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Tailored Chemotherapy Information Faxed to General Practitioners Improves Confidence in Managing Adverse Effects and Satisfaction With Shared Care: Results From a Randomized Controlled Trial

Michael Jefford, Carl Baravelli, Paul Dudgeon, Adrian Dabscheck, Melanie Evans, Michael Moloney, Penelope Schofield

From the Supportive Care Research Group, Peter MacCallum Cancer Centre; Division of Surgical Oncology, Peter MacCallum Cancer Centre; Pharmacy, Peter MacCallum Cancer Centre; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

Corresponding author: Michael Jefford, MBBS, MPH, MHlthServMt, PhD, FRACP, Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Locked Bag 1, A’Beckett St, Victoria 8006, Australia; e-mail: Michael.Jefford{at}petermac.org

	ABSTRACT

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Purpose General practitioners (GPs) play a critical role in the treatment of patients with cancer; yet often lack information for optimal care. We developed standardized information for GPs about chemotherapy (CT). In a randomized controlled trial we assessed the impact of sending, by fax, information tailored to the particular patient's CT regimen. Primary end points were: confidence treating patients who were receiving CT (confidence), knowledge of adverse effects and reasons to refer the patient to the treatment center (knowledge), and satisfaction with information and shared care of patients (satisfaction).

Methods Focus group work informed the development of the CT information which focused on potential adverse effects and recommended management strategies. GPs of patients due to commence CT were randomly assigned to receive usual correspondence with or without the faxed patient/regimen-specific information. Telephone questionnaire at baseline and 1 week postintervention assessed knowledge, confidence, and satisfaction.

Results Ninety-seven GPs managed 97 patients receiving 23 types of CT. Eighty-one (83.5%) completed the follow-up questionnaire. GPs in the intervention group demonstrated a significantly greater increase in confidence (mean difference, 0.28; 95% CI, 0.10 to 0.47) and satisfaction (mean difference, 0.57; 95% CI, 0.27 to 0.88) compared with usual care, reflecting a 7.1% and 10.5% difference in score, respectively. No differences were detected for knowledge. GPs receiving the CT sheet found correspondence significantly more useful (P < .001) and instructive (P < .001) than GPs who received standard correspondence alone.

Conclusion Information about CT faxed to GPs is a simple, inexpensive intervention that increases confidence managing CT adverse effects and satisfaction with shared care. This intervention could have widespread application.

	INTRODUCTION

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Many patients with cancer receive treatment as outpatients. This is becoming increasingly common, in part due to improved supportive measures and also due to pressure on inpatient resources. A push toward greater care in the community places increased demand on primary care doctors (general practitioners [GPs] referred to as family physicians in some countries). Many patients have long-established relationships with their GP and may consult them for advice regarding current cancer treatments.^1,2 It is therefore vital that GPs have adequate knowledge of cancer treatments and feel confident managing these aspects of their patients’ care.

Good communication is vital to ensure effective shared care between cancer treatment centers and community doctors.³ Unfortunately, many studies suggest that information provided to GPs is grossly inadequate.^4-12 The literature suggests that GPs wish to receive information about proposed treatments, potential adverse effects, and how to manage these effects; however, frequently do not receive this information.^5,6,10,12 McConnell et al¹⁰ found that 93.4% of GPs wanted information about adverse effects of treatments, 91.5% wished to receive suggestions for management of adverse effects, and 85.8% would like to be informed of indicators for unscheduled review by the oncologist. Actual letters contained this information in 16.2%, 5.1%, and 8.1% of cases.

Pringle¹³ has suggested the reply letter is the "most neglected route of GP education."GPs are receptive to the use of referral replies as sources of learning.¹⁴ Gagliardi et al¹⁴ also note that GPs prefer continuing medical education that is directly related to their clinical work.

GPs appear to have a preference for structured information, relevant to their needs.^15,16 McConnell et al concluded "for GPs, standard information sheets may be included with the reply letter concerning the cancer type, potential side effects of the treatment proposed and recommendations for their management. More than 90% of GPs want this information and less than 20% of oncologist reply letters currently provide any of these details."¹⁰

Because of the strong desire for this information and the important role of GPs, at least in some countries, in the community management of people with cancer,^1,2 we developed information materials for GPs regarding chemotherapy (CT), potential adverse effects, and their recommended management. The information was tailored to the specific type of CT the patient was receiving. The aim of this study was to examine the effectiveness of this information in improving GPs knowledge and confidence regarding the treatment of patients who were receiving CT, and their satisfaction with information provision and the perception of the shared care of the patients.

Hypotheses
GPs randomly allocated to the intervention group (receiving faxed CT information tailored to their patient), would report an increase in: confidence treating patients who were receiving CT; knowledge of CT adverse effects, and satisfaction with information received and the shared care of their patients, compared with GPs receiving the usual correspondence alone (control). Secondary end points included how useful and instructive GPs found the information.

	METHODS

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Ethics Approval/Study Registration
The Human Research Ethics Committee at Peter MacCallum Cancer Centre approved the study. It was registered with the Australian Clinical Trials Registry (number 12606000215527).

Phase 1: Development of Information Sheets
A focus group was held with GPs to determine preferred content and format of the sheets. The group comprised 10 GPs from two suburban practices and was held at the practice location of the Peter MacCallum Cancer Centre GP liaison officer (A.D.). GPs treated patients receiving treatment at the Peter MacCallum Cancer Centre and several other hospitals. The group was facilitated by a behavioral scientist (P.S.) and medical oncologist (M.J.), experienced in conducting groups. A semi-structured interview covered communication between treatment centers and GPs, information about CT, and discussion about the content and format of a suggested covering letter and a suggested CT information sheet. The group was audio-taped and a research assistant (M.E.) took notes. On the basis of these results, sheets were then developed in collaboration with pharmacy staff at the Peter MacCallum Cancer Centre and reviewed by medical (including GPs), nursing and pharmacy staff before approval.

Phase 2: The Trial
Participants were GPs of patients receiving CT at the Peter MacCallum Cancer Centre. Inclusion criteria were: GP of a patient scheduled to commence a CT regimen for which a standard CT sheet was available (sheets were not prepared for patients receiving investigational agents or chemoradiotherapy protocols); agree to be randomly assigned to receive faxed information (or not); agree to participate in two brief telephone surveys; and provide verbal informed consent to participate in this study. GPs could only be recruited once.

Design and Procedure
A convenience sample of 100 GPs was intended. With 50 GPs in each group, there was an 80% power to detect effect size differences of 0.567 or more between the groups. Randomization lists were developed by biased coin procedure. GPs were randomly assigned 1:1 to receive by fax (or not), a cover letter, and CT information sheet relevant to their patients’ regimen. The patient's GP was contacted, advised of the study, and verbal consent obtained. A structured questionnaire was administered by phone. Following this, randomization was revealed. Sequentially numbered, opaque envelopes concealed experimental group allocation from the research assistant until after baseline data collection. GPs randomly assigned to intervention were immediately faxed the letter and CT sheet. The practice was contacted to confirm receipt of information and asked to file it in the patient's record. GPs randomly assigned to usual care received only usual correspondence from their patient's oncologist, whereas GPs randomly assigned to the intervention received faxed information and usual correspondence. All GPs were contacted by telephone about a week (median, 7 days; range, 6 to 15) after the administration of the baseline questionnaire, to participate in a follow-up interview.

Measures
Perceived confidence. Baseline and follow-up questionnaires consisted of purpose-specific items. Perceived confidence in managing CT adverse effects was rated on a unipolar 5-point response scale, from 1 "not at all confident" to 5 "extremely confident". Respondents were asked, "how would you rate your overall confidence in managing patients with:" "nausea/vomiting", "febrile neutropenia", "fatigue", "mucositis", and "diarrhea/constipation" (all sheets covered all of these items). These five items were collapsed into a single mean score at baseline and follow-up. Internal consistency was = .77 (baseline) and .84 (follow-up).

Unprompted recall of knowledge. GPs were asked "can you name possible side effects associated with your patient's CT regimen?" and "under what circumstances would you refer a patient receiving this CT regimen back to Peter Mac for management?" A medical oncologist, blinded to the participant's experimental group, rated responses as correct or incorrect. Correct responses were summed for the two items.

Satisfaction with communication. GPs were asked to rate on a 5-point scale, from very dissatisfied to very satisfied how satisfied they were with the shared care of their patient between themselves and the treatment center and how satisfied they were with the communication they had received from the treatment center about their patient. Although not formally defined in Australia, shared care refers to collaboration between specialists/specialist centers and local health care practitioners. The two items were collapsed into a mean score. Internal consistency was = .73 (baseline) and .89 (follow-up).

Perceptions of correspondence. GPs were asked at follow-up how useful total received correspondence was. The eight items are listed in Figure 1 and were averaged into a single score. The internal consistency of this measure was = .96. In addition, GPs were asked if the information as a whole was: "instructive," "easy to understand," and "the right length."

View larger version (22K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1. Percentage of general practitioners (GPs) who answered either very useful or extremely useful to statements preceded by the stem: can you rate how useful you think the information was in respect to ... ? UC, usual correspondence; CT sheets, chemotherapy sheets.

	RESULTS

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Focus Group
General views regarding communication from treatment centers suggested that information was often received too late and often inadequate. Information frequently did not describe the proposed treatment, potential adverse effects, details of follow-up, or what was required of the GP.

There was broad agreement that it was important to know about treatment intent, names of drugs, potential adverse effects, how to manage these, and when to refer back to the cancer center. It was suggested that, particularly for newer treatments, Internet references might be useful.

Regarding the suggested cover sheet, it was important to know details of the treating doctor, type of cancer, and patient understanding of treatment intent. With respect to CT information, GPs strongly endorsed the single-page format. The preference was that information be sent directly to the patient's electronic medical record, but felt information sent by fax would be acceptable.

Cover Letter
A single page cover letter was developed. This was generic, but contained several patient-specific fields. These included: name of the patient; name of treating doctor; type of cancer; treatment intent (to cure the disease, to increase the chance of long-term, disease-free survival [adjuvant treatment], or to palliate symptoms/improve quality-of-life/extend survival), and type of CT. These fields were recorded in an Excel database (Microsoft Corporation, Redmond, WA) and automatically merged to the letter using mail merge (Microsoft Word; Microsoft). The sheet also included the telephone number of the drug information service at the Peter MacCallum Cancer Centre and listed a number of relevant, reputable Internet sites.

Chemotherapy Sheets
Single-page sheets were developed for 23 CT regimens, used to treat hematologic and solid tumors. Each sheet named component drugs, explained the treatment cycle, listed common adverse effects, and suggestions for management. The sheets also included advice about when to call the Peter MacCallum Cancer Centre, how to contact relevant staff, and had a further information section.

Trial Profile
Figure 2 shows the trial profile. Of 460 patients commencing CT, 141 had GPs that were eligible. Of these, 28 were not approached because the research assistant was not available and 16 refused participation. Of the 97 who consented to participate, 47 were randomly assigned to the intervention condition, and 50 to control. Ten GPs randomly assigned to the intervention condition and six to the control withdrew before follow-up. In total, 81 GPs completed the follow-up questionnaire.

View larger version (31K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 2. Flow chart describing potentially eligible general practitioner (GP) participants and actual involvement in the study. RT, radiation therapy; CT, chemotherapy; UC, usual correspondence.

Sample Characteristics and Success of Randomization and Effects of the Intervention
Overall, there were no significant differences between the two groups with respect to age, sex, overall experience, or oncology caseload (Table 1). Similarly, no significant differences were observed for any of the major outcome variables at baseline. The mean, SE, treatment effect, t value, and P value of each of the main outcome variables are listed in Table 2.

No differences were detected between groups for either knowledge of adverse effects (mean difference, 0.28; 95% CI, –0.33 to 0.88) or awareness of reasons to refer a patient back to the treatment center (mean difference, 0.19; 95% CI, –0.19 to 0.57).

Satisfaction
GPs randomly assigned to the intervention reported a significant increase in satisfaction at follow-up compared with GPs randomly assigned to usual correspondence (mean difference, 0.42; 95% CI, 0.16 to 0.97). This represented a 10.5% difference in score between the groups. A medium effect size was observed (Hedge's g = 0.65).

Perceptions of Correspondence/the Intervention
The average rating of the usefulness of the correspondence received from the hospital, measured across several collapsed items was 4.4 (standard deviation [SD], 0.67) for GPs randomly assigned to the intervention group, and 2.4 (SD, 1.02) for GPs randomly assigned to the control group. This difference was significant (mean difference, 1.94; 95% CI, 1.45 to 2.43; t(50) = 8.0; P < .001; Fig 1).

GPs in the intervention were more likely to agree or strongly agree that information was instructive (96.7% v usual correspondence 42.3%; P < .001), easy to understand (92.9 v 73.1%; P < .005) and the right length (89.3% v 65.4%; P < .001; Fig 3).

View larger version (18K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 3. Percentage of general practitioners (GPs) who answered either agree or strongly agree to statements preceded by the stem: thinking about the information as a whole, did you think the information was ... ? UC, usual correspondence; CT sheets, chemotherapy sheets.

	DISCUSSION

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We found that providing GPs with standardized information relevant to their particular patient, in addition to usual correspondence, improved GPs confidence managing CT adverse effects and their level of satisfaction with the shared care of their patient and with communication received from the treatment center. Compared with GPs receiving usual correspondence alone, those who also received the faxed information were more likely to consider correspondence to be useful, instructive, and easy to understand.

However, the study did not result in increased GP knowledge of CT adverse effects. This may be due to measurement issues. There was variation in the level of detail and precision of GPs unprompted recall of adverse effects and reasons to refer the patient back (eg, febrile neutropenia or progressive cardiomyopathy as potential adverse effects versus generally unwell or malaise). Despite this, responses were all awarded the same score per correct response. Measuring knowledge based on a sum of correct responses may have failed to distinguish responses that were more meaningful than others. That is to say, a response such as "a possible side effect of CT x is febrile neutropenia" might be considered to reflect a greater understanding than "malaise". It might also be that GPs did not necessarily study the CT sheet; rather, using it as a reference if the patient needed assistance. Awareness that useful information was at hand may have mediated GPs confidence in treating patients receiving CT. A further limitation is that the outcome measures do not have proven reliability and validity.

An encouraging observation was that GPs, despite being extremely busy, were keen to participate in the study, as demonstrated by a high response rate. Our belief, borne out by comments from some participants, was that this was because the intervention was timely, useful, relevant to their patient's care, and clinically relevant. We are encouraged to use this strategy in other research studies; for example, in providing GPs with information about survivorship care after completion of cancer treatments, as recommended by the Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition.¹⁷

Others have investigated the effect of providing GPs with additional information about cancer and cancer treatments. James et al¹⁸ reported that GPs found that a general information pack about pediatric oncology helped them to care for pediatric patients with cancer and their families. The authors also reported the pack improved communications between GPs and the oncology department. A study from Denmark assessed the impact of a structured oncology information pack sent to GPs when newly referred patients visited the oncology department for the first time.¹⁹ The pack appeared to improve GP knowledge and GPs felt more confident supporting their patients. Furthermore, GPs’ satisfaction with the oncology department improved. This reflects our findings in terms of satisfaction and confidence, but not knowledge. Notably, however, this study assessed improved knowledge in the intervention group only, and used a single self-report item "did you feel that the information material had improved your knowledge of oncology and intersectional cooperation?"

There are indications that these types of intervention not only improve the perceptions of GPs but also patients. A shared care program between an oncology department in Denmark and GPs included transfer of information between doctors and improved communication processes.²⁰ The program had a positive effect on patients’ perceptions of cooperation between the hospital and community settings. Patients’ perceptions of their GPs knowledge appeared higher for GPs assigned to the intervention group.

The rationale for this study was that the intervention might have a number of potential benefits. Patients may experience improved care as a result of more integrated health care delivery. They might also experience fewer uncontrolled adverse effects as a result of their GP's improved confidence. For GPs, improved information might improve knowledge, confidence, and satisfaction with shared care with the treatment center. For the treatment center, the intervention may lead to fewer unplanned admissions due to inadequately controlled adverse effects, potentially fewer admissions of seriously unwell patients, more rapid triage of patients with life-threatening adverse effects, such as febrile neutropenia, and hopefully also an improved relationship with the GP community. Many of the above benefits remain untested; however, we are encouraged by the positive impact on GPs and the work by Nielsen et al.²⁰

In this study, standard information about CT treatments, potential adverse effects, how to manage these adverse effects, and when to contact the treatment center was developed for GPs. GPs found the information useful and instructive. When evaluated in a randomized, controlled trial, GPs who received this information in addition to usual correspondence, were more confident treating patients who were receiving CT and were more satisfied with the shared care of their patient and with communication received from the hospital. This is an effective, rapid, and inexpensive intervention that should be widely implemented and has the potential to improve outcomes for patients, as well as for GPs and cancer treatment centers.

	AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

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The author(s) indicated no potential conflicts of interest.

	AUTHOR CONTRIBUTIONS

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Conception and design: Michael Jefford, Adrian Dabscheck, Penelope Schofield

Administrative support: Michael Jefford, Carl Baravelli, Adrian Dabscheck, Melanie Evans, Michael Moloney, Penelope Schofield

Provision of study materials or patients: Michael Jefford, Carl Baravelli, Melanie Evans, Michael Moloney, Penelope Schofield

Collection and assembly of data: Michael Jefford, Carl Baravelli, Melanie Evans, Penelope Schofield

Data analysis and interpretation: Michael Jefford, Carl Baravelli, Paul Dudgeon, Penelope Schofield

Manuscript writing: Michael Jefford, Carl Baravelli, Penelope Schofield

Final approval of manuscript: Michael Jefford, Carl Baravelli, Paul Dudgeon, Adrian Dabscheck, Melanie Evans, Michael Moloney, Penelope Schofield

	ACKNOWLEDGMENTS

 
We thank Richard Fisher, PhD, for reviewing the manuscript and all GP participants.

	NOTES

 
Supported by unrestricted educational grant from Roche Products (Australia).

Presented in part at the 43rd Annual Meeting of the American Society of Clinical Oncology, June 1-5, 2007, Chicago, IL.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

	REFERENCES

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1. Kendall M, Boyd K, Campbell C, et al: How do people with cancer wish to be cared for in primary care? Serial discussion groups of patients and careers. Fam Pract 23:644-650, 2006[Abstract/Free Full Text]

2. Williams PT: The role of family physicians in the management of cancer patients. J Cancer Educ 9:67-72, 1994[Medline]

3. Hampson JP, Roberts RI, Morgan DA: Shared care: A review of the literature. Fam Pract 13:264-279, 1996[Abstract/Free Full Text]

4. Westerman RF, Hull FM, Bezemer PD, et al: A study of communication between general practitioners and specialists. Br J Gen Pract 40:445-449, 1990[Medline]

5. Tattersall MH, Griffin A, Dunn SM, et al: Writing to referring doctors after a new patient consultation: What is wanted and what was contained in letters from one medical oncologist? Aust N Z J Med 25:479-482, 1995[Medline]

6. Tattersall MH, Butow PN, Brown JE, et al: Improving doctors’ letters. Med J Aust 177:516-520, 2002[Medline]

7. Stalhammar J, Holmberg L, Svardsudd K, et al: Written communication from specialists to general practitioners in cancer care: What are the expectations and how are they met? Scand J Prim Health Care 16:154-159, 1998[CrossRef][Medline]

8. Newton J, Hutchinson A, Hayes V, et al: Do clinicians tell each other enough? An analysis of referral communications in two specialties. Fam Pract 11:15-20, 1994[Abstract/Free Full Text]

9. Newton J, Eccles M, Hutchinson A: Communication between general practitioners and consultants: What should their letters contain? BMJ 304:821-824, 1992[Abstract/Free Full Text]

10. McConnell D, Butow PN, Tattersall MH: Improving the letters we write: An exploration of doctor-doctor communication in cancer care. Br J Cancer 80:427-437, 1999[CrossRef][Medline]

11. Johansson B, Berglund G, Hoffman K, et al: The role of the general practitioner in cancer care and the effect of an extended information routine. Scand J Prim Health Care 18:143-148, 2000[CrossRef][Medline]

12. Babington S, Wynne C, Atkinson CH, et al: Oncology service correspondence: Do we communicate? Australas Radiol 47:50-54, 2003[CrossRef][Medline]

13. Pringle M: Referral letters: Ensuring quality. Practitioner 235:507-510, 1991[Medline]

14. Gagliardi A: Use of referral reply letters for continuing medical education: A review. J Contin Educ Health Prof 22:222-229, 2002[CrossRef][Medline]

15. Ray S, Archbold RA, Preston S, et al: Computer-generated correspondence for patients attending an open-access chest pain clinic. J R Coll Physicians Lond 32:420-421, 1998[Medline]

16. Dunn DC, Dale RF: Combined computer generated discharge documents and surgical audit. BMJ (Clin Res Ed) 292:816-818, 1986[Abstract/Free Full Text]

17. Institute of Medicine: From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC, National Academies Press, 2005

18. James JA, Harris DJ, Mott MG, et al: Paediatric oncology information pack for general practitioners. BMJ (Clin Res Ed) 296:97-98, 1988[Abstract/Free Full Text]

19. Kousgaard KR, Nielsen JD, Olesen F, et al: General practitioner assessment of structured oncological information accompanying newly referred cancer patients. Scand J Prim Health Care 21:110-114, 2003[CrossRef][Medline]

20. Nielsen JD, Palshof T, Mainz J, et al: Randomised controlled trial of a shared care programme for newly referred cancer patients: Bridging the gap between general practice and hospital. Qual Saf Health Care 12:263-272, 2003[Abstract/Free Full Text]

Submitted October 4, 2007; accepted December 12, 2007.

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