Cancer survivorship: a challenge for primary care physicians

Original Publication: Grunfeld, E. Cancer survivorship: a challenge for primary care physicians. Br J Gen Pract. 2005 October 1; 55(519): 741-742.

An important aspect of the medical management of cancer survivors is cancer-specific follow-up care. Follow-up care consists of periodic routine visits and tests towards the broad goals of detecting recurrence, monitoring late effects of treatment, screening for related new primary cancers and providing psychosocial support. The frequency of visits and the types of tests vary according to the type of cancer. The growing research literature on cancer follow-up care has challenged some of the basic tenets on the value of routine visits and tests for detecting recurrence, as exemplified by current guidelines on breast¹ and colorectal cancer,² which recommend very few routine tests (for example, only mammograms are recommended for breast cancer) and focus on history taking and physical examination. Also challenged is the long-held tradition of providing routine follow-up care in cancer specialist clinics. It has now been shown in two randomized controlled trials - one conducted in the UK and one in Canada - that primary care-based follow-up of breast cancer patients is a safe alternative to specialist follow-up as measured by a range of outcomes, such as delay in diagnosing recurrence, the rate of recurrence-related serious clinical events, health-related quality of life and patient satisfaction.^3-5 While these two trials studied breast cancer patients the findings can be arguably viewed as proof of principle for the other most prevalent cancers. Previous research has suggested that family physicians wish to be more involved in the ongoing care of their patients with cancer.⁶ These two trials have shown that not only are general practitioners willing to assume primary responsibly for follow-up care, but that they can do so with outcomes similar to specialist care.

For survivors of childhood cancers, some have recommended follow-up for life in specialist clinics. Whether this is sensible or feasible is questionable both from the perspective of resource implications and from the perspective of a child growing to adulthood with the associated changes in healthcare needs and location of care. Moreover, pediatric oncology clinics do not have the skills to manage the range and changing healthcare needs of survivors of childhood cancer throughout their lifespan: it is general practitioners who are experts in this form of care. Fragmenting care is not in the best interests of the patient. When discharged, almost all patients are discharged to the care of their family physician,⁷ and survivors of childhood cancer ranked primary care physicians as the most practical source of long-term medical care.⁸

Comprehensiveness of care is one of the important potential benefits for cancer survivors of primary care-based follow-up. Most cancer survivors require not just surveillance for the index cancer, but general medical and preventive care. Two studies that examined this question found that patients followed solely by a primary care physician were more likely to receive general medical and preventive care, but less likely to receive cancer specific surveillance such as colonoscopy and mammography.^9,10 This finding may be due to ambiguity as to which healthcare practitioner is primarily responsible for aspects of the patient's care, and can potentially be addressed by a clear allocation of responsibility for follow-up to the general practitioner. For the patient, both forms of care are important and neither should be neglected. It can be argued, however, that for long-term survivors of breast, colorectal and prostate cancer the greater health threat lies with other  conditions than with the index cancer.

The possibility of devolution of long-term follow-up care to the primary care setting poses important challenges for general practitioners and cancer specialists alike. These challenges are akin to the dissemination and uptake of new knowledge that faces us in all areas of medicine.¹¹ In the two breast cancer follow-up trials3,4 primary care physicians provided follow-up care with the aid of a simple guideline. While guidelines are an important tool¹² they are not always sufficient.¹¹ Many studies have shown that adherence to guidelines by general practitioners can be suboptimal. Mechanisms to improve adherence to guidelines is a hotly researched area of medicine.¹¹ This research points to the multiple factors that influence adherence to guidelines such as the credibility of the guideline producer, potential barriers and supports within the practice environment and - above all - factors unique to the specific patient. Primary care physicians will vary their adherence to a guideline recommendation according to factors unique to the specific patient.¹² This points to the importance of engaging cancer survivors as active participants in their long-term care.

General practitioners have stated that they wish to be more involved in the care of their patients with cancer. With the growing prevalence of cancer survivors in the population, the opportunity - along with the challenge - is upon us now.

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References:

1. Smith, TJ; Davidson, NE; Schapira, DV, et al. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol. 1999;17:1080-1082.

2. Benson, AB; Desch, CE; Flynn, PJ, et al. 2000 Update of American Society of Clinical Oncology Colorectal Cancer Surveillance Guidelines. J Clin Oncol. 2000;18(20):3586-3588.

3. Grunfeld, E; Levine, MN; Julian, JA, et al. A randomized trial of long term follow-up for early stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2005 in press.

4. Grunfeld, E; Mant, D; Yudkin, P, et al. Routine follow up of breast cancer in primary care: a randomised trial. BMJ. 1996;313:665-669.

5. Grunfeld, E; Fitzpatrick, R; Mant, D, et al. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomised controlled trial. Br J Gen Pract. 1999;49:705-710.

6. Grunfeld, E; Mant, D; Vessey, MP; Fitzpatrick, R. Specialist and general practice views on routine follow-up of breast cancer patients in general practice. Fam Pract. 1995;12:60-65.

7. Taylor, A; Hawkins, M; Griffiths, A, et al. Long-term follow-up of survivors of childhood cancer in the UK. Pediatric Blood Cancer. 2004;42:161-168.

8. Zebrack, B; Eshelman, DA; Hudson, MM, et al. Health care for childhood cancer survivors: insights and perspectives from a Delphi panel of young adult survivors of childhood cancer. Cancer. 2004;100:843-850.

9. Earle, CC; Neville, BA. Under use of necessary care among cancer survivors. Cancer. 2004;101:1712-1719.

10. Earle, CC; Burstein, HJ; Winer, EP; Weeks, JC. Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol. 2003;21:1447-1451.

11. Grimshaw, JM; Thomas, RE; MacLennan, G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):1-72.

12. Zitzelsberger, L; Grunfeld, E; Graham, ID. Family physicians' perspectives on practice guidelines related to cancer control. BMC Fam Pract. 2004;5:25.