Primary Care Providers Need Improved Resources to Manage Long-Term Thyroid Cancer Surveillance and Survivorship Care
2020; Mary Ann Liebert, Inc.; Volume: 32; Issue: 9 Linguagem: Inglês
10.1089/ct.2020;32.443-446
ISSN2329-972X
Autores Tópico(s)Thyroid and Parathyroid Surgery
ResumoClinical ThyroidologyVol. 32, No. 9 Thyroid CancerFree AccessPrimary Care Providers Need Improved Resources to Manage Long-Term Thyroid Cancer Surveillance and Survivorship CareTyler DrakeTyler DrakeDivision of Endocrinology and Metabolism; Department of Medicine; Minneapolis VA Healthcare System; University of Minnesota Medical School; Minneapolis, Minnesota, U.S.A.Search for more papers by this authorPublished Online:2 Sep 2020https://doi.org/10.1089/ct.2020;32.443-446AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Review of: Radhakrishnan A, Reyes-Gastelum D, Gay B, Hawley ST, Hamilton AS, Ward KC, Wallner LP, Haymart MR 2020 Primary care provider involvement in thyroid cancer survivorship care. J Clin Endocrinol Metab 105(9):dgaa437. PMID: 32639557.SUMMARYBackgroundThere is a growing population of thyroid cancer survivors resulting from the increasing prevalence and excellent long-term outcomes of patients with differentiated thyroid cancer (DTC). While these patients are most often initially treated by cancer specialists such as endocrinologists and thyroid surgeons, it is reasonable that management may be transitioned at some point to their primary care provider (PCP). Prior work in breast and colon cancer has shown that PCPs and cancer specialists have different preferences and attitudes with regard to models for cancer survivorship care (1). Studies have shown that PCPs often feel that they lack confidence in caring for cancer survivors (2) and feel unprepared to evaluate and manage long-term effects for them (3). Currently, little is known about PCPs caring for thyroid cancer survivors and their confidence in handling survivorship care, such as the serial measurements of serum thyroglobulin levels and the role of periodic surveillance neck ultrasounds.MethodsThis study is a survey of U.S. PCPs identified by patients diagnosed with differentiated thyroid cancer between 2014 and 2015 (4). Patients were identified from the Georgia and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries, and patients were asked to identify an “other doctor most involved in your thyroid cancer treatment decision making (other than your surgeon or endocrinologist).” A total of 289 PCPs were surveyed using a modified Dillman method consisting of initial mailings, cash incentives, follow-up phone calls, and repeat mailings to nonresponders. A similar number of PCPs were surveyed from each site.Survey content was developed to determine involvement of PCPs in long-term surveillance and their confidence in handling thyroid cancer survivorship care. PCPs were asked “After patients are finished with their primary treatment for thyroid cancer and their treating physician thinks there is no signs of residual disease, how often are you involved in the long-term surveillance for progression or recurrence?” PCPs were then asked their confidence level in discussing follow-up care for thyroid cancer patients, including the role of serum thyroglobulin levels, the role of surveillance neck ultrasounds, when to end long-term surveillance, and indications for referral back to the specialist.Multiple physician characteristics were obtained, including specialty, years in practice, sex, race, practice location, and number of patients typically seen. Respondents were asked what education resource was the most influential in their decisions on how to treat thyroid nodule and thyroid cancer patients. Additionally, PCPs were asked whether they were familiar with two established guidelines: the 2015 American Thyroid Association (ATA) Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (5), and the National Comprehensive Cancer Network's (NCCN) 2017 Clinical Practice Guidelines in Oncology: Thyroid Carcinoma (6).ResultsOf the 289 PCPs surveyed, 15 were excluded and 162 responded (response rate 56%). The majority of PCPs were White (67.3%), worked in private practice (74.1%), and had practiced for over 20 years (63.2%). A total of 62% of respondents somewhat/strongly agreed that “PCPs have the skills necessary to initiate appropriate screening to detect recurrence” and 53% somewhat/strongly agreed that “PCPs should have responsibility for providing continuing care after treatment.” The majority (54.3%) reported recently published clinical guidelines as the most influential source in their decisions on how to treat thyroid nodule and thyroid cancer patients, yet 72.1% reported not having read either the most recent ATA or NCCN guidelines for thyroid cancer.Seventy six percent of PCPs reported sometimes to almost always being involved in the long-term surveillance of their patients. However, the frequency of being highly confident in key aspects of thyroid cancer survivorship care—when to refer back to the specialist (39.1%), the role of neck ultrasound in long-term surveillance (36.2%), the role of serum thyroglobulin levels (27.2%), and when to end long-term surveillance (13.8%)—was low.Bivariate analyses showed that PCPs who had read either the ATA or NCCN guidelines were more likely to report being involved (88.4% vs. 70.9%, P = 0.03) than those who had not read the guidelines. In addition, PCPs who reported recently published clinical guidelines as being the most influential in their decision on how to treat thyroid cancer patients were more likely to report being involved (83.7% vs. 66.6%, P = 0.01). With multivariable logistic-regression models, PCPs who reported recently published clinical guidelines as being the most influential in their decision making had increased odds of being involved in thyroid cancer survivorship care (OR, 4.29; 95% CI, 1.56–11.82), and PCPs who somewhat/strongly agreed with the belief that PCPs have the skills necessary to initiate appropriate screening to detect recurrence had increased odds of reporting involvement (OR, 4.21; 95% CI, 1.58–11.21). PCPs involved in long-term surveillance were more likely to report high confidence in discussing the role of serum thyroglobulin levels than were PCPs who were not involved (33.4% vs. 7.4%; P<0.01). There were no statistically significant associations in the other aspects of thyroid cancer survivorship care, including the role of neck ultrasounds, when to end long-term surveillance, and when to refer back to the specialist.ConclusionsThe majority of PCPs surveyed in this U.S. study reported being involved in the long-term treatment of their patients with DTC, yet there were gaps in their confidence with regard to handling thyroid cancer survivorship care. Clinical guidelines that specifically delineate the roles of PCPs are one option to increase improved primary care involvement in long-term thyroid cancer monitoring.COMMENTARYThis study (4) provides a crucial first step in understanding and then improving the role of PCPs in the long-term care of thyroid cancer patients. It shows that the majority of PCPs believe that they can and should be involved in the long-term follow-up, yet it also highlights major gaps in their confidence in providing this care. It is remarkable how low PCP confidence is in handling various survivorship care actions such as measurement of serum thyroglobulin levels (27%), neck ultrasounds (36%), referring back to a cancer specialist (39%), and ending long-term surveillance (14%). The study highlights the need for education and clear instructions by a cancer specialist when a patient is referred back to their PCP. It does not address how a cancer specialist and PCP should work together but highlights the need for future work in this area.The major limitation of this study is that it is a survey study and therefore can show only associations and not causation. Clinical guidelines were identified to be the most influential source of information to PCPs and predicted PCP involvement in long-term surveillance, yet the majority of PCPs had not read the current ATA or NCCN guidelines on thyroid cancer. While the authors suggest clinical guidelines that delineate PCP roles as one way to improve PCP confidence, it is unclear how effective this would be when established guidelines are not necessarily read. Clinical guidelines are often long and complex, and it may be unreasonable to expect PCPs to have read all current clinical guidelines for every type of cancer. As the authors outline, one potential solution to this would be for a focused summary on cancer surveillance specifically targeting the role of PCPs as part of the ATA and NCCN guidelines. Also, this study does not address how patients feel about this topic, yet prior work has shown that thyroid cancer survivors greatly prefer monitoring by a specialist than by their PCP (7). Finally, the majority of PCPs in this study reported working in private practice, and it is unclear how these results would translate to a university or Veterans Administration (VA) setting, for example.With the growing population of thyroid cancer survivors, it is imperative to ensure proper long-term cancer surveillance, and this increase will mean that many patients will need to have their PCPs involved in this care. While PCPs are willing and able to take on this surveillance, there are gaps in their confidence, and therefore potentially their knowledge, with regard to how to perform this task. This study is the first step toward closing this gap, and it underscores the need for future work in creating interdisciplinary long-term surveillance models for thyroid cancer.References1. Cheung WY, Aziz N, Noone AM, Rowland JH, Potosky AL, Ayanian JZ, Virgo KS, Ganz PA, Stefanek M, Earle CC 2013 Physician preferences and attitudes regarding different models of cancer survivorship care: A comparison of primary care providers and oncologists. J Cancer Surviv 7:343–354. Crossref, Medline, Google Scholar2. Dossett LA, Hudson JN, Morris AM, Lee MC, Roetzheim RG, Fetters MD, Quinn GP 2017 The primary care provider (PCP)–cancer specialist relationship: A systematic review and mixed-methods meta-synthesis. CA Cancer J Clin 67:156–169. Crossref, Medline, Google Scholar3. Bober SL, Recklitis CJ, Campbell EG, Park ER, Kutner JS, Najita JS, Diller L 2009 Caring for cancer survivors: A survey of primary care physicians. Cancer 115: 4409–4418. Crossref, Medline, Google Scholar4. Radhakrishnan A, Reyes-Gastelum D, Gay B, Hawley ST, Hamilton AS, Ward KC, Wallner LP, Haymart MR 2020 Primary care provider involvement in thyroid cancer survivorship care. J Clin Endocrinol Metab 105(9):dgaa437. Crossref, Medline, Google Scholar5. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, et al. 2016 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 26:1–133. Link, Google Scholar6. Haddad RI, Lydiatt WM, Bischoff L, Busaidy NL, Byrd D, Callender G, Dickson P, Duh Q-Y, Ehya H, Haymart, et al. 2017 NCCN Clinical Practice Guidelines in Oncology: Thyroid carcinoma. Accessed at http://www.klinikum.uni-muenchen.de/Schilddruesenzentrum/download/inhalt/Leitlinien/NCCN/thyroid_2017.pdf Google Scholar7. Bender JL, Wiljer D, Sawka AM, Tsang R, Alkazaz N, Brierley JD 2016 Thyroid cancer survivors’ perceptions of survivorship care follow-up options: a cross-sectional, mixed-methods survey. Support Care Cancer 24:2007-2015. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 32Issue 9Sep 2020 InformationCopyright 2020 American Thyroid Association, Inc.To cite this article:Tyler Drake.Primary Care Providers Need Improved Resources to Manage Long-Term Thyroid Cancer Surveillance and Survivorship Care.Clinical Thyroidology.Sep 2020.443-446.http://doi.org/10.1089/ct.2020;32.443-446Published in Volume: 32 Issue 9: September 2, 2020PDF download
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