Patient and Provider Experiences With Precision Oncology: Qualitative Descriptive Study at the Department of Veterans Affairs

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Abstract
Background: Precision oncology (PO) improves and extends the lives of patients living with cancer, but multiple studies have documented its underuse in practice. Specifically, studies note a significant lack of PO use within the Veterans Affairs (VA) medical system. A paucity of implementation of PO in oncologic practice poses a significant barrier to providing the most up-to-date guideline-based care. Objective: While several studies have explored determinants of PO use, we sought to contribute to the body of knowledge by additionally focusing on the unique perspectives of patients, as well as conducting a comprehensive study within the VA medical system, the United States’ largest single-payer health care system. We conducted interviews with both patients and providers at multiple VA sites to identify and characterize barriers and facilitators of PO use in clinical care. Methods: Using a qualitative descriptive approach, we conducted semistructured interviews with 17 patients with cancer and 16 oncology providers recruited from multiple VA sites. Cancer types included prostate, gastrointestinal, and lung. Data were analyzed via a team-based coding approach using directed content analysis. Data were coded and then aggregated into themes and mapped to the Theoretical Domains Framework (TDF) and Behavior Change Wheel sources of behavior (Capability, Opportunity, and Motivation) based on the consensus of the study team. Results: The patient sample consisted of 17 all-male veterans seen at VA oncology clinics in 2022. Participants predominantly self-identified as White (n=9, 52.9%) or Black (n=6, 35.3%), and the majority (n=11, 64.7%) held a high school degree or a higher level of education. The provider sample consisted of 16 physicians, all of whom held MD degrees and practiced oncology. The provider sample represented 6 states, was 50% (8/16) female, and participants averaged 14 years in their current position. The overarching theme was the “Precision Oncology Feedback Loop,” which captured the essence of the complex processes involved in facilitating PO care in the VA system. The TDF and Behavior Change Wheel helped categorize findings to identify where issues in the feedback loop could facilitate or generate barriers to care. Conclusions: Our findings expand on the current literature by highlighting both patient and provider experiences across key TDF domains (Environmental Context and Resources, Knowledge, Memory, and Attention). The conceptual model produced by the analysis illustrates the complexities associated with the implementation. Our findings support the design of multilevel interventions that target increased knowledge or education, improved workflow, and ease of communication to enhance PO delivery.

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