Tuesday, October 20, 2020

Cancer survivorship: what is the family physician's role?

 - Kenny Lin, MD, MPH

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized. The National Cancer Institute estimated that in 2019, cancer survivors numbered 16.9 million, or about 5 percent of the U.S. population. During the past few years, American Family Physician has published clinical reviews of the American Cancer Society's guidelines on primary care for survivors of prostate cancer, colorectal cancer, and breast cancer. The American Academy of Family Physicians' policy on Cancer Care recommends that "the physician workforce, including family physicians, should be educated about the protocols for survivorship management."

A recent qualitative study published in the Annals of Family Medicine found that the reality on the ground is more complex than current guidelines and policy suggest. Dr. Benjamin Crabtree and colleagues recorded lengthy interviews with 38 clinicians in 14 U.S. primary care practices that had been previously recognized for workforce innovation by the Robert Wood Johnson Foundation. In these interviews, clinicians were "asked to describe how they viewed their role in cancer survivorship, decisions of when and where to refer patients, and knowledge about new primary care–friendly survivorship care guidelines."

Analysis of the interviews revealed a lack of consensus about the role of primary care in cancer survivorship. For example, several clinicians felt that follow-up cancer care was exclusively the responsibility of oncologists, but the majority expressed that providing this care fell within their purview. However, they reported obstacles ranging from inadequate knowledge / education to "an uneasy relationship with oncology" and a lack of clarity about when care could be transitioned from the oncologist to primary care.

Clinicians also disagreed about whether cancer survivors should be treated as a "distinct patient population" (requiring a systematic health system approach) or like any other patient with a chronic disease. The researchers theorized that these divergent views reflected an "identity crisis" about their care roles for these patients:

Several clinicians expressed mixed opinions, contradicted themselves, vacillated on their stance, or paused when asked about their/primary care’s role in cancer survivorship care. In fact, some clinicians struggled to talk about cancer survivorship at all in their interviews. ... These clinicians, with an identity based on delivering whole-person, comprehensive, coordinated care, appeared to hit a wall of identity confusion when confronted with a swiftly changing highly specialized knowledge base and a highly variable group of patients referred to as “cancer survivors.”

Options for resolving this identity crisis, according to the researchers, could involve developing new cancer-focused curricula for primary care residency programs and continuing medical education; constructing more well-defined management boundaries between primary care and oncology; and/or having their professional organizations "consider coproducing and translating new knowledge about care for cancer survivors that primary care clinicians can prioritize, personalize, and integrate to address patients’ needs and values within a shared decision-making framework." With the population of cancer survivors expected to increase by 30 percent over the next decade, clarifying the appropriate role of family physicians remains an urgent national need.