America's 12 million cancer survivors are caught in the tussle between oncologists and primary care physicians who differ on knowledge, attitudes, and practices needed by patients. That is the key finding of the first nationally representative survey of doctors that reveals how these differences pose significant barriers to effective communication and coordination of care following initial cancer treatment.
The study, published online today in the Journal of General Internal Medicine
, included results of a survey of 1,072 primary cancer physicians (PCP) and 1,130 oncologists randomly sampled from among all U.S. practicing physicians during 2009.
The authors say the findings are of considerable concern, given the rapidly increasing cancer survivor population and looming shortages of both oncology specialists and primary care physicians who will be needed to provide care to this population. Because many individuals stop seeing their oncologist after the first few years following their initial cancer treatment, primary care doctors often assume a large share of providing care to survivors. Optimal cancer survivorship care includes not only surveillance for recurrence or second cancers, but also addressing the long-term and late medical effects of cancer or its treatment, providing psychosocial support, and managing other diseases or conditions.
Several factors may present challenges to ensuring a smooth transition for survivors as they move from initial acute care to post-treatment care, says the study's lead author, Arnold L Potosky, Ph.D., director of health services research at Georgetown Lombardi Comprehensive Cancer Center, a part of Georgetown University Medical Center.
"What the survey tells us is that many doctors, particularly primary care doctors don't have a high level of confidence in their own knowledge of some aspects of survivorship care, and many oncologists believe that PCPs are not adequately prepared to provide such care. We also see some evidence of knowledge deficits in both physician groups in terms of guideline-based care for survivors," he says.
"Although both oncologists and primary care doctors routinely recommended the use of several laboratory and imaging tests to detect cancer recurrence that are not part of guideline-directed care, more of the primary care physicians recommended these tests than did oncologists," Potosky says.
He says reasons for over-testing may include the practice of defensive medicine, reimbursement incentives for office-based lab testing, or uncertainty regarding best care practices. In some cases, such testing may also be influenced by survivors' requests.
The "Survey of Physicians Attitudes Regarding the Care of Cancer Survivors" asked both groups of doctors several questions about providing cancer survivorship care including the doctors' confidence in their knowledge about such care, and cancer surveillance practices.
In 2006, a report from the Institute of Medicine (IOM) recommended that patients completing primary treatment for cancer, and their primary care providers, be given a summary of their treatment and a comprehensive plan for follow-up.
Such a plan would inform patients (and their providers) of the long-term effects of cancer and its treatment, identify psychosocial support resources in their communities, and provide guidance on follow-up care, prevention, and health maintenance.
Julia Rowland, Ph.D., director of the Office of Cancer Survivorship at the National Cancer Institute and a co-author, says this study suggests several key insights regarding the implementation of the IOM's recommendations.
"More training and education on cancer survivorship is critical for the primary care physician and the oncologist," she says. "This might include identification of who may be best equipped to provide different aspects of care. Use of a survivorship care plan has the potential to serve as a valuable tool for helping to improve communication about as well as coordination of care between specialists and primary care physicians for survivors who are post-treatment."
The authors suggest that a cancer survivor, upon finishing treatment, meet with the treating oncologist to summarize the care received and outline appropriate follow-up care based on personal treatment history. They add that patients should find out what aspects of care to expect from the oncologist and the primary care physician respectively.