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Primary Care Docs Ambivalent About Cancer Decisions

A survey of primary care physicians (PCPs) showed that as many as a third reported involvement in patients’ breast cancer treatment decisions, but many of them were uncomfortable with the discussions or lacked knowledge or confidence.

PCPs most often discussed surgery with patients (34%), followed by radiation therapy (23%), and chemotherapy (22%). Among the clinicians who were involved in discussions about treatment, as many as 25% said they were uncomfortable with the discussions. About 10-20% said they lacked knowledge or confidence in their ability to contribute, as reported online in Cancer.

“As initial treatment options for early-stage breast cancer increasingly become more nuanced, PCPs may be more often consulted by their patients for their input,” said Lauren P. Wallner, PhD, of the University of Michigan in Ann Arbor, and co-authors. “As such, efforts to educate PCPs about the specifics of the various treatment options so that they can effectively support patients in making high-quality decisions appear warranted.”

The findings did not come as a surprise and are consistent with other evidence on the topic, said Richard Wender, MD, of the American Cancer Society. The results reflected a bell-shaped curve of knowledge and comfort for PCPs’ involvement in cancer treatment decisions: Some primary care doctors feel more prepared and confident about the discussions than others do.

However, Wender took issue with the authors’ suggestion that education of PCPs about cancer treatment decisions would be helpful.

“Primary care physicians — and their teams — have an incredible amount of responsibility on their plates,” said Wender, speaking from a background in primary care. “They have enormous responsibility in cancer care for behavioral counseling, for vaccinations, for screening, and for survivorship follow-up and well care. It’s not realistic to think we’re going to be able to enhance primary care physicians’ knowledge of cancer treatment options to a great extent.”

Instead, he would like to see more interaction between oncologists and primary care practitioners to establish some basic principles about cancer care to apply in discussions with patients.

A spokesperson for the American Society of Clinical Oncology cited an ASCO statement on survivorship care plans, which emphasized the need for increased communication among oncologists, patients, and PCPs. The spokesperson also referenced the National Academies of Sciences, Engineering, and Medicine report “Lost in Translation,” which identified communication and coordination of care between the oncology team and primary care providers as an essential component of survivorship care. Wallner and coauthors noted that treatment decisions for patients with early-stage breast cancer involve discussions among multiple oncology providers, but the participation of PCPs in treatment decisions remained unknown. To investigate the issue, they surveyed 517 PCPs identified from Georgia and Los Angeles registries participating in the NCI Surveillance, Epidemiology, and End Results program.

Respondents indicated how often they discussed surgery, radiation therapy, and chemotherapy options with patients who had early-stage breast cancer; how comfortable they were with the discussions; whether they had the knowledge to participate in decision making; and how confident they were in their ability to help.

The results showed that the survey participants most often discussed surgery with patients, whereas discussions about radiation therapy and chemotherapy occurred less often but to a similar degree. PCPs who expressed more confidence in their knowledge of treatment options were more likely to have discussions with patients.

A substantial proportion of the PCPs who discussed breast cancer treatment decisions with patients nonetheless expressed some ambivalence. The proportion who said they felt comfortable with the discussions were 22% for surgery, 16% for radiation therapy, and 25% for chemotherapy. The percentages who said they had appropriate knowledge about the treatments were 17% for surgery and 9% for both radiation therapy and chemotherapy. The proportion who said they felt confident about discussing treatment options were 18% for surgery, 14% for radiation therapy, and 16% for chemotherapy.

The authors acknowledged several limitations of the study: there was no direct measure of PCP involvement in decision making; the inherent limitations of a cross-sectional study; there was no information about the quality or content of discussions with patients; and an inability to account for confounding factors.

The authors also cited prior research involving prostate cancer, which showed that PCP participation did not influence treatment decisions.

“Therefore, the extent to which PCP involvement in the treatment decision may influence a patient’s appraisal of the decision-making process and the ultimate treatment decision itself remains poorly understood,” they wrote.

The study was supported by the National Cancer Institute, the CDC, the California Department of Public Health, and the Cancer Prevention Institute of California.

Wallner reported having no relevant relationships. One or more co-authors disclosed relationships with Myriad Genetics, the Doris Duke Charitable Foundation, the Komen Foundation, the Greenwall Foundation, Vizient, Amgen, and Equity Quotient.