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Originally published as JCO Early Release 10.1200/JCO.2008.21.4023 on March 30 2009 © 2009 American Society of Clinical Oncology.
"Doc, Should I See You or My Oncologist?" A Primary Care Perspective on Opportunities and Challenges in Providing Comprehensive Care for Cancer SurvivorsDepartment of Ambulatory Care and Prevention, Harvard Medical School; and Department of Medicine, Harvard Vanguard Medical Associates, Boston, MA As a primary care provider, my answer to the question raised in the title of this editorial is simple: a cancer survivor should see a primary care provider. Ask an oncologist or a cancer survivor, and the answers are likely to vary. I have heard my oncology colleagues say that they enjoy "social" visits from their cancer survivors, but at the same time, they are concerned about their full schedules, which do not allow them sufficient time to see newly diagnosed patients. I have heard patients with cancer and their family members question the need to see primary care providers and ask in bewilderment which specialists they should see for their organ-related complaints. Although I have had cancer survivors who have "forgotten" about their prior cancer diagnoses, I have 5-year survivors of early breast cancer who not only see me regularly, but also seek annual visits with their oncologists, radiation oncologists, surgical oncologists, and gynecologists. In light of the growing number of cancer survivors, many of whom are living longer,1 the article by Cheung et al2 addressing survivorship care in this issue of Journal of Clinical Oncology (JCO) is relevant and timely. Cheung et al2 surveyed 255 primary care providers, 123 oncologists, and 431 of their so-called cancer-free patients to compare expectations for cancer survivorship care. The survey asked patients to describe the degree of responsibility that their primary care providers or the oncologists should assume with respect to surveillance of their most recent cancer, screening for cancers other than their primary malignancy, general preventive health, and management of other comorbidities. The physician surveys—sent to the one primary care provider and one oncologist identified by each patient as the main physicians responsible for his or her care—asked physicians to describe their perceived roles in the same four areas. The study included 409 matched patient-oncologist pairs, 233 patient–primary care provider pairs, and 232 primary care provider–oncologist pairs. The study2 found that although patients expected both their oncologists and primary care providers to be involved in surveillance for cancer recurrence and other cancer screening, they expected the oncologists to be primarily responsible for cancer recurrence. Although most oncologists agreed with having a significant role in surveillance for cancer recurrence, about half expected to play a minimal role in screening for other cancers, and about one third expected to share this responsibility with the primary care providers. Most primary care providers expected to be responsible for both screening for other cancers and cancer recurrence, although about one third expected to share this role with the oncologists. Patients clearly preferred their primary care providers to have a major role in general preventive care and treatment of other comorbidities, and did not expect their oncologists to have a significant role in these aspects of care. For the most part, primary care providers and oncologists agreed with their patients. Oncologists and primary care providers agreed that the latter group should have a significant role in treating other medical problems (in fact, 84% of primary care providers expected to have full responsibility). Although oncologists were interested in sharing responsibility for general preventive care with primary care providers, primary care providers expected to have full or most of the responsibility for this aspect of care. The Cheung et al2 findings suggest that patients expect their oncologists, primary care providers, or both to be responsible for their care; that oncologists want to have a role in cancer-related care; and, not surprising to me, that my primary care colleagues expect to have a significant role in essentially all domains of cancer survivorship care. So where do we go from here? What is the role of primary care providers in cancer survivorship care? Whether patients have cancer, congestive heart failure, or diabetes, primary care providers are trained to provide comprehensive care to patients with complex medical conditions.3 Therefore, primary care providers should be best equipped to handle each of the four areas of cancer survivorship care outlined in the Cheung et al2 study. But are they? Great focus is placed on chronic diseases, such as congestive heart failure, diabetes, and end-stage renal disease, in general medical education and residency training. However, aside from the few exceptions likely to emerge, there are no curricula focusing on cancer survivorship. General medical training in cancer focuses on the acute phase and occurs mostly in inpatient settings (although there is some exposure to ambulatory care). In previous studies, although primary care providers expressed an interest in caring for cancer survivors,4 only about half reported being comfortable with having responsibility for surveillance of cancer recurrence.5 Caring for adult survivors of childhood cancers is even more challenging for primary care providers, who typically encounter few such patients in their practice,6 and are likely ill-prepared to handle the numerous potential long-term complications,7 particularly when such patients often lack specific knowledge about prior diagnosis and treatment.8 Yet previous research has shown that a patient who is followed by a primary care provider gets more preventive care than does a patient seen primarily by an oncologist.9,10 Because most cancer survivors are elderly patients,1 primary care providers are likely best equipped to address the comorbidities that are often neglected among cancer survivors.11 A question difficult to raise in JCO is this: should a so-called cancer-free cancer survivor continue to see an oncologist? True, some patients may have formed bonds with their oncologists, who supported them through times of crisis,12 and perhaps want to remain in touch with their oncologists should they need their care again. But does an ongoing relationship with an oncologist affect the care a cancer survivor receives? Snyder et al13 found that 5 years after completion of treatment for colorectal cancer, patients shifted from receiving care from oncologists to receiving care from primary care providers. However, in this shift to primary care, the frequency of cancer screening began to drop, just as the rate of influenza vaccination began to rise. Numerous other studies have found decreases in the rate of mammographic surveillance among patients with breast cancer in the years after treatment.14–17 Whether this is because of less contact with oncologists over time is not clear. Yet in terms of health outcomes, such as recurrence and death, data have shown that at least among breast cancer survivors, there were no differences among those receiving care from their oncologists compared with those receiving care from primary care providers.18 The question of whether specialists can or should provide comprehensive care to patients with complex medical conditions is not unique to cancer,19–22 yet no clear solutions have been found. Perhaps there is a role for a shared model. A previous study10 found that cancer survivors who continued to see oncology specialists were more likely to receive appropriate follow-up mammography for their cancer, but those who were monitored by primary care providers were more likely to receive all other non–cancer-related preventive services. Those who saw both types of physicians received more of both types of services. Although effective models of care for cancer survivors are still being developed, a Cochrane review23 examining the effectiveness of shared care in chronic disease management found no evidence to support this model of care. Acknowledging the projected shortage in the oncology workforce,24 as well as the potential limitations of primary care providers in the future,25 I ask with caution: should primary care providers be charged with all aspects of care for cancer survivors? If so, are there optimal ways to achieve the transition of patients into primary care settings and also improve the care of cancer survivors who are already receiving care in these settings? In a previous study,5 more than half of primary care providers rated the current transfer of care from oncologists to primary care providers as fair or poor. In a qualitative study,26 primary care providers viewed themselves as playing an important role in the post-treatment period and indicated that written care plans for follow-up would help them improve their survivorship practices. The American Society of Clinical Oncology, among other organizations and cancer centers, is actively developing care plan summaries. As a primary care provider, my advice is to keep it simple. Previous literature has shown that physicians typically do not follow guidelines,27 and primary care providers certainly do not need more guidelines to add to their list. In addition, primary care providers probably do not need much information about specific chemotherapy agents used or total dose of radiation administered. However, in the transition, they do need some basic education, guidance, and resources in the following areas: cancer surveillance modalities, intervals, and duration; general and risk-based screening for other cancers; surveillance for and management of treatment-related morbidity, including potential interactions between cancer and noncancer medications or treatments; prevention and risk-modifying strategies, such as diet and exercise; counseling for genetic implications for patients and their families; resources for possible financial and other psychosocial implications of cancer or treatment; and finally, coordination of care, if needed, with whom, and when. The Cheung et al2 study helps us understand the expectations of patients, oncologists, and primary care providers about cancer survivorship care. It underscores the need for oncologists and primary care providers to work together to clarify their roles in survivorship care and build systems that will deliver quality comprehensive care to a growing population of cancer survivors. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES 1. Institute of Medicine and National Research Council of the National Academies. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press, 2006. 2. Cheung WY, Neville BA, Cameron DB, et al: Comparisons of patient and physician expectations for cancer survivorship care. J Clin Oncol 27:2489–2495, 2009. 3. Larson EB, Fihn SD, Kirk LM, et al: The future of general internal medicine: Report and recommendations from the Society of General Internal Medicine (SGIM) task force on the Domain of General Internal Medicine. J Gen Intern Med 19:69–77, 2004.[CrossRef][Medline] 4. Grunfeld E, Mant D, Vessey MP, et al: Specialist and general practice views on routine follow-up of breast cancer patients in general practice. Fam Pract 12:60–65, 1995. 5. Nissen MJ, Beran MS, Lee MW, et al: Views of primary care providers on follow-up care of cancer patients. Fam Med 39:477–482, 2007.[Medline] 6. Duffey-Lind EC, O'Holleran E, Healey M, et al: Transitioning to survivorship: A pilot study. J Ped Oncol Nursing 23:335–343, 2006.[CrossRef] 7. Oeffinger KC, Mertens AC, Sklar CA, et al: Chronic health conditions in adult survivors of childhood cancer. N Engl J Med 355:1572–1582, 2006. 8. Kadan-Lottick NS, Robison LL, Gurney JG, et al: Childhood cancer survivors' knowledge about their past diagnosis and treatment: Childhood Cancer Survivor Study. JAMA 287:1832–1839, 2002. 9. Snyder CF, Earle CC, Herbert RJ, et al: Trends in follow-up and preventive care for colorectal cancer survivors. J Gen Intern Med 23:254–259, 2008.[CrossRef][Medline] 10. Earle CC, Burstein HJ, Winer EP, et al: Quality of non–breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol 21:1447–1451, 2003. 11. Earle CC, Neville BA: Under use of necessary care among cancer survivors. Cancer 101:1712–1719, 2004.[CrossRef][Medline] 12. Mariscotti J: A delicate dance: Negotiating the doctor-patient relationship during cancer treatment. Oncologist 13:1205–1206, 2008. 13. Snyder CF, Earle CC, Herbert RJ, et al: Preventive care for colorectal cancer survivors: A 5-year longitudinal study. J Clin Oncol 26:1073–1079, 2008. 14. Doubeni CA, Field TS, Yood MU, et al: Patterns and predictors of mammography utilization among breast cancer survivors. Cancer 106:2482–2488, 2006.[CrossRef][Medline] 15. Keating NL, Landrum MB, Guadagnoli E, et al: Factors related to underuse of surveillance mammography among breast cancer survivors. J Clin Oncol 24:85–94, 2006. 16. Geller BM, Kerlikowske K, Carney PA, et al: Mammography surveillance following breast cancer. Breast Cancer Res Treat 81:107–115, 2003.[CrossRef][Medline] 17. Lash TL, Silliman RA: Medical surveillance after breast cancer diagnosis. Med Care 39:945–955, 2001.[CrossRef][Medline] 18. Grunfeld E, Levine MN, Julian JA, 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. 19. Ayanian JZ, Landrum MB, Guadagnoli E, et al: Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med 347:1678–1686, 2002. 20. Zimmerman DL, Selick A, Singh R, et al: Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 18:305–309, 2003. 21. Bonarjee VV, Dickstein K: Management of patients with heart failure: Are internists as good as cardiologists? Eur Heart J 22:530–531, 2001. 22. Ward MM: Provision of primary care by office-based rheumatologists: Results from the national ambulatory medical care survey, 1991-1995. Arthritis Rheum 42:409–414, 1999.[CrossRef][Medline] 23. Smith SM, Allwright S, O'Dowd T: Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev 3:CD004910; 2007.[Medline] 24. Erikson C, Salsberg E, Forte G, et al: Future supply and demand for oncologists, challenges to assuring access to oncology services. J Oncol Pract 3:79–86, 2007. 25. Hauer KE, Durning SJ, Kernan WN, et al: Factors associated with medical students' career choices regarding internal medicine. JAMA 300:1154–1164, 2008. 26. Hewitt ME, Bamundo A, Day R, et al: Perspectives on post-treatment cancer care: Qualitative research with survivors, nurses, and physicians. J Clin Oncol 25:2270–2273, 2007. 27. Cabana MD, Rand CS, Powe NR, et al: Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465, 1999.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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