|Follow-up of cancer in primary care versus secondary care: systematic review
|Lewis RA, Neal RD, Williams NH, France B, Hendry M, Russell D, Hughes DA, Russell I, Stuart NS, Weller D, Wilkinson C
The review concluded that available weak evidence suggested breast cancer follow-up in primary care was effective and that interventions that improved communication between primary and secondary care could lead to greater general practitioner involvement. The authors' cautious conclusions were supported by the results of the review and are likely to be reliable.
To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients.
MEDLINE, EMBASE, CINAHL, PsycINFO, AMED, BIOSIS Previews, Index to Scientific and Technical proceedings, Science Citation Index, Social Science Citation Index, Cochrane databases, DARE, HTA database, NHS EED, System for Information on Grey Literature, British Nursing Index, Health Management Information Consortium, trial registries and cancer websites were searched from inception to February 2007 without any language restrictions. Search terms were reported. Reference lists of identified systematic reviews and studies and abstracts from conference proceedings were handsearched.
Studies and economic evaluations that compared cancer follow-up in primary care with that in a secondary care setting or compared hospital follow-up with formal primary care involvement were eligible for inclusion. Studies of patient initiated follow-ups that reported primary care-related outcomes were also considered. Cancer patients (any type, stage, age) who were free of active disease or did not require routine hospital visits were eligible for inclusion. All outcomes were considered.
Studies included evaluated primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up and hospital follow-up versus patient initiated or minimal follow-up. Patient ages varied. Cancer conditions evaluated included breast, colon, colorectal and gastric cancers. The length of follow-up ranged from six months to a median of 3.5 years. Outcomes assessed included patient well-being (psychological morbidity and quality of life), recurrence rate, survival and costs.
Two reviewers independently screened identified articles for eligibility.
Assessment of study quality
Quality of randomised controlled trials (RCTs) was assessed according to the following criteria: adequacy of reporting; external validity; internal validity (bias minimisation and control for confounding); and study power. A modified version of the checklist developed by Drummond and Jefferson was used to assess the quality of economic evaluations.
Two reviewers independently assessed the quality of included studies. Disagreements were resolved by discussion.
Data on the number of patients in comparison interventions (primary versus secondary care, general practitioner (GP) formal involvement, patient initiated follow-ups) and outcomes were extracted and entered into a predefined form. Data were extracted by one reviewer and checked by a second independent reviewer. Disagreements were resolved by discussion.
Methods of synthesis
Study results were presented using tables and summarised in a narrative synthesis.
Results of the review
Eleven published studies (10 RCTs and 1 non-randomised) (n=2,908 patients) and two ongoing studies were included in this review. Methodological quality varied between studies. Allocation concealment was adequate in three studies. Five studies used blinded outcome assessment. Only four studies adjusted for losses to follow-up. Sample sizes ranged from 62 to 968.
Primary versus secondary care: The five studies comprised three RCTs and two studies reported only as abstracts (one RCT, one non-randomised). There were no statistically significant differences between the intervention groups in the outcomes of patient well-being (psychological morbidity and quality of life), recurrence rate or survival (three RCTs, n=1,467).
Involvement of GP in cancer care versus conventional follow-up (three RCTs): There were no statistically significant differences between the intervention groups in the outcomes of patient well being (two RCTs, n=339) or satisfaction (one RCT, n=248). Involvement of a GP in cancer care was associated with a statistically significant increase in the contact with either the GP or home-care nurse at six months (two RCTs, n=775). There was no statistically significant difference between the intervention groups for hospital admissions and outpatient visits (one RCT, n=527). Pre-arranged formal consultations with a GP did not result in a significant increase in additional GP visits at six months (one RCT, n=91).
Patient-initiated or minimal follow-up (three studies): There were no statistically significant differences between the groups for the number of GP visits (two RCTs, n=255) or cancer-related GP referrals (one study, n=62).
The cost of GP breast cancer follow-up was significantly less than routine hospital follow-up (mean difference £130 per patient, 95% CI £112 to £149; one RCT, n=296).
Available weak evidence suggested that breast cancer follow-up in primary care was effective and that interventions that improved communication between primary and secondary care could lead to greater GP involvement.
The review question was clearly stated. Several relevant databases were searched without language restrictions, hence risk of language bias was minimised. Efforts were made to search for unpublished papers. Appropriate steps were taken to minimise risk of reviewer error and bias in the review methods. Validity was assessed with appropriate criteria and the quality of studies reported in full. The decision to summarise results narratively was supported by differences in the methods used to analyse and report outcome measures. This was a generally well-conducted review. The authors' cautious conclusions were supported by the results of the review and are likely to be reliable.
Implications of the review for practice and research
Practice: The authors stated that with further training for GPs, rapid access to hospital specialists and annual mammography, breast cancer follow-up might be feasible and cost-effective in primary care.
Research: The authors stated that further large RCTs that evaluated ideal hospital-based cancer follow-up in the primary care settings were needed. The studies should include robust psychosocial outcome measures and health-economic evaluations.
Cancer Research UK grant number C8350/A4543.
Lewis RA, Neal RD, Williams NH, France B, Hendry M, Russell D, Hughes DA, Russell I, Stuart NS, Weller D, Wilkinson C. Follow-up of cancer in primary care versus secondary care: systematic review. British Journal of General Practice 2009; 59(564): e234-e247
Subject indexing assigned by NLM
Ambulatory Care /economics /standards; Continuity of Patient Care /economics /standards; Cost-Benefit Analysis; Delivery of Health Care /organization & administration /standards; Family Practice /economics /standards; Humans; Neoplasms /economics /therapy; Patient Satisfaction; Primary Health Care /economics /standards; Randomized Controlled Trials as Topic
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.