Primary care has growing role in colorectal cancer follow-up

There are more than 1 million survivors of colorectal cancer in the United States today, according to registry data, and all require follow-up for potential cancer recurrence, new cancer, and myriad physical and psychological effects.

“Oncologists are left often with the continuing care of these patients, which is not ideal,” said Carmen E. Guerra, MD, associate professor of medicine at the Hospital of the University of Pennsylvania in Philadelphia. “We do not have enough of a workforce to handle that in oncology, plus be able to care for every new case diagnosed.”

Increased attention to transitioning colorectal cancer patients who have completed their treatment back into the care of their primary care clinicians is increasingly important, she said.

But a study published in 2011 in the Journal of General Internal Medicine showed that, of a nationally representative sample of more than 1,000 primary care physicians, fewer than one-fourth expressed a high confidence in their ability to care for patients with late physical effects of breast or colon cancer, and fewer than one-half were very confident about ordering appropriate tests for detecting recurrent cancer.

To help bridge this gap, the American Cancer Society (ACS) recently released its Colorectal Cancer Survivorship Care Guidelines, designed to help guide primary care physicians in patients' long-term management.

Optimal management

The ACS guidelines, which were published online Sept. 8, 2015, by CA: A Cancer Journal for Clinicians, are divided into 5 main sections: surveillance for recurrence; screening for second primary cancer; assessment and management of physical and psychological long-term and late effects of both disease and treatment; health promotion; and care coordination.

The first 2 categories, cancer recurrence or a new primary cancer, pose the highest long-term health risk to colorectal cancer survivors, Dr. Guerra said. From 3 to 5 years post-treatment, survivors of stage I-III cancer should undergo what she called the 4 pillars of surveillance: a history and physical every 6 months; a carcinoembryonic antigen biomarker test every 6 months if the patient might need further therapeutic intervention for recurrent disease; CT scans of the chest, abdomen, and pelvis every 12 months; and colonoscopy in year 4.

In addition, the guidelines state that female colorectal cancer survivors with Lynch syndrome, who are at increased risk for endometrial and ovarian cancer, should undergo annual endometrial sampling and transvaginal ultrasound, said April Barbour, MD, FACP, an internist with GW Medical Faculty Associates and professor of medicine at the George Washington University School of Medicine and Health Sciences.

“The guidelines give more specific recommendations about when to do these things and how often,” Dr. Guerra said. “That is the real advantage of these guidelines is that they are clear.”

Regular screening for other types of cancer can sometimes be overlooked by oncologists and is a good fit for primary care, said Alok Khorana, MD, FACP, director of gastrointestinal malignancies at Cleveland Clinic.

“Oncologists tend to subspecialize, and although it may sound surprising, we tend to forget about screening for other cancers by ordering things like Pap smears or mammograms,” Dr. Khorana said. “PCPs [primary care physicians] play an important role in adhering to prescribed screening guidelines by age and risk category.”

Internists should also be alert for other common physical late effects of colorectal cancer, said Dr. Khorana, including:

• gastrointestinal issues, especially in patients treated with pelvic radiation or those who had surgery to shorten the bowel,
• cognitive dysfunction, commonly seen in patients treated with chemotherapy,
• neuropathy, seen in patients treated with chemotherapy, specifically the FOLFOX regimen,
• fatigue,
• sexual dysfunction, more commonly seen in rectal cancer survivors, and
• urinary dysfunction.

Although psychological problems, such as depression and anxiety, can occur in survivors of any type of cancer, “one of the effects more specific to colorectal cancer has to do with the social effects when a patient ends up with an ostomy or stoma,” Dr. Barbour said. “They often have concerns about how they will function or be accepted by family and friends.”

Primary care physicians shouldn't shy away from asking patients about their feelings or bringing up sensitive topics, Dr. Barbour stressed. These conversations can help validate those concerns for patients and help them understand that they are not the only ones who feel that way, she said.

Dr. Khorana noted that most large hospitals or health systems have stoma clinics, stoma nurses, and even stoma support groups. Patients should be made aware of these and should consider asking for referral, he said.

Managing the transition

Both physician and patient preference will dictate when a patient who has completed colorectal cancer treatment will move from the care of an oncologist back to a primary care physician, Dr. Khorana said.

“Once patients have developed a close relationship with an oncologist, they tend to want to continue that because they feel the oncologist has the best knowledge of what has happened and would be best at keeping a close eye on their care,” he said.

Dr. Barbour agreed. “The oncologist has been there through what were probably some of the darkest days of these patients' lives, and many patients don't want to stop seeing them,” she explained. “Some oncologists are also resistant because these patients—the survivors—are gratifying and rewarding patients to see and follow up.”

And Dr. Guerra noted that comanagement rather than a complete transition to primary care is best during the 1- to 2-year post-treatment interval, when recurrence or late effects are most likely.

Ideally, oncologists would help ease the complete transition by using a “verbal handoff,” Dr. Khorana said, contacting the PCP to discuss the patient and what has been done so far. The use of survivorship care plans can help, too, Dr. Barbour explained. For example, the American Society of Clinical Oncology provides a form specifically for colorectal cancer survivors that is designed to give primary care physicians basic information about a patient's cancer case and follow-up, including treatment received, any complications, and the testing or monitoring needed going forward. (This form and others are online )

Successful transitions happen when both the oncologist and the PCP work together and understand each other's roles, Dr. Barbour said. “Primary care physicians don't want to take the place of the oncologist,” she said. “They want to work alongside and complement the care provided so the patient has the best long-term outcome.”