to the targeted participants. Five 3‐day intensive communication courses were held for oncologists from different geographical regions in Italy. The courses included formal lectures, small group work, role play and interviews with simulated patients. Participants completed questionnaires before and after the 3‐day workshop. An improvement in self‐efficacy, knowledge of communication skills, favourable changes in attitudes towards disclosure of medical information and assessing patients' concerns and fears were demonstrated at the end of the course. The course was feasible and succeeded in improving parameters associated with effective communication behaviours.     

“Breaking Bad News”: Standardized Patient Intervention improves communication skills for hematology-oncology fellows and advanced practice nurses

Background. Breaking bad news is 1 of cancer specialists’ most common and difficult duties, yet hematology-oncology fellowship programs typically offer little formal preparation for this daunting task. We designed the Breaking Bad News Standardized Patient Intervention (BBNSPI) as a standardized patient educational intervention to improve the communication skills of hematology-oncology fellows (HOFs) and advanced practice nurses (APNs) in breaking bad news to cancer patients. Methods. A total of 6 HOFs and 2 APNs participated in the preintervention test and an educational session designed to improve communication skills. A total of 5 HOFs and 1 APN participated in the postintervention test 1 week later. Results. The average test score of the participants improved from 56.6% in the preintervention test to 68.8% (P<.005) in the postintervention test. The preintervention perception survey showed that 2 of 6 subjects (33%) expected the intervention to improve their communication skills in breaking bad news compared to 5 of 6 subjects (83%) in the postintervention survey (P<.08). The long-term intervention perception survey showed that all 6 subjects (100%) thought the intervention improved their communication skills in breaking bad news to cancer patients^* (P<.048). Conclusions. BBNSPI improved HOFs’ and APNs’ communication skills in breaking bad news to cancer patients. The perception of the subjects about BBNSPI was positive.     

Development of communication skills workshop for oncology advanced practice nursing students

Background. Communication skills have not traditionally been included in nursing curriculum. The best educational method to improve health care providers’ practice in comunication skills is first, introduction of content, followed by continuous skills assessment and mentored feedback.Methods. A communication skills workshop using standardized patients (SPs) was planned for oncology nurse practitioner students. A 6-step development plan was used to design, implement, and evaluate the curriculum. Three patient cases using SPs were developed to represent a specific communication skill. SP teaching methodology is relatively new to nursing curriculum.Results. Four methods of evaluation revealed a high level of satisfaction with the course, a high level of communications skills demonstrated during the course, and student need to have more communication content throughout their curriculum. Confidence in communication skills increased following the workshop.Conclusions. This methodology has widespread application to other areas of cancer nursing including nurses with less oncology experience and practicing nurses on the oncology units. In addition, there is application throughout nursing curriculum for undergraduate and graduate programs. The content should be presented earlier in the curriculum and then reinforced throughout the remaining courses with clinical follow-up.     

Patient Enrollment onto Clinical Trials: the Role of Physician Knowledge

Sixty-six attending physicians at academic medical centers completed a 43-question self-assessment evaluating communication skills, comfort with clinical trial enrollment, and knowledge of patient-related barriers to enrollment on clinical trials. Responses and demographic information were analyzed for trends and for association with estimated trial enrollment. Physician-described enrollment of patients onto trials varied widely, with estimated enrollment varying from less than 5 patients to well over 125 enrolled during the previous year. Participants perceived themselves to have excellent communication skills and were comfortable with the trial enrollment process, though did not consistently identify patient-related barriers to enrollment. Physician knowledge of clinical trials currently enrolling within their field was associated with increased patient enrollment on study (p?=?0.03). Academic physicians expressed confidence in their skills related to clinical trial enrollment despite less than ideal reported enrollment. Knowledge of clinical trials currently enrolling within a physician’s specialty was associated with estimated patient enrollment, and may represent a correctable barrier to trial enrollment.     

The relationship between medical students’ knowledge,confidence, experience,and skills related to colorectal cancer screening

Background. Medical student colorectal cancer prevention education is crucial to improving cancer screening rates. Methods. We surveyed 146 medical students about their knowledge, confidence, and experience with colorectal cancer screening. We then used a multivariate general linear model to assess the relationships between these variables and colorectal cancer screening skills as measured in a standardized patient evaluation. Results. Type and amount of experience providing colorectal cancer screening counseling predicted student performance in the standardized patient encounter, although knowledge and confidence did not. Conclusions. Increased practice performing cancer screening may improve medical students’ ability to implement cancer prevention strategies with patients.     

Using simulated interviews to teach junior medical students to disclose the diagnosis of cancer

Background. Disclosing cancer is a difficult task for junior doctors. Methods. We conducted a survey of 4th-year (of 6 years) medical students’ (N=50) expectations of training in breaking bad news and then designed a course for students in their 5th-year oncology clerkship. The course comprised (a) a group discussion that taught a 6-point protocol for delivering a diagnosis (N=40), (b) a videotaped simulated interview with actors to assess protocol implementation and communication skills (N=18), and (c) feedback from a senior physician. The impact of the course was assessed during the end-of-year faculty examination (N=55). Results. Most students considered breaking bad news most difficult for the diagnosis of cancer or neurodegenerative disease and desired appropriate training. Their primary concerns were attitude and choice of words. During the interview, their greatest difficulty was asking patients what they want to know. In the end-of-year examination, students who took part in both the group discussion and a simulated interview did significantly better in remembering items of the 6-point protocol than those who had only taken part in the group discussion. Conclusion. This pilot study shows that our course improves students’ knowledge in breaking bad news such as cancer. However, its effectiveness after graduation still needs to be determined. Assessing knowledge is feasible using interviews with simulated patients in France.     

Learning amid controversy: Prostate cancer knowledge and screening practices among US medical students

Background. No studies have examined medical students’ recommendation and use of prostate-specific antigen (PSA) testing and digital rectal exam (DRE) to screen for prostate cancer. We hypothesized that students’ race and extent of training on these techniques would be associated with their administration of them. Methods. We analyzed multiinstitutional longitudinal data from a cohort of 2181 medical students in the class of 2003. We queried students’ health behavior, their knowledge of prostate cancer racial disparities, their frequency of performing a PSA test or a DRE on a man 50 years of age or older (senior year only), the perceived relevance of such services to their future practice, and their training on PSA and DRE. We examined predictors of students’ administering PSA and DRE tests to patients during the senior year and changes in the predictors over time. Results. Respectively, 27% and 34% of students reported using the PSA and DRE “usually/always” during their senior year. Black students reported administering the PSA test more often than did students of other races, but race was not a significant predictor of PSA screening after controlling for personal healthy behavior. High perceived relevance to future practice and extensive training on PSA were most strongly associated with administration of PSA. Conclusions. The association between healthy personal behavior and PSA administration confounded the association between race and PSA screening. These results may help explain differences in prostate cancer screening among physicians and help medical educators tailor their curricula on prostate cancer screening.     

Raising awareness on physician-patient communication in IPF: an Italian multicenter study exploring the pulmonologist’s perspective

Background:Idiopathic pulmonary fibrosis (IPF) remains a debilitating, poor prognosis disease requiring a patient-centered approach.Objectives:To explore the pulmonologist’s perspective on physician-patient communication.Methods:A faculty of psychologists and pulmonologists organized a training course consisting of two workshops 12 months apart. Self-assessment questionnaires (pre- and post-course), role play (RP) simulations (during both workshops) and clinical consultation observations followed by semi-structured interviews (during the 12 months) were employed to evaluate the pulmonologists’ knowledge of patient-centered medicine and communication/relational skills (questionnaires), their communication style (RP) and possible communication/relational difficulties (semi-structured interviews).Results:Twenty-three pulmonologists attended the first workshop and 14 the second one; 10 attended both. The questionnaires revealed the interest in patient-centered medicine and communication but also the need for deeper knowledge and improved skills. From the RP sessions performed during the first workshop, a disease-oriented approach emerged; notably, after the training, some improvements suggested a more patient-centered approach, e.g., a more frequent exploration of the patient agenda. Finally, the semi-structured interviews allowed to identify the low patients’ cultural level and the poor general knowledge of IPF among the barriers hampering an effective communication with the clinician, who, however, is responsible for overcoming these obstacles.Conclusions:Despite the overall disease-prone approach to IPF patients, there was room for improvement through adequate training, which, in practice, may ameliorate communication and drive towards patient-centeredness. Exploring the pulmonologists’ needs may help tailoring training interventions. Raising awareness on these topics is crucial to ensure IPF patients optimal care.     

Japanese physicians encounter various ethical dilemmas in medical decisions concerning the end of life

Background. Medical decisions concerning the end of life (MDEL) have recently been the subject of sustained ethical debate in Japan. However, no study has been undertaken to provide a picture of the kinds of ethical dilemmas Japanese physicians encounter in their care of the terminally ill. We therefore conducted a national survey of Japanese physicians involved in medical care for the terminally ill in their everyday practice. Methods. A postal questionnaire was sent to 500 physician members of the Japan Society of Cancer Therapy for an inquiry into their experience on ethical dilemmas in MDEL. Results. A total of 339 physicians (68%) responded, of whom 11% answered that they were always, 26% often, and 39% sometimes perplexed by ethical dilemmas in MDEL. A total of 386 dilemmas were reported by 267 respondents as the most perplexing, including those related to decisions about life-sustaining treatment, patients' families' demands or requests for medical care, patients' refusal of or demand for medical care, and truth-telling to a terminal cancer patient. Many respondents wondered whether cardiopulmonary resuscitation should be performed for a terminally ill patient, in what situation life-sustaining treatment should be withheld, and whose wishes for medical care should be prioritized in the face of disagreement between patients and their families. Conclusion. Our study suggests that Japanese physicians are faced with various perplexing ethical dilemmas. Serious efforts to resolve these problems in research, education, and physician-patient communication are imperative.     

Breaking bad news--development of a hospital-based training workshop

The skills required to break bad news have been written about extensively and are taught in medical schools. Recent initiatives have concentrated on improving the skills of doctors and nurses in senior positions, who act as role models for their junior colleagues. A multiprofessional learning situation can be a threatening environment, in which colleagues may worry about exposing some of the weaknesses in their knowledge and skills regarding communication with patients. We describe the initiation, running, and evaluation of successful training workshops on breaking bad news in a large British district hospital.     

Current Status of Advance Care Planning and End-of-life Communication for Patients with Advanced and Metastatic Breast Cancer

BackgroundAdvance care planning (ACP) is a process that supports adults in understanding and sharing their personal values, life goals, and preferences regarding future medical care. We examined the current status of ACP and end‐of‐life (EOL) communication between oncologists and patients with metastatic breast cancer.Materials and MethodsWe conducted a survey among 41 institutions that specialize in oncology by using an online tool in October 2019. Participants (118 physicians) from 38 institutions completed a 39‐item questionnaire that measured facility type and function; physicians’ background and clinical approach, education about EOL communication, and understanding about ACP; and the current situation of ACP and EOL discussions.ResultsNinety‐eight responses concerning physicians’ engagement in ACP with patients were obtained. Seventy‐one (72%) answered that they had engaged in ACP. Among these, 23 (33%) physicians used a structured format to facilitate the conversation in their institutions, and only 6 (8%) settled triggers or sentinel events for the initiation of ACP. In the multivariable analysis, only the opportunity to learn communication skills was associated with physicians’ engagement with ACP (odds ratio: 2.8, 95% confidence interval: 1.1–7.0). The frequency and timing of communication about ACP and EOL care with patients substantially varied among the oncologists. Communication about patients’ life expectancy was less frequent compared with other topics.ConclusionThe opportunity to improve EOL communication skills promoted physicians’ engagement with ACP among patients with metastatic/advanced breast cancer. However, there were still substantial variabilities in the method, frequency, and timing of ACP and EOL communication among the oncologists.Implications for PracticeThis study found that the opportunity to improve end‐of‐life (EOL) communication skills promoted physicians’ engagement in advance care planning (ACP) among patients with metastatic/advanced breast cancer. All oncologists who treat said patients are encouraged to participate in effective education programs concerning EOL communication skills. In clinical practice, there are substantial variabilities in the method, frequency, and timing of ACP and EOL communication among oncologists. As recommended in several clinical guidelines, the authors suggest a system that identifies patients who require conversations about their care goals, a structured format to facilitate the conversations, and continuous measurement for improving EOL care and treatment.     

Factors influencing physicians' detection of cancer patients' and relatives' distress: can a communication skills training program improve physicians' detection?

Purpose: This study aimed to assess the impact on physicians' detection of patients' and relatives' distress of six 3‐h consolidation workshops (CW) following a 2.5‐day communication skills basic training (BT) program and to investigate factors associated with detection of distress. Methods: Physicians, after BT, were randomized to CW or to a waiting list. Physicians' detection of patients' and relatives' distress was measured through differences between physicians' ratings of patients' and relatives' distress (VAS) and patients' and relatives' self‐reported distress (HADS). Communication skills were analysed according to the CRCWEM. Results: Mixed‐effects modelling of physicians' detection of patients' distress showed a positive group by time effect in favour of physicians in the CW group. Detection of patients' distress was associated negatively with patients' distress, positively with physicians' concurrent use of psychological assessment and supportive skills, and negatively with general assessment skills. Mixed‐effects modelling of physicians' detection of relatives' distress showed no significant group by time effect. Detection of relatives' distress was associated negatively with relatives' distress and with general assessment skills. Conclusion: CW following a 2.5‐day BT are needed to improve physicians' detection of patients' distress in three‐person interviews. Results indicate the need to further improve physicians' detection of relatives' distress. Copyright © 2007 John Wiley & Sons, Ltd.     

Cancer patients' reluctance to disclose their emotional distress to their physicians: a study of Japanese patients with lung cancer

Purpose: To explore cancer patients' concerns about emotional disclosure (ED) to their physicians, and to investigate the factors associated with them. Subjects and Methods: Randomly selected ambulatory patients with lung cancer participated in this study. An 18‐item questionnaire to assess patients' beliefs regarding ED to their physicians was developed for this study. Factor analysis was used to extract the underlying factors of this scale. Patients were asked to answer this questionnaire along with other self‐administered questionnaires. Results: Complete data were available from 104 patients. Four factors were extracted by factor analysis: ‘Hesitation to disturb the physicians by ED’, ‘No perceived need for ED’, ‘Negative attitude towards ED’, and ‘Fear of a negative impact of ED’. All factors reached standards of internal consistency. The prevalence of the above concerns, in that order, among the patients was 68, 67, 46, and 20%. Patients with high distress levels were significantly more likely to endorse ‘Negative impact’ (p=0.02). Older patients were more likely to report ‘Negative attitude’ (p=0.06), whereas male patients were more likely than females to report ‘Hesitation’ (p=0.05). Conclusion: Knowledge of such patient‐related barriers should better prepare physicians to build good communication channels with their cancer patients. Copyright © 2007 John Wiley & Sons, Ltd.     

Quality of life after thyroid cancer: An assessment of patient needs and preferences for information and support

Background. In this article, we desscribe the quality of life and central information and support needs of people with thyroid cancer. We also describes patients’ preferences for services to address their needs. This report may help patients to anticipate how thyroid cancer will affect them and inform physicians on useful ways to help address their patients’ needs. Methods. We collected data through a survey (n=62) of people who had been treated for thyroid cancer. Results. Most respondents indicated that quality of life was quite good, and most of their information needs were adequately addressed during routine care. However, respondents also indicated a desire for ongoing access to information, including information about lifestyle factors that might affect risk of recurrence, signs and symptoms of recurrence, and recent developments in thyroid cancer diagnostics and treatments. They also reported some unmet social and emotional support needs. Respondents reported a strong preference for gaining access to information through convenient resources such as the Internet. Conclusions. Patient care following thyroid cancer treatment could be improved by providing ongoing education about lifestyle factors related to cancer risk, disease surveillance, and resources for treating and coping with cancer. Health care providers should become familiar with local and Internet-based sources of information and support related to thyroid cancer to improve patient access to this information.