Care of Cancer Survivors: Oncologists vs Primary Care Docs

Roxanne Nelson

August 04, 2011

August 4, 2011 — The number of cancer survivors in the United States has grown to nearly 12 million individuals. Survivorship often comes with complex issues, but oncologists and primary care physicians (PCPs) disagree about to the ideal model of care for survivors.

The results of a study published online July 22 in the Journal of General Internal Medicine suggest that oncologists have an "unfavorable view" of giving PCPs a central role in caring for cancer survivors. PCPs also expressed mixed views about assuming increased responsibility for survivorship care.

The majority of oncologists favored a model led by oncologists, but almost half of all PCPs preferred a shared-care model or one led by PCPs.

Both groups of physicians, however, departed substantially from guidelines recommending routine blood tests, and both groups reported substantial overuse of chest x-rays and computed tomography scans.

"I think the key message that comes most directly from the paper is the need for doctor-to-doctor communication," explained lead author Arnold L. Potosky, PhD, director of health services research at Georgetown University, Lombardi Comprehensive Cancer Center, in Washington, DC.

He pointed out that follow-up care can be provided in many ways — from oncology specialists, nurse-led clinics, or PCPs. "But whatever the setting, it's important that there be communication between everyone involved, so that there's an agreed-upon plan for both cancer follow-up and noncancer care," Dr. Potosky told Medscape Medical News.

"We hope that these results stimulate policies and practice to improve care coordination and communication between oncologists and PCPs," he added. "Cancer survivors also see these results and understand how important it can be for them to advocate for better communication between the doctors who provide their care."

Barriers Between Oncologists and PCPs

These data reflect the results of a study that was presented at this year's annual meeting of the American Society of Clinical Oncologists (ASCO), which looked at barriers between PCPs and medical oncologists. Those results suggested a need for increased coordination between clinicians and a need for improved physician education and training in survivorship-care planning.

As reported by Medscape Medical News, that study found that PCPs were significantly more likely to report that they "often/always" order tests or treatments as malpractice protection because of concern about missed care and because they lack adequate training to manage patient problems.

In contrast, medical oncologists were more likely to report (often/always or sometimes) being concerned about duplication of care and about which physician should be providing general preventive healthcare. Medical oncologists were less likely to report inadequate training and less likely to often/always order extra tests because of malpractice concerns.

Coordination of care remains problematic because of the fragmented healthcare system, said Wendy Demark-Wahnefried PhD, RD, professor in the Department of Nutrition Sciences and associate director of cancer prevention and control at the University of Alabama Comprehensive Cancer Center in Birmingham.

"Currently, we have fragmentation, and part of that may be the perception of pressures of practicing medicine in 2 very different spheres," said Dr. Denmark-Wahnefried, who acted as a discussant of the study at the ASCO meeting.

It is important to look at how medical oncologists and PCPs can overcome these different concerns, resolve this fragmentation, and improve the care of cancer survivors, she added.

Need for PCP Skills

In the survey by Dr. Potosky and colleagues, a large number of PCPs expressed uncertainty about their own level of skills and knowledge of survivor care. Less than 60% of PCPs, for example, agreed that they possessed the skills necessary to care for treatment effects in survivors of breast or colon cancer, and less than half of PCPs felt very confident in their knowledge of testing for recurrence or caring for the psychosocial effects of cancer. In addition, only 23% of PCPs reported feeling very confident in their ability to care for the late physical effects of cancer or its treatments.

The views of many oncologists echoed these opinions, but were more negative. Only 38% of oncologists agreed that PCPs have the skills necessary to initiate the appropriate screening or diagnostic work-ups to detect recurrent breast cancer, and about a quarter strongly or somewhat agreed that PCPs possess the skills necessary to provide follow-up care related to the effects of breast cancer or its treatment.

Improving Care?

Given the current system, Dr. Potosky is unsure of how PCPs can improve their skills or knowledge. "Our survey did not specifically ask PCPs how open they are to further training in skills," he said. "An alternative that we mention in the paper is specialty survivorship clinics led by generalists or even allied health professionals with specific training in cancer survivors."

He pointed out that survivorship-care plans and treatment summaries, which have been advocated in recent years, and are now starting to be used in specialized centers. "Hopefully, these strategies can be refined and improved so that they can be more readily disseminated to more practice settings," Dr. Potosky added.

Study Details

Dr. Potosky and colleagues sought to compare PCPs' and oncologists' knowledge, attitudes, and practices for follow-up care of breast and colon cancer survivors. Using the American Medical Association Physician Masterfile to obtain a nationally representative sample of physicians, they mailed questionnaires to 1072 PCPs and 1130 medical oncologists in 2009. The response rate was 65%.

The shared-care model was preferred by 38% of PCPs, whereas 25% of PCPs felt that oncologist should have the primary responsibility for follow-up care, and 10% preferred a PCP-led model.

Conversely, 57% of oncologists preferred an oncologist-led model, 16% preferred a shared-care model, and 2% preferred a PCP-led model. However, similar proportions of PCPs and oncologists (~22%) endorsed specialized survivorship-care clinics.

Overall, oncologists had more confidence in their ability to care for survivors. In caring for patients with late physical effects of cancer, 23% of PCPs and 77% of oncologists expressed high confidence in their knowledge. In addition, 85% of oncologists stated that the were "very confident" about ordering appropriate tests for detecting recurrent breast cancer; only 40% of PCPs expressed this level of confidence (P < .001). The results for colon cancer were comparable to those for breast cancer.

Many oncologists expressed less confidence in PCPs than the PCPs themselves. For example, whereas 75% of PCPs believed that they have the skills necessary to initiate appropriate screening or diagnostic work-ups to detect recurrent breast cancer, only 38% of oncologists did. Likewise, only 8% of oncologists believed that PCPs are better able than oncologists to provide psychosocial support for breast cancer survivors, compared with 51% of PCPs (all P < .001). These perceptions of PCP skills in providing care to colon cancer survivors were virtually identical to those for breast cancer.

These findings are significant, the authors note, because a lack of receptiveness to PCP involvement in the care of survivors, especially by oncologists, "could compromise efforts to promote shared care or PCP-led delivery models, which may be a key strategy in meeting the care needs of the many survivors who see only their PCP annually."

Funding for the Survey of Physicians Attitudes Regarding the Care of Cancer Survivors (SPARCCS) was provided by the National Cancer Institute and the American Cancer Society Intramural Research funds. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online July 22, 2011. Abstract

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