Would you expect a world-renowned dumpling restaurant to also offer a critically acclaimed baklava? 

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I wouldn’t. 

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It would be highly unusual for a chef to specialize in both kinds of foods. Yet, we expect community oncologists to be experts in all cancer types that walk through their door. One community oncologist in a small group practice attests “I am responsible for treating it all.”  

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In practice, “treating it all” means dealing with 10-15 different types of cancer in a single day while under intense time pressures [1]. If we don’t require a chef to excel in multiple cusines, it is unreasonable to expect a community oncologist to stay abreast of the latest advances in 10-15 different types of cancer, especially given the exponential growth of medical information today. 

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Community oncologists try hard to keep up to date with the tsunami of medical information by reading widely; however, they must focus on the cancers they see most often. The most commonly diagnosed cancers in the US are prostate, breast, lung and bronchus, and colorectal [2]. Since community oncologists are on the frontline of cancer care they also diagnose and treat less common cancer types and even some benign hematology cases. This is especially a challenge for the 10.5% of America’s oncology workforce who are rural oncologists [3]. 

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Despite their best efforts to stay up-to-date, there are a handful of scenarios where community oncologists confront uncertainty. Community oncologists highlighted the following scenarios:

1. When cancer patients exceed second-line or third-line therapy
2. When encountering rare or uncommon cancers
3. When encountering a patient that has an unusual set of comorbidities
4. When new evidence could change the current standard of care

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Below are real-world examples of these scenarios encountered by Primum:

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Scenarios when community oncologists face uncertainty

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Scenario 1: When cancer patients exceed second-line or third-line therapy

A community oncologist from Indiana had a breast cancer patient who relapsed on third-line therapy. He did not have prior experience treating a patient like this, so he consulted the NCCN guidelines. The guidelines did not offer a clear next step. In fact, the guidelines state that the “optimal sequence among options is not known” when an invasive breast cancer patient reaches third-line systemic therapy. [4]

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Scenario 2: When encountering rare or uncommon cancers

A community oncologist from Arkansas recognized she had not previously seen a patient with a particular combination of symptoms and blood work. Lab tests ordered at that time pointed to multiple differential benign hematology diagnoses. Most of these possible diagnoses were outside the typical scope of her practice. 

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Scenario 3: When encountering a patient that has an unusual set of comorbidities

A community oncologist from Florida was curious to know the best treatment for a patient with a cardiac-related comorbidity. The comorbidity would have greatly affected the type of therapy the oncologist could provide, and the oncologist was unsure of the next step in care.

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Scenario 4: When new evidence could change the current standard of care

Data from new papers on DRVd suggest this regimen may be more effective for newly diagnosed multiple myeloma patients than RVd. Multiple community oncologists are curious whether the DRVd data is strong enough for DRVd to displace RVd as the standard of care in this patient population.

This scenario also occurs frequently in solid tumors as advances in precision medicine shift the standard of care for specific patients based on each patient’s tumor genetics.

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So what do oncologists do when they face the unknown? 

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Typically, oncologists take one of three approaches when they face one of the scenarios described above: (1) refer the patient to a specialist, (2) reach out to a friend or colleague via a curbside consult, or (3) make a treatment decision based on online information.

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Referring patients to a specialist is a double-edged sword: it gives the patient access to the latest knowledge, but it delays care while often increasing patient travel and financial burdens. Although referring the patient frees the community oncologist to treat patients with more familiar diseases, it misses an opportunity for professional development and reduces revenue to the practice.

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A community oncologist who engages in a curbside consult seeks advice from their network of mentors and peers regarding a particular patient case. The curbside consult usually occurs within a few days of a request being made via text, call, or email. Unfortunately, not every physician network contains the right expertise for every patient. This is especially true for early career oncologists who have more limited networks.

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Finally, oncologists may leverage online information sources to support their decision-making. Popular sources of information, like the National Comprehensive Cancer Network (NCCN) guidelines and UpToDate, provide detailed information to oncologists. However, while these sources are detailed, they lack the specific context of the patient being treated. Oncologists may use these sources to form a general opinion on the next line of treatment, but printed guidelines are dated the moment they are published.

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Expertise matters when discovering the right solution 

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Every oncologist makes the journey from the uncertain “I think I know how to proceed” to a more confident “I know what to do.” The journey is time-consuming and increasingly complex as cancer care continues to evolve rapidly.

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Primum provides a support network to help oncologists move from “I think” to “I know” quickly and confidently. We connect oncologists with a panel of specialists to attain patient-specific insights that can be implemented in their community. Insights that promise a better outcome for the patients they serve. We want to work together with you to arm community oncologists with the best information possible to care for their patients. Kindly visit us here.

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Sources:

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[1] trapelo, “Dr. Jack West Part 2: Bridging the Gap Between Academic and Community Oncology for Better Precision Medicine Outcomes”, The Precision Medicine Podcast, September 2019. https://www.trapelohealth.com/dr-jack-west-city-of-hope-part-two

[2] Siegel et al., “Cancer Statistics, 2022.” CA: A Cancer Journal for Clinicians, January 2022. 

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[3] American Society of Clinical Oncology. State of Cancer Care in America. Retrieved August 11, 2022, from http://www.asco.org/research-data/reports-studies/state-cancer-care-america

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[4] NCCN Guidelines, “Breast Cancer - Version 4.2022”, National Comprehensive Cancer Network, June 2022. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

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