Delivering colon cancer survivorship care in primary care; a qualitative study on the experiences of general practitioners

Background: With more patients in need of oncological care, there is a growing interest to transfer survivorship care from specialist to general practitioner (GP). The ongoing I CARE study was initiated in 2015 in the Netherlands to compare (usual) surgeon- to GP-led survivorship care, with or without access to a supporting eHealth application (Oncokompas). Methods: Semi-structured interviews were held at two separate points in time (i.e. after 1- and 5-years of care) to explore GPs’ experiences with delivering this survivorship care intervention, and study its implementation into daily practice. Purposive sampling was used to recruit 17 GPs. Normalisation Process Theory (NPT) was used as a conceptual framework. Results: Overall, delivering survivorship care was not deemed difficult and dealing with cancer repercussions was already considered part of a GPs’ work. Though GPs readily identified advantages for patients, caregivers and society, differences were seen in GPs’ commitment to the intervention and whether it felt right for them to be involved. Patients’ initiative with respect to planning, absence of symptoms and regular check-ups due to other chronic care were considered to facilitate the delivery of care. Prominent barriers included GPs’ lack of experience and routine, but also lack of clarity regarding roles and responsibilities for organising care. Need for a monitoring system was often mentioned to reduce the risk of non-compliance. GPs were reticent about a possible future transfer of survivorship care towards primary care due to increases in workload and financial constraints. GPs were not aware of their patients’ use of eHealth. Conclusions: GPs’ opinions and beliefs about a possible future role in colon cancer survivorship care vary. Though GPs recognize potential benefit, there is no consensus about transferring survivorship care to primary care on a permanent basis. Barriers and facilitators to implementation highlight the importance of both personal and system level factors. Conditions are put forth relating to time, reorganisation of infrastructure, extra personnel and financial compensation. Trial registration: Netherlands Trial Register; NTR4860. Registered on the 2nd of October 2014

Effect of general practitioner-led versus surgeon-led colon cancer survivorship care, with or without eHealth support, on quality of life (I CARE): an interim analysis of 1-year results of a randomised, controlled trial

Background: Colon cancer is associated with an increased risk of physical and psychosocial morbidity, even after treatment. General practitioner (GP) care could be beneficial to help to reduce this morbidity. We aimed to assess quality of life (QOL) in patients who received GP-led survivorship care after treatment for colon cancer compared with those who received surgeon-led care. Furthermore, the effect of an eHealth app (Oncokompas) on QOL was assessed in both patient groups. Methods: We did a pragmatic two-by-two factorial, open-label, randomised, controlled trial at eight hospitals in the Netherlands. Eligible patients were receiving primary surgical treatment for stage I–III colon cancer or rectosigmoid carcinoma and qualified for routine follow-up according to Dutch national guidelines. Patients were randomly assigned (1:1:1:1)—via computer-generated variable block randomisation stratified by age and tumour stage—to survivorship care overseen by a surgeon, survivorship care overseen by a surgeon with access to Oncokompas, survivorship care overseen by a GP, or survivorship care overseen by a GP with access to Oncokompas. Blinding of the trial was not possible. The primary endpoint of the trial was QOL at 5 years, as measured by the change from baseline in the European Organistion for Research and Treatment of Cancer QLQ-C30 summary score. Here, we report an unplanned interim analysis of QOL at the 12-month follow-up. Grouped comparisons were done (ie, both GP-led care groups were compared with both surgeon-led groups, and both Oncokompas groups were compared with both no Oncokompas groups). Differences in change of QOL between trial groups were estimated with linear mixed-effects models. A change of ten units was considered clinically meaningful. Analysis was by intention to treat. This trial is registered with the Netherlands Trial Register, NTR4860. Findings: Between March 26, 2015, and Nov 21, 2018, 353 patients were enrolled and randomly assigned. There were 50 early withdrawals (27 patient decisions and 23 GP withdrawals). Of the remaining 303 participants, 79 were assigned to surgeon-led care, 83 to surgeon-led care with Oncokompas, 73 to GP-led care, and 68 to GP-led care with Oncokompas. Median follow-up was 12·2 months (IQR 12·0–13·0) in all groups. At baseline, QOL was high in all trial groups. At 12 months, there was no clinically meaningful difference in change from baseline in QOL between the GP-led care groups and the surgeon-led care groups (difference in summary score –2·3 [95% CI –5·0 to 0·4]) or between the Oncokompas and no Oncokompas groups (−0·1 [–2·8 to 2·6]). Interpretation: In terms of QOL, GP-led survivorship care can be considered as an alternative to surgeon-led care within the first year after colon cancer treatment. Other outcomes, including patient and physician preferences, will be important for decisions about the type of survivorship care. Funding: Dutch Cancer Society (KWF)