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From Cancer Patient to Cancer Survivor: Lost in Transition
addition, shared-care models depend on (1) professional training, (2) general practitioners viewing their role in cancer care as enhancing patient care and improving their job satisfaction, and (3) appropriate remuneration.
Long-term cancer survivors who have been followed for many years by specialists are sometimes reluctant to return to their primary care physician for follow-up, even when reassured that they are at low risk of recurrence. One group of British clinicians noted that a feeling often expressed by patients seen for many years in their specialty clinics was “As long as I keep coming here I feel I’ll be alright” (Glynne-Jones et al., 1997). These clinicians concluded that reassurance rather than the detection of recurrence was the most important function of follow-up and so developed a formal system of discharge from their hospital-based oncology clinic to primary care providers for follow-up. As part of the planned discharge, patients were counseled and given a written contract reassuring them of their good prognosis and commitment to continued care from the specialist if necessary. Primary care physicians were informed of the discharge plan. Of the long-term cancer survivors invited to participate, 63 percent agreed to be discharged to primary care. Of the patients who agreed to the contract, 85 percent remained with their primary care provider at 13 months. The planned discharge was viewed as successful, and investigators noted the need to address patients’ expectations regarding follow-up and the duration of specialty follow-up early in the treatment process. Investigators highlighted the need to address anxiety among patients as this is a deterrent to acceptance of a transfer to primary care.
A trial conducted at a breast clinic in London showed that reducing the number of hospital-based follow-up visits was not associated with increased visits to local practitioners or to higher use of a telephone hotline (Gulliford et al., 1997). Women diagnosed within the past 5 years were seen every 3 to 6 months in the conventional arm of the trial, but annually during the visit for mammography in the reduced visit arm (for women treated with lumpectomy). Nearly all (93 percent) women were willing to participate in the trial. Twice as many patients in both groups preferred reducing rather than increasing follow-up visits.18
Evidence that generalists are as effective as specialists in providing follow-up care for women with breast cancer is available from clinical trials. General practitioner follow-up did not increase length of time to diagnosis of a recurrent cancer (as measured at 18 months) or adversely effect quality of life (Grunfeld et al., 1996). Women who had follow-up
This study was not designed to assess differences in survival or length of time to diagnose recurrent cancer.