Acceptability and Feasibility of a Patient Support Coordinator (PSC) Model of Serious Illness Communication in Outpatient Oncology

Acceptability and Feasibility of a Patient Support Coordinator (PSC) Model of Serious Illness Communication in Outpatient Oncology | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Acceptability and Feasibility of a Patient Support Coordinator (PSC) Model of Serious Illness Communication in Outpatient Oncology Alston Ng, Su-Min Yeo, Wu Meng Tan, Bernard Chua, Rieka Erina, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8796566/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Conventional serious illness conversations (SICs) face significant barriers including clinical time constraints and limited patient-clinician rapport. We evaluated a novel model that nested SICs within non-clinician-led supportive listening delivered by a Patient Support Coordinator (PSC). This exploratory study aimed to assess the acceptability and feasibility of this patient-led approach in outpatient oncology to support its iterative adaptation and implementation. Methods This single-arm, non-randomized pilot study used a convergent parallel mixed-methods design in outpatient oncology. Acceptability was assessed through Feeling Heard and Understood (FHU) and Client Satisfaction (CSQ) surveys with a predefined threshold ≥ 12/16. Qualitative interviews with patients (n = 21) and oncologists (n = 2) provided data on intervention acceptability and implementation feasibility. Results Enrollment (90.3%) and retention (85.7%) rates surpassed feasibility targets. High acceptability was demonstrated by median scores of 13/16 for the FHU (n = 19) and 15/16 for the CSQ (n = 20). While most participants met the FHU threshold, four scored below 12 due to gendered discomfort, mismatched expectations, and perceptions that they were coping well and had no need of supportive listening. Trial registration The study was retrospectively registered with ClinicalTrials.gov (Trial Registration Number: NCT07428655). Trial Registration ClinicalTrials.gov NCT07428655, retrospectively registered on 23 February 2026. Advanced cancer Serious illness communication Supportive listening Palliative care Breast cancer Mixed methods research Feasibility study Advance Care Planning Psychosocial Support Figures Figure 1 1. Background Individuals with life-limiting illnesses like cancer often experience significant anxieties regarding with prognostic uncertainty and complex care decisions.[ 1 , 2 ] Evidence suggests that values-informed discussions called serious illness conversations (SICs) can alleviate these anxieties; early initiation of these conversations has been demonstrated to promote a sense of peace and hope while strengthening patient-clinician rapport.[ 3 – 5 ] Timely initiation of SICs is also associated with a reduced incidence of burdensome end-of-life care, including fewer hospitalizations and lower rates of chemotherapy in the final weeks of life.[ 6 , 7 ] Despite these benefits, longitudinal engagement in SICs is frequently hindered by clinical practice barriers like a lack of time,[ 1 , 8 , 9 ] lack of rapport,[ 10 , 11 ] and concerns about causing distress in patients.[ 1 , 4 , 12 ] Even when augmented by behavioural nudges in a study context, SIC engagement for high-risk patients remained below 15%.[ 13 ] In routine practice, these conversations often happen too late, focus narrowly on resuscitation preferences, and are typically limited to a single discussion at the end of life.[ 6 , 14 ] We addressed these challenges by testing an alternative model in which SICs take place within the broader remit of supportive listening in outpatient oncology. In contrast to conventional SIC practice where the patients’ goals and priorities are elicited by their primary physicians and with reference to prompts and questions found in the Serious Illness Conversation Guide (SICG), our model of care aims to foster unstructured, open-ended conversations that are based on the patient’s immediate interests and concerns. These conversations are facilitated by a Patient Support Coordinator (PSC), a non-clinician with whom patients have no prior relationship. However, as a novel approach to serious illness care, it remains unclear if nesting SICs within supportive listening is acceptable to patients and operationally feasible in the context of outpatient oncology. 2. Methods 2.1. Aims This exploratory study aims to assess the acceptability and feasibility of the PSC intervention in the outpatient oncology setting, with the goal of generating insights that support its iterative adaptation and implementation at scale. Its specific aims are: 1. To assess the acceptability of engaging the PSC in discussions about their goals, priorities, and values, and understand patient perspectives on the utility of supportive listening delivered by the PSC; 2. To assess the feasibility of implementing the PSC intervention in the outpatient oncology setting, with feasibility defined both by (i) participant enrolment and retention rates, and (ii) clinicians’ perceptions of the relevance and ease of integrating the intervention into routine workflow. 3. To identify factors shaping the perceived utility and impact of the intervention from patient and clinician perspectives. 2.2. Study design This is a single-arm, non-randomized pilot study that uses a convergent parallel mixed-methods design. 2.3. Trial registration The study was retrospectively registered with ClinicalTrials.gov (Trial Registration Number: NCT07428655). 2.4. Study setting This study was conducted in the outpatient clinics of two participating breast oncologists at the National Cancer Centre Singapore (NCCS). 2.5. Inclusion criteria Patients were eligible for recruitment if they are 21 years of age or older, diagnosed with advanced cancer (Stage III or IV) or assessed to be at risk of recurrence by their oncologist, aware of their cancer diagnosis, and able to communicate in English or Mandarin. Individuals incapable of providing informed consent due to cognitive impairment or poorly controlled mental health conditions were excluded. 2.6. Recruitment We aimed to recruit at least 25 individuals via convenience sampling to generate preliminary insights into the utility and feasibility of the PSC model in cancer care. The target sample size was determined with reference to existing research on patient experiences in serious illness communication,[4,15–17] rather than statistical power for outcome detection. Following oncologist-confirmed chart reviews by the first author (AN), potential participants were introduced to the PSC during routine consultations. Study procedures were then explained to eligible patients in a separate room. Patients were informed that clinically relevant information would be shared with their oncologists, and that an independent researcher would conduct post-intervention interviews and surveys to understand their experience with the program. 2.7. Ethical considerations This study was approved by the SingHealth Centralized Institutional Review Board (IRB 2025-1184). All participants provided their written informed consent prior to study participation. 2.8. Intervention The PSC model is a short-term, non-clinician-led intervention where the exploration of SIC topics is embedded flexibly within supportive listening sessions. Session frequency and modality, whether in person or via telephone, are tailored to participant preferences. Following a three-month period of proactive, PSC-initiated check-ins, participants transition into an ad-hoc phase where they may request additional support as needed, as shown in Figure 1. Each session begins with a brief distress screening, which provides a point-of-entry for participants to raise issues of concern for supportive listening or discussion (see Appendix S1 for intervention handbook). The model was conceptualized and iteratively refined by the first author (AN) under the clinical supervision of a senior palliative care physician (SN). To prepare for this role, AN received training in supportive listening, motivational interviewing, distress screening, symptom management, and care escalation protocols. 2.9. Data collection and analysis To assess acceptability, participants completed the four-item Feeling Heard and Understood (FHU) survey and the Client Satisfaction Questionnaire (CSQ). Acceptability was defined as a rating of ≥12 out of 16 for each scale (corresponding to 3 out of 4 per item). Semi-structured interviews further explored intervention utility, novelty, and views on intervention parameters. Feasibility was assessed using enrolment (target: ≥60%) and retention (target: ≥70%) rates, with targets defined with reference to figures from other early-phase psychosocial interventions for women with breast cancer.[18,19] Feedback on workflow integration and the utility of PSC-generated insights was also collected from participating clinicians. To reduce response bias, the second author (YSM), who was not involved in the intervention delivery, conducted all interviews. Data were analyzed using the framework method.[20] AN and YSM independently coded transcripts to develop and iteratively refine an analytical framework, resolving discrepancies through discussion. A coding matrix was used to facilitate systematic comparison of experiences across participant categories. To address potential interpretive bias arising from the first author’s dual role as interventionist/ PSC and analyst, the research team engaged in regular study discussions. Interpretations were further validated by the third author (SN) to ensure they remained robustly grounded in the data. Quantitative feasibility indicators (enrolment and retention rates) were summarized descriptively. Qualitative and quantitative findings were integrated though a convergent parallel design: data from both sources were triangulated to identify areas of complementarity or divergence in participant experiences. 3. Results 3.1. Participant characteristics Of the 28 women with advanced breast cancer recruited, 21 were interviewed and 20 completed evaluation surveys. Attrition arose from clinical deterioration (n=2) and fatigue-related refusal to participate in post-intervention study activities (n=2). One of the four participants who withdrew from the intervention consented to an interview to share her reasons for doing so. Characteristics of participants included in this analysis are summarised in Table 1. Table 1. Characteristics of patient participants (n=21) Characteristic n (%) Age group 75 2 (9.5%) Ethnicity Chinese 16 (76.2%) Malay 3 (14.3%) Other 2 (9.5%) Marital status Married 11 (52.4%) Single 5 (23.8%) Separated/ divorced 2 (9.5%) Widowed 3 (14.3%) Employment status Working full-time 5 (23.8%) Working part-time 1 (4.8%) Unemployed 4 (19.0%) Retired 11 (52.4%) Disease stage III 2 (9.5%) IV 19 (90.5%) Disease presentation De novo 12 (57.1%) Recurrent 9 (42.9%) Time since diagnosis <1 year 5 (23.8%) 1-2 years 7 (33.3%) 3-4 years 5 (23.8%) ≥5 years 4 (19.0%) Current treatment modality Oral only 7 (33.3%) Parenteral (IV/ injection) only 10 (47.6%) Combination oral and parenteral 4 (19.0%) Current line of therapy 1 st 7 (33.3%) 2 nd or 3 rd 7 (33.3%) 4 th or higher 5 (23.8%) Adjuvant 2 (9.5%) The study sample was demographically diverse, encompassing a broad age range (mean age = 64 years, SD = 11) and representation across ethnic, marital, and employment backgrounds. Most of the participants were living with stage IV disease and receiving ongoing maintenance therapy with palliative intent through varying modalities, while two had stage III disease and were in remission at recruitment. 3.2. Acceptability to participating patients: Quantitative findings Complete survey data were obtained for the FHU (n=19) and CSQ (n=20). One participant did not complete the FHU, while another was not surveyed given her withdrawal from the intervention. Overall, results indicated high intervention acceptability, with median scores of 13/16 for the FHU and 15/16 for the CSQ (Table 2). Table 2. Quantitative survey results Instrument Measure Mean rating Median rating Feeling Heard and Understood scale (FHU) 1 (n=19) “I felt heard and understood by this provider.” 3.21 3 “I felt this provider puts my best interests first when making recommendations about my care.” 3.37 4 “I felt this provider saw me as a person, not just someone with a medical problem.” 3.58 4 “I felt this provider understood what is important to me in my life.” 3.32 3 Sum (out of 16) 13.5 13 Client Satisfaction Questionnaire (CSQ) 2 (n=20) “To what extent has our service met your needs?” 3.45 3.5 “Has the service you received helped you deal more effectively with your problems?” 3.65 4 “If you were to seek help again, would you come back to our service?” 3.7 4 “In an overall, general sense, how satisfied are you with the service you received?” 3.6 4 Sum (out of 16) 14.4 15 While the predefined acceptability threshold was met by all participants for the CSQ, four individuals (Pt15, Pt21, Pt23, and Pt25) recorded FHU scores below the benchmark of 12/16, indicating the presence of factors that hindered the development of rapport and therapeutic alliance. As detailed in the subsequent qualitative findings (Section 3.5), these lower ratings were associated with specific relational barriers and structural constraints. 3.3. Perceptions of intervention utility: Qualitative findings from patient perspectives Most participants (n=18) described the PSC intervention as valuable and useful in their interviews. In our analysis, we identified three sources of value for participants. 3.3.1. Psychological safety and emotional outlet For many, the intervention provided a safe and dedicated space for them to express their vulnerability and to experience a validation of uncomfortable feelings, something several participants felt was unavailable in their home environment: “With family, you don’t say much. I talk to (PSC), at least I can tell him many things… Sometimes, when I feel very down or when I think too much, I can talk to him. With family members, it’s harder to communicate. They don’t understand… They tell me, ‘It is like that, stop worrying.’” (Pt01, 70s) [Translation YSM’s] Even among participants who felt well-supported by their loved ones, the opportunity to air grievances provided relief from the perceived burden of “heaping on negativity on (loved ones),” (Pt21) offering an opportunity for participants to vent their doubts without social consequence. 3.3.2. Humanizing the care experience The intervention appeared to bridge an affective gap in standard oncology care, which participants consistently characterized as focused exclusively on physical pathology. By attending to the non-medical aspects of the self, the PSC model humanized the care experience and addressed psychosocial needs for which the clinic setting appeared to have “no room”: “Not just the physical aspect is being healed here, it is integrated—the emotional, the mental… Deep inside you, you have the hurt, the scar, the pain – that part (that) is emotional that was not healed… (but) No doctor will talk to you about this… I don’t know if it’s about training, but they have no room for emotions.” (Pt16, 60s) “I feel that somebody cares for me, willing to listen to me and my nonsense… I thought to extend my time with him also. Ya, worth my time, even though talking to him, I’m really late [for consultation with oncologist] already.” (Pt08, 60s) The sense “that there’s someone who cares for them” (Pt03) was reinforced by the PSC’s continued availability as a ready source of support, mitigating the perceived alienation in being patients who “just come for treatment” (Pt03). This sentiment was echoed by Pt14, who contrasted the impersonal accessibility of the institutional hotline with the “comfort” and “connection” of having a “direct” and “personal” relationship with the PSC. 3.3.3. Meaning-making and biographical reflection At times likened to “psychotherapy” or “counseling,” the intervention served to facilitate meaning-making and self-discovery for a subset of participants (n=7). Pt04, for instance, felt comforted in realizing that “It’s not wrong to feel (the) way” she does, while Pt16 experienced newfound appreciation for herself as she gained clarity on her identity: “Talking to him is like a mirror, and I realized I can appreciate myself… I dig up who I was when I was a child, and I realized, ‘Yeah, I was a giver, I have been a giver.’ I didn’t realize that until our discussion… It’s something untapped, you know? It’s been there all along.” (Pt16) Further, reflecting on the illness journey allowed some participants like Pt14 to acknowledge “the big picture,” transforming the injuriousness of their illness experiences into an affirmation of their inner strength: “It does bring back memories that maybe you don’t want to remember too much. But I think it’s also good because it allows me to reflect… and think, ‘Wow, actually, how did I go through that?’… In fact, (reflecting) sort of made me stronger.’” (Pt14, 50s) 3.4. Factors supporting participants’ engagement in intervention The PSC intervention appeared to be effective at facilitating spontaneous reflections on goals and priorities, which participants perceived as functionally therapeutic and indicative of the PSC’s genuine concern for their well-being. We identified two key factors that encouraged their sustained participation in the intervention. 3.4.1. Affective quality of genuine care Central to the participants’ engagement was the felt quality of being cared for, which participants identified as the intervention’s most enduring impact. This relational resonance often transcended specific conversational content, persisting even after details of what was discussed were forgotten. As exemplified by Pt23’s quote, the sense that the PSC embodied a genuine interest in and care for her helped the dialogue feel relaxed and the exploration of values and goals natural: “I felt he sincerely wanted to help, and so we could chat very naturally… The first time I talked to him, it lasted almost an hour. There was nothing we didn’t talk about.” (Pt23, 90s) [Translation YSM’s] This felt quality of care appeared to be anchored in what they perceived to be the PSC’s responsive, participant-led approach, which balanced engagement with emotionally “heavy” topics with providing protective distance from emotionally distressing topics: “I don’t see in his face that he became bored because it’s heavy… The environment he gave, the setting we have is: Be yourself. It's not like: We have to achieve this, we have to answer this question.” (Pt16, 50s) “When you talk to him, he’s not just following a script… (And it’s) good that he did not (talk about) disease spread. That spread, I don’t dare to think about it… I don’t dare to think about the future.” (Pt10, 70s) [Translation YSM’s] 3.4.2. ‘Dual-outsider’ status The PSC occupied a dual-outsider position that serves as a structural advantage in fostering psychological safety and promoting participant engagement. As a non-clinician uninhibited by medical strictures, the PSC was described as an interlocutor with whom participants felt comfortable disclosing their “unorthodox (health-improving) methods” without fear of clinical disapprobation. Crucially, because the PSC lacked the authority to interpret medical results, the intervention was decoupled from the clinical context and thus alleviated prognostic anxieties. The affective contrast between clinical and non-clinical contexts was most visible in the participants’ initial apprehensions about the intervention, with several participants expressing their concern that the oncologist’s introduction of the intervention hinted at imminent deterioration. These anxieties, however, were allayed when the coordinator underscored his lack of medical training. The PSC’s simultaneous distance from the participants’ social worlds also facilitated self-expression and engagement. Most participants practiced protective buffering, attempting to shield their loved ones from their “pent-up angst” and fears. As a “professional stranger” (Pt14) with confidentiality obligations, the PSC provided a low-stakes environment for such disclosures. This was particularly valued among participants where existing social ties appeared inadequate or inappropriate in addressing illness-related distress or carried risks of gossip: “Sometimes you need to speak, but not (to a) friend… No doubt (there can be) nice friends, but they don’t know (cancer). Some of them like to spread [news/ information]… I don’t like to talk to them.” (Pt18) The professional distance afforded by the PSC’s ‘outsider’ role thus offered a safe platform for emotional “release” (Pt18) and meaning-making, without risking undesired disclosure or compromising the social connections participants sought to preserve. 3.5. Challenges and difficulties raised in patient interviews While the intervention was largely well-received, some participants reported encountering certain challenges in their interviews. 3.5.1. Gendered positionality For Pt01 and Pt21, the PSC’s gender identity functioned as a barrier to self-disclosure regarding sensitive physical concerns and body image issues. Pt01, for instance, withheld concerns about her mastectomy, explaining to the female interviewer: “Because you’re a woman, I can talk to you about it. As for (PSC), I didn’t talk to him about it, because he’s a man. How could I? He doesn’t understand how a woman feels. He doesn’t even know those two things [breasts] are for.” (Pt01) [YSM’s translation] 3.5.2. Mismatched expectations of expertise A mismatch between participant needs and the coordinator's generalist support was reported by two participants. Pt27, who characterized the supportive listening as “basic,” expressed a preference for a specialized provider to assist her in managing her fear of cancer recurrence. This perceived inadequacy was echoed by Pt23, whose desire for treatment-related recommendations to achieve remission was left unfulfilled due to the PSC’s lack of clinical training. 3.5.3. Perceived irrelevance/ misunderstanding of intervention intent For three participants (Pt13, Pt15, and Pt25), the perceived irrelevance of the intervention stemmed from a misunderstanding of its primary intent. Pt15, for instance, described the PSC’s role as being “to console” patients; Pt13 distanced herself from “those people who need [psychiatric] medication” for serious mental illnesses, whom she considered the primary target audience for supportive listening. Positioning themselves as emotionally resilient and unaffected by their clinical condition, these participants rejected the premise that they needed emotional comfort or validation, and concluded that the intervention was of limited relevance to them. 3.5.4. Modality-specific aversion Finally, Pt26’s rationale for withdrawal highlights the impact of modality-specific triggers. Despite her initial agreement to telephone-based supportive listening sessions, she eventually withdrew because the medium evoked aversive associations with “very serious” family emergencies. This suggests that associations evoked by modality can override the presumed advantage of convenience, necessitating a more nuanced assessment of participant preferences during the onboarding process. 3.6. Intervention acceptability: Integration of findings The synthesis of quantitative and qualitative data reveals a high degree of convergence in participant perspectives of intervention acceptability. Survey data indicated strong global satisfaction, while interviews provided insights into both relational enablers and difficulties encountered by participants. Table 3 below examines the barriers raised by participants whose FHU scores fell below the acceptability threshold. Table 3. Joint display of acceptability outliers Participant FHU score CSQ score Qualitative theme Integrative insight Pt15 11/16 12/16 Gendered positionality Male facilitator identity constrained disclosure of body-image concerns. Pt23 9/16 12/16 Mismatched expectations Misunderstanding of program’s non-clinical scope depressed FHU ratings, given PSC’s inability to provide “recommendations about (her) care” (Item 2 of FHU, for which Pt23 gave a rating of 1/4). Pt15 11/16 12/16 Perceived irrelevance Program objectives misunderstood to be about providing consolation; identity as emotionally indifferent to cancer and “not depressed” rendered the intervention irrelevant. Pt25 11/16 14/16 Perceived irrelevance Program objectives misunderstood to be about addressing depression in demoralized patients. Described herself as having overcome cancer-related distress, and thus perceived intervention as being of limited value to her. The difference between CSQ and FHU scores among these participants suggests that the presence of relational or interpretive challenges did not diminish their overall satisfaction with the program. Patient experience may be further enhanced by (i) proactively clarifying program objectives, the non-clinical scope of intervention, and the generalist nature of psychosocial support provided to mitigate mismatched expectations, and (ii) implementing gender-concordant matching where feasible. 3.7. Intervention feasibility: Quantitative findings Benchmarked against other early-phase psychosocial interventions in breast cancer populations, this study achieved a high degree of implementation feasibility in outpatient oncology. Of the eligible participants approached for participation, 90.3% (n=28/31) consented to enrolment, surpassing the ≥60% target and indicating robust intervention interest. Further, the model demonstrated strong longitudinal engagement, with a retention rate of 85.7% (n=24/28) among enrolled participants, likewise exceeding the ≥70% target. These figures suggest that the intervention was minimally burdensome to and was sufficiently valued by enrolled participants. 3.8. Intervention feasibility: Qualitative findings from clinician feedback Both participating oncologists endorsed the intervention, citing minimal workflow disruption and identifying several perceived benefits. That the clinicians were asked to introduce the PSC intervention to patients was not experienced by either as an inconvenience, but, according to one of the oncologists, conferred strategic oversight, allowing him to align the timing of introduction with specific clinical objectives for each patient. Beyond perceived time savings that allowed clinicians to focus more fully on treatment-related discussions, the intervention was also viewed as useful in surfacing concerns that may not emerge within routine clinical encounters. One oncologist described an instance in which a significant misunderstanding regarding treatment intentions was revealed through the PSC’s engagement with the patient and her caregiver: “(PSC) was able to break the barrier to have the conversation with them… to understand why they have such misconceptions… The patient’s husband did not want to raise his concerns to me directly for fear of me altering the treatment to be suboptimal for the patient… Because of this fear, which was unfounded, I would never have known.” (St01) Both oncologists also perceived the PSC to be well-placed in offering an alternative perspective on their patients’ concerns and priorities. While both found the PSC’s findings to be broadly consonant with their impressions of their patients, this third-party perspective was nonetheless valued in adding “nuance and texture” to their understanding of their patients’ preferences (St02). One oncologist further posited that emotionally sensitive explorations of goals and values may be more feasibly initiated within a non-clinical context, corroborating our findings in Section 3.4.2: “There's a different signature coming from the treating oncologist than from (the PSC), because if the treating oncologist asks it, there will be some patients who think, ‘If you're asking me what I would want if things are not going well, does it mean that things are not going well now?’” (St02) With respect to documentation, both clinicians regarded the PSC’s summaries of patients’ goals and preferences as adequate, relevant, and useful for care planning. The only suggestion raised was to streamline operational processes by granting the PSC direct access to the structured advance care planning (ACP) note in the electronic documentation system, with the proviso that these entries are reviewed and endorsed by the treating oncologist beforehand. 1 FHU uses a 4-point scale to denote degrees of concurrence, with 0 corresponding to “Not at all true,” 1 “A little bit true,” 2 “Somewhat true,” 3 “Very true,” and 4 “Completely true.” 2 CSQ-4 uses a 4-point scale with item-specific response options. A higher rating indicates greater satisfaction or a more favorable appraisal of the intervention. 4. Discussion Findings from this pilot study suggest that the PSC intervention is highly acceptable and feasible in an outpatient oncology setting, as evinced in high enrolment (90.3%) and retention (85.7%) rates and positive reviews from most participants. Quantitative ratings for FHU (median rating: 13/16) and CSQ (median: 15/16) were corroborated by participants’ qualitative feedback, with most finding the intervention beneficial in providing emotional comfort, humanizing the care experience, or fostering meaning-making. While FHU ratings fell below the acceptability threshold (≥ 12) for four participants, these scores were primarily associated with specific circumstantial constraints and conceptual misalignments rather than a systemic failure of the intervention model. Taken together, the results lend support to the acceptability of the intervention and its concept of nesting values-based exploration within a relational framework of supportive listening. Clinician endorsement further underscored the model’s operational feasibility, highlighting its limited impact on workflow and its perceived utility in offering insights that might otherwise remain unavailable. The potential value of the model is underscored by the prevalence of psychological and existential distress associated with advanced cancer, with some estimates suggesting about half of all individuals with cancer experience severe or prolonged cancer-related distress.[ 21 – 23 ] Meta-analytic data suggest that post-traumatic stress disorder (PTSD) affects around 10% of individuals diagnosed with breast cancer, with some studies demonstrating a prevalence as high as 32.3%.[ 24 , 25 ] Given that engagement in SIC has been shown to improve anxiety and depression symptoms in patients,[ 26 ] this model may further augment these salutary effects by facilitating longitudinal reflection outside the clinic setting. This intervention represents a departure from existing healthcare communication initiatives, which typically involve clinicians engaging their patients in SIC during clinic consultations. Alternative approaches to advance care planning (ACP) see task-shifting or task-sharing, with non-clinical staff providing education on goals of care, encouraging engagement in discussions with physicians,[ 27 , 28 ] or directly completing scripted ACP conversations with patients.[ 29 , 30 ] In contrast to these approaches, this intervention focuses on fostering psychological safety and offering emotional support, with the clarification of goals and values arising spontaneously through supportive listening and ultimately secondary to the patients’ interests, comfort, and preferences. To our knowledge, this study offers a proof-of-concept for a novel model of serious illness communication, with a trained non-clinician serving as the primary facilitator of biographical reflection and values clarification through supportive listening and without the use of structured communication tools or scripted questions. Several limitations warrant consideration. The small sample size and single-arm, non-randomized design restrict generalizability to broader oncology populations. Additionally, because the first author delivered the intervention, it is difficult to decouple the model’s efficacy from individual practitioner competence. However, the valued qualities of relational authenticity and psychological safety are theoretically consistent with the core tenets of supportive listening, suggesting that the reported benefits are at least partially a function of the intervention’s design. Further, the first author’s dual role as PSC and analyst introduced potential interpretive bias, but this was partially mitigated by using an independent interviewer and collaborative coding. Finally, we acknowledge that this trial was registered retrospectively. While we made every effort to adhere strictly to the original protocol approved by the Institutional Review Board, the lack of prospective registration may be perceived as a limitation regarding the pre-specification of study outcomes. 5. Conclusion The PSC intervention offered an acceptable and feasible framework for facilitating serious illness conversations within outpatient oncology. By training a non-clinician to deliver patient-led supportive listening, the intervention achieved robust enrollment and retention rates, and received positive appraisals from both patients and clinicians alike. The model addresses common clinical barriers to serious illness communication, with qualitative findings providing preliminary evidence of its potential to enhance the care experience and support the psychological well-being of patients. Future studies should evaluate the model’s scalability and its comparative impact against conventional clinician-led SICs. Declarations Ethics approval and consent to participate This study obtained approval from the institutional review board at the SingHealth Centralised Institutional Review Board (CIRB), reference number: 2025-1184. All participants signed informed consent prior to study participation. This study was conducted in compliance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Competing interests The authors declare no conflict of interest. Funding This work was supported by Lien Centre for Palliative Care Research Incubator Award, ref: LCPC-EX25-0001. Authors' contributions AN: Formal analysis, Data curation, Writing – Original draft preparation, Writing – Review & Editing; YS: Investigation, Formal analysis, Writing – Review & Editing; TWM: Conceptualization, Supervision; BC: Conceptualization, Supervision; RE: Resources, Supervision; SN: Writing – Review & Editing, Supervision, Funding Acquisition. Acknowledgements The study team extends its thanks to the Lien Centre for Palliative Care and its clinician partners for supporting the trial of the Patient Support Coordinator model of supportive listening and serious illness communication at the National Cancer Centre Singapore (NCCS). References Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003. Nikbakhsh N, Moudi S, Abbasian S, Khafri S. Prevalence of depression and anxiety among cancer patients. Caspian J Intern Med. 2014 Summer;5(3):167. 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Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians’ and Administrators’ Experiences During a Pragmatic Trial. J Gen Intern Med. 2023;38. Patel MI, Periyakoil VS, Blayney DW, Moore D, Nevedal A, Asch S, et al. Redesigning Cancer Care Delivery: Views Patients Caregivers JOP. 2017;13(4):e291–302. Manz CR, Zhang Y, Chen K, Long Q, Small DS, Evans CN, et al. Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol. 2023;9(3):414. Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL, et al. Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study. J Clin Oncol. 2012;30(35):4387. Xu L, Sommer RK, Nyeko L, Michael C, Traeger L, Jacobsen J. Patient Perspectives on Serious Illness Conversations in Primary Care. J Palliat Med. 2022;25(6):940–4. Borregaard Myrhøj C, Novrup Clemmensen S, Sax Røgind S, Jarden M, Toudal Viftrup D. Serious illness conversations in patients with multiple myeloma and their family caregivers—A qualitative interview study. Eur J Cancer Care. 2022;31(1):e13537. Hanley S, Cotner CE, Fenton A, Wright AA, Manz CR. Barriers to Serious Illness Conversations Among Patients with Advanced Cancer: A Qualitative Study. J Pain Symptom Manag. 2025;69(2):183–e1894. Vilhauer RP, McClintock MK, Matthews AK. Online Support Groups for Women with Metastatic Breast Cancer: A Feasibility Pilot Study. J Psychosoc Oncol. 2010;28(5):560–86. Rigg A, Kemp E, Koczwara B, Butow P, Girgis A, Hulbert-Williams NJ, et al. Feasibility, acceptability, and preliminary efficacy of a self-directed online psychosocial intervention for women with metastatic breast cancer: Finding My Way-Advanced. Support Care Cancer. 2024;32(11):744. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. Stevens JM, Montgomery K, Miller M, Saeidzadeh S, Kwekkeboom KL. Common patient-reported sources of cancer‐related distress in adults with cancer: A systematic review. Cancer Med. 2024;13(13):e7450. Miovic M, Block S. Psychiatric disorders in advanced cancer. Cancer. 2007;110(8):1665–76. Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-oncology. 2001;10(1):19–28. Swartzman S, Booth JN, Munro A, Sani F. Posttraumatic stress disorder after cancer diagnosis in adults: A meta-analysis. Depress Anxiety. 2017;34(4):327–39. Arnaboldi P, Riva S, Crico C, Pravettoni G. A systematic literature review exploring the prevalence of post-traumatic stress disorder and the role played by stress and traumatic stress in breast cancer diagnosis and trajectory. BCTT. 2017;9:473–85. Bernacki R, Paladino J, Neville BA, Hutchings M, Kavanagh J, Geerse OP, et al. Effect of the Serious Illness Care Program in Outpatient Oncology: A Cluster Randomized Clinical Trial. JAMA Intern Med. 2019;179(6):751–9. Patel MI, Kapphahn K, Dewland M, Aguilar V, Sanchez B, Sisay E et al. Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer: A Randomized Clinical Trial. JAMA Oncol [Internet]. 2022 Jun 30 [cited 2025 Feb 12]; Available from: https://jamanetwork.com/journals/jamaoncology/fullarticle/2793859 Rodriguez GM, Parikh DA, Kapphahn K, Gupta DM, Fan AC, Shah S, et al. Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning: A Randomized Clinical Trial. JAMA Oncol. 2024;10(7):949–53. Kvale EA, Huang CH, Niranjan SJ, Dionne-Odom JN, Kenzik K, Bevis KS, et al. Barriers and facilitators of navigator-led advance care planning conversations in older patients with cancer. J Clin Oncol. 2016;34(26suppl):17–17. Rocque GB, Dionne-Odom JN, Huang CHS, Niranjan SJ, Williams CP, Jackson BE, et al. Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations. J Pain Symptom Manag. 2017;53(4):682–92. Additional Declarations No competing interests reported. Supplementary Files AppendixS1.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 May, 2026 Reviews received at journal 02 May, 2026 Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 04 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers invited by journal 02 Mar, 2026 Editor assigned by journal 01 Mar, 2026 Editor invited by journal 24 Feb, 2026 Submission checks completed at journal 23 Feb, 2026 First submitted to journal 23 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8796566","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600866776,"identity":"e2b2486b-fa63-442b-baf5-045b4e7b9542","order_by":0,"name":"Alston Ng","email":"","orcid":"","institution":"National Cancer Centre Singapore","correspondingAuthor":false,"prefix":"","firstName":"Alston","middleName":"","lastName":"Ng","suffix":""},{"id":600866777,"identity":"9406d2cf-d8ad-4e22-978c-b5c6eb3c8236","order_by":1,"name":"Su-Min Yeo","email":"","orcid":"","institution":"National Cancer Centre Singapore","correspondingAuthor":false,"prefix":"","firstName":"Su-Min","middleName":"","lastName":"Yeo","suffix":""},{"id":600866778,"identity":"d14033aa-58ed-45e0-b806-6f4ab42b9140","order_by":2,"name":"Wu Meng Tan","email":"","orcid":"","institution":"National Cancer Centre Singapore","correspondingAuthor":false,"prefix":"","firstName":"Wu","middleName":"Meng","lastName":"Tan","suffix":""},{"id":600866779,"identity":"2e92d2c5-dc40-4d60-a3f0-249c9c41af85","order_by":3,"name":"Bernard Chua","email":"","orcid":"","institution":"National Cancer Centre Singapore","correspondingAuthor":false,"prefix":"","firstName":"Bernard","middleName":"","lastName":"Chua","suffix":""},{"id":600866780,"identity":"33825ffd-9443-4b79-a3e4-b20f5a289719","order_by":4,"name":"Rieka Erina","email":"","orcid":"","institution":"National Cancer Centre Singapore","correspondingAuthor":false,"prefix":"","firstName":"Rieka","middleName":"","lastName":"Erina","suffix":""},{"id":600866781,"identity":"14b6e29b-da73-4c03-9fa6-c21dcd3d714b","order_by":5,"name":"Shirlyn Neo","email":"data:image/png;base64,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","orcid":"","institution":"National Cancer Centre Singapore","correspondingAuthor":true,"prefix":"","firstName":"Shirlyn","middleName":"","lastName":"Neo","suffix":""}],"badges":[],"createdAt":"2026-02-05 11:54:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8796566/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8796566/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104178859,"identity":"424db45b-2265-4c3e-aacd-c59becd06df4","added_by":"auto","created_at":"2026-03-08 16:59:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":469218,"visible":true,"origin":"","legend":"\u003cp\u003eIntervention overview\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8796566/v1/726a568987a39a6e8b5386e8.jpg"},{"id":104404389,"identity":"d4d8ca7d-5fb4-405d-8d58-ff37e0ccfdc4","added_by":"auto","created_at":"2026-03-11 12:20:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1660466,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8796566/v1/b3f0c942-99d4-4f76-8fdf-d4b61bdcaac1.pdf"},{"id":104178860,"identity":"296e3b7f-48fc-4ed2-a58b-4fe5402076eb","added_by":"auto","created_at":"2026-03-08 16:59:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":263562,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8796566/v1/21581718d89f0dead94aaa49.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acceptability and Feasibility of a Patient Support Coordinator (PSC) Model of Serious Illness Communication in Outpatient Oncology","fulltext":[{"header":"1. Background","content":"\u003cp\u003eIndividuals with life-limiting illnesses like cancer often experience significant anxieties regarding with prognostic uncertainty and complex care decisions.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Evidence suggests that values-informed discussions called serious illness conversations (SICs) can alleviate these anxieties; early initiation of these conversations has been demonstrated to promote a sense of peace and hope while strengthening patient-clinician rapport.[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Timely initiation of SICs is also associated with a reduced incidence of burdensome end-of-life care, including fewer hospitalizations and lower rates of chemotherapy in the final weeks of life.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite these benefits, longitudinal engagement in SICs is frequently hindered by clinical practice barriers like a lack of time,[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] lack of rapport,[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and concerns about causing distress in patients.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Even when augmented by behavioural nudges in a study context, SIC engagement for high-risk patients remained below 15%.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] In routine practice, these conversations often happen too late, focus narrowly on resuscitation preferences, and are typically limited to a single discussion at the end of life.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe addressed these challenges by testing an alternative model in which SICs take place within the broader remit of supportive listening in outpatient oncology. In contrast to conventional SIC practice where the patients\u0026rsquo; goals and priorities are elicited by their primary physicians and with reference to prompts and questions found in the Serious Illness Conversation Guide (SICG), our model of care aims to foster unstructured, open-ended conversations that are based on the patient\u0026rsquo;s immediate interests and concerns. These conversations are facilitated by a Patient Support Coordinator (PSC), a non-clinician with whom patients have no prior relationship. However, as a novel approach to serious illness care, it remains unclear if nesting SICs within supportive listening is acceptable to patients and operationally feasible in the context of outpatient oncology.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003ch2\u003e2.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Aims\u003c/h2\u003e\n\u003cp\u003eThis exploratory study aims to assess the acceptability and feasibility of the PSC intervention in the outpatient oncology setting, with the goal of generating insights that support its iterative adaptation and implementation at scale. Its specific aims are:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp;\u0026nbsp;To assess the acceptability of engaging the PSC in discussions about their goals, priorities, and values, and understand patient perspectives on the utility of supportive listening delivered by the PSC;\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp;\u0026nbsp;To assess the feasibility of implementing the PSC intervention in the outpatient oncology setting, with feasibility defined both by (i) participant enrolment and retention rates, and (ii) clinicians\u0026rsquo; perceptions of the relevance and ease of integrating the intervention into routine workflow.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp;\u0026nbsp;To identify factors shaping the perceived utility and impact of the intervention from patient and clinician perspectives.\u003c/p\u003e\n\u003ch2\u003e2.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Study design\u003c/h2\u003e\n\u003cp\u003eThis is a single-arm, non-randomized pilot study that uses a convergent parallel mixed-methods design.\u003c/p\u003e\n\u003ch2\u003e2.3.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Trial registration\u003c/h2\u003e\n\u003cp\u003eThe study was retrospectively registered with ClinicalTrials.gov (Trial Registration Number: NCT07428655).\u003c/p\u003e\n\u003ch2\u003e2.4.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Study setting\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in the outpatient clinics of two participating breast oncologists at the National Cancer Centre Singapore (NCCS).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.5.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Inclusion criteria\u003c/h2\u003e\n\u003cp\u003ePatients were eligible for recruitment if they are 21 years of age or older, diagnosed with advanced cancer (Stage III or IV) or assessed to be at risk of recurrence by their oncologist, aware of their cancer diagnosis, and able to communicate in English or Mandarin. Individuals incapable of providing informed consent due to cognitive impairment or poorly controlled mental health conditions were excluded.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.6.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Recruitment\u003c/h2\u003e\n\u003cp\u003eWe aimed to recruit at least 25 individuals via convenience sampling to generate preliminary insights into the utility and feasibility of the PSC model in cancer care. The target sample size was determined with reference to existing research on patient experiences in serious illness communication,[4,15\u0026ndash;17] rather than statistical power for outcome detection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing oncologist-confirmed chart reviews by the first author (AN), potential participants were introduced to the PSC during routine consultations. Study procedures were then explained to eligible patients in a separate room. Patients were informed that clinically relevant information would be shared with their oncologists, and that an independent researcher would conduct post-intervention interviews and surveys to understand their experience with the program.\u003c/p\u003e\n\u003ch2\u003e2.7.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ethical considerations\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the SingHealth Centralized Institutional Review Board (IRB 2025-1184). All participants provided their written informed consent prior to study participation.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.8.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intervention\u003c/h2\u003e\n\u003cp\u003eThe PSC model is a short-term, non-clinician-led intervention where the exploration of SIC topics is embedded flexibly within supportive listening sessions. Session frequency and modality, whether in person or via telephone, are tailored to participant preferences. Following a three-month period of proactive, PSC-initiated check-ins, participants transition into an ad-hoc phase where they may request additional support as needed, as shown in Figure 1.\u003c/p\u003e\n\u003cp\u003eEach session begins with a brief distress screening, which provides a point-of-entry for participants to raise issues of concern for supportive listening or discussion (see Appendix S1 for intervention handbook). The model was conceptualized and iteratively refined by the first author (AN) under the clinical supervision of a senior palliative care physician (SN). To prepare for this role, AN received training in supportive listening, motivational interviewing, distress screening, symptom management, and care escalation protocols.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.9.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Data collection and analysis\u003c/h2\u003e\n\u003cp\u003eTo assess acceptability, participants completed the four-item Feeling Heard and Understood (FHU) survey and the Client Satisfaction Questionnaire (CSQ). Acceptability was defined as a rating of \u0026ge;12 out of 16 for each scale (corresponding to 3 out of 4 per item). Semi-structured interviews further explored intervention utility, novelty, and views on intervention parameters. Feasibility was assessed using enrolment (target: \u0026ge;60%) and retention (target: \u0026ge;70%) rates, with targets defined with reference to figures from other early-phase psychosocial interventions for women with breast cancer.[18,19] Feedback on workflow integration and the utility of PSC-generated insights was also collected from participating clinicians.\u003c/p\u003e\n\u003cp\u003eTo reduce response bias, the second author (YSM), who was not involved in the intervention delivery, conducted all interviews. Data were analyzed using the framework method.[20] AN and YSM independently coded transcripts to develop and iteratively refine an analytical framework, resolving discrepancies through discussion. A coding matrix was used to facilitate systematic comparison of experiences across participant categories. To address potential interpretive bias arising from the first author\u0026rsquo;s dual role as interventionist/ PSC and analyst, the research team engaged in regular study discussions. Interpretations were further validated by the third author (SN) to ensure they remained robustly grounded in the data.\u003c/p\u003e\n\u003cp\u003eQuantitative feasibility indicators (enrolment and retention rates) were summarized descriptively. Qualitative and quantitative findings were integrated though a convergent parallel design: data from both sources were triangulated to identify areas of complementarity or divergence in participant experiences.\u003c/p\u003e"},{"header":"3. Results","content":"\u003ch2\u003e3.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Participant characteristics\u003c/h2\u003e\n\u003cp\u003eOf the 28 women with advanced breast cancer recruited, 21 were interviewed and 20 completed evaluation surveys. Attrition arose from clinical deterioration (n=2) and fatigue-related refusal to participate in post-intervention study activities (n=2). One of the four participants who withdrew from the intervention consented to an interview to share her reasons for doing so. Characteristics of participants included in this analysis are summarised in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eCharacteristics of patient participants (n=21)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u0026lt;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e45 \u0026ndash; 59\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e60 \u0026ndash; 75\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e13 (61.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u0026gt;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e16 (76.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eMalay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e3 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e11 (52.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eSeparated/ divorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e3 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eWorking full-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eWorking part-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e1 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e11 (52.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e19 (90.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease presentation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eDe novo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e12 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eRecurrent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e9 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime since diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u0026lt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e1-2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e7 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e3-4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u0026ge;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent treatment modality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eOral only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e7 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eParenteral (IV/ injection) only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e10 (47.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eCombination oral and parenteral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent line of therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e7 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e or 3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e7 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003e4\u003csup\u003eth\u003c/sup\u003e or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eAdjuvant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe study sample was demographically diverse, encompassing a broad age range (mean age = 64 years, SD = 11) and representation across ethnic, marital, and employment backgrounds. Most of the participants were living with stage IV disease and receiving ongoing maintenance therapy with palliative intent through varying modalities, while two had stage III disease and were in remission at recruitment.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acceptability to participating patients: Quantitative findings\u003c/h2\u003e\n\u003cp\u003eComplete survey data were obtained for the FHU (n=19) and CSQ (n=20). One participant did not complete the FHU, while another was not surveyed given her withdrawal from the intervention. Overall, results indicated high intervention acceptability, with median scores of 13/16 for the FHU and 15/16 for the CSQ (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eQuantitative survey results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstrument\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eFeeling Heard and Understood scale (FHU)\u003csup\u003e1\u003c/sup\u003e (n=19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;I felt heard and understood by this provider.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;I felt this provider puts my best interests first when making recommendations about my care.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;I felt this provider saw me as a person, not just someone with a medical problem.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;I felt this provider understood what is important to me in my life.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eSum (out of 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eClient Satisfaction Questionnaire (CSQ)\u003csup\u003e2\u003c/sup\u003e (n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;To what extent has our service met your needs?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;Has the service you received helped you deal more effectively with your problems?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;If you were to seek help again, would you come back to our service?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026ldquo;In an overall, general sense, how satisfied are you with the service you received?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eSum (out of 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e14.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhile the predefined acceptability threshold was met by all participants for the CSQ, four individuals (Pt15, Pt21, Pt23, and Pt25) recorded FHU scores below the benchmark of 12/16, indicating the presence of factors that hindered the development of rapport and therapeutic alliance. As detailed in the subsequent qualitative findings (Section 3.5), these lower ratings were associated with specific relational barriers and structural constraints.\u003c/p\u003e\n\u003ch2\u003e3.3.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Perceptions of intervention utility: Qualitative findings from patient perspectives\u003c/h2\u003e\n\u003cp\u003eMost participants (n=18) described the PSC intervention as valuable and useful in their interviews. In our analysis, we identified three sources of value for participants.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e3.3.1. Psychological safety and emotional outlet\u003c/h3\u003e\n\u003cp\u003eFor many, the intervention provided a safe and dedicated space for them to express their vulnerability and to experience a validation of uncomfortable feelings, something several participants felt was unavailable in their home environment:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;With family, you don\u0026rsquo;t say much. I talk to (PSC), at least I can tell him many things\u0026hellip; Sometimes, when I feel very down or when I think too much, I can talk to him. With family members, it\u0026rsquo;s harder to communicate. They don\u0026rsquo;t understand\u0026hellip; They tell me, \u0026lsquo;It is like that, stop worrying.\u0026rsquo;\u0026rdquo; (Pt01, 70s) [Translation YSM\u0026rsquo;s]\u003c/p\u003e\n\u003cp\u003eEven among participants who felt well-supported by their loved ones, the opportunity to air grievances provided relief from the perceived burden of \u0026ldquo;heaping on negativity on (loved ones),\u0026rdquo; (Pt21) offering an opportunity for participants to vent their doubts without social consequence.\u003c/p\u003e\n\u003ch3\u003e3.3.2. Humanizing the care experience\u003c/h3\u003e\n\u003cp\u003eThe intervention appeared to bridge an affective gap in standard oncology care, which participants consistently characterized as focused exclusively on physical pathology. By attending to the non-medical aspects of the self, the PSC model humanized the care experience and addressed psychosocial needs for which the clinic setting appeared to have \u0026ldquo;no room\u0026rdquo;:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not just the physical aspect is being healed here, it is integrated\u0026mdash;the emotional, the mental\u0026hellip; Deep inside you, you have the hurt, the scar, the pain \u0026ndash; that part (that) is emotional that was not healed\u0026hellip; (but) No doctor will talk to you about this\u0026hellip; I don\u0026rsquo;t know if it\u0026rsquo;s about training, but they have no room for emotions.\u0026rdquo; (Pt16, 60s)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I feel that somebody cares for me, willing to listen to me and my nonsense\u0026hellip; I thought to extend my time with him also. Ya, worth my time, even though talking to him, I\u0026rsquo;m really late [for consultation with oncologist] already.\u0026rdquo; (Pt08, 60s)\u003c/p\u003e\n\u003cp\u003eThe sense \u0026ldquo;that there\u0026rsquo;s someone who cares for them\u0026rdquo; (Pt03) was reinforced by the PSC\u0026rsquo;s continued availability as a ready source of support, mitigating the perceived alienation in being patients who \u0026ldquo;just come for treatment\u0026rdquo; (Pt03). This sentiment was echoed by Pt14, who contrasted the impersonal accessibility of the institutional hotline with the \u0026ldquo;comfort\u0026rdquo; and \u0026ldquo;connection\u0026rdquo; of having a \u0026ldquo;direct\u0026rdquo; and \u0026ldquo;personal\u0026rdquo; relationship with the PSC.\u003c/p\u003e\n\u003ch3\u003e3.3.3. Meaning-making and biographical reflection\u003c/h3\u003e\n\u003cp\u003eAt times likened to \u0026ldquo;psychotherapy\u0026rdquo; or \u0026ldquo;counseling,\u0026rdquo; the intervention served to facilitate meaning-making and self-discovery for a subset of participants (n=7). Pt04, for instance, felt comforted in realizing that \u0026ldquo;It\u0026rsquo;s not wrong to feel (the) way\u0026rdquo; she does, while Pt16 experienced newfound appreciation for herself as she gained clarity on her identity:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Talking to him is like a mirror, and I realized I can appreciate myself\u0026hellip; I dig up who I was when I was a child, and I realized, \u0026lsquo;Yeah, I was a giver, I have been a giver.\u0026rsquo; I didn\u0026rsquo;t realize that until our discussion\u0026hellip; It\u0026rsquo;s something untapped, you know? It\u0026rsquo;s been there all along.\u0026rdquo; (Pt16)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther, reflecting on the illness journey allowed some participants like Pt14 to acknowledge \u0026ldquo;the big picture,\u0026rdquo; transforming the injuriousness of their illness experiences into an affirmation of their inner strength:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It does bring back memories that maybe you don\u0026rsquo;t want to remember too much. But I think it\u0026rsquo;s also good because it allows me to reflect\u0026hellip; and think, \u0026lsquo;Wow, actually, how did I go through that?\u0026rsquo;\u0026hellip; In fact, (reflecting) sort of made me stronger.\u0026rsquo;\u0026rdquo; (Pt14, 50s)\u003c/p\u003e\n\u003ch2\u003e3.4.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Factors supporting participants\u0026rsquo; engagement in intervention\u003c/h2\u003e\n\u003cp\u003eThe PSC intervention appeared to be effective at facilitating spontaneous reflections on goals and priorities, which participants perceived as functionally therapeutic and indicative of the PSC\u0026rsquo;s genuine concern for their well-being. We identified two key factors that encouraged their sustained participation in the intervention.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e3.4.1. Affective quality of genuine care\u003c/h3\u003e\n\u003cp\u003eCentral to the participants\u0026rsquo; engagement was the felt quality of being cared for, which participants identified as the intervention\u0026rsquo;s most enduring impact. This relational resonance often transcended specific conversational content, persisting even after details of what was discussed were forgotten. As exemplified by Pt23\u0026rsquo;s quote, the sense that the PSC embodied a genuine interest in and care for her helped the dialogue feel relaxed and the exploration of values and goals natural:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I felt he sincerely wanted to help, and so we could chat very naturally\u0026hellip; The first time I talked to him, it lasted almost an hour. There was nothing we didn\u0026rsquo;t talk about.\u0026rdquo; (Pt23, 90s) [Translation YSM\u0026rsquo;s]\u003c/p\u003e\n\u003cp\u003eThis felt quality of care appeared to be anchored in what they perceived to be the PSC\u0026rsquo;s responsive, participant-led approach, which balanced engagement with emotionally \u0026ldquo;heavy\u0026rdquo; topics with providing protective distance from emotionally distressing topics:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t see in his face that he became bored because it\u0026rsquo;s heavy\u0026hellip; The environment he gave, the setting we have is: Be yourself. It\u0026apos;s not like: We have to achieve this, we have to answer this question.\u0026rdquo; (Pt16, 50s)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When you talk to him, he\u0026rsquo;s not just following a script\u0026hellip; (And it\u0026rsquo;s) good that he did not (talk about) disease spread. That spread, I don\u0026rsquo;t dare to think about it\u0026hellip; I don\u0026rsquo;t dare to think about the future.\u0026rdquo; (Pt10, 70s) [Translation YSM\u0026rsquo;s]\u003c/p\u003e\n\u003ch3\u003e3.4.2. \u0026lsquo;Dual-outsider\u0026rsquo; status\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe PSC occupied a dual-outsider position that serves as a structural advantage in fostering psychological safety and promoting participant engagement. As a non-clinician uninhibited by medical strictures, the PSC was described as an interlocutor with whom participants felt comfortable disclosing their \u0026ldquo;unorthodox (health-improving) methods\u0026rdquo; without fear of clinical disapprobation. Crucially, because the PSC lacked the authority to interpret medical results, the intervention was decoupled from the clinical context and thus alleviated prognostic anxieties. The affective contrast between clinical and non-clinical contexts was most visible in the participants\u0026rsquo; initial apprehensions about the intervention, with several participants expressing their concern that the oncologist\u0026rsquo;s introduction of the intervention hinted at imminent deterioration. These anxieties, however, were allayed when the coordinator underscored his lack of medical training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe PSC\u0026rsquo;s simultaneous distance from the participants\u0026rsquo; social worlds also facilitated self-expression and engagement. Most participants practiced protective buffering, attempting to shield their loved ones from their \u0026ldquo;pent-up angst\u0026rdquo; and fears. As a \u0026ldquo;professional stranger\u0026rdquo; (Pt14) with confidentiality obligations, the PSC provided a low-stakes environment for such disclosures. This was particularly valued among participants where existing social ties appeared inadequate or inappropriate in addressing illness-related distress or carried risks of gossip:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Sometimes you need to speak, but not (to a) friend\u0026hellip; No doubt (there can be) nice friends, but they don\u0026rsquo;t know (cancer). Some of them like to spread [news/ information]\u0026hellip; I don\u0026rsquo;t like to talk to them.\u0026rdquo; (Pt18)\u003c/p\u003e\n\u003cp\u003eThe professional distance afforded by the PSC\u0026rsquo;s \u0026lsquo;outsider\u0026rsquo; role thus offered a safe platform for emotional \u0026ldquo;release\u0026rdquo; (Pt18) and meaning-making, without risking undesired disclosure or compromising the social connections participants sought to preserve.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.5.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Challenges and difficulties raised in patient interviews\u003c/h2\u003e\n\u003cp\u003eWhile the intervention was largely well-received, some participants reported encountering certain challenges in their interviews.\u003c/p\u003e\n\u003ch3\u003e3.5.1. Gendered positionality\u003c/h3\u003e\n\u003cp\u003eFor Pt01 and Pt21, the PSC\u0026rsquo;s gender identity functioned as a barrier to self-disclosure regarding sensitive physical concerns and body image issues. Pt01, for instance, withheld concerns about her mastectomy, explaining to the female interviewer:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Because you\u0026rsquo;re a woman, I can talk to you about it. As for (PSC), I didn\u0026rsquo;t talk to him about it, because he\u0026rsquo;s a man. How could I? He doesn\u0026rsquo;t understand how a woman feels. He doesn\u0026rsquo;t even know those two things [breasts] are for.\u0026rdquo; (Pt01) [YSM\u0026rsquo;s translation]\u003c/p\u003e\n\u003ch3\u003e3.5.2. Mismatched expectations of expertise\u003c/h3\u003e\n\u003cp\u003eA mismatch between participant needs and the coordinator\u0026apos;s generalist support was reported by two participants. Pt27, who characterized the supportive listening as \u0026ldquo;basic,\u0026rdquo; expressed a preference for a specialized provider to assist her in managing her fear of cancer recurrence. This perceived inadequacy was echoed by Pt23, whose desire for treatment-related recommendations to achieve remission was left unfulfilled due to the PSC\u0026rsquo;s lack of clinical training.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e3.5.3. Perceived irrelevance/ misunderstanding of intervention intent\u003c/h3\u003e\n\u003cp\u003eFor three participants (Pt13, Pt15, and Pt25), the perceived irrelevance of the intervention stemmed from a misunderstanding of its primary intent. Pt15, for instance, described the PSC\u0026rsquo;s role as being \u0026ldquo;to console\u0026rdquo; patients; Pt13 distanced herself from \u0026ldquo;those people who need [psychiatric] medication\u0026rdquo; for serious mental illnesses, whom she considered the primary target audience for supportive listening. Positioning themselves as emotionally resilient and unaffected by their clinical condition, these participants rejected the premise that they needed emotional comfort or validation, and concluded that the intervention was of limited relevance to them.\u003c/p\u003e\n\u003ch3\u003e3.5.4. Modality-specific aversion\u003c/h3\u003e\n\u003cp\u003eFinally, Pt26\u0026rsquo;s rationale for withdrawal highlights the impact of modality-specific triggers. Despite her initial agreement to telephone-based supportive listening sessions, she eventually withdrew because the medium evoked aversive associations with \u0026ldquo;very serious\u0026rdquo; family emergencies. This suggests that associations evoked by modality can override the presumed advantage of convenience, necessitating a more nuanced assessment of participant preferences during the onboarding process.\u003c/p\u003e\n\u003ch2\u003e3.6.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intervention acceptability: Integration of findings\u003c/h2\u003e\n\u003cp\u003eThe synthesis of quantitative and qualitative data reveals a high degree of convergence in participant perspectives of intervention acceptability. Survey data indicated strong global satisfaction, while interviews provided insights into both relational enablers and difficulties encountered by participants. Table 3 below examines the barriers raised by participants whose FHU scores fell below the acceptability threshold.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eJoint display of acceptability outliers\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFHU score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCSQ score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntegrative insight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003ePt15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e11/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eGendered positionality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eMale facilitator identity constrained disclosure of body-image concerns.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003ePt23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMismatched expectations\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eMisunderstanding of program\u0026rsquo;s non-clinical scope depressed FHU ratings, given PSC\u0026rsquo;s inability to provide \u0026ldquo;recommendations about (her) care\u0026rdquo; (Item 2 of FHU, for which Pt23 gave a rating of 1/4).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003ePt15\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e11/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ePerceived irrelevance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eProgram objectives misunderstood to be about providing consolation; identity as emotionally indifferent to cancer and \u0026ldquo;not depressed\u0026rdquo; rendered the intervention irrelevant.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003ePt25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e11/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e14/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ePerceived irrelevance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eProgram objectives misunderstood to be about addressing depression in demoralized patients. Described herself as having overcome cancer-related distress, and thus perceived intervention as being of limited value to her.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe difference between CSQ and FHU scores among these participants suggests that the presence of relational or interpretive challenges did not diminish their overall satisfaction with the program. Patient experience may be further enhanced by (i) proactively clarifying program objectives, the non-clinical scope of intervention, and the generalist nature of psychosocial support provided to mitigate mismatched expectations, and (ii) implementing gender-concordant matching where feasible.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.7. \u0026nbsp; \u0026nbsp; \u0026nbsp;Intervention feasibility: Quantitative findings\u003c/h2\u003e\n\u003cp\u003eBenchmarked against other early-phase psychosocial interventions in breast cancer populations, this study achieved a high degree of implementation feasibility in outpatient oncology. Of the eligible participants approached for participation, 90.3% (n=28/31) consented to enrolment, surpassing the \u0026ge;60% target and indicating robust intervention interest. Further, the model demonstrated strong longitudinal engagement, with a retention rate of 85.7% (n=24/28) among enrolled participants, likewise exceeding the \u0026ge;70% target. These figures suggest that the intervention was minimally burdensome to and was sufficiently valued by enrolled participants.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.8.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intervention feasibility: Qualitative findings from clinician feedback\u003c/h2\u003e\n\u003cp\u003eBoth participating oncologists endorsed the intervention, citing minimal workflow disruption and identifying several perceived benefits. That the clinicians were asked to introduce the PSC intervention to patients was not experienced by either as an inconvenience, but, according to one of the oncologists, conferred strategic oversight, allowing him to align the timing of introduction with specific clinical objectives for each patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond perceived time savings that allowed clinicians to focus more fully on treatment-related discussions, the intervention was also viewed as useful in surfacing concerns that may not emerge within routine clinical encounters. One oncologist described an instance in which a significant misunderstanding regarding treatment intentions was revealed through the PSC\u0026rsquo;s engagement with the patient and her caregiver:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;(PSC) was able to break the barrier to have the conversation with them\u0026hellip; to understand why they have such misconceptions\u0026hellip; The patient\u0026rsquo;s husband did not want to raise his concerns to me directly for fear of me altering the treatment to be suboptimal for the patient\u0026hellip; Because of this fear, which was unfounded, I would never have known.\u0026rdquo; (St01)\u003c/p\u003e\n\u003cp\u003eBoth oncologists also perceived the PSC to be well-placed in offering an alternative perspective on their patients\u0026rsquo; concerns and priorities. While both found the PSC\u0026rsquo;s findings to be broadly consonant with their impressions of their patients, this third-party perspective was nonetheless valued in adding \u0026ldquo;nuance and texture\u0026rdquo; to their understanding of their patients\u0026rsquo; preferences (St02). One oncologist further posited that emotionally sensitive explorations of goals and values may be more feasibly initiated within a non-clinical context, corroborating our findings in Section 3.4.2:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There\u0026apos;s a different signature coming from the treating oncologist than from (the PSC), because if the treating oncologist asks it, there will be some patients who think, \u0026lsquo;If you\u0026apos;re asking me what I would want if things are not going well, does it mean that things are not going well now?\u0026rsquo;\u0026rdquo; (St02)\u003c/p\u003e\n\u003cp\u003eWith respect to documentation, both clinicians regarded the PSC\u0026rsquo;s summaries of patients\u0026rsquo; goals and preferences as adequate, relevant, and useful for care planning. The only suggestion raised was to streamline operational processes by granting the PSC direct access to the structured advance care planning (ACP) note in the electronic documentation system, with the proviso that these entries are reviewed and endorsed by the treating oncologist beforehand.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e FHU uses a 4-point scale to denote degrees of concurrence, with 0 corresponding to \u0026ldquo;Not at all true,\u0026rdquo; 1 \u0026ldquo;A little bit true,\u0026rdquo; 2 \u0026ldquo;Somewhat true,\u0026rdquo; 3 \u0026ldquo;Very true,\u0026rdquo; and 4 \u0026ldquo;Completely true.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e CSQ-4 uses a 4-point scale with item-specific response options. A higher rating indicates greater satisfaction or a more favorable appraisal of the intervention.\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eFindings from this pilot study suggest that the PSC intervention is highly acceptable and feasible in an outpatient oncology setting, as evinced in high enrolment (90.3%) and retention (85.7%) rates and positive reviews from most participants. Quantitative ratings for FHU (median rating: 13/16) and CSQ (median: 15/16) were corroborated by participants\u0026rsquo; qualitative feedback, with most finding the intervention beneficial in providing emotional comfort, humanizing the care experience, or fostering meaning-making. While FHU ratings fell below the acceptability threshold (\u0026ge;\u0026thinsp;12) for four participants, these scores were primarily associated with specific circumstantial constraints and conceptual misalignments rather than a systemic failure of the intervention model. Taken together, the results lend support to the acceptability of the intervention and its concept of nesting values-based exploration within a relational framework of supportive listening. Clinician endorsement further underscored the model\u0026rsquo;s operational feasibility, highlighting its limited impact on workflow and its perceived utility in offering insights that might otherwise remain unavailable.\u003c/p\u003e \u003cp\u003eThe potential value of the model is underscored by the prevalence of psychological and existential distress associated with advanced cancer, with some estimates suggesting about half of all individuals with cancer experience severe or prolonged cancer-related distress.[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Meta-analytic data suggest that post-traumatic stress disorder (PTSD) affects around 10% of individuals diagnosed with breast cancer, with some studies demonstrating a prevalence as high as 32.3%.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Given that engagement in SIC has been shown to improve anxiety and depression symptoms in patients,[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] this model may further augment these salutary effects by facilitating longitudinal reflection outside the clinic setting.\u003c/p\u003e \u003cp\u003eThis intervention represents a departure from existing healthcare communication initiatives, which typically involve clinicians engaging their patients in SIC during clinic consultations. Alternative approaches to advance care planning (ACP) see task-shifting or task-sharing, with non-clinical staff providing education on goals of care, encouraging engagement in discussions with physicians,[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] or directly completing scripted ACP conversations with patients.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] In contrast to these approaches, this intervention focuses on fostering psychological safety and offering emotional support, with the clarification of goals and values arising spontaneously through supportive listening and ultimately secondary to the patients\u0026rsquo; interests, comfort, and preferences. To our knowledge, this study offers a proof-of-concept for a novel model of serious illness communication, with a trained non-clinician serving as the primary facilitator of biographical reflection and values clarification through supportive listening and without the use of structured communication tools or scripted questions.\u003c/p\u003e \u003cp\u003eSeveral limitations warrant consideration. The small sample size and single-arm, non-randomized design restrict generalizability to broader oncology populations. Additionally, because the first author delivered the intervention, it is difficult to decouple the model\u0026rsquo;s efficacy from individual practitioner competence. However, the valued qualities of relational authenticity and psychological safety are theoretically consistent with the core tenets of supportive listening, suggesting that the reported benefits are at least partially a function of the intervention\u0026rsquo;s design. Further, the first author\u0026rsquo;s dual role as PSC and analyst introduced potential interpretive bias, but this was partially mitigated by using an independent interviewer and collaborative coding. Finally, we acknowledge that this trial was registered retrospectively. While we made every effort to adhere strictly to the original protocol approved by the Institutional Review Board, the lack of prospective registration may be perceived as a limitation regarding the pre-specification of study outcomes.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe PSC intervention offered an acceptable and feasible framework for facilitating serious illness conversations within outpatient oncology. By training a non-clinician to deliver patient-led supportive listening, the intervention achieved robust enrollment and retention rates, and received positive appraisals from both patients and clinicians alike. The model addresses common clinical barriers to serious illness communication, with qualitative findings providing preliminary evidence of its potential to enhance the care experience and support the psychological well-being of patients. Future studies should evaluate the model\u0026rsquo;s scalability and its comparative impact against conventional clinician-led SICs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study obtained approval from the institutional review board at the SingHealth Centralised Institutional Review Board (CIRB), reference number: 2025-1184. All participants signed informed consent prior to study participation. This study was conducted in compliance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Lien Centre for Palliative Care Research Incubator Award, ref: LCPC-EX25-0001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAN: Formal analysis, Data curation, Writing \u0026ndash; Original draft preparation, Writing \u0026ndash; Review \u0026amp; Editing; YS: Investigation, Formal analysis, Writing \u0026ndash; Review \u0026amp; Editing; TWM: Conceptualization, Supervision; BC: Conceptualization, Supervision; RE: Resources, Supervision; SN: Writing \u0026ndash; Review \u0026amp; Editing, Supervision, Funding Acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study team extends its thanks to the Lien Centre for Palliative Care and its clinician partners for supporting the trial of the Patient Support Coordinator model of supportive listening and serious illness communication at the National Cancer Centre Singapore (NCCS).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBernacki RE, Block SD. 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BMC Med Res Methodol. 2013;13(1):117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevens JM, Montgomery K, Miller M, Saeidzadeh S, Kwekkeboom KL. Common patient-reported sources of cancer‐related distress in adults with cancer: A systematic review. Cancer Med. 2024;13(13):e7450.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiovic M, Block S. Psychiatric disorders in advanced cancer. Cancer. 2007;110(8):1665\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-oncology. 2001;10(1):19\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwartzman S, Booth JN, Munro A, Sani F. Posttraumatic stress disorder after cancer diagnosis in adults: A meta-analysis. Depress Anxiety. 2017;34(4):327\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnaboldi P, Riva S, Crico C, Pravettoni G. A systematic literature review exploring the prevalence of post-traumatic stress disorder and the role played by stress and traumatic stress in breast cancer diagnosis and trajectory. BCTT. 2017;9:473\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernacki R, Paladino J, Neville BA, Hutchings M, Kavanagh J, Geerse OP, et al. Effect of the Serious Illness Care Program in Outpatient Oncology: A Cluster Randomized Clinical Trial. JAMA Intern Med. 2019;179(6):751\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel MI, Kapphahn K, Dewland M, Aguilar V, Sanchez B, Sisay E et al. Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer: A Randomized Clinical Trial. JAMA Oncol [Internet]. 2022 Jun 30 [cited 2025 Feb 12]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://jamanetwork.com/journals/jamaoncology/fullarticle/2793859\u003c/span\u003e\u003cspan address=\"https://jamanetwork.com/journals/jamaoncology/fullarticle/2793859\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodriguez GM, Parikh DA, Kapphahn K, Gupta DM, Fan AC, Shah S, et al. Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning: A Randomized Clinical Trial. JAMA Oncol. 2024;10(7):949\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKvale EA, Huang CH, Niranjan SJ, Dionne-Odom JN, Kenzik K, Bevis KS, et al. Barriers and facilitators of navigator-led advance care planning conversations in older patients with cancer. J Clin Oncol. 2016;34(26suppl):17\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocque GB, Dionne-Odom JN, Huang CHS, Niranjan SJ, Williams CP, Jackson BE, et al. Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations. J Pain Symptom Manag. 2017;53(4):682\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Advanced cancer, Serious illness communication, Supportive listening, Palliative care, Breast cancer, Mixed methods research, Feasibility study, Advance Care Planning, Psychosocial Support","lastPublishedDoi":"10.21203/rs.3.rs-8796566/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8796566/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eConventional serious illness conversations (SICs) face significant barriers including clinical time constraints and limited patient-clinician rapport. We evaluated a novel model that nested SICs within non-clinician-led supportive listening delivered by a Patient Support Coordinator (PSC). This exploratory study aimed to assess the acceptability and feasibility of this patient-led approach in outpatient oncology to support its iterative adaptation and implementation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-arm, non-randomized pilot study used a convergent parallel mixed-methods design in outpatient oncology. Acceptability was assessed through Feeling Heard and Understood (FHU) and Client Satisfaction (CSQ) surveys with a predefined threshold\u0026thinsp;\u0026ge;\u0026thinsp;12/16. Qualitative interviews with patients (n\u0026thinsp;=\u0026thinsp;21) and oncologists (n\u0026thinsp;=\u0026thinsp;2) provided data on intervention acceptability and implementation feasibility.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEnrollment (90.3%) and retention (85.7%) rates surpassed feasibility targets. High acceptability was demonstrated by median scores of 13/16 for the FHU (n\u0026thinsp;=\u0026thinsp;19) and 15/16 for the CSQ (n\u0026thinsp;=\u0026thinsp;20). While most participants met the FHU threshold, four scored below 12 due to gendered discomfort, mismatched expectations, and perceptions that they were coping well and had no need of supportive listening.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eThe study was retrospectively registered with ClinicalTrials.gov (Trial Registration Number: NCT07428655).\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov NCT07428655, retrospectively registered on 23 February 2026.\u003c/p\u003e","manuscriptTitle":"Acceptability and Feasibility of a Patient Support Coordinator (PSC) Model of Serious Illness Communication in Outpatient Oncology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 16:59:47","doi":"10.21203/rs.3.rs-8796566/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-05T06:03:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T21:20:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T20:00:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320141184438605941535334199098977933353","date":"2026-04-04T08:08:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236282673524994272170293141201185923876","date":"2026-04-02T04:08:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-02T15:56:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-01T16:35:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-24T06:28:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-23T22:49:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2026-02-23T22:44:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20ce3244-6b91-4f1d-ac8b-dec9845dc767","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-05T06:03:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T21:20:32+00:00","index":84,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T11:38:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 16:59:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8796566","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8796566","identity":"rs-8796566","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}