However, workshop participants raised a number of obstacles to achieving patient-centered cancer treatment planning in practice, suggesting that there is much room for improvement. Some of these challenges stem from the patient and include patients' lack of assertiveness, health literacy, and numeracy, and their emotional state and concurrent illnesses. Others were a result of physician limitations, such as a lack of time to explain complex information and a lack of tools to facilitate treatment planning, as well as insensitivity to patients' informational, cultural, and emotional needs. Many participants stressed the variable and often suboptimal communication between the patient and health care provider that may not be culturally or personally appropriate and information overload for the patient or family, without appropriate written documentation of treatment plans, options, and expectations that the patient and family might refer to after a visit. For example, recent studies found that only half of early-stage breast cancer patients knew that patients treated with mastectomy and those treated with lumpectomy have equivalent survival outcomes [16
], and only 11% of patients were able to answer three questions about breast reconstruction correctly [17
]. The lack of decision support tools (such as those embedded within electronic health record systems) was also cited as a barrier to cancer treatment planning, especially given the increasingly complex medical data that health care providers need to consider when making treatment decisions.
In addition, a number of system challenges were emphasized at the workshop, including a lack of financial incentives for providers to devote the time and effort required for patient-centered care planning, the costs of providing patient-centered cancer care, and the fragmentation of the health care system. Many workshop participants stressed that the current reimbursement system for health care does not compensate providers for the time it takes to develop, discuss, and document a treatment plan. Some workshop participants also questioned how the provision of patient-centered cancer treatment planning would affect the already high costs of medical care. For example, one workshop participant said it is difficult to imagine how the additional costs of supporting patient navigation will be borne, given the current economic climate: “To put a new player on the ground, you are going to have to save somewhere, and continuity of care and systems that are organized to realize those cost savings aren't out there right now.” However, others suggested that patient navigation may likely reduce health care costs by averting readmissions and costly errors, and could improve the efficiency and effectiveness of the medical system by fostering low no-show rates, better adherence to treatment regimens, and timely access to medical care before major health complications develop. Several workshop participants called for the inefficiency and waste in the current health care system to be addressed so that resources could be redirected to providing better, more comprehensive, and more coordinated care to patients.
Many workshop participants noted that insufficient coordination of cancer care, which involves multiple specialties, providers, and locations, can also hamper the development of comprehensive treatment plans. A particular coordination challenge is the frequent lack of involvement of primary care providers in cancer treatment planning. The primary care team may know the patient and family better and longer than the oncology team, and may need to be kept abreast of their patient's cancer treatments because it influences how they care for a patient's concurrent illnesses and conditions. Numerous factors that might contribute to that lack of involvement were noted, including inappropriate exclusion by the oncology team, the inability of primary care physicians to devote the time needed to keep up with myriad complex and rapidly changing cancer treatment regimens, and the lack of availability of primary care physicians resulting from workforce shortages. Referral patterns may also hamper coordination between primary care and oncology. Primary care practitioners have a number of referral options to consider when their patient is facing a cancer diagnosis, including cancer centers, community oncology practices, or general surgery, and some workshop participants noted that it can be difficult for primary care practitioners to know which option is best suited to their patient's needs. Similarly, a surgeon may refer a patient to a medical oncologist following surgery, but the patient's primary care practitioner may not be included in this process.