Breast cancer survivors are more likely to receive recommended care when they see both an oncology specialist and a primary care physician, data from a study of trends in survivor care between 1998 and 2002 in nearly 24,000 survivors suggest.
The finding that survivors who are seen by both a primary care physician and an oncology specialist receive more preventive care doesn't necessarily suggest that all survivors should be followed by both, but it does emphasize the importance of coordination of care between both in providing follow-up care, Claire F. Snyder, Ph.D., said.
Dr. Snyder of Johns Hopkins University, Baltimore, and her colleagues used data from the Surveillance, Epidemiology and End Results Medicare-linked database (SEER-Medicare) to look at preventive, screening, and surveillance care trends in the 23,731 survivors of stage I-III breast cancer who were older than age 65 years, in fee-for-service Medicare, and diagnosed between 1998 and 2002. The survivors were grouped into five cohorts based on their year of diagnosis, and trends in this population were compared with those in controls.
Most survivors (55%–60% in each cohort) were followed during their first year of survivorship (defined as beginning 366 days after their diagnosis date) by both a primary care physician (defined as a general practitioner, internist, family physician, ob.gyn., geriatrician, or a multispecialty group practice) and an oncology specialist (defined as a medical oncologist, hematologist-oncologist, general surgeon, oncologic surgeon, or radiation oncologist). The percentage of survivors who were followed by only an oncology specialist increased, and the percentage who were followed by only a primary care physician decreased over the study period, Dr. Snyder said.
The findings of the study, which was funded by the American Cancer Society, were reported in the Journal of Clinical Oncology.
When survivor care was compared based on whether patients saw a primary care physician only, an oncologist only, both a primary care physician and an oncologist, or neither of the two, those who were seen by both were shown—after adjustment for age, race, comorbidities, SEER region, cancer stage, total number of visits, socioeconomic status, urban/rural location, and diagnosis year—to be more likely to receive each of the types of preventive care that were measured in this study (J. Clin. Oncol. 2009 Jan. 21 [doi:10.1200/JCO.2008.18.0950]).
Of all survivors (from all five cohorts) who were seeing both a primary care physician and an oncology specialist, 60% received flu shots, compared with fewer than about 50% in the other physician-mix groups; nearly 40% received cholesterol screening, compared with between 20% and just over 30% in the other groups; about 33% received colorectal cancer screening, compared with about 13%–22% in the other groups; and about 18% underwent bone densitometry, compared with fewer than 14% in the other groups, Dr. Snyder said.
Although the study has several strengths—including comparison of cohorts over time, examination of trends in the key first year of survivorship, and use of controls for comparing trends—it is limited by the inclusion of only those survivors who were older than age 65 years in the Medicare fee-for-service program, and by the lack of data on why specific preventive services were or were not provided, the investigators noted.
In an earlier iteration of the study, data comparing 23,731 survivors with an equal number of “screening controls” (defined as those matched by age, ethnicity, sex, and region, as well as mammogram in the survivor's year of diagnosis) were presented by Dr. Snyder at the annual meeting of the American Society of Clinical Oncology.
Breast cancer survivors were found to be less likely to receive preventive care, with the exception of mammography, than were screening controls. However, trends over time in survivors' care tended to be better than in screening controls, Dr. Snyder said. No differences were seen over time in trends in primary care provider visits, but survivors' visits to other physician specialists increased faster than did those of controls.
Dr. Snyder noted that both survivors and screening controls received more flu shots (with similar increases over time in both groups), and more cholesterol screening (with a faster increase in rates among survivors over time) in 2002, compared with 1998. Also, more survivors received bone densitometry in 2002, compared with 1998; the rate in screening controls didn't change significantly over time. In the case of colorectal cancer screening, both groups received less screening in 2002, compared with 1998, she said.
Dr. Cathy Eng, a medical oncologist with a focus on colorectal cancer, said during a discussion of the findings at the ASCO conference that coordination of care is warranted, and noted that the reduction in colorectal cancer screening is particularly disappointing and of concern in this population, given the preventability of colorectal cancer.
“We must educate our patients and colleagues about proper surveillance,” said Dr. Eng of the University of Texas M.D. Anderson Cancer Center in Houston, adding that too often the patient's prior cancer diagnosis becomes the “only diagnosis of concern,” with diet, exercise, treatment of other comorbidities, and prevention of other conditions taking a back seat to that diagnosis.
Dr. Snyder noted that “we are still trying to figure out the best approaches for providing survivorship care in a coordinated and efficient manner.”
Following the ASCO meeting, the study was expanded to include the second control group. Compared with “comorbidity controls” (defined as controls matched by age, ethnicity, sex, region, and comorbidity), survivors were more likely to receive preventive care. An exception was for cholesterol screening in the 1999 and 2000 cohorts. No differences were seen for trends in primary care provider visits or visits to other physicians. The only difference in trends over time in the rate of screening between survivors and comorbidity controls was in influenza vaccination.
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