Select Excerpts from the Interview with Dr Wolmark

Track 7 (See Figure 1)

DR LOVE: This survey demonstrates that in lower-risk settings, oncologists are more likely to use adjuvant chemotherapy in breast cancer than they are in colon cancer. Any thoughts?

DR WOLMARK: I believe it underscores a disconnect. It underscores a heterogeneity and an inconsistency among oncologists, primarily. It’s not an inconsistency in the benefit for and responsiveness of the tumor in breast cancer as opposed to colon cancer. The philosophy of a medical oncologist specializing in breast cancer is somewhat different from the philosophy of an individual treating colon cancer.

DR LOVE: One of the issues regarding breast versus colon cancer in the lower-risk, node-negative situation is that there is not as much data in colon cancer as there is in breast cancer.

DR WOLMARK: We may not have as much support in the number of patients treated. However, I believe it’s consistent to state that we have no reason, biologically, to assume that low-risk colon cancer will respond or benefit in a different manner than Stage III colon cancer.

You can make the same statement for Stage I and II breast cancer. And yet we haven’t been inhibited by the threshold to be reached before administering chemotherapy in breast cancer, whereas we have been inhibited by that threshold in colon cancer.

I do want to clarify something: I’m not suggesting that every patient who has Stage II colon cancer should receive chemotherapy — it may be that the majority should not. But I do believe that the patient has to be an integral part of the decision-making process. The patient should be provided with an opportunity to participate in determining whether he or she will receive chemotherapy.

Track 8 (See Figure 7a)

DR LOVE: It’s challenging to understand the mindset of someone who’s just been diagnosed with breast cancer or colon cancer. For people without the disease, it’s difficult to comprehend why someone might want to receive chemotherapy for a one percent reduction in relapse rate.

DR WOLMARK: I’m not sure we have to analyze what’s going through their minds, but we do need to assure ourselves that they understand the information we’re presenting.

The stick figure diagrams you used in the survey make it unequivocally clear what the benefit is, and despite that fact, we still see that a significant proportion of patients, even for a one percent absolute benefit in terms of recurrence, would still have elected to proceed with adjuvant chemotherapy.

DR LOVE: It’s also interesting that at the other end of the spectrum, where we presented a scenario with a 10 percent reduction in the absolute chance of experiencing recurrence, 12 percent of people still wouldn’t want chemotherapy in that situation.

DR WOLMARK: Absolutely, and one has to respect that. I believe this information is quite useful.

Track 9 (See Figure 7b and Figure 7c)

DR LOVE: Another goal of this survey was to evaluate what the difference in opinion was between men and women. Some people interpreted the proactivity expressed in the surveys of patients with breast cancer as gender related.

Interestingly, in this survey of people with colorectal cancer, we really didn’t see a difference in the responses between men and women.

DR WOLMARK: I was struck by that result, but I wasn’t surprised by it. Certainly, these are data rather than speculation, and there does not appear to be a large difference between the responses or preferences of men versus women. You didn’t find any disparate preference relative to age. That’s all comforting, supportive and meaningful information.

DR LOVE: Another interesting observation is that these were patients who had received adjuvant chemotherapy, and there wasn’t a large difference between patients who did and did not receive oxaliplatin, which potentially brings additional side effects and toxicity.

DR WOLMARK: I would have expected a difference, yet there was none. So again, I think we have to listen.

Track 9 (See Figure 8)

DR LOVE: We also surveyed 150 randomly selected medical oncologists and 24 researchers in gastrointestinal cancer. We presented exactly the same scenarios that we presented to the patients and said, “What fraction of patients do you think would want to be treated in this situation?” Now, they’re considering every patient they might see in their practice.

The kinds of people who might have come into this type of survey might have been atypical in some respect. Yet, in any event, the clinicians’ predictions anticipated a much lower willingness to undergo therapy than what the patients expressed. What were your thoughts on that?

DR WOLMARK: I wasn’t surprised, but a consistent trend is evident — that regardless of whether they are medical oncologists or clinical investigators, they underestimate the desire of their patients to proceed with chemotherapy. You showed this in your previous study, and I believe you’ve shown it again here.

Track 10 (See Figure 9a, Figure 9b and 9c)

DR LOVE: The other interesting and unexpected finding from this survey relates to the patients’ experiences compared to what they expected. We interviewed seven patients and a few spouses for our audio program, and I started to hear a consistent story in the interviews that was reflected in the survey.

This was expressed in statements like, “They told me I wasn’t going to experience nausea, vomiting and hair loss, but then I talked to my aunt, who underwent chemotherapy, and she was really sick and lost all of her hair,” or, “My friend had chemotherapy...”

In fact, more than half of the patients went into this expecting to experience nausea, vomiting and hair loss and then were surprised that the symptoms didn’t appear.

DR WOLMARK: I believe that’s useful information that we can share with patients for whom we’re contemplating chemotherapy, as a tool to put these percentages into proportion and tell them, “This is what other patients who have received chemotherapy thought of the toxicity.”

We overestimated the impact of nausea, vomiting and hair loss, just as you point out here, and we underestimated the neurotoxicity in that patients thought the neurotoxicity was worse than what they had expected. That’s useful information for patients who are faced with making the decision of whether to go forward with it.

DR LOVE: My hypothesis, too, is that “Aunt Nellie” might have received AC for breast cancer, which doesn’t cause neurotoxicity but does cause alopecia and potential GI toxicity.

The patients might be receiving a lot of information, perhaps in the oncologists’ waiting rooms, that’s being transferred around.

DR WOLMARK: Our trial data can talk about “an eight percent incidence of Grade III neurotoxicity,” but what does that actually mean? Obtaining feedback from patients who’ve received the same regimen, I believe, could be helpful to other patients.

Track 11 (See Figure 10)

DR LOVE: We also asked the patients to grade the care they received from their oncologists using an A through F system. Again, the types of people who participated in this survey may not be representative of people in practice, but ninety percent or more of the oncologists received As or Bs for overall care.

However, when we asked specifically about providing information, approximately one quarter of these patients weren’t happy with the information they were receiving. They graded the doctors with a C or worse.

DR WOLMARK: The fact that patients were happy and awarded high marks to the medical oncologists is gratifying. When we hear some of the reports as to how well we’re doing, particularly from entities outside of the medical profession, it is reassuring to have that objective information.

I believe the fact that the vast majority gave high marks overall is important. The next issue becomes a matter of how we fine tune our methods so that we can relay the additional information to patients in a meaningful manner.

DR LOVE: I wonder whether oncologists underestimate how much competing information is reaching patients, particularly through the Internet and talking to people, including other patients, and that people receiving huge volumes of information want more out of their oncologists.

DR WOLMARK: Perhaps it’s a matter of wanting information specifically tailored to their personal situations, because the survey indicates that patients respect their physicians as capable individuals.

I believe the medical oncologists want this as much as the patients do. Oncologists want their patients to be informed. This discloses areas in which we can do better.

DR LOVE: The patients obviously are tremendously interested in treatment side effects. And one of the things that an oncologist can’t tell them is what it’s like to go through this.

DR WOLMARK: Precisely.

Track 12 (See Figure 11)

DR LOVE: The last thing I want to talk to you about is what the patients said to us about participation in clinical trials. First, most of these patients did not receive information about participating in clinical trials, but they listened to our audio program in which we discussed clinical trials, and of the people who didn’t receive information, 80 percent would have liked to have received this information.

DR WOLMARK: That underscores the fact that the vast majority of patients are not apprised of clinical trials as an option. In response to the question, “Were you offered participation in a clinical trial as part of your treatment?” most said no.

We have to acknowledge that our great hope that resources would be available to increase participation in clinical trials as a result of the initiatives from the NCI has taken an unfortunate turn. Clinical trials are time consuming.

Medical oncologists who participate in clinical trials have to do so with an altruistic intent, believing that the state of the art will benefit by their participation. We’re not providing the resources and the support to make that something the medical oncologists can do in a practical fashion.

The amount of effort, time and paperwork and the logistic labyrinth required to participate in clinical trials, and a shrinking budget, make this a daunting task.

What we can say candidly to patients is that if they participate in a clinical trial, they will be receiving the highest standard of care, which is mandated prospectively by the protocol document. I sincerely believe that the level of care within a clinical trial is better than the average level of care delivered outside of a clinical trial.

The fact that participating in a clinical trial will further the state of the art, even when an intervention is considerably less of a hurrah than trastuzumab in breast cancer, as undoubtedly most of them will be, is also a great assurance.

If the patient says, “No, I don’t think this clinical trial is for me. I’m not comfortable with the fact that my therapy is going to be decided at random,” you can try to inform that patient that therapy selected at random isn’t necessarily therapy that’s going to put him or her at a disadvantage — quite the contrary.

In the end, you have to respect the wishes of the individual. However, I would like to see them arrive at their conclusion after being informed of the opportunity rather than not being offered the opportunity to participate.

I will always remember one anecdote. We had a panel of patients who participated in NSABP trials, and we asked them, “Why did you participate?”

One individual, a nurse, made quite a poignant remark: “I’ve heard over and over the concern about therapy being selected at random. Well, before I heard about the NSABP protocol, I went to six medical oncologists and heard six different recommendations for treatment. Here, I see with this study that it’s limited to two or three options.” She continued, “You want random, you go out there and poll eight or nine medical oncologists, and you’ll see what random is.”

All the recommended therapies are based on research, and they’re all therapies that I believe are effective — yet they differ from one oncologist to the next.

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