Metastatic Lung Cancer
Differences of opinion : a survey of knowledge and bias among clinicians regarding the role of chemotherapy in metastatic non-small cell lung cancerRoss R. Jennens Study objectives: To quantify clinician knowledge and bias regarding the role of chemotherapy for stage IV non-small cell lung cancer (NSCLC).
Design, setting, and participants: A 16-question, multiple-choice questionnaire was sent to all Australian general internists, pulmonary and palliative care physicians, medical and radiation oncologists, and thoracic surgeons to assess beliefs concerning the role of chemotherapy in metastatic NSCLC. An overall assessment of "pessimism" and "optimism" regarding the role of chemotherapy in metastatic NSCLC was made, and knowledge of specific outcome measures was evaluated.
Measurements and results: A total of 1,325 questionnaires were mailed, with 679 replies (51%) received and 544 replies (41%) assessable. Overall, 60% of respondents were deemed to have good knowledge. There was a wide variation in knowledge between specialist groups (p < 0.0001), with more medical oncologists (76%) but fewer thoracic surgeons (35%) and general internists (50%) with good knowledge. Fewer medical oncologists (6%) were classified as pessimistic compared with palliative care physicians (31%), radiation oncologists (28%), or pulmonary physicians (22%). Sixty-eight percent of respondents agreed that most patients receiving chemotherapy have symptomatic improvement. More medical oncologists (77%) and pulmonary physicians (73%), but fewer general internists (55%) and palliative care physicians (57%) agreed with this. Medical oncologists were far more likely to agree that chemotherapy was of benefit in patients aged [greater than or equal to] 70 years compared with any of the other specialist groups.
Conclusions: There were significant differences regarding the perceived role of chemotherapy in metastatic disease between the various specialty groups involved in the treatment of NSCLC. Many clinicians had a poor understanding of contemporary data regarding the use of chemotherapy in metastatic NSCLC. This study raises substantial issues regarding the beliefs of clinicians treating NSCLC and emphasizes the importance of multidisciplinary assessment.
Key words: attitudes; clinical practice patterns; non-small cell lung cancer; physician knowledge; prognosis; questionnaire
Abbreviations: BSC = best supportive care; ECOG = Eastern Cooperative Oncology Group; NSCLC = non-small cell lung cancer; PBC = platinum-based combination chemotherapy; PS = performance status; QOL = quality of life
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Lung cancer is the most common cause of cancer morality in Australia, with almost 8,000 new cases diagnosed in 1999, accounting for 19% of all cancer-related deaths. (1) The role of chemotherapy in metastatic (stage IV) non-small cell lung cancer (NSCLC) has evolved rapidly over the past decade. Older trials (2) using alkylating agents showed a detrimental effect on survival, contributing to a sense of pessimism regarding chemotherapy among clinicians treating NSCLC. However, the introduction of newer agents has resulted in level 1 evidence supporting a survival benefit from platinum-based combination chemotherapy (PBC) regimens compared with best supportive care (BSC). (2-4) Although the use of chemotherapy in this setting appears to be increasing, only a subset of potentially suitable patients ever receive chemotherapy. (5) This may be because of patient preference or unsuitability that may be due to severe illness or comorbidities, but it is possible that some patients who could benefit from chemotherapy may not receive it because of physician bias.
Clinicians in the United States have previously been surveyed to assess their perceptions and beliefs regarding treatment options in NSCLC. In 1998, Perez (6) reported significant variation between specialities regarding the use of chemotherapy for metastatic NSCLC, with the majority recommending only supportive care, except for medical oncologists who predominantly recommended chemotherapy. Schroen et al (7) surveyed pulmonologists and thoracic surgeons in 2000, and reported only one third of respondents believed chemotherapy conferred a survival benefit in stage IV NSCLC. Surveys (8,9) of clinicians in the mid-1990s in Italy and the United Kingdom showed a similar wide range of beliefs and a low use of chemotherapy for metastatic NSCLC.
No surveys have previously been reported specifically assessing clinician beliefs regarding the management of metastatic NSCLC. We hypothesized that there is a diverse range of beliefs between specialist groups, and thus sought to assess and quantify these beliefs.
MATERIALS AND METHODS
Participants and Questionnaire Tool
A 16-question, multiple-choice questionnaire (see "Appendix") was sent to all Australian consultant general internists (physicians), pulmonary and palliative care physicians, medical and radiation oncologists, and thoracic surgeons. Eligible clinicians were identified by the databases of the Internal Medicine Society of Australia and New Zealand, the Thoracic Society of Australia and New Zealand, the Australasian Chapter of Palliative Medicine of The Royal Australasian College of Physicians, the Medical Ontology Group of Australia, the Faculty of Radiation Oncology of the Royal Australian & New Zealand College of Radiologists, and the Royal Australasian College of Surgeons, respectively. Trainees and clinicians not in active practice were excluded.
The questionnaire included demographic data and an estimate of the number of patients with lung cancer seen annually. Questions to assess clinician knowledge of survival and response rates to PBC for metastatic NSCLC were asked, along with assessment of beliefs regarding the role of chemotherapy for symptom relief and in certain subgroups of patients.
The questions were designed by consensus opinion of a group including representatives from the disciplines of medical oncology, radiation ontology, pulmonary medicine, and thoracic surgery. The questions were specifically focused on chemotherapeutic management of stage IV NSCLC. Completed questionnaires were analyzed if they were returned within 6 weeks after mailing. Respondents were deemed assessable if they worked in clinical practice with adult patients and saw at least one patient a year with metastatic NSCLC.
Statistical Analysis
Data were analyzed comparing beliefs regarding chemotherapy and clinician characteristics. The results were analyzed using Pearson's [chi square] test with a two-sided analysis and deemed statistically significant if p < 0.05. To allow for multiple pairwise comparisons between specialist groups, comparisons were only considered statistically significant when using the procedure of Benjamini and Hochberg. (10) Statistical analysis was performed using computer software (Microsoft Excel 97: Microsoft; Redmond, WA).
An assessment of "knowledge" regarding survival and response rate was prospectively defined based on the summation of five answers, scoring 1 point for each correct answer. Consultants were deemed to have "good" knowledge if they scored [greater than or equal to] 3. Correct answers were determined from recently published, large-phase III trials and meta-analyses. (2-4,11-15) The correct answers, for a patient with newly diagnosed metastatic NSCLC who is otherwise well and of Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 to 2 are as follows: median survival without PBC, 3 to 6 months; 1-year survival without PBC, < 15%; median survival with PBC, 7 to 11 months; 1-year survival with PBC, 31 to 45%; and objective response rate to PBC, 15 to 30%.
The summation of seven answers was prospectively defined to produce an overall assessment of "pessimism" or "optimism" regarding the role of chemotherapy in metastatic NSCLC. Points were awarded for each answer from -2 for a very pessimistic response, through +2 for a very optimistic response (Table 1). Respondents were considered pessimistic if their total score was [less than or equal to] -3, and optimistic if [greater than or equal to] +3.
RESULTS
A total of 1,325 questionnaires were sent. Of the 679 replies received (51%), 544 respondents (41%) were assessable. Demographics are detailed in Table 2.
Overall, 325 of the 544 respondents (60%) were deemed to have good knowledge regarding survival and response rate data for patients with metastatic NSCLC (Table 3). Paired comparisons showed more medical oncologists had good knowledge (76%) compared with thoracic surgeons (35%, p < 0.0001), general internists (50%, p = 0.0001) or pulmonary physicians (56%, p < 0.001). The percentage of clinicians with good knowledge was not statistically different (p = 0.28) between those who saw < 10 patients per year (57%), 10 to 30 patients per year (61%), or > 30 patients per year (63%). The questions pertaining to 1-year survival estimates were most frequently incorrect, with only 37% of respondents selecting the correct 1-year survival rate with chemotherapy, and 48% selecting the correct 1-year survival rate without chemotherapy.
Of the 544 assessable consultants, 104 consultants (19%) were classified as "pessimists" (Table 4), with marked variation between specialist groups (p < 0.001). Paired comparisons between specialist groups demonstrated significantly fewer medical oncologists were deemed pessimistic (6%), compared with palliative care physicians (31%, p < 0.0001), radiation oncologists (28%, p < 0.0001), or pulmonary physicians (22%, p < 0.001). Of the 104 clinicians classified as pessimists, the questions which most frequently produced pessimistic responses were as follows: the belief that 1-year survival with PBC is < 30% (90 clinicians [87%], of whom 40 clinicians [38%] believed 1-year survival with PBC is < 15%), and the belief that 1-year survival with PBC is similar or worse than without PBC (86 clinicians [83%]).
Overall, 106 of the 544 respondents (19%) were classified as overly optimistic (Table 5), with significant variation between specialist groups (p < 0.001). 39% of thoracic surgeons were optimistic, significantly more than palliative care physicians (9%, p < 0.002), radiation oncologists (11%, p < 0.001), or pulmonary physicians (16%, p < 0.004). There were also more optimists among the general internists compared with radiation oncologists (28% vs 11%, p < 0.004).
The number of respondents who were classified as optimistic or pessimistic was analyzed according to other demographics. There was no difference when stratified by number of patients with NSCLC seen, age of consultant, or city vs rural/regional practice. Doctors who worked in private practice were more likely to be optimistic than those who worked in the public system (all public, 16%; mostly public, 18%; mostly private, 24%; all private, 28%; p < 0.05).
In total, 364 of the 544 assessable specialists (68%) agreed that most patients have symptomatic improvement from chemotherapy (Table 6), with significant variation between specialist groups (p = 0.003). Fewer general internists agree with this statement (55%) than medical oncologists (77%, p < 0.001) or pulmonary physicians (73%, p < 0.002). Also, fewer palliative care physicians (57%) agreed with this statement than medical oncologists (77%, p = 0.01). Clinicians who saw > 10 patients with lung cancer per year were more likely to believe in the palliative benefit from chemotherapy compared with those who saw < 10 patients (72% vs 60%, p < 0.05).
There were 118 respondents (24%) who believed chemotherapy is the largest portion of treatment expense in metastatic NSCLC. A higher proportion of radiation oncologists (42%), but fewer pulmonary physicians (14%) and medical oncologists (15%) believed this.
Regarding the belief that chemotherapy is not useful for patients aged > 70 years, 154 of the 544 respondents (29%) agreed (Table 7). A striking difference was noted with far fewer medical oncologists agreeing with this statement (8%) compared with all other specialty groups (p < 0.0001). Higher proportions of general internists (41%) and palliative care (50%) physicians did not feel chemotherapy was useful in patients aged > 70 years. Fifty-two percent of consultants agreed that chemotherapy is not beneficial in patients who are ECOG PS 2, and there were no statistically significant differences between any of the groups of specialists (Table 7).
DISCUSSION
There were significant differences of beliefs regarding the role of chemotherapy in metastatic NSCLC between the various specialty groups. Significant heterogeneity between specialist groups suggests that level 1 evidence supporting the use of PBC regimens in patients with metastatic NSCLC who have an ECOG PS [less than or equal to] 1 to improve survival and quality of life (QOL) (2-4) has not been accepted or understood by all specialists involved in the treatment of NSCLC.
Knowledge scores were higher among medical oncologists than other specialist groups, which likely reflects a good understanding of the role of chemotherapy by the specialists who prescribe it and discuss its role with patients. However of concern was that 24% of medical oncologists were classified as not having good knowledge, and this group did not differ demographically (for example in terms of number of lung cancer patients seen or clinician's age) compared with the medical oncologists with good knowledge. Fewer thoracic surgeons, general internists, and pulmonary physicians had good knowledge of chemotherapy in the metastatic setting, presumably due to less familiarity with its use.
This study confirms higher levels of pessimism about chemotherapy in metastatic NSCLC among pulmonary physicians, radiation oncologists, and palliative care physicians. Pulmonary physicians and radiation oncologists are frequently the initial specialists consulted by patients with lung cancer, and are often the "gatekeepers" to subsequent referral. Excessive pessimism may result in a negative bias against referral to a medical oncologist, or by presenting to the patient the opinion that chemotherapy is not worthwhile. This has been previously reported in a large US retrospective study of 12,015 patients with metastatic lung cancer between 1991 and 1996, where of the 8917 patients who did not receive chemotherapy, 36% were never assessed by an oncologist. (16) Similarly, pessimism regarding chemotherapy among palliative care physicians may lead to underutilization of palliative chemotherapy to assist with symptom control.
Only 68% of respondents believed that patients receiving chemotherapy for metastatic NSCLC will potentially have improvement in their symptoms. This finding was similar to a US survey (7) of pulmonologists and thoracic surgeons reported in 2000, of whom only 64% believed chemotherapy conferred a palliative benefit. In both studies, this result was influenced by the number of patients with lung cancer seen per year, suggesting that clinicians with more experience treating lung cancer were more convinced by the palliative benefit of chemotherapy. Over the past decade, there have been a number of prospective randomized studies confirming symptom relief and improved QOL with chemotherapy treatments compared with BSC. (11,12,17-23) Based on these findings, the Lung Cancer Guidelines Project by the American College of Chest Physicians concluded that chemotherapy can have a palliative effect on disease-related symptoms and can improve QOL compared with BSC. (3)
Lung cancer is typically a disease of the elderly, and with an aging population, the incidence of lung cancer among those aged > 70 years is rising. (24) Although data specifically addressing the role of chemotherapy for elderly patients with metastatic NSCLC are limited, there is evidence to support its role. The only randomized phase III trial (25) to date comparing chemotherapy to BSC in elderly patients demonstrated superiority of single-agent vinorelbine over BSC, with improved median survival time (28 weeks vs 21 weeks) and 1-year survival (32% vs 14%). Benefit from PBC in the elderly has only been demonstrated retrospectively from subgroup analysis of phase III trials (26,27) that included a percentage of elderly patients. In these studies, age did not influence survival or response rates, and leukopenia and neuropsychiatric complications were the only increased toxicities among the patients aged > 70 years. No increase in life-threatening toxicity or infection rate was observed. Single-agent chemotherapy is currently recommended as standard of care for elderly patients of adequate performance status with metastatic NSCLC. (28-30) Nevertheless, our survey has shown marked differences in beliefs regarding the role of chemotherapy in these patients. This suggests that data supporting its use have been incorporated into medical oncologist practices, but to a lesser extent by other specialty groups, particularly general internists and palliative care physicians.
PS is one of the most powerful predictors of survival in metastatic NSCLC. (31) Patients with an ECOG PS of 0 or 1 are generally considered suitable for chemotherapy, whereas it is not recommended for patients with a PS of 3 or 4. (3) The use of chemotherapy in patients with PS 2 remains controversial, which is reflected by the range of beliefs reported here, with approximately half of specialists from all disciplines believing chemotherapy is not useful in patients with PS 2. Nonrandomized studies (25,32-34) have shown that using reduced doses or a non-platinum-containing regimen can be beneficial in patients with PS 2, but there are insufficient data to recommend chemotherapy routinely in this group of patients. (3)
Beliefs regarding the relative costs of lung cancer treatment were explored. Approximately one fourth of respondents believed that chemotherapy costs were the largest proportion of treatment expense among patients with metastatic NSCLC. This conflicts with available literature identifying hospitalization during the diagnostic and terminal phases as the most expensive portion of lung cancer care. (35-37)
This study has a number of limitations. Firstly, the correct answers regarding survival and response rates were based on published results from large randomized phase III trials. Although the hypothetical patient in the questionnaire matched the patient inclusion criteria of such trials as closely as possible (newly diagnosed, otherwise well, and of good performance status), it does not account for the inherent bias in the selection of patients for clinical trials. Nonmedical factors are important in determining which patients are referred to oncologists, enroll in clinical trials, or receive chemotherapy. (16) A clinician's belief regarding median survival is likely to be a composite of knowledge of available literature as well as clinical experience. For example, patients with metastatic NSCLC initially referred to a palliative care physician may be older, have major comorbidities, or more advanced disease that may shorten survival. This may bias the palliative care physician's perspective regarding median survival of patients with metastatic NSCLC. Judgment based on clinical experience can also impact on a clinician's beliefs, resulting in a different answer without necessarily being incorrect.
Secondly, this survey provides only a brief profile of beliefs regarding chemotherapy in metastatic NSCLC. It does not attempt to address questions concerning management of other stages of NSCLC, the role of radiotherapy, or the impact of the multidisciplinary team approach to lung cancer care.
CONCLUSION
This survey is the first study to specifically assess clinician beliefs regarding the role of chemotherapy for metastatic NSCLC. It demonstrates that 40% of these clinicians (including 24% of medical oncologists) do not have a good knowledge of survival and response rates to chemotherapy, despite consistency of such results in published data over the past decade. There remains a significant degree of pessimism regarding the potential benefits of chemotherapy, particularly among pulmonary physicians, radiation oncologists, and palliative care physicians. Almost a third of respondents did not believe chemotherapy offered symptomatic benefit, and a similar number would not consider chemotherapy for patients aged > 70 years.
The results from this survey highlight deficiencies in knowledge among lung cancer clinicians. Little improvement is seen compared with US surveys from the late-1990s. How is this best addressed? Education must be focused not just on the doctors delivering chemotherapy, but also the referring specialists. Development of guidelines to assist clinicians and the management of patients by multidisciplinary teams may also improve this outcome.
APPENDIX
NON-SMALL CELL LUNG CANCER QUESTIONNAIRE
Please tick the appropriate box
1. Do you work in clinical []1 []2
practice with adult patients Yes No
and see at least one patient a
year with non-small cell lung
cancer (NSCLC)?
If your answer to question 1 is "No," please go to Question 13.
2. On average, how many new []1 []2 []3
patients with NSCLC do you see <10 11-30 >30
each year?
For questions 3-11, estimate your answer based on a newly diagnosed
patient who is otherwise well and has a good performance status (ECOG
0-2, i.e. active for >50% of waking hours).
3. The median survival for []1 []2 []3 []4
patients with Stage IV <3 3-6 7-11 [grea-
(metastatic) NSCLC without months months months ter
chemotherapy is: than
or
equal
to] 12
months
4. The 1-year survival for []1 []2 []3 []4
patients with Stage IV NSCLC 15% 15-30% 31-45% >45%
without chemotherapy is:
5. The median survival for []1 []2 []3 []4
patients with Stage IV NSCLC <3 3-6 7-11 [grea-
with platinum-based months months months ter
chemotherapy is: than
or
equal
to] 12
months
6. The 1-year survival for []1 []2 []3 []4
patients with Stage IV NSCLC 15% 15-30% 31-45% >45%
with platinum-based
chemotherapy is:
7. The objective response rate []1 []2 []3 []4
(percentage of patients 15% 15-30% 31-45% >45%
obtaining [greater than or
equal to] 50% reduction in
tumour size) with platinum-
based chemotherapy in Stage IV
NSCLC is:
For questions 8-11, tick the box that corresponds to your level of
agreement with each statement.
Nei-
ther
Some- agree
what nor Some-
Strongly dis- dis- what Strongly
disagree agree agree agree agree
8. Most patients receiv- []1 []2 []3 []4 []5
ing chemotherapy for
Stage IV NSCLC have
improvement in their
symptoms.
9. For Stage IV NSCLC, []1 []2 []3 []4 []5
the cost of chemo-
therapy is the
largest portion of
treatment expense.
10. Chemotherapy is []1 []2 []3 []4 []5
generally not bene-
ficial in patients
>70 years old with
Stage IV NSCLC.
11. Chemotherapy is []1 []2 []3 []4 []5
generally not bene-
ficial in patients
with Stage IV NSCLC
who are ECOG perform-
ance status 2 (i.e.
symptomatic and
needing to rest for
up to 50% of waking
hours)
12. The percent- []1 []2 []3 []4
age of None <25% 25-50% >50%
patients I
see with
Stage IV
NSCLC whom I
refer for or
give chemo-
therapy to
is:
13. My practice []1 []2
is predomi- Capi- Rural/
nantly based tal Regio-
in the fol- city nal
lowing re-
gion:
14. The basis of []1 []2 []3 []4
my practice All Mostly Mostly All
is: public public pri- pri-
hospi- hospi- vate vate
tal tal
15. My main area []1 []2 []3 []4 []5 []6
of specialty Gene- Respi- Thora- Radia- Medi- Palli-
is: ral ratory cic tion cal ative
medi- medi- surge- onco- onco- care
cine cine ry logy logy
16. My age is: []1 []2 []3 []4
39 40-49 50-59 60
years years years years
or old old or
young- older
er
Table 1--Scoring for Pessimism and Optimism Scores
Variables -2 -1
Median survival without PBC (question 3) Longer * Same *
One-year survival without PBC Higher * Same *
(question 4)
Median survival with PBC (question 5), mo < 3 3-6
One-Year survival with PBC (question < 15 15-30
6), %
Objective response rate to PBC < 15
(question 7), %
Belief that chemotherapy improves Strongly Somewhat
symptoms (question 8) disagree disagree
Rate of referral for/offering None < 25
chemotherapy to (question 12), %
Variables +1 +2
Median survival without PBC (question 3) 2 ([dagger]) 3 ([dagger])
One-year survival without PBC 3 ([dagger])
(question 4)
Median survival with PBC (question 5), mo [greater
than or
equal to]
12
One-Year survival with PBC (question > 45
6), %
Objective response rate to PBC 31-45 > 45
(question 7), %
Belief that chemotherapy improves Somewhat Strongly
symptoms (question 8) agree agree
Rate of referral for/offering > 50
chemotherapy to (question 12), %
* Compared with response for equivalent question with PBC (question 5
and question 6).
([dagger]) No. of categories lower than response for equivalent
question with PBC (question 5 and question 6).
Table 2--Demographics *
General Pulmonary Thoracic
Variables Internists Physicians Surgeons
Total No. identified 298 430 123
Replies 137 (46) 208 (48) 45 (37)
Assessable 101 (34) 166 (39) 31 (25)
NSCLC patients seen per year
< 10 86 22 23
10-30 14 57 52
> 30 1 20 26
Region of practice
Capital city 61 74 94
Rural/regional 38 23 3
Both 1 3 3
Type of practice
Mostly public 61 52 81
Mostly private 37 44 19
Both equally 2 3 0
Consultant age, yr
[less than or equal to] 39 12 24 26
40-49 35 42 35
50-59 37 23 32
[greater than or equal
to] 60 17 10 6
Palliative
Radiation Medical Care
Variables Oncologists Oncologists Physicians
Total No. identified 170 203 101
Replies 111 (65) 115 (57) 47 (47)
Assessable 92 (54) 109 (54) 45 (45)
NSCLC patients seen per year
< 10 20 28 24
10-30 50 43 51
> 30 30 28 20
Region of practice
Capital city 76 82 62
Rural/regional 22 17 38
Both 2 2 0
Type of practice
Mostly public 73 72 87
Mostly private 26 27 13
Both equally 1 1 0
Consultant age, yr
[less than or equal to] 39 37 35 18
40-49 41 42 44
50-59 18 18 29
[greater than or equal
to] 60 3 5 9
* Data are presented as No. (%) or % unless otherwise indicated.
Table 3--Knowledge Regarding Response Rate and
Survival With and Without Chemotherapy for Stage IV
NSCLC by Specialist Group *
Good
Specialist Category No. Knowledge, %
Overall 544 60
Thoracic surgeons 31 35
General internists 101 50
Pulmonary physicians 166 56
Palliative care physicians 45 56
Radiation oncologists 92 67
Medical oncologists 109 76
* p < 0.0001.
Table 4--Pessimism Concerning the Role of
Chemotherapy for Stage IV NSCLC by Specialist
Group *
Specialist Category No. Pessimists, %
Overall 544 19
Medical oncologists 109 6
Thoracic surgeons 31 13
General internists 101 17
Pulmonary physicians 166 22
Radiation oncologists 92 28
Palliative care physicians 45 31
* p < 0.001.
Table 5--Optimism Concerning the Role of
Chemotherapy for Stage IV NSCLC by Specialist
Group *
Specialist Category No. Optimists, %
Overall 544 19
Palliative care physicians 45 9
Radiation oncologists 92 11
Pulmonary physicians 166 16
Medical oncologists 109 23
General internists 101 28
Thoracic surgeons 31 39
* p < 0.001.
Table 6--Belief That Chemotherapy for Stage IV
NSCLC Improves Symptoms, by Specialist Category
(Question 8)
Specialist Category No. Agree, % *
Overall 544 68
General internists 101 55
Palliative care physicians 45 57
Radiation oncologists 92 64
Pulmonary physicians 166 73
Thoracic surgeons 31 74
Medical oncologists 109 77
* No. of respondents who "somewhat agree" or "strongly agree" to
question 8 (p = 0.003).
Table 7--Belief That Chemotherapy for Stage IV NSCLC Is Not Useful for
Patients Aged > 70 Years (Question 10) or ECOG Performance Status 2
(Question 11)
Agree Question p Value
Specialist Category No. 10, % * ([dagger])
Overall 544 29
Medical oncologists 109 8
Thoracic surgeons 31 26 0.0083
Pulmonary physicians 166 27 0.0002
Radiation oncologists 92 34 < 0.0001
General internists 101 41 < 0.0001
Palliative care physicians 45 50 < 0.0001
Agree Question
Specialist Category 11, % *
Overall 52
Medical oncologists 55
Thoracic surgeons 52
Pulmonary physicians 48
Radiation oncologists 52
General internists 53
Palliative care physicians 55
* No. of respondents who "somewhat agree" or "strongly agree" to
question 10 and question 11. Question 10: p < 0.0001; question 11:
p = 0.92.
([dagger]) Compared with medical oncologists for question 10.
ACKNOWLEDGMENT: We thank Associate Professor Richard Fisher for statistical advice, and Mrs. Margaret Hardingham for clerical assistance.
* From the Departments of Medical Ontology (Drs. Jennens, de Boer, and Rosenthal), Respiratory Medicine (Dr. Irving), and Radiation Oncology (Dr. Ball), Royal Melbourne Hospital, Parkville, VIC, Australia.
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* From the Departments of Medical Ontology (Drs. Jennens, de Boer, and Rosenthal), Respiratory Medicine (Dr. Irving), and Radiation Oncology (Dr. Ball), Royal Melbourne Hospital, Parkville, VIC, Australia.
Manuscript received January 7, 2004; revision accepted June 16, 2004.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: permissions@chestnet.org).
Correspondence to: Ross R. Jennens, MBBS, Department of Medical Oncology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; e-mail: ross.jennens@petermac.org
COPYRIGHT 2004 American College of Chest Physicians
COPYRIGHT 2005 Gale Group
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