PCPs Discuss Cancer Therapy With Patients, Despite 'Gaps'

Nick Mulcahy

February 20, 2019

The life of a US primary care provider (PCP) may be busy, complex, and underpaid. But, according to new research, a substantial minority will nonetheless find time to help their patients with decisions about breast cancer treatment, a matter outside the scope of typical practice.

In a survey of 517 PCPs who have patients with breast cancer, 34% reported that they discussed surgery, 23% discussed radiation, and 22% discussed chemotherapy options with their patients.

PCPs were defined as those in general/internal medicine, family medicine, and obstetrics/gynecology.

The new study was published online February 1 in Cancer. 

Understandably, some of these physicians also said they had gaps in knowledge and confidence in these consultations.

Adding cancer treatment decision-making to their plates is not feasible.    Lauren Wallner, PhD, MPH

"Efforts to increase PCPs' knowledge about breast cancer treatment options may be warranted," say the study authors, led by Lauren Wallner, PhD, MPH, of the University of Michigan Rogel Cancer Center in Ann Arbor.

However, commenting to Medscape Medical News, Wallner acknowledged that PCPs are overtaxed and that "adding cancer treatment decision-making to their plates is not feasible."

However, Wallner had a more modest proposal: "Improving the communication between the oncologist and PCP during initial treatment may help to better support the patient."

Asked for comment, Jonathan Sussman, MD, an oncologist at Juravinski Cancer Centre, Hamilton, Ontario, Canada, said, "the findings of the survey do not surprise me." 

Sussman, who was not part of the current study but has studied this issue in Canada, pointed out that "many current cancer treatments outside of surgery are not really covered in either medical school or in primary care residency curricula." Also, few trainees have the opportunity to gain experience by having rotations in oncology, he added.

Were PCPs Truthful in the Survey?

Breast cancer patients tend to turn to their established and trusted caregivers, with about one third reporting that their PCP participated in their oncology treatment decisions, according to previous research (J Clin Oncol. 2016;34:3969-3975) that was described as surprising.

So the current team of investigators, who are from the Cancer Surveillance and Outcomes Research Team, decided to survey over 500 PCPs to find out how they felt about such talks. The PCPs were linked to 1077 women treated for early stage breast cancer who were part of the Individualized Cancer Care (iCanCare) study.

The linked study data allowed the researchers to check whether what the PCPs were reporting tied in with what patients were reporting. Turns out, it did.

The team compared the PCPs' claims with patients' reports of their PCPs' participation in their breast cancer treatment decisions. "There was a clear pattern of concordance for all three decisions," write the study authors.

The survey also sought to characterize PCPs' perspectives on their ability to participate in these decisions.

For example, surgery was the treatment modality that PCPs were most likely to discuss. However, of the physicians who reported surgery-related discussions, 22% were not comfortable and 17% had self-described insufficient knowledge.

The study team wants to help these folks, said Wallner.

"If they're going to be involved, we need to find a way to make sure they have the knowledge to do so and we support them in a way that ensures they're confident and able to do so," she said in a press statement.

Sussman suggests one possible way of providing support is to make treatment practice guidelines more accessible to primary care providers to reference, "if they want to participate a bit more in supporting their patients' treatment decision-making."

In the study, the majority of PCPs positively appraised their ability to participate in breast cancer treatment discussions. Members of this confident group were more likely to participate in all three treatment decisions.

The study authors say there is a growing body of evidence that PCPs want to be involved in the care of cancer patients "throughout the continuum," which would include treatment discussions.

But will PCPs get paid for their labor, especially in later years of care?

"Currently, survivorship care planning and related visits are not directly reimbursed," said Wallner.

Wallner called the lack of payment "a major hurdle when we think about how to better support providers in participating in survivorship care." The problem, however, applies to both PCPs and oncologists.

"Addressing the evolving needs of cancer survivors over time requires more time than the typical reimbursable office visit allows," she summarized.

The study was partially funded by the National Cancer Institute and Rogel Cancer Center. The study authors have reported no relevant financial relationships.  

Cancer. Published online February 1, 2019. Abstract

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