The role of family physicians in cancer care: perspectives of primary and specialty care providers

Care Coordination Between Family Physicians and Palliative Care Physicians for Patients With Cancer: Results of a Quality Improvement Initiative

PURPOSE

At our institution's cancer palliative care (PC) clinic, new referrals from oncologists were scheduled for consultation and ongoing follow-up by PC physicians without input from the patients' family physicians (FPs). FPs reported that they felt out of the loop. We implemented a quality improvement (QI) initiative aimed at systematically facilitating care coordination between FPs and PC physicians.

METHODS

A coordination toolkit was sent from the PC physician to the FP whenever the PC physician received a consultation request from an oncologist. The toolkit included an introduction to the PC physician team; an opportunity for the FP to choose how best to collaborate with PC physicians to meet the patient's PC needs; and contact information for access to 24/7 PC physician support. Responses from FPs regarding their preferred level of engagement with PC determined further care planning in the clinic. We measured feasibility, response rate, and qualitative surveys of FPs about the usefulness of the intervention.

RESULTS

Two hundred fourteen new consultations were eligible for a standardized letter over the 6-month implementation period. Feasibility for sending the toolkit was 90.0% and response rate for collaborative care preference from FPs was 86.0%, with median response time of 3-4 days. 78.9% of FPs indicated they would prefer ongoing consultative care by the PC physician, while 18.6% indicated that PC physician consultation was not needed, or that the FP would provide primary PC after a one-time PC physician consultation.

CONCLUSION

We successfully implemented a QI initiative to improve care coordination between FPs and PC physicians for patients with cancer. The coordination toolkit can protect the patient-FP primary PC relationship and optimize specialist PC resource utilization for complex patients.

Patient and Provider Attitudes and Preferences Regarding Early Palliative Care Delivery for Patients with Advanced Gastrointestinal Cancers: A Prospective Survey

Early integrated palliative care (EIPC) for patients with advanced cancers requires the involvement of family doctors (FDs) and oncologists. We compared attitudes between patients and their providers regarding the delivery of EIPC. Patients with newly diagnosed incurable gastrointestinal (GI) cancer at a tertiary cancer centre in Ontario, Canada, were surveyed using a study-specific instrument regarding the importance of and preferences for accessing support across eight domains of palliative care. Physicians within the circle of care completed a parallel survey for each patient. The concordance between patient and physician responses was analyzed. A total of 66 patients were surveyed (median age 69, 35% female). All had an oncologist, 12% had a specialist palliative care provider (SPC), and 97% had an FD, but only 41% listed the FD as part of the care team. In total, 95 providers responded (oncologist = 68, FD = 21, SPC = 6; response rate 92%; 1-3 physician responses per patient). Disease management and physical concerns were most important to patients. Patients preferred to access care in these domains from oncologists or SPCs. For all other domains, most patients attributed primary responsibility to self or family rather than any healthcare provider. Thus, concordance was poor between patient and physician responses. Across most domains of palliative care, we found low agreement between cancer patients and their physicians regarding responsibilities for care, with FDs appearing to have limited involvement at this stage.

Cardiovascular disease risk assessment and multidisciplinary care in prostate cancer treatment with ADT: recommendations from the APMA PCCV expert network

PURPOSE

Androgen deprivation therapy (ADT) is the mainstay approach for prostate cancer (PCa) management. However, the most commonly used ADT modality, gonadotropin-releasing hormone (GnRH) agonists, has been associated with an increased risk of cardiovascular disease (CVD).

METHODS

The PCa Cardiovascular (PCCV) Expert Network, consisting of multinational urologists, cardiologists and oncologists with expertise in managing PCa, convened to discuss challenges to routine cardiovascular risk assessment in PCa management, as well as how to mitigate such risks in the current treatment landscape.

RESULTS

The experts identified several barriers, including lack of awareness, time constraints, challenges in implementing risk assessment tools and difficulties in establishing multidisciplinary teams that include cardiologists. The experts subsequently provided practical recommendations to improve cardio-oncology care for patients with PCa receiving ADT, such as simplifying cardiovascular risk assessment, individualising treatment based on CVD risk categories, establishing multidisciplinary teams and referral networks and fostering active patient engagement. A streamlined cardiovascular risk-stratification tool and a referral/management guide were developed for seamless integration into urologists' practices and presented herein. The PCCV Expert Network agreed that currently available evidence indicates that GnRH antagonists are associated with a lower risk of CVD than that of GnRH agonists and that GnRH antagonists are preferred for patients with PCa and a high CVD risk.

CONCLUSION

In summary, this article provides insights and guidance to improve management for patients with PCa undergoing ADT.

Barriers and facilitators to integrated cancer care between primary and secondary care: a scoping review

PURPOSE

This scoping review identifies and characterises reported barriers and facilitators to providing integrated cancer care reported in the international literature, and develops recommendations for clinical practice.

METHODS

This scoping review included literature published between 2009 and 2022 and describes the delivery of integrated cancer care between primary and secondary care sectors. Searches were conducted of an online database Ovid Medline and grey literature.

RESULTS

The review included thirty-two papers. Barriers and facilitators to integrated cancer care were identified in three core areas: (1) at an individual user level around patient-healthcare professional interactions, (2) at an organisational level, and (3) at a healthcare system level. The review findings identified a need for further training for primary care professionals on cancer care, clarity in the delineation of primary care and oncologist roles (i.e. who does what), effective communication and engagement between primary and secondary care, and the provision of protocols and guidelines for follow-up care in cancer.

CONCLUSIONS

Information sharing and communication between primary and secondary care must improve to meet the increasing demand for support for people living with and beyond cancer. Delivering integrated pathways between primary and secondary care will yield improvements in patient outcomes and health economic costs.

Exploring Family Physician Training Needs to Improve Cancer Patient Care

Family physicians have multifaceted roles in cancer patient care and oncology education among this group is unfortunately inadequate. This study explored the needs and perspectives of family physicians regarding their oncology training and experiences. As well, physician cancer care experiences, knowledge use, and continuing education practices were elucidated. The authors employed a qualitative approach with family physicians participating in semi-structured interviews. General practitioners in oncology were excluded. Purposeful sampling was used, with recruitment through Ontario regional primary cancer care leads and social media. Interviews were transcribed, and thematic analysis was conducted. Thirteen participants were interviewed-1.6:1 female: male, ages 30-39, practicing for an average of 9 years (0.5-30 years), with urban and suburban practices. Most trained in Canada as undergraduates and completed their residency in Ontario; 62% had participated in at least one oncology continuing medical education session. Three major themes emerged: delineation of roles, oncology knowledge and education, and palliative care. Participants reported role uncertainty after cancer diagnosis, with oncology teaching at all levels described as lacking relevance. Palliative care rotations were an avenue for oncology education and where participants returned to cancer care. Changing existing teaching, information access, and avenues of oncology experiences may be the next step to supporting successful cancer care by family physicians.

Exploring Men's Experiences with Follow-Up Care following Primary Treatment for Prostate Cancer in Atlantic Canada: A Qualitative Study

Prostate cancer is a common and life-altering condition among Canadian men, yet little is known about how follow-up care is provided to those who have completed treatment. Despite improving survival rates, survivors experience ongoing needs and are often not provided with support to manage them. This study sought to investigate the post-treatment experiences and needs of prostate cancer survivors and to determine if and how these needs are being met. Using a qualitative description design, prostate cancer survivors who had completed treatment took part in semi-structured interviews. The interviews were recorded and analyzed thematically. The participants experienced varying levels of satisfaction with their follow-up care. While primary care providers played significant roles, continuity of care and specialist involvement varied. Most participants felt unprepared to manage the long-term effects of their cancer due to a lack of information and resources from their healthcare providers. Instead, participants turned to their peers for support. Ongoing physical and psychosocial needs went unmet and had significant impacts on their daily lives. Participants felt that support for these issues should be automatically integrated into their follow-up care. In summary, this study revealed the importance of integrated, patient-centered follow-up care for prostate cancer in Atlantic Canada.

The underutilization of preventive cardiovascular measures in patients with cancer: an analysis of the Behavioural Risk Factor Surveillance System, 2011-22

AIMS

This study aimed to characterize the influence of a cancer diagnosis on the use of preventive cardiovascular measures in patients with and without cardiovascular disease (CVD).

METHODS AND RESULTS

Data from the Behavioural Risk Factor Surveillance System Survey (spanning 2011-22) were used. Multivariable logistic regression models adjusted for potential confounders were applied to calculate average marginal effects (AME), the average difference in the probability of using a given therapy between patients with and without cancer. Outcomes of interest included the use of pharmacological therapies, physical activity, smoking cessation, and post-CVD rehabilitation. Among 5 012 721 respondents, 579 114 reported a history of CVD (coronary disease or stroke), and 842 221 reported a diagnosis of cancer. The association between cancer and the use of pharmacological therapies varied between those with vs. without CVD (P-value for interaction: <0.001). Among patients with CVD, a cancer diagnosis was associated with a lower use of blood pressure-lowering medications {AME: -1.46% [95% confidence interval (CI): -2.19% to -0.73%]}, lipid-lowering medications [AME: -2.34% (95% CI: -4.03% to -0.66%)], and aspirin [AME: -6.05% (95% CI: -8.88% to -3.23%)]. Among patients without CVD, there were no statistically significant differences between patients with and without cancer regarding pharmacological therapies. Additionally, cancer was associated with a significantly lower likelihood of engaging in physical activity in the overall cohort and in using post-CVD rehabilitation regimens, particularly post-stroke rehabilitation.

CONCLUSION

Preventive pharmacological agents are underutilized in those with cancer and concomitant CVD, and physical activity is underutilized in patients with cancer in those with or without CVD.

LAY SUMMARY

•This paper compared the use of preventive cardiovascular measures, both pharmaceutical and non-pharmaceutical, in patients with and without cancer.•In patients with cardiovascular disease and cancer, there is a lower use of preventive cardiovascular medications compared with those with cardiovascular disease but without cancer. This includes a lower utilization of blood pressure-lowering medications, cholesterol-lowering medications, and aspirin.•Patients with cancer reported lower levels of exercise but higher levels of smoking cessation compared with those without cancer.

How can counselling by family physicians on nutrition and physical activity be improved: trends from a survey in Germany

PURPOSE

Cancer and its therapy causes severe symptoms, most of which are amendable to nutrition and physical activity (PA). Counselling on nutrition and PA empowers patients to take part more actively in their treatment. Many cancer patients are yet in need of information on these topics. In this study, we investigate the perception of family physicians (FP) on nutrition and PA in cancer patient care and assess barriers and steps to improve their involvement in counselling on these topics.

METHODS

Based on qualitative content analysis of 5 semi-structured interviews with FP, a questionnaire was developed and completed by 61 German FP.

RESULTS

Most of the FP acknowledged the importance of nutrition and PA during (91.4%) and after (100%) cancer therapy. While many participants were involved in cancer patient care, 65.6% of FP viewed themselves as primary reference person to address these topics. However, a third (32.8%) of FP were unfamiliar with information thereof. Some were unsatisfied regarding timely updates on their patient's treatment course via discharge letters (25.0%) or phone calls (36.2%). FP would like to dedicate more consultation time addressing nutrition and PA than they currently do (p < 0.001).

CONCLUSION

Communication btween healthcare practitioners about mutual cancer patient's treatment must be improved, e.g. utilising electronic communication to quicken correspondence. Acquisition of information on nutrition and PA in cancer patient care needs to be facilitated for FP, approachable by compiling reliable information and their sources. Involvement of FP in structured treatment programs could benefit cancer patient care.

TRIAL REGISTRATION NUMBER

(May 7, 2021): 2021-2149-Bef.

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models

BACKGROUND

Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta.

METHODS

We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis.

RESULTS

Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible.

INTERPRETATION

Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.

Implementation of a Web-Based Communication System for Primary Care Providers and Cancer Specialists

Healthcare providers have reported challenges with coordinating care for patients with cancer. Digital technology tools have brought new possibilities for improving care coordination. A web- and text-based asynchronous system (eOncoNote) was implemented in Ottawa, Canada for cancer specialists and primary care providers (PCPs). This study aimed to examine PCPs' experiences of implementing eOncoNote and how access to the system influenced communication between PCPs and cancer specialists. As part of a larger study, we collected and analyzed system usage data and administered an end-of-discussion survey to understand the perceived value of using eOncoNote. eOncoNote data were analyzed for 76 shared patients (33 patients receiving treatment and 43 patients in the survivorship phase). Thirty-nine percent of the PCPs responded to the cancer specialist's initial eOncoNote message and nearly all of those sent only one message. Forty-five percent of the PCPs completed the survey. Most PCPs reported no additional benefits of using eOncoNote and emphasized the need for electronic medical record (EMR) integration. Over half of the PCPs indicated that eOncoNote could be a helpful service if they had questions about a patient. Future research should examine opportunities for EMR integration and whether additional interventions could support communication between PCPs and cancer specialists.

Web-Based Asynchronous Tool to Facilitate Communication Between Primary Care Providers and Cancer Specialists: Pragmatic Randomized Controlled Trial

BACKGROUND

Cancer poses a significant global health burden. With advances in screening and treatment, there are now a growing number of cancer survivors with complex needs, requiring the involvement of multiple health care providers. Previous studies have identified problems related to communication and care coordination between primary care providers (PCPs) and cancer specialists.

OBJECTIVE

This study aimed to examine whether a web- and text-based asynchronous system (eOncoNote) could facilitate communication between PCPs and cancer specialists (oncologists and oncology nurses) to improve patient-reported continuity of care among patients receiving treatment or posttreatment survivorship care.

METHODS

In this pragmatic randomized controlled trial, a total of 173 patients were randomly assigned to either the intervention group (eOncoNote plus usual methods of communication between PCPs and cancer specialists) or a control group (usual communication only), including 104 (60.1%) patients in the survivorship phase (breast and colorectal cancer) and 69 (39.9%) patients in the treatment phase (breast and prostate cancer). The primary outcome was patient-reported team and cross-boundary continuity (Nijmegen Continuity Questionnaire). Secondary outcome measures included the Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire on Major Depression, and Picker Patient Experience Questionnaire. Patients completed the questionnaires at baseline and at 2 points following randomization. Patients in the treatment phase completed follow-up questionnaires at 1 month and at either 4 months (patients with prostate cancer) or 6 months following randomization (patients with breast cancer). Patients in the survivorship phase completed follow-up questionnaires at 6 months and at 12 months following randomization.

RESULTS

The results did not show an intervention effect on the primary outcome of team and cross-boundary continuity of care or on the secondary outcomes of depression and patient experience with their health care. However, there was an intervention effect on anxiety. In the treatment phase, there was a statistically significant difference in the change score from baseline to the 1-month follow-up for GAD-7 (mean difference -2.3; P=.03). In the survivorship phase, there was a statistically significant difference in the change score for GAD-7 between baseline and the 6-month follow-up (mean difference -1.7; P=.03) and between baseline and the 12-month follow-up (mean difference -2.4; P=.004).

CONCLUSIONS

PCPs' and cancer specialists' access to eOncoNote is not significantly associated with patient-reported continuity of care. However, PCPs' and cancer specialists' access to the eOncoNote intervention may be a factor in reducing patient anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03333785; https://clinicaltrials.gov/ct2/show/NCT03333785.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

Patient and Healthcare Provider Perspectives on the Implementation of a Web-Based Clinical Communication System for Cancer: A Qualitative Study

Previous research has identified communication and care coordination problems for patients with cancer. Healthcare providers (HCPs) have reported communication issues due to the incompatibility of electronic medical records (EMR) software and not being consistently copied on patient reports. We evaluated an asynchronous web-based communication system ("eOncoNote") for primary care providers and cancer specialists to improve cancer care coordination. The objectives were to examine patients' perceptions of the role of eOncoNote in their healthcare, and HCPs' experiences of implementing eOncoNote. Qualitative interviews were conducted with patients with breast and prostate cancer, primary care providers, and cancer specialists. Eighteen patients and fourteen HCPs participated. Six themes were identified from the patient interviews focusing on HCP and patient roles related to care coordination and patient awareness of communication among their HCPs. Four themes were identified from HCP interviews related to the context of care coordination and experience with eOncoNote. Both patients and HCPs described the important role patients and caregivers play in care coordination. The results show that patients were often unaware of the communication between their HCPs and assumed they were communicating. HCPs encountered challenges incorporating eOncoNote into their workflow.

Cancer survivorship care and general practice: A qualitative study of roles of general practice team members in Australia

Primary care providers, including general practice teams (GPTs), are well positioned within the community to integrate cancer survivorship care into ongoing health management. However, roles of GPT members in delivery of cancer survivorship care have not been explored. The purpose of this study is to explore these roles from the perspectives of General Practitioners (GPs), Practice Nurses (PNs) and Practice Managers (PMs). An interpretive qualitative study using semi-structured in-depth telephone interviews with ten GPs, nine PNs and five PMs was conducted. Interviews were recorded, transcribed and analysed using grounded theory methods. Perspectives of roles in delivery of cancer survivorship care were highly variable. Variation was evident among perceptions of needs of cancer survivors, individual team members' scopes of practice, and individual professional knowledge and skills. A lack of clarity in roles and responsibilities of GPT members was thought to contribute to a lack of consistency in survivorship care. Reducing variations in perceptions of survivorship care in the primary care setting should be a priority. Such efforts may include development of practical guidance to support GPT members to clarify scopes of practice within the team. In addition to accessible comprehensive education programs, other innovative, tailored individualised education approaches may be helpful. System-level support in clarifying and supporting the roles of the primary care team is needed to facilitate a survivorship delivery system at general practice level where those within GPT can ensure that individual patients' needs are met in a timely and effective manner.

Cardiometabolic Comorbidities in Cancer Survivors

There are nearly 17 million cancer survivors in the United States, including those who are currently receiving cancer therapy with curative intent and expected to be long-term survivors, as well as those with chronic cancers such as metastatic disease or chronic lymphocytic leukemia, who will receive cancer therapy for many years. Current clinical practice guidelines focus on lifestyle interventions, such as exercise and healthy eating habits, but generally do not address management strategies for clinicians or strategies to increase adherence to medications. We discuss 3 cardiometabolic comorbidities among cancer survivors and present the prevalence of comorbidities prior to a cancer diagnosis, treatment of comorbidities during cancer therapy, and management considerations of comorbidities in long-term cancer survivors or those on chronic cancer therapy. Approaches to support medication adherence and potential methods to enhance a team approach to optimize care of the individual with cancer across the continuum of disease are discussed.

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Cancer survivors are at increased risk for several chronic conditions, including hypertension, dyslipidemia, and diabetes.

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Determining optimal management of comorbidities for patients with cancer is critical.

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A multidisciplinary care approach is recommended throughout the continuum of active cancer treatment and survivorship.

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Survivorship research should focus on medication adherence and coordination of care.

Molecular Pathology Education: A Suggested Framework for Primary Care Resident Training in Genomic Medicine: A Report of the Association for Molecular Pathology Training and Education Committee

Developments in genomics are profoundly influencing medical practice. With increasing use of genetic and genomic testing across every aspect of the health care continuum, patients and their families are increasingly turning to primary care physicians (PCPs) for discussion and advice regarding tests, implications, and results. Yet, with the rapid growth of information, technology, and applications, PCPs are finding it challenging to fill the gaps in knowledge and support the growing needs of their patients. A critical component in expanding PCP genomic literacy lies in the education of physicians in training and in practice. Although a framework for developing physician competencies in genomics has already been developed, the Association for Molecular Pathology is uniquely situated to actively utilize the skills of its members to engage and support PCPs in this effort. This report provides an overview and a suggested basic teaching framework, which can be used by molecular professionals in their individual institutions as a starting point for educational outreach.

A Qualitative Needs Analysis of Skin Cancer Care from the Perspectives of Patients, Physicians, and Health Insurance Representatives-A Case Study from Eastern Saxony, Germany

Skin cancer is one of the most common cancers worldwide and the number of patients is steadily increasing. In skin cancer care, greater interdisciplinary cooperation is required for prevention, early detection, and new complex systemic therapies. However, the implementation of innovative medical care is a major challenge, especially for rural regions with an older than average, multimorbid population, with limited mobility, that are long distances from medical facilities. Solutions are necessary to ensure comprehensive oncological care in rural regions. The aim of this study was to identify indicators to establish a regional care network for integrated skin cancer care. To capture the perspectives of different stakeholder groups, we conducted two focus groups with twenty skin cancer patients and their relatives, a workshop with eight physicians, and three semi-structured interviews with health insurance company representatives. Qualitative data were recorded, transcribed, and analyzed following Mayring's content analysis methods. We generated ten categories based on the reported optimization potentials; five categories were assigned to all three stakeholder groups: Prevention and early diagnosis, accessibility of physicians/clinics, physicians' resources, care provider's responsibilities, and information exchange. The results indicate the need for stronger integration of care in the region. They provide the basis for regional networking as, for example, the conception of treatment pathways or telemedicine with the aim to improve a comprehensive skin cancer care. Our study should raise awareness and postulate as a demand that all patients receive guideline-based therapy, regardless of where they live.

Primary health care workers perspective towards cancer in Fiji: a qualitative study

Background:

By 2040, the predicted global cancer burden is expected to be more than 27 million new cancer cases per year. Understanding primary health care workers’ (HCWs) perception on cancer can highlight new ways in which cancer advocacy can be increased. This study aimed to explore the perceptions of primary HCWs in Lautoka, Fiji, towards common cancers with focus on knowledge, risk perceptions, barriers and preventive approaches.

Methods:

The study used a qualitative method approach. The study was conducted among primary HCWs at four purposively selected health centres in Lautoka Subdivision, Fiji, from 1 March 2021 to 1 April 2021. Focus group discussions (FGDs) were conducted with primary HCWs. A semi-structured open-ended questionnaire was used to collect data, and the FGDs were audio-recorded. These audio recordings were transcribed and analysed using thematic analysis.

Results:

The responses from the four FGDs with six primary HCWs in each group emerged four major themes. These themes were cancer knowledge, health professional training, barriers and challenges and awareness strategies. Primary HCWs were not fully aware about common cancers and were not confident to discuss about cancer with their patients which is an important role of primary HCWs in cancer management. This lack of knowledge was attributed to less training received in primary care setting. Barriers to accessing cancer screening included misconceptions about cancer, negative attitudes from patients, stigmatization, lack of resources at health facility and less informed health staff. Community outreach programmes, opportunistic screening, community HCWs and the concept of a cancer hub centre were awareness strategies highlighted by primary HCWs.

Conclusions:

Lack of knowledge about common cancers among primary HCWs is a concern that is depicted well in this study. This low knowledge was attributed to lack of training on cancers received by primary HCWs. Guidelines on cancer screening and diagnosis can be developed by the health ministry to assist primary HCWs in detecting patients at pre-cancerous stage.

Primary Care Physicians' Perspectives in Leading Breast Cancer Follow-Up Care

INTRODUCTION

Limited data exist on the barriers associated with transitioning breast cancer follow-up care to primary care physicians (PCPs). This study aimed to describe the current perspectives of PCPs in managing breast cancer follow-up.

METHOD

An online survey was distributed to PCPs in Toronto, ON, Canada. Questions examined PCPs' view of transitioning breast cancer follow-up care to their practices.

RESULTS

Of 800 PCPs invited, 126 responded (response rate: 15.7%). The types of practice models amongst respondents included blended capitation (42.9%), blended salary (27%), and fee-for-service (17.5%). Seventy-seven percent of respondents stated they provided follow-up care. Approximately half of the respondents stated they were somewhat comfortable providing follow-up care. PCP-led follow-up care was considered either very (49.2%) or somewhat appropriate (30.2%). When asked about financial remuneration, 43.7% of respondents stated it was somewhat important. The factors that influenced the feasibility of PCP-led follow-up care included receipt of a detailed follow-up care plan provided by the specialist after discharge (81%), the ability to re-refer to specialists rapidly (56.3%), and the ability to obtain regular updates of best practice changes (59.5%). The preferred means of educational updates included E-mail (40.5%), continuing medical education events (30.2%), and electronic medical records (19.8%). When the fee model was taken into consideration there was no significant difference in opinions regarding follow-up care.

CONCLUSIONS

Transitioning to a PCP-led model was supported by most of the PCPs who participated in this study. Their perspective on PCP-led follow up care and barriers associated with implementation of this model of care needs to be further explored with future studies that include larger sample size and a more diverse PCP population.

Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study

BACKGROUND

Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process.

METHODS

We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis.

RESULTS

Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians.

INTERPRETATION

These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Discharging the complex patient - changing our focus to patients' networks of care providers

Background

A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning.

Methods

This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical.

Results

We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial.

Conclusions

Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06841-2.

Junior Doctor Evaluation of Radiation Oncology Education and Training in Medical Schools and Prevocational Training in Australia

The purpose of this study is to evaluate radiation oncology (RO)-specific education, confidence and knowledge of junior doctors in Australian teaching hospitals. A 38-item web-based survey was emailed to prevocational junior doctors working in Australian hospitals in New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between November 2017 and January 2018. The survey evaluated RO educational and clinical exposure of participants during medical school, and prevocational training and their confidence and knowledge of the specialty. A total of 183 respondents across 17 Australian hospital networks completed the survey. During medical school, 53.4% had RO incorporated into their formal curriculum, 19.5% had no formal lectures and 51.7% had never visited a RO department. As a junior doctor, 73.8% of respondents did not receive any formal RO education. When compared with other oncology specialties, fewer junior doctors were confident in consulting the RO team (21.0%) compared with medical oncology (42.0%), palliative care (75.2%) and haematology (40.1%). Majority of respondents (61.6%) showed limited understanding of radiation safety. On multivariate sub-group analysis, both confidence and knowledge in RO improved when RO was incorporated into the formal medical school curriculum. This survey highlights the current low confidence and poor knowledge standard amongst Australian junior doctors on RO due to inadequate teaching during medical school and prevocational training and suggests improvement through standardisation of formal RO curriculum teaching within medical school and prevocational training.

French general practitioners' attitude towards breast cancer in older women: A qualitative study

INTRODUCTION

In France, general practitioners (GPs) are usually the first-line healthcare contact for breast cancer (BC) screening/diagnosis in older women, information about therapies, access to cancer specialists, management of comorbidities and follow-up. GPs' practices may influence the factors involved in the unfavorable prognosis of BC in older patients: delay in diagnosis, insufficiently active treatment and the impact of associated morbidities.

OBJECTIVE

The aim of this study was to explore GPs' experience, to understand the factors which shape their care of older women with BC and to identify ways in which this care might be improved.

METHOD

This was a two-part qualitative study among GPs following COREQ guidelines. We analysed themes arising from group and semi-directive personal interviews.

RESULTS

GPs had diverse attitudes caused by 1/ the GPs' professional values, in response to their mission for local referral, their overall knowledge of the patient's context and wishes; 2/ the impact of comorbidities; 3/ the GPs' own experiences (confrontation with the disease, emotional ties established with the patient, embarrassment about examinations); 4/ prejudicial connotations (therapies judged as being too aggressive). GPs expressed interest for training, for inclusion in a coordinated multidisciplinary organisation with oncologists and geriatricians, confirming the GP's position (to better inform their patients, participate in the therapeutic decision and ensure the continuity of care).

CONCLUSION

To improve their care of older patients with BC, GPs would welcome improved relationships with geriatricians and oncologists, more information support and a more clearly defined role in the geriatric oncology care pathway.

Cross-sectoral communication by bringing together patient with cancer, general practitioner and oncologist in a video-based consultation: a qualitative study of oncologists' and nurse specialists' perspectives

Shared care models in the field of cancer aim to improve care coordination, role clarification and patient satisfaction. Cross-sectoral communication is pivotal. Involvement of patients may add to intended mechanisms.A randomised controlled trial 'The Partnership Study' tested the effect of bringing together patient, general practitioner (GP) and oncologist for a consultation conducted by video.

PURPOSE

As part of the process evaluation, this study aimed to explore experiences, attitudes and perspectives of the oncological department on sharing patient consultations with GPs using video.

METHODS

Four semistructured interviews with five oncologists and four nurse specialists were conducted in February 2020. We focused on the informants' experiences and reflections on the potential of future implementation of the concept 'inviting the GP for a shared consultation by video'. The analyses were based on an inductive, open-minded, hermeneutic phenomenological approach.

RESULTS

A total of six overall themes were identified: structuring consultation and communication, perceptions of GP involvement in cancer care, stressors, making a difference, alternative ways of cross-sector communication and needs for redesigning the model. The concept made sense and was deemed useful, but solving the many technical and organisational problems is pivotal. Case-specific tasks and relational issues were targeted by pragmatically rethinking protocol expectations and the usual way of communication and structuring patient encounters. Case selection was discussed as one way of maturing the concept.

CONCLUSION

This Danish study adds new insight into understanding different aspects of the process, causal mechanisms as well as the potential of future implementation of video-based tripartite encounters. Beyond solving the technical problems, case selection and organisational issues are important. Acknowledging the disruption of the usual workflow, the introduction of new phases of the usual encounter and the variety of patient-GP relationships to be embraced may help to better understand and comply with barriers and facilitators of communication and sharing.

TRIAL REGISTRATION NUMBER

NCT02716168.

The effect of comorbidity on primary care use during breast cancer chemotherapy: a population-based retrospective cohort study using CanIMPACT data

BACKGROUND

Patients with breast cancer visit their primary care physicians (PCPs) more often during chemotherapy than before diagnosis, but the reasons are unclear. We assessed the association between physical comorbidities and mental health history (MHH) and the change in PCP use during adjuvant breast cancer chemotherapy.

METHODS

We conducted a population-based, retrospective cohort study using data from the Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT) project. Participants were women 18 years of age and older, who had received a diagnosis of stage I-III breast cancer in Ontario between 2007 and 2011 and had received surgery and adjuvant chemotherapy. We used difference-in-difference analysis using negative binomial modelling to quantify the differences in the 6-month rate of PCP visits at baseline (the 24-month period between 6 and 30 months before diagnosis) and during treatment (the 6 months from start of chemotherapy) between physical comorbidity and MHH groups.

RESULTS

Among 12 781 participants, the 6-month PCP visit rate increased during chemotherapy (mean 2.3 visits at baseline, 3.4 visits during chemotherapy). Patients with higher physical comorbidity levels or MHH visited their PCPs 4.2 or 1.7 more times, respectively, over 6 months compared to those with low physical comorbidity or no MHH at baseline and 2.5 or 1.1 more times, respectively, over 6 months during treatment. During treatment, the adjusted 6-month rate of PCP visits more than doubled in the group with the fewest physical comorbidities or no MHH compared with baseline (rate ratio 2.52, 95% confidence interval [CI] 2.43-2.61). This increase was lower in those with MHH (rate ratio 1.81, 95% CI 1.68-1.96) and in the highest physical comorbidity group (rate ratio 1.16, 95% CI 1.07-1.28).

INTERPRETATION

Patients with breast cancer who have more physical comorbidities and MHH have a higher frequency of PCP visits during adjuvant chemotherapy but lower absolute and relative increases in visits compared with baseline. Therefore, PCPs can expect to see their patients with fewer physical comorbidities and no MHH more often during chemotherapy. Primary care physicians can plan for their patients with high physical comorbidity levels and MHH to continue having frequent appointments while they undergo chemotherapy, and they can expect their patients with low physical comorbidity levels and no MHH to increase the frequency of their visits during chemotherapy, and should be prepared to provide breast cancer-related care to these patients.

Soins de suivi pour les survivants du cancer : évaluation d’une séance d’information

Offert dans un hôpital de soins tertiaires en Ontario, au Canada, le Programme de bien-être au-delà du cancer procure aux survivants du cancer l’information et les ressources nécessaires pour l’autogestion de leurs soins de suivi (ex. acquérir les notions et compétences pertinentes pour s’adapter à une maladie chronique) après un traitement actif contre le cancer (chimiothérapie, radiothérapie, etc.). Une évaluation a été menée sur la séance de deux heures (composante de l’ensemble du Programme de bien-être au-delà du cancer) destinée aux survivants afin de déterminer si le fait d’y participer avait augmenté les connaissances et suscité l’adhésion au principe d’autogestion des soins de suivi. Les survivantes du cancer du sein (n = 107) et les survivants du cancer colorectal (n = 38) qui étaient présents ont répondu avant et après la séance à des questionnaires portant sur les besoins informationnels et l’intention d’assurer son propre suivi de santé. L’augmentation perçue des connaissances et l’intention d’autogérer ses soins de suivi ne dépendait ni de l’âge, ni du sexe, ni du temps écoulé depuis le diagnostic. Après la séance, les survivants ont dit en connaître davantage (F(1,11) = 144,6, p < .001) et vouloir s’investir dans leurs soins (F(1,103) = 57,3, p < .001). L’amélioration des connaissances était prédictive d’une plus grande volonté d’autogestion (R2 = .64; F(4,86) = 38,5, p < .001). Les survivants du cancer colorectal se sont montrés plus motivés à autogérer leurs soins que les survivantes du cancer du sein (β = .14, t = 2,2, p < .05). Ces résultats guideront l’élaboration et la mise en oeuvre des futures séances d’information destinées aux survivants.

An evaluation of a cancer survivorship education class for follow-up care

The Wellness Beyond Cancer Program is part of a tertiary care hospital in Ontario, Canada. It provides cancer survivors with information and resources needed to self-manage their follow-up care (i.e., learn relevant information and skills to adapt to life with a chronic illness) after active cancer treatment (i.e., chemotherapy, radiation). A program evaluation was conducted on the two-hour survivorship education class (one component of the overall Wellness Beyond Cancer Program) with the purpose of evaluating whether attendance increased survivors' perceived knowledge and intent to self-manage follow-up care. Breast (n = 107) and colorectal (n = 38) cancer survivors who attended classes completed questionnaires on information needs and intent to self-manage pre- and postclass. Perceived increase in knowledge and intent to self-manage follow-up care were unrelated to age, gender, or time since diagnosis. After attending the class, survivors reported increased knowledge (F(1,11) = 144.6, p < .001) and intent to participate in self-management of their follow-up care (F(1,103) = 57.3, p < .001). Improvements in knowledge predicted increased intent to self-manage (R2 = .64; F(4,86) = 38.5, p < .001). Colorectal cancer survivors showed greater improvement in intent to self-manage than breast cancer survivors (β = .14, t = 2.2, p < .05). These results can inform the development and implementation of future education classes for survivors.

Timing of Chemoradiation in Newly Diagnosed Glioblastoma: Comparative Analysis Between County and Managed Care Health Care Models

BACKGROUND

Glioblastoma multiforme (GBM) is a primary brain malignancy with significant morbidity and mortality. The current standard of treatment for GBM is surgery followed by radiotherapy and temozolomide. Despite an established treatment protocol, there exists heterogeneity in outcomes due to patients not receiving all treatments. We analyzed patients in different health care models to investigate this heterogeneity.

METHODS

A retrospective analysis was performed at 2 hospitals in San Bernardino County, California, for patients with newly diagnosed GBM from 2004 to 2019. Patients younger than 18 years of age, with history of low-grade glioma, who had undergone prior treatment, and those lost to follow-up were excluded.

RESULTS

A total of 57 patients were included in our study. Chemotherapy was started at 41 ± 30 and 77 ± 68 days in the health maintenance organization (HMO) and county model, respectively (P = 0.050); radiation therapy was started at 46 ± 34 and 85 ± 76 days in the HMO and county models, respectively (P = 0.036). In individuals who underwent both chemotherapy and radiation therapy (XRT), the difference in time to XRT was no longer significant (P = 0.060). Recurrence time was 309 ± 263 and 212 ± 180 days in the HMO and county groups, respectively (P = 0.379). The time to death was 412 ± 285 and 343 ± 304 days for HMO and county models, respectively (P = 0.334).

CONCLUSIONS

Our study demonstrates a statistically significant difference in time to adjuvant therapies between patients within a county hospital and a managed health care organization. This information has the potential to inform future policies and care coordination for patients within the county model.

Cross-sectoral video consultation in cancer care: GPs' evaluation of a randomised controlled trial

Background

Shared care models present an opportunity for patients to receive the benefits of specialist care combined with the continuity of care provided by a GP.

Aim

To test the effects on GP-perceived involvement in cancer care and their satisfaction with this cross-sectoral information after bringing the patient, GP, and oncologist together in a shared video consultation.

Design & setting

GPs from the Region of Southern Denmark evaluated a randomised controlled trial testing shared video consultations.

Method

This study describes secondary outcomes based on a 4 months' follow-up survey from GPs participating in The Partnership Project (PSP). Patient perception of coordination of care at 7 months' follow-up was the primary outcome of the PSP. A tripartite video consultation was conducted during cancer treatment to share tasks and roles between health professionals with the patient.

Results

The study included 281 patients, and 105 unique GPs returned 124 questionnaires. Video consultations were accomplished in 68% of scheduled cases. The study found an increased odds ratio (OR) of 3.03 for GP satisfaction with the distribution of tasks and roles, and they experienced more involvement in the cancer patients' trajectory. The study found an increased OR of 6.95 for the GP perception of more direct contact and dialogue with the Department of Oncology. There was a decreased OR of 0.88 for the GP to be engaged in handling anxiety and psychological concerns.

Conclusion

The study showed that involving the GP in one shared consultation increased the odds of the GP being satisfied with the distribution of tasks and roles, and feeling more involved in the cancer patient’s trajectory. However, recruitment and response rates from GPs were limiting factors.

From symptom to cancer diagnosis: Perspectives of patients and family members in Alberta, Canada

BACKGROUND

Significant intervals from the identification of suspicious symptoms to a definitive diagnosis of cancer are common. Streamlining pathways to diagnosis may increase survival, quality of life post-treatment, and patient experience. Discussions of pathways to diagnosis from the perspective of patients and family members are crucial to advancing cancer diagnosis.

AIM

To examine the perspectives of a group of patients with cancer and family members in Alberta, Canada, on factors associated with timelines to diagnosis and overall experience.

METHODS

A qualitative approach was used. In-depth, semi-structured interviews with patients with cancer (n = 18) and patient relatives (n = 5) were conducted and subjected to a thematic analysis.

FINDINGS

Participants struggled emotionally in the diagnostic period. Relevant to their experience were: potentially avoidable delays, concerns about health status, and misunderstood investigation process. Participants emphasized the importance of their active involvement in the care process, and had unmet supportive care needs.

CONCLUSION

Psychosocial supports available to potential cancer patients and their families are minimal, and may be important for improved experiences before diagnosis. Access to other patients' lived experiences with the diagnostic process and with cancer, and an enhanced supportive role of family doctors might help improve experiences for patients and families in the interval before receiving a diagnosis of cancer, which may have a significant impact on wellbeing.

Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study

BACKGROUND

Breast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so.

OBJECTIVE

To explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists.

METHODS

Eleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12.

RESULTS

Majority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme.

CONCLUSIONS

PCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation.

Important knowledge items with regard to the benefits of exercise for patients with epilepsy: Findings of a qualitative study from Palestine

OBJECTIVES

Physicians and complementary alternative medicine (CAM) specialists are not formally educated/trained on the benefits of exercises for people living with epilepsy (PWE). This study was performed to develop a consensus-based knowledge items on the benefits of exercises for PWE that physicians and CAM specialists need to know.

METHODS

Knowledge items were collected after an extensive review of the scientific literature and from in-depth interviews with key contacts in the domain (6 primary healthcare providers, 4 neurologists, 4 exercise and medicine specialists, 4 CAM practitioners, 4 researchers who did studies on the benefits of exercise for PWE, and 4 PWE). Items collected were reviewed by 12 researchers who did studies on exercise for PWE. A Delphi technique was followed among a panel of 50 members to develop the consensus-based core list.

RESULTS

The final consensus-based core list contained 64 items that were grouped into the following categories: 1) general items recommending exercise for PWE, 2) benefits of exercise on prevention of seizures, 3) benefits of exercise on antiepileptic therapy, 4) benefits of exercise in preventing comorbidities associated with epilepsy, 5) benefits of exercise in improving quality of life of PWE, and 6) psychosocial benefits of exercise for PWE.

CONCLUSION

This consensus-based core list might guide educators, trainers, or authorities while designing educational or training courses to increase knowledge of physicians in primary healthcare and CAM specialists with regard to the benefits of exercise for PWE. Further investigations are needed to determine if such consensus-based core list might improve care and wellbeing of PWE.

Investigating whether shared video-based consultations with patients, oncologists, and GPs can benefit patient-centred cancer care: a qualitative study

Background

Guidelines have proposed that GPs should have a central role as coordinators of care and support patients with cancer during all stages of treatment, follow-up, and rehabilitation. Multidisciplinary video consultation involving the patient with cancer, the oncologist, and the GP may help to define roles and tasks, and this resulting clarity may enable greater support for patients with cancer.

Aim

To explore the consultation structure, content, and task clarification when a GP and an oncologist are attending a video consultation with a patient with cancer.

Design & setting

A qualitative study took place in the Region of Southern Denmark to investigate multidisciplinary video consultations, based on thematic analysis.

Method

Recordings of 12 video consultations were analysed using the framework method. A combined deductive and inductive approach was undertaken. The deductive themes were selected based on a consultation guide given to the doctors before the consultations.

Results

The study identified 15 themes, which were grouped into the following three categories: the implications of sharing a consultation; consultation structure; and health concerns.

Conclusion

Multidisciplinary video-based consultations with a patient and two health professionals succeeded in having a patient-centred communication style. In clarifying tasks between the GP and oncologist to support the patient, work-related issues and professional support for psychosocial challenges were always a task for the GP. Dissemination of this first-line evidence may improve acceptability among medical specialists and help assist GPs in supporting patients with cancer. However, focus on the involvement of relatives should be emphasised.

Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer

Background

Patients suffering from cancers are increasingly numerous in general practice consultations. The General Practitioner (GP) should be at the heart of the management of patients. Several studies have examined the perceptions of GPs confronted with the patient suffering from cancer and the relationships of GPs with oncologists, but few studies have focused on the patients’ perspective. We studied the three-way relationship between the oncologist, the GP, and the patient, from the patient’s point of view.

Methods

A questionnaire validated by a group consisting of GPs, oncologists, nurses, an epidemiologist and quality analyst, was administered over a three-week period to patients suffering from cancer receiving chemotherapy in a day hospital.

Results

The analysis was based on 403 questionnaires. Patients had confidence in the GP’s knowledge of oncology in 88% of cases; 49% consulted their GP for pain, 15% for cancer-related advice, and 44% in emergencies. Perceived good GP/oncologist communication led patients to turn increasingly to their GP for cancer-related consultations (RR = 1.14; p = 0.01) and gave patients confidence in the GP’s ability to manage cancer-related problems (RR = 1.30; p < 0.01). Mention by the oncologist of the GP’s role increased the consultations for complications (RR = 1.82; p < 0.01) as well as recourse to the GP in an emergency (RR = 1.35; p < 0.01).

Conclusion

Patients suffering from cancer considered that the GP was competent, but did not often consult their GP for cancer-related problems. There is a discrepancy between patients’ beliefs and their behaviour. When the oncologist spoke to patients of the GP’s role, patients had recourse to their GP more often. Systematically integrating a GP consultation to conclude cancer diagnosis disclosure, could improve management and care coordination.

Disparities in health care determine prognosis in newly diagnosed glioblastoma

OBJECTIVE Glioblastoma (GBM) is an aggressive brain malignancy with a short overall patient survival, yet there remains significant heterogeneity in outcomes. Although access to health care has previously been linked to impact on prognosis in several malignancies, this question remains incompletely answered in GBM. METHODS This study was a retrospective analysis of 354 newly diagnosed patients with GBM who underwent first resection at the authors' institution (2007-2015). RESULTS Of the 354 patients (median age 61 years, and 37.6% were females), 32 (9.0%) had no insurance, whereas 322 (91.0%) had insurance, of whom 131 (40.7%) had Medicare, 45 (14%) had Medicaid, and 146 (45.3%) had private insurance. On average, insured patients survived almost 2-fold longer (p < 0.0001) than those who were uninsured, whereas differences between specific insurance types did not influence survival. The adjusted hazard ratio (HR) for death was higher in uninsured patients (HR 2.27 [95% CI 1.49-3.33], p = 0.0003). Age, mean household income, tumor size at diagnosis, and extent of resection did not differ between insured and uninsured patients, but there was a disparity in primary care physician (PCP) status-none of the uninsured patients had PCPs, whereas 72% of insured patients had PCPs. Postoperative adjuvant treatment rates with temozolomide (TMZ) and radiation therapy (XRT) were significantly less in uninsured (TMZ in 56.3%, XRT in 56.3%) than in insured (TMZ in 75.2%, XRT in 79.2%; p = 0.02 and p = 0.003) patients. Insured patients receiving both agents had better prognosis than uninsured patients receiving the same treatment (9.1 vs 16.34 months; p = 0.025), suggesting that the survival effect in insured patients could only partly be explained by higher treatment rates. Moreover, having a PCP increased survival among the insured cohort (10.7 vs 16.1 months, HR 1.65 [95% CI 1.27-2.15]; p = 0.0001), which could be explained by significant differences in tumor diameter at initial diagnosis between patients with and without PCPs (4.3 vs 4.8 cm, p = 0.003), and a higher rate of clinical trial enrollment, suggesting a critical role of PCPs for a timelier diagnosis of GBM and proactive cancer care management. CONCLUSIONS Access to health care is a strong determinant of prognosis in newly diagnosed patients with GBM. Any type of insurance coverage and having a PCP improved prognosis in this patient cohort. Higher rates of treatment with TMZ plus XRT, clinical trial enrollment, fewer comorbidities, and early diagnosis may explain survival disparities. Lack of health insurance or a PCP are major challenges within the health care system, which, if improved upon, could favorably impact the prognosis of patients with GBM.

Improving Interorganizational Coordination Between Primary Care and Oncology: Adapting a Chronic Care Management Model for Patients With Cancer

The objective of this study was to explore the implementation of a payment and delivery system innovation to improve coordination and communication between primary care and oncology. We employed a qualitative case study approach, conducting interviews (n = 18), and reviewing archival materials. Chronic care coordinators and the cancer center social worker acted as boundary spanners. The chronic care coordinator role built on medical home infrastructure, applying the chronic care model to cancer care. Coordination from primary care to oncology became more routinized, with information sharing prompted by specific events. These new boundary spanner roles enabled greater coordination around uncertain and interdependent tasks. Recommendations for scaling up include the following: establish systematic approaches to learning from implementation, leverage existing capacity for scalability, and attend to the content and purpose of information sharing.

Insurance type impacts the economic burden and survival of patients with newly diagnosed glioblastoma

OBJECTIVE

Glioblastoma (GBM) carries a high economic burden for patients and caregivers, much of which is associated with initial surgery. The authors investigated the impact of insurance status on the inpatient hospital costs of surgery for patients with GBM.

METHODS

The authors conducted a retrospective review of patients with GBM (2010-2015) undergoing their first resection at the University of California, San Francisco, and corresponding inpatient hospital costs.

RESULTS

Of 227 patients with GBM (median age 62 years, 37.9% females), 31 (13.7%) had Medicaid, 94 (41.4%) had Medicare, and 102 (44.9%) had private insurance. Medicaid patients had 30% higher overall hospital costs for surgery compared to non-Medicaid patients ($50,285 vs $38,779, p = 0.01). Medicaid patients had higher intensive care unit (ICU; p < 0.01), operating room (p < 0.03), imaging (p < 0.001), room and board (p < 0001), and pharmacy (p < 0.02) costs versus non-Medicaid patients. Medicaid patients had significantly longer overall and ICU lengths of stay (6.9 and 2.6 days) versus Medicare (4.0 and 1.5 days) and privately insured patients (3.9 and 1.8 days, p < 0.01). Medicaid patients had similar comorbidity rates to Medicare patients (67.8% vs 68.1%), and both groups had higher comorbidity rates than privately insured patients (37.3%, p < 0.0001). Only 67.7% of Medicaid patients had primary care providers (PCPs) versus 91.5% of Medicare and 86.3% of privately insured patients (p = 0.009) at the time of presentation. Tumor diameter at diagnosis was largest for Medicaid (4.7 cm) versus Medicare (4.1 cm) and privately insured patients (4.2 cm, p = 0.03). Preoperative (70 vs 90, p = 0.02) and postoperative (80 vs 90, p = 0.03) Karnofsky Performance Scale (KPS) scores were lowest for Medicaid versus non-Medicaid patients, while in subgroup analysis, postoperative KPS score was lowest for Medicaid patients (80, vs 90 for Medicare and 90 for private insurance; p = 0.03). Medicaid patients had significantly shorter median overall survival (10.7 months vs 12.8 months for Medicare and 15.8 months for private insurance; p = 0.02). Quality-adjusted life year (QALY) scores were 0.66 and 1.05 for Medicaid and non-Medicaid patients, respectively (p = 0.036). The incremental cost per QALY was $29,963 lower for the non-Medicaid cohort.

CONCLUSIONS

Patients with GBMs and Medicaid have higher surgical costs, longer lengths of stay, poorer survival, and lower QALY scores. This study indicates that these patients lack PCPs, have more comorbidities, and present later in the disease course with larger tumors; these factors may drive the poorer postoperative function and greater consumption of hospital resources that were identified. Given limited resources and rising healthcare costs, factors such as access to PCPs, equitable adjuvant therapy, and early screening/diagnosis of disease need to be improved in order to improve prognosis and reduce hospital costs for patients with GBM.

Gaps and delays in survivorship care in the return-to-work pathway for survivors of breast cancer-a qualitative study

Introduction

The number of survivors of breast cancer (bca) in Canada has steadily increased thanks to major advances in cancer care. But the resulting clientele face new challenges related to survivorship. The lack of continuity of care and the side effects of treatment affect the resumption of active life by survivors of bca, including return to work (rtw). The goal of the present article was to outline gaps and delay in survivorship care in the rtw pathway of survivors of bca.

Methods

This qualitative interpretative descriptive study recruited 9 survivors of bca in the province of Quebec. Interviews were conducted at the end of cancer treatments (n = 9), 1 month before rtw (n = 9), and after rtw (n = 5). In an iterative process, a content analysis was performed.

Results

The interviews highlighted gaps in survivorship care and the paucity of dedicated resources for cancer survivors. Participants received neither a survivorship care plan nor information about cancer survivorship (for example, transition to a new normal, side effects, rtw).

Conclusions

Support for survivors of bca resuming their active lives has to be optimized. We suggest that health professionals have to intervene at 1, 3, and 6 months after cancer treatment. At those points, survivors of bca need support for side-effects management, the rtw decision, resource navigation, and reintegration of daily activities. Also, delay in clinical pathways seems to be longer, and much attention is needed to accompany the transition to a "normal life" after cancer.

Are general practitioners getting the information they need from hospitals and specialists to provide quality cancer care for Indigenous Australians?

BACKGROUND

Cancer care involves many different healthcare providers. Delayed or inaccurate communication between specialists and general practitioners (GP) may negatively affect care.

AIM

To describe the pattern and variation of communication between primary healthcare (PHC) services and hospitals and specialists in relation to the patient's cancer care.

METHODS

A retrospective audit of clinical records of Indigenous Australians diagnosed with cancer during 2010-2016 identified through 10 PHC services in Queensland is described. Poisson regression was used to model the dichotomous outcome availability of hospital discharge summary versus not.

RESULTS

A total of 138 patient records was audited; 115 of those patients visited the PHC service for cancer-related care after cancer diagnosis; 40.0% visited the service before a discharge summary was available, and 36.5% of the patients had no discharge summary in their medical notes. While most discharge summaries noted important information about the patient's cancer, 42.4% lacked details regarding the discharge medications regimen.

CONCLUSIONS

Deficits in communication and information transfer between specialists and GP may adversely affect patient care. Indigenous Australians are a relatively disadvantaged group that experience poor health outcomes and relatively poor access to care. The low proportion of discharge summaries noting discharge medication regimen is of concern among Indigenous Australians with cancer who have high comorbidity burden and low health literacy. Our findings provide an insight into some of the factors associated with quality of cancer care, and may provide guidance for focus areas for further research and improvement efforts.

What Do Primary Healthcare Providers and Complementary and Alternative Medicine Practitioners in Palestine Need to Know about Exercise for Cancer Patients and Survivors: A Consensual Study Using the Delphi Technique

Background

Exercise has physiologic and psychological benefits for cancer patients and survivors. Today, various exercises are recommended as adjunct to therapies for cancer patients and survivors. This study was conducted to develop a consensual core list of important knowledge items that primary healthcare providers and complementary and alternative medicine (CAM) practitioners need to know on the role of exercises and physical activities in stimulating anticancer immunity.

Methods

Knowledge items were collected following interviews with key contact experts (4 oncologists, 3 exercise and medicine specialists, 2 researchers, 2 cancer patients, and 3 survivors) and extensive literature review. The collected knowledge items were rated by 9 researchers who conducted research on exercise and cancer. A modified two-iterative Delphi technique was employed among a panel (n = 65) of healthcare providers and CAM practitioners to develop the consensual core list of knowledge items.

Results

Of the 49 knowledge items, consensus was achieved on 45 (91.8%) items in 6 categories. Of those, 9 (20.0%) were general items on recommending moderate to vigorous habitual exercises and physical activities. The rest of items were related to the effects of habitual exercises and physical activities on the functions of immune system and exposure to carcinogens 16 (35.6%), anticancer therapies 12 (26.7%), metastasis of cancer 3 (6.7%), metabolism within tumors 3 (6.7%), and myokines release 2 (4.4%).

Conclusion

Formal consensus was achieved for the first time on a core list of knowledge items on how exercises and physical activities might stimulate anticancer immunity. This core list might be considered at the time of developing training/educational interventions and/or continuing education for primary healthcare providers and CAM practitioners. Future studies are still needed to investigate if such consensual lists might improve congruence in cancer care continuum and improve survival rates and wellbeing of cancer patients and survivors.

2018 Hematology/Oncology Pharmacist Association Best Practices for the Management of Oral Oncolytic Therapy: Pharmacy Practice Standard

PURPOSE:

The aim of the current work was to present a pharmacy practice standard from the Hematology/Oncology Pharmacy Association (HOPA) on the management of oral oncolytic therapy.

METHODS:

The HOPA Standards Committee organized a work group of oncology pharmacist specialists to create a pharmacy practice standard for the management of oral oncolytic therapy that describes the pharmacist’s role on the cancer care team, provides examples of practice tools and resources, summarizes current data related to outcomes, and discusses opportunities to enhance the care of patients with cancer who receive oral oncolytic therapy. We reviewed primary literature, including currently published oral oncolytic guidelines and HOPA’s Scope of Hematology/Oncology Pharmacy Practice.

RESULTS:

Management of oral oncolytic therapy was divided into the following primary areas: prescribing, education, dispensing and distribution, and monitoring and follow-up. Pharmacists’ roles were summarized in each area with a focus on interprofessional collaboration, communication, patient safety, and quality of patient care. Standards describe the best practices in each area (Table 1).

CONCLUSION:

Multiple opportunities exist for pharmacists to enhance the care of patients with cancer who receive oral oncolytics through collaboration with oncology care team members. The role of the oncology pharmacist in the care of this patient population is critical given the complexities related to cost, tolerability, and safety of oral oncolytic medications; issues of access; and the monitoring and follow-up of patients receiving this therapy.

Rural Primary Care Offices and Cancer Survivorship Care: Part of the Care Trajectory for Cancer Survivors

Background:

A cancer diagnosis is a monumental event in a patient’s life and with the number of cancer survivors increasing; most of these patients will be taken care of by a primary care provider at some point after their cancer therapy. The purpose of this study is to identify primary care physician’s needs to care for a patient who has had cancer.

Methods:

A cross-sectional survey of the physician members of the Iowa Research Network was conducted. The survey was designed to measure physician confidence in cancer survivor’s care, office strategies regarding cancer survivorship care, and resources available for patients with cancer. Two hundred seventy-four Iowa Research Network members were invited to participate in this survey.

Results:

Eighty-two physicians (30%) completed the questionnaire with 96% reporting that they are aware of their patient’s cancer survivorship status. Seventy-one physicians reported they were aware of cancer survivorship status by an oncologist sending a note to the office, 68 being diagnosed in their office, 61 by the patient keeping the office apprised, and 15 receiving a survivorship care plan. Physicians reported the top changes in a cancer survivor’s physical health as fatigue (81%) and pain (59%). Sixty-two physicians reported not feeling confident for managing chemobrain, cardiotoxicity (71%), and skin changes (35%). Male physicians were significantly more confident managing patients’ skin changes (P = .049) and musculoskeletal disturbances than female physicians (P = .027), while female physicians were significantly more confident managing early-onset menopause than male physicians (P = .027).

Conclusion:

Most respondents are aware of their patients who are cancer survivors and are mostly confident in the care they provide for them related to long-term effects and side effects of cancer therapies with limited receipt of cancer survivorship care plans.

Integrating primary care providers through the seasons of survivorship

Traditionally, the role of primary care providers (pcps) across the cancer care trajectory has focused on prevention and early detection. In combination with screening initiatives, new and evolving treatment approaches have contributed to significant improvements in survival in a number of cancer types. For Canadian cancer survivors, the 5-year survival rate is now better than it was a decade ago, and the survivor population is expected to reach 2 million by 2031. Notwithstanding those improvements, many cancer survivors experience late and long-term effects, and comorbid conditions have been noted to be increasing in prevalence for this vulnerable population. In view of those observations, and considering the anticipated shortage of oncology providers, increasing reliance is being placed on the primary care workforce for the provision of survivorship care. Despite the willingness of pcps to engage in that role, further substantial efforts to elucidate the landscape of high-quality, sustainable, and comprehensive survivorship care delivery within primary care are required. The present article offers an overview of the integration of pcps into survivorship care provision. More specifically, it outlines known barriers and potential solutions in five categories: ■ Survivorship care coordination■ Knowledge of survivorship■ pcp-led clinical environments■ Models of survivorship care■ Health policy and organizational advocacy.

Surgical breast cancer patient pathway: Experiences of patients and relatives and their unmet needs

BACKGROUND AND AIM

Breast cancer is the most common cancer disease in women worldwide. In Denmark, the law prescribes cancer patient pathways (CPPs) in general and thus also for breast cancer. Although results from patient satisfaction surveys show overall satisfaction with the pathway, a call for improvement has been voiced for some areas. The aim of this study was to explore patients' and relatives' experiences with the surgical breast CPP and to identify any unmet needs.

METHOD

This study was based on focus groups with patients who had surgery for breast cancer, and their relatives. The settings were two Danish surgical breast cancer clinics.

FINDINGS

Overall, patients and relatives found the structure of the surgical breast CPP satisfactory. The time in the surgical department was short, and most patients found it difficult to cope with the situation. Empathy and a supportive relationship between patients, relatives and health-care professionals were of great importance. Five key points were identified in which some of the participants had unmet needs. Suggestions for change were related to information, communication, choice of treatment, flexibility in the pathway and easy access to the clinic after surgery.

CONCLUSION

Although patients and relatives found the CPP for breast cancer satisfactory and well planned, suggestions for change were made relating to unmet needs with respect to five key points in the pathway. Implementing findings from this study in clinical practice requires co-operation between health-care professionals and support from the leaders of the organization.

[Knowledge and attitude among general practitioners in Andalusia (Spain) on the identification of subjects at high risk of breast and colorectal cancer]

AIMS

To assess the knowledge and attitude among general practitioners in Andalusia on the identification of subjects with elevated risk for breast cancer, colorectal cancer, and hereditary cancers, as well as to detect barriers to accessibility to the screening programs.

METHODS

A descriptive, cross-sectional study was conducted based on an online survey of 24 questions. Data are shown as frequencies, and association tests were statistically used. The level of significance was set at<.05.

RESULTS

Survey response rate was 32%, of which 224 were valid, and included 56% men, and a mean age±DE of 46±12 years. Established criteria for high risk breast cancer were already known by 71.4% [95% CI 65-76], being worst in those living in big cities (P<.014). Among general practitioners, 86% were allowed to order mammography in women with lumps or at moderate to high risk for breast cancer. As regards colorectal cancer, 87.9% of general practitioners knew the risk factors. Among general practitioners, 58.2% [95% CI 49-62] were allowed to order a colonoscopy if clinical suspicion was present, especially if they lived in large cities (P<.0001).

CONCLUSIONS

The screening program for breast cancer is well-known by general practitioners, and the access to mammography is successful. Most of the general practitioners consider the follow-up program for persons at high risk for colorectal cancer appropriate, although half of those surveyed had some barriers to ordering colonoscopy. Knowledge on hereditary cancer is limited, and varies among areas. There is also a general lack of awareness on hereditary cancer and genetic counselling units.

Evaluation of the delivery of survivorship care plans for South Asian female breast cancer survivors residing in Canada

Background

This paper focuses on phase iii of a study evaluating the development and implementation of a survivorship care plan (scp) that could ultimately improve post-treatment quality of life for South Asian (sa) breast cancer survivors (bcss). Evaluating the utility of the scp was important to understand how sociocultural influences might affect uptake of the scp by sa bcss, especially as they transition from treatment to community care.

Methods

Post-treatment discharge planning using an individualized scp at discharge for sa female breast cancer patients with stage i or ii disease was offered as a pilot service to oncologists at BC Cancer's Fraser Valley and Abbotsford centres. A longitudinal study using a mixed-methods approach was used to evaluate the utility of that service at 1 year after discharge.

Results

Participants (n = 16) completed a survey about their scp delivery experience, and a 1-year post implementation survey about the scp content and its utility. Most participants reported the discharge appointments to be extremely or very helpful with respect to post-treatment care questions. All have visited their family physicians for follow-up as recommended. The three major sources of support were family, faith, and family physician. Qualitative responses from the health care professionals who developed or implemented the scps identified two challenges in scp delivery: engaging patients or family members in relationship, and translating key information through interpreters.

Conclusions

It is important to evaluate the utility of scps for sa female survivors, who might differ from the general bcs population because of a different understanding of the disease; language barriers; strong influence of family members; societal stigmas; and personal, social, cultural, and religious beliefs and values. A formal nurse-led discharge appointment with discussions about follow-up care and an individualized scp outlining the short- and long-term effects of treatment are recommended. Particular attention has to be paid to the practical and psychosocial needs of sa bcss and their supporting family members.

The Gen-Equip Project: evaluation and impact of genetics e-learning resources for primary care in six European languages

Purpose

Genetic advances mean patients at risk of genetic conditions can be helped through testing, clinical screening, and preventive treatment, but they must first be identified to benefit. Ensuring quality of genetic care for patients requires genetic expertise in all health services, including primary care. To address an educational shortfall, a series of e-learning resources was developed in six languages to equip primary care professionals with genetic skills relevant for practice. The purpose of the study was to evaluate these resources using Kirkpatrick’s framework for educational outcomes.

Methods

Mixed methods (qualitative and quantitative) were used over four phases of the study.

Results

A high level of satisfaction with the resources was reported. Knowledge and skills improved significantly after using the education material. Participants reported changes in confidence and practice behavior, including family history taking, seeking advice from specialists and referring patients. The resources helped users to learn how to explain genetics. Many visited the resources repeatedly and some used them to educate colleagues or students.

Conclusion

Gen-Equip modules are effective in improving genetic knowledge, skills, and attitudes for primary care professionals. They provide both continuing professional development and just-in-time learning for a potentially large global audience at a practical level.