For Early Breast Cancer, Family Physicians Shown to Provide Same Quality of Long-term Follow-up Care as Specialists

Family physicians can provide the same level of long-term follow-up care for early-stage breast cancer patients as oncologists, according to a Canadian study published in the Journal of Clinical Oncology (2006;24:835–837). The study by Eva Grunfeld, MD, DPhil, of Dalhousie University, and colleagues, confirmed results from a similar study she had conducted in the United Kingdom a decade before (BMJ 1996;313:665–669).Figure: Eva Grunfeld, MD, DPhil: “The study tested the hypothesis that follow up by a patient's family physician is a safe, acceptable alternative to follow up by an oncologist, and showed that women should not be concerned about recurrence-related serious clinical events occurring more frequently, or their health-related quality of life being affected negatively.”In an accompanying editorial to the new study, James L. Khatcheressian, MD, and Thomas J. Smith, MD, both from Massey Cancer Center of Virginia Commonwealth University, refer to the original report as a landmark article for women with breast cancer and their health care providers, noting that it shows conclusively that health outcomes for women after primary treatment of breast cancer are the same if they are followed by their family physicians or cancer center specialists. “Medical, psychosocial, and all other measured outcomes were the same. There really is no other conclusion that can be drawn,” the editorial said. Call for ASCO to Partner with Primary Care Doctors Despite the double endorsement, the editorial goes on to raise questions and offer some practical steps to improve follow-up of breast cancer patients, including a call for the American Society of Clinical Oncology to begin partnering with primary care physicians and for shared patients to further improve the follow-up process. In a telephone interview, Dr. Grunfeld, Director of the Cancer Outcomes Research Program and Professor of Medicine at Dalhousie in Halifax, Nova Scotia, clarified that the study focused more on follow-up surveillance than treatment of women completing primary treatment for early-stage disease. “The study tested the hypothesis that follow-up by a patient's family physician is a safe, acceptable alternative to follow-up by an oncologist, and showed that women should not be concerned about recurrence-related serious clinical events occurring more frequently, or their health-related quality of life being affected negatively.” Study Details The randomized, controlled trial conducted at six regional cancer centers in Ontario, involved 968 women with early-stage breast cancer who had completed adjuvant treatment, were disease free, and were nine to 15 months post-diagnosis; some patients may still have been receiving adjuvant hormonal therapy. Patients were enrolled between January 1997 and June 2001, and were observed until their fifth-year anniversary on the trial, or June 30, 2003, depending on which came first. The patients were randomly allocated to be seen by either their oncologist or own family physician. Family physicians were given a one-page guideline on follow-up care that recommended physical examination and taking a medical history every three to six months for three years, every six months for two years, and then annually; yearly mammograms; and diagnostic tests to investigate possible signs or symptoms of recurrence or a new primary tumors—however, these tests were not to be performed routinely. In addition, physicians seeing patients on tamoxifen were also instructed to take a history of vaginal bleeding every visit, and perform a pelvic exam yearly. If patients had a recurrence or new primary, they were to be referred back to the cancer center. Of those seen by family physicians, 54 had recurrences (11.2%) and 29 died (6%). Those followed up by oncologists had 64 recurrences (13.2%) and 30 died (6.2%). Seventeen (3.5%) of the family practice-followed patients experienced recurrence-related serious clinical events as contrasted with 18 patients (3.7%) of those seen by oncologists. In addition, there were no statistically significant differences between the two groups for the secondary outcome health-related quality of life. Unique Opportunity to Work in Cancer Center as Family MD Dr. Grunfeld's interest in the study evolved from her own practice experience, she noted. Trained as both a family physician and epidemiologist, and serving as a clinician scientist, she had the unique opportunity to work in a cancer center as a family physician seeing mostly breast cancer and some colorectal cancer patients. “I was struck by two things,” she said. “The huge volume of breast cancer patients that had to be seen at the clinic, and the fact that many of those patients were having well checkups and had no problems. I also saw that when patients did have a problem there was almost no time to deal with them because of the overload—a poignant example of our focusing our energies in the wrong direction. “And the other part was that I was fresh out of my family medicine training program, and was very junior at that point, but I felt very confident in my skills. I didn't see patients in that follow-up who I felt I didn't have the required skills.” She noted that although she was not trained to prescribe chemotherapy or make decisions about radiotherapy, she was comfortable doing the patient follow-up, and began to think about the issue of rehabilitation and the philosophy of survivorship, leading to her first study in the UK. Dr. Grunfeld said it was significant that both the Canadian and UK studies came to the same conclusion in two completely different health care settings.Figure: James L. Khatcheressian, MD: “What we don't know is how good or comfortable family practitioners would be at continuing hormonal therapy when patients will need it for another five years, or how good they will be at addressing other survivorship issues including such side effects of treatment as hot flashes, depression, anxiety, vaginal dryness, and urogenital atrophy. Those things still have to be addressed.”Definition of Family Physicians She also said family physicians in Canada were defined as those physicians receiving two years post-medical school training in family medicine, rather than the four-years training required of specialists, adding that general internists and other physicians, such as gynecologists, who could be considered as primary care physicians in the United States, were not included in the Canadian study, and that family physicians were called general practitioners in the UK. However, she said that any physician in the US who considered himself or herself a primary care physician and had breast cancer patients, would be appropriate to partner with oncologists in continuing patient care. Differences in Situations in US vs Canada In a telephone interview, Dr. Khatcheressian, Assistant Professor at Virginia Commonwealth, said it was noteworthy that the family physicians in Canada had less education than many US counterparts and had still performed as well as the oncologists. He pointed out that both the Canadian and UK health systems are publicly funded, while in the US, most medical care other than Medicare is private. “The JCO study answers a very specific question that it's safe for patients to get their surveillance follow-up care from family physicians—that's the landmark part of the study,” he said. “What we don't know is how good or comfortable family practitioners would be at continuing hormonal therapy when patients will need it for another five years, or how good they will be at addressing other survivorship issues including such side effects of treatment as hot flashes, depression, anxiety, vaginal dryness, and uro-genital atrophy. Those things still have to be addressed. “Most oncologists don't know this,” he continued, “but only about 30% to 40% of breast cancer recurrences are actually found during clinician visits. The vast majority are found between scheduled visits, and they could be local or regional recurrences or metastatic disease.”Figure: Patricia A. Ganz, MD: “Patients should be in the driver's seat when making decisions about their care, and now I have a paper I can pull out and show them with confidence that they have a choice in their follow-up care.”Practical Steps to Improve Follow-up Care Dr. Khatcheressian and Dr. Smith, Professor and Chairman, Hematology/Oncology and Palliative Care at Massey, provided a number of practical steps—for all physicians, specialist or generalist—to improve follow-up care for breast cancer patients, including: Working with patient advocacy groups to educate their constituents about what medical science can and cannot do, and to evolve the most efficient methods of follow up. Developing and incorporating a one-page follow-up guideline into family physicians practices. Experimenting with patient-controlled follow-up methods such as USB flash drives issued to patients with a form to be completed by medical professionals following each visit. Following the guidelines already in place. During his interview, Dr. Khatcheressian discussed the need to offload follow-up patients in busy clinics when oncologists can't see new patients in a timely matter. He also expressed concern that third-party payers in this country could potentially use this study to deny referrals to oncologists for follow-up care. “This study reflects the evidence of what's been found—and we need to practice evidence-based medicine,” he said. Need for Oncologists to be More Organized in Writing End-of-Treatment Plans? Patricia A. Ganz, MD, Professor of Health Services and Medicine at the UCLA School of Public Health, and Director of the Division of Cancer Prevention and Control Research of UCLA's Jonsson Comprehensive Cancer Center, is also an Associate Editor of JCO and a member of ASCO's Board of Directors. Dr. Ganz and ASCO President Sandra J. Horning, MD, are Co-chairs of ASCO's Survivorship Task Force, and Dr. Ganz was a member of the Institute of Medicine Committee that wrote the IOM' recent survivorship report, “From Cancer Patient to Cancer Survivor: Lost in Transition,” released last November. During a phone interview, Dr. Ganz concurred with Dr. Khatcheressian's comment about the value of practicing evidence-based medicine as it pertains to the Canadian study. She also noted the need to make room for new patients in practices filled with survivors. But she acknowledged that many oncologists could be more organized in writing end-of-treatment plans. “Here I am, a survivorship expert, and I don't do this. We should be doing a better job of developing survivorship plans to be given to patients and primary care physicians. We need to find a better way to keep people in the loop and work on a transition plan,” she said, adding that many oncologists and patients might be reluctant to part from each other because of the intense personal relationship fostered during treatment. “Patients should be in the driver's seat when making decisions about their care, and now I have a paper I can pull out and show them with confidence that they have a choice in their follow-up care.” Recommendation for Reimbursement for Level 4–5 Visit She said this transition process could be aided if oncologists were reimbursed for a level four or five comprehensive visit for scheduling a 40-minute end-of-treatment visit with their patients, and that this kind of recognition could help move a lot of things forward.Figure: Clifford A. Hudis, MD: “Implementing this would require a really tightly coordinated, robust system tying family doctors back to the oncologist, and this isn't something you can necessarily count on, especially with the mobility of Americans.”Related Events at ASCO Annual Meeting Dr. Ganz said that ASCO is currently preparing survivorship guidelines that will be discussed during an educational session at the annual meeting in June, and that the Society will debut its new Patient and Survivor Care track at the meeting. Dr. Grunfeld's study had been presented as a poster at ASCO's 2004 meeting in New Orleans, and Dr. Grunfeld said she had encountered two types of reactions from oncologists at that time: “One was ‘my patients won't need me anymore’—it was almost a sense of abandonment. “My response to that,” Dr. Grunfeld said, is that since the oncologists' experience is so valued and has proven to provide such enormous benefits in terms of improving survival and alleviating symptoms, then it seems that those efforts should be channeled where they are needed the most. “The other point raised was about oncologist burnout. Oncologists said that if they didn't see well patients, they couldn't deal just with sick and dying patients all the time. My response to this is that oncologists see a lot of patients during treatment where the goal is survival, and it's a very tough road, but there is a very positive outcome they know will result for it. “My ultimate objective for patients,” she continued, “is to be offered a choice by being able to make an informed decision. There will always be a proportion of patients who don't wish to be followed by their family physicians and will continue their care in a specialist's office. And alleviating the enormous numbers and bringing it down to a manageable size could also help the burnout. “And finally, it's what the patient needs, not the oncologist.” Some Resistance Dr. Grunfeld noted there had been a certain degree of resistance to her thesis and study, which she said she attributed partly to territoriality and partly to selection bias—i.e., clinicians remember unusual cases and oncologists will remember the case when a family physician might have missed something or had a problem with a patient, influencing decisions in subsequent situations. “Of course, the problem is it's the oncologist's perspective; from the family physician's perspective, it will be the mistakes that the oncologist made that will be remembered.” She said family physicians have been welcoming and supportive of the study, with two corollaries—they get the guidelines that tell them what to do; and they have access to specialists when they need them. Dr. Grunfeld is now looking at factors that affect follow-up care and is involved in a study testing interventions that will facilitate transition from intensive treatment to survivorship for patients. ‘Presumes Static Situation’ One oncologist who doesn't think the study will have much impact on his clinical practice is Clifford A. Hudis, MD, Chief of the Breast Cancer Medicine Service at Memorial Sloan-Kettering Cancer Center. “I don't dispute the results of the trial,” he explained. “I think it's a well-done study that looks at an important question. But it does presume a static situation going forward, and presumes that other components of care will be perfect and that family physicians will be able to keep up with evolving developments in late management of early-stage breast cancer. “Implementing this would require a really tightly coordinated, robust system tying family doctors back to the oncologist, and this isn't something you can necessarily count on, especially with the mobility of Americans.” Dr. Hudis said the study gives oncologists comfort with patients who say it's difficult to continue coming in once the acute phase of treatment is completed, and want to follow up with family physicians. “This is okay if patients still keep in touch by phone or electronically. But my caveat is there is a possibility that in the future we could see late treatment changes in an ER-negative breast cancer patient similar to what we've already seen with ER-positive patients, making it incumbent upon us to have a really robust way to maintain contact and keep track of these patients. With so much mobility, we don't want a system with people getting lost and being denied the benefits of treatment changes.” He gave an example of a breast cancer patient who finished treatment in March 2005 and wasn't being followed up by an oncologist and thus might not have known that it there was the announcement at that year's ASCO meeting in May about the very positive results with Herceptin. “Who would call these patients to let them know?” he asked.

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