SPARCCS provides current nationally representative data comparing U.S. PCPs’ and oncologists’ knowledge, attitudes, and practices regarding the care of cancer survivors. The findings reported in this paper have several important implications for health policy and research aimed at improving the care of cancer survivors. First, we found disagreement among PCPs and oncologists regarding the ideal model of care for cancer survivors (Fig. ). While most oncologists favored an oncologist-led model, nearly half of PCPs favored a shared care model or one led by PCPs.
These results suggest an unfavorable view among oncologists regarding a central role for PCPs in caring for cancer survivors—an interpretation reinforced by our results showing oncologists’ generally negative perceptions of PCPs’ skills in caring for survivors. The results also reflect mixed views among PCPs about assuming increased responsibility for survivorship care. These findings are significant, because lack of receptiveness to PCP involvement in cancer survivors’ care, especially among oncologists, could compromise efforts to promote shared care or PCP-led delivery models, which may be a key strategy to meet the care needs of the many survivors who see only their PCP annually11–13
However, 22% of physicians in both groups endorsed the alternative model of specialty clinics either led by physicians, oncology nurses, or physician assistants, such as those already established by some cancer centers43
. With PCP shortages projected5,6
and likely to accelerate due to efforts to expand access to primary care under health care reform, this model may offer a more feasible and cost-efficient alternative to physician-led programs4,21–23
. Given the anticipated shortage of oncologists and growth in the cancer survivor population, there is a clear need for closer examination of the costs and effectiveness of such alternative delivery models for cancer survivor care. Our findings suggest that a sizable segment of physicians may be receptive to such models.
Consistent with their attitudes towards models of care, many PCPs reported uncertainty about their own skill levels and lack of confidence in their knowledge of cancer survivor care. For example, less than 60% agreed that PCPs had the necessary skills to care for treatment effects in survivors of breast or colon cancer. Furthermore, less than half of PCPs felt very confident in their knowledge of testing for recurrence or caring for psychosocial effects of cancer, and only 23% felt very confident in their knowledge of caring for the late physical effects of cancer or its treatments (Fig. ). Oncologists’ opinions about PCP skills in these domains were more negative; far less than half of oncologists agreed that PCPs had the skills necessary to provide care for the late effects of cancer or initiate appropriate testing to detect recurrences.
Taken as a whole, these findings suggest significant attitudinal barriers among both PCPs and oncologists that could impede implementation of new delivery models in which PCPs assume greater responsibility for cancer survivor care. This approach is consonant with movement toward establishing patient-centered medical homes for all patients44–46
. Successful implementation of this type of model, however, may first require directly addressing the unfavorable attitudes of many oncologists and some PCPs regarding PCPs’ ability to care for cancer survivors.
Yet the problem is not merely one of overcoming unfavorable attitudes; our study also suggests that many PCPs—and even some oncologists—may lack critical knowledge or training to care for cancer survivors. The responses to the clinical vignettes reflect that both PCPs and oncologists deviate from guidelines by endorsing more testing, and at more frequent intervals, than the guidelines suggest (Table ). Although both groups departed substantially from guidelines, PCPs diverge more substantially than do oncologists, consistent with our findings of deficits in confidence regarding their knowledge of follow-up care (Fig. ). The observed systematic bias towards excessive use of non-recommended surveillance tests in both physician groups may contribute to increasing health care costs or iatrogenic harms among cancer survivors47–49
. The reasons for physicians’ overuse of follow-up blood and imaging tests remain to be elucidated, but may be due in part to the practice of defensive medicine, reimbursement incentives for office-based lab testing, or uncertainty regarding best care practices given the limited evidence base informing the development of clinical practice guidelines and areas of disagreement between the guidelines of different professional groups. Despite uncertainty regarding the validity of guidelines, our results suggest a need for broader training about appropriate post-treatment surveillance testing.
Interestingly, specialty differences in recommendations for clinic follow-up and physical examinations showed a different pattern than those observed for surveillance testing. Professional guidelines suggest performing physical exams every 6 months for colon cancer survivors and annually for breast cancer survivors. However, our results showed that physicians’ recommended intervals for physical exams were nearly identical for the two survivor groups, with PCPs favoring annual and oncologists opting for 6-month intervals. Responses may reflect the care patterns and experiences most familiar to each of these practitioner groups, rather than lack of awareness of guidelines; for example, annual health examinations are a common practice among PCPs.
The current study has several strengths and limitations. SPARCCS is a large, nationally representative survey designed to obtain the perspectives of US-based PCPs and oncologists practicing in the full spectrum of health care delivery settings, and it builds upon prior physician surveys conducted in other countries or in smaller, less representative physician groups15,24,26,28,50
. Our survey had a good response rate and no measurable response bias, and results are generalizable to US PCPs and oncologists. However, our limited focus on two common cancers may underestimate knowledge gaps, given that PCPs likely have lower awareness for rarer cancers, their treatments and long-term adverse effects. Finally, our analyses in this initial overview paper were descriptive, and did not assess the association between multiple physician characteristics or practice setting variables and our main outcomes; these more detailed analyses for each outcome will be addressed in future separate papers.
Our study suggests several key insights regarding implementation of the Institute of Medicine (IOM) recommendations to improve cancer survivor care45
. First, PCPs require more training and education to enhance their knowledge and confidence in providing quality follow-up cancer care44
. Succinct, explicit, patient-specific, actionable information in the form of ‘survivorship care plans’, as recommended by the IOM, might potentially address much of this concern and also help address any underuse of evidence-based surveillance testing45
. Such efforts should also ensure that PCPs are informed of follow-up care guidelines. A randomized controlled trial demonstrated that when PCPs are made aware of such guidelines, patient outcomes including complications, recurrence, and quality of life are similar to those of patients followed by oncologists51
. Second, efforts to improve awareness and adherence to guidelines may reduce routine use of non-guideline surveillance testing among both PCPs and oncologists. However, it is unlikely that guideline adherence will occur without changes in coverage policies or reimbursement, informed by systematic research on the benefits and harms of such testing. Third, oncologists' willingness to share survivorship care responsibilities with PCPs or other allied health professionals must be further explored and negotiated. Finally, our results should be interpreted in light of prior research showing that survivors have a keen interest in their own follow-up care, and that greater communication about their expectations would likely enhance the quality of survivor care15,28,45,52
. Integrating survivors’ perspectives and preferences will help providers, payers, policymakers, and researchers to develop and disseminate communication strategies such as survivorship care plans, and improved models of care that ensure survivors are no longer “lost in transition” between specialists and PCPs.