Experiences of interaction between people with cancer and their healthcare professionals: A systematic review and meta-synthesis of qualitative studies

Purpose: This study investigates patients ’ experiences of interaction with their healthcare professionals (HCPs) during cancer treatment and identifies elements that HCPs can utilize to improve cancer care provision. Methods: PubMed, CINAHL, PsycINFO, SCOPUS


Introduction
Every stage in the cancer continuum is accompanied by symptoms such as pain, fatigue, weight loss, and psychological distress, and the importance of supportive care for patients diagnosed with cancer is increasingly being acknowledged (Berman et al., 2020;Hui et al., 2018;Jordan et al., 2018).Supportive care in cancer is defined as the prevention and management of the adverse effects of cancer and its treatment, from diagnosis through treatment to post-treatment care, in a person-centered manner (Jordan et al., 2018;MASCC).Supportive care includes basic care, i.e., information provision and symptom management, as well as more specialized interventions such as nutritional support, exercise therapy, music therapy, counseling, meditation, and comprehensive palliative care (Institute, 2022).
In general, different healthcare professionals, including physicians, nurses, dieticians, occupational therapists, physiotherapists, psychologists, spiritual caregivers and social workers, play a role in delivering supportive care (Holmes et al., 2021;Selby et al., 2019).These professionals usually collaborate as part of a multidisciplinary team to provide timely and effective treatment of physical and psychological impairments resulting from the disease or its treatment, thus optimizing patients' quality of life (Hui et al., 2018;Silver et al., 2013Silver et al., , 2015)).Delivering supportive care for patients who have cancer requires enhanced skills and knowledge of the healthcare professionals involved, including interpersonal and communication aptitudes, to create adequate patient-professional interactionas laid down in professional competency profiles and frameworks by several international professional bodies (Fitch, 1994, Fitch, 2008;1994;Society, 2018;Support, 2017).
In the literature, communication and interaction are often used interchangeably or synonymously (Fleischer et al., 2009).Interaction, however, encompasses more than only effective communication.Casu et al. associates interaction with person-centeredness and, therefore, with aspects such as informational and support needs, respect, the interest of the professional in the patient, and the ability to actively listen to and involve the patient in the care choices (Casu et al., 2019).Such aspects have also been noted as essential to delivering high-quality cancer care (Institute of Medicine Committee on Quality of Health Care in, 2001), and person-centered interaction has been shown to positively influence patient satisfaction (Baker et al., 2013;Lee et al., 2020;Moore et al., 2012;Moreno et al., 2019), potentially leading to better health outcomes (Forbes et al., 2020;Hoffman et al., 2003;Umihara et al., 2016;Wright, 1998).While the benefits of effective patient-professional interaction in cancer care are known, patients' expectations and preferences regarding their healthcare professionals should be clarified.
In the last decade, an abundance of qualitative studies investigating patients' needs and experiences related to interaction with healthcare professionals during their cancer treatment has been published.Conducting a systematic overview and qualitative meta-synthesis of these publications may provide insights into the existing body of evidence and establish the level of saturation on these topics (Goodman, 2008;Howitt, 2019).
Therefore, this study aimed to identify and appraise the current body of evidence investigating patients' experiences of interaction with healthcare professionals while receiving cancer treatment, provide an overarching thematic synthesis of high-quality study results, and provide recommendations for crucial interpersonal and communication skills expected from healthcare professionals working with patients with cancer.

Methods
The systematic review of the literature took place between July 2019 and April 2022.The review protocol was prospectively submitted for registration in the International Prospective Register of Systematic Reviews under the identification number: CRD42019139427.

Data sources and searches
Qualitative studies, using either semi-structured interviews or focus groups as data collection methods, were eligible for review.Multiple electronic searches in PubMed.gov,Embase, SCOPUS, CINAHL, and PsycInfo databases, respectively, were conducted between August 2019 and February 2022.Additionally, reference lists of included papers were hand searched for potentially eligible papers.
The search strategy used several combinations of four groups of index terms and respective keywords: Neoplasm (cancer, tumor, malignancy, etc.); Patient satisfaction (patient's perspective, patient's view, patient's desire, etc.); Qualitative research (focus groups, interviews, needs assessment, etc.); Professional-patient (Physician-patient relations, Nurse-patient relations, therapeutic alliance, etc.).The search strings were executed in the corresponding databases by an experienced medical information specialist (exact search strings: see supplementary material).

Study selection
Qualitative studies investigating adult patients' experiences with interaction with all healthcare professionals (i.e., physicians, nursing professionals, allied health professionals) during cancer treatment were included.Studies were eligible for appraisal if they: 1) applied welldescribed qualitative data collection methods such as focus groups or semi-structured interviews, 2) included patient populations, and 3) were published after 2010.Studies investigating the interaction experience from the healthcare professionals' perspective were excluded, as were studies on patients in the diagnosis or end-of-life stage of cancer care.Retrieved records were imported and organized in Covidence.org.After duplicate removal title and abstract of remaining records were screened for eligibility by one reviewer (RC, MM, ME, RM).Consensus meetings were held to resolve disagreements between reviewers.

Quality assessment and data extraction
Three researchers conducted the critical appraisal (RC, MM, and RM), and each article was independently assessed by at least two reviewers, using the Critical Appraisal Skills Programme checklist for qualitative research (CASP).The Critical Appraisal Skills Programme checklist consists of 10 items assessing qualitative studies' methodological rigor and validity and has been widely used in qualitative meta-syntheses (Butler et al., 2016).The Critical Appraisal Skills Programme checklist qualitative checklist is divided into three sections.Section A (6 questions) evaluates the internal validity or methodological rigor of the study, section B (3 questions) evaluates the results of the study, and section C (1 question) evaluates the external validity and implications of the study results (CASP).Each question contains several hints to assist in scoring and is marked either "yes", "no", or "can't tell".Scoring guidelines (yes: 1 point, can't tell: 0.5 points and no: 0 points) as proposed by Butler et al. (2016) were applied by two reviewers, and the final appraisal score (maximum 10 points) was determined through a consensus meeting.
As Butler et al. (2016) suggest, articles were excluded for further review when receiving a score of <1 on item 7: "Have ethical issues been taken into consideration?" on the Critical Appraisal Skills Programme checklist.Additionally, we chose to exclude articles from the meta-synthesis when items 5: "Was the data collected in a way that addressed the research issue?", or 8, "Was the data analysis sufficiently rigorous?" received a score of 0, since low scores on these items pose a serious threat to the methodological rigor (Charmaz, 2006;Howitt, 2019;Mays and Pope, 2000).
The following data were extracted from the studies meeting the quality criteria: the country where the study was conducted, population data (demographics, type of cancer, treatment received), methods (data collection methods, topics investigated), and the results (first-order constructs, i.e., participant's quotes and second-order constructs, i.e., interpretations).

Data synthesis and analysis
We used thematic synthesis to analyze the data (Thomas and Harden, 2008).This systematic method consists of coding data excerpts from the included studies to yield descriptive and analytical themes (Nicholson et al., 2016).A new dataset was formed from the extracted individual study results.Analysis was conducted as follows: First, all text fragments relevant to this study's purpose were coded (RC).Text blocks were considered pertinent to our study if they depicted interaction with healthcare professionals from the patient's viewpoint.Next, a code list was generated, after which codes were re-read and grouped into meaningful categories.These results were discussed in reflexivity meetings, after which -as the last analysis step -themes were generated from the categories (Charmaz, 2006;Thomas and Harden, 2008).Analysis was conducted in MAXQDA 2022 (VERBI Software, 2021).Throughout the different stages of analysis, several reflexivity meetings with the research team were held to reduce researcher bias and increase the richness of the findings (Creswell and Creswell, 2017).Lastly, a sensitivity analysis was conducted through which the identified themes were verified against individual study results, population characteristics, and study settings (Fig. 2).

Results
After duplicate removal title and abstract of remaining records (n = 10332) were screened for eligibility, leaving 406 studies meeting the inclusion criteria (Fig. 1: PRISMA flowchart).Eighty-eight articles were appraised, after which 37 studies were excluded due to threats to methodological rigor.One additional study was excluded after quality appraisal as the focus of that study was retrospectively found irrelevant to this study's aim (Rohde et al., 2019).A total of 50 articles are included in this meta-synthesis (Table 2).All these studies were conducted to either investigate patients' interaction preferences with healthcare professionals or evaluate interventions adjacent to innovative care projects aimed at improving patient-professional interaction.

Population characteristics
A total of 1245 patients under active cancer treatment were included across the 50 studies, of whom 45% (n = 558) was female, 36% (n = 444) was male, and 19% (n = 243) was unspecified.Across all study samples, age ranged from 18 to 92 years.Patients were diagnosed with 21 different types of cancer, the majority being gastrointestinal (34 studies), breast (25 studies), genitourinary (20 studies) and lung cancer (16 studies).Cancer treatments received at time of study were chemotherapy, radiotherapy, surgery, hormone therapy, endocrine therapy, and disease surveillance (Table 2).

Data synthesis
The main concept describing positively perceived interaction, emerging from data analysis, was "person-centered care", incorporating the following themes: "Support, respect, and agency", "Quantity, timing and clarity of information", "Confidence, honesty and expertise".

Feeling safe in a welcoming and familiar environment.
Studies identified a patient-perceived reduced burden of disease when experiencing a friendly and positive social and physical environment in which they received their treatments (references 2, 6, 18, 22, 30, 36, 37 in Table 2).In addition, relational continuity, defined as being able to count on the same healthcare professionals throughout the entire care process, was positively perceived and increased feelings of safety in the healthcare institution (references 1, 2, 12, 14, 22-24, 27, 36, 46, 47 in Table 2).

Having agency.
Several studies identified patients being appreciative of being involved in decision-making regarding their treatment plan, as this was perceived as being given control and being part of the team striving towards the best possible outcome (references 2, 8, 14, 15, 21, 22, 25, 26, 28, 30, 35, 38, 39, 41, 46, 47, 49 in Table 2).In this context, patients perceived it as essential that healthcare professionals provide advice regarding treatment decision-making (references 7, 17, 23, 35, 38, 41, 49 in Table 2).In contrast, several other studies described patients' negative experiences regarding shared decision-making, experiencing this as a burden.Instead, patients in these studies expressed that healthcare professionals should use their expertise to recommend treatment options (references 2, 28, 41, 47, 49 in Table 2).(See Table 3 for example quotes).

Theme 2: quantity, timing and clarity of information
Themes related to quantity, timing, and clarity of received information were identified in 45 studies (8 high, 15 medium, and 23 lowquality studies) (Table 3) as important aspects to a positively perceived interaction between patients and healthcare professionals.However, preferences varied across study populations.Some studies reported patients' preferences for receiving detailed disease information, treatment options and consequences, whereas other studies reported on patients preferring less detail.Several studies identified patients perceiving the quantity of information as being overwhelming and therefore difficult to grasp.The following subcategories illustrate experiences of quantity, timing, and clarity of information provided and verbal and non-verbal communication aspects in patient-professional interaction.

Theme 3: confidence, honesty, and expertise
A show of confidence, honesty, and expertise by healthcare providers was perceived positively by patient populations in 41 studies (7 high, medium, and 19 low-quality papers) (Table 3), and these aspects were identified as key elements in developing a trusting relationship between patients, relatives, and healthcare professionals.The following subcategory illustrates patient experiences further: 3.3.3.1.Being in the hands of confident and honest professionals.In most studies where "trust" was identified as a theme, patients experienced this as a given because of the professional's qualifications.Trust increased when dealing with known experts in the field, as this increased feelings of safety (references 1, 2, 5-7, 9-14, 17, 18, 20, 22-24, 26, 28, 30, 32-35, 38-42, 47 in Table 2).In addition, greater trust in healthcare professionals was experienced when patients were met with selfconfident professionals showing to be in control and projecting honesty and integrity (references 1, 2, 5-9, 13, 17, 20, 22-32, 40, 41 in Table 2).Nevertheless, professionals being able to recognize the limit to their own expertise and who do not hesitate to consult or refer to a colleague or scientific literature were highly appreciated by patients (references 2, 14, 24 in Table 2).

Sensitivity analysis
All studies were conducted in western countries with various healthcare models.The larger part of the studies (78%) included patient populations in disease stages I-III.The three transcending themes identified in this meta-synthesis were equally distributed across the studies.See Fig. 2 for an overview of the themes, cross-checked against the individual study results, settings, and populations.

Discussion
The objective of this systematic qualitative meta-synthesis was to gather, appraise, and provide an overarching thematic synthesis of results from the current body of qualitative research on positive and negative experiences of patients receiving cancer treatment regarding    their interaction with healthcare professionals, and to identify elements that professionals can use to optimize the interaction with their patients.This study identified three themes: "Support, respect, and agency", "Amount, timing and clarity of information provided", and "Confidence, honesty, and expertise", within one overarching concept connected with positive experiences of patient-professional interaction: "Personcentered care".Person-centered care is a concept that actively involves patients as partners of healthcare professionals, ensuring that patients' preferences, needs, and values guide clinical decisions.In the past decades, personcentered care has been shown to improve health outcomes and increase patient satisfaction, making it a key component of high-quality care (Loonen et al., 2018;McMillan et al., 2013).
Across all included studies, positive experiences related to fundamental principles of person-centered care, as defined by Geirtes et al. (Gerteis et al., 1993) and the National Academy of Medicine (Institute of Medicine Committee on Quality of Health Care in, 2001): "respect for patients' values, preferences, and expressed needs", "information, communication, and education", "physical comfort", and "emotional support -relieving fear and anxiety".In contrast, as shown in this qualitative meta-synthesis, the provision of care which lacked person-centeredness, especially when adopting a paternalistic approach and ignoring patients' preferences regarding information provision and support needs, repeatedly resulted in negative experiences.Since even the most recent studies report negative patient experiences, our results seem to indicate that the application of the person-centered concept is not yet optimal.
The first theme -Support, respect, and agencyreflects that each person with cancer has personal needs and expectations and wants to be seen and treated accordingly.It also reflects that individuals with cancer value being supported in their autonomy.However, although supporting patients' autonomy by providing them with information, giving them the possibility to make their own decisions, and empowering them towards healthier behaviors is an important goal for healthcare professionals (Chen et al., 2016;Velikova et al., 2018), recent literature shows that this goal is often unmet.For example, in a recently published overview of systematic reviews, Chaboyer et al. identify self-management, autonomy, education of patients and families, and emotional and psychological care, including spiritual support, as missed nursing care, i.e., nursing care that is often lacking, which is consistent with our findings (Chaboyer et al., 2021).
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differences in the amount and kind of (emotional, social and/or spiritual) support needed and the extent to which each individual wants to have agency.Previous studies found that discrepancies between information needed to be able to take part in decision making and the information available and provided, as well as an authoritarian attitude of the healthcare professional, were potential reasons for patients preferring to leave the decisions up to healthcare professionals (Frosch et al., 2012;Rutten et al., 2005).On the contrary, in a survey study of cancer survivors, Chawla and Arora reported that patients who preferred not taking part in decision making had greater trust in their physicians (Chawla and Arora, 2013).These findings imply that healthcare professionals should be aware of the need to create a safe and welcoming environment and individualize their approach to facilitate shared decision making.
In cancer care, providing individualized support is essential to improve health outcomes (Berman et al., 2020).Several studies found that the support provided by healthcare professionals plays an important role in improving the quality of life of patients with cancer.This support is not merely instrumental (i.e., making sure treatment is adequately followed or providing effective symptom remediation) but also strongly related to feelings of being seen, heard, encouraged, and coached in an individualized manner (Cochrane et al., 2022;Faller et al., 2019;Sweegers et al., 2019).In contrast, poorly executed fundamental care threatens patients' feelings of safety, quality of life, empowerment, functioning, and satisfaction (Feo and Kitson, 2016;Jackson and Kozlowska, 2018).
Together, these findings imply that healthcare professionals should be consciously aware of their supportive role in treating patients during cancer care.While individualized support is invaluable, care should be taken to avoid patients' dependency on healthcare professionals.Such reliance is not desirable from a healthcare cost containment perspective but also conflicts with the objective to improve adaptation and selfmanagement in patients (Huber et al., 2011).
The second theme -Quantity, timing, and clarity of informationshows the need for tailoring the information provision to patients.Too much information can be overwhelming or confusing, but too little information may cause anxiety.Previous systematic reviews found that communication and information needs of patients with cancer evolve throughout the continuum of care and are often unmet.During the treatment phase, information needs revolve around the stage of the disease, treatment options, and side effects.In the post-treatment phase, patients need more information on rehabilitation, self-management, follow-up, and long-term side effects (Chaboyer et al., 2021;Rutten et al., 2005;Wang et al., 2018).
Furthermore, many patients are anxious or show signs of depression, which influences their needs concerning information communication and their ability to process such information (Goerling et al., 2020;Nguyen et al., 2019).Kessels (2003) reported patients' recall of medical information to be poor, as 40-80% of the information provided by healthcare professionals was immediately forgotten.This was explained by the use of complex medical terminology or patient educational level, as well as the mode in which information was presented.As our meta-synthesis shows, timely and effective provision of personalized information to patients with cancer is challenging for many healthcare professionals.Indeed, the results of this meta-synthesis show negative patient experiences when receiving an overwhelming or unclear amount of information.This was due to healthcare professionals' use of technical terminologies or ignored patients' preferences to receive less information or at another moment.Since patients' preferences regarding disease information, treatment options, and consequences differ substantially from one individual to another, healthcare professionals should continually assess what information is needed and when, and if it is correctly received.
All in all, patients should be involved in deciding the timing, quantity and mode of information provided, and healthcare professionals should include this as an explicit point of discussion in their consultations.
The last theme of this review -Confidence, honesty, and expertisereveals that people with cancer prefer interacting with honest professionals who are experts in their field and show confidence.The findings of this theme are consistent with the results of a literature review looking into the strength, correlates, and consequences of patients' trust in their physician which identified honesty and communication of expertise as elements enhancing patients' trust (Hillen et al., 2011).In addition, a recent study investigated the preferences of patients with metastasized breast cancer regarding supervised exercise programs also identified lack of expertise of healthcare professionals as a barrier for patients to adhere to their physiotherapy treatment (Ten Tusscher et al., 2019).Therefore, patients need to know that their healthcare providers are qualified to provide cancer care.At the same time, as shown in several studies on the learning needs of healthcare professionals for the treatment of patients with cancer, professionals of several disciplines, including physicians, nurses, and allied health professionals, indicate a lack of expertise in several aspects of cancer care such as knowledge of medical treatment or psychosocial and practical education on managing emotional and late effects of cancer treatment (Bradford et al., 2018;Klemp et al., 2011;Puts et al., 2021;Ten Tusscher et al., 2020).The findings of these studies, along with the results of this meta-synthesis, suggest that providing high-quality cancer care requires ongoing education and training opportunities specific to oncology healthcare professionals.

Strengths and limitations
This qualitative meta-synthesis included an extensive systematic search, selection, and appraisal method and followed the guidelines of several scientific publications regarding the synthesis of data from the included studies.Although we did not search in grey literature or unpublished work, a vast number of articles was identified, and we found indications for data saturation.Therefore, we do not think that any missed paper would have had major consequences for our findings and conclusions.We provide a comprehensive overview of themes related to patient-professional interaction, as found in qualitative cancer care studies published in the last decade, that can inform clinical practice.However, several limitations to our study can be identified.
Firstly, since few guidelines exist for conducting qualitative metasyntheses, our methodological approach leaned heavily on the review protocol proposed by Butler et al. (2016).We applied a strict cut-off score on our quality appraisal (<7.5/10 is considered low quality).Therefore, studies contributing to our topic were possibly excluded from this review due to this strict appraisal method.However, our search yielded an extensive and varied amount of high-quality studies representative of the study domain.Within this body of literature, consistency and saturation of findings seem to be present, and we doubt that studies of lower quality would change the current insights.
Secondly, data synthesis was conducted based on the published reports of qualitative studies as we did not have access to the raw data.Although we followed strict guidelines for data analysis, we recognize that this approach might impact the richness of the data.
Thirdly, most papers included focus on patients' interaction with physicians and nurses and not with other essential (allied health) professionals.Nevertheless, we believe that the lessons learned from the patients' experiences described in the studies we included apply to all healthcare professionals who provide supportive care to patients with cancer.In relation to this, as the sensitivity analysis shows, this study's results were equally distributed across the included studies within various healthcare systems and patient populations.However, results cannot be extrapolated to contexts markedly different from the healthcare settings and systems in which the included studies were conducted.

Implications
Healthcare professionals are trained to assess patients' (dis)ability Table 3 Example quotes.

Sub-category
Example quotes (quality according to Critical Appraisal Skills Programme score) Experiencing emotional, spiritual, and social support "It makes you feel like she's not just giving you a treatment.She's [the physician] here and she cares about you." (Jacobsen et al., 2015) (high-quality paper) "When one says, 'I want to talk to a doctor,' then there's someone available the whole week who explains everything to you.(…) Simply time.They take time and explain everything carefully" (P05b, female, aged 42 years, suffering from cancer of the small intestine).(Masel et al., 2016) (Aagaard et al., 2018;Abt Sacks et al., 2016;Alpert et al., 2019;Anderson et al., 2021;Appleton et al., 2018;Back et al., 2014;Best et al., 2014;Blakely et al., 2017;Brincat et al., 2021;Candela et al., 2020;Couchman et al., 2019;Daem et al., 2019;Devitt et al., 2020;Donachie et al., 2020;Farias et al., 2017;Herrmann et al., 2021;Hess et al., 2021;Hillen et al., 2012;Hopmans et al., 2015;Jacobsen et al., 2015;Jordan et al., 2022;Kumar et al., 2020;Kvale and Bondevik, 2010;Lawhon et al., 2021;Lowe et al., 2021;Martinsson et al., 2016;Masel et al., 2016;McNair et al., 2016;Myren et al., 2021;Nababan et al., 2020;Niranjan et al., 2020;Noteboom et al., 2021;Pedersen et al., 2013;Prip et al., 2022;Retrouvey et al., 2019;Sattar et al., 2018;Schildmann et al., 2013;Step and Ray, 2011;Tanay et al., 2014;Twibell et al., 2020;van Bruinessen et al., 2013;van Egmond et al., 2019;Vaughan et al., 2021;Wagland et al., 2019;Wong et al., 2011) Timing and quantity of information provided "I like that the doctor was very expansive in what they were saying.And giving a lot of information, without the patient having to ask a lot of questions or think up what the next question is they should be asking.''(Back et al., 2014)  "[the information] was put so bluntly.And I thought it could have been more gentle.And the doctor admitted she doesn't take that approach.But when you're talking to someone older who already has other medical challenges perhaps it could have been done with a little more gentleness … rather than I don't believe in buttering things up, I ′ m gonna tell you straight as it is.We like that approach but in this particular case I think it could have been a little more gentle."(Male, prostate cancer) (Sattar et al., 2018) (moderate-quality paper) "[About humor] It creates a bond …" (Tanay et al., 2014) (low-quality paper) "I asked "[…] What are the chance that I live or not live?What are the odds 50/50 or 60/40?"He replied that we are not in the business of odds and removed the eye contact.And his body language showed either he was not confident, or it was bad news for me … so it gave me a bad feeling."[P016].(Brincat et al., 2021) (moderate-quality paper) Theme 3: Confidence, honesty, and expertise 41 studies (Aagaard et al., 2018;Abt Sacks et al., 2016;Anderson et al., 2021;Appleton et al., 2018;Back et al., 2014;Best et al., 2014;Blakely et al., 2017;Brincat et al., 2021;Candela et al., 2020;Couchman et al., 2019;Daem et al., 2019;den Herder-van der Eerden et al., 2017;Devitt et al., 2020;Donachie et al., 2020;Farias et al., 2017;Herrmann et al., 2021;Hess et al., 2021;Hillen et al., 2012;Hopmans et al., 2015;Jacobsen et al., 2015;Jordan et al., 2022;Kumar et al., 2020;Kvale and Bondevik, 2010;Lawhon et al., 2021;Lowe et al., 2021;Martinsson et al., 2016;Masel et al., 2016;McNair et al., 2016;Myren et al., 2021;Nababan et al., 2020;Niranjan et al., 2020;Noteboom et al., 2021;Pedersen et al., 2013;Retrouvey et al., 2019;Rocque et al., 2019;Salmon et al., 2011;Sattar et al., 2018;Schildmann et al., 2013;van Bruinessen et al., 2013;van Egmond et al., 2019;Wagland et al., 2019) Being in the hands of confident and honest professionals "I trust their judgement more than mine" (patient 6) (Rocque et al., 2019)  and needs before or during treatment.We believe this needs assessment should include preferences regarding communication and the type of personal support needed.In addition, our analysis shows that people with cancer have particular interaction needs and healthcare professionals working in cancer care need to recognize what these needs are to provide high-quality care.All in all, the results of this review highlight that even though enhanced interpersonal aptitudes of healthcare professionals are already recognized as indispensable when providing supportive cancer care, the negative experiences voiced by patients in many of the included studies show that better and constant attention should be given to these skills.Therefore, theoretical and practical training aiming to improve verbal and non-verbal communication, empathy, active listening, and collaboration skills should be emphasized in the undergraduate education of healthcare professionals and through continuing education related to oncology specializations.Besides, future research should focus on developing educational programs providing healthcare professionals with the knowledge and abilities to improve patient-professional interaction, thus delivering optimal personcentered care.Furthermore, healthcare professionals' perspective of patient interaction is underexposed in this meta-synthesis, as this was beyond the scope of our study.Future studies investigating this critical aspect could further enhance the insights provided in our review.

Conclusions
This systematic review underscores that patients with cancer highly value healthcare professionals with strong interpersonal skills who are able to provide care in a person-centered manner.It is currently acknowledged that skills, such as verbal and non-verbal communication, empathy, active listening, and collaboration are essential for healthcare professionals providing supportive care to patients with cancer and should continuously be emphasized in the education of oncology healthcare professionals.Our results clarify the meaning of these skills by breaking them down into two categories.Firstly, into an interpersonal aspect depicting the importance of inspiring trust and showing personal interest in the patient.Secondly, into a technical aspect including the ability of healthcare professionals to know when, how and what type of information to communicate to actively involve the patient in the treatment process to stimulate self-management and shared decision making.

Declaration of competing interest
None declared.

Fig. 2 .
Fig. 2. Sensitivity analysis.Shown are the number of studies per country including Stage I-III and Stage IV patients (top) and finding each of the respective themes (bottom), AUS: Australia, AUT: Austria, BE: Belgium, CA: Canada, DK: Denmark, FR: France, GER: Germany, IT: Italy, MT: Malta, NL: Netherlands, NOR: Norway, SP: Spain, SWE: Sweden, UK: United Kingdom, USA: United States of America, COMB: Combined.

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Table 1
Quality appraisal.

Table 1
(continued ) Hard exclusion criteria (data collection/data analysis/ethical considerations)

Table 2
Study characteristics.

2: Quantity, clarity, and timing of communicated information 45 studies
(high-quality paper) Feeling respected and treated as a person "When a clinician is very kind, that is 20% of your recovery.Only being nice.And when he is disrespectful, you decline with 20%".F, 66y.(Hopmans et al., 2015) (low-quality paper) "He [oncologist] knew me by my name, my face.When I came in, it was like they treated you like you were a person and not just cattle coming through.He used to call me his most delicate patient."(Fariaset al., 2017) (low-quality paper) Feeling safe, in a welcoming and familiar environment "Well, they get to know you by your first name and it is a very friendly atmosphere, even though it's quite a serious time in your life, they try and make you at ease, which was good" P27.(Appleton et al., 2018) (moderate-quality paper) "So maybe not directly in the consultation room but you sit down in a room where the atmosphere is a bit more "comfortable".There you can have a water and a coffee for example.You just loosen it up a bit." (Patient, female, 29 y, acute lymphoblastic leukemia) ( Herrmann et al., 2021) (moderate-quality paper) Having agency "I think it's really good giving lots of information but then leaving some of the decision up to the patient, that feels like you're being, I suppose, more in control."(Bestet al., 2014) (moderate-quality paper) "The problem is I've asked them [clinicians] about treatments and the best treatment and they haven't been able to give me an answer […] They say it's up to me to decide which treatment I want.Unfortunately, because I'm not qualified in that area I can't give an opinion on that, so I'm a bit in limbo [about] which is the best treatment […] I'm very, very depressed about it."(67 years, stage I, AS: TDM2; DRS 30) (Wagland et al., 2019) (low-quality paper) Theme (Kvale and Bondevik, 2010"I don't want you to, like, half-lie to me.That [qualitative statement], to me, is half lying, you know, it's saying, 'Oh,' you know, 'it often returns,' whereas this one tells me, 'Hey, it does return most of the time.It's up to you to help it not return.'"Patient8.(Blakelyetal., 2017)(low-quality paper) "One discovers very quickly if the nurses have knowledge about the disease.They know what they are talking about.That makes me feel secure.I do not have confidence in all the nurses.I ask the ones I trust."(KvaleandBondevik,2010) (low-quality paper) R.Collet et al.