Internists preferred to coordinate with specialists for care of childhood cancer survivors

Internists reported feeling uncomfortable with routine medical treatment of childhood cancer survivors because of unfamiliarity with long-term surveillance guidelines for this population, according to recent study findings published in the Annals of Internal Medicine.

Tara O. Henderson, MD, MPH, of the University of Chicago Medical Comer Children's Hospital, and colleagues conducted a randomized cross-sectional survey of 1,110 internists between September 2011 and August 2012 to determine reported attitudes and knowledge about the care of childhood cancer survivors (CCSs).

In the 5 years preceding the survey, 51% of participants reported caring for at least one adult CCS, of whom 72% reported they never received a treatment summary.

Eighty-four percent of physicians surveyed preferred caring for CCSs in collaboration with a cancer center-based physician or long-term follow-up clinic compared with 5.1% who reported they would care for CCSs independently. Only 10.5% reported they would refer CCSs to a cancer center-based physician, long-term follow-up program or another primary care physician.

Internists reported being “somewhat comfortable” caring for CCSs, on average. Twenty-five percent of physicians reported being “somewhat comfortable” or “comfortable” caring for osteosarcoma survivors, 27% reported the same for acute lymphoblastic leukemia, and 36.9% reported the same for Hodgkin’s lymphoma. Internists reported they were more likely to be comfortable treating male CCSs. Surveyed physicians also were more likely to be comfortable treating CCSs if they had a larger patient volume and had seen at least one CCS patient in the past 5 years.

Twelve percent of participants reported they were “somewhat familiar” with available surveillance guidelines for CCSs. Fewer than 10% (9.4%; 95% CI, 7.7-11.2) were in agreement with current North American Children’s Oncology Group guidelines on breast cancer surveillance in women exposed to chest radiation. Nearly 20% (17.8%; 95% CI, 15.6-20.2) were aware of the need for annual mammograms for surveillance for early breast cancer. Biennial echocardiographic surveillance for cardiac dysfunction was correctly recommended by 14.9% (95% CI, 12.8-17.1). Annual surveillance for serum thyroid-stimulating hormone and free thyroxin testing for thyroid dysfunction was recommended by 76.4% of participants (95% CI, 73.7-78.8). All three surveillance questions were answered in concordance with the North American Children’s Oncology Group guidelines by just 5.4% of participants.

“In summary, our study suggests that internists who provide most primary care in the United States are generally uncomfortable with caring for CCS, and most have suboptimal knowledge of the available guidelines for late effects of surveillance,” the researchers wrote. “Concentrated efforts to improve these gaps should include enhanced education of PCPs through webinars, education sessions at national meetings, and guidelines linked to internal medicine websites. Focused efforts should also be made to improve co-management by oncologists and PCPs throughout the cancer care trajectory (cancer diagnosis through survivorship). Given current technologies, [survivorship care plan] creation and dissemination efforts should potentially be streamlined through electronic medical records, web-basedtools, and parallel smartphone and tablet applications.”

In an accompanying editorial, Jill P. Ginsberg, MD,and Dava Szalda, MD, both of The Children’s Hospital of Philadelphia, wrote that pediatricians play an important role in helping prepare for the transition of CCSs to the adult health care setting.

“Successful care of CCSs is a shared responsibility among pediatric oncology care providers, patients acting as their own advocate, and internists who will become the source of ongoing care for this growing population,” they wrote. “Integration of innovative educational approaches for internists in the established medical school curriculum and beyond and the implementation of thoughtful, patient-focused transition practices will help to eliminate current disparities in the care of CCSs.”

For more information:

Suh E. Ann Intern Med. 2014;doi:10.7326/M13-1941.

Szalda D. Ann Intern Med. 2014;doi:10.7326/M13-2718.

Disclosure: The study was funded in part by the National Cancer Institute.