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Family Physician Versus Specialist Care for Breast Cancer Follow-Up

Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

To the Editor:

As two of the physicians (one of whom is a general practitioner with a practice limited to oncology) who recruited patients to the study by Grunfeld et al,¹ we were struck by the irony of the placement of an editorial entitled "Increasing Trial Generalizability"² immediately before the study report. In the study, breast cancer patients approximately 1 year after diagnosis were randomly assigned to follow-up either at a cancer center or with their family physician.

Although the study authors state that their trial had a 58% acceptance rate by patients approached to participate, most readers would not be aware of the degree to which the patients who were approached were already preselected by their oncologist. For example, the study was not even mentioned to patients in our practice who had a high likelihood of early relapse, poor insight into their disease, or a poor compliance record with treatment and/or follow-up. Of the patients with whom the study was discussed, a high percentage either had no family doctor or felt uncomfortable leaving their follow-up in his/her hands. Thus, only a fraction of the eligible patients were formally approached by the study nurse. Although we do not know the exact number of eligible patients at each cancer center, the fact that it took 4.5 years to recruit 968 patients in six regional cancer centers, when approximately 1,000 new breast cancer patients were referred to medical oncology each year at our center alone during the study period, gives some estimate of the degree of preselection that took place.

The results of this study should be reassuring to those patients who, after discussion with their family physician and oncologist, opt to be followed by their family physician. However, we take issue with the statement in the opening paragraph of the editorial by Khatcheressian and Smith³ that the study "...shows conclusively that the health outcomes for women after primary treatment of breast cancer are the same if they are followed by their family physician or cancer center specialists." One can only say that the health outcomes are the same, at least in the first 3.5 years after completion of treatment (the median follow-up interval of this long-term follow-up study), for that small subgroup of patients who are similar to the patients who were enrolled onto the randomized trial.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Grunfeld E, Levine M, Julian J, et al: Randomized trial of long term follow up for early stage breast cancer: A comparison of family physician versus specialist care. J Clin Oncol 24:848-855, 2006[Abstract/Free Full Text]

2. Gotay CC: Increasing trial generalizability. J Clin Oncol 24:846-847, 2006[Free Full Text]

3. Khatcheressian J, Smith T: Randomized trial of long-term follow-up for early-stage breast cancer: A comparison of family physician versus specialist care. J Clin Oncol 24:835-837, 2006[Free Full Text]

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