Oncologists Don't Discuss Healthy Lifestyles With Cancer Survivors

Missed Opportunity?

Roxanne Nelson, RN, BSN

August 28, 2019

Physicians caring for cancer survivors don't always promote healthy lifestyle changes, and oncologists and other specialists are less likely to do so than primary care physicians (PCPs).

So suggest the results from a new survey of 91 physicians.

This included 30 PCPs, 30 oncologists, and 31 specialists (urologists, dermatologists, and gynecologists who treated survivors of prostate cancer, melanoma, and breast cancer, respectively). In addition, interviews were conducted with 12 oncologists to identify barriers to promoting health behavior change.

Less than a third of the oncologists said that they discuss healthy lifestyles with cancer survivors, citing that time is an issue, that they aren't trained for it, and that they are concerned that the extra information will overwhelm patients.

However, the majority of PCPs said that they recommended health promotion such as weight loss and smoking cessation to at least some cancer survivors.

These results suggest that many oncologists are not following practice guidelines that recommend clinicians counsel cancer survivors on adopting a healthy lifestyle.

"Even though oncologists clearly believe that cancer survivors should adopt a healthy lifestyle, they said they don't have the time to address more than cancer care," said lead author Tammy Stump, PhD, a postdoctoral fellow in the department of preventive medicine at Northwestern University Feinberg School of Medicine, Chicago, in a statement.

The study was published online August 26 in Cancer.

Commenting on the study, Wendy Demark-Wahnefried, PhD, RD, professor and Webb-endowed chair of nutrition sciences, University of Alabama at Birmingham, noted that the data from this paper suggest that PCPs are significantly more likely to refer to dieticians, exercise specialists, and other experts in this regard. "The oncologists may be lagging in this particular area," she said.

She pointed out that "this is unfortunate" and suggested that there may be a misunderstanding in what is expected. "While the guidelines encourage oncologists to advise their patients on the importance of weight management, regular exercise and a healthful diet, the expectation is that the oncologist will deliver the message and then make a referral to professionals who have the time, resources, and knowledge to invoke the necessary behavior changes."

"No one expects the oncologist to actually provide the counseling," she said.

Limited Discussions on Health Promotion

The survey results showed that 90% of PCPs reported recommending health promotion such as weight loss and smoking cessation to at least some cancer survivors.

However, the percentage of other physicians who did so was much lower; only 26.75% oncologists and 9.7% of clinicians in other specialties reported that they ever did so.

In one scenario posed in the survey, a physician had 2 minutes remaining in the visit with a cancer survivor. Only 8.8% reported that they would use that time to discuss topics related to health promotion, but PCPs were significantly more likely to do so vs oncologists and specialists (P = .02).

Similarly, if an overweight patient requested information about weight loss, 93.3% of PCPs reported that they would encourage health behavior change, while less than half of oncologists and specialists would do so (P < .001).

Oncologists perceived weight gain ambivalently, the authors note. One interviewed oncologist commented that "our goal is often don't lose weight, because losing weight is the first bad sign that we're heading toward progression of disease. We definitely jump on weight loss and we aren't so jumpy on weight gain. I often use the phrase, 'In my world, I'm not too unhappy about gaining weight.' "

No Adherence With Weight Loss?

Another finding was concern that the health promotion message would interfere with the use of medication regimens to prevent cancer recurrence. While most physicians believed that at least half of the patients would continue to take their medications, they also felt that patients would not do so if they were also trying to lose weight.

When looking at beliefs pertaining to adherence to drug regimens, physicians predicted that 57% would adhere to their medication regimens, but that percentage dropped to 10.7% if the patient was trying to lose weight at the same time (P < .05).

One oncologist noted that "most people are saying that patients cannot do both . . . like chewing gum and walking."

Commenting on the findings to Medscape Medical News, Demark-Wahnefried found this surprising, especially since there are no systematic data to support it. "I don't doubt that this is a finding that arose from this mixed method study, but it only surveyed 30 oncologists from Northwestern University," she emphasized. "Therefore, I would be cautious on whether these findings can be generalized more broadly."

While this was a small sample of physicians, and especially oncologists, another commentator noted that it was seen across the board for all the physicians surveyed. Colleen Doyle, MS, RD, managing director of nutrition and physical activity at the American Cancer Society, noted that "the physicians all agreed that there would be reluctance to remain on the treatment regimen, if they are trying to lose weight."

"Studies like this certainly raise some interesting issues and help us understand things we need to delve into," she added.

Another expert also found these results unexpected.

"That struck me as odd, unless they are talking about breast and prostate cancer, where patients can gain weight from the treatment, and that may be an issue," said Deborah K. Mayer, PhD, RN, Frances Hill Fox distinguished professor in the School of Nursing and director of cancer survivorship at the University of North Carolina, Chapel Hill.

"But that's not the case for all cancer patients," she said. "And it still doesn't mean you shouldn't try losing weight."

Adherence to long-term medication is an issue, Mayer added, and can be related to cost, toxicity, or other factors, "but I think it might be a stretch to link adherence to weight loss."

Oncologist Say Cancer Control is Priority

Even though oncologists acknowledged that cancer survivors can derive both physical and psychological benefits from adopting health behavior changes, all of the oncologists interviewed stated that cancer control is their primary concern, which reduced the priority of providing health promotion advice. One oncologist said, "We're so focused on the life-or-death aspect of cancer, everything falls through the cracks."

Oncologists also emphasized their lack of time and resources to discuss health promotion during regular visits, and that this type of advice could be provided to cancer survivors elsewhere in the health care system.

Several suggested that "a well established survivorship clinic is the best way to [provide health-promotion advice] . . . because then all [oncologists] would have to do is say, 'I'd like to refer you to the survivorship clinic.' "

A Component of Survivorship

Commenting on the findings to Medscape Medical News, Mayer said that the paper shows that oncologists haven't fully embraced health promotion as a component of survivorship care. "Screening and surveillance for cancer recurrence is what they do well, but at this point, most patients are also asking what they can be doing at this point to help themselves. This is a time when they may be open to messages about behavior change and health promotion."

Previous studies have shown that roughly 10% of all survivors follow all of the recommended health behaviors, Mayer noted. "They don't smoke, they don't drink a lot, they eat a healthy diet, and maintain a healthy weight."

"About 10% of patients do none of these things," she continue, "and the rest (about 80% of patients) are somewhere in between, where there is at least one health behavior can be targeted."

"So while oncologists may not be doing the health behavior counseling themselves, they could be doing an assessment and referring them to programs or other health professionals," Mayer suggested.

"That's why survivorship care, as part of follow-up care, needs to focus on other things in addition to whether the tumor has recurred. Patients have more needs than just to know that their cancer hasn't come back," she emphasized.

Doyle noted that one point that really caught her attention in this study was that all physicians were unlikely to advise health behavior change when cancer survivors exhibited comorbid cardiometabolic disease, even though this group may have the greatest need to improve health behaviors.

"These are the same things that we talk about when it comes to reducing your risk of cancer — but from the recurrence and survival perspective, our recommendations to cancer survivors is to be physically active, eat a healthy diet, and watch your weight," said Doyle. "All of those things absolutely help for cardiovascular disease and diabetes, too. So there's a 'triple whammy' benefit to helping cancer survivors adopt and continue a healthy lifestyle."

The study also looked at barriers that may be preventing physicians from discussing lifestyle changes, with one being that patients are too stressed and have a lot of fatigue. "But we know from an evidence-based perspective that physical activity will help cancer survivors reduce their stress level and fatigue," Doyle noted. "So this is something that we really need to educate healthcare providers about."

"Importantly," Doyle continued, "How do we educate from a communications perspective? This is a very stressful time for the patient, and you want to talk to them and help them in a way that is empowering and motivational, and not what's going to make them feel guilty."

More data is needed, Doyle added, "About how we can change behavior and support long-term behavior change, and right now we don't have a lot of hard-and-fast answers."

Research was supported, in part, by the National Institutes of Health's National Center for Advancing Translational Sciences. Stump received salary support from the National Institutes of Health/National Cancer Institute training grant. Mayer reports being a stockholder and adviser to CareVive. The remaining study coauthors and Doyle have disclosed no relevant financial relationships.  

Cancer. Published online August 26, 2019. Abstract

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