Is High Patient–Doc Chemo Goal Agreement an Outlier?

Liam Davenport

January 03, 2019

Recording treatment goals in oncology management software and clinical notes may prompt discussions with patients over treatment intent and reduce discrepancies between oncologist and patient understanding, argue a group of US physicians.

Their new study identified a far lower discordancy rate in patient–physician understanding of chemotherapy intent than previously seen in the literature.

Seth M. Maliske, MD, Aspirus Wausau Hospital, Wausau, Wisconsin, and colleagues studied more than 130 cancer patients receiving their first chemotherapy treatment at the University of Iowa in Iowa City. The overall rate of discordance (17.29%) was found to be significantly less than the proposed acceptable level of 33% (P < .01).

The research was published online in the European Journal of Cancer Care on December 3.

Notably, only 7% of patients with cancer that could not be cured with chemotherapy believed that their treatment had a curative intent.

These results are strikingly different from those seen in previous studies.

In 2012, Medscape Medical News reported a national survey of 1193 patients with advanced-stage cancer showing that 69% of lung cancer and 81% of  colorectal cancer patients misunderstood the intent of chemotherapy.

Crucially, the majority of patients mistakenly believed that chemotherapy might cure their disease.

Despite acknowledging that "our data illustrate the lowest current documented rate of discordance," Maliske and colleagues say that "17.3% of patients misunderstanding their goals of treatment is still too high" and therefore "want to pursue measures that work towards a 100% concordance rate."

To those ends, the authors would like to see the "hard stop" to document treatment goals in the Beacon oncology software program (Epic), which is employed at the University of Iowa, be required instead of optional, as it is now.

Thomas J. Smith, MD, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, Baltimore, Maryland, is an expert on this subject.

The current results are "vastly different from the literature," and have several possible explanations, he told Medscape Medical News.

"First, this is the first contemporaneous study, in real time, with modern day oncology to look at the issue. Second, Beacon may indeed be driving the bus toward better understanding," he said.

"Third, they may have gotten a somewhat misrepresentative sample in that only half the doctors and patients filled out the Beacon questions," Smith added.

"Only a ‘hard stop' study will tell if this is the case."

Smith continued: "Fourth, people in Iowa are white, well educated, and, I bet, in general trust their doctors and the health system. This is not the case in a lot of practice venues. And Iowans are known for their practicality."

These characteristics, he said, could be "vastly" important in trying to understand physician–patient discrepancies.

Smith added that, if he was designing the next study, he would find out why the approximately 7% of patients who underestimated their chances of cure die, and determine whether they "do as well as, or worse than, those with realistic expectations of cure".

He would also like to repeat the study in more ‘real world' settings and with a Beacon hard stop, and to "make sure that patients understand their prognosis by asking [their physician]."

The researchers say that the discussion of treatment goals between oncologists and cancer patients is "always challenging and requires effective communication to provide compassionate patient care that respects patient autonomy".

However, studies have shown that these discussions do not always take place and, when they do, there are large discrepancies between patients and their clinicians over the goal of chemotherapy, with discordance rates as high as 81%.

The researchers argue that requiring the documentation of treatment goals during chemotherapy may serve as a reminder to have such discussions and potentially improve communication.

Study Details

Since 2011, the Beacon software program has included a "treatment goal" field, with options to choose from "curative," "palliative," "symptoms control," and "others."

The study authors therefore set out to examine patients' shared understanding of treatment goals as well as the use of the treatment-goal field and its documentation in the clinical notes.

They studied outpatients and inpatients, including those on clinical trials, who were receiving chemotherapy between 2012 and 2014 under the care of 23 oncologists across multiple specialties.

All patients were receiving their first cycle of chemotherapy and were interviewed within 21 days of starting treatment to determine their recall of discussions regarding therapy intent.

Of 207 patients included in the analysis, a therapy goal was documented by physicians on Beacon in 57% of cases, and the goal was recorded in the notes in 45.4%.

This meant that 56 (27%) of the 207 patients did not have any form of documented treatment goal.

After removing patients with missing or contradictory information, a total of 133 patient–physician dyads remained for analysis, representing 64.3% of the original cohort.

The majority (69.9%) of patients were younger than 65 years, 55.6% were women, 66.2% were married, and 81.2% were employed or retired. Only 3.8% were taking part in clinical trials.

The team found that there was no significance difference in the directionality of discordance between patients and physicians (P = .61), and the inter-rate agreement between patients and oncologists was "adequate," at kappa = 0.64.

They note that, with 23 patients and oncologists disagreeing over intended treatment goals, the overall rate of discordance, at 17.3%, was significantly less than the proposed clinically acceptable threshold of 33% (P < .01).

The results also revealed that, among the 23 discordant patient–physician dyads, 56.5% were discordant in the sense of patients identifying no possibility of cure while the physician's intent was curative.

In the remaining 43.5% of cases, the patients understood that there was a curative intent, while the physician's goal was noncurative. This equated to 7.5% of the overall study cohort.

Interestingly, 13 (22.8%) of 57 patients with curable-intent cancer believed that their chemotherapy had a noncurative intent.

The findings were unaffected by taking into account patient age, gender, and marital and unemployment status.

The researchers conclude: "Discrepancy still exists between documentation of goals of therapy and patients' understanding of the same, indicating ongoing lack of proper communication between oncologists and their patients."

They added that "efforts to promote utilization of computerized entry of treatment goal fields in an attempt to improve communication are advocated for future research."

The study was in part supported by a National Institutes of Health (NIH) and Clinical and Translational Science Awards (CTSA) grant.

Varun Monga, one of the study's authors, was the recipient of the NIH CTSA grant, which was paid to the University of Iowa Carver College of Medicine. Study author Mohammed Milhem serves in a consulting or advisory role for several companies, including Genentech/Roche, EMD Serono, Novartis, Eisai, and BristolMyers Squibb.

Eur J Cancer Care. Published online December 3, 2018. Abstract

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