Anxiety is highly prevalent among breast cancer patients, with more than one-third of patients in the U.S. experiencing a degree of anxiety throughout their diagnosis and treatment [1–3]. Importantly, breast cancer patients who have symptoms of anxiety have a higher risk for both morbidity and mortality [4, 5]. It is critical that cancer care providers have the tools to understand and address the high prevalence of anxiety in breast cancer patients to meet the needs of this population. Current research favors anxiety and psychological distress as outcomes of medical interactions [6, 7]. However, given the high prevalence of anxiety in this patient population, it is important to investigate the ways in which pre-existing levels of anxiety affect additional aspects of breast cancer patients’ processing and coping with their diagnosis. One potential consequence of anxiety ahead of a medical appointment is patients’ illness uncertainty. Using Uncertainty in Illness Theory  and patient-centered communication  as frameworks, this study explores how breast cancer patient uncertainty and anxiety pre-appointment influence patient-provider communication and subsequent post-appointment uncertainty.
Breast Cancer and Uncertainty
Illness uncertainty is a cognitive and emotional state in which patients dealing with novel, complex, and/or ambiguous health events are unable to make meaning of these events . Breast cancer patients experience this throughout the illness trajectory, from diagnosis to treatment and beyond [3, 10, 11]. Uncertainty about the diagnosis, cancer-related symptoms, illness prognosis, and treatment decisions all contribute a worse quality of life for breast cancer patients [12–14]. Moreover, illness uncertainty is positively correlated with anxiety during diagnosis  and is associated with worse psychological well-being during both the treatment and post-treatment stages .
Uncertainty in Illness Theory (UIT) posits that illness uncertainty is influenced by patients’ perceptions of illness-related events (stimuli frame), and appraisal of the stimuli frame is influenced by patients’ cognitive capacity [8, 17]. UIT further suggests that appraisals of illness uncertainty subsequently influence coping with illness. Most investigations of UIT that measure psychological features have considered it in relation to coping and as a final outcome of the model [16–19], but have not explored how cognitive capacity is posited to affect patient outcomes. This study seeks to further understand the cognitive capacity construct, investigating how clinical anxiety acts as an independent variable in the model. We propose the following hypotheses (see Fig. 1A for the hypothesized model):
H1: Clinical anxiety will be positively associated with breast cancer patients’ pre-appointment illness uncertainty.
H2: Breast cancer patients’ pre-appointment illness uncertainty will be positively associated with post-appointment illness uncertainty.
Patient-Centered Communication and Uncertainty
One way clinicians can manage patients’ illness uncertainty is through patient-centered communication [16, 20, 21]. Patient-centered communication is conceptualized as communication that (1) elicits patient perspectives, (2) seeks to understand each patients’ unique psychosocial context, (3) creates treatment plans aligned with patients’ beliefs, and (4) creates shared power within the interaction . Patient-centered communication predicts patient outcomes including improved satisfaction, psychological adjustment, stronger therapeutic relationships, and increased patient participation [9, 23–25]. However, it is unclear whether pre-existing anxiety affects how provider communication facilitates this process. In contexts outside of breast cancer, uncertainty is associated with cognitive states that bias information processing and subsequent communication . It is possible that patient anxiety and uncertainty prior to medical encounters may similarly bias information processing and, subsequently, change dynamics of patient-provider communication. However, the connection between illness uncertainty and communication consequences in oncology appointments has not been investigated. Understanding the conditions for effective patient-centered communication is important for optimally supporting breast cancer patient well-being. The following sections will discuss specific patient and provider communication behaviors that significantly impact the level of patient-centered communication in breast cancer appointments.
Patients: Empathic Opportunities
Empathic communication, specifically empathic opportunities, is a robustly operationalized aspect of patient-centered communication in the cancer context [27–29]. Empathic opportunities refer to patient statements that express an emotion such as fear, worry, or relief and explicitly give the medical provider the opportunity to respond empathically . We argue that empathic opportunities align with the first two tenants above (communication that elicits patient perspectives and seeks to understand patients’ unique psychosocial context). Although not patient-centered communication itself, they may indicate a level of comfort with the provider implicit in providing such an opportunity. Moreover, multiple instances of empathic opportunities may indicate a positive reception of previous opportunities and the establishment of a positive patient-provider relationship . Given that illness uncertainty and pre-appointment anxiety may bias patients’ processing of provider communication, this study investigates the following research questions:
RQ1: Is pre-appointment illness uncertainty associated with differing levels of empathic opportunities per minute from breast cancer patients?
RQ2: Are empathic opportunities from breast cancer patients associated with differing levels of post-appointment uncertainty?
Providers: Interruptions & Responses to Empathic Opportunities
One goal of patient-centered care is to facilitate patient participation within medical interactions. Notably, patient participation is also influenced by patients’ psychological processing. Patients with better psychological adjustment are often more participative than those experiencing maladaptive coping styles . Thus, to support all breast cancer patients, providers need to communicate in ways that facilitate both patient involvement within medical appointments and considers patients’ psychological well-being. Encouraging empathic opportunities may help achieve this goal. However, cancer care providers often miss these opportunities [30, 32], which may hinder patient comfort and participation. One way that these opportunities could be missed is through provider conversational dominance, specifically, provider interruptions. When providers interrupt patients, patients may not have the opportunity to fully express their thoughts, feelings, and concerns, which is in direct opposition to the goals of patient-centered communication. Thus, we argue that provider interruptions stand to hinder tenants of patient-centered communication (communication that elicits patient perspectives and creates shared power within the interaction). To investigate the relationships between patient illness uncertainty, oncologist interruptions, and oncologist responses to empathic openings, the following research questions are proposed:
RQ3: Is pre-appointment illness uncertainty associated with differing levels of interruptions by the oncologist?
RQ4: Are interruptions by the oncologist associated with differing levels of post-appointment illness uncertainty?
RQ5: Does the type of provider response to empathic opportunities (missed or not) influence post-appointment illness uncertainty?