Knowledge of Primary Care Physicians About Breast-Cancer-Related Lymphedema: Turkish Perspective

Breast-cancer-related lymphedema (BCRL) is a common complication of breast cancer treatment. Informing patients about BCRL can contribute to decrease their risk of developing the condition or prevent it from progressing further. In order to educate patients about BCRL effectively, clinical knowledge of clinicians must be adequate. In study, we aimed to reflect BCRL knowledge and attitude of Turkish primary care physicians (PCPs). This questionnaire-based study was conducted by face-to-face interview method. The participants included actively working PCPs from all parts of Turkey. The questionnaire elicited data on physicians’ demographics, the BCRL knowledge, self-reported BCRL knowledge, referral patterns, and education. A total of 314 PCPs with a mean age of 36.9 %?±?8.1 years (mean?±?standard deviation) were included in the study. Median BCRL knowledge score of all study group was 15 (11–18) [median (25–75 % range)]. PCPs who received education about BCRL during their medical faculty and/or residency periods had significantly higher knowledge scores (p?=?0.005). Of PCPs, 94.9 % indicated to make a BCRL referral for a breast cancer patient. Among them, 55 % preferred to make a referral to a general surgeon, 28.2 % to an oncologist, and 16.8 % to a physical medicine and rehabilitation specialist. Assessment of factors related with BCRL should be part of routine evaluation of patients with breast cancer in primary care. Education of PCPs about BCRL is warranted in order to improve the BCRL care.     

BRCA testing of breast cancer patients: medical specialists' referral patterns,knowledge and attitudes to genetic testing

VAN RIEL E., WÁRLÁM‐RODENHUIS C.C., VERHOEF S., RUTGERS E.J.TH. & AUSEMS M.G.E.M. (2010) European Journal of Cancer Care 19 , 369–376
BRCA testing of breast cancer patients: medical specialists' referral patterns, knowledge and attitudes to genetic testing This study explores knowledge about hereditary breast cancer, attitudes about BRCA testing and referral pattern to a family cancer clinic among medical specialists. A total of 92 questionnaires were completed by surgeons (38), medical oncologists (29), radiation oncologists (13) and radiologists (12). The response rate was 51%. A substantial (11–56%) proportion of medical specialists do not refer patients who meet current criteria for BRCA testing. Although questions on inheritance were less well answered, overall knowledge was good. They had a positive attitude, but were concerned about the distress DNA testing might cause to family members. The majority (75%) stated that the best time for referral is after adjuvant therapy or during follow‐up, but another important determinant was the patient's wish or need (12%). Further studies are needed to gain insight into the actual referral process, while ongoing training of medical specialists about genetic aspects of breast cancer is also necessary.     

Care of long‐term cancer survivors

BACKGROUND:

Studies have shown that follow‐up care for cancer patients differs by physician specialty, and that coordination between specialists and generalists results in better care. Little is known, however, regarding which specialties of physicians provide care to long‐term cancer survivors.

METHODS:

The authors used Surveillance, Epidemiology, and End Results data from 1992 through 1997 that were linked to 1997‐2003 Medicare data to identify persons diagnosed >5 years earlier with bladder, female breast, colorectal, prostate, or uterine cancer. Physician specialties were assigned by combining Medicare data with the American Medical Association Masterfile and the Unique Physician Identification Number Registry. The percentage of long‐term survivors who visited physicians of interest was determined by analyzing Medicare outpatient claims submitted 6 to 12 years after initial diagnosis.

RESULTS:

Over the entire study period, 46% of female breast cancer survivors, 26% of colorectal cancer survivors, and 14% of prostate cancer survivors saw hematologists/oncologists. Radiation oncologists were seen by 11%, 2%, and 14% of breast, colorectal, and prostate cancer survivors, respectively. Survivors also sought care from specialists related to their cancer: 19% of breast cancer survivors had a cancer‐coded visit with a surgeon, 26% of colorectal cancer survivors visited a gastroenterologist, and 68% of prostate cancer survivors visited a urologist. The percentage of survivors who visited cancer and cancer‐related physicians declined each year. In contrast, nearly 75% of female breast, colorectal, and prostate cancer survivors saw primary care providers, and these percentages did not decrease annually.

CONCLUSIONS:

The findings of the current study underscore the need to include both primary care providers and cancer‐related specialists in education and guidelines regarding cancer survivorship. Cancer 2009. © 2009 American Cancer Society.     

Evolving perspectives on genetic discrimination in health insurance among health care providers

Previous studies have documented that concerns about genetic discrimination (GD) may influence access to and participation in medically necessary care. We sought to characterize how GD issues influence current cancer genetics professional (CGP) practice, determine if their attitudes regarding GD have changed over time, and compare their knowledge and attitudes regarding laws prohibiting GD to a contemporary cohort of non-genetics clinicians. Members of the National Society of Genetic Counselors Familial Cancer Special Interest Group were invited to complete a 39 item online survey, adapted from previously published instruments. The resulting data were compared to a survey of CGPs published in 2000 and to a contemporary cohort of non-genetics clinicians (n = 1,181). There were 153 qualified respondents. Compared to the historical CGP cohort (n = 163), a significantly greater proportion said they would bill insurance for the cost of genetic testing for themselves (P < 0.0001). Most CGPs (94%) considered the risk of GD to be low to theoretical, concordant with 64% who expressed confidence in existing federal laws prohibiting GD. The mean knowledge score of CGPs regarding GD protective laws was significantly greater than that of non-genetics clinicians (P < 0.001). As barometers of change, CGPs show a migration in opinion over the past 8 years, with decreased fear of GD and greater knowledge of laws prohibiting GD compared to non-genetics clinicians. Better knowledge of GD and protective legislation, may facilitate non-genetics clinician utilization of genetics and personalized medicine.     

The association between chronic disease burden and quality of life among breast cancer survivors in Missouri

Greater chronic disease burden may decrease quality of life (QOL) of breast cancer survivors. Our objective was to investigate the association between chronic disease burden and QOL in breast cancer survivors at 1 year post-diagnosis. We analyzed cross-sectional data collected 1 year post-diagnosis from a sample of female breast cancer survivors identified from the Missouri cancer registry. We used eight RAND-36 subscales to assess physical, emotional, and social functioning QOL domains. Using Katz’s measure of comorbidity, we computed chronic disease burden (0, 1, and 2+). Multivariable general linear models for each QOL subscale were used to examine associations between chronic disease burden and QOL after controlling for potential covariates: socio-demographic, clinical, psychosocial, behavioral risk factors, and access to medical care. Participants (n = 1089) were 58-year old on average (range 27–96) and mostly White (92%), married (68%), had at least a high school education (95%), and had health insurance (97%). Sixty-six percent of survivors had a chronic disease burden score of 0, 17% had 1, and 17% had 2+. Chronic disease burden was significantly associated with each QOL subscale in crude models (P < 0.001). In fully adjusted models, chronic disease burden was still significantly correlated with six subscales, but not with the emotional well-being and role limitations due to emotional problems subscales. One year post-diagnosis, breast cancer survivors with higher chronic disease burden had lower physical and social functioning than survivors without additional health conditions. These differences were not fully explained by relevant covariates. Identifying modifiable targets for intervention will be critical for improving QOL outcomes among survivors who have other chronic health conditions.     

Survivorship care after breast cancer: Follow‐up practices of Australian health professionals and attitudes to a survivorship care plan

Objective: The increasing number of breast cancer survivors and the complexity of follow‐up care make the provision of high‐quality survivorship care a challenge. This study explored the follow‐up practices of health professionals and their attitudes to alternative models such as shared care and the use of a survivorship care plan. Methods: Specialist oncologists (surgeons, medical and radiation oncologists) breast physicians and breast‐care nurses completed an online survey. Results: A total of 217 practitioners completed the survey, which was estimated to include 42.8% of oncologists treating breast cancer in Australia. One‐third of responding specialists reported spending more than 25% of their clinical time providing follow‐up care. They reported many positive aspects to follow‐up consultations and viewed follow‐up care as an important part of their clinical role but expressed concern about the sustainability of follow‐up care in their practices. The follow‐up intervals and recommendations were in line with national guidelines. The specialists were supportive of sharing follow‐up care with primary‐care physicians, breast physicians and breast‐care nurses. Most professionals felt that a survivorship care plan would improve care and said they would use a proforma. Conclusion: The oncologists felt that follow‐up care was an important part of their role and they were supportive of the concepts of shared care programs and a survivorship care plan. Input from consumers is required to evaluate the acceptability of these alternative models and to assess ways of implementing these changes to work towards a more comprehensive and sustainable method of delivering survivorship care.     

Public and Professional Educational Needs for Downstaging Breast Cancer in Egypt

We conducted focus groups with women from urban and rural areas in the Nile Delta region to investigate their attitudes regarding breast cancer diagnosis, treatment, and screening. Six 60-min focus groups, each group comprised of 6–10 women with ages between 20–69 years, were conducted. Discussions included breast health, breast cancer diagnosis, treatment, early detection and screening, and communication for breast health. Almost all urban and rural women reported that women do not see physicians until they are seriously ill or have advanced cancer. They reported that oncologists or gynecologists were important to be seen first if a woman suspected breast cancer and primary care physician are not the primary line of cancer diagnosis. Other deterring factors besides distrust in primary care physicians included attitude that breast cancer equals death and lack of knowledge of early detection and screening techniques. Women felt that public education campaigns must be implemented to improve early detection and screening methods for breast cancer. The majority of beliefs regarding breast cancer and screening were common among urban and rural women. Culture-specific and tailored professional and public education programs in developing countries are essential for achieving downstaging cancer.     

Providers of follow-up care in a population-based sample of breast cancer survivors

To describe which providers provide breast cancer survivorship care, we conducted a longitudinal survey of nonmetastatic breast cancer patients identified by the SEER registries of Los Angeles and Detroit. Multinomial logistic regression examined the adjusted odds of surgeon compared with a medical oncologist follow-up or primary care provider compared with medical oncologist follow-up, adjusting for age, race/ethnicity, insurance, tumor stage, receipt of chemotherapy, endocrine therapy use, and visit to a medical oncologist at the time of diagnosis. Results were weighted to account for sample selection and nonresponse. 844 women had invasive disease and received chemotherapy or endocrine therapy. 65.2 % reported medical oncologists as their main care provider at 4 years, followed by PCP/other physicians (24.3 %) and surgeons (10.5 %). Black women were more likely to receive their follow-up care from surgeons (OR 2.47, 95 % CI 1.16–5.27) or PCP/other physicians (OR 2.62, 95 % CI 1.47–4.65) than medical oncologists. Latinas were more likely to report PCP/other physician follow-up than medical oncologists (OR 2.33, 95 % CI 1.15–4.73). Compared with privately insured women, Medicaid recipients were more likely to report PCP/other physician follow-up (OR 2.52, 95 % CI 1.24–5.15). Women taking endocrine therapy 4 years after diagnosis were less likely to report surgeons or PCP/other physicians as their primary provider of breast cancer follow-up care. Different survivorship care patterns emerge on race/ethnicity and insurance status. Interventions are needed to inform patients and providers on the recommended sources of breast cancer follow-up.     

Healthcare professionals' knowledge and practice of physical activity promotion in cancer care: Challenges and solutions

Limited research exists regarding healthcare professionals' knowledge and practice of physical activity promotion for cancer survivors in Ireland. There is also a lack of research identifying the barriers experienced by oncology professionals when promoting physical activity, or referring patients to community‐based exercise programmes. This study aims to identify healthcare professionals' knowledge, barriers and practices in relation to physical activity promotion for cancer survivors, and to generate guidance regarding the optimisation of the referral process to community‐based exercise programmes. Oncology healthcare professionals (n = 114) were invited to participate in two rounds of an online Delphi study. The response rates in rounds one and two were 38% (43/114) and 70% (30/43). Most respondents acknowledged the value of physical activity for cancer survivors (≥86%) and agreed that discussing physical activity with cancer patients was part of their role (88%). However, the majority of recommendations provided to patients did not align with the current physical activity guidelines. Strategies related to four themes that could optimise the referral process to community‐based exercise programmes achieved consensus, including providing education to healthcare professionals and patients regarding the benefits of physical activity and the logistics and quality of programmes, and optimising the logistics of the referral process.     

Diagnostic Methods,Risk Factors,Prevention, and Management of Breast Cancer-Related Lymphedema: Past,Present, and Future Directions

Purpose of Review

Breast cancer-related lymphedema (BCRL) is a chronic, adverse, and much feared complication of breast cancer treatment, which affects approximately 20% of patients following breast cancer treatment. BCRL has a tremendous impact on breast cancer survivors, including physical impairments and significant psychological consequences. The intent of this review is to discuss recent studies and analyses regarding the risk factors, diagnosis, prevention through early screening and intervention, and management of BCRL.

Recent Findings

Highly-evidenced risk factors for BCRL include axillary lymph node dissection, lack of reconstruction, radiation to the lymph nodes, high BMI at diagnosis, weight fluctuations during and after treatment, subclinical edema within and beyond 3 months after surgery, and cellulitis in the at-risk arm. Avoidance of potential risk factors can serve as a method of prevention. Through establishing a screening program by which breast cancer patients are measured pre-operatively and at follow-ups, are objectively assessed through a weight-adjusted analysis, and are clinically assessed for signs and symptoms, BCRL can be tracked accurately and treated effectively. Management of BCRL is done by a trained professional, with research mounting towards the use of compression bandaging as a first line intervention against BCRL. Finally, exercise is safe for breast cancer patients with and without BCRL and does not incite or exacerbate symptoms of BCRL.

Summary

Recent research has shed light on BCRL risk factors, diagnosis, prevention, and management. We hope that education on these aspects of BCRL will promote an informed, consistent approach and encourage additional research in this field to improve patient outcomes and quality of life in breast cancer survivors.

     

Fertility preservation in women undergoing treatment for breast cancer in the UK: a questionnaire study

Objective.

Fertility preservation is an important survivorship issue for women treated for breast cancer. The aim of this work was to examine the referral practices of health care professionals who treat women with breast cancer in the United Kingdom, and to investigate their understanding and knowledge of the fertility preservation options available.

Method.

An invitation to participate in a confidential, online questionnaire was e-mailed to surgeons, oncologists, and clinical nurse specialists who manage patients with breast cancer in the United Kingdom.

Results.

n = 306 respondents. Factors which influenced whether fertility preservation options were discussed with a patient included the following: patient''s age (78%), final tumor/nodes/metastasis status (37.9%); concern that fertility preservation would delay chemotherapy (37.3%); whether the patient had children (33.5%) or a partner (24.7%); estrogen receptor expression (22.6%), lack of knowledge regarding the available options (20.9%); and concern that fertility preservation would compromise the success of cancer treatment (19.8%). Twenty-seven percent did not know whether fertility preservation was available for their patients on the National Health Service. Nearly half (49.4%) of respondents said that gonadotropin-releasing hormone agonists were used for fertility preservation outside the setting of a clinical trial. Knowledge regarding the available options varied according to different members of the multidisciplinary team, with consultant oncologists better informed than consultant surgeons or clinical nurse specialists (p < .05).

Conclusions.

Many health care professionals have incomplete knowledge regarding the local arrangements for fertility preservation for patients with breast cancer. This may result in patients receiving inadequate or conflicting information regarding fertility preservation.     

Timing of palliative care referral and symptom burden in phase 1 cancer patients

BACKGROUND:

Phase 1 trials offer patients with advanced cancer the opportunity to pursue life‐prolonging cancer treatments. In the current study, the timing of referral and symptom burden between patients referred to palliative care by phase 1 oncologists and those referred by non‐phase 1 oncologists were compared.

METHODS:

All 57 patients with advanced solid tumors who were referred by phase 1 oncologists to the palliative care outpatient clinic at The University of Texas M. D. Anderson Cancer Center (MDACC) between 2007 and 2008 were included. The comparison cohort was comprised of 114 non‐phase 1 patients who were stratified by age, sex, and cancer diagnosis in a 1:2 ratio. Information regarding patient characteristics, Edmonton Symptom Assessment Scale (ESAS), timing of referral, and survival was retrieved.

RESULTS:

Both cohorts had the following matched characteristics: average age of 57 years, with44% of the patients being female and 47% having gastrointestinal cancers. At the time of palliative care consultation, patients referred by phase 1 oncologists were more likely than patients referred by non‐phase 1 oncologists to have a better performance status (Eastern Cooperative Oncology Group 0–1: 61% vs 36% [P = .003). The ESAS was not significantly different with the exception of better well‐being in the phase 1 cohort (mean, 4.5 vs 5.5; P = .03). No difference was found for the duration between registration at MDACC and palliative care consultation (13 months vs 11 months; P = .41) and overall survival from the time of palliative care consultation (5 months vs 4 months; P = .69).

CONCLUSIONS:

Outpatients referred to palliative care by phase 1 oncologists were found to have a better performance status but similar symptom burden compared with patients referred by non‐phase 1 oncologists. Patients with phase 1 involvement did not appear to have delayed palliative care referral compared with non‐phase 1 patients. The results of the current study support the development of a simultaneous care model. Cancer 2010. © 2010 American Cancer Society.     

The effects of oncotype DX recurrence scores on chemotherapy utilization in a multi-institutional breast cancer cohort

The use of clinicopathologic features in decision-making in early stage estrogen receptor (ER)-positive breast cancer (BC) may lead to over or under treatment. We investigated the effect of the Oncotype Dx? (ODX) on chemotherapy (CTX) utilization in two cancer centers. 276 cases of node-negative ER-positive BC had ODX between 2005 and 2009. Age at diagnosis, tumor size, grade, and progesterone receptor (PR) status were abstracted from records and provided to two medical oncologists blinded to the ODX score. A recommendation for or against CTX was made based on clinicopathologic characteristics. Median age was 55 years. Mean tumor size was 1.6 cm. The median 10-year Adjuvant! Online (AO) mortality risk was 8. The median Nottingham Prognostic Index (NPI) was 3.3. The median ODX recurrence score was 17. Without knowledge of the ODX, oncologists were more likely to recommend CTX to younger women (P < 0.0001), women with negative PR status (P < 0.0001), higher NPI (P < 0.012), and tumors > 1 cm (P = 0.033). On average, CTX recommended patients had larger tumors (2.0 vs. 1.2 cm) and higher AO 10-year mortality (11.4 vs. 4.4%). ODX resulted in a change in management for 38% of women. Of 188 total patients who did not receive CTX, 71 had a recommendation favoring CTX by an oncologist blinded to the ODX score. In our multi-institutional cohort, the ODX score had a significant impact on the receipt of adjuvant CTX and altered management for 38% of women.     

Supportive versus palliative care: What's in a name?

BACKGROUND:

Palliative care has been progressively adopted by American cancer centers; however, referrals to palliative care continue to occur late in the trajectory of illness. It was hypothesized that the perceived association between the name palliative care and hospice was a barrier to early patients' referral. The objectives of this study were to determine the perception of the impact of the name palliative care compared with supportive care on patient referral and to determine whether there was an association between demographic factors and the perceptions of the 2 names by medical oncologists and their midlevel providers (advance practice nurses and physician assistants) at a comprehensive cancer center.

METHODS:

A survey was conducted among a random sample of 100 medical oncologists and 100 midlevel providers from The University of Texas M. D. Anderson Cancer Center. Information was collected on demographics, previous experience in palliative care, and attitudes and beliefs toward the impact of the name palliative care compared with supportive care on patient referral.

RESULTS:

A total of 140 of 200 (70%) participants responded (74 midlevel providers and 66 medical oncologists). Median age was 43 years (range, 34.5‐50 years), and there were 83 (60%) women. Midlevel providers and medical oncologists generally agreed in their responses to most of the items. More participants preferred the name supportive care (80, 57%) compared with palliative care (27, 19% P < .0001). Medical oncologists and midlevel providers stated increased likelihood to refer patients on active primary (79 vs 45%, P < .0001) and advanced cancer (89 vs 69%, P < .0001) treatments to a service named supportive care. The name palliative care compared with supportive care was perceived more frequently by medical oncologists and midlevel providers as a barrier to referral (23 vs 6% P < .0001), decreasing hope (44 vs 11% P < .0001), and causing distress (33 vs 3% P < .0001) in patients and families. There were no significant associations among the perception of the 2 names and age (P = .82), sex (P = .35), or prior training in palliative care (P > .99).

CONCLUSIONS:

The name palliative care was perceived by medical oncologists and midlevel providers as more distressing and reducing hope to patients and families. Medical oncologists and midlevel providers significantly prefer the name supportive care and stated more likelihood to refer patients on active primary and advanced cancer treatments to a service named supportive care. Cancer 2009. © 2009 American Cancer Society.     

Adherence to a randomized controlled trial of aerobic exercise in breast cancer survivors: the Yale exercise and survivorship study

Purpose  To examine predictors of exercise adherence in breast cancer survivors. Methods  Seventy-five breast cancer survivors were randomly assigned to exercise (n = 37) or usual care (n = 38). Demographic, prognostic, physiologic, and psychosocial information was collected at baseline and 6 months. The exercise goal was 30 min of exercise 5 days/week for 6 months. Results  Women randomized to exercise participated in moderate-intensity recreational exercise for 123 ± 52 min/week (81% of the prescribed 150 min/week) over 6 months. Baseline variables associated with better adherence were lower body mass index (BMI), smaller waist circumference, higher amounts of physical activity 6 months prior to enrollment, being in the preparation vs. contemplation Stage of Change and higher FACT-B breast cancer subscale score. After adjusting for these variables, lower BMI and higher Stage of Change continued to be associated with better adherence (p < 0.05). Conclusions  Future studies of exercise and breast cancer prognosis should target obese women for participation, as well as women just beginning to contemplate participation and its benefits after a cancer diagnosis.     

Different professionals' knowledge and perceptions of the management of people with pancreatic cancer

Background: Pancreatic cancer is generally associated with a very poor prognosis. The knowledge, beliefs and opinions of clinicians caring for people with pancreatic cancer may affect preferences for particular therapies and may impact upon patient outcomes. The aim of this study was to conduct a postal survey of clinicians who consult patients with pancreatic cancer to assess their knowledge regarding the disease itself and the effectiveness of various treatments, and to gauge their opinions regarding aspects of management. Methods: A 20‐item multiple‐choice questionnaire was mailed to medical and radiation oncologists, gastroenterologists, general surgeons and hepatopancreatobiliary (HPB) surgeons in Australia. Questions assessed knowledge of survival following surgery for resectable disease, and survival and response rate following chemoradiation for locally advanced disease and chemotherapy for advanced disease. Beliefs regarding the need for tissue diagnosis and perceptions of benefit of various treatment strategies were also sought. Results: Overall, knowledge was fair (average knowledge score 4.1 out of 8); 56% of HPB surgeons and 55% of medical oncologists had good knowledge, compared with 39% of gastroenterologists and general surgeons. There were marked differences in opinion regarding requirement for tissue diagnosis before further management. There was considerable variation in opinion regarding the benefit of postoperative adjuvant chemotherapy. Conclusion: These findings argue strongly for the development of evidence‐based guidelines. Multidisciplinary management teams may help educate individual clinicians and professional groups and are likely to result in improved outcomes for patients.