Comparisons of patient and physician expectations for cancer survivorship care, WY Cheung, BA Neville, DB Cameron

Tags: cancer, oncologists, American Society of Clinical Oncology, cancer survivorship, preventive health care, cancer recurrence, physicians, survivorship, cancer survivors, primary care providers, pairs, medical problems, PCPs, subset analysis, cancer treatment, response categories, respondents, cancer survivor, patient factors, substantial responsibility, oncologist, cancer diagnosis, primary health care provider, Winson Y. Cheung, Concordance, Craig C. Earle Administrative, Survey responses, preventive care, J Clin Oncol, Harvard School of Public Health, physician participation, Perini Family Cancer Survivor, Institute of Clinical Evaluative Sciences, National Cancer Institute of Canada, Dana-Farber Cancer Institute, patient, colorectal cancer, MMWR Morb Mortal Wkly Rep, Jemal A, Ward E, breast cancer, Cancer statistics, testicular cancer, primary care services
Content: VOLUME 27 NUMBER 15 MAY 20 2009 JOURNAL OF CLINICAL ONCOLOGY
ORIGINAL REPORT
From the Harvard School of Public Health; Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; and Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada. Submitted September 25, 2008; accepted December 3, 2008; published online ahead of print at www.jco.org on March 30, 2009. Supported by funds from the Perini Family Cancer Survivor's Center, an award from the Canadian Association of Medical Oncologists, and a grant from the National Cancer Institute of Canada. Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article. Corresponding author: Craig C. Earle, MD, MSc, FRCPC, Institute of Clinical Evaluative Sciences, 2075 Bayview Ave, G Wing 106, Toronto Ontario M4N 3M5, Canada; e-mail: [email protected] on.ca. © 2009 by American Society of Clinical Oncology 0732-183X/09/2715-2489/$20.00 DOI: 10.1200/JCO.2008.20.3232
Comparisons of Patient and Physician Expectations for cancer survivorship Care Winson Y. Cheung, Bridget A. Neville, Danielle B. Cameron, E. Francis Cook, and Craig C. Earle ABSTRACT Purpose To compare expectations for cancer survivorship care between patients and their physicians and between primary care providers (PCPs) and oncologists. Methods Survivors and their physicians were surveyed to evaluate for expectations regarding physician participation in primary cancer follow-up, screening for other cancers, general preventive health, and management of comorbidities. Results Of 992 eligible survivors and 607 physicians surveyed, 535 (54%) and 378 (62%) were assessable, respectively. Among physician respondents, 255 (67%) were PCPs and 123 (33%) were oncologists. Comparing patients with their oncologists, expectations were highly discrepant for screening for cancers other than the index one (agreement rate, 29%), with patients anticipating significantly more oncologist involvement. Between patients and their PCPs, expectations were most incongruent for primary cancer follow-up (agreement rate, 35%), with PCPs indicating they should contribute a much greater part to this aspect of care. Expectations between patients and their PCPs were generally more concordant than between patients and their oncologists. PCPs and oncologists showed high discordances in perceptions of their own roles for primary cancer follow-up, cancer screening, and general preventive health (agreement rates of 3%, 44%, and 51%, respectively). In the case of primary cancer follow-up, both PCPs and oncologists indicated they should carry substantial responsibility for this task. Conclusion Patients and physicians have discordant expectations with respect to the roles of PCPs and oncologists in cancer survivorship care. Uncertainties around physician roles and responsibilities can lead to deficiencies in care, supporting the need to make survivorship care planning a standard component in cancer management. J Clin Oncol 27:2489-2495. © 2009 by American Society of Clinical Oncology
INTRODUCTION There are more than 8 million people in the United States with a personal history of cancer.1 As a result of advances in screening and therapeutic strategies, a significant number of patients diagnosed with cancer today will not die as a direct result of their disease.2,3 For these individuals, secondary malignancies and preventable conditions, such as heart disease and diabetes, will become their greatest threats to life, underscoring the importance of their ongoing cancer- and noncancerrelated follow-up.4-10 An emphasis on surveillance for the primary cancer, however, can shift attention away from other essential aspects of care, and concerns have been raised about the quality of preventive health and general medical care among cancer survivors.11-14
primary care providers (PCPs) and oncology specialists contribute to the medical management of cancer survivors, but their respective responsibilities are poorly defined. Studies indicate that patients observed exclusively by PCPs undergo fewer screening tests for cancers, whereas those assessed predominantly by oncologists receive less than recommended noncancer-related care.11-14 These findings suggest that there may be a lack of clarity surrounding the relative roles that PCPs and cancer specialists play as patients transition from active Cancer Treatment to cancer survivorship. Furthermore, little is known on whether patients' expectations of care are consistent with those of their physicians and how potential discrepancies may affect survivorship planning. We conducted self-administered surveys to compare cancer survivors' expectations of care from
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their PCPs and oncologists with the roles that these physicians perceive for themselves and to identify potential patient and physician characteristics for areas in which there is disagreement. A better understanding of patient and physician perceptions of their roles in the survivorship process can help inform future survivorship care planning. METHODS General Overview Two separate but complementary questionnaires were developed, pilot tested, revised using a modified Delphi approach, and distributed to consecutive cancer survivors. Survivors were asked to identify their PCP and the oncologist most responsible for their ongoing cancer care; the physician version of the survey was then sent to these providers. All participants were mailed a package containing a cover letter that introduced the study and invited their participation, a copy of the survey, a postage-paid envelope in which to return the completed questionnaire, and an opt-out card that requested baseline demographical data should they decide not to participate. For patients, two copies of a consent form were enclosed, and they were asked to sign and return one copy to the study investigators and keep the other for their records. For physicians, receipt of a completed survey inferred implied consent. Monetary incentives of US$2 were included in each questionnaire package. Two subsequent contacts were made with nonresponders at 2 and 4 weeks after the initial mailing. The institutional review board at Dana-Farber/Harvard Cancer Center in Boston, MA, approved this study before it was conducted, between May 2006 and August 2007. Patient Questionnaire Survivors were identified as having at least one component of their cancer management at the Dana-Farber/Brigham and Women's Cancer Center in Boston according to its clinical operations and research information system, English-speaking, 2 years from their diagnosis, still alive according to the death index, and not undergoing cancer treatment. The questionnaire asked respondents whether they were cancer free; if they answered that they were not, the survey would be excluded. The patient questionnaire consisted of questions that inquired about demographics and general medical health, diagnosis and treatment-related information pertaining to the primary cancer, patterns of follow-up, and expectations of survivorship care from their PCPs and specialty physicians. For the main outcome measure of survivorship care expectations, patients were asked to describe the degree of responsibility that their PCP or cancer doctor should assume with respect to four key cancer survivorship care areas: (1) surveillance of their most recent cancer, (2) screening for cancers other than their primary malignancy, (3) general preventive health, and (4) management of other comorbidities. Responses to these questions were evaluated on a 5-point Likert scale where patients graded expectations of physician responsibility as "full," "a lot," "some," "a little," or "none." Respondents were asked to identify one PCP and one oncologist whom they perceived to be the main physicians responsible for their ongoing medical care. The patient opt-out card included four questions about age, sex, and type and diagnosis date of the primary cancer. Physician Questionnaire PCPs and oncologists who were identified by responding survivors were selected for participation in this study. The physician questionnaire was shorter and consisted of 10 questions that focused primarily on demographics, descriptions of current medical practice and past training, and the physicians' perceived roles in the four key areas of cancer survivorship care, which were assessed using the same Likert scale. The physician opt-out card contained five questions about age, sex, physician subspecialty, clinical practice setting, and year of medical school graduation. Statistical Analyses All statistical analyses were conducted with SAS version 9.1.3 (SAS Institute Inc, Cary, NC). Baseline demographics and characteristics for the
patient and physician cohorts were summarized with descriptive statistics. Survey responses from patients were matched with those of their self-identified PCPs and oncologists to form patient-PCP and patient-oncologist pairs, respectively. Similarly, surveys from PCPs were matched with those belonging to the corresponding oncologists to generate PCP-oncologist pairs. Agreement in survivorship care expectations within these survey pairs were assessed with concordance/discordance rates. Because a physician may have cared for more than one patient and contributed more than once to the analysis, we performed a subset analysis in which we limited the data set to one response per physician by randomly selecting only one of their matched patient-physician surveys. We subsequently compared this with the analysis that allowed for multiple patients matched to a physician to examine for any differences in results. For our analyses, responses of "full" and "a lot" were grouped together to form a category of "substantial" physician responsibility, whereas responses of "a little" and "none" were combined to indicate "minimal" physician responsibility. This produced three possible response categories--"substantial," "some," and "minimal"--which were used to generate concordance/discordance rates and entered into the statistical tests. Alternative response categories were also explored in our analysis by collapsing the 5-point Likert responses into different combinations (eg, "none," "a little/some," and "a lot/full"), but similar results were obtained. For patient-PCP and patient-oncologist pairs, concordance was defined as complete agreement in response categories, whereas discordance was signified by any disagreement in response categories between the respondents of a matched survey pair. For PCP-oncologist pairs, however, any responses that represented a potential duplication of medical services (ie, both physicians indicating substantial responsibility) or omission of medical services (ie, both physicians claiming minimal responsibility) were considered discordant. Multivariable logistic regression analyses were conducted to calculate the Odds ratios for discordant survivorship care expectations, dependent on patient factors and physician characteristics. All tests were two-sided, where a P value less than .05 was considered statistically significant. RESULTS Patient and Physician Characteristics A total of 1,044 questionnaires were sent to potential cancer survivors. Fifty-two were excluded because of death. Of the 992 potential respondents, 69 were not locatable, 52 opted out of participation, and 336 failed to respond. Thus the overall response rate for patients was 54% (535 of 992 patients). Among them, 104 patients (19%) indicated they were not cancer free or were undergoing active cancer treatment, such as chemotherapy, radiation, or immunotherapy, leaving 431 (81%) assessable surveys for analyses. For physicians, 609 surveys were distributed. Two physicians were unable to participate as a result of death, leaving 607 potential respondents. Ten were not locatable, another 10 opted out, and 209 did not respond, resulting in a physician response rate of 62% (378 of 607 physicians). Among the physician participants, 255 (67%) were PCPs and 123 (33%) were oncologists. In the patient cohort, the median age of respondents was 57 years (range, 16 to 91 years), and there were more females than males (73% v 27%). Breast cancer survivors, white patients, those who were married, achieved beyond a high school level education, and had at least good self-perceived health were highly represented. There were no significant differences in the response pattern by primary cancer site. For physicians, the median age was 50 years (range, 31 to 79 years), and more respondents practiced in the community than in the academic setting (59% v 41%). Additional baseline characteristics for patients and physicians are summarized in Table 1. Nonrespondents
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Table 1. Baseline Characteristics of Patient and Physician Respondents
Survey Respondents
Clinical Characteristic Patients, N 431 Age, years Median Range Sex Male Female Cancer site Breast Lung Gastrointestinal Genitourinary Gynecologic Hematologic Head and neck Other Unreported Marital status Single Married Separated/divorced/widow Education Less than 8th grade Some high school High school graduation Some university University graduation Graduate school Unreported Race Black Asian White Multiracial Other Income Less than $20,000 $20,000-$39,000 $40,000-$59,000 $60,000-$79,000 More than $80,000 Unreported Ever smoker Yes No Unreported General health Poor Fair Good Very good Excellent Unreported Physicians, N 378 Age, years Median Range Sex Male Female Practice Academic Community Specialty primary care physician Oncology Unreported
No.
%
57 16-91
117
27
314
73
216
50
21
4
30
7
43
10
17
4
39
9
26
6
28
6
21
4
46
11
320
74
65
15
4
1
11
3
60
14
82
19
106
25
166
39
2
0.5
10
2
7
2
406
94
2
0.5
6
1
23
6
39
9
41
10
49
12
199
48
80
15
200
47
229
52
2
1
5
1
24
6
112
26
187
44
99
23
4
1
50 31-79
239
63
139
37
156
41
222
59
251
66
113
30
14
4
who formally opted out of survey participation did not differ significantly from respondents with respect to demographic features (all P .05). Overall, there were 409 matched patient-oncologist survey pairs, 233 patient-PCP pairs, and 232 PCP-oncologist pairs. The mean number of patients managed by each physician was 1.2 (range, one to four) for PCPs and 4.2 (range, one to five) for oncologists. The subset analysis that explored one response per physician did not appreciably change the results from our main analysis of multiple responses per physician. Expectations of Patients Versus Oncologists Expectations between patients and their oncologists for the four different survivorship care measures are summarized and compared in Tables 2 and 3. Agreements in expectations between patients and oncologists ranged from 29% to 91%. Concordances between patients and their oncologists were highest with respect to surveillance for primary cancer recurrence, but lowest in terms of screening for other cancers. In general, patients indicated higher expectations than their oncologists with regards to an oncologist's role in cancer survivorship care. This was particularly evident for cancer screening, where 216 patients (58%) revealed that their oncologists should be more involved. For 119 (32%) of these cases, patients rated their expectations for cancer screening as two response categories higher than their oncologists. Similarly, 94 (28%) and 92 patients (28%) expected more
Table 2. Expectations Between Patients and Their Oncologists on the Role of Oncologists in Cancer Survivorship Care
Expected Role of Oncologists in: Follow-up for cancer recurrence, n 409 None A little Some A lot Full Screening for other cancers, n 374 None A little Some A lot Full General preventive health care, n 340 None A little Some A lot Full Treatment of other medical problems, n 329 None A little Some A lot Full
Patients
No.
%
6
2
3
1
26
6
123
30
251
61
25
7
22
6
81
22
125
33
121
32
119
35
74
22
94
27
34
10
19
6
151
46
77
23
75
23
19
6
7
2
Oncologists
No.
%
0
0
8
2
183
45
218
53
75
20
92
25
111
30
87
23
9
2
107
31
70
21
147
43
16
5
0
112
34
164
50
51
15
2
1
0
NOTE. n number of paired patient-oncologist surveys with responses. Values for n differed in the survivorship care areas because of a different number of missing responses for each category.
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Table 3. Correlation Between Patients and Their Oncologists on the Role of Oncologists in Cancer Survivorship Care
Patient Expectations
Oncologist Expectations
Minimal
Some
Substantial
Follow-up for cancer recurrence, n 409 Minimal Some Substantial Concordance Screening for other cancers, n 374 Minimal Some Substantial Concordance General preventive health care, n 340 Minimal Some Substantial Concordance Treatment of other medical problems, n 329 Minimal Some Substantial Concordance
0
0
0
1
2
5
8
24
369
371 of 409 (91%)
16
32
119
16
30
65
15
19
62
108 of 374 (29%)
106
43
28
79
45
23
8
6
2
153 of 340 (45%)
186
66
24
41
8
2
1
1
0
194 of 329 (59%)
NOTE. Bold italic text indicates concordant expectations.
participation from their oncologists for preventive health care as well as for management of their comorbidities, respectively.
Table 4. Expectations Between Patients and Their PCPs on the Role of PCPs in Cancer Survivorship Care
Patients
PCPs
Expected Role of PCPs in:
No.
%
No.
%
Follow-up for cancer recurrence, n 213
None
7
3
1
1
A little
46
22
5
2
Some
90
42
61
29
A lot
56
26
125
58
Full
14
7
21
10
Screening for other cancers, n 219
None
7
3
1
1
A little
8
4
2
1
Some
26
12
5
2
A lot
103
47
83
38
Full
75
34
128
58
General preventive health care, n 233
None
1
1
2
1
A little
1
1
0
Some
12
5
5
2
A lot
67
28
43
18
Full
152
65
183
79
Treatment of other medical problems, n 231
None
1
1
3
1
A little
0
2
1
Some
11
5
2
1
A lot
61
26
32
14
Full
158
68
192
83
NOTE. n number of paired patient-PCP surveys with responses. Values for n differed in the survivorship care areas because of a different number of missing responses for each category. Abbreviation: PCPs, primary care providers.
Expectations of Patients Versus PCPs Tables 4 and 5 highlight survivorship care expectations of pa- tients and their matched PCPs. Expectations were in agreement between 35% and 92% of the time for primary cancer follow-up and the treatment of other medical problems, respectively. In contrast to the patient-oncologist pairs, however, a number of PCPs demonstrated higher expectations than their patients and envisioned greater involvement in cancer survivorship care. The most significant discordance was observed for primary cancer follow-up, where 116 PCPs (55%) expected to contribute more to this aspect of survivorship care than patients had perceived for their PCPs. For 32 (15%) of these cases, physician responses were two expectation categories higher than those provided by patients. Overall, expectations between patients and PCPs were less discordant than those between patients and oncologists. Expectations of PCPs Versus Oncologists Survivorship care expectations between PCPs and oncologists are summarized and compared in Tables 6 and 7. With the exception of treatment of general medical problems, where agreement in expectations was high, the concordance rates for the remaining survivorship care domains were poor, including primary cancer surveillance (concordance rate 3%), cancer screening (44%), and preventive health care (51%). Both PCPs and oncologists expected to be prominently involved in these cancer survivorship care areas, which resulted in no-
ticeable overlaps in expectations. As an example, for primary cancer follow-up, there were 151 cases (65%) in which both physician types indicated that they carried substantial responsibility for the surveillance of primary cancer recurrence. Likewise, there were 52 cases (23%) where both PCPs and oncologists indicated that they should play a significant role in screening for other cancers. Conversely, there were rare instances where both types of physicians felt that they had minimal responsibility for some aspect of patient care. In multivariable analyses to evaluate for determinants of discordant patient-physician and PCP-oncologist expectations for cancer survivorship care, we were unable to identify any clear, consistent clinical predictors. Although there was a trend to suggest that discordant patient-physician expectations were more likely to occur for patients who were older, poorer, nonwhite, and less educated, none achieved consistent statistical significance. Physician characteristics in the multivariable model also failed to correlate with discordant expectations. DISCUSSION With the recent recommendations from the Institute of Medicine that highlight the importance of cancer survivorship care planning, the
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Table 5. Correlation Between Patients and Their PCPs on the Role of PCPs in Cancer Survivorship Care
Patient Expectations
PCP Expectations
Minimal
Some
Substantial
Follow-up for cancer recurrence, n 213 Minimal Some Substantial Concordance Screening for other cancers, n 219 Minimal Some Substantial Concordance General preventive health care, n 233 Minimal Some Substantial Concordance Treatment of other medical problems, n 231 Minimal Some Substantial Concordance
0
4
1
21
23
18
32
63
51
74 of 213 (35%)
1
1
1
1
2
2
13
23
175
178 of 219 (81%)
0
0
2
0
0
5
2
12
212
212 of 233 (91%)
0
1
4
0
0
2
1
10
213
213 of 231 (92%)
NOTE. Bold italic text indicates concordant expectations. Abbreviation: PCPs, primary care providers.
medical care of cancer survivors is increasingly being recognized as an important area for quality improvement.15 Unfortunately, studies to date show that the quality of cancer survivorship care is frequently suboptimal, partly because of the fact that key survivorship care issues remain relatively neglected and poorly understood in clinical practice. preliminary research has suggested that an apparent disconnect between patients and providers and between physicians themselves with respect to the goals of care, as patients proceed from a phase of active cancer treatment to one of cancer survivorship, may contribute to gaps in management.11-14 We found significant disagreements in expectations between patients and their physicians, as well as between PCPs and oncologists. The precise reasons for these discordances are unclear, but discrepancies in patient and physician expectations have previously been observed in other medical settings.16,17 These prior reports were concerned with either the disclosure of poor prognostic information or exposure to potentially high-risk interventions, and deficiencies were attributed largely to a lack of patient-physician communication. Although the transition from cancer patient to cancer survivor is generally considered to be a time of celebration and relief, survivorship care planning also entails necessary discussions about the acute and late toxicities of treatment, the ongoing need for cancer surveillance and noncancer-related health maintenance, the real potential for disease recurrence in the near future, and other pertinent psychosocial issues such as possible return to employment, all of which can be unpleasant topics for patients and physicians. Therefore, patients may be reluctant to actively seek survivorship care planning in an effort to defer dealing with these issues, whereas physicians may similarly avoid such
Table 6. Expectations Between Oncologists and PCPs on Their Respective Roles in Cancer Survivorship Care
PCPs
Oncologists
Expected Role of MD in:
No.
%
No.
%
Follow-up for cancer recurrence, n 231
Fully by oncologist
1
1
126
54
Mainly by oncologist
6
2
101
44
Partly by PCP/oncologist
69
30
4
2
Mainly by PCP
125
54
0
Fully by PCP
30
13
0
Screening for other cancers, n 231
Fully by oncologist
1
1
4
2
Mainly by oncologist
1
1
50
22
Partly by PCP/oncologist
4
2
75
32
Mainly by PCP
84
35
67
29
Fully by PCP
141
61
35
15
General preventive health care, n 232
Fully by oncologist
2
1
0
Mainly by oncologist
0
10
4
Partly by PCP/oncologist
4
2
101
44
Mainly by PCP
42
18
54
23
Fully by PCP
184
79
67
29
Treatment of other medical problems, n 232
Fully by oncologist
2
1
0
Mainly by oncologist
2
1
1
1
Partly by PCP/oncologist
2
1
40
17
Mainly by PCP
31
13
128
55
Fully by PCP
195
84
63
27
NOTE. n number of paired oncologist/PCP surveys with responses. Values for n differed in the survivorship care areas because of a different number of missing responses for each category. Abbreviations: PCPs, primary care providers; MD, physician.
discussions because of concerns that they may elicit resentment from and increase emotional distress for patients. Our study reveals that expectations regarding the follow-up of the primary cancer were most discordant between patients and their PCPs, and that expectations regarding screening for other cancers were most discordant between patients and their oncologists. Because of the intense relationship that develops during cancer treatment and the potential for cancer and its treatment to have effects on other medical problems, many patients come to view their oncologist as their Primary Health Care provider. Understandably, many patients assume their oncologist will manage anything related to their original cancer diagnosis, including screening for other cancers. Our data suggest, however, that oncologists often do not see themselves in these roles. With a lack of clarity about which provider is responsible for care, patients may not receive necessary services of demonstrated benefit. There are several potential explanations for these findings. A study conducted by the American Society of Clinical Oncology has shown that specialty physicians are commonly reluctant to participate in primary care services, which would be one plausible explanation for our observation.18 Oncologists may feel that they are poorly equipped to handle noncancer-related issues or that they lack the time and resources to adequately provide all aspects of health maintenance for
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Table 7. Correlation Between Oncologists and PCPs on Their Respective Roles in Cancer Survivorship Care
Oncologist Expectations
PCP Expectations
Substantial
Minimal
Oncologist Some Oncologist Oncologist
Follow-up for cancer recurrence, n 231
Minimal PCP
6
0
0
Some PCP
70
0
0
Substantial PCP
151
4
0
Concordance
6 of 231 (3%)
Screening for other cancers, n 231
Minimal PCP
0
1
1
Some PCP
2
1
1
Substantial PCP
52
73
100
Concordance
101 of 231 (44%)
General preventive health care, n 232
Minimal PCP
0
1
1
Some PCP
1
1
2
Substantial PCP
9
99
118
Concordance
119 of 232 (51%)
Treatment of other medical problems, n 232
Minimal PCP
0
0
4
Some PCP
0
1
1
Substantial PCP
1
39
186
Concordance
187 of 232 (81%)
NOTE. Bold italic text indicates concordant expectations.
survivors. In the domains of primary cancer follow-up and cancer screening, the requirement for substantial coordination of care among several specialties for items such as imaging and endoscopy may lead to uncertainty on the part of both patients and providers about who is responsible. Conversely, there may also at times be overuse of medical services caused by poor communication as patients visit different physicians for the same issue and have blood tests and imaging repeated unnecessarily. This is substantiated by the discordant expectations between physician types seen in our study where both PCPs and oncologists perceived responsibility for some of the same aspects in care. There are some limitations to our findings. First, our study was conducted at a geographically localized group of institutions with a large representation of white, well-educated, and female patients. These subsets of patients might have superior access to oncology care and specialist follow-up. Consequently, they may have different cancer survivorship care expectations than those belonging to minority groups, and therefore, our results may not be completely generalizable. Second, our analyses were confined to surveys that were successfully returned, and although we could not detect baseline differences between respondents and nonrespondents, they may have had differ-
ent experiences of care. Third, each physician completed the questionnaire only once, and their questions were not directed to the care of a particular patient, but to any of their patients who might be a cancer survivor. It is foreseeable that some answers might have been different if they were answering about a specific patient. Fourth, the survey questions asked about overall survivorship care rather than care within a particular time period after cancer diagnosis, because certain aspects of survivorship care, such as general preventive care, should ideally occur indefinitely after completion of cancer treatment. It is possible that some respondents may have interpreted the survivorship care role in the context of a specific timeframe. Finally, we primarily focused our study on four key cancer survivorship care domains, but future work will be needed to explore expectations regarding the management of psychosocial and supportive care issues (eg, employment and insurance concerns) and other parameters that may cause discordant perceptions, such as physician time constraints, different communication styles and formats, and system infrastructure problems. In summary, when comparing patient and physician expectations toward key areas of cancer survivorship care, we found that there are uncertainties surrounding the perceived responsibilities of physicians and the delivery of care to cancer survivors, especially with respect to primary cancer follow-up and screening for other cancers. With these findings in hand, the next logical step would be to ascertain the mechanisms for such misperceptions and to identify methods that can more clearly outline the roles of each physician type in the survivorship care process. To the extent that patients simply lack the appropriate information about provider roles, this should highlight a valuable opportunity for increased patient education and empowerment. These findings should provide further support for recent recommendations to create models of survivorship care where relevant information about diagnosis, treatments, and future plans can be explicitly shared and coordinated among all of those involved.15 AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. AUTHOR CONTRIBUTIONS Conception and design: Winson Y. Cheung, Craig C. Earle Financial support: Craig C. Earle Administrative support: Craig C. Earle Provision of study materials or patients: Craig C. Earle Collection and assembly of data: Winson Y. Cheung, Bridget A. Neville, Danielle B. Cameron Data Analysis and interpretation: Winson Y. Cheung, Bridget A. Neville, E. Francis Cook, Craig C. Earle Manuscript writing: Winson Y. Cheung, Craig C. Earle Final approval of manuscript: Winson Y. Cheung, Bridget A. Neville, Danielle B. Cameron, E. Francis Cook, Craig C. Earle
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Expectations for Cancer Survivorship Care
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