Cancer Risk Reduction in the Trenches: PCPs Respond

Zosia Chustecka

October 25, 2016

Cancer is often cited as the disease most Americans fear, and the latest statistics from the National Cancer Institute show that it will affect more than 1 in 3 people (39%).

But the risk for many cancers could be reduced. The American Institute for Cancer Research (ACIR) said recently that "we can prevent nearly one-third of the cancers that occur every year in the US if Americans made healthier choices, including moving more and eating smart."

So what is being done down in the trenches?

A new survey conducted by Medscape Medical News reveals that primary care practitioners (PCPs) are doing what they can ― a majority of practitioners (71%) said that they initiate discussions about reducing cancer risk with all of their patients, and nearly all (93%) said they recommend one or more screening tests for cancer.

The findings come from the newly released WebMD/Medscape Cancer Attitudes and Behavior Survey, which involved detailed questionnaires that were completed in September 2016 by 754 PCPs who were Medscape users and by 1508 members of the general public who were WebMD site users.

The majority of the PCPs were physicians (n = 574), but there were also physician assistants (n = 80) and nurse practitioners n = 80). The specialty practice areas that were included in the survey were family medicine (n = 361), internal medicine (n = 233), and obstetrics/gynecology (n = 160).

The WebMD Audience

The fact that the members of the general public who took part in this survey were all WebMD users is notable, as it marks them out as being interested in health, and presumably motivated to maintain it. However, one of the items on the questionnaire was particularly revealing. The majority of this audience (79%) said they have or have had a close family member with cancer, and nearly half said they had a parent with cancer (47%).

In addition, half of the WebMD audience (51%) said they have experienced symptoms or signs they believed could be cancer. The majority of these respondents said they had made an appointment with their doctor (75%), and about half reported that everything was fine (39%). However, 1 in 5 (20%) of these respondents went on to be diagnosed with cancer.

Discussing Cancer Risk Reduction

The WebMD survey found that slightly more than half (53%) of the WebMD audience is concerned about getting cancer, but it also revealed that the majority believed that they can lower their risk for cancer (76%) and are also doing something about it (71%).

In the Medscape part of the survey, practitioners gauged concern about cancer as being somewhat higher, and they reported that about two thirds of their patients (67%) were worried about it.

Although a majority of practitioners (71%) said that they initiate discussions about reducing cancer risk with all of their patients, only 1 in 4 (27%) of the public surveyed reported that their PCP initiated a discussion about cancer risk reduction.

Maybe part of this disconnect is that some individuals may not have recalled the discussion that took place as being about cancer prevention ― a discussion that included advice on weight loss, exercise, and not smoking (which the majority of practitioners said they discussed) could have been perceived as being about health generally.

There was also a disconnect in answers to a separate question. Most practitioners (90%) said that they discussed the patient’s family history of cancer (90%), but only 57% of the public surveyed said that the PCP had asked about this.

Lack of time was the reason the majority (68%) of practitioners gave for not discussing strategies for reducing cancer risk with their patients, but there was also evidence of frustration in the answers, as 28% of practitioners agreed with this response: "I have not found these discussions to be effective in producing behavior change and/or compliance."

Asked to comment on the findings, Richard Wender, MD, chief cancer control officer at the American Cancer Society, said: "These results didn't surprise me. Many people aren't aware of the strong link between obesity, healthy eating, and physical activity and cancer. I was actually surprised and pleased that more than half of respondents were aware of this relationship.

"On the other hand, almost 30% of clinicians didn't mention this link, so we have some work to do. They may be aware of the relationship but may just be at a loss as to how to approach this epidemic. We can do a lot better job helping clinicians make a difference," he added.

What Do You Do to Reduce Your Risk?

When the questionnaire asked both groups what they do personally to reduce their risk for cancer, the answers from the public and practitioners were broadly similar on many of the lifestyle items, including not smoking, limiting or avoiding alcohol, eating a healthy diet, and getting regular exercise.

However, the practitioners said they were more likely to maintain a healthy body weight (73% vs 53% of the public).

When it comes to interventions, the responses from the two groups were similar for undergoing recommended screening tests (eg, mammography and colonoscopy) and wearing sunscreen, but practitioners were more likely to have a wellness exam (79% vs 53% among public).

There was also a striking difference in the responses about vaccination ― 63% of practitioners vs 25% of the public said they would get vaccines that could protect against cancer. The two vaccines that were mentioned in the questionnaire were those against hepatitis B (offering protection against liver cancer) and human papillomavirus (HPV) (offering protection against cervical cancer and other HPV-related cancers).

Commenting specifically on this finding, Dr Wender said that this "apparent lack of interest in receiving cancer preventive vaccines" among the public is "perhaps the most concerning result...but this has to be interpreted with care. Many respondents are past the age for which the HPV vaccine is recommended, and many are not at risk for hepatitis B. It's likely that some people were aware of these age guidelines.

"On the other hand, we have an amazing opportunity to potentially eliminate HPV-related cancers of the cervix and head and neck. We need to do a better job at getting the word out and overcoming misconceptions about this and other vaccines," he commented to Medscape Medical News.

Cancer Screening

The vast majority of practitioners taking part in the Medscape survey said that they recommend cancer screening tests to their patients:

  • mammograms were recommended by 99% of practitioners,

  • Pap tests for cervical cancer by 98%,

  • colonoscopy by 98%,

  • skin/mole checks by 89%,

  • dental exams for oral cancer by 68%,

  • prostate specific antigen (PSA) tests for prostate cancer by 67%,

  • digital rectal exams (DREs) for prostate cancer by 65%, and

  • low-dose chest CTs for lung cancer by 49%.

Responses for prostate cancer screening in particular were notable. Two thirds of practitioners are screening for prostate cancer in the primary care setting, although in 2012, the US Preventive Services Task Force (USPSTF) recommended against routine use of the PSA test, and there has also been some debate about the usefulness of DRE for prostate cancer screening.

Some of this may be explained by the answers to the next set of questions. Only half of the practitioners (49%) said that they changed their practice in response to new cancer screening guidelines. Among the other half of practitioners, 40% said that they "adopt new guidelines on a case-by-case basis when it makes sense for my patients," and 21% said that they stick with their "current practices until the evidence for a change is conclusive enough to me."

Looking over these responses, Dr Wender commented: "Clinicians recognize that sometimes cancer screening guidelines are not in universal agreement."

Talking specifically about the responses about prostate cancer screening, Dr Wender said: "In fact, the USPSTF is the only US organization that recommends against prostate cancer screening. Every other major guideline organization [including the American Cancer Society, which Dr Wender represents] recommends offering screening using shared decision making."

"Thus, an individualized approach is very sensible. Our ability to wisely treat prostate cancer is getting better. This is not the time to be abandoning screening," he told Medscape Medical News.

Some of the answers from the WebMD audience about cancer screening could help practitioners prepare to answer various objections to the tests. About a third of the respondents said they believed that they did not need a colonoscopy, and nearly half said that they did not need a mammography. The main objection to these tests was anticipation of it being unpleasant. A majority cited the prep for colonoscopy (71%) and the pain/embarrassment associated with a mammogram (74%) as reasons for not undergoing the screenings.

The last item on the questionnaire asked for opinions about current US spending on cancer research ― just over half of the WebMD audience (56%) said that the United States devotes too few resources toward cancer research, and 39% of practitioners responding to the Medscape survey agreed.

US spending on cancer research has been in the news throughout the past year, with the "Cancer Moonshot" making many headlines. The latest and final report on this project, issued this month, proclaims that "we as a Nation are positioned to end cancer as we know it." But the big question now is, how much funding for this project will be approved by Congress, and will it be sufficient?

Information Is "Power Tool Against Cancer"

"Information can be a powerful tool in the fight against cancer," said Steven L. Zatz, MD, chief executive officer at WebMD. "The findings of our WebMD/Medscape Cancer Attitudes and Behavior Survey underscore the need for more communication between health professionals and patients regarding factors that increase the risk of cancer.

"WebMD and Medscape are committed to the goals of the Cancer Moonshot initiative ― raising awareness, informing, and educating on the topics of cancer prevention, diagnosis, treatment, and survivorship to consumers, patients, physicians, and healthcare professionals," he added.


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