Communication Is Key for Prioritizing Patients and Personalizing PDAC Care

Tilak Sundaresan, MD

The optimal pancreatic cancer management settings are those that empower patients to speak transparently with their oncologists about their individual needs and goals, which may look different from what their oncologists might expect, such as personal decisions to decline treatment in favor of prioritizing certain quality-of-life (QOL) measures, according to Tilak Sundaresan, MD, and Nicole S. Evans, MD.

In an interview with OncLive^®, Sundaresan and Evans discussed the implications of a retrospective study evaluating reasons for non-treatment among a real-world cohort of patients with pancreatic ductal adenocarcinoma,1 as well as ways that conversations between oncologists and patients may be enhanced to allow for better communication and education on both sides of the diagnosis. They shared the rationale for and findings from this study in another article.

Sundaresan is a medical oncologist and chief of Oncology and Hematology at the San Francisco Medical Center at Kaiser Permanente San Francisco in California. Evans is a gastroenterologist at Kaiser Permanente Southern California in Downey.

OncLive: How has this research changed the way you think about presenting treatment options to patients, and what conversation strategies may be most effective for fostering constructive communication between you and your patients regarding their care?

Sundaresan: The framework I had going into this work once I saw that one-third of patients were not receiving treatment was: How do we reduce that number? How do we go from one-third of patients not getting treatment to like 10% of patients not getting treatment? That’s because my bias as an oncologist who specializes in the management of pancreatic and biliary malignancies. My bias is to treat these patients.

I’ve changed my approach to how I think about this finding. Since a lot of this decision-making is driven by patients, I’m more interested in: How do we not necessarily increase the proportion of patients receiving treatment, but rather, how do we do a better job of understanding why patients are choosing not to receive treatment? What’s driving that decision? Is it a concern about the toxicity of treatment? Is it a concern about how treatment might interfere with their goals and values? If we can better understand that, how can we do a better job of aligning the information we give patients with the things that are most important to them?

This is a paradigm shift happening in oncology more generally. We’ve been thinking about QOL in many respects for some time, but we’ve not done as good a job of having a systematic way of being able to speak to patients about what elements of QOL are most important to them and how the various ways that we can approach treatments directed against the cancer would impact those elements of QOL.

A somewhat analogous evolution is happening in the management of rectal cancer right now. Since the 2023 ASCO Annual Meeting and the publication of the [phase 2/3] PROSPECT study [NCT01515787], we’ve learned that we have ways of de-escalating the intensity of treatment for patients, or at least changing the spectrum of adverse effects [AEs] they experience with various types of treatment. Now, when we see a new patient with rectal cancer, we are forced by our data to have nuanced conversations with them about what specific elements of QOL are most important to them and how we can match their treatment to those different values.

In pancreatic cancer, we haven’t had the chance to have that nuanced conversation in a more systematic way. As oncologists, probably the first question we ask our patients is: What’s most important to you, and how can we align our approach to managing your cancer with your priorities? However, we have the opportunity to be even more systematic about that, producing tools that can help oncologists meet patients where they are and focus on informing patients about the things that are most important to them.

One of my main interests and one of the things I’ve taken out of this study is that shift in how I think about this. My goal now is not what I had started with, which was: What can I do to improve treatment rates in patients with pancreatic cancer in our system? [Now, my goal has changed to]: What can I do to develop a systematic way to empower the conversation between an oncologist and a patient to make an educated decision about whether the patient wants to receive treatment, and if so, what kind?

Evans: In general, when we think about this in a big-picture way, the question is: What conversations are being had with patients, and at what point in their workup and treatment are these conversations happening? An implication [of these findings] is understanding early detection strategies, patient education, and counseling.

Based off this study’s findings, what next steps are planned for research in this area?

Sundaresan: We’re working with some of our colleagues in the Kaiser Permanente Northern California Division of Research who have more expertise about the clinical interview and are designing tools to assist those conversations. For example, we have a colleague [in that division], Melisa Wong, MD, MAS, AGSF, who’s done a lot of great work and is doing some ongoing research evaluating a tool to characterize a patient’s options for treatment in what she calls a best-case, worst-case, most-likely-case scenario. It’s a template that oncologists and patients can use to think through AEs associated with treatment, what treatment could look like, and what no treatment could look like. [This tool would provide] a more structured template to have a conversation like that. We’re thinking about partnering with her to specifically look at this population of patients with pancreatic cancer and better understand whether a tool like that could be useful for pancreas cancer oncologists to have that conversation with patients.

Evans: We thought about some subsequent studies that can be interesting as a follow-up, including doing a survey-based study to understand [patients’] rationale [for declining treatment]. [Our study was] all based on chart review and trying to dig into notes that were written, but there are limitations with that. [Giving] patients the opportunity to answer questions to explain why they’re making that decision in the moment would be interesting.

[We would also like to conduct a] secondary analysis on this nonmetastatic group to better understand their outcomes based upon the extent of their disease. We didn’t necessarily have a good understanding about the anatomic extent of their disease. [We want to] fine-tune some of those data.

Overall, what can those in the oncology community do to better understand patients’ reasons for declining treatment and address individual needs?

Sundaresan: [This research has] been impactful for me because it’s given me insight into my own biases in how I approach patients with newly diagnosed pancreatic cancer. It’s important for us as oncologists to acknowledge that there is this intrinsic bias for us. At the end of the day, we think the most about how to treat patients with cancer-directed therapy, [such as] chemotherapy and all the other tools we have in our toolbox. Understanding that bias is important. It’s going to help me better navigate my conversations with patients and try to be as aware of [my biases] as possible [so I can] meet patients where they are in their decision-making.

Evans: In talking about this with Dr Sundaresan, who is involved in some of these working groups and multi-institutional projects, we talked about how maybe we can incorporate our results and findings [into clinical practice] in a way that would be beneficial. For instance, a working group is looking at standardizing management for nonmetastatic pancreatic cancer. Some of the [standardization measures] would be giving patients a schema right from the beginning of their entire treatment algorithm, including genetics evaluation and nutrition consultation, standardizing everything and laying it out early. Can we also make sure these conversations about understanding treatment rates and the patients’ concerns are [happening] earlier? [This research may spur] a lot of communication-based algorithms for care.

Reference

Sundaresan TK, Evans NS, Gupta S, et al. Treatment rates and reasons for non-treatment in a real-world cohort of patients with pancreatic cancer. J Clin Oncol. 2024;42(suppl 16):e13554. doi:10.1200/JCO.2024.42.16_suppl.e13554