The journey from cancer patient to cancer survivor: A 5-year longitudinal study

Reviewer: Christine Hill, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: June 3, 2007

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Presenter: Snyder, C.F.
Presenter's Affiliation: Johns Hopkins School of Medicine, Baltimore, MD
Type of Session: Scientific

Background

  • Over 10 million cancer survivors currently reside in the United States, and this number is estimated to continue to rise at a rate of approximately 3% each year.
  • Cancer survivors require attentive medical care after completing cancer treatment, and their comprehensive care should include assessment for recurrent cancer, monitoring for late effects of treatment, and screening for second malignant diseases in addition to general preventive care and care for any chronic medical conditions.
  • Cancer survivors may be at increased risk for cardiovascular disease, obesity, osteoporosis, and general functional decline when compared to the general population.
  • The responsibility for medical care after cancer lies to both the oncologist and the primary care provider; however, the roles of differing healthcare providers may become unclear.
  • This study was carried out in order to assess the physician specialists seen by cancer survivors, and how this may affect preventive care offered to patients after cancer treatment.

Materials and Methods

  • This study is a longitudinal, retrospective, descriptive, cohort study, which examined a population of stage I-III colorectal cancer survivors diagnosed with cancer in the year 1997.
  • The SEER-Medicare database was used to examine physician visits and preventive care services during 5 years following treatment. The year of diagnosis (diagnosis date + 365 days) was not assessed.
  • Patients were excluded from the study if they were deceased during the study period, developed a subsequent malignancy, received any chemotherapy or radiation treatment during any part of the study after the year of diagnosis, or utilized hospice care.
  • Visits to oncologic specialists (medical oncologist, radiation oncologist, general surgeon, or colorectal surgeon) were recorded as oncology appointments. Visits to primary care physicians, family practice physicians, or internal medicine physicians were recorded as primary care provider (PCP) visits. Visits to any other medical specialist were recorded separately.
  • Preventive care was assessed by five preventive actions (influenza vaccination, cholesterol screening, mammography, cervical cancer screening, and bone densitomery).

Results

  • 1541 patients met the eligibility criteria. The mean age of the study population was 76 years, and 85% of patients were Caucasian.
  • Over the five years of follow-up, the average number of PCP visits per year increased from 4.2 in year one to 4.7 in year five (p = 0.002). The average number of oncology visits per year declined from 1.3 in year one to 0.5 in year five (p < 0.001).
  • In year one of follow-up, 37% of patients had both PCP and oncology appointments, 44% saw only a PCP, and 8% saw only an oncologist. 11% did not see a physician. In year 5, 21% of patients saw both a PCP and an oncologist, 62% saw only a PCP, 4% saw only an oncologist, and 11% did not see a physician. The trend displayed was highly statistically significant (p < 0.001).
  • Patients who saw both an oncologist and a PCP over the 5 years of follow-up combined were more likely to undergo each of the preventive actions recorded than patients seeing either type of physician only.
  • 61.7% of patients seeing both types of physicians received influenza vaccination, as compared to 52.4% who saw only a PCP and 49.2% who saw only an oncologist (p < 0.001).
  • 35.7% of patients who saw both physicians had cholesterol screening versus 33.5% who saw only a PCP and 24.3% who saw only an oncologist (p < 0.001).
  • 54.3% of female patients less than 76 years old who saw both physicians underwent mammography, as compared to 32.1% who saw only a PCP and 42.3% who saw only an oncologist (p < 0.001).
  • 20.6% of female patients who saw both physicians had cervical cancer screening, versus 14.3% seeing only a PCP and 11.9% seeing only an oncologist (p < 0.001).
  • Bone densitometry was obtained for 12% of patients who saw both physicians, 10.7% who saw only a PCP, and 5.5% who saw only an oncologist (p < 0.001).

Author's Conclusions

  • As time from treatment increases, patients are more likely to follow with a PCP than an oncologist.
  • Patients who continue to see both a PCP and an oncologist are most likely to have adequate preventative care, including cancer screening.
  • With the exception of mammography, patients who see only a PCP are more likely to have adequate preventive care than those who see only an oncologist. Patients who saw only an oncologist were more likely to undergo mammography than those who saw only a PCP within this population.
  • These data demonstrate that preventive medicine, including cancer screening, is largely inadequate for cancer survivors in the United States.
  • Documented survivorship plans are necessary to facilitate communication between oncologists and primary care providers to ensure that patients receive adequate preventive care.

Clinical/Scientific Implications

  • This large, retrospective, cohort study demonstrates clearly that the role of the oncologist decreases as survivorship time increases. As a result, communication with patients and other physicians is essential so that patients may have adequate evaluation for disease recurrence, late effects of treatment, and preventive care that is recommended for the general healthy population.
  • After a patient is treated for cancer care, the responsibility to ensure that he or she has adequate follow-up care lies largely on the oncologist. To this end, well-documented explanations of necessary follow-up care should be given to patients and other physicians at the completion of cancer care to allow improved communication and improve long term care.
  • Plans for follow-up of oncology patients should encompass both specific care for the initial cancer diagnosis and risk-management for late effects of treatment, as well as preventive medicine and aggressive screening for second malignancies.


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