ASCO 2019: Cancer care – what the primary care physician can do
What might improve prognosis of cancer patients aside from new drugs? Maybe an alliance of the oncologist and a patient’s PCP! Why vaccination plans and diabetes prevention matter for patient survival.
Within the first sessions of this year’s ASCO, the topic “Bringing the Primary Care Physician “Back” Into Cancer Care” equally attracted doctors, patient advocates and cancer survivors. The panel consisting of a PCP (Larissa Nekhlyudov, MD, MPH, Brigham & Women’s Hospital) a gastrointestinal medical oncologist (Piyush Srivastava, MD, Kaiser Permanente), an oncologist (Trevor Augustus Jolly, MBBS, University of North Carolina at Chapel Hill) and a patient advocate and two-time cancer survivor (Elizabeth Schiff) discussed three patient cases to demonstrate when and how a PCP is required in the care of a cancer patient.
Cardiovascular risk factors
Many patients who develop cancer have more problems than just their tumors. In fact, a study from 2011 showed that breast cancer patients with stage I or II disease are more likely die from a cause that is not related to their tumor, most prominently from cardiovascular disease (Patnaik et al., Breast Cancer Research 2011). Also for patients with prostate cancer, two other, fairly large, studies implicate that prevalence of diabetes is associated with earlier death (Lee et al., Springerplus 2016, and Nik-Ahd et al., Cancer 2019). For example, in a meta-analysis of 17 cohort studies, pre-existing diabetes was associated with a 29% increase in prostate cancer-specific mortality and a 37% increase in all-cause mortality (Lee et al., Springerplus 2016).
Given that cardiovascular risk factors such as diabetes, obesity or dyslipidemia could be easily addressed in a PCP’s practice, having a PCP being part of the cancer team might help. “Oncologists often are not familiar with hypertension, hyperlipidemia or diabetes. This is why, at this point, I think we need to go after a more collaborative approach that involves the PCP,” says oncologist Trevor Jolly. Larissa Nekhlyudov, a PCP herself, criticizes that this route is frequently not taken in practice: “I recall certain patients which showed a trend of elevated blood sugar for months in their health records that was never addressed. When we then looked at their HbA1c levels, they were already diabetic. Therefore, when you see a patient with signs of pre-diabetes, let their PCP know.”
Sexual impairment and other uncomfortable truths
While patients are often fairly hesitant to bring up the topic with their oncologists, side-effects such as impaired sexual function and osteoporosis are very frequent among patients receiving cancer treatment. “The one thing that is uniformly answered with ‘yes’ on our review assistance form is sexual dysfunction,” oncologist Piyush Srivastava even recounts. “Which means that sexual dysfunction is not just a consequence of estrogen or androgen deprivation therapy.” It might even be difficult to guess how many patients are concerned with problems of sexual health, since, most often, patients seem to not turn to their doctors with this problem. “Men who have gone through this are elated that there is a solution for sexual problems. There is real hesitancy to bring sexual health up with doctors,” recounts patient advocate Elizabeth Schiff. If patients do seek advice from their PCPs, they might need help from their oncologists as well: “Many PCPs are hesitant to address sexual health, also because they do not have a standard solution to this combination of problems, and ask themselves: Can I put this patient on estrogen? Which kind of estrogen? Finally, the usual mantras that we have as a PCP may not apply to these patients. This is where collaboration is most needed,” Nekhlyudov explains.
Beyond sexual health, there is more that patients keep from their doctors. This shows the case of a 60-year old woman with chronic lymphocytic leukemia who has become symptomatic and is considered for therapy with a novel tyrosine kinase inhibitor. Among the factors to be considered in the therapy decision is the elderly husband that she is taking care of. “Sometimes, patients do not disclose key informations about their psychosocial situation to their oncologist, because they don’t want the things in their life to interfere with their treatment plan.” Nekhlyudov explains. “In order for this not to happen, make sure that the patient knows that they can talk to you as an oncologist, the nurse or the PCP,” Jolly suggests. “Sometimes, I turn to cancer care centers for advice when a patient does not have a support system to take care of their life,” Nekhlyudov explains her approach. “They typically have more resources to take care of this.”
Vaccination is an issue for cancer patients
One topic where the PCP is needed is the vaccination of cancer patients. On the one hand, patients that are about to undergo chemotherapy might become more vulnerable to vaccine-preventable diseases. “Therefore, it is important that the PCP advises the oncologist which vaccinations are missing.” Jolly says. On the other hand, mutual communication is required, as for example CLL patients should absolutely not receive live vaccines. Another example is immunotherapy, where overshooting immune reactions are not exactly wished for. “When patients are on immunotherapy, I would not want to vaccinate them – I would not want to be the one who ‘rocks the boat’,” says Nekhlyudov.
Factor time
In sum, both panelists and the audience mostly agreed to a collaboration of oncologists and PCPs for cooperative cancer care. However, many explained they wished they had more time for cancer patients. Also for patients, cancer diagnosis, therapy or follow-up is time consuming. Many see more than just one doctor in each of these phases, as one cancer survivor in the audience explains: “Every few weeks, I have to see my oncologist. Additionally, I regularly have to see my dermatologist, gynecologist and PCP. It is a matter of time” Schiff understands that it is a hard choice between seeing the oncologist and seeing the PCP. “If you’re in active treatment, I would imagine you’d see your oncologist,” Schiff said. “But this is where the communication between the oncologist and the PCP is essential.”
Jolly considers that that seeing several experts might even be beneficial: “I think taking care of patients is playing Jenga; I don’t think that everyone has to take care of everything. Sometimes it’s enough for every provider to just take one of these blocks down. Nobody knows it all. You have to approach it in a collaborative way.”
References
“Bringing the Primary Care Physician Back Into Cancer Care,” presented at ASCO 2019.
Lee J et al. Diabetes and mortality in patients with prostate cancer: a meta-analysis. Springerplus. 2016
Nik-Ahd F et al. Poorly controlled diabetes increases the risk of metastases and castration-resistant prostate cancer in men undergoing radical prostatectomy: Results from the SEARCH database. Cancer. 2019
Patnaik JL et al. Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study. Breast Cancer Res. 2011