Study: Are PCPs equipped to provide follow-up cancer care?

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Most primary care physicians (PCPs) are confident in their abilities to provide cancer survivors with adequate follow-up care, an assurance in the skills of PCPs shared by less than one-fourth of oncologists, who see themselves as better-equipped to care for survivors. Meanwhile, both PCPs and oncologists order significantly more screening than professional guidelines recommend.

In light of the growing number of cancer survivors in the U.S., coupled with a dwindling supply of PCPs and oncologists, the National Cancer Institute and the American Cancer Society co-sponsored the "Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS)." SPARCCS surveyed 1,072 PCPs and 1,130 oncologists in an effort to understand physician perceptions toward the models of care most appropriate to caring for survivors of cancer.

The results, published online July 25 in the Journal of General Internal Medicine, comprised a nationally representative sample of non-federal PCPs and oncologists who spend at least 20 percent of their work directly involved in patient care. The demographics of respondents (2,202) and non-respondents/excluded subjects (1,394) did not differ significantly.

Fifty-nine percent of PCPs believed they possessed the necessary skills to provide follow-up care related to the effects of breast cancer. Only 23 percent of oncologists, however, felt equally confident in the skills of PCPs regarding follow-up care. PCPs showed similar confidence in their own abilities to initiate the appropriate screening and diagnostic work-ups to detect recurrent breast cancer. Only 38 percent of oncologists shared confidence in these skills for PCPs.

With regard to optimal models of care for cancer survivors, 38 percent of PCPs advocated a shared model with responsibilities falling on both PCPs and oncologists. Only 16 percent of oncologists agreed with the shared model of care, though, while 57 percent preferred an oncologist-led regimen. One-quarter of PCPs thought oncologists should direct a survivor’s care.

Oncologists expressed significantly greater confidence in their ability to order the appropriate tests to detect recurrent disease. Eighty-five percent of oncologists said they were “very confident” in their level of knowledge, compared with 40 percent of PCPs who expressed similar levels of confidence in their own abilities to order the right tests.

Ninety percent of PCPs and 65 percent of oncologists recommended colonoscopies more frequently than the four- to five-year intervals recommended by guidelines. Nearly all physicians in both specialties recommended yearly mammograms for breast cancer survivors.

Oncologists and PCPs endorsed non-recommended blood tests substantially more often than non-indicated imaging studies.

Physician responses reflected “that both PCPs and oncologists deviate from guidelines by endorsing more testing, and at more frequent intervals, than the guidelines suggest. Although both groups departed substantially from guidelines, PCPs diverge more substantially than do oncologists, consistent with our findings of deficits in confidence regarding their knowledge of follow-up care,” explained Arnold L. Potosky, PhD, from the Lombardi Comprehensive Cancer Center at Georgetown University Medical Center in Washington, D.C., and colleagues.

“Both physician groups demonstrated substantial overuse of chest x-rays and CT scans. PCPs were much more likely than oncologists to endorse non-guideline imaging tests such as chest x-rays, bone scans and MRI,” the authors wrote.

Potosky and co-authors hypothesized that these findings might contribute to increasing healthcare costs and iatrogenic harms among cancer survivors. They cited defensive medicine and uncertainty of appropriate imaging guidelines as plausible causes, and called for better education and training of imaging guidelines.

“Taken as a whole,” Potosky and colleagues reflected, “these findings suggest significant attitudinal barriers among both PCPs and oncologists that could impede implementation of new delivery models in which PCPs assume greater responsibility for cancer survivor care.”