As our aging population increases, so does the demand for oncology services; however, as ASCO and other organizations have pointed out, a workforce shortage of oncology care specialists looms in the not-so-distant future. Given the growing need for care models that meet this demand, a better understanding of the involvement of primary care physicians in cancer care is needed. To shed light on this issue, The ASCO Post recently spoke with health services researcher Lauren P. Wallner, PhD, MPH, of the University of Michigan Rogel Cancer Center, who has conducted several studies looking at the interface of primary care physicians and cancer care.1–4
Lauren P. Wallner, PhD, MPH
Please tell us a bit about your background and your current work.
I’m part of a large investigative group called CanSORT, which stands for Cancer Surveillance and Outcomes Research Team. Our work focuses largely on improving the quality and delivery of cancer care, including issues around treatment decision-making, from diagnosis to end-of-life care. My research program is tailored to adults with favorable-prognosis cancers, specifically the survivorship period after the primary diagnosis.
Breast Cancer Treatment Decisions
Please describe your study of primary care provider involvement in breast cancer treatment decisions.
The idea of integrating primary care physicians into cancer care is becoming more popular, and there are National Academy of Medicine recommendations and survivorship care guidelines that recommend primary care takes on a bigger role. We published a prior study from a large population-based sample of patients with breast cancer where we asked to what extent primary care physicians were discussing their treatment options with them.4 To our surprise at the time, we found that one-third of patients said their primary care providers were often involved in the decision-making process.
We’re a multidisciplinary group of investigators, consisting of multiple oncologists, primary physicians, and social scientists like myself, and the results left us scratching our heads because it was certainly more than we would have expected. When we typically think about treatment decision-making, we spend a lot of time focusing on the patient-oncologist interaction, and now we were really thinking about the role of primary care physicians. We were fortunate to receive additional funding from the University of Michigan Rogel Cancer Center to conduct a survey study of the primary care physicians who care for these patients with breast cancer.
Using Surveillance, Epidemiology, and End Results (SEER) registries, we surveyed 517 primary care physicians who were linked to 1,077 women with early-stage breast cancer diagnosed between 2013 to 2015 from Georgia and Los Angeles.1 The physicians were asked whether they had discussed surgery, radiation, or chemotherapy options with their patients. They were also asked how comfortable they were discussing these issues and whether they felt they had the knowledge to help with treatment decisions. We appraised their ability to participate in treatment decision-making based on their reported level of confidence.
“One caveat of this work is that we still don’t know if the involvement of primary care physicians in cancer treatment decision-making improves patient outcomes.”— Lauren P. Wallner, PhD, MPH
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What were some of your specific findings?
We found that up to one-third of the primary care providers said that they were involved in their breast cancer patient’s treatment decisions—a similar number to what we saw in the large breast cancer study. In this study, there was more involvement in surgical decisions; about one-fourth of the primary care providers said they participated in radiation and chemotherapy decision-making. But despite this level of involvement, a notable minority of primary care providers reported that they were not confident that their current state of knowledge was adequate to effectively participate in these conversations. So there are still important gaps of knowledge on the primary care side.
Not surprisingly, we found that older primary care providers were more likely to be comfortable with shared decision-making with their patients with cancer. Physicians who have a longstanding relationship with their patient often are more attuned to their patient’s values and preferences.
I would also say that, along with other existing literature, our results suggest that more primary care providers are involved in cancer care treatment decisions than we previously thought, but we still have an opportunity to make sure that they get the support they need to better help their patients with cancer. That support could include having more educational material available on the nuances of treatment or more streamlined communication avenues with oncologists. One caveat of this work is that we still don’t know if the involvement of primary care physicians in cancer treatment decision-making improves patient outcomes. That’s the next step.
Spectrum of Involvement
In what areas of treatment decision-making do you think primary care physicians can be most effective?
We don’t know that because this work doesn’t delve into the nature of the
conversations between patients and their primary care physicians or who is initiating them. One could imagine a patient asking for an opinion and the primary care provider saying that there are a number of treatment options that you need to speak to your oncologist about. That interaction is considered participation along with the other end of the spectrum, in which the primary care provider actually goes down the list of options in an active shared decision-making conversation.
In the broader landscape of things, we know that primary care providers usually have had a longer relationship with patients with cancer, and prior research has shown that primary care providers are more in tune with patients’ wants and needs, so they may provide an additional opportunity in overall shared decision-making, which is very important in early-stage breast cancer. These women are often choosing between surgical decisions that have comparable outcomes, and knowing their values and preferences helps support them through the difficult process.
“We have to find ways to support the role of primary care physicians so they are more actively involved throughout the continuum of cancer care.”— Lauren P. Wallner, PhD, MPH
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What can we take away from this work that will help primary care providers be better members of the cancer care continuum?
There are a couple of things that need to happen to support a stronger primary care provider–oncologist model of care. There needs to be a better clarification of the roles played by primary care providers, which obviously changes during the continuum of care into survivorship, a period when the primary care provider can be more involved. We have data that show there’s a lack of clarity—not only among patients but also among the providers—about who is doing what. If we’re going to improve the coordination of care, survivorship care guidelines need more clarity.
We also have to be cognizant of time constraints on both the oncologist and primary care sides and recognize that any educational opportunity aimed at addressing this shared care model should be usable within today’s ultra-busy practice context. Moreover, the current reimbursement structure, particularly for survivorship care is lacking, considering the length of visits that are required to deal with a multitude of health issues. The handoff doesn’t only occur when the patient with cancer finishes treatment.
Lastly, we know very little about the potential role of the primary care provider in palliative and end-of-life care, which needs more research. We have to find ways to support the role of primary care physicians so they are more actively involved throughout the continuum of cancer care. ■
DISCLOSURE: Dr. Wallner reported no conflicts of interest.
1. Wallner LP, Li Y, McLeod MC, et al: Primary care provider–reported involvement in breast cancer treatment decisions. Cancer 125:1815-1822, 2019.
2. Radhakrishnan A, McLeod MC, Hamilton AS, et al: Preferences for physician roles in follow-up care during survivorship: Do patients, primary care providers, and oncologists agree? J Gen Intern Med 34:184-186, 2019.
3. Wallner LP, Li Y, Furgal AKC, et al: Patient preferences for primary care provider roles in breast cancer survivorship care. J Clin Oncol 35:2942-2948, 2017.
4. Wallner LP, Abrahamse P, Uppal JK, et al: Involvement of primary care physicians in the decision making and care of patients with breast cancer. J Clin Oncol 34:3969-3975, 2016.