This study aimed to explore physicians’ knowledge and attitudes regarding CRF, its management, and corresponding clinical practice guidelines. Moreover, its coverage in medical education and training was studied with the aim of deriving suggestions for improvements.
The majority of the physicians felt rather informed and capable of competently counseling patients. Accordingly, in a previous study on the knowledge of HCPs of CRF, physicians had greater knowledge of CRF than other HCPs [24]. Contrary to our results, in a study among HCPs working in palliative care participants did not feel confident in assessing and managing CRF [19]. As only HCPs from in-clinic palliative care were considered in that study, CRF management may be more challenging if patients are limited in mobility [25]. However, even if most of our participants felt rather informed about CRF, a considerable proportion still felt poorly informed.
Most physicians were unaware of any (inter)national CRF guidelines. Among international guidelines, those from the ESMO were best known to participants. National guidelines, which at least partially cover CRF, were more (if not sufficiently) familiar to physicians. Similarly, in a survey among HCPs in Australia CRF-related guidelines were used by less than a quarter in daily clinical practice [22]. Accordingly, the physicians in our study mentioned a lack of time to read the comprehensive guidelines, as well as noticeable gaps in clinical use. This observation is supported by Pearson, et al. [26], wherein HCPs also indicated a lack of practical details and clinical tools in the CAPO guidelines. Additionally, a majority of our participants acknowledged that guidelines implementation requires compatibility with existing procedures, which is also similar to the results of Pearson, et al. [26] However, almost 40% of our participants disagreed with the necessity of guidelines training for effective implementation. It is hypothesized that a lack of time in healthcare is one cause underlying this disagreement. This could further hint at low expectations regarding a single training session and the need for more practical and steady support, such as with the use of pocket guidelines or checklists. However, there are promising results from brief one-time training on CRF guidelines among HCPs [23]. The importance is highlighted by the fact that the completion of advanced training for palliative care among our sample population increased the likelihood of knowing guidelines, which was correspondingly associated with a greater level of perceived knowledge and self-efficacy.
Despite their poor guidelines knowledge, physicians were quite aware of physical activity, exercise, and psychotherapy as being effective interventions to reduce CRF. For physical activity, this is not only discernible in the rating of its scientific evidence but also in a high recommendation rate, including a high recommendation frequency. Even if lower, the recommendation rate for exercise was also acceptable. However, as both physical activity and supervised exercise have highly supporting evidence, exercise should generally be offered as an option in addition to physical activity. Although the evidence ratings in the cohort of psycho-oncologists were similar to those of physicians for the three intervention groups, among psycho-oncologists an even smaller percentage recommended exercise to the majority of their patients, thus indicating a knowledge-to-practice gap [20].
Among physicians a knowledge-to-practice gap was observed regarding psychotherapeutic interventions. Although more than 80% of participants reported of knowing about the efficacy of psychotherapeutic interventions, only half of them recommended them, which is quite alarming. Such reluctance among HCPs has also been reported in a previous study [12]. In conjunction with our results, Senf, et al. [27] reported of positive beliefs among oncologists about the efficacy of psycho-oncology regarding emotional distress in cancer patients, whereas psycho-oncological issues were covered in fewer than every second consultation. Barriers were primarily perceived on the patient side; e.g., patients either refused to talk about emotional distress or refused psycho-oncological counseling [27]. Accordingly, only 28.9% of 4,020 cancer patients in Germany reported of the use of psychotherapy and/or psychological counseling in terms of cancer-related distress [28]. Due to the assumed multiple causes of CRF and its tremendous impact on patients’ quality of life, the reluctance of HCPs to recommend psychosocial interventions, as well as to use these interventions on the patient side, needs to be considered. Psycho-social support should be suggested more often.
Finally, yoga and other mind-body interventions as further promising methods should be generally offered and discussed with patients presenting with CRF symptoms [29–31]. However, as reported in Martin, et al. [12], less than half of our participants recommended those interventions, and likewise seemed to be unsure about the corresponding scientific evidence. Apart from insufficient knowledge, certain (negative) representations of mind-body interventions may be causal for recommending them only to selected individuals, thus resulting in low recommendation rates.
4.1. Clinical Implications
The need for guidelines-orientated training on CRF becomes apparent. As guidelines are based on current research, physicians may rely more easily on the provided information due to increased confidence. Participants themselves called for more opportunities to participate in CRF workshops. Those should offer information on CRF in a broader theoretical context, e.g., being covered in physical and psychosocial long-term effects of cancer (treatment) and in an interprofessional setting. Comprehensive patient information about the etiology of CRF and local treatment options may further help HCPs in counseling. Overall, physicians need to be encouraged to devote more attention to the management of CRF.
4.2. Study Limitations
This is the first study in Germany investigating CRF knowledge among physicians and their perspectives on current CRF management. Due to various approaches employed in recruitment, we could invite physicians working in different care settings throughout Germany to participate in the study. Nevertheless, the abandonment of random sampling at one point during the recruitment process (due to the fact that physicians were too hard to contact) can be seen as being limiting to our study results. Moreover, a selection bias cannot be ruled out. It is reasonable to hypothesize that participants in this study were more interested in the topic and thereby more knowledgeable than the average physician in Germany. Consequently, the identified lack of knowledge, as well as the knowledge-to-practice gap, may be more pronounced outside of this sample. The small size of some subgroups, such as in workplaces, further prevented more comprehensive analyses. However, due to the significance of rehabilitation facilities in CRF management, it may be of interest to explore more precisely the CRF-related knowledge of physicians in rehabilitation.