Importance of Communication Skills Training and Meaning Centered Psychotherapy Concepts among Patients and Caregivers Coping with Advanced Cancer

Latinos are more likely to be diagnosed with advanced cancer and have specific existential and communication needs. Concepts within Meaning-Centered Psychotherapy (MCP) interventions and Communications Skills Training (CST) assist patients in attending to these needs. However, Latino-tailored MCP interventions have yet to be adapted for advanced cancer patients and caregivers. A cross-sectional survey was administered to Latino advanced cancer patients and caregivers where participants rated the importance of the goals and concepts of MCP and CST. Fifty-seven (n = 57) Latino advanced cancer patients and fifty-seven (n = 57) caregivers completed the survey. Most participants rated MCP concepts as extremely important, ranging from 73.75% to 95.5%. Additionally, 86.8% favored finding meaning in their life after a cancer diagnosis. Participants (80.7%) also selected the concept of finding and maintaining hope to cope with their cancer diagnosis. Finally, participants found CST concepts and skills acceptable, ranging from 81.6% to 91.2%. Results indicate the acceptability of Meaning-Centered Therapy and Communication Skills Training among Latino advanced cancer patients and caregivers coping with advanced cancer. These results will inform the topics to be discussed in a culturally adapted psychosocial intervention for advanced cancer patients and their informal caregivers.


Introduction
Foreign-born Latinos, from countries such as Cuba, Puerto Rico, Mexico, and Central and South America, are more likely to be diagnosed with cancer at an advanced stage when compared to non-Latino whites [1][2][3]. In addition, foreign-born Latinos have specific existential [4] and communication needs [5,6]. An advanced cancer diagnosis can cause physical, emotional, psychosocial, and existential stress not only for the patient but also for the caregiver [7][8][9][10]. Cancer as a significant stressor has been treated with several psychotherapeutic interventions designed to address this existential suffering and communication need. Specifically, Meaning-Centered Psychotherapy (MCP) and Communication Skills Training (CST) have shown an effect by targeting the specific psycho-spiritual needs of patients with advanced cancer and enhancing a sense of meaning, peace, and purpose as they face an advanced diagnosis [11][12][13], while CST targets communication skills with patients and caregivers coping with cancer [14].
William Breitbart developed Meaning-Centered Psychotherapy (MCP) as an intervention to address the existential distress often experienced by patients with advanced skills training approach was adapted for non-spousal patients' caregivers by eliminating spousal terms (e.g., taking care of your partner-spouse) and using general caregiving terms (e.g., taking care of your significant other). The concepts related to CST involve learning how to share thoughts about cancer, express feelings regarding a cancer diagnosis, learn strategies to accept others' perspectives, and acquire communication strategies to accept and validate others [14].
Participants for this study comprised patients and caregivers who were recruited as dyads from an oncology clinic in the southern area of Puerto Rico between October 2020 and September 2021. The Ponce Research Institute Institutional Review Board (IRB) and Ethical Committee approved all the study procedures. An IRB-approved introductory letter to familiarize potential participants with the study. Patients' inclusion criteria included: (1) patients with solid stage III or IV tumors, (2) age 21 or older, and (3) self-reported Latino. Eligible family caregivers included those who were: (1) a caregiver with a family member diagnosed with solid stage III or IV tumors referred by the advanced cancer patient, (2) age 21 or older, and (3) self-reported Latino. Patients' exclusion criteria included: (1) diagnosed with a major disabling medical or psychiatric condition, (2) unable to understand the consent procedure, or (3) too ill to participate, reported by the patient and determined by the PI's judgment. After completing the screening process, those eligible and interested were consented and scheduled to complete the questionnaire. Following informed consent, patients, and family caregivers (FCs) were assigned a subject number and administered the survey and self-report assessment to evaluate the patients' and FCs' perspectives and psychosocial needs.
The cross-sectional survey in Spanish included rating the importance of the goals and concepts of MCP and CST. In addition, the survey included general demographic questions (age, education, and gender) and a series of standardized scales described in the protocol paper [37]. Participants were given USD 15 as compensation for their time and effort.
All analyses were conducted using IBM SPSS Statistics 21. The database was checked for coding errors and missing data using descriptive statistics. The analyses included descriptive statistics and frequency analysis for the survey to rate the importance of the goals and concepts of MCP and CST. The study was properly powered to use the findings in this formative work. The G Power statistical program [38] was used to determine the sample size. The study had a power of 0.80 (p < 0.05) to detect a medium-sized effect (Cohen's d = 0.50) [38]. Based on the analysis, the team recruited a sample of 114 participants (57 advanced cancer patients; 57 family caregivers).

Meaning Centered Psychotherapy Concepts: Dyads
When asked about MCP concepts, the majority of participants rated the concepts as extremely important, ranging from 73.75 to 95.5%. Participants (95.5%) ranked the concept of their "love for loved ones" as extremely important when coping with a cancer diagnosis.
Participants (91.2%) valued the concept of "maintaining hope" as extremely important. Many participants (89.5%) ranked the concept of "being responsible for themselves after cancer diagnosis" as extremely important. Most participants (89.5%) rated the concept of their "love for life" extremely important when coping with a cancer diagnosis. Participants (87.6%) ranked the concept of "finding beauty in music, nature, and other life experience" as extremely important. Regarding the concept of the "care of others after a cancer diagnosis", 86% of participants rated it as extremely important. Most participants (81.6%) ranked the concept of "understanding their life's purpose after a cancer diagnosis" as extremely important. Additional concepts were ranked as extremely important: "reflecting or thinking about their changes after a cancer diagnosis" (79.8%), "changing or adjusting their attitude when circumstances are out of their control" (77.25), "creating meaning in life or thinking about their purpose" (78.1%), "reflecting on heritage and thinking about their life's contributions" (75.4%), and "making sense of the cancer experience" (73.7%) (see Table 2 for more details). Most participants (86.8%) chose the concept of "finding meaning in their life after a cancer diagnosis". Moreover, 80.7% of participants selected the concept of "finding and maintain hope to cope with their cancer diagnosis" (see Table 3).

Meaning Centered Psychotherapy Concepts: Patients
When asked about MCP concepts, most patients rated the concepts as extremely important, ranging from 75.4% to 94.7%. Patients (94.7%) ranked the concept of their "love for loved ones" as extremely important when coping with a cancer diagnosis. Patients (93%) assessed the concept of "maintaining hope" as extremely important. Many patients (91.2%) ranked the concept of "persevering a sense of humor has helped them cope with their cancer diagnosis" as extremely important. Most patients (89.5%) rated the concepts of their "love for life", "being responsible for themselves after cancer diagnosis", and "finding beauty in music, nature, and other life experience" as extremely important when coping with a cancer diagnosis Regarding the concept of the "care of others after a cancer diagnosis", 82.4%% of patients rated it as extremely important. Additional concepts were ranked as extremely important:" create meaning in life or think about their purpose in life" (78.9%), "changing or adjusting their attitude when circumstances are out of their control" (78.9%), "understand their life's purpose after being diagnosed with cancer" (77.2%), "making sense of the cancer experience" (77.2%), "reflect or think about how they have changed after a cancer diagnosis" (75.4%), and "reflect on their heritage or thinking about what they have contributed with their life" (75.4%) (see Table 4 for more details). Most patients (84.2%) chose the concept of "Find meaning in life after a cancer diagnosis". Moreover, 80.7% of patients selected "finding and maintaining hope to cope with their cancer diagnosis" (see Table 5).

Meaning Centered Psychotherapy Concepts: Caregivers
When asked about MCP concepts, the majority of caregivers ranked the concepts as extremely important, ranging from 70.2 to 96.4%. Caregivers (96.4%) rated the concept of their "love for loved ones" as extremely important when coping with a cancer diagnosis. Caregivers (89.5%) also rated the concepts of "maintaining hope", "being responsible for themselves after a cancer diagnosis", "love for life has helped them cope after a cancer diagnosis", and "taking care of others after a cancer diagnosis" as extremely important. Most caregivers (86%) ranked the concept of "understanding their life's purpose after a cancer diagnosis" as extremely important. Caregivers (84.2%) ranked "finding beauty in music, nature, and other life experience" as extremely important. Regarding the concept of "reflect or think about how they have changed after a cancer diagnosis", 84.2% of caregivers rated it as extremely important. Many caregivers (83.9%) rated "preserving a good sense of humor" as extremely important when coping with a cancer diagnosis. Additional concepts were ranked as extremely important: "creating meaning in life or thinking about their purpose" (77.2%), "changing or adjusting their attitude when circumstances are out of their control" (75.4%), "reflecting on heritage and thinking about their life's contributions" (75.4%), and "making sense of the cancer experience" (70.2%) (see Table 6 for more details). Most caregivers (89.5%) chose the concept of "finding meaning in their life after a cancer diagnosis". Moreover, 80.7% of caregivers selected "finding and maintaining hope to cope with their cancer diagnosis" (see Table 7).

Communication Skills Training Concepts:Dyads
When asked about communication skills training concepts and skills, most participants wanted to learn more, ranging from 81.6% to 91.2%. Most participants (91.2%) chose that they would like to acquire problem-solving skills, and 90.4% favored the concept of "wanting to learn that they worry about each other". A large portion (89.5%) favored the concept of "learning ways to show they are accompanying each other in the process". Participants (86.6%) also favored the concept of "learning to talk about their thoughts regarding cancer". Eighty-six percent (86%) of participants favored the concept of "acquiring communication strategies to accept and validate others". Furthermore, 85.8% of participants chose the concept of "wanting to express their feelings about cancer" and 85.1% selected the concept of "acquiring communication skills to accept other people's feelings". Many participants (82.5%) favored the concept of "learning communication strategies to accept other people's perspectives". Finally, 81.6% of participants selected the concept of "reviewing their life and considering their heritage" (see Table 8 for more details).

Communication Skills Training Concepts: Patients
When asked about communication skills training concepts and skills, most patients wanted to learn more, ranging from 80.7% to 91.2%. Most patients (91.2%) selected that they would like to acquire problem-solving skills. A large portion (89.5%) favored the concepts of "wanting to learn that they worry about each other", "learning ways to show they are accompanying each other in the process", "learning to talk about their thoughts regarding cancer", and "wanting to express their feelings about cancer". Patients (87.7%) also favored the concepts of "acquiring communication strategies to accept and validate others" and "acquiring communication skills to accept other people's feelings". Furthermore, 84.2% of patients chose the concept of "learning communication strategies to accept other people's perspectives" Finally, 80.7% of patients selected the concept of "reviewing life and considering their heritage" (see Table 9 for more details).

Communication Skills Training Concepts: Caregivers
When asked about communication skills training concepts and skills, most caregivers wanted to learn more, ranging from 80.7% to 91.2%. Most caregivers (91.2%) chose that they would like to acquire problem-solving skills and favored the concept of "wanting to learn that they worry about each other". A large portion (89.5%) favored the concept of "learning ways to show they are accompanying each other in the process". Caregivers (87.7%) also favored "learning to talk about their thoughts regarding cancer". Additionally, caregivers (84.2%) selected "acquiring communication strategies to accept and validate others". Moreover, 82.5% of caregivers chose the concepts of "acquiring communication skills to accept other people's feelings" and "reviewing their life and considering their heritage". Many (82.1%) favored the strategy of "wanting to express their feelings about cancer". Finally, 80.7% of caregivers selected the concept of "learning communication strategies to accept other people's perspective" (see Table 10 for more details).

Discussion
When patient and caregiver dyads were asked about the concepts of MCP and CST, the majority of participants favorably rated all of the concepts. The acceptance of MCP concepts ranged from 73.75% to 95.5%, while CST ranged from 81.6% to 91.2%. Comparable results were seen in the adaptation of MCP for a Latino population, where patients expressed a need to integrate communication skills as well as accepted MCP concepts in the process of adapting to their cancer diagnosis [37,39]. Some of the many MCP concepts included finding meaning in family and loved ones, maintaining hope, taking responsibility to care for oneself, finding meaning in life after a diagnosis, maintaining a love for life, and preserving a sense of humor. Moreover, the literature acknowledges the efficacy of interventions designed to improve dyadic communication among cancer patients and caregivers [40]. However, studies with Latino patient-caregiver dyads are lacking. A portion of CST concepts includes having problem-solving skills, worrying about each other, demonstrating companionship through the journey, learning to talk about a cancer diagnosis, and acquiring communication strategies.
Results indicate that participants favored love for their loved ones to cope with their diagnosis, which is consistent with studies that underscore how many patients lean on family for support as a coping mechanism during a cancer diagnosis [41]. Additionally, family is an important value to Latinos [42], which could explain why many participants consider it important to take care of others after a cancer diagnosis. Latino patients have reported the desire for assistance in finding hope and meaning in life [43]. Given that participants were also caregivers, many regarded maintaining hope as essential. These results are congruent with literature where caregivers used hope and prayer while caring for a family member with cancer [20]. However, while patients may use hope as a coping mechanism, it can become a difficult topic when discussing end-of-life [19]. The current literature regarding Latino cancer patients and meaning highlights the use of positive reframing and meaning to cope with a cancer diagnosis [41]. Additionally, in the same study, some of the participants integrated the value of life with purpose into their experience with cancer. These results are congruent with the participants' selection of the concepts of finding meaning, creating meaning, and finding purpose in their life. MCP attempts to assist participants in the search for meaning and purpose through experiential sources of meaning. Moreover, participants favor the discussion of "making sense", which is seen in advanced cancer patients as an attempt to make sense of and understand the terminality of an advanced cancer diagnosis experience [44].
Many of the participants indicated that reflecting on the changes in one's life after receiving a cancer diagnosis was important. Even though the MCP concept of change after a diagnosis focuses on general life, hope, and experiences, Latino participants might also reflect on changes attributed to physical changes [45,46], sexuality [46], work [47], or overall quality of life [48]. Regarding responsibility for oneself after a cancer diagnosis, many participants found this to be required within the cancer trajectory. These results are seen in the literature where Latino cancer patients take responsibility for their part in the cancer trajectory [49]. Concerning humor as a coping mechanism, a study with Hispanic male cancer survivors yielded how the survivors used humor as one of many coping mechanisms during their diagnosis and treatment process [50]. Even though our sample includes men, women, patients, and caregivers, most selected humor to cope with their diagnosis.
Some Latinos would rather not discuss the end-of-life stage [18] or death [19]; however, dyads within this study ranked different communication skills as essential. These results could be attributed to integrating cultural factors and values in adapting interventions [51]. The integration of cultural values within interventions has been shown to be successful [52]. For instance, communication interventions aimed at Latinos and their caregivers with a chronic illness (diabetes) yield positive results. Firstly, dyads with good relationships had better care routines, considered the program successful in managing the disease at home, and had better social support [53]. Couples' CST results underscore the benefits of communication between the advanced cancer patient and partner. Some benefits include: the desire not to be seen as a "patient" and "caregiver," symptom management, support for a partner, decision making, conflict resolution, and preparation for death [14]. These results are seen within the team's sample, with participants favoring problem-solving skills and companionship throughout the process. Delivering tailored communication interventions proves to be acceptable and beneficial for the patient and caregiver [54]. Thus, it is highly imperative that caregiver-patient dyads are provided with the necessary skills to discuss thoughts about cancer, express their feelings about cancer, and acquire the necessary communication skills they might need in their daily lives.

Conclusions
Results within this study show how advanced cancer patients and caregivers favor Meaning-Centered Psychotherapy and Communication Skill training concepts. Existing literature also aids in showing how patients favor these concepts independently and when integrated into an MCP intervention or a communication-based intervention. These results highlight the importance of integrating both patient and caregiver perspectives into the development and application of a culturally adapted psychosocial intervention.

Limitations
The instrument used in the study, which contained Meaning-Centered Concepts and Communication Skills Training, was developed in a questionnaire manner; therefore, analyses were limited to a descriptive approach. As a result, inferential analyses cannot be measured. If a scale were to be devised, the analysis could explore statistical differences between patients and caregivers, as well as sex, income, and clinical variables.