University of Groningen The role of the general practitioner in the care for patients with colorectal cancer Brandenbarg, Daan

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The role of the general practitioner in the care for patients with colorectal cancer

Brandenbarg, Daan

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2018

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Brandenbarg, D. (2018). The role of the general practitioner in the care for patients with colorectal cancer.

Rijksuniversiteit Groningen.

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Summary

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1 Summary

This thesis describes the role of Dutch general practitioners (GPs) during all phases of care for colorectal cancer (CRC): early diagnosis, care during treatment and follow-up for CRC, and care for long term health problems. The role of the GP was described using the longitudinal primary care registry database of the Registration Network Groningen (RNG), including the electronic patient records of participating GPs. Perspectives of patients concerning follow-up care and the role of the GP during treatment and follow-up for CRC were also included by a review of available literature and a qualitative analysis of interviews among patients. The available evidence for effective strategies to reduce fatigue, a major long term health problem for survivors of CRC, was systematically reviewed.

In Chapter 2 we presented the results of a multi methods study consisting of a quantitative analysis of health care use and qualitative content analysis of electronic patient records. We compared health care use of patients in the year prior to referral for a CRC diagnosis with health care use of age, gender, and GP matched controls. In addition, we qualitatively explored the diagnostic trajectory of a purposive sample of patients with CRC. Patients diagnosed with CRC had more face-to-face consultations and medication prescriptions in general practice in the year prior to their referral compared to controls. The largest differences were found for ICPC chapters D (digestive), L (musculoskeletal), and R (respiratory). Multiple consultations coded as ICPC D were more frequently observed for patient with CRC: 46% had 2 or more contacts for gastro-intestinal reasons in the year before referral, compared to only 12.2% of controls. The qualitative analysis of the electronic patient records showed that CRC patients presented a variety of complaints in the abdominal and pelvic region, such as stomach complaints/vomiting, flatulence, bloating, rumbling in the abdominal area, and back pain. General complaints such as fatigue or feeling ill were also frequently observed.

Our qualitative analysis suggested that missed diagnostic opportunities appeared during the diagnostic trajectory. These can be related to patient factors. Some patients appeared to wait long before mentioning symptoms or had been put at ease after symptoms temporarily diminished. Similarly, doctor factors could also contribute to missed diagnostic opportunities such as GPs attributing symptoms to co-morbid conditions, medication use, the explanation of their patient about their symptoms, or because they stuck to an initial diagnosis. In other cases, improvements in the diagnostic process within general practice were not possible, mainly because the GP appeared to act swiftly on alarm symptoms.

In Chapter 3 we compared health care use of patients in the first year after referral for curative treatment for CRC with age, gender, and GP matched controls. We analyzed face-to-face contacts, prescribed medication, and referrals. Patients treated for CRC showed more face-to-face consultations, medication prescriptions, and referrals in this period, both compared to controls and to their healthcare use prior to treatment. Contacts appeared to be related to side effects of treatment, such as anemia, abdominal pain, constipation, skin problems and urinary infections. Also, GPs prescribed more medication for these problems. These results suggest the GP is involved in the treatment of side-effects of curative treatment for CRC. Moreover, GPs prescribed more

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psycholeptics, mostly related to anxiety and sleep disorders, suggesting that the GP provided psychological support in the period after referral for CRC.

In Chapter 4 we compared health care use between survivors of CRC and age, gender, and GP matched controls during the follow-up period, which we defined as the period one year after treatment to six years after treatment. Patients showed significantly more face-to-face contacts in the 2nd_{, 3}rd_{and 6}th_{year after diagnosis, were prescribed more drugs in the 2}nd_{, 3}rd_{and 6}th_year

after diagnosis and had more referrals in the 2nd_{and 5}th_{year after diagnosis. This suggests that}

involvement of the GP was higher during the initial years of follow-up, decreased over time and rose again during the end of hospital follow-up. For the entire study-period (2−6 years after diagnosis) significantly more patients contacted their GP for digestive reasons (e.g. constipation). Contacts coded as psychological (e.g. sleep disturbance), general and unspecified (e.g. tiredness and adverse drug effects), and blood or blood forming organs (e.g. anemia), were significantly more frequent in CRC patients. Contacts for Neurological, Urological, Musculoskeletal and Cardiovascular reasons differed between patients and controls only in the 2nd_{and/or 3}rd_{year after}

diagnosis. During the entire study period, significantly more patients were prescribed medication for the nervous system, mainly analgesics and psycholeptics (especially benzodiazepines). In the 2nd_{to 5}th_{year after diagnosis drugs for the alimentary tract (e.g. laxatives) were prescribed to a}

greater percentage of patients. Drugs for the blood and bloodforming organs (e.g. antianemic preparations) were prescribed to significantly more patients in the 2nd_{to 4}th_{year after diagnosis.}

These results suggest involvement of the GP during the follow-up period after CRC for health problems possibly related to (late) side effects of CRC treatment and for psychological problems.

From a review of the available literature among survivors of all types of cancer it appeared that patients want intensive follow-up which comprises a lot of testing (Chapter 5). Patients believe that at follow-up visits recurrences will be detected. But maybe more important, patients would like to get the reassurance that they have no recurrences. Also, they expect that during follow-up visits, relevant information and advices on (long term) side effects, prognosis, prevention, and lifestyle, will be addressed. Psychosocial support should also be an important aspect of follow-up care according to patients. Consistency of care as well as continuity of care is very important. The lifetime increased risk for cancer recurrences makes patients vulnerable, resulting in a desire for long and intensive follow-up periods.

Experiences and views of CRC patients about their GPs’ role during treatment and follow-up care are presented in Chapter 6. Patients seemed to perceive a role for the GP directly after initial treatment related to clarification of medical issues, lifestyle advice, and care for treatment-related side effects. In some cases the GP was even more involved, mediating a switch in chemotherapy in order to reduce side-effects of this treatment. Over the years, during follow-up the role of the GP seemed to return to normal, providing routine health care, and managing co-morbidities. In some cases the GP kept being involved in cancer related care, providing psychosocial support for both patients and family members. Concerning the organization of future follow-up care, most patients expressed a clear preference for specialist-led services, whereas some said that primary care-led care would be more accessible and less expensive, and therefore might be a realistic option.

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Summary

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1

In Chapter 7 we systematically reviewed the evidence available for the effectiveness of post treatment physical activity on fatigue in survivors of CRC. We observed no significant combined effect of physical activity on fatigue levels, nor a clinically relevant effect, from randomized controlled trials. Observational studies in this review seemed to suggest that increased levels of physical activity were associated with lower fatigue levels. Since patients studied in the randomized controlled trials were not fatigued at baseline, studies were not powered for differences in fatigue. Besides, interventions had substantial dropouts, were relatively short, or based in secondary care. Definitive conclusions about effective physical activity programs to reduce fatigue for patients with CRC in primary care cannot yet be convincingly drawn.

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