Many general internists uncomfortable caring for childhood cancer survivors, unfamiliar with relevant cancer surveillance guidelines

Internists reported that they were “somewhat uncomfortable” caring for childhood cancer survivors, were unfamiliar with available surveillance guidelines, and preferred to collaborate with cancer treatment centers and clinicians in a recent survey.

Researchers mailed a survey between September 2011 and August 2012 to a random sample of general internists. The survey used a 7-point Likert scale to measure comfort levels with caring for survivors and familiarity with available surveillance guidelines and a clinical vignette to assess compliance with the Children's Oncology Group Long-Term Follow-Up Guidelines. Results appeared in Annals of Internal Medicine on Jan. 7.

The response rate was 61.6% (1,110 of 1,801). More than half the internists (51.1%) reported caring for at least 1 survivor, but 72% of these physicians had never received a treatment summary from the patient's cancer care clinician or team. Only 5.5% of internists preferred to care for survivors independently. Most (84%) preferred to comanage with a cancer center-based physician or long-term-follow-up clinic, and 10.5% said they would refer survivors to a cancer center-based physician, follow-up program, or another primary care clinician.

On average, internists were “somewhat uncomfortable” caring for survivors of Hodgkin's lymphoma, acute lymphoblastic leukemia and osteosarcoma. A smaller proportion of respondents said that they were “somewhat comfortable” or “comfortable” caring for Hodgkin's lymphoma (36.9%), acute lymphoblastic leukemia (27%), and osteosarcoma survivors (25%). Comfort levels were higher among male internists, those with a larger patient volume and those who had seen at least 1 survivor in the preceding 5 years.

Internists reported being “somewhat unfamiliar” with available surveillance guidelines, and only 12% stated that they felt at least “somewhat familiar” with them.

Knowledge of available surveillance guidelines for breast cancer and cardiac and thyroid function was assessed by using a clinical vignette, which found:

• 9.4% of internists (95% CI, 7.7% to 11.2%) complied with guidelines for breast cancer surveillance in women exposed to chest radiation by recommending annual mammography and breast MRI, and an additional 17.8% (95% CI, 15.6% to 20.2%) recognized the need for surveillance for early breast cancer with annual mammograms;
• 14.9% (95% CI, 12.8% to 17.1%) correctly recommended biennial echocardiographic surveillance for cardiac dysfunction;
• 76.4% (95% CI, 73.7% to 78.8%) correctly recommended annual surveillance with serum thyroid-stimulating hormone and free thyroxin testing for thyroid dysfunction; and
• 5.4% (95% CI, 4.2% to 6.9%) answered all 3 surveillance questions correctly.

The most useful tools, according to the internists, would be long-term follow-up guidelines and patient-specific standardized letters from specialists with follow-up recommendations sent directly to the primary care physician (PCP). The researchers concluded, “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 comanagement by oncologists and PCPs throughout the cancer care trajectory (cancer diagnosis through survivorship).”

The authors of an accompanying editorial wrote that caring for childhood cancer survivors is a shared responsibility among pediatric oncology care clinicians, patients and internists.

ACP Internist addressed how internists can better handle the adult survivors of childhood cancer, as well as survivors of other pediatric diseases, in a story in its September 2010 issue.