Survivorship care for cancer patients in primary versus secondary care: a systematic review

In February 2020, a systematic search was performed in MEDLINE and EMBASE to identify original studies on cancer survivorship care. General terms for survivorship care, including follow-up and aftercare, were used. In addition to the MEDLINE and EMBASE search, reference checking was performed to identify possible other relevant publications. (See Appendix 1 for the search strategy.)

Original studies comparing cancer survivorship care in primary to secondary-based care were included. As health care systems differ around the globe, generalist professions providing primary- or community-based care, such as a general practitioner (GP), primary care physicians (PCPs), and family physicians (FPs), were included in this review. Studies reporting on patients of any age who were (curatively) treated for any type or stage of cancer were eligible. No restrictions were made on the type of outcomes. Economic evaluations of cancer survivorship care programs were also considered for inclusion. Studies on shared care and patient or physician preferences for survivorship care were excluded from this review.

All studies were screened on title and abstract by two independent researchers (JV and TW). Subsequently, complete texts were read to ensure inclusion criteria, and data were extracted. Data extraction was performed by one researcher (JV) based on a predefined data format. Disagreement between the two researchers on study selection and data extraction was resolved by discussion or, if necessary, by consulting a third independent researcher (KvA).

As we intended a broad and conclusive review, no restrictions were made on the type of patient, outcomes, or methodology, which resulted in substantial heterogeneity of studies. Therefore, meta-analyses were not feasible and a narrative synthesis was used.

Outcomes were grouped into three distinctive categories: (1) clinical outcomes as measured by medical records (including survival, serious clinical events, and documented follow-up care), (2) patient-reported outcomes as measured by patient questionnaires and interviews (including quality of life, symptoms, patient satisfaction, and self-reported receipt of survivorship care), and (3) costs of survivorship care programs (including societal and patient costs).

A risk of bias analysis was performed for all included studies according to the designated quality assessment tools as advised by the Cochrane collaboration. The consort instrument was used for randomized clinical trials [17], and the ROBINS-I for (non-randomized) observational studies [18].

The systematic search retrieved 1766 original studies (Fig. 1). Reference checking did not identify any additional studies. After title and abstract screening, full text of 42 studies was reviewed. Based on the predefined eligibility criteria, 16 studies were included in this review. Figure 1 illustrates the selection process.

Risk of bias assessment revealed low risk of bias in 10 studies, intermediate in 3, and high risk of bias in 3 out of 16 studies (see Appendix Table 5). Risk of bias was often inherent to the design of the study, including selection, misclassification, recall, and interviewer bias.

Table 1 shows the baseline characteristics of the included studies. Seven randomized controlled trials (RCTs) were included in this review [19‐25]. Three studies of Grunfeld et al. were based on the same RCT, but reported on separate outcomes [20‐22]. Other included studies were based on a type of observational study [26‐34]. Most studies reported on patients with solid tumors, such as breast and colorectal cancers. The number of patients ranged from 98 in a retrospective cohort study [26] to 5009 in a quasi-experimental observational study [29]. Six studies reported on physicians working in primary care, of which two studies did not further specify the provider type [31, 32]. The length of follow-up ranged from 1 to 15 years.

Ten studies reported on clinical outcomes (see Table 2). No important differences were seen in survival between follow-up strategies after 3 up to 15 years of follow-up [30, 33, 34]. Follow-up in secondary care was associated with shorter relapse-free survival (RFS) and higher likelihood of receiving palliative treatment with chemotherapy (58% versus 34%, p = 0.03) in pancreatic cancer patients in a cohort study, in part because patients in secondary care had more advanced primary tumors [33]. Eight studies examined the occurrence of serious clinical events. No differences were seen relating to the number (and time of diagnosis) of recurrences and metastases [19, 20, 23‐26], deaths [23, 25, 29], or other clinical events [23, 24, 26] between primary and secondary care–based follow-up.

Documented follow-up care, as measured by adherence to medical guidelines and follow-up tests, was assessed by two RCT’s. Murchie et al. [24] found that 98.1% of patients in primary-based care were seen according to guidelines versus 80.9% of patients in secondary-based care (p = 0.020). In the second study, patients in primary care were more likely to have one or more fecal blood tests (rate ratio 2.4, CI 1.4–4.44, p = 0.003), whereas patients in secondary care were more likely to have ultrasounds and colonoscopies, although it remained unclear whether or not this was done in accordance with follow-up guidelines [25].

Eleven studies, including all six RCTs, measured patient-reported outcomes (see Table 3). After adjustment for clinical and pathological covariates, no differences were seen in overall quality of life (QoL) and anxiety and depression between survivorship care strategies [19, 20, 23‐26]. One observational study examined other bothersome symptoms, showing less fatigue among breast cancer patients in primary care (62.0% versus 81.1%, p = 0.005) [31].

High levels of patient satisfaction and perception of care were found for survivorship care in both primary- and secondary-based care [22, 24‐27, 32]. Using an adapted validated questionnaire, higher levels of patient satisfaction were found in primary care–based groups in two RCTs (9 out of 15 aspects by Grunfeld et al. [22] and 6 out of 15 by Murchie et al. [24]). In contrast, a questionnaire administered in an observational study [26] showed greater satisfaction in all 6 dimensions for breast cancer patients in secondary-based care (p < 0.05).

Five observational studies examined self-reported receipt of survivorship care by means of questionnaires and interviews. Disparate results were seen among primary- and secondary-based care, but there was no evidence for a more favorable strategy based on these results. Two studies showed a lower adherence to recommended periodic clinical examinations for breast cancer patients by physicians working in primary care (approximately 80% versus 90% in secondary care, p < 0.05) [31, 32]. In another study, patients in primary care were more likely to receive examination as is recommended by national guidelines (58% versus 36%, p = 0.004) [27]. No differences were seen in patient self-reported mammogram frequency [28, 31, 32]. Maly et al. [28] found a higher uptake of preventive tests, including Pap smear (AOR 2.90, CI 1.05–8.04, p = 0.040) and colonoscopy (AOR 2.99, CI 1.5–8.51, p = 0.041), among underserved breast cancer patients in primary care. Physicians in primary care helped more often with lifestyle improvements for colorectal cancer patients [27], but this was not the case among breast cancer patients [31].

Survivorship care in primary care was associated with lower societal and patient costs in all four studies that performed cost analyses (see Table 4) [19, 21, 26, 29]. The main cost driver in all studies was the mean cost per visit, including organizational and physician costs.

A recent Cochrane review found little to no effects on pre-defined outcomes for RCTs comparing non-specialist (e.g., PCP-led, nurse-led, patient-initiated, and shared care) to specialist-led follow-up [12]. The certainty of evidence was generally low due to the limited amount of RCTs. Similarly to the Cochrane review, this review found no important differences in survivorship care between primary and secondary care relating to clinical (survival and recurrences) and patient-reported outcomes (quality of life and symptoms).

This review has identified additional outcomes in comparison with the Cochrane review relating to the content and quality of survivorship care. 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. Showing differences in these types of outcomes requires great numbers of patients and considerable follow-up time among often older patients with comorbidities, making this a challenging undertaking.

This review has examined patient’s perceptions and satisfaction with care as indicators for the quality of survivorship care. High levels of quality of care were found for survivorship care in both primary- and secondary-based care. Two out of three RCTs showed higher levels of patient satisfaction with primary-based care, illustrating its feasibility [22, 24]. The aggregation of these results provides us with the indication that survivorship care in primary care is similar to care by a specialist. Moreover, survivorship care in primary care led to lower costs in all studies that performed cost-analyses.

Our review provides additional evidence to previous literature by focusing exclusively on survivorship care by physicians working in primary care and by including non-randomized studies in the results. By performing a non-restrictive search and selection strategy, two additional outcomes relating to the content and quality of survivorship care have been identified in comparison with the recent Cochrane review. The search strategy, including reference checking, provides a sensitive search result.

There are some limitations that need to be addressed. Inherent to the design of some studies, differences were seen in baseline characteristics. Older patients and patients with prognostic better disease stage were sometimes more likely to receive follow-up in primary care [26, 27, 30‐34]. Despite adjusting for covariates, these differences might have influenced outcomes. Due to the substantial heterogeneity in outcomes and methodology, no data could be pooled for meta-analyses, hampering the interpretation of results. However, using a narrative synthesis, no important differences were seen relating to clinical and patient-reported outcomes. These results are in line with previous reviews [12‐16].

As the number of cancer survivors is rapidly increasing and resources are limited [12‐16], alternative survivorship care strategies for the hospital-based survivorship care are deemed desirable. This review showed that cancer survivorship care in primary care seems feasible and worthwhile to consider. However, the role and capacity of physicians in primary care can vary depending on context and setting [10, 11]. Most studies were performed in the UK and Canada in which physicians work as gate-keepers to secondary health care services. In these countries, a publicly funded universal health care system is in place. Other studies were performed in countries such as the US and Spain in which the health care system is both publicly and privately funded, and the role of primary care could be less distinguished. The randomized trials that could be identified, were limited to countries with a universal health care system, so further research is warranted to evaluate whether the results of these trials are also applicable to other health care systems. Furthermore, both clinical and patient-reported outcomes might change over time and could be affected by the length of follow-up. Therefore, to assess durable effects of survivorship care, greater number of patients and considerable follow-up time in these trials would be preferable. Moreover, the impact on the work-load for primary care physicians needs to be evaluated in case of growing numbers of patients in primary care–based cancer survivorship care.