Addressing Patient Communication Challenges

Addressing Patient Communication Challenges

There is no question that advances in cancer diagnostics and treatment have dramatically improved the cancer care landscape. However, these advances have led to increased costs and more complex treatments, causing oncologists to struggle with the sheer scope of information they’re expected to know and communicate to patients.

For example, should oncologists ask patients about the potential financial burden of their cancer treatment? Should oncologists explain the results of complex genetic tests to patients or turn to specialists? How can oncologists manage patient expectations about targeted therapies and immunotherapies when only a subset of patients responds extremely well (so-called exceptional responders) to treatment?

Three Education Sessions during the 2018 Annual Meeting will delve into these topics, present the latest research, and provide practical solutions.*

Financial Burden of Cancer Care

Dr. Ryan D. Nipp
During the Education Session “Communicating the Financial Burden of Treatment With Patients” on June 3, session Chair Ryan D. Nipp, MD, MPH, of Massachusetts General Hospital Cancer Center, will present the clinician’s perspective on discussing cancer care costs with patients, concerns physicians and patients have about discussing financial issues, and practical strategies to alleviate financial distress.

“Immunotherapies and targeted therapies are new and exciting, but they can also be more expensive than the older treatments such as chemotherapy,” Dr. Nipp said. From 1965 to 2013, the average monthly cost of cancer treatment increased from $100 to $10,000.1 “Although patients with a good prognosis live longer, they may need to take their medications over a longer period of time, which can add to their financial burden,” he explained.

To better understand the financial burdens faced by patients and their families, Gery P. Guy Jr., PhD, MPH, of the Centers for Disease Control and Prevention, will present the latest research on the costs of cancer care, share the publicly available data sources to examine the financial burden, and emphasize the need for more research in this area during his presentation, “Cost in the Era of Targeted Therapies and Immunotherapies for Cancer.”

Studies show that when patients delay or forego care to defray costs, they may experience decreased quality of life, increased risk of depressed mood, and higher frequency of worrying about cancer recurrence.2 However, research also shows that patients want to discuss the financial impact of care with their oncology team.3,4 Therefore, medical organizations, including ASCO, recommend that clinicians discuss the cost of care with patients.

“We need to think of cost information as another piece of informed decision-making, which ultimately empowers patients,” Dr. Nipp said.

Although oncologists can’t be expected to navigate the maze of insurance coverage, just knowing which medications are more expensive than others can jumpstart the conversation. For example, Dr. Nipp may say to a patient, “I have heard this is an expensive medication. Let me know if you have any problems with your insurance coverage or trouble affording this prescription.”

To round out the session, Ellen M. Sonet, MBA, JD, of CancerCare, will discuss several strategies for assisting patients experiencing financial burdens including assessments, referrals, and interventions during her presentation, “Assisting Patients With the Cost Burden of Cancer Diagnosis and Treatment: Next-Generation Sequencing Testing, Off-Label Medications, and More.”

Next-Generation Sequencing

Dr. Ben H. Park
Technology has dramatically improved the pace of genetic testing using DNA. It took more than a decade to sequence the first human genome; now a human genome can be sequenced in 1 or 2 days.

“We have seen a confluence of better, faster, and cheaper next-generation sequencing (NGS) technologies and more targeted therapies approved for cancers,” Ben H. Park, MD, PhD, of the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, said. “However, NGS is a fast-moving target. Although some NGS platforms are now U.S. Food and Drug Administration (FDA)–
approved to screen for many abnormalities, NGS technologies have outpaced FDA-approved therapies and are being used to guide therapeutic decision-making outside of these intended uses.”

Dr. Park will chair the Education Session “Helping Our Patients Understand Molecular Testing and Its Implications” on June 4. He will discuss how academic medical centers and community molecular tumor boards can guide interpretation and analysis of test results and the differences between germline and somatic testing techniques, their limitations, and his recommendations.

“The results from NGS testing can vary significantly depending on the exact test performed and analysis of sequencing data,” he said. “For example, the germline tests we do with a cheek swab specimen only look for heritable mutations, but the tumor tests we conduct predominantly look for mutations within the cancer. Using only one test can result in incomplete information.”

Even when genetic mutations are identified, though, they may not have FDA-approved therapies. During his presentation, “Discussing Test Results: Understanding Actionable and Nonactionable Mutations,” Michael P. Mullane, MD, of Aurora Cancer Care, will discuss how to prioritize actionable versus nonactionable mutations based on different levels of evidence, the challenges of false positives, and the reports that molecular tumor boards provide to referring physicians and their patients.

Finally, Aaron S. Mansfield, MD, of the Mayo Clinic, will discuss treatment recommendations, the identification of FDA-approved therapies, label versus off-label use, clinical trials, and how to identify and prioritize molecular trials during his talk, “Identifying Appropriate Trials for Our Patients and Considering Compassionate Use Programs.”

Communicating Prognosis

Dr. Thomas W. LeBlanc
Shared decision-making requires that patients be informed azbout their prognosis. Although all oncologists talk with patients about what to expect, studies show that more than half of patients with advanced cancer surveyed have inaccurate perceptions of their prognosis and tend to overestimate the likelihood of a cure and their survival.5-7

“Other studies suggest that some oncologists avoid or rarely engage patients in these conversations unless patients explicitly ask about their prognosis,” Thomas W. LeBlanc, MD, MA, MHS, FAAHPM, of Duke University School of Medicine, said. As chair of the session “How Much Time Do I Have, Doc? Communicating Prognosis in the Era of Exceptional Responders,” on June 4, Dr. LeBlanc will set the stage for these topics by presenting research on prognostication involving patients and physicians’ perceptions and biases.

For example, oncologists may be reluctant to communicate a negative prognosis when they have seen even a small number of patients in similar situations do much better than expected. “The research also shows that as oncologists get closer to patients and develop long-term relationships, they become less accurate in estimating patients’ survival,” Dr. LeBlanc said.

Communicating prognosis to patients is further complicated by the fact that only a minority of patients respond exceptionally well to immunotherapies. “Because we can’t predict with any degree of certainty who will respond well, we may further avoid communicating prognostic information,” Dr. LeBlanc said.

During her presentation, “Exceptional Responders, Hope, and Prognostication: Making a Tough Problem Even Tougher,” Jennifer S. Temel, MD, of Massachusetts General Hospital, will discuss the impact of novel immunotherapies on oncologists’ ability to formulate and communicate a prognostic estimate to their patients with advanced disease.

Paul R. Helft, MD, of Indiana University Melvin and Bren Simon Cancer Center, will present various strategies to improve communication skills, including training programs and pairing with palliative care specialists during his presentation, “Necessary Collusion: Prognostic Communication With Advanced Cancer Patients.”

–Christine Lehmann, MA

*Program information updated as of February 22. For session time and location information, please refer to the ASCO iPlanner on the Attendee Resource Center (am.asco.org/arc).