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Radiation oncologists not always included in treatment-related decision making for breast cancer
A substantial minority of radiation oncologists are not included in the decision-making process for breast cancer treatment, a survey of breast cancer surgeons and radiation oncologists indicates.
Their exclusion may be leading to an increase in mastectomies compared with breast-conserving therapies, researchers suggest.
“Ultimately, the findings of this study serve to highlight a potential area for quality improvement in breast cancer care,” Reshma Jagsi, MD, DPhil, an assistant professor of radiation oncology at the University of Michigan Medical School, and colleagues wrote. “Despite the widespread availability of tumor boards for care discussion, a substantial minority of radiation oncologists indicated a problem with other providers failing to include them in the decision-making process early enough.”
The researchers surveyed radiation oncologists and surgeons to assess where they differed in their treatment attitudes. Participants had treated patients diagnosed with breast cancer in Detroit and Los Angeles. Researchers received survey responses from 318 surgeons and 117 radiation oncologists.
The survey asked about challenges related to coordinated care, as well as the respondents’ attitudes related to three treatment scenarios.
More than 90% of the participants had access to a group through which specialists could discuss a plan of treatment (ie, a tumor board). Despite this, about 50% of surgeons indicated that few or almost none of the breast cancer patients they saw had been seen by a radiation oncologist before making the decision to undergo surgery. In addition, only about 25% of surgeons reported discussing a majority of their cases with a radiation oncologist. In contrast, 57% of radiation oncologist reported that they discuss treatment plans with a medical oncologist before starting radiotherapy.
When asked about possible treatment scenarios, radiation oncologists were more likely than surgeons to favor the use of radiation in a patient with 3/20 lymph nodes positive undergoing mastectomy (P=.03). In addition, surgeons were more likely than radiation oncologists to favor more widely clear margins after breast conservation survey (P=.001).
When asked to divulge challenges related to multidisciplinary care, 27.9% of radiation oncologists said that getting other providers to include them in the patient’s decision process at an early enough point was their biggest challenge in the previous 12 months.
If efforts are made to increase multidisciplinary involvement in treatment-related decisions, “patients may benefit from exposure to a variety of viewpoints before proceeding with definitive local therapy decisions,” the researchers wrote. “[That would make] their decision-making process more fully informed and potentially more in accord with their underlying preferences.”
Perspective
Back to TopThe report by Jagsi and colleagues highlights several obstacles to true multidisciplinary care at cancer centers. Although this analysis focuses on the lack of breast cancer treatment planning for radiation oncology issues, it is likely that the biases held by different disciplines represent a “cultural divide” and are not easily overcome by the mechanisms of tumor boards, as there is no obligation for every case to be presented or to be formally referred to every discipline.
A true multidisciplinary practice should establish internal standards and clinical pathways that are consistent with current evidence-based guidelines, and — for areas of controversy — should seek to establish and document the rationale for decisions in specific cases. Although disparate beliefs and interpretations of the best practice are likely to persist across disciplines, open discussions and additional activities such as journal clubs can maximize harmonization of care. This takes commitment and time, but it also elevates the quality of care across all modalities.
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