Tailored chemotherapy information faxed to general practitioners improves confidence in managing adverse effects and satisfaction with shared care: results from a randomized controlled trial

Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens

PURPOSE

Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development.

METHODS

A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy.

RESULTS

Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating).

CONCLUSION

To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.

Experimental system of care coordination for the home return of patients with metastatic cancer: a survey of general practitioners

BACKGROUND

To promote improved coordination between general practice and hospital, the French clinical trial CREDO ("Concertation de REtour à DOmicile") is testing an innovative experimental consultation for patients with metastatic cancer who are returning home. This consultation involves the patient, the patient's referring GP (GP_ref) and a GP with specific skills in oncology (GP_onc) in a specialized care center. The objective of our study is to explore the satisfaction of GPs_ref about this consultation, in the phase of interaction between GP_onc and GP_ref.

METHODS

This observational, cross-sectional, multicenter study explored the satisfaction of GPs_ref who had participated in this type of consultation, via a telephone survey.

RESULTS

One Hundred GPs_ref responded to the questionnaire between April and September 2019 (overall response rate: 55%). 84.5% were satisfied with the consultation, and the majority were satisfied with its methods. Half of the GPs_ref learned new information during the consultation, three-quarters noted an impact on their practice, and 94.4% thought that this type of coordination between the GP_ref and the oncology specialist could improve general practice - hospital coordination.

CONCLUSIONS

For GPs, the CREDO consultation seems to be practical and effective in improving the coordination between general medicine and hospital. GPs would benefit from such coordination for all patients with cancer, several times during follow-up and at each occurrence of a medically significant event.

Understanding the Attitudes and Beliefs of Oncologists Regarding the Transitioning and Sharing of Survivorship Care

Transitioning survivorship care from oncologists to primary care physicians (PCPs) is a reasonable alternative to oncologist-led care. This study assessed oncologists’ attitudes and beliefs regarding sharing/transitioning survivorship care. A prospective survey of oncologists within a regional cancer program assessing self-reported barriers and facilitators to sharing/transitioning survivorship care was disseminated. In total, 63% (n = 39) of surveyed oncologists responded. Patient preference (89%) and anxiety (84%) are key to transition of care decisions; reduced remuneration (95%) and fewer longitudinal relationships (63%) do not contribute. Oncologists agreed that more patients could be shared/transitioned. Barriers include treatment-related toxicities (82% agree), tumor-specific factors (60–90% agree) and perception of PCP willingness to participate in survivorship care (47% agree). Oncologists appear willing to share/transition more survivors to PCPs, though barriers exist that warrant further study. Understanding these issues is critical to developing policies supporting comprehensive survivorship care models that address both cancer and non-cancer health needs. The demonstrated feasibility of this project warrants a larger-scale survey of oncologists with respect to the transition of survivorship care to PCPs, to further inform effective interventions to support high-quality survivorship care.

Future care for long-term cancer survivors: towards a new model

Purpose

The increase in the prevalence "long-term cancer survivor” (LCS) patients is expected to increase the cost of LCS care. The aim of this study was to obtain information that would allow to optimise the current model of health management in Spain to adapt it to one of efficient LCS patient care.

Methods

This qualitative study was carried out using Delphi methodology. An advisory committee defined the criteria for participation, select the panel of experts, prepare the questionnaire, interpret the results and draft the final report.

Results

232 people took part in the study (48 oncologists). Absolute consensus was reached in three of the proposed sections: oncological epidemiology, training of health professionals and ICT functions.

Conclusion

The role of primary care in the clinical management of LCS patients needs to be upgraded, coordination with the oncologist and hospital care is essential. The funding model needs to be adapted to determine the funding conditions for new drugs and technologies.

The effect of comorbidity on primary care use during breast cancer chemotherapy: a population-based retrospective cohort study using CanIMPACT data

BACKGROUND

Patients with breast cancer visit their primary care physicians (PCPs) more often during chemotherapy than before diagnosis, but the reasons are unclear. We assessed the association between physical comorbidities and mental health history (MHH) and the change in PCP use during adjuvant breast cancer chemotherapy.

METHODS

We conducted a population-based, retrospective cohort study using data from the Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT) project. Participants were women 18 years of age and older, who had received a diagnosis of stage I-III breast cancer in Ontario between 2007 and 2011 and had received surgery and adjuvant chemotherapy. We used difference-in-difference analysis using negative binomial modelling to quantify the differences in the 6-month rate of PCP visits at baseline (the 24-month period between 6 and 30 months before diagnosis) and during treatment (the 6 months from start of chemotherapy) between physical comorbidity and MHH groups.

RESULTS

Among 12 781 participants, the 6-month PCP visit rate increased during chemotherapy (mean 2.3 visits at baseline, 3.4 visits during chemotherapy). Patients with higher physical comorbidity levels or MHH visited their PCPs 4.2 or 1.7 more times, respectively, over 6 months compared to those with low physical comorbidity or no MHH at baseline and 2.5 or 1.1 more times, respectively, over 6 months during treatment. During treatment, the adjusted 6-month rate of PCP visits more than doubled in the group with the fewest physical comorbidities or no MHH compared with baseline (rate ratio 2.52, 95% confidence interval [CI] 2.43-2.61). This increase was lower in those with MHH (rate ratio 1.81, 95% CI 1.68-1.96) and in the highest physical comorbidity group (rate ratio 1.16, 95% CI 1.07-1.28).

INTERPRETATION

Patients with breast cancer who have more physical comorbidities and MHH have a higher frequency of PCP visits during adjuvant chemotherapy but lower absolute and relative increases in visits compared with baseline. Therefore, PCPs can expect to see their patients with fewer physical comorbidities and no MHH more often during chemotherapy. Primary care physicians can plan for their patients with high physical comorbidity levels and MHH to continue having frequent appointments while they undergo chemotherapy, and they can expect their patients with low physical comorbidity levels and no MHH to increase the frequency of their visits during chemotherapy, and should be prepared to provide breast cancer-related care to these patients.

[A survey among family doctors on care reality of patients under oral tyrosine kinase inhibitor therapies]

INTRODUCTION

Oral tyrosine kinase inhibitor (TKI) therapies are becoming increasingly more important in the treatment of malignant diseases. Monitoring with focus on adherence, side effects and interactions poses new challenges for medical care. The role and capabilities of family doctors in the care of TKI patients are yet unclear and should be uncovered in a nationwide survey.

METHODS

From April to July 2016, 3,000 family doctors in Germany were asked to complete a written questionnaire regarding their capabilities for co-supervision of TKI patients.

RESULTS

The response rate was 18% (n=553). The peak age was between 50 and 60 years. 81% were specialists in general medicine, 14% specialists in internal medicine and 5% general practitioners. 98% cared for no or less than 10 TKI patients per quarter. Knowledge of side effects and interaction potential of TKIs was low in over 90%. 83% preferred monitoring by the treating oncologist and 93% felt uncertain about treatment monitoring. The control of adherence was of little importance in 66%. The number of treated TKI patients had a significant impact on knowledge and opportunities for treatment monitoring. There was a significant correlation between knowledge about TKIs and confidence in treatment monitoring. In general, younger doctors tended to be more confident in treatment monitoring, and specialists in internal medicine tended to have more knowledge than specialists in general medicine general practitioners and general practitioners.

DISCUSSION

Currently, the low number of TKI patients, little knowledge about TKI, and the desire for specialist care are limiting the possibilities of co-caring for TKI patients by family doctors.

CONCLUSION

Although family doctors are generally motivated to care for tumor patients, routine treatment controls of TKI patients conducted by family doctors seem hardly possible at the moment and should currently remain with the specialist.

Inventory of tools for care coordination between general practice and hospital system for patients suffering from cancer in active phase of treatment: A scoping review

INTRODUCTION

During the active phase of treatment, major difficulties appear in the transmission and quality of the information communicated to the General Practitioner (GP). Our objective was to carry out an inventory of the coordination tools used to improve exchanges between the hospital and the GP in the management of the patient suffering from cancer during this phase.

MATERIAL AND METHOD

A scoping review was conducted using MEDLINE databases via PubMed, The Cochrane Library, Web of Science. Articles published between 1998 and 2018, in English and French, were analysed.

RESULTS

Over 4,863 articles were extracted, and 11 studies were included. They highlight an increase in the quality of patient care after the introduction of information sheets or training by video vignettes with GPs. They demonstrate the importance of using standardised letters between health professionals. The role of a "leader physician" is discussed, and its first evaluations are positive. An increase in information transmitted to GPs leads to a better satisfaction of patients and GPs.

CONCLUSION

Communication tools are essential for the transmission of information, but direct and oral communication between all health professionals seems to be a point to be further developed.

Differences in primary care providers’ and oncologists’ views on communication and coordination of care during active treatment of patients with cancer and comorbidities

Introduction

Management of comorbid diseases in patients with cancer is often unclear. The purpose of our study was to identify differences and similarities between primary care providers and oncologists’ knowledge, attitudes, and beliefs regarding coordination of care and comorbid disease management for patients undergoing active cancer treatment.

Methods

We conducted a cross-sectional study using an anonymous self-administered survey which was available to approximately 600 providers in primary care and medical oncology practicing in both outpatient and inpatient settings from March to December 2014 at three academic hospitals in New York City (Mount Sinai Hospital, Mount Sinai Beth Israel, and Weill Cornell). Our survey instrument assessed physician knowledge, attitudes, and beliefs using a clinical vignette of a cancer patient undergoing active treatment. Descriptive statistics were used to summarize the demographic and practice details of survey responses, and univariate analyses were used to assess differences in responses between primary care providers and oncologists.

Results

The survey was completed by 203 providers, including 127 primary care providers (62.5%), 32 medical oncologists (15.8%), 11 palliative care physicians (5.4%), and 33 nurse practitioners or physician assistants (16.3%). Medical oncologists admitted more uncertainty regarding who should manage preventive care as compared to primary care providers (34.4% vs. 16.5%, p = 0.02), whereas primary care providers were more concerned about duplicated care (22.8% vs. 6.3%, p = 0.03). Both primary care providers and medical oncologists agreed that diabetes should be actively managed during cancer treatment. More primary care providers felt less strict glycemic control was allowable (56.8% vs. 37.5%, p = 0.05) and that it is allowable for patients to miss some diabetes-related visits (80.6% vs. 56.3%, p = 0.01).

Discussion

Primary care providers and medical oncologists differ in their knowledge, attitudes, and beliefs regarding coordination of care and management of comorbid conditions in patients undergoing cancer treatment. These differences reflect systemic challenges to provision of care to cancer patients and the need for a model of care coordination.

Defining success factors to describe coordinated care in cancer

Providing coordinated care remains a challenge for cancer services globally. There is a lack of consensus in the literature about what constitutes successful coordinated care. This study aimed to define and prioritize a set of consensus-driven success factors that can lead to coordinated care. A mixed-methods approach was used that included literature review, a broad call for submissions from relevant stakeholders, and a priority-setting process based on a modified nominal group technique. Thirty articles that related to success factors in coordinated care were identified in the literature. Twenty submissions were received from a broad range of stakeholders. From these sources, a set of 20 success factors was derived. Seventy stakeholders attended a series of workshops across New South Wales, Australia, to review and prioritize these 20 success factors against significance and measurability. Clear consensus was reached on prioritizing two success factors linked to improving coordinated care from first presentation to diagnosis and ensuring that patients are routinely screened for physical and supportive care needs. Other highly ranked factors included the need for a comprehensive care plan and the identification of patients at higher risk for disjointed care. This study defines and prioritizes a set of success factors related to coordinated care in cancer. These success factors will be used to guide the development of interventions that target improving coordinated care as well as supporting the development of new funding models based on performance indicators derived from these factors.

SCORE: Shared care of Colorectal cancer survivors: protocol for a randomised controlled trial

Background

Colorectal cancer (CRC) is the most common cancer affecting both men and women. Survivors of CRC often experience various physical and psychological effects arising from CRC and its treatment. These effects may last for many years and adversely affect QoL, and they may not be adequately addressed by standard specialist-based follow-up. Optimal management of these effects should harness the expertise of both primary care and specialist care. Shared models of care (involving both the patient’s primary care physician [PCP] and specialist) have the potential to better support survivors and enhance health system efficiency.

Methods/design

SCORE (Shared care of Colorectal cancer survivors) is a multisite randomised controlled trial designed to optimise and operationalise a shared care model for survivors of CRC, to evaluate the acceptability of the intervention and study processes, and to collect preliminary data regarding the effects of shared care compared with usual care on a range of patient-reported outcomes. The primary outcome is QoL measured using the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire. Secondary outcomes are satisfaction with care, unmet needs, continuity of care and health resource use. The shared care model involves replacement of two routine specialist follow-up visits with PCP visits, as well as the provision of a tailored survivorship care plan and a survivorship booklet and DVD for CRC survivors. All consenting patients will be randomised 1:1 to either shared care or usual care and will complete questionnaires at three time points over a 12-month period (baseline and at 6 and 12 months). Health care resource use data will also be collected and used to evaluate costs.

Discussion

The evaluation and implementation of models of care that are responsive to the holistic needs of cancer survivors while reducing the burden on acute care settings is an international priority. Shared care between specialists and PCPs has the potential to enhance patient care and outcomes for CRC survivors while offering improvements in health care resource efficiency. If the findings of the present study show that the shared care intervention is acceptable and feasible for CRC survivors, the intervention may be readily expanded to other groups of cancer survivors.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617000004369p. Registered on 3 January 2017; protocol version 4 approved 24 February 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2245-4) contains supplementary material, which is available to authorized users.

GPs' assessment of cooperation with other health care providers involved in cancer care-a cross-sectional study

Cancer is a complex disease requiring the involvement of several health care providers. A possible constant in the cancer care process is the general practitioner (GP). The aim of this project was to evaluate GPs' satisfaction with cooperation with other health care providers in the cancer care process of their patients and to explore which variables are associated with higher satisfaction with cooperation with other health care providers. We considered the following health care providers: outpatient oncology specialists, physicians in relatively small hospitals (≤400 beds), physicians in relatively large hospitals (>400 beds), home care services, outpatient psycho(onco)logists/psychotherapists, hospice/palliative care units and specialised palliative home care. The cross-sectional study was carried out as a postal survey all over Germany. Data were analysed descriptively and by means of logistic regression. Overall satisfaction with cooperation with other health care providers involved in cancer care was rather high. Only cooperation with outpatient psycho(onco)logists/psychotherapists was rated as not assessable/irrelevant by a majority of GPs. For all other health care providers under review, both communication and the transfer of sufficient information in good time were associated with overall satisfaction with cooperation. Little association was found between GP and practice variables and overall satisfaction with cooperation with the considered health care providers.

The Impact of Survivorship Care Planning on Patients, General Practitioners, and Hospital-Based Staff

BACKGROUND

In 2005, the Institute of Medicine recommended that all cancer patients receive a survivorship care plan (SCP). Despite widespread support, few centers have routinely implemented them. Understanding of their impact is limited.

OBJECTIVES

The aims of this study were to examine the impact of SCP delivery on patients and healthcare professionals at an Australian comprehensive cancer center and determine enablers and barriers to implementation.

METHODS

Six groups were surveyed: (1) patients who had received SCPs; (2) nurse coordinators using SCPs, (3) general practitioners (primary care, GPs) of patients who had received SCPs, (4) clinical service chairs, (5) heads of allied health, and (6) nurse coordinators not using SCPs (nonengaged nurse coordinators). Groups 1 to 3 completed written questionnaires. Groups 4 to 6 participated in semistructured interviews.

RESULTS

Fifty patients, 7 nurse coordinators, 18 GPs, 7 clinical service chairs, 4 heads of allied health, and 8 nonengaged nurse coordinators participated. Eighty-seven percent of patients considered the SCP to be very or somewhat useful; 50% felt it helped them understand their cancer experience. All engaged nurse coordinators reported SCPs to be very or somewhat useful, and 86% believed SCPs improved communication with GPs. General practitioners felt SCPs were very or somewhat useful (67%) and wished to receive SCPs for future patients (83%). Organizational and clinical leadership, multidisciplinary engagement, resourcing, and timing of SCP delivery were considered critical enablers.

CONCLUSION

Patients and healthcare professionals support the use of SCPs; however, they are resource intensive and require significant organizational support.

IMPLICATIONS FOR PRACTICE

Nurses are instrumental to SCP implementation. Attention to enablers and barriers is important for successful implementation.

The Effectiveness of Information Technology-Supported Shared Care for Patients With Chronic Disease: A Systematic Review

Background

In patients with chronic disease, many health care professionals are involved during treatment and follow-up. This leads to fragmentation that in turn may lead to suboptimal care. Shared care is a means to improve the integration of care delivered by various providers, specifically primary care physicians (PCPs) and specialty care professionals, for patients with chronic disease. The use of information technology (IT) in this field seems promising.

Objective

Our aim was to systematically review the literature regarding the effectiveness of IT-supported shared care interventions in chronic disease in terms of provider or professional, process, health or clinical and financial outcomes. Additionally, our aim was to provide an inventory of the IT applications' characteristics that support such interventions.

Methods

PubMed, Scopus, and EMBASE were searched from 2006 to 2015 to identify relevant studies using search terms related to shared care, chronic disease, and IT. Eligible studies were in the English language, and the randomized controlled trials (RCTs), controlled trials, or single group pre-post studies used reported on the effects of IT-supported shared care in patients with chronic disease and cancer. The interventions had to involve providers from both primary and specialty health care. Intervention and IT characteristics and effectiveness—in terms of provider or professional (proximal), process (intermediate), health or clinical and financial (distal) outcomes—were extracted. Risk of bias of (cluster) RCTs was assessed using the Cochrane tool.

Results

The initial search yielded 4167 results. Thirteen publications were used, including 11 (cluster) RCTs, a controlled trial, and a pre-post feasibility study. Four main categories of IT applications were identified: (1) electronic decision support tools, (2) electronic platform with a call-center, (3) electronic health records, and (4) electronic communication applications. Positive effects were found for decision support-based interventions on financial and health outcomes, such as physical activity. Electronic health record use improved PCP visits and reduced rehospitalization. Electronic platform use resulted in fewer readmissions and better clinical outcomes—for example, in terms of body mass index (BMI) and dyspnea. The use of electronic communication applications using text-based information transfer between professionals had a positive effect on the number of PCPs contacting hospitals, PCPs’ satisfaction, and confidence.

Conclusions

IT-supported shared care can improve proximal outcomes, such as confidence and satisfaction of PCPs, especially in using electronic communication applications. Positive effects on intermediate and distal outcomes were also reported but were mixed. Surprisingly, few studies were found that substantiated these anticipated benefits. Studies showed a large heterogeneity in the included populations, outcome measures, and IT applications used. Therefore, a firm conclusion cannot be drawn. As IT applications are developed and implemented rapidly, evidence is needed to test the specific added value of IT in shared care interventions. This is expected to require innovative research methods.

Physician cooperation in outpatient cancer care. An amplified secondary analysis of qualitative interview data

The importance of outpatient cancer care services is increasing due to the growing number of patients having or having had cancer. However, little is known about cooperation among physicians in outpatient settings. To understand what inter- and multidisciplinary care means in community settings, we conducted an amplified secondary analysis that combined qualitative interview data with 42 general practitioners (GPs), 21 oncologists and 21 urologists that mainly worked in medical practices in Germany. We compared their perspectives on cooperation relationships in cancer care. Our results indicate that all participants regarded cooperation as a prerequisite for good cancer care. Oncologists and urologists mainly reported cooperating for tumour-specific treatment tasks, while GPs' reasoning for cooperation was more patient-centred. While oncologists and urologists reported experiencing reciprocal communication with other physicians, GPs had to gather the information they needed. GPs seldom reported engaging in formal cooperation structures, while for specialists, participation in formal spaces of cooperation, such as tumour boards, facilitated a more frequent and informal discussion of patients, for instance on the phone. Further research should focus on ways to foster GPs' integration in cancer care and evaluate if this can be reached by incorporating GPs in formal cooperation structures such as tumour boards.

The primary care provider (PCP)-cancer specialist relationship: A systematic review and mixed-methods meta-synthesis

Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.

ProCare Trial: a phase II randomized controlled trial of shared care for follow-up of men with prostate cancer

OBJECTIVES

To test the feasibility and efficacy of a multifaceted model of shared care for men after completion of treatment for prostate cancer.

PATIENTS AND METHODS

Men who had completed treatment for low- to moderate-risk prostate cancer within the previous 8 weeks were eligible. Participants were randomized to usual care or shared care. Shared care entailed substituting two hospital visits with three visits in primary care, a survivorship care plan, recall and reminders, and screening for distress and unmet needs. Outcome measures included psychological distress, prostate cancer-specific quality of life, satisfaction and preferences for care and healthcare resource use.

RESULTS

A total of 88 men were randomized (shared care n = 45; usual care n = 43). There were no clinically important or statistically significant differences between groups with regard to distress, prostate cancer-specific quality of life or satisfaction with care. At the end of the trial, men in the intervention group were significantly more likely to prefer a shared care model to hospital follow-up than those in the control group (intervention 63% vs control 24%; P<0.001). There was high compliance with prostate-specific antigen monitoring in both groups. The shared care model was cheaper than usual care (shared care AUS$1411; usual care AUS$1728; difference AUS$323 [plausible range AUS$91-554]).

CONCLUSION

Well-structured shared care for men with low- to moderate-risk prostate cancer is feasible and appears to produce clinically similar outcomes to those of standard care, at a lower cost.

The role of the GP in follow-up cancer care: a systematic literature review

PURPOSE

The purpose of the present study is to explore the role of the general practitioners, family physicians and primary care physicians (GP) in the provision of follow-up cancer care.

METHODS

PubMed, MEDLINE and CINAHL were systematically searched for primary research focussing on the role of the GP from the perspective of GPs and patients. Data were extracted using a standardised form and synthesised using a qualitative descriptive approach.

RESULTS

The initial search generated 6487 articles: 25 quantitative and 33 qualitative articles were included. Articles focused on patients' and GPs' perspectives of the GP role in follow-up cancer care. Some studies reported on the current role of the GP, barriers and enablers to GP involvement from the perspective of the GP and suggestions for future GP roles. Variations in guidelines and practice of follow-up cancer care in the primary health care sector exist. However, GPs and patients across the included studies supported a greater GP role in follow-up cancer care. This included greater support for care coordination, screening, diagnosis and management of physical and psychological effects of cancer and its treatment, symptom and pain relief, health promotion, palliative care and continuing normal general health care provision.

CONCLUSION

While there are variations in guidelines and practice of follow-up cancer care in the primary health care sector, GPs and patients across the reviewed studies supported a greater role by the GP.

IMPLICATIONS FOR CANCER SURVIVORS

Greater GP role in cancer care could improve the quality of patient care for cancer survivors. Better communication between the tertiary sector and GP across the cancer phases would enable clear delineation of roles.

An e-health strategy to facilitate care of breast cancer survivors: A pilot study

AIM

Innovative e-health strategies are emerging, to tailor and provide convenient, systematic and high-quality survivorship care for an expanding cancer survivor population. This pilot study tests the application of an e-health platform, "Healthy.me," in a breast cancer survivor cohort at Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia.

METHODS

Fifty breast cancer patients were recruited to use the Healthy.me website, designed by the Centre of Health Informatics at the University of New South Wales, over a 4-month period. Telephone and online questionnaires were used at 1 and 4 months and a face-to-face feedback at study completion, to gather qualitative and quantitative data regarding feasibility of Healthy.me.

RESULTS

Healthy.me was reported to be a useful online resource by most users. Usage declined from 76% at 1 month to 48% at 4 months. Breast cancer survivors enjoyed a variety of tailored information regarding health and life-style issues. Positive aspects of Healthy.me were the convenient access to trusted information, and interaction with their peers and healthcare professionals. Barriers to usage contributing to usage decline were lack of reported patient time to re-access information, limited content updates and technical factors.

CONCLUSIONS

This pilot study suggested the potential of an e-health strategy such as Healthy.me in addressing the needs of a growing breast cancer survivor population. Ongoing development of a more robust e-health resource and integration with primary care models is warranted.

Characteristics and outcome of unplanned hospital admissions in patients with lung cancer: a longitudinal tertiary center study. Towards a strategy to reduce the burden

BACKGROUND

Unplanned hospital admissions (UHAs) are frequent in lung cancer, but literature on this topic is scarce. The aim of this study is to gain insight in the demographics, patterns of referral, causes, presenting symptoms, and final outcome of these UHAs. A strategy to improve quality of care and reduce the number and cost of UHAs was suggested based upon these findings.

PATIENTS AND METHODS

In retrospective analysis of all consecutive UHAs in a 6-month period in a tertiary center, demographics, pattern of referral, clinical data, tumor control status, final diagnosis, duration of hospitalization, and outcome were examined.

RESULTS

Two hundred seven UHAs were recorded. Male/female ratio was 185/62, mean age 65.5 years, performance status (PS) on admission 0-1 in 32 %, 2 in 37.2 %, and 3-4 in 30.8 % of patients. Patient referral occurred by general practitioner in 33.6 % or specialist in 25.5 % and in 40.9 % on own initiative. UHAs were therapy-related in 23.9 %, cancer-related in 47.4 %, comorbidity-related in 19.4 %, or of unclear nature in 9.3 %. Most frequent causes were infections (21.9 %) and respiratory problems (17.0 %). Mean length of stay was 9.5 days. Final outcome was 10.1 % mortality, 6.9 % hospice care transfers, and 79.4 % home returns (including 18.2 % same day returns).

CONCLUSION

UHAs in lung cancer were more cancer- than therapy-related. Majority of patients (2/3) were not seen by their general practitioner. A significant number of same day returns were noted. UHAs in patients with poor PS, uncontrolled cancer and cancer-related events had the worst outcome. This work is a first step in identifying specific characteristics of UHAs in lung cancer patients, which may lead to strategies to reduce the burden of UHAs.

Randomized Controlled Trial of Shared Care for Patients With Cancer Involving General Practitioners and Cancer Specialists

Little benefit was seen for a shared care model in the majority of domains including empowerment, symptom prevalence, and psychological adjustment to cancer. The shared care model showed efficacy in clinically anxious patients.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia

PURPOSE

People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer.

METHODS

This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients.

RESULTS

ED (529,377) presentations occurred over the 36 months, of which 2.4% (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33%, p < 0.001), with twice the rate of hospital admission (90 vs 46%, p < 0.001), longer inpatient length of stay (5.6 vs 2.8 days, p < 0.001) and had higher inpatient mortality (7.9 vs 1.0%, p < 0.001). Acuity and arriving by ambulance were significant predictors of hospital admission, with cancer-related attendances having ten times the odds of admission compared to other attendances (OR = 10.4, 95% CI 9.8-11.1).

CONCLUSIONS

ED presentations by people with cancer represent a more urgent, complex caseload frequently requiring hospital admission when compared to other presentations, suggesting that for optimal cancer care, close collaboration and integration of oncology, palliative care and emergency medicine providers are needed to improve pathways of care.

Keeping primary care "in the loop": General practitioners want better communication with specialists and hospitals when caring for people diagnosed with cancer

AIM

To investigate general practitioners' (GP) perceptions about communication when providing cancer care.

METHODS

A self-report survey, which included an open response section, was mailed to a random sample of 1969 eligible Australian GPs. Content analysis of open response comments pertaining to communication was undertaken in order to ascertain GPs' views about communication issues in the provision of cancer care.

RESULTS

Of the 648 GPs who completed the survey, 68 (10%) included open response comments about interprofessional communication. Participants who commented on communication were a median age of 50 years and worked 33 h/week; 28% were male and 59% practiced in the metropolitan area. Comments pertaining to communication were coded using five non-mutually exclusive categories: being kept in the loop; continuity of care; relationships with specialists; positive communication experiences; and strategies for improving communication.GPs repeatedly noted the importance of receiving detailed and timely communication from specialists and hospitals, particularly in relation to patients' treatment regimes and follow-up care. Several GPs remarked that they were left out of "the information loop" and that patients were "lost" or "dumped" after referral.

CONCLUSION

While many GPs are currently involved in some aspects of cancer management, detailed and timely communication between specialists and GPs is imperative to support shared care and ensure optimal patient outcomes. This research highlights the need for established channels of communication between specialist and primary care medicine to support greater involvement by GPs in cancer care.

Protocol for the ProCare Trial: a phase II randomised controlled trial of shared care for follow-up of men with prostate cancer

INTRODUCTION

Men with prostate cancer require long-term follow-up to monitor disease progression and manage common adverse physical and psychosocial consequences of treatment. There is growing recognition of the potential role of primary care in cancer follow-up. This paper describes the protocol for a phase II multisite randomised controlled trial of a novel model of shared care for the follow-up of men after completing treatment for low-moderate risk prostate cancer.

METHODS AND ANALYSIS

The intervention is a shared care model of follow-up visits in the first 12 months after completing treatment for prostate cancer with the following specific components: a survivorship care plan, general practitioner (GP) management guidelines, register and recall systems, screening for distress and unmet needs and patient information resources. Eligible men will have completed surgery and/or radiotherapy for low-moderate risk prostate cancer within the previous 8 weeks and have a GP who consents to participate. Ninety men will be randomised to the intervention or current hospital follow-up care. Study outcome measures will be collected at baseline, 3, 6 and 12 months and include anxiety, depression, unmet needs, prostate cancer-specific quality of life and satisfaction with care. Clinical processes and healthcare resource usage will also be measured. The principal emphasis of the analysis will be on obtaining estimates of the treatment effect size and assessing feasibility in order to inform the design of a subsequent phase III trial.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the University of Western Australia and from all hospital recruitment sites in Western Australia and Victoria.

RESULTS

of this phase II trial will be reported in peer-reviewed publications and in conference presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12610000938000.

The role of primary care in early detection and follow-up of cancer

Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.

Interventions to improve continuity of care in the follow-up of patients with cancer

BACKGROUND

Care from the family physician is generally interrupted when patients with cancer come under the care of second-line and third-line healthcare professionals who may also manage the patient's comorbid conditions. This situation may lead to fragmented and uncoordinated care, and results in an increased likelihood of not receiving recommended preventive services or recommended care.

OBJECTIVES

To classify, describe and evaluate the effectiveness of interventions aiming to improve continuity of cancer care on patient, healthcare provider and process outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organization of Care Group (EPOC) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, and PsycINFO, using a strategy incorporating an EPOC Methodological filter. Reference lists of the included study reports and relevant reviews were also scanned, and ISI Web of Science and Google Scholar were used to identify relevant reports having cited the studies included in this review.

SELECTION CRITERIA

Randomised controlled trials (including cluster trials), controlled clinical trials, controlled before and after studies and interrupted time series evaluating interventions to improve continuity of cancer care were considered for inclusion. We included studies that involved a majority (> 50%) of adults with cancer or healthcare providers of adults with cancer. Primary outcomes considered for inclusion were the processes of healthcare services, objectively measured healthcare professional, informal carer and patient outcomes, and self-reported measures performed with scales deemed valid and reliable. Healthcare professional satisfaction was included as a secondary outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers described the interventions, extracted data and assessed risk of bias. The authors contacted several investigators to obtain missing information. Interventions were regrouped by type of continuity targeted, model of care or interventional strategy and were compared to usual care. Given the expected clinical and methodological diversity, median changes in outcomes (and bootstrap confidence intervals) among groups of studies that shared specific features of interest were chosen to analyse the effectiveness of included interventions.

MAIN RESULTS

Fifty-one studies were included. They used three different models, namely case management, shared care, and interdisciplinary teams. Six additional interventional strategies were used besides these models: (1) patient-held record, (2) telephone follow-up, (3) communication and case discussion between distant healthcare professionals, (4) change in medical record system, (5) care protocols, directives and guidelines, and (6) coordination of assessments and treatment.Based on the median effect size estimates, no significant difference in patient health-related outcomes was found between patients assigned to interventions and those assigned to usual care. A limited number of studies reported psychological health, satisfaction of providers, or process of care measures. However, they could not be regrouped to calculate median effect size estimates because of a high heterogeneity among studies.

AUTHORS' CONCLUSIONS

Results from this Cochrane review do not allow us to conclude on the effectiveness of included interventions to improve continuity of care on patient, healthcare provider or process of care outcomes. Future research should evaluate interventions that target an improvement in continuity as their primary objective and describe these interventions with the categories proposed in this review. Also of importance, continuity measures should be validated with persons with cancer who have been followed in various settings.

How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management

BACKGROUND

Multimodal cancer care requires collaboration among different professionals in various settings. Practice guidelines provide little direction on how this can best be achieved. Research shows that collaborative cancer management is limited, and challenged by numerous issues. The purpose of this research was to describe conceptual models of collaboration, and analyze how they have been applied in the clinical management of cancer patients.

METHODS

A review of the literature was performed using a two-phase meta-narrative approach. The first phase involved searching for conceptual models of collaboration. Their components and limitations were summarized. The second phase involved targeted searching for empirical research on evaluation of these concepts in the clinical management of cancer patients. Data on study objective, design, and findings were tabulated, and then summarized according to collaborative model and phase of clinical care to identify topics warranting further research.

RESULTS

Conceptual models for teamwork, interprofessional collaboration, integrated care delivery, interorganizational collaboration, continuity of care, and case management were described. All concepts involve two or more health care professionals that share patient care goals and interact on a continuum from consultative to integrative, varying according to extent and nature of interaction, degree to which decision making is shared, and the scope of patient management (medical versus holistic). Determinants of positive objective and subjective patient, team and organizational outcomes common across models included system or organizational support, team structure and traits, and team processes. Twenty-two studies conducted in ten countries examining these concepts for cancer care were identified. Two were based on an explicit model of collaboration. Many health professionals function through parallel or consultative models of care and are not well integrated. Few interventions or strategies have been applied to promote models that support collaboration.

CONCLUSIONS

Ongoing development, implementation and evaluation of collaborative cancer management, in the context of both practice and research, would benefit from systematic planning and operationalization. Such an approach is likely to improve patient, professional and organizational outcomes, and contribute to a collective understanding of collaborative cancer care.

Role of the general practitioner during the active breast cancer treatment phase: an analysis of health care use

Purpose

Little is known about the actual involvement of the general practitioner (GP) during the active breast cancer treatment phase. Therefore, this study explored (disease-specific) primary health care use among women undergoing active treatment for breast cancer compared with women without breast cancer.

Methods

A total of 185 women with a first diagnosis of early-stage breast cancer between 1998 and 2007 were identified in the primary care database of the Registration Network Groningen and matched with a reference population of 548 women without breast cancer on birth year and GP.

Results

Since diagnosis, patients with breast cancer had twice as many face-to-face contacts compared with women from the reference population (median 6.0 vs 3.0/year, Mann–Whitney (M-W) test p < 0.001). The median number of drug prescriptions and referrals was also significantly higher among patients than among the reference population (11.0 vs 7.0/year, M-W test p < 0.001 and 1.0 vs 0.0/year, M-W test p < 0.001). More patients than women from the reference population had face-to-face contacts or were prescribed drugs for reasons related to breast cancer and its treatment, including gastrointestinal problems, psychological reasons and endocrine therapy.

Conclusions

During the active breast cancer treatment phase, GPs are involved in the management of treatment-related side effects and psychological symptoms, as well as in the administration of endocrine therapy. Based on the findings of this study, interventions across the primary/secondary interface can be planned to improve quality of life and other outcomes in patients undergoing breast cancer treatment.

The primary care physician role in cancer genetics: a qualitative study of patient experience

BACKGROUND

Increased availability of genetic testing is changing the primary care role in cancer genetics. The perspective of primary care physicians (PCPs) regarding their role in support of genetic testing has been explored, but little is known about the expectations of patients or the PCP role once genetic test results are received.

METHODS

Two sets of open-ended semi-structured interviews were completed with patients (N=25) in a cancer genetic programme in Ontario, Canada, within 4 months of receiving genetic test results and 1 year later; written reports of test results were collected.

RESULTS

Patients expected PCPs to play a role in referral for genetic testing; they hoped that PCPs would have sufficient knowledge to appreciate familial risk and supportive attitudes towards genetic testing. Patients had more difficulty in identifying a PCP role following receipt of genetic test results; cancer patients in particular emphasized this as a role for cancer specialists. Still, some patients anticipated an ongoing PCP role comprising risk-appropriate surveillance or reassurance, especially as specialist care diminished. These expectations were complicated by occasional confusion regarding the ongoing care appropriate to genetic test results.

CONCLUSIONS

The potential PCP role in cancer genetics is quite broad. Patients expect PCPs to play a role in risk identification and genetics referral. In addition, some patients anticipated an ongoing role for their PCPs after receiving genetic test results. Sustained efforts will be needed to support PCPs in this expansive role if best use is to be made of investments in cancer genetic services.

The interface of primary and oncology specialty care: from diagnosis through primary treatment

In this article, we review the challenges and opportunities related to developing effective, collaborative relationships between primary care and oncology providers during the initial cancer treatment period. This point in the cancer care continuum is complex and often represents the first major transition in care between primary care providers and oncology specialists. Patients often receive care from multiple providers in a number of different settings and are faced with making treatment decisions in a short, concentrated period of time. Patients consistently report having significant informational and emotional needs that are often unmet during this period. Using the published literature, we have identified a number of challenges during this part of the treatment continuum that may limit providers' ability to deliver effective care, including provider care discontinuities, information exchange problems, and gaps in provider role clarity that may be especially problematic within the context of managing comorbid health conditions. The limited published literature specific to this step in the cancer care trajectory supports the importance of ongoing primary care-specialist collaboration during this phase in the care continuum for both medical and psychosocial care. How to best achieve effective collaboration between providers requires further research in information exchange and tools to support it, evaluation of shared care models specific to the cancer context, and studies of the potential role of multidisciplinary case conferencing that include the primary care provider.

Chemotherapy outpatients' unplanned presentations to hospital: a retrospective study

GOAL OF WORK

This descriptive, retrospective study sought to identify the nature and magnitude of chemotherapy outpatients' unplanned presentations and admissions to the emergency department and/or cancer centre at a large metropolitan tertiary hospital, and to explore the antecedents to those presentations.

PATIENTS AND METHODS

Retrospective data were collected for outpatients who made an unplanned presentation to a large metropolitan hospital in Sydney, Australia between October 1, 2006 and September 30, 2007. Detailed information was collected for those who had received cytotoxic chemotherapy at the hospital's cancer centre within the 6 months prior to the unplanned presentation to hospital. Demographic and explanatory variables were identified, including: reasons for presentation, cancer diagnosis, chemotherapy regimens, and position in the chemotherapy trajectory.

MAIN RESULTS

The Cancer Institute NSW figures indicate that each year approximately 518 outpatients are treated with chemotherapy at the participating cancer centre. During the study period, 316 cancer outpatients made 469 unplanned presentations to either the Cancer Centre or the hospital emergency department. Of those outpatients presented, 233 (73.7%) had received chemotherapy in the previous 6 months and made a total of 363 presentations. Of these 363 presentations, 253 (69.7%) occurred within 4 weeks of receiving chemotherapy. The majority of presentations by those who had received chemotherapy in the previous 6 months resulted in hospital admission (87.6%) for a median length of stay of 5 days. The most frequent presentation symptoms were nausea and/or vomiting (45.2%), pain (27%), fever and/or febrile neutropenia (23.4%), shortness of breath (19.3%), dehydration (12.1%), anaemia (8.8%), fatigue (8.8%), diarrhoea (8.8%), and anxiety and/or depression (5.5%).

CONCLUSIONS

Chemotherapy outpatients have significant unmet needs following treatment, indicating an urgent need for improved continuity of care and better integration of primary and tertiary health care services.

What determines the health-related quality of life among regional and rural breast cancer survivors?

OBJECTIVE

To assess the health-related quality of life (HRQoL) of regional and rural breast cancer survivors at 12 months post-diagnosis and to identify correlates of HRQoL.

METHODS

In 2006/07, 323 (202 regional and 121 rural) Queensland women diagnosed with unilateral breast cancer participated in a population-based, cross-sectional study. HRQoL was measured using the Functional Assessment of Cancer Therapy, Breast plus arm morbidity (FACT-B+4) self-administered questionnaire.

RESULTS

In age-adjusted analyses, mean HRQoL scores of regional breast cancer survivors were comparable to their rural counterparts 12 months post-diagnosis (122.9, 95% CI: 119.8, 126.0 vs. 123.7, 95% CI: 119.7, 127.8; p>0.05). Irrespective of residence, younger (<50 years) women reported lower HRQoL than older (50+ years) women (113.5, 95% CI: 109.3, 117.8 vs. 128.2, 95%CI: 125.1, 131.2; p<0.05). Those women who received chemotherapy, reported two complications post-surgery, had poorer upper-body function than most, reported more stress, reduced coping, who were socially isolated, had no confidante for social-emotional support, had unmet health care needs, and low health self-efficacy reported lower HRQoL scores.

CONCLUSIONS AND IMPLICATIONS

The results underscore the importance of supporting and promoting regional and rural breast cancer programs that are designed to improve physical functioning, reduce stress and provide psychosocial support following diagnosis. Further, the information can be used by general practitioners and other allied health professionals for identifying women at risk of poorer HRQoL.

Views of primary care physicians and oncologists on cancer follow-up initiatives in primary care: an online survey

INTRODUCTION

Primary care physicians (PCPs) are playing an increasing role in the follow-up of cancer in England. In 2003 a Cancer Care Review (CCR) was introduced to ensure contact between PCPs and cancer patients within 6 months of diagnosis. The NHS also intends to introduce survivorship care plans (SCP). The aims of this study were to: describe current practice and views in primary care with respect to the CCR and information provision from secondary to primary care following final discharge from hospital follow-up; and to seek views on the perceived usefulness, content, and feasibility of a SCP.

METHODS

An on-line questionnaire survey of 100 oncologists and 200 PCPs.

RESULTS

Half of PCPs undertook the CCR opportunistically, and only 64% had an agreed structure. Forty percent felt the CCR was useful for the doctor, and 60% useful for the patient. Most PCPs and oncologists think a SCP would be useful, but only 40% oncologists thought that it would be easy to produce. At discharge from follow-up, more than half of oncologists said they provided information on histology, treatment, requirements for screening and surveillance, and referral guidance. Less than half provide information on potential late effects and symptoms of recurrence. PCPs felt that information on all of these areas was important and that the information they receive is often inadequate.

DISCUSSION/CONCLUSIONS

The CCR has not been implemented systematically. There is support for the introduction of a SCP and broad agreement on content. However, careful planning is needed to ensure all necessary information is included and to overcome barriers of implementation.

IMPLICATIONS FOR CANCER SURVIVORS

Further research should explore what cancer survivors would find useful in a primary care-based CCR and what should be included in a SCP. This should be clearly communicated to the relevant health care professionals to maximise the benefits cancer survivors and their families gain from these policy initiatives.

The role of the primary care physician during the active treatment phase

Although more research needs to be done to determine the optimal role for PCPs during the active phase of cancer treatment, patients, PCPs, and oncologists all see a significant role for primary care in the care of patients with cancer. In the United States, family physicians are actively involved in the care of cancer patients, especially in provision of support, education, and care of intercurrent illness and chronic disease. Fatigue, depression, pain, and psychosocial distress are important symptoms that should be screened for and addressed. The PCP should be aware of adverse effects of chemotherapy and radiation and cancer-related emergencies. Sexual and intimacy concerns, including contraception and fertility, are important to patients entering active cancer treatment but may not be addressed adequately in usual cancer care. Advising the patient in active cancer treatment on issues of general health including common nutritional issues can provide value through the treatment period. Use of CAM is common and several modalities have been shown to benefit patients in the course of cancer treatment.

Caring for cancer survivors: a survey of primary care physicians

BACKGROUND

The number of long-term US cancer survivors is expected to double by the year 2050. Although primary care physicians (PCPs) provide the majority of care for long-term cancer survivors, to the authors' knowledge, few data to date have detailed PCP practice patterns, attitudes, and challenges in caring for long-term cancer survivors.

METHODS

Self-administered surveys were mailed to 406 community- and academic-based general internal medicine physicians in Denver, Colorado. Survey development included in-depth physician interviews and pretesting. Of the 299 responses, 72 were ineligible; an analysis of the data from 227 surveys is presented.

RESULTS

The response rate was 76%. Community-based PCPs comprised 70% of completed surveys. Reported care patterns were assessed to create a multidimensional care score reflecting levels of attention to 4 areas of survivorship care: monitoring for cancer recurrence, management of late effects, sexual functioning, and mental health. Only 24% of PCPs met criteria for routinely providing more multidimensional survivorship care. More recent medical school graduates reported providing less multidimensional survivorship care when compared with their more experienced colleagues. Approximately 82% of PCPs believed that primary care guidelines for adult cancer survivors are not well defined, and 47% of PCPs cited inadequate preparation and lack of formal training in cancer survivorship as a problem when delivering care to long-term survivors.

CONCLUSIONS

Although PCPs provide the bulk of care for long-term survivors within the survivorship phase of the cancer trajectory, only a small subset have reported providing multidimensional survivorship care. Results underscore a need for substantially increased training in survivorship care to support the delivery of multidimensional primary care for long-term survivors.