Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study

Laura A. M. Duineveld; Kristel M. van Asselt; Willem A. Bemelman; Anke B. Smits; Pieter J. Tanis; Henk C. P. M. van Weert; Jan Wind

doi:10.1370/afm.1919

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Comment to the letter of M. Heins
Laura A. Duineveld

Published on: 18 July 2016
Re: Duineveld et al. Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study
Marianne J. Heins

Published on: 21 June 2016

Published on: (18 July 2016)
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Comment to the letter of M. Heins
Laura A. Duineveld, MD
Other Contributors:
Thank you for your comment.
We agree on the suggestions that have been made by Heins et al. to efficiently shift coordination of follow-up care to primary care. We agree that this can only be done under clearly defined conditions and with agreement and participation of all stakeholders, medical specialists, patients and primary care physicians (PCPs). Medical specialist and patients should be informed that the...
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Thank you for your comment.
We agree on the suggestions that have been made by Heins et al. to efficiently shift coordination of follow-up care to primary care. We agree that this can only be done under clearly defined conditions and with agreement and participation of all stakeholders, medical specialists, patients and primary care physicians (PCPs). Medical specialist and patients should be informed that the content of follow-up of colon cancer is in accordance with national guidelines and is identical in primary care and secondary care. Furthermore, since many patients who have been treated for cancer already visit their PCP several times a year, as mentioned by Heins et al., symptoms suggestive of recurrent disease can be monitored more continuously, providing a window of opportunity to detect symptomatic recurrent disease early.
On the other hand, PCPs should be aware that recurrent disease of colon cancer can become symptomatic in between routine follow-up visits. In a qualitative study in which the perspectives of Dutch primary care physicians regarding their current and future role in survivorship care of colon cancer were explored most PCPs indicated that they were willing to be more involved in survivorship care, including follow-up of colon cancer because this increases continuity of care for patients.(1) However, some participants did not feel confident in providing this care due to a lack of expertise, as has been indicated by Heins et al. Therefore, in case survivorship care is shifted to primary care, agreements with medical specialists should be made including easily accessible consultations, fast referrals and diagnostic testing in the hospital.(1)
Currently, a multi-centre randomized controlled trial is carried out in the Netherlands in which primary care led survivorship care including follow-up will be evaluated in comparison with secondary care for patients with colon cancer. Also, the eHealth application Oncokompas2.0 used by patients as a guide on self-help and on when to contact their PCP, will be assessed.(2) Main outcome is quality of life and secondary outcomes include number of diagnostic investigations, referrals and related communication between secondary and primary care, (time of) recurrence detection and protocol adherence.(2) The multidisciplinary guideline, a survivorship care plan including symptoms that could indicate recurrent disease and steps that should be undertaken when recurrent disease is suspected, are handed out to the PCP participating in this study. Although it has been demonstrated that PCP-led survivorship follow-up care was comparable to specialist care with respect to quality of life, efficiency of recurrence detection and anxiety levels (3,4) the result of the multi- centre trial mentioned above should be awaited before primary care-led survivorship care including follow-up could be implemented nationwide.
Laura Duineveld M.D., Henk van Weert M.D. PhD, Jan Wind M.D. PhD
1. Duineveld LAM, Wieldraaijer T, Wind J,et al. Primary care-led survivorship care for patients with colon cancer and the use of eHealth: a qualitative study on perspectives of general practitioners. BMJ Open 2016;6:e010777.
2. Duineveld LA, Wieldraaijer T, van Asselt KM, et al. Improving care after colon cancer treatment in The Netherlands, personalised care to enhance quality of life (I CARE study): study protocol for a randomised controlled trial. Trials. 2015 Jun 26;16:284.
3. Augestad KM, Norum J, Dehof S, et al. Cost-effectiveness and quality of life in surgeon versus general practitioner-organised colon cancer surveillance: a randomised controlled trial. BMJ Open. 2013;3(4).
4. Watchow DA, Weller DP, Esterman A, et al. General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer. 2006;94(8):1116-1121
Competing interests: None declared
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Competing Interests: None declared.
Published on: (21 June 2016)
Page navigation anchor for Re: Duineveld et al. Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study
Re: Duineveld et al. Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study
Marianne J. Heins, Researcher
Other Contributors:
With pleasure we read the article of Duineveld et al. [1] on the follow-up after colon cancer. In their discussion they suggest that "considering the fact that primary care-led follow-up might be more cost-effective and that more generalist care is desired in the care of patients after their initial treatment, the role of coordinating follow-up care might be shifted toward primary care physicians."
We think this...
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With pleasure we read the article of Duineveld et al. [1] on the follow-up after colon cancer. In their discussion they suggest that "considering the fact that primary care-led follow-up might be more cost-effective and that more generalist care is desired in the care of patients after their initial treatment, the role of coordinating follow-up care might be shifted toward primary care physicians."
We think this is a good suggestion, but several steps will have to be taken. First of all, it is important that medical specialists and patients agree with shifting the role of coordinating follow-up care toward primary care physicians. For this, they must have sufficient confidence in the ability of primary care physicians to recognize symptoms suggestive of recurrence and know that patients will be referred to secondary care promptly when needed.
Secondly, primary care physicians should be aware of the significant risk of recurrence when patients present with symptoms between scheduled follow-up visits and should know when to refer to secondary care. The study of Duineveld et al shows that almost half of the recurrences of colorectal cancer were detected in symptomatic patients. The non-specific nature of symptoms which led to the detection of a recurrence suggests that primary care physicians should be alerted by any symptom presented by the patient. This requires proper training of primary care physicians and clear guidelines tailored to the primary care setting. Ideally, they should be developed in collaboration between medical specialists and primary care physicians, to obtain confidence in and support for these guidelines by both groups.
Thirdly, if patients visit primary care physicians with symptoms between follow-up visits, prompt diagnostic evaluation, consultation with a secondary care specialist or referral to secondary care should be easily available. This requires good communication between primary and secondary care and good organization.
Finally, also patients should be educated about the significant risk of recurrence between visits and the symptoms that could indicate recurrence. As many patients already visit their primary care physician several times a year [2], increasing the role of primary care physicians in follow-up may possibly lead to earlier detection of symptomatic recurrence. This however, needs to be established in well designed studies. Besides, many patients already visit their primary care physician for chronic diseases, the practice is often nearby and care is more cost-effective [3,4].
Marianne Heins, PhD; Joke Korevaar, PhD; Francois Schellevis, MD PhD
References:
1. Duineveld LAM, van Asselt KM, Bemelman WA et al. Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study Ann. Fam. Med 2016 14:215-220
2. Heins MJ, Schellevis FG, Rijken PM, Van der Hoek L, Korevaar JC. Determinants of increased primary health care use in cancer survivors. J Clin Oncol. 2012;30(33):4155-4160
3. Augestad KM, Norum J, Dehof S, et al. Cost-effectiveness and quality of life in surgeon versus general practitioner-organised colon cancer surveillance: a randomised controlled trial. BMJ Open. 2013;3(4).
4. Watchow DA, Weller DP, Esterman A, et al. General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer. 2006;94(8):1116-1121
Competing interests: None declared
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Competing Interests: None declared.