DESCRIPTION (provided by applicant): The goal of this pilot proposal is to design a survey to elicit oncologists' attitudes towards treating patients with advanced cancer. Specifically, we wish to understand oncologists' attitudes in two main areas: 1) the role of palliative care in the treatment of any patient with metastatic cancer; and 2) the role, if any, of value in making treatment decisions for patients with metastatic solid tumors who are at the end-of-life (with end-of-life defined by interviewees). The ultimate purpose of this research is thus also twofold: a) to improve patient receipt of timely palliative care, a service that has been repeatedly shown to be of substantial benefit to patients with cancer; and b) to improve the effectiveness of oncologist-oriented value strategies. As this area of inquiry has been little studied in the peer-reviewed literature, and we endeavor to create a high- quality survey that cogently queries oncologists about their attitudes towards caring for patients with metastatic cancer, we begin by conducting semi-structured interviews to understand the domains and items oncologists feel are important in considering value and palliative care. We conduct qualitative analyses of these interviews and use results to inform design of a closed-ended survey. Our future goals include pre-testing this survey with oncologists, and writing a proposal to disseminate this survey to a large sample of oncologists nationwide. Our interest in understanding oncologists' attitudes towards palliative care for patients with metastatic cancer stems from the incongruence that currently exists between research and practice. There is a strong body of evidence indicating that palliative care improves quality of life and reduces symptoms for patients with cancer. The vast majority of cancer specialty societies also recommend early exposure to palliative care for patients. However, despite the strong evidence base and support from the quality-of-care establishment, many cancer patients, both within and outside of VA, do not receive any palliative care, or are provided palliative care so late in the course of disease they are not able to recognize its full benefit. Furthermore, the extent to which oncologists provide palliative care themselves (primary palliative care) is entirely unknown. This proposal aims to understand oncologists' perceptions of palliative care, including whether they consider it to be a useful service, when they prefer to provide it themselves (primary palliative care) versus refer out to palliative care specialists (secondary palliative care), and what they feel is the appropriate timing of palliative care. This proposal also aims to understand the role oncologists feel value should play in the provision of care for patients at the end-of life. In healthcare, value indicates an achievement of patient outcomes proportional to the resources spent to achieve them. As both quality and cost contribute to this definition, it avoids the common pitfall, prevalent in the political landscape, f equating value with simple cost cutting. Value in cancer can be important to evaluate for a number of reasons, not the least of which is the substantial financial difficulties patients face a a result of their cancer-related medical treatment. However, value, and in particular costs, can be a contentious topic; it is for this reason we feel it is ripe for empirical exploration. Additioally, as determining end-of-life itself is debated within the oncologist community, we take this opportunity to query oncologists about their definitions of this stage of life. We believe results from this pilot work, and from the larger proposal work this pilot study will inform, will provide ey sources of information that can be used to improve patients' receipt of palliative care as appropriate, and to improve the effectiveness of oncologist-oriented value strategies. Oncologists are both the gatekeepers to palliative care, either because they provide it themselves or refer patients to palliative care services. They also guide the purchasing of care for their patients. Understanding their attitudes towards caring for patients with metastatic cancer is a vital step in partnering with clinicians to ensure patients receive high-value care tha maximizes their health-related quality of life.

This proposal explores oncologists' attitudes towards treating patients with metastatic cancer. We will query oncologists regarding the role of primary and secondary palliative care in treating patients with metastatic cancer and the optimal timing of each type of palliative care. We will also query oncologists about the role, if any, that value plays in making treatment decisions for patients with metastatic solid tumors who are at the end-of-life (with end-of-life being interviewee-defined). The goal of this pilot proposal is to design a survey that will, through a future VA proposal, be disseminated to a large national sample of oncologists. We begin by conducting interviews with physicians to identify domains and items that are important to oncologists, rather than being investigator-driven. We will analyze interviews and use results to create the closed-ended survey. Results from this body of work can be used to inform strategies to improve patient receipt of appropriate and timely palliative care and to increase the effectiveness of oncologist-oriented value strategies.