Oncologists' and primary care providers' awareness of late effects of cancer treatment: Implications for survivorship care

Reporter: J Taylor Whaley
The Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 2 de junio del 2012

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Presenter: Larissa Nekhlyudov, MD, MPH
Presenter's Affiliation: Harvard Medical School and Harvard Vanguard Medical Associates, Boston, MA

Background

  • Cancer survivorship is on the rise with an estimated 12 million cancer survivors living in the United States today.
  • Unfortunately, all cancer treatments cause side effects, and many survivors are faced with long-term effects of treatments.
  • Cancer survivors are often required to cope with numerous long-term morbidities that have the potential to significantly impact their overall outcomes. Previous studies have documented that co-morbidities and non-cancer symptoms drive both quality of life and functionality.
  • It has been shown that oncologist visits decline sharply more than 5 years following completion of cancer therapy. As patients transition from active treatment to follow-up, transitions in care across different specialties are critical. For this reason, multidisciplinary awareness of long-term effects of cancer treatment is vital.
  • The goal of the current study was to describe and compare primary care providers' (PCP) and oncologists' awareness of long-term effects associated with the most common chemotherapies currently utilized in the treatment of cancers.

Materials and Methods

  • The authors utilized the Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) to evaluate the knowledge of actively practicing physicians.
    • SPARCCS is a survey tool from the NCI to identify perceptions, knowledge, and practices of primary care and oncology specialist physicians regarding post-treatment follow-up care of adult cancer survivors.
  • For a physician to be included in the study entry:
    • He/ she needed to practice in a non-Federal practice
    • Be < 76 years of age
    • Devote greater than 20% of his/her time to clinical work
  • The survey was sent to 3596 physicians nationwide. It was completed by a nationally representative sample of 1,072 PCPs and 1,130 oncologists (cooperation rate 65%).
  • Respondents were asked to report for each of four standard chemotherapy drugs used to treat breast or colorectal cancer the five long-term effects they had observed and/or had seen reported in the literature.
  • The main toxicities for the chemotherapies questioned are below:
    • Doxorubicin: Cardiac Toxicity
    • Cyclophosphamide: Premature Menopause or Second Malignancies
    • Paclitaxel: Peripheral Neuropathy
    • Oxaliplatin: Peripheral Neuropathy
  • The survey asked physicians to match the chemotherapy to the most common toxicity in a word-matching technique. The physician could answer "I do not know."
  • The authors contrasted the physicians' responses and, using separate multinomial logistic regression models, determined predictors of their ability to identify the main late-term effects for all agents, adjusting for physician demographics and practice characteristics

Results

  • The most common demographic for responding physician was white, male, U.S trained, and board-certified.
  • Of PCPs, 40% of physicians specialized in family medicine, 40% internal medicine, and 20% ObGyn.
  • 95% of oncologists identified cardiac dysfunction as a long-term effect of doxorubicin, and peripheral neuropathy as long-term effect of both taxol (97.3%) and oxaliplatin (96.6%)
  • Primary care physicians correctly identified these in only 55.1%, 21.8% and 21.8% of cases, respectively.
  • Most oncologists identified premature menopause (71.4%) and secondary malignancies (62.0%) as long-term effects of cyclophosphamide, compared with only 14.8% and 17.2% of PCPs.
  • The major long-term effects of all four chemotherapy drugs were identified by 65% of oncologists and only 6% of PCPs.
  • In adjusted models, oncologists were more likely to identify the main long-term effects for all chemotherapy drugs if they spent >51% of their time on patient care, and less likely if they were not board certified.
  • Although the questionnaire sent to physicians was fairly simple, it failed to define a long-term effect on the basis of time. Therefore, some physicians may have been unclear with respect to the toxicities.

Authors' Conclusions

  • Oncologists often identified the main long-term effects of common chemotherapies while PCPs did not.
  • While not surprising, these findings emphasize that during the transition of patients from oncology to primary care settings, PCPs should be informed about the long-term effects of cancer treatment so that they may be better prepared to recognize and address these among survivors in their post-treatment care.
  • Ongoing education of physicians in fields outside of oncology, particularly PCPs, who are frequently involved in cancer survivors continued care, is critical. PCPs should be informed on potential late complications so patients can receive proper treatment and maintain their quality of life and function.

Clinical Implications

  • The authors present the study, which is certainly thought provoking. Although the results are not unexpected, they highlight a critical need for education of medical practitioners outside of oncology regarding cancer survivorship.
  • Previous studies into survivorship have demonstrated that cancer survivors perceive a lack of coordination and communication during follow up between the oncologists and PCPs.
  • Much interest has risen regarding the most appropriate model for follow up cancer care. These include oncologist driven, PCP driven, and shared care.
  • For this reason, survivorship plans have recently moved into public interest. The Institute of Medicine has recommended that all individuals following cancer therapy be provided with a summary of the treatments received and a follow up "care plan". The care plan should include the possible late side effects, recommendations for cancer screening, psychosocial effects, financial issues, recommendations for a healthy lifestyle, genetic counseling, referrals for follow-up care and a list of support resources.
  • This study highlights the need for survivorship care plans, which may serve not only to inform survivors, but their future healthcare providers regarding late effects for which they may be at risk based on their cancer treatments.
  • Certainly, additional studies are needed to improve long term care of cancer survivors.

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