General Internists Need Help With Childhood Cancer Survivors

Jenni Laidman

January 07, 2014

Most general internists were unable to recommend appropriate cancer surveillance for adult survivors of childhood lymphoma when reviewing a patient vignette provided in a survey.

The survey results, which were published in the January 7 issue of the Annals of Internal Medicine, show that few internists are comfortable caring for adult CCSs.

They also highlight how little progress has been made by general internists and oncologists in helping cancer patients successfully transition into regular medical care, one of the study's authors, Tara Henderson, MD, MPH, assistant professor of pediatrics and director of the Childhood Cancer Survivors Center at the University of Chicago Medicine Comer Children's Hospital, told Medscape Medical News.

Although the Institute of Medicine (IOM) has taken on the issue of caring for cancer survivors — first in 2003, and then in 2006 with its report entitled From Cancer Patient to Cancer Survivor: Lost in Transition — physicians still have a long way to go to improve this transition, Dr. Henderson noted.

"We've created this new chronic illness that patients don't even know they have. It's our shared responsibility to know how to care for them better," she said.

In fact, CCSs are 3 times more likely to have a chronic health condition than age-matched control subjects, according to an accompanying editorial.

Survey Results

Of the 1801 general internists mailed the survey between September 2011 and August 2012, 1110 responded (61.6%). The survey asked about physician comfort in caring for CCSs and tested physician knowledge of the Children's Oncology Group (COG) long-term follow-up guidelines with a clinical vignette.

Only 36.9% of respondents said they were somewhat comfortable or comfortable caring for survivors of Hodgkin's lymphoma, 27.0% said they were somewhat comfortable or comfortable caring for survivors of acute lymphoblastic leukemia, and 25.0% said they were comfortable or somewhat comfortable caring for survivors of osteosarcoma.

On multivariate analysis, comfort levels were highest among internists with larger patient volumes, those who had seen at least 1 CCS patient in the previous 5 years, and those who were male. Still, the survey found that only 12.0% of internists said they were at least "somewhat familiar" with the surveillance guidelines for CCSs.

Physicians were presented with a vignette describing the hypothetical case of a 29-year-old female survivor of Hodgkin's lymphoma, which was designed to assess knowledge of surveillance guidelines. Results showed that most internists were unfamiliar with COG guidelines.

Only 5.4% of respondents answered 3 questions about surveillance correctly. For instance, COG guidelines recommend annual mammograms and breast MRI screening for Hodgkin's lymphoma survivors, yet only 17.8% of respondents recommended annual mammograms and only 9.4% recommended annual breast MRI.

Although only 14.9% of the internists knew to recommend an annual echocardiogram for the patient, 76.4% knew to recommended yearly thyroid-stimulating hormone and free thyroxine tests. Internists who had seen at least 1 CCS patient in the previous 5 years were more likely to recommend an annual mammogram and breast MRI (odds ratio [OR], 1.75) or a mammogram only (OR, 1.33).

Most respondents (84.0%) said they would rather work collaboratively with a physician based at a cancer center or a long-term follow-up clinic when caring for a CCS. However, there appears to be little contact between the treating oncologist and the internist. Although 51.1% of surveyed internists said they had seen at least 1 adult CCS in the previous 5 years, only 25.0% said they had received a treatment summary for the patient from the oncology center.

The 2006 IOM report recommended a survivorship care plan for each cancer patient that would provide a postcancer roadmap for the primary care physician. Such a plan would include a treatment summary, information on potential late cancer treatment effects, surveillance guidelines, and contact information for the treating cancer center. Yet such treatment plans appear to be rare. "What we learned in this study is that only 15% of physicians have a treatment summary," Dr. Henderson reported.

Part of the challenge for primary care physicians is the relative rarity of CCS in any general medical practice. "It's a growing population, but these doctors are seeing, at most, a couple of these patients a year," Dr. Henderson said. Physicians might not be aware that women who were exposed to chest radiation during their treatment have a higher risk of developing breast cancer than carriers of the BRCA1 and BRCA2 mutations.

Further, creating a survivorship care plan for each patient is a huge task for cancer care specialists. "I have a nurse practitioner who spends all day Monday making up survivorship care plans. It takes a long time to go through the medical record for each patient," Dr. Henderson explained. The process needs to be streamlined to take full advantage of electronic technologies, she said.

More Training Needed

In their editorial, Dava Szalda, MD, and Jill P. Ginsberg, MD, both from The Children's Hospital of Philadelphia, assert that medical schools and continuing medical education programs need to provide training on cancer survivorship, especially considering that the cure rate for pediatric cancers is 80%. They note that everyone involved in patient care needs to play a role in improving care — the general practitioner, the pediatric oncologist, and even the patient.

"Pediatric oncology teams should prepare CCSs for transition to the adult healthcare setting. Key components for a successful transition include developing self-management skills; obtaining knowledge of the CCS's diagnosis, treatment exposures, and risk for late effects; and setting realistic expectations about transfer to adult primary care providers. Pediatric oncology care providers need to ensure that patients can help advocate for their own care needs throughout their lifetime," the editorialists write.

This can be accomplished with "targeted transition readiness assessments and tools, standard policies and practices around the transition process, and creation and dissemination of a personalized care plan to survivors and primary care providers," they add.

The authors have disclosed no relevant financial relationships.

Ann Intern Med. 2014;160: 11-17, 66-67. Abstract, Editorial

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