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Survivorship incorporated into primary cancer care may be more cost effective and lead to better clinical and patient-reported outcomes in patients with breast cancer and other malignancies.
Primary survivorship care may be feasible and lead to similar effects on clinical and patient-reported outcomes as well as result in lower costs when compared with secondary care, according to a study published in Journal of Cancer Survivorship.
This study gathered results from 7 randomized trials and 9 observational studies. Most of the studies examined patients with solid tumor malignancies, such as breast cancer (n = 7) and colorectal cancer (n = 3). Of these, clinical outcomes were reported in 10, patient-reported outcomes in 11, and costs effectiveness in 4. When comparing primary and secondary care, there were no major differences in clinical and patient-reported outcomes.
“In this review, similar effects on clinical and patient-reported outcomes were seen for survivorship care in primary- compared with secondary-based care. Although the evidence should be interpreted with caution, survivorship care in primary care seems feasible and results in lower costs,” wrote investigators of the study.
A low risk of bias was determined for 10 studies, intermediate risk for 3, and high risk for 3. Bias was often related to the design of the study, which included selection of the participants, misclassification, recall, and interviewer bias.
Patient populations ranged from 98 in an experimental study to 5009 in a quasi-experimental observational study. Length of study ranged from 1 to 15 years.
No differences were seen in survival by follow-up strategies after 3 and up to 15 years. The follow-up for secondary care was associated with shorter relapse-free survival as well as a higher likelihood of receiving palliative treatment with chemotherapy in a cohort study of patients with pancreatic cancer, in part attributable to more advanced disease observed in secondary care (58% vs 34%; P = .03). Additionally, 8 studies examined the occurrence of serious clinical events with none finding differences related to the number or recurrences and metastases, time of diagnosis, death, and other clinical events between primary and secondary care–based follow-up.
In 2 randomized clinical trials, documented follow-up care as measured by adherence to medical guidelines and follow-up tests found 98.1% of patients in primary care were seen in accordance with professional guidelines compared with just 80.9% in secondary care (P = .020). The second study showed that patients treated in primary care were more likely to have fecal blood test (rate ratio, 2.4; CI, 1.4-4.44; P = .003) compared with those in secondary care who were more likely to have ultrasounds and colonoscopies; however, it was unclear if this was done per follow-up guidelines.
For patient-reported outcomes, there were no differences found in quality of life, anxiety, or depression between survivorship strategies after adjusting for clinical and pathological covariates. An observational study indicated less fatigue was reported in patients with breast cancer who were treated as part of primary care (62.0% vs 81.1%; P = .005). Another study compiling questionnaires indicated that patients with breast cancer were more satisfied with secondary-based care (P <.05)
Across 5 observational studies examining self-reported receipt of survivorship care, there was no evidence to show either primary or secondary care as the favorable strategy. There were 2 studies that showed lower adherence to clinical examinations for patients with breast cancer by physicians working in primary care (approximately 80% vs 90% in secondary care; P <.05). Another study showed that patients receiving primary care were more likely to receive examinations as stated by national guidelines (58% vs 36%; P = .004).
There were no differences found in patients self-mammogram frequency, but 1 study did find a higher uptake in preventative tests, such as Pap smears (adjusted odds ratio [AOR], 2.90; CI 1.05-8.04; P = .040), and a colonoscopy (AOR, 2.99; CI, 1.5-8.51; P = .041). It was found that physicians treating patients with colorectal cancer helped more with lifestyle improvements compared with those treating breast cancer.
In all 4 studies that performed cost analyses, primary care was found to have lower societal and patient costs with the main cost driver in all studies being the mean cost per visit, which included organizational and physician response.
“The content of survivorship care is examined by both documented follow-up care and self-reported receipt of survivorship care. Some differences were seen in these outcomes, especially relating to the adherence to guidelines and follow-up tests, but the results showed no favorite strategy. It remains unclear whether or not these differences may affect other outcomes, such as detection of recurrences and survival,” concluded investigators.
Vos JAM, Wieldraaijer T, van Weert HCPM, van Asselt KM. Survivorship care for cancer patients in primary versus secondary care: a systematic review. J Cancer Surviv. 2021;15(1):66-76. doi:10.1007/s11764-020-00911-w