Annette J. Berendsen

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Increased primary health care use in the first year after colorectal cancer diagnosis.

Abstract Objective. The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC). Design. Historical prospective study, using primary care data from two cohorts. Setting. Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30 000 patients. Subjects. Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358). Main outcome measures. Primary healthcare use in the period 1998–2009. Findings. Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23–92%) more face-to-face contacts, 68% (range 36–108%) more drug prescriptions, and 35% (range –4–90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients. Conclusions. The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services.

Out-of-hours medical care for terminally ill patients: A survey of availability and preferences of general practitioners

Background: Continuity of care is one of the core values of good medical care for terminally ill patients. The availability of one’s own general practitioner (GP) out of hours is regarded as important for personal continuity. Few data are available about the extent of out-of-hours care given by GPs to their terminally ill patients. Aim: The objective of this study was to determine to which level GPs are available out of hours for their own terminally ill patients and to elicit what factors are relevant to this availability. Design and setting: The research questions were investigated using a cross-sectional study of Dutch GPs. A questionnaire was sent to a random sample of 691 Dutch GPs. Results: The response rate was 47% (n = 327). Of the respondents, 86% was willing to provide out-of-hours care for their own terminally ill patients. These figures are higher than reported in previous studies. This study shows that out-of-hours availability correlates most strongly with the GPs’ perception of duties of care. Availability is negatively influenced if the GP is in a salaried job, if he or she works in a city based practice, or if home is far from the practice. A correlation between age, sex, and experience of GPs and availability for out-of- hours care for their terminally ill patients was not confirmed. Conclusions: The reported out-of-hours availability of GPs for terminally ill patients is still high. GPs’ perception of their duty of care might change in the next generations, and the increasing number of salaried GPs, living far from their practice, might threaten out-of-hours availability for terminally ill patients. GPs’ perception of their duty of care might change in the next generations, and the increasing number of salaried GPs living far from their practice might threaten out-of-hours availability for terminally ill patients.

Knowledge and preferences regarding cardiopulmonary resuscitation: A survey among older patients

OBJECTIVE Survival rates following cardiopulmonary resuscitation (CPR) are low for older people, and are associated with a high risk of neurological damage. This study investigated the relationship between the preferences, knowledge of survival chances, and characteristics among older people regarding CPR. METHODS A cross-sectional, self-administrated survey was distributed by researchers to 600 patients aged at least 50 years. The 14-question survey tool was used to collect basic demographic data, knowledge about CPR, and preference for CPR. We performed binary logistic regression analysis to predict whether patients wanted to receive CPR or not. RESULTS The response rate was 48%. Most respondents (84%) predicted the estimated survival rate to be higher than the actual rate. Patients were significantly less likely to want to receive CPR if they correctly estimated the survival rate, had ever contemplated CPR, were older, or female. Discussing CPR with a doctor had no influence on patient preference for CPR. CONCLUSION Older patients choose to receive CPR based on incorrect knowledge. PRACTICE IMPLICATIONS Doctors should be aware of the impact of knowing the true chances of survival on patient preference for CPR. Knowledge and skills need to be updated to provide this information to patients.

COPD exacerbations in general practice: variability in oral prednisolone courses

BackgroundThe use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based. However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-morbidity.MethodsCross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the Netherlands.ResultsThe response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity.ConclusionUnder normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.

Second cancers after childhood cancer - GPs beware!

Abstract Background. One of the long-term effects in childhood cancer survivors (CCS) is the development of second cancers. In a cohort of CCS, this study describes how second cancers were presented, the way they were diagnosed, and the knowledge CCS had about their increased risk to develop a second cancer. Patients and methods. Selected participants were all adult five-year CCS (n = 1275) who were treated at the University Medical Center Groningen since 1965. Of these, 84 (6.6%) had developed a second cancer, of which 27 had died. The 57 survivors were asked to participate in a telephone interview. Results. Of the 57 CCS, 35 (61%) participated. Together they had developed 45 second cancers. Most participants (97%) were seen at the long-term follow-up clinic. Of all second cancers, 89% caused symptoms. Of all second cancers, the majority (56%) were first presented at the general practitioners (GPs) office and 20% at follow-up testing. Of these CCS, only 28% were aware of their increased risk of developing a second cancer. Conclusions. It is important to inform CCS continuously regarding their increased risk, as a relatively small percentage are aware of this. Since most of these patients first reported their symptoms to the GP, all GPs should be aware of this increased risk, in particular because this concerns cancer at a younger age than normally expected. A survivor care plan might be an effective way of communication with both CCS and GPs.

Herkenning van overbelasting bij sporters

SamenvattingVan de Ven M, Otter R, Berendsen AJ, Brink MS. Herkenning van overbelasting bij sporters. Huisarts Wet 2014;57(8):426-9. Een 27-jarige amateurwielrenster kwam met vermoeidheidsklachten bij de huisarts. Ze hield trainingen vaak niet meer vol, haar prestaties liepen terug en ze had geregeld last van bovensteluchtweginfecties. Nadat lichamelijk onderzoek en algemeen screenend laboratoriumonderzoek geen bijzonderheden hadden opgeleverd, rees het vermoeden dat er sprake was van overtraindheid. Niet-functionele overbelasting en het overtrainingssyndroom worden veroorzaakt door een disbalans tussen fysieke stressfactoren, psychosociale stressfactoren en herstelfactoren. De belangrijkste symptomen zijn een afname van het prestatieniveau en een uitgesproken vermoeidheid. Het is belangrijk om ander onderliggend somatisch lijden uit te sluiten. Een diagnostische test om overtraindheid aan te tonen is tot op heden nog niet voor handen.AbstractVan de Ven M, Otter R, Berendsen AJ, Brink MS. Recognizing overtraining in sportsmen and women. Huisarts Wet 2014;57(8):426-9. A 27-year-old amateur cyclist went to her general practitioner because of fatigue. She often could not finish training sessions, her performance declined, and she regularly had upper respiratory tract infections. As physical examination and laboratory investigations were normal, the GP suspected overtraining. Both non-functional over-reaching (NFOR) and the overtraining syndrome (OTS) are caused by an imbalance between physical stress, psychosocial stress, and recovery. The main symptoms are fatigue and diminished performance. As there is no diagnostic tool to identify NFOR and OTS, it is important to exclude underlying disease.

Do breast cancer survivors visit their General Practitioner for psychological problems? Reply to: Heins et al.: For which health problems do cancer survivors visit their General Practitioner?

With keen interest we read the recent article of Heins et al. published in the European Journal of Cancer. The authors examined reasons for increased primary health care use among patients with breast, prostate and colorectal cancer 2–5 years after diagnosis, when compared to non-cancer controls. They concluded that primary health care use in cancer survivors is mainly higher for common acute symptoms, such as back or abdominal pain and common infections. Furthermore, they concluded that the number of General Practitioner (GP) contacts related to psychosocial problems is also slightly increased in cancer survivors, but is not a major cause for the increase in health care use. However, breast cancer patients had more contacts with the GP for sleep problems and depression than controls. In a recently published study, we observed increased primary health care utilisation among breast cancer survivors. Just as in the study of Heins et al. diseases and symptoms were coded using the ICPC-I (International Classification of Primary Care). As GPs might have

Nazorg en controle voor kanker

SamenvattingInleiding De meeste patiënten komen na een behandeling voor kanker in een traject van nazorg en controle terecht. Door de stijging van het aantal patiënten met kanker en de toenemende overleving komt er steeds meer druk op deze zorg te liggen. In dit literatuuronderzoek beschrijven wij de verwachtingen en voorkeuren van patiënten met betrekking tot deze zorg.Methode Een literatuuronderzoek op basis van een systematische zoekstrategie in de databases van PubMed, CINAHL en PsychInfo. We hebben de gevonden onderzoeken gescreend en de gegevens van zowel kwalitatieve als kwantitatieve onderzoeken verzameld.Resultaten Na screening hebben we 12 artikelen geïncludeerd. Deze beschrijven gezamenlijk 849 patiënten tussen de 28 en 90 jaar. Patiënten verwachten dat controle gericht is op het opsporen van recidieven. Ze willen veel klinische tests, omdat die hen gerust kunnen stellen. Daarnaast vinden patiënten dat artsen hun tijdens de nazorg en controle voldoende informatie moeten verstrekken en advies moeten geven over hun ziekte en leefstijl. Bovendien verwachten ze psychosociale ondersteuning. Daarbij is continuïteit van de zorgverlener belangrijk.Conclusie Patiënten lijken na de behandeling voor kanker een grote behoefte te hebben aan klinische tests. De nazorg en controle moeten duurzaam en effectief zijn. De huisarts kan nut en noodzaak van klinische onderzoeken verduidelijken en speelt een rol bij de psychosociale ondersteuning.

Correspondence between primary and secondary care about patients with cancer: A qualitative mixed-methods analysis

Abstract Cancer care is complex and involves many different healthcare providers, especially during diagnosis and initial treatment, and it has been reported that both general practitioners and oncology specialists experience difficulties with interdisciplinary communication. The aim of this qualitative study was to explore information sharing between primary and secondary care for patients with lung, breast or colorectal cancer. A qualitative content analysis of 50 medical files (419 documents) was performed, which identified 70 correspondence‐related items. Six main topics were identified in most referral letters from primary to secondary care, but it was particularly notable that highly relevant information regarding the past medical history was often mixed with less relevant information. To lesser extents, the same held true for the medication list and presenting history. In the letters from specialists, nine topics were identified in most letters. Although information about actual treatment was always present, only limited detail, if any, was given about the intent of the treatment (curative or palliative) or the treatment alternatives. Interviews with nine healthcare providers confirmed these issues. These findings indicate that neither the initial referral nor the specialist correspondence is tailored to the needs of the recipient.