Many primary care providers believe they are ill‐prepared for talks with patients with breast cancer
Authors: Mike Fillon
Journal: CA A Cancer Journal for Clinicians (2019)

A new study in Cancer (published online February 1, 2019. doi:10.1002/cncr.31998) reports that although approximately 1 in 3 primary care providers (PCPs) discuss breast cancer treatment options with their patients who are newly diagnosed with early-stage breast cancer, many report gaps in their knowledge and that they lack of confidence in this role. “This [involvement of PCPs] was somewhat surprising to us, as we tend to focus primarily on the role of the oncologists when thinking about shared decision making for breast cancer,” says the study's lead author Lauren P. Wallner, PhD, MPH, an assistant professor of medicine and epidemiology at the University of Michigan in Ann Arbor. Although Dr. Wallner and her team believe the findings might signal good news for team-based care, they also say it raises questions regarding whether PCPs have the resources they need to properly advise patients with cancer. “I'm not surprised by this confidence gap,” says J. Leonard Lichtenfeld, MD, MACP, interim chief medical and scientific officer at the American Cancer Society in Atlanta, Georgia. During his career, Dr. Lichtenfeld has practiced as both a PCP and an oncologist. “I think many PCPs are not comfortable advising patients about their [cancer treatment] options because in many cases they feel they don't understand all the options.” According to Dr. Wallner, ensuring that physicians do have appropriate resources and support to be prepared for these conversations is paramount, both because so many PCPs are involved in cancer care earlier than thought and because of the prevalence of breast cancer. “As the number of women diagnosed with breast cancer continues to grow and treatments become more nuanced, PCPs may be consulted more frequently about these treatment decisions,” she says. Dr. Wallner and her colleagues surveyed 517 clinicians who were identified by 1077 women who were treated for stage I and stage II breast cancer as their PCP. The patients, who were aged 20 to 79 years, were selected using Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County, California, from 2013 to 2015. The investigators asked PCPs about the frequency of their involvement in discussing options for surgery, radiation, or chemotherapy with their patients. For each treatment modality, PCPs recorded answers using a 5-point scale that ranged from “sometimes,” “often,” or “always” to “rarely” or “never.” PCPs also were asked to consider how comfortable they were discussing surgery, radiation, and chemotherapy, with 5 possible responses ranging from “not at all comfortable” to “extremely comfortable.” They were asked to evaluate their knowledge level and whether they felt confident enough to help patients in treatment decision making, with 5 response options ranging from “strongly disagree” to “strongly agree.” To facilitate statistical analyses, the investigators grouped responses into 2 categories: less involvement, comfort, or agreement (corresponding to the 2 lowest response options for each question) or more (corresponding to the 3 highest response options). They found that approximately 34% of physicians considered themselves to be more involved in discussing surgery options with their patients. The corresponding values for more involvement in discussing radiation and chemotherapy were 23% and 22%, respectively. Of the PCPs who reported more involvement in surgical decisions, 22% reported less comfort in having a discussion, and 17% reported less agreement with the statement that they had the necessary knowledge to participate in treatment decision making. In multivariable analyses controlling for several PCP demographic and practice-related variables, greater PCP confidence in knowledge regarding surgery, radiation, and chemotherapy options was strongly associated with more frequent involvement in discussing these options with their patients. Because the study did not address the details of discussions between PCPs and patients, Dr. Wallner says it is unclear whether or how these conversations are affecting cancer care. “We do not yet fully understand the nature and content of these discussions and how they influence patients' treatment decisions and outcomes,” she says. Moreover, Dr. Lichtenfeld says, the study's findings should not discourage or diminish the role of PCPs in cancer care. “With my background as a [primary care] clinician and oncologist, I know patients often reach back to their PCP for counsel and advice. And one of the things I believe in very strongly is that PCPs don't have to be experts to be excellent physicians on behalf of their patient.” Although it may not be up to the PCP to make the ultimate care decisions, Dr. Lichtenfeld says, their relationships with patients and familiarity with their overall health histories can be a significant strength. “They may know the patient better from past contacts and therefore may be better able to help a woman weigh her own values as to what is the best decision for her,” he says. “Even if [the provider] doesn't understand everything, that might not be as important as simply listening and counseling and even making a phone call to ask why recommendations are being made.” According to Dr. Wallner, because of the rapidly changing treatment landscape and limited time PCPs already have to address all of their patients' health care needs, keeping up to date on treatment guidelines would not even be possible. Instead, she says that “better communication between the oncologist and the PCP about the treatment strategies may be a more feasible strategy to engage PCPs as needed during treatment.” In the end, Dr. Wallner says additional research is needed to understand how PCPs fit into the overall journey of the patient with cancer and whether their involvement influences patients' treatment decisions and outcomes. “To what extent PCPs are involved in other cancer treatment decisions remains largely unknown,” she says.