Medical World News: Managed Care Updates, April 2019

Despite Involvement in Cancer Treatment Decisions, PCPs Lack Knowledge, Confidence

As the healthcare system continues to strive to be patient-centered, team-based care has emerged as an important tool for improving quality of care and patient satisfaction, particularly in oncology. Within the care team, the primary care provider (PCP) plays an integral role, as they are often the provider managing the patient’s other comorbidities and general care, and thus they have a better understanding of the patient’s preferences and values. However, while patients often come to these providers first to discuss cancer treatment options, PCPs report significant knowledge gaps regarding these treatments.

According to a study in Cancer,¹ one-third of PCPs reported participating in breast cancer treatment decisions with their patients, but a significant number of these PCPs nonetheless indicated that they were not comfortable with or did not feel that they had the necessary knowledge to participate in the treatment decision-making process.

“Primary care physicians may be involved in cancer care earlier than we thought,” Lauren P. Wallner, PhD, MPH, a health services researcher at the University of Michigan Rogel Cancer Center, said in a statement.² “If we are going to promote their involvement, we may need to start doing that earlier, around the time of initial treatment, and ensure [that] PCPs have the information they need to effectively participate in the decision-making process.”

Drawing on data from the Individualized Cancer Care study, which included 1077 women with early-stage breast cancer and their 517 PCPs, the researchers identified women aged 20 to 79 years from Los Angeles County, California, and Georgia who had been diagnosed between 2013 and 2015. PCPs were asked whether they had discussed surgery, radiation, or chemotherapy options with their patients and how comfortable they were with doing so.

Survey answers revealed that 34% of PCPs had discussed surgery options with their patients, 23% had discussed radiation, and 22% had discussed chemotherapy. Across all 3 treatment options, PCPs who reported ability to participate in the decision-making process were more likely to have these discussions and have them more often.

However, the survey also revealed that among PCPs who discussed surgery options with their patients, 22% reported not being comfortable having those conversations, 17% reported that they did not have the necessary knowledge to do so, and 18% reported that they lacked the confidence to do so.

Similar findings were seen across the other 2 treatment options. Sixteen percent of PCPs who discussed radiation with their patients reported that they were not comfortable having those discussions, 9% reported not having the knowledge to help with these discussions, and 14% reported that they lacked the confidence to do so. Among PCPs who discussed chemotherapy with patients, 25% reported not being comfortable, 9% reported not having the knowledge, and 16% reported not having the confidence to help with these decisions.

Reflecting on these findings, the researchers emphasized the need for efforts to better communicate with PCPs and to educate them about the specifics of cancer treatments.

REFERENCES:

1. Wallner L, Li Y, McLeod M, et al. Primary care provider-reported involvement in breast cancer treatment decisions [published online February 1, 2019]. Cancer. doi: 10.1002/cncr.31998.
2. Some primary care providers not prepared to help with cancer treatment decisions [news release]. Ann Arbor, MI: Michigan Medicine; February 12, 2019. newswise.com/articles/view/707938/?sc=sphr&xy=10023599. Accessed March 18, 2019.

Treatment Advances Avert More Than Half a Million Breast Cancer Deaths Over 3 Decades

As many as 614,500 breast cancer deaths have been averted since 1989, according to a new study.¹ This figure can be attributed to greater usage of preventive screening measures as well as advancements in treatment.

Beginning in 1969, the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program have annually gathered data on the frequency of breast cancer and associated mortality rates in the United States. It was observed that these rates among afflicted women increased 0.4% annually from 1975 to 1990. It was then found that mortality rates began to decrease 1.8% per year from 1990 to 1995, 3.4% from 1995 to 1998, and 1.8% from 1998 to 2015. Cumulatively, breast cancer mortality rates among females between the ages of 40 and 84 years dropped by 41.6% from 1989 to 2015.

The authors applied age-adjusted population and mortality rate data from the SEER program to predict the total amount of breast cancer deaths avoided by preventive screening and advancements in treatment from 1989 to the present. Four different assumptions about background mortality rates were applied to approximate deaths avoided for women aged between 40 and 84 years. These assumptions included an increase of 0.94% per year in the absence of screening or treatment, an increase based on the trend from 1979 to 1989, an increase of 0.4% per year based on what was observed from 1975 to 1990, and a flat mortality rate since 1989. The approximations were calculated by measuring the difference between SEER-reported and background mortality rates for each 5-year age group then multiplied by the population for each group.

SEER data were used to project total yearly breast cancer deaths deterred in 2012 and 2015, and estimated SEER data were used to evaluate deaths avoided in 2018. Research conducted by the authors has shown the total number of breast cancer deaths prevented since 1989 ranged from 237,234 to 370,402 in 2012, from 305,934 to 483,435 in 2015, and from 384,046 to 614,484 in 2018. Applying the same assumptions to the approximated amount of total lives saved in a single year, data show these numbers fall between 20,860 and 33,842 in 2012, between 23,703 and 39,415 in 2015, and between 27,083 and 45,726 in 2018.

Breast cancer mortality rates steadily increased prior to 1990, according to the data. In the 1980s, advances in treatment, including chemotherapy and hormonal therapy, entered clinical practice. It is estimated that together they were successful in reducing mortality rates by 1989.

During the same time period, physicians began to advocate that early detection was also crucial for saving lives. As a result, screening mammography grew in popularity and became more broadly clinically practiced. While the long-term benefits of mammography were shown to be invaluable in the saving of thousands of lives, those benefits did not accrue immediately. Research involving randomized controlled trials showed that preventive screening “require[d] 5 to 7 years to demonstrate an evident mortality reduction due to the longer interval between screen detection and prevented death.” The prevalence of mammography screening has drastically fluctuated since its inception. Data released by the CDC’s National Health Interview Survey show that in 1987, 29% of women aged more than 40 years participated in screening within a 2-year window. The same survey reported that mammography was at the height of its popularity in the year 2000, at 70%, then alarmingly fell to 64% in 2015. Presently, only about half of women aged more than 40 years receive recommended screening mammography.

“The best possible long-term effect of our findings would be to help women recognize that early detection and modern, personalized breast cancer treatment save lives, and to encourage more women to get screened annually starting at age 40,” R. Edward Hendrick, PhD, of the University of Colorado School of Medicine and one of the study’s authors, said in a statement.

REFERENCE:

Hendrick RE, Baker JA, Helvie MA. Breast cancer deaths averted over three decades [published online February 11, 2019]. Cancer. doi: 10.1002/cncr.31954.