PCPs Should Support Survivorship, Not Directly Influence Cancer Decisions

A recently published survey of primary care physicians (PCPs) showed how ambivalent many doctors are to discuss cancer treatment options with their patients. The investigation was specific to early stage breast cancer, where the standard of care is relatively consistent and straightforward.

But even early-onset breast cancer is nuanced. And PCPs are rarely trained in the increasingly complex specialty of cancer care. Rare malignancies, tests/imaging, prognostication assays, drug pipeline, genetic mutations… PCPs are burdened enough; there should be no expectation of deep involvement in cancer treatment decision-making.

The survey results, published in the journal Cancer, highlighted these numbers:

PCPs surveyed: 517

Percentage of PCPs comfortable in discussing cancer treatment decisions:

Surgery: 34%

Radiation Therapy: 23%

Chemotherapy: 22%

Percentage of PCPs who said they had appropriate knowledge about cancer treatments:

Surgery: 17%

Radiation Therapy: 9%

Chemotherapy: 9%

Percentage of PCPs who said they feel confident about discussing cancer treatments:

Surgery: 18%

Radiation Therapy: 14%

Chemotherapy: 16%

Twenty-five percent of PCPs shared they were uncomfortable discussing cancer treatment, in general, with their patients.

It is clear that the concerns regarding lack of comfort, knowledge, and confidence about cancer treatment decision-making are well-founded.

[Note: There were inherent limitations of the study. For those wanting a deeper look, see the publication.]

Surgery, radiation therapy, and chemotherapy remain the primary interventions for conventional cancer care, but all the options evolving from targeted therapies, immunotherapies, and hormonal therapies are dizzying. It’s incredibly complicated. Certainly we should not expect PCPs to gain enough subject matter knowledge—let alone rising to the level of subject matter expertise—to have substantive conversations with patients about treatment decisions, whether for early stage breast cancer or a rare metastatic sarcoma.

Do not hesitate to ask your PCP directly about her level of comfort and knowledge in the field of cancer care, specifically about evolving treatment options, and the medical literature that supports the decision-making process.

In instances that your PCP has the time and bandwidth to speak directly with your oncologist—review various options, consult the cancer care guidelines, and identify applicable trials—you will have increased assurance that you will have an active partner and, therefore, you should listen closely to what is said.

Back in 1991, when I was diagnosed with leukemia, my oncologist played a dual role as my PCP. It made sense. He knew me, and he was trained in internal medicine. So I dropped my previous PCP, the person who actually diagnosed my leukemia. When my oncologist’s practice flourished (sadly, they all do), he pushed me to get a PCP—it was several years before I relented.

The Appropriate Role of PCP in a Cancer Setting

I realize how important PCPs are. Many of us have had a long, trusted relationship with our doctor—sometimes spanning decades. You may be quite fortunate to have a wonderful relationship with an empathetic, caring soul.

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Your PCP should play a critical, collaborative role with your overall oncology care team. Moreover, PCPs should help ensure that patients seek second opinions at NCI-designated comprehensive cancer centers here in the U.S. They should be aware of treatment side effects, in order to understand when patients are not being well managed, or otherwise need more additional support.

PCPs should focus on strong communication and regular updates, flowing both ways, with a patient’s oncologist. The PCP and oncologist should work together in understanding and managing comorbidities (additional underlying health conditions such as diabetes, heart disease, and hypertension) and how various drug regimens may impact these conditions. They should work together to identify unmet emotional and psychological needs, and refer out to specialists as necessary.

Ideally, a PCP’s role should be to support cancer patients more broadly, and over the long-term journey of survivorship.

Most importantly, PCPs, in conjunction with a patient’s oncologist, should be part of the survivorship care plan development process. Specifically, PCPs, along with their oncologist counterparts, must support their patients following the American Cancer Society Survivorship Care Guidelines.

Your Role with a PCP in a Cancer Setting

It is important not to have unrealistic expectations of your oncologist or PCP as it relates to practical self-care that incorporates an integrative approach to the management of cancer and long-term survival. Let your oncologist be the disease expert, while you become your own health expert.

Your PCP may or may not have a level of training (within her medical school curriculum) matched to the core tenets of lifestyle medicine, which include nutrition, physical activity, and stress reduction techniques. Given less than 50% of PCPs across the U.S. speak with their patients about sensible, healthy lifestyle choices, you may not find meaningful support in this vital area from either your PCP or oncologist.

Unless your PCP closely follows cancer care guidelines, the evolving drug pipeline, shifting standard of care, and human trials, you are best served by getting treatment advice from your oncologist. In most cases your best outcome will result from also obtaining a second, and sometimes a third, opinion from an academic clinician-investigator(s) with expertise in the particular malignancy you are hosting.

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Photo credit: bigstock.com/PaskoMaksim