PCPs Stepping In for Care of Cancer Patients

Howard Wolinsky

August 03, 2022

In the face of a shortage of oncologists and the growth in numbers of cancer survivors, primary care physicians are picking up the slack in the care of these patients, a new study has confirmed.

The researchers found that two thirds of cancer survivors said they received maintenance care ― which included review of new or existing medical problems and medications taken, the ordering of necessary lab tests, referrals, and more ― from primary care providers.

However, many patients reported gaps in that care, which represents an important area for improvement, according to the researchers, whose findings appear in the Journal of the American Board of Family Medicine. A particular concern was that people in the study often said they did not recall having received written summaries or instructions from primary care physicians.

"At times, patients are confused about what to expect by way of their treatment and prognosis," William Rayburn, MD, MBA, an ob/gyn affiliated with the Medical University of South Carolina, Charleston, and a co-author of the study, told Medscape Medical News. "They may not receive written summaries or instructions that can compound the situation. There may be some gaps in care or delays in being monitored and treated."

Rayburn noted that the use of electronic medical records can improve communication between patients and physicians and reduce such gaps.

A Growing Population

The number of cancer survivors in the United States has surpassed 18 million, but oncologists are in short supply ― meaning primary care physicians will be increasingly tasked with handling cancer-related care, according to Patricia Ganz, MD, director of the UCLA Center for Cancer Prevention and Control Research at Los Angeles, who was not involved in the study.

She said 5% to 10% of patients in a typical primary care practice will have a history of cancer. "They should at least have some understanding of whether any special follow-up tests are needed because of the past diagnosis or treatments," she said.

For their study, Rayburn and his colleagues used data from the US Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System. Respondents completed a cancer survivorship module from 2016 to 2020.

The analysis included 36,737 cancer survivors who had completed interviews in 33 states. Most of their healthcare came from primary care physicians, chiefly family physicians (42%) and general internists (26%).

Roughly 73% of patients had had one type of cancer, including skin, breast, male reproductive, female reproductive, gastrointestinal, head and neck, urinary, and thoracic cancers, as well as leukemia/lymphoma.

When seen by primary care physicians rather than subspecialists, a lower proportion of patients recalled receiving summaries of either their cancer treatments (44.3%, 95% CI: 42.5% – 46.2%, vs 50.5%, 95% CI: 49.4% – 51.7%) or follow-up instructions (69.9%, 95% CI: 68.8% – 71.0%, vs 78.7%, 95% CI 77.1% – 80.2%), regardless of their cancer type.

However, Ganz said that that finding doesn't necessarily mean the summaries were not provided to patients.

"The fact that many patients did not remember receiving this [communication] could be because it wasn't done, but also because they can't remember back a decade," Ganz told Medscape.

Ganz said the findings show both the advantages and potential pitfalls of sharing care between primary care physicians and oncology specialists.

"Primary care clinicians do a much better job of managing other common chronic health problems, such as diabetes, high blood pressure, immunizations, cardiac risk reduction medications, so their involvement is more important post treatment than the oncology specialist," she said.

But for patients treated with more complex cancer regimens, such as chemotherapy, radiotherapy, and targeted therapies, primary care physicians may not be familiar with some follow-up needs or the late effects of treatment, and that is where a treatment summary may be most valuable, she added.

Unlike care for patients with heart disease or diabetes, long-term care for cancer survivors is currently not integral in medical school education or primary care residency training, according to the study authors.

"Our results strengthen the need for integrating cancer survivorship topics into residency education," they write. "Another training option could be postgraduate work in shadowing at cancer centers to bolster patient and oncologist receptivity in collaborating and transitioning into continuity care."

Rayburn contrasted primary care and oncology care, which can touch on every organ system, from skin to bones.

"Cancer is often very complex and 'experimental' in providing therapy. This is usually beyond the expectation of a family medicine trainee," he said.

But Ganz said primary care specialists can provide good care to cancer survivors as long as the patients have access to oncologists.

Primary care physicians are "extremely well suited for most of the ongoing care survivors need, which are lifestyle health promotion and disease prevention and management of chronic disease and mental health issues," she said. "Heart disease is the major cause of death in breast cancer patients, not breast cancer, in fact," Ganz said.

Rayburn and Ganz reported no relevant financial relationships.

J Am Board Fam Med. July 2022;35:708-715. Full text

Howard Wolinsky is a Chicago-based medical journalist. You can read more of his stories about prostate cancer at TheActiveSurveillor.com.

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