Multi-specialty physician perspectives on barriers and facilitators to the use of neoadjuvant therapy for pancreatic ductal adenocarcinoma

Abstract

Presenter: Jordan M Cloyd MD | The Ohio State University Background: Neoadjuvant therapy (NT) is increasingly utilized for patients with localized pancreatic ductal adenocarcinoma (PDAC). Given the importance of completing multimodality therapy on patient outcomes, the purpose of this qualitative study was to characterize physician perspectives on barriers and facilitators to delivering NT. Methods: A purposive sample of surgical, medical, and radiation oncologists (n=9 each) from the state of Ohio participated in semi-structured interviews that explored themes on current indications for, as well as barriers and facilitators to delivering NT for PDAC. The interview script was developed using evidence synthesis, stakeholder engagement, and data from preliminary surveys. Interviews were transcribed and then coded by 3 independent researchers, iteratively identifying themes until saturation was achieved. Results: Participants (n=27) were heterogeneous in specialty, years of experience, practice setting (academic vs community), gender, and geography (Figure). The most commonly cited advantage of NT overall (n=17) was the ability to downstage patients with advanced disease whereas surgeons were more likely than non-surgeons to cite improved patient selection for surgery and ensuring receipt of non-surgical therapies. The main indication for NT was felt to be concern about operative resectability (n=17) whereas surgeons were more likely to believe NT was indicated for all patients (n=7 of 9). The most commonly cited disadvantages and barriers to NT were toxicity from treatment, lack of access, limited evidence and/or protocols, conflicting opinions on treatment approach, and challenges with care coordination and communication among providers. Patient preference for immediate surgery was frequently cited (n=21) as a barrier to NT, but most participants felt that patients eventually understood the treatment recommendation after informed discussion (n=26) and placed their trust in health care providers (n=16). Recommendations to enhance the delivery of NT included improved patient education and navigation, better communication among providers and with patients, and developing better evidence and protocols for NT. Conclusion: In this qualitative study of multi-specialty physicians from diverse practice settings, most physicians agreed on the current indications for and advantages of NT for PDAC. Surgeons were more likely to endorse NT for all patients. In addition to better evidence and protocol standardization, improved communication and care coordination were identified as factors necessary to enhance the delivery of NT.