Q&A: The role of PCPs in cancer care

The American Cancer Society estimates there will be approximately 1.8 million new cancer diagnoses and 606,520 cancer-related deaths in the United States this year. As of January 2019, there were about 16.9 million cancer survivors in the country, representing approximately 5% of the U.S. population, according to the National Cancer Institute.

Previous research has shown that primary care physicians often feel ill-equipped to discuss treatment options with patients who have cancer, and there is a lack of understanding on proper long-term care. Further, many oncologists and PCPs disagree on who should ultimately manage care for cancer survivors.

Healio Primary Care recently spoke with Peer Perspective Board Member Martin J. Edelman, MD, G. Morris Dorrance Jr. Chair in Medical Oncology, deputy cancer center director for clinical research and department chair of hematology/oncology at Fox Chase Cancer Center, about common misconceptions of cancer care among PCPs, long-term effects of cancer treatment they should be aware of, and the role of PCPs in cancer and survivorship care.

Q: As a lung cancer expert, what do you want PCPs to know about the management of this disease?

A: The management of lung cancer, as with other solid tumors, is very dependent on the extent and stage of disease, but also increasingly on various molecular markers, particularly in advanced stages.

A patient who has an “inoperable” cancer is not necessarily an incurable patient. In locally advanced lung cancer, which is about 30% to 40% of the 200,000 cases of non-small cell lung cancer in the United States per year, the use of chemotherapy, radiation and immunotherapy has curative potential in 35% to 45% of patients, but it is critical that these patients are assessed by a multidisciplinary team from the beginning. That said, there are essentially no areas of lung cancer therapy where a medical oncologist should not be involved very early on.

In patients with resectable disease, early stage 1 and 2, the use of adjuvant therapy needs to be considered. This clearly improves the rate of cure.

In advanced disease, treatment is becoming increasingly complicated. There are at least eight different targetable mutations, as well as immunotherapy options and various chemotherapy, immunotherapy and targeted therapy combinations and sequences. The toxicities of these approaches are very variable. Patients are frequently able to live full and extended lives now, even with advanced disease. Twenty years ago, the 1-year survival rate was about 20% in advanced disease. Now that’s become our 5-year survival rate.

Q: What are some common misconceptions PCPs have about cancer care?

A: There are any number. To begin with, some believe that all patients who are diagnosed with lung cancer will die, which is clearly not true. There is also a general belief that surgery is uniquely beneficial in cancer. It is one critical mode of treatment, but for localized disease, sometimes radiation is the better option. Even in advanced disease, surgery can play an important role.

There is also the belief that chemotherapy is always an awful experience. No question there are common and serious toxicities, but many of these, including nausea and vomiting, have been substantially controlled with modern supportive care. The most crucial thing for a PCP to know for the newly diagnosed patient is that the patient needs early assessment by a multidisciplinary team, preferably with a specialty interest in that area. Ideally, this should be done before the patient is committed to any treatment.

Q: What is the role of PCPs in cancer care?

A: A lot depends upon one’s particular interest and the amount of time that they have. Once upon a time, I was a general internist. I always say their jobs are somewhat harder than mine because I know that patients walking in frequently have a serious illness, whereas in internal medicine, of the 20 to 30 patients who are seen in a day, you have to identify the one who has a major problem while still dealing with all the other significant issues and management of conditions like hypertension, diabetes, etc.

The PCP plays an essential role in screening. In lung cancer, we know that screening the appropriate population — those 55 years and older with significant smoking histories — with low-dose CT results in improved cure rates. The uptake has been scant — around 10% of these patients undergo screening. So that is an unexploited area.

In addition to screening, the PCP also plays an essential role while the patient is undergoing therapy for their malignancy. Whether it is short- or long-term treatment, patients still have other medical problems that need to be addressed. We should never lose sight of that. If I wave a wand over my patients and take away their lung cancer, most of them will still have COPD or coronary disease because 85% of the patients are smokers, and those things need to be dealt with. The management of those other medical problems doesn’t stop. And knowledge of drugs that oncologists use and how they interact with other drugs is important, but all of this cannot be turned over to the medical oncologist. There must be a partnership in disease management.

Q: What new trends in cancer care should PCPs be aware of?

A: There are any number of new approaches and therapies. The first wave of personalized treatment, which began in the early 2000s with drugs that target specific mutations, has been revolutionary in many malignancies. For the past 5 years, we have seen the dawn of effective immunotherapy which has dramatically changed outcomes for a portion of patients with lung cancer. Coming down the pike are combinations of immunotherapeutics, and hopefully more widespread use of cellular therapeutics in solid tumors instead of just hematologic malignancies. Antibody-drug conjugates, in which an antibody against a surface antigen peculiar to the cancer is coupled with a chemotherapeutic agent, are increasingly being investigated. These agents combine the advantages of targeted agent specificity with the chemotherapeutics toxicity to cancer cells. The targeting of the agent avoids much of the potential toxicity. This class of drugs has been particularly useful so far in breast cancer and lymphomas. All of these developments, along with advances in radiotherapy such as stereotactic therapy and an increasingly aggressive approach towards oligometastatic disease, have changed the game. People are living for very long periods of time, even with advanced disease. People in primary care need to be aware of that because prognosis and treatment approaches are changing at such a dramatic rate, it probably is best to defer much of that discussion to the specialist. For example, as I have already mentioned, we are becoming increasing aggressive in our treatment of patients with one to three areas of metastatic disease (“oligometastatic”) with surgical and radiation procedures, which was not the case before.

Q: What are the long-term effects of cancer treatment? How should PCPs manage these effects?

A: This gets into the issue about survivorship, which is something that I have been interested in for a long time. One of the first papers that I wrote and am most proud of looked at follow-up strategies. Remarkedly little good data exists regarding follow-up testing and what we should or should not do in advanced disease. I think the tendency is to over-image patients. For example, PET scans are way overutilized in follow-up. Professional organizations like the American Society of Clinical Oncology and others have come out with Choosing Wisely guidelines for various scans.

Follow-up strategies must be adjusted for the type of malignancy and the risk and timing of recurrence. For example, if a patient treated with curative intent for limited-stage small-cell lung cancer is going to relapse, it is going to be predominately happen within the first 3 years or so. But after that, they are still at risk for secondary malignancies. Those occur very commonly in patients with heavy smoking histories. There are also issues of other related comorbidities due to tobacco exposure such as COPD and CVD that need to be addressed. The reality is that these patients need to be closely followed for the medical complications of their primary disease and the things that cause that disease, but also the consequences of what happens over time.

There a few things about treatment that are sometimes not well understood. Chemotherapy drugs that we use now have a relatively low risk for secondary malignancies. Many of us were educated in an era where alkylators were in constant and heavy use, and that tended toward this risk for secondary hematologic malignancies — particularly acute leukemias or myelodysplasia, which would occur with 2 to 3 years. That is relatively uncommon with the drugs that are employed in most solid tumors today, though it could still happen.

There are a lot of other issues. For example, a lot of drugs we use in breast cancer — HER2/neu-directed therapies — are associated with cardiac risks. We have very little knowledge or understanding of what will happen in the long term with immunotherapy drugs simply because they have not been used for a long time. All the immunotherapeutics are pretty much associated with a significant incidence of thyroid disease. That usually will develop during the time of treatment but can occur later.

Patients who have received radiation are at a continuous risk for malignancy over time in radiated areas, particularly younger women who have undergone breast radiation. They are at risk for breast cancer over time, but also cardiac risks.

All of these things need to be understood. PCPs should not look at chemotherapy or cancer treatment as a black box. They should understand what each individual drug therapeutic does to the body, and also understand long-term complications of regionalized treatments like surgery or radiation.

Disclosure: Healio Primary Care was unable to confirm relevant financial disclosures at the time of publication.