Too many clinicians may be practicing under the misconception that pancreatic cancer is not worth treating, despite evidence that survival can be significantly prolonged and quality of life improved, according to Canadian researchers.
Results from a population-based analysis of almost 11,000 Ontario patients who were newly diagnosed with noncurable pancreatic adenocarcinoma from 2005 to 2016 showed that 65% were referred to a medical oncologist and that only 38% received treatment.
These findings are in sharp contrast to the high rates of oncology referral and treatment for other metastatic cancers, say Julie Hallet, MD, of Sunnybrook Health Sciences Center and the University of Toronto, in Ontario, Canada, and colleagues.
Up to 90% of patients with colorectal cancer have a consultation with a medical oncologist and undergo treatment for the disease, the researchers note in a report published online on May 27 in the Canadian Medical Association Journal.
"Our results suggest a possible lack of informed discussion regarding cancer-directed therapy," the authors write.
"Knowing that a patient's initial negative perception of the risks and benefits of chemotherapy is not associated with receipt of chemotherapy, communication and shared decision-making with oncology providers is critical," they add.
Although the researchers say they were encouraged by finding "higher odds of consultation with medical oncology in more recent years," they note that more work is needed.
The first thing that needs to be addressed is "debunking the stigma of pancreatic cancer," Hallet told Medscape Medical News.
Nihilism is a big problem with this cancer. Dr Julie Hallet
"Nihilism is a big problem with this cancer," she said. "Healthcare providers may not think treatment should be offered or do not know that new treatments can provide better outcomes. Patients may be discouraged by hearing words like 'advanced,' 'inoperable,' or 'metastases.' Education is required to improve the understanding of this disease."
Even in a public healthcare system, patient characteristics can have an impact on the information patients receive before making a treatment decision. The study showed that oncologists considered age and socioeconomic status when talking to a patient about treatment.
Oncologists "may be reluctant to provide chemotherapy to older or more socially fragile patients, despite the evidence of benefit," the authors suggest.
Among patients who present with advanced or metastatic pancreatic cancer, 80% are candidates for noncurative management, the researchers note.
In its 2018 guideline update, the American Society of Clinical Oncology recommends that most patients with pancreatic adenocarcinoma receive noncurative management, they point out.
"We could achieve better results by getting more people to an oncologist and better access to best practice treatments right now than with new and often expensive experimental drugs in the future," said Hallet in a statement.
A recent study showed that multimodal therapies, including chemotherapy, radiotherapy, and nerve blocks, can reduce symptom burden and extend median survival for up to 11 months, compared to 6 months with no therapy.
Study Details
Hallet and colleagues found that a patient's being referred to a medical oncologist had more to do with the practice patterns and beliefs of the primary care physician than with a patient's characteristics or access to care.
Primary care physicians should "not prejudge the cancer, the patient performance, or the toxicity of potential therapy," said Hallet. "It deserves a discussion so that everyone has an opportunity to make informed decision regarding therapy."
The analysis also showed that if the initial oncology consultation was with a medical or radiation oncologist, the likelihood of the patient's receiving treatment was significantly higher than if the patient was referred to a specialized surgeon.
However, more than half (56%) of the patients who received treatment were not referred to a medical oncologist.
Oncologists create a barrier to cancer care when they require that a diagnosis be confirmed with a biopsy, Hallet pointed out. This can also discourage physicians and patients from pursuing the consultation.
What is needed, she suggested, is "a path of least resistance" to cancer care, with fewer restrictions and faster appointments.
Oncologists must be careful not to project any negativity about the diagnosis when talking to patients about the pros and cons of therapeutic options. Instead, oncologists should provide objective information and give the patient room to say "yes" or "no," Hallet said.
The study was supported by the Canadian Institutes of Health Research. Hallet has relationships with Ipsen Biopharmaceuticals Canada and Novartis Oncology. Coauthor Sten Myrehaug, MD, has a relationship with Ipsen Biopharmaceuticals Canada and Novartis Oncology. Other coauthors have disclosed no relevant financial relationships.
CMAJ. Published online on May 26, 2019. Full text
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