WASHINGTON — Collaboration between oncologists and primary care physicians can ensure seamless care for cancer patients, according to a hematologist and a family practice physician who gave a joint presentation at the annual Community Oncology Conference.
Routine use of printed forms can facilitate exchange of important information, Dr. Leslie R. Laufman and Dr. Mary Beth Hall advised, outlining a blueprint for cooperation.
They counseled, however, that even when forms are used, there will be times when one provider or the other needs to pick up the phone and initiate discussion of a patient's medical treatment and/or psychosocial issues.
Communication between a cancer patient's oncologist and primary care physician is critical, but in many cases it isn't carried out effectively, said Dr. Laufman of Ohio State University, Columbus, who is also in private practice in oncology in Columbus, and Dr. Hall, a family physician in private practice in Newark, Ohio.
Many aspects of the “division of labor” were described as straightforward:
▸ The oncologist handles the cancer status definition, the cancer treatment plan, urgent care during treatment, the unique side effects of the chemotherapy agents, and possibly entering patients into clinical trials.
▸ The primary care physician provides ongoing medical care for noncancer health issues, helps manage psychosocial issues that either predate or accompany the cancer diagnosis, helps with family-related issues, and possibly plays a role in palliative care.
The primary care physician needs to receive timely information from the oncologist regarding the patient's initial consultation, including diagnosis, prognosis, treatment plan and objectives, likely toxicities or cancer-related problems, and plans for home care. “We are very anxious to hear how the patient is going to do,” Dr. Hall said.
Access to educational materials—such as newsletters or links to Internet sites—would be very helpful, as would the oncologist's direct telephone number, she added. “I promise we won't abuse it. It just comes in handy to have it right there in the patient's chart so that we can do a rapid phone consult. … And it works both ways. The oncologist needs our phone number too.”
Any hospitalization plans, as well as the patient's advance directive status, should be provided to the primary care physician. It is important to spell out ahead of time which physician will manage the patient in the hospital or whether the two will collaborate.
Some aspects of a cancer patient's care might present a conflict or be overlooked unless they are anticipated and addressed. Among these are the management of pain, depression, or insomnia that develops in response to the cancer or its treatment, hospitalization for acute toxicities, long-term follow-up, and screening for new primary cancers.
“Who tells the patient about needing a colonoscopy if they have breast cancer? One may assume the other is doing that,” Dr. Hall noted as an example.
Both physicians should ask patients whether they are taking any type of alternative treatments that could interact with their prescribed agents, and should inform the other physician if they are. St. John's wort is a common one that some patients take for depression but that can also cause bleeding.
“Patients don't always tell you. You have to ask them,” she said.
Much of the communication between the two physicians can be accomplished through printed forms.
A recommended template for such letters was developed by Dr. Ted C. Braun and his associates at the Tom Baker Cancer Centre, a large tertiary referral center in Calgary, Alta. (Can. Family Physician 2003;49:884).
Dr. Laufman discussed a single-page (front and back) “precertification” form that she uses both as an in-house communication tool within her three-oncologist practice and also with the patient's primary care physician.
The form includes items to be circled and lines to be filled in for treatment goals and options, patient status, and comorbidities, along with documentation of what the patient has been taught and of consent to treatment.
The physician fills out his or her part of the form, signs off, and then forwards it to the nurses who do the same when they conduct patient teaching. It then goes to the billing department to ensure likely coverage for treatment before it is sent to the pharmacy technician for drug dispensing.
Formal chemotherapy orders are listed for the entire duration of therapy, with information about doses, schedule, lab parameters, and premedications, along with a formal amendment procedure for any changes. The patient also signs it. The whole form also serves as a legal document, Dr. Laufman said.
A version of the form is then sent, along with a cover letter, to the primary care physician. “This is one of the things that makes our practice work very, very well,” she said.