ARTICLE
Auteur(s) : Nicolas
Penel1,2, François Valentin1, Sandrine
Giscard3, Luc Vanseymortier1, Régis
Beuscart2
1Département de cancérologie générale, Centre Oscar
Lambret, Lille
2Equipe d’accueil 2694: santé publique, épidémiologie et
modélisation des maladies chroniques, Université Lille II
3Cellule Qualité, Direction, Centre Oscar Lambret,
Lille
Nowadays, it is clearly demonstrated that optimal cancer treatment
is based on a multidisciplinary medical decision making in
conformity to evidence-based medicine reported under the clinical
practice guidelines [1]. The objective of guidelines development is
to assist physicians and patients in making optimal health care
decisions, which in turn should improve the quality of clinical
practice [2]. This process is usually realized into
specialized-team in hospital or in professional network. But, the
report of this decision making is a new opportunity of information
and communication with extra-hospital care-providers, especially
general practitioners (GPs).Good communication is a key feature of
the collaboration between GPs and cancer specialists. Information
from hospitals to the GPs is often delayed [3] and information in
the discharge letters may be inadequate or lacking [3, 4]. Several
studies indicate that replies to referrals and discharge letters
from specialists to GPs are insufficient in regard to both the
content and timing of information. This issue is often
underestimated by oncologists, as well as other specialists
[5-7].In consequence, we carried out a questionnaire-audit on the
GPs satisfaction with a structured report of medical decision
making by our regional multidisciplinary cancer committee.
Methods
Organisation of the multidisciplinary cancer committee
Since January 2001, we had organized weekly a multidisciplinary
cancer committee for all consecutive new cases (or cases with new
cancer event) of adult soft tissue sarcoma, melanoma or carcinoma
of unknown primary. The multidisciplinary cancer committee is based
at the Département de Cancérologie Générale, in Oscar Lambret
Cancer Centre, the Comprehensive Cancer Centre of Northern France
(Nord-Pas-de-Calais, 4 millions of inhabitants). The
multidisciplinary cancer committee includes at least one member of
each speciality: surgeon, medical oncologist, radiation oncologist,
pathologist and radiologist. The primary aim of this committee is
to establish the patient-centred optimal therapeutic strategy
according to validated practice guidelines: Standard Option and
Recommendations (SOR) of the Fédération Nationale des Centres de
Lutte Contre le Cancer [8-10].
After the multidisciplinary cancer committee, a structured
report of decision is written and validated by the responsible of
the committee (NP), included in the medical hospital file of each
patient, and sent to the extra-hospital different care-providers,
including GPs. This structured report includes: names of physicians
constituting the multidisciplinary cancer committee, date, short
summary of clinical status (previous co morbidities, evaluation of
general condition, location and size of the tumour, previous
treatment), TNM classification, precise histological diagnosis,
practice guidelines used for the decision making, possibility of
clinical trial (and short description of the clinical trial),
identification of the specialist in charge of patient and a short
conclusion.
Questionnaire-based audit
This questionnaire-based audit was carried out during the period
February 2006-April 2006 : 113 GPs, which had had
referred a patient in the last 18 months, had received a
questionnaire, with information letter and a copy of the structured
report concerning their own patient. This questionnaire was
constructed with the quality-manager of our hospital (SD) and
secondly validated and modified according to the point of view of a
representative panel of 6 GPs. The questionnaire includes 20
closed-ended questions, 3 open-ended questions and the possibility
to give some suggestions. The audit had begun on February 2006. The
responses were received until the 14 April 20066.
Patient selection
All consecutive structured reports for patients with new cancer or
new cancer event were considered for the audit. The cases with
benign tumours were excluded (3 cases). For patient with several
consecutive structured reports, only the first structured report
was taken into account.
Analysis
Concerning the closed-ended questions, the results are presented by
percentage with their 95% confidence intervals (CI95%). Content
analysis was used to analyse the responses to open-ended questions
and suggestions. This method is widely used in communication
research and is appropriate for analysing open-ended questions. The
method includes data reduction and transformation of data into a
form required for analysis [11, 12].
Results
Patient characteristics and response rate to the questionnaire
audit
110 structured reports concerning 110 different patients were
included. The patients suffered from soft tissue sarcoma (78
cases), melanoma (21 cases) or carcinoma of unknown primary
(11 cases). The medical decision was a curative-intent
strategy in 42 cases and a palliative strategy on 68 cases.
At the 14 April, 52 questionnaires were returned (47%, CI95% =
37,9-56,6).
Response to the closed-ended questions
In table 1( Table 1 ), the responses to
the closed-ended questions are presented.
Table 1 Answers to closed-ended questions
|
Question
|
Yes
|
No
|
Absence of answer
|
|
Are you interested in this report?
|
50/52
|
0
|
2/52
|
|
96% [91-100]
|
4% [0-9]
|
|
Do you get it within a reasonable delivery time?
|
38/52
|
13/52
|
1/52
|
|
73% [61-85]
|
25% [13-36]
|
2% [1–5]
|
|
Is the report clear enough?
|
47/52
|
4/52
|
1/52
|
|
90% [82-98]
|
8% [4-15]
|
2% [1-5]
|
|
Are you satisfied with the structure of the report?
|
48/52
|
3/52
|
1/52
|
|
92% [85-99]
|
6% [1-12]
|
2% [1-5]
|
|
Does the report meet your expectations?
|
41/52
|
7/52
|
4/52
|
|
79% [68-90]
|
13% [4-22]
|
8% [4-15]
|
|
Is the clinical description of the case complete enough?
|
44/52
|
6/52
|
2/52
|
|
84% [74-94]
|
12% [3-20]
|
4% [1-9]
|
|
Is the conclusion clear enough?
|
46/52
|
3/52
|
3/52
|
|
88% [79-97]
|
6% [0-12]
|
6% [0-12]
|
|
Is the treatment clearly described?
|
41/52
|
8/52
|
3/52
|
|
79% [68-89]
|
15% [5-25]
|
6% [0-12]
|
|
Is ay piece of information lacking in the report?
|
9/52
|
29/52
|
14/52
|
|
17% [7-27]
|
56% [42-69]
|
27% [15-39]
|
|
Do you know the disease described in the report?
|
44/52
|
6/52
|
2/52
|
|
84% [75-94]
|
12% [3-20]
|
4% [1-9]
|
|
Do you need any piece of information concerning this disease?
|
30/52
|
21/52
|
1/52
|
|
56% [44-71]
|
40% [27-53]
|
4% [1-9]
|
|
Is the knowledge of treatment strategy useful to you?
|
49/52
|
2/52
|
1/52
|
|
94% [88-100]
|
4% [1-9]
|
4% [1-9]
|
|
Do you need any piece of information concerning the treatment
strategy?
|
18/52
|
26/52
|
8/52
|
|
34% [21-47]
|
50% [36-63]
|
16% [5-25]
|
|
Did the patient consult you immediately after the multidisciplinary
cancer committee?
|
42/52
|
9/52
|
1/52
|
|
81% [70-91]
|
17% [7-27]
|
4% [1-9]
|
|
|
|
|
|
Is the prognosis clearly stated?
|
31/52
|
20/52
|
1/52
|
|
60% [46-72]
|
38% [25-51]
|
4% [1-9]
|
|
Is it difficult to transcribe the decision to the patient?
|
19/52
|
29/52
|
4/52
|
|
36% [24-48]
|
56% [42-69]
|
8% [4-15]
|
|
Do you have enough pieces of information to answer any question
from your patient?
|
33/52
|
16/52
|
3/52
|
|
64% [50-76]
|
30% [18-43]
|
6% [0-12]
|
|
Does the patient consult you regularly during the treatment?
|
44/52
|
6/52
|
2/52
|
|
84% [75-94]
|
12% [3-20]
|
4% [1-9]
|
|
Do you wish to participate to this multidisciplinary committee?
|
10/52
|
41/52
|
1/52
|
|
19% [8-30]
|
79% [67-89]
|
4% [1-9]
|
|
Do you think it is necessary to improve the communication between
the patient, the GPs and the cancer specialists?
|
29/52
|
15/52
|
8/52
|
|
56% [42-69]
|
29% [16-41]
|
14% [5-25]
|
Response to the 3 open-ended questions
Is any piece of information missing? If yes, which one?
Nine GPs (17%) answered that a piece of information is missing.
Those missing pieces of information were:
- – side-effects of treatment, especially side-effects of
chemotherapy (5 cases) ;
- – clear statement of disease prognosis
(3 cases) ;
- – clear global information, the report seems to be too
technical (1 case).
Do you need any piece of information concerning the treatment
strategy? If yes, which one?
Eighteen GPs (34%) answered that a piece of information is
missing concerning treatment strategy. 13 out of 18 GPs had
described those elements:
- – side-effects of treatment, especially side-effects of
chemotherapy (11 cases) ;
- – follow-up strategy (1 case) ;
- – patient knowledge concerning the severity of illness
(1 case).
- Do you wish to participate to this multidisciplinary committee?
If yes, how could you participate to it?
Ten GPs (18%) wish participate to multidisciplinary cancer
committee. 7 out of 10 had given the mean:
- – phone in 5 cases
- – e-mail in 1 case
- – video-conference in 1 case.
Four GPs had written that they could not participate because of
lack of time.
Suggestions
At the end of the questionnaire, the GPs could give some
suggestions : 10 out of 52 (18%) had given some suggestions:
- – carry on evaluating and ameliorating the structured
report (3 cases) ;
- – send more rapidly the structured report during the
clinical pathway (3 cases) ;
- – accompany the structured report by a phone call
(2 cases) ;
- – accompany the structured report by a summarize of
practice guidelines used (2 cases).
Discussion
We carried out a questionnaire-based audit on satisfaction of GPs
concerning a structured report on multidisciplinary medical
decision for cancer patients. The response rate of the audit is
52%. For most points, the GPs are satisfied of the information
given by the structured report. The estimated global satisfaction
of the information given was 79% (CI95% = 68-89). Few GPs wish
participate to multidisciplinary cancer committee. The patient
consults frequently the GPs immediately after the multidisciplinary
cancer committee. The amelioration axes are possibly: access to a
short summary of clinical practice guidelines (for example, by an
internet site), send an accompanying letter summarising main
chemotherapy-side-effects and propositions of treatment of those
toxicities, send more rapidly the structured report during the
clinical pathway.
There are several limitations to this audit. First, this audit
was realized in a comprehensive cancer centre in Northern France
and our results may not be directly applicable to other areas in
France or abroad. For example, in our area the number of
physicians, especially cancer specialists, is very weak and the GP
is the main care-provider of cancer patients. Moreover, this audit
is based on relatively rare cancers treated in very specialized
structure. The same audit conducted for patients with breast, lung
or colon cancers possibly give different results.
The role of GPs in the care of cancer patients during treatment
and follow-up periods is well-establish. The fact that GPs are
involvement in the diagnosis of a large proportion of cancer has
been amply documented [13], and their role in palliative care has
been demonstrated [14]. Many cancer patients want to have a single
care provider to support and counsel them. The GP is the obvious
person to assume this role, because most of patients with cancer
are treated as outpatient and may feel left alone in some crucial
moments [11, 15]. Nevertheless, the communication between
specialists and GPs remains unsatisfactory. For example, a
suggested obstacle is a perceived inferiority among GPs and a sense
of not being recognized by specialists as peers in the management
of cancer patients [16], despite the well recognized importance of
continuous psychosocial support from a GP throughout the course of
the disease [16-18]. A new approach (shared programs), particularly
developed in United-Kingdom, try to ameliorate those relations. The
shared programs improve the inter-sectoral communication by a
cooperative approach, where professionally or organisationally
separated care providers assume joint responsibility for patient
treatment and care. The experience concerning shared care program
is increasing in several medical areas: diabetes, hypertension,
asthma and rarely cancers [17, 19, 20]. The key-point of shared
program is the knowledge transfer of competence through hospital to
GPs, by an excellent inter-communication [17, 18]. In oncology, few
interventions had investigated the mean of communication
amelioration [19, 20].
Moreover, a Canadian study had clearly shown that GPs consider
written communication alone as inadequate. GPs require a
face-to-face and/or telephone communication with the cancer
specialist to negotiate their respective roles, and to discuss the
patient’s prognosis and the effectiveness of proposed treatment
[18].
To conclude, the communication between GPs and cancer
specialists appears a key-point of cancer patient treatment and
follow-up. The structured report of a multidisciplinary cancer
committee is a new opportunity to ameliorate this communication.
Our first audit suggests several amelioration axes. We plan to
implement and evaluate those modifications in future audits.
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