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Assessment of the interest of the geriatric oncology consultation among French general practitioners
J O U RN A L OF GE RI A TR IC O N CO LOG Y 7 ( 20 1 6 ) 4 7 –52
Available online at www.sciencedirect.com
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Assessment of the interest of the geriatric oncology consultation among French general practitioners Claire Charbonniera,1 , Sophie Mariliera,1 , Sandrine Dabakuyob , Adèle Cueff b , Valérie Quipourta , Patrick Manckoundiaa,c,⁎ a
Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France Côte d’Or Breast and Gynaecological Cancer Registry, Centre George François Leclerc, 1 rue du Professeur Marion, BP 77980, Dijon Cedex, France c Inserm/U1093 Cognition, Action and Sensorimotor Plasticity, University of Burgundy Franche-Comté, Dijon, France b
AR TIC LE I N FO
ABS TR ACT
Article history:
Objective: We assessed the interest of the geriatric oncology (GO) consultation (GOC) among
Received 25 June 2015
general practitioners (GPs).
Received in revised form
Materials and Methods: We conducted a survey among GPs whose patients had had a GOC in
14 September 2015
2012. A questionnaire was sent to GPs. The 1st part collected GPs' characteristics including
Accepted 14 October 2015
medical education in geriatrics and GO, and knowledge of GOC. The following parts
Available online 26 October 2015
concerned the GOC and included the cancer type, GOC report and care plan. Results: One-hundred twenty-six questionnaires corresponding to 94 GPs were collected.
Keywords:
Concerning the GPs' characteristics, age range 50–59 (44.7%), men (62.8%) and urban practice
Elderly patients
(79.8%) were the most represented, 80.8% had no expertise in geriatrics, 60.6% knew of the
General practitioners
existence of GOCs, and 14.9% had received medical education in GO. The most frequent
Geriatric oncology consultation
cancer location was gynecological (40.7%) (82.6% were breast cancers). Of the GPs, 69.8% had received a GOC report and 92% were (very) satisfied with the delivery time. A care plan was proposed after the GOC in 83% of cases. It was satisfactory in 96.4% of cases, and applied by 74.7% of GPs. Sixteen percent of GPs were called by the GO team. The less the GP was satisfied with the GOC, the more he or she wanted phone contact (p = 0.02); 94% of GPs considered the GOC (very) satisfactory. Sixty-seven percent of GPs wanted to be trained in GO. Conclusion: Very few GPs had been trained in geriatrics and/or GO. They were mostly satisfied with GOC and expressed a wish to be trained in GO. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction In parallel with the aging of world population, the incidence of cancer in the elderly will increase; over 30% of cancers occur in people aged 75 and over.1 Thus, geriatric oncology
(GO), which came into being in the late 1980s under the leadership of Balducci and Monfardini, is a medical discipline that brings together geriatrics and oncology.2–5 It is a global approach to the management of elderly patients suffering from cancer with the aim to offer them the most appropriate
⁎ Corresponding author at: Service de Médecine Interne Gériatrie, Hôpital de Champmaillot CHU BP 87 909, 2, rue Jules Violle, F21079 Dijon Cedex, France. Tel.: +333 80 29 39 70; fax: +333 80 29 36 21. E-mail address: [email protected] (P. Manckoundia). 1 Because of each of these authors contributed equally, all should be considered first authors.
http://dx.doi.org/10.1016/j.jgo.2015.10.184 1879-4068/© 2015 Elsevier Ltd. All rights reserved.
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JO U RN A L OF GE RI A TR IC O N COL O G Y 7 (2 0 1 6 ) 4 7 –5 2
therapeutic strategy, so as to improve their health and quality of life.6,7 In France, in 2003, the fight against cancer and the management of elderly people became health priorities. Thus, the establishment of GO results from a request from the National Cancer Institute (Institut National du Cancer: INCA, created in 2004) and the authority responsible for providing care (Direction Générale de l’Offre de Soins: DGOS) in 3 successive cancer plans: 2003–2009, 2009–2013 and 2014–2019. The objective of this INCA initiative was to improve the management of elderly people with cancer by reinforcing clinical research targeting this population.4 This led to the creation of GO Coordination Units in 2011, including the GO Coordination Unit of Burgundy (GOCUB). These units replaced pilot units created in 2006. The main objective of GO Coordination Units is to improve the management of elderly people suffering from cancer by fostering cooperative decisions between oncologists and/or organ specialists and/or surgeons and/or radiotherapists on the one hand and geriatricians on the other hand. In this system, the role of general practitioners (GP), who are automatically informed of all therapeutic proposals and decisions by letter or email or phone calls from the different specialists, remains crucial in the coordination of patient care. In addition to improving the quality of care provided to patients aged 75 and over with cancer, and developing a clinical research program, the GOCUB promotes education on GO. We thus conducted a survey among French GPs to evaluate their opinions regarding the GO consultation (GOC) proposed by the GOCUB. The GOC is conducted by a geriatrician trained in GO in order to assess elderly patients with cancer before oncological management.
2. Method 2.1. Population In June 2013, a questionnaire validated by the scientific committee of the GOCUB was sent to all GPs for whom one or several patients aged 75 and more had had a GOC between January 1st and December 31st 2012, in the GOCUB context. A follow-up phone call was made in July 2013 to improve the response rate. Elderly people suffering from cancer are referred for a GOC (conducted by the geriatrician) by the oncologist, radiotherapist, surgeon or organ specialist before the oncological treatment is started. The aim is to finalize therapeutic decisions in the management of this specific population. The GOC took place in either a geriatrics day hospital, or the Anticancer Centre, or within the framework of the mobile GO unit in the departments of our university hospital or in private practice. The GOC should lead to a personalized care plan sent to all physicians involved in the management of the patient, including GPs. General practitioners who followed several patients received one questionnaire for each patient. Because this was an observational survey among voluntary GPs, with no modification in the usual management of patients, no written consent of the participants (GP) was necessary. In addition, the Ethics Committee of our institution was
consulted; however, its approval was not necessary for the same reasons.
2.2. Recorded Data The questionnaire consisted of 21 questions, either binary choice (yes/no) or multiple choice questions, and was divided into 3 parts: – The first part concerned the GPs: 1) identification of the GP; 2) age range: 30–39, 40–49, 50–59, and ≥ 60 years; 3) type of practice: urban or rural; 4) geriatric education: skills in GO, university diploma or diploma in complementary specialized studies; 5) knowledge of the existence of a GOC; 6) continuing medical education (CME) in GO; and 7) referral or not to the specialist during the management of cancer in a subject aged 75 and over. Indeed, in France, there are several levels of training in GO for GPs, in particular, ranging from simple awareness courses to a formal qualification. – The 2nd part concerned the result of the GOC: 8) type of cancer managed; 9 to 12) GOC report: received or not by the GP, delivery time, reading the report in full and impact on the management of the patient; 13 to 16) care plan: proposed or not by the specialist in GO, GP's satisfaction or not with the care plan proposed, application or not of care plan by the GP, reasons for not applying of the care plan (several reasons were possible for each patient); 17) phone contact with the GO team during the GOC in order to discuss patients' files directly with the GOC team. The care plan proposed recommendations to GPs for the management of their elderly patients with cancer. These included therapeutic modifications, physiotherapy and nutrition management, for example. – The last part concerned the synthesis of the GOC: 18) level of GP's satisfaction with the GOC as a whole; 19 to 20) wish for a future GOC or collaboration with the GO team, and 21) wish for training in GO. We chose to distinguish between “satisfaction with the care plan proposed” and “satisfaction with the GOC as a whole”, as GPs could be satisfied with the GOC as a whole, but not completely satisfied with the care plan established at the end of the GOC, or vice versa.
2.3. Data Analysis First, the population of responder GPs was compared with the non-responder GPs concerning sex, type of practice and cancer location, in order to ensure the absence of bias linked to non-response. Then, the characteristics of the responder GP population were described and analyzed.
2.4. Statistical Analysis Qualitative variables were described as numbers (N) and percentages. Statistical analyses were performed using the chi-square test or Fisher's exact test. Results were considered statistically significant for p < 0.05. Statistical analyses were performed using Stata software (version 11).
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J O U RN A L OF GE RI A TR IC O N CO LOG Y 7 ( 20 1 6 ) 4 7 –52
Table 2 – Knowledge consultation.
3. Results
Knowledge of GOC
3.1. Number of Questionnaires Analyzed A total of 287 patients had a GOC in 2012, but the names of 3 GPs were not recorded. Thus, 284 questionnaires were sent to 218 different GPs. We received 133 questionnaires from 99 GPs, representing an initial response rate of 46.8%. Among these 133 questionnaires, 126, corresponding to 94 GPs, were exploitable. Indeed, 4 corresponded to 3 GPs who no longer followed the patient and 3 questionnaires corresponded to 2 GPs who had died. Finally, the response rate was 44.4%.
3.2. Comparison of Responder and Non-responder General Practitioners The comparison between responder GPs, whose questionnaires were exploitable (94), and non-responder GPs (119) revealed no significant difference for sex (p = 0.14), type of practice (urban vs. rural) (p = 0.63) or the cancer type (gynecological, digestive or other) (p = 0.80). The comparison regarding the age was not possible because this information was unavailable for non-responder GPs.
3.3. Description of Responder General Practitioners This description concerns 126 questionnaires from 94 GPs. Table 1 shows the characteristics of responder GPs. The age range of 50–59 was the most represented with 42 GPs, i.e. 44.7%. No GP was aged below 30. Of the responder GPs, 59 (62.8%) were men and 35 (37.2%) women, and 79.8% (75) worked in an urban environment. A total of 76 GPs (80.8%) had no particular skills in geriatrics, and 57 GPs (60.6%) knew about the existence of a GOC. Only 14 GPs (14.9%) had been
Table 1 – Characteristics practitioners.
of
Variable Age range (years)
Type of practice Geriatric education
Knowledge of GOC GO CME
Referral to specialist
responder N = 94
<30 30–39 40–49 50–59 >60 Urban Rural Yes No Missing data Yes No Yes No Missing data Never Sometimes Often Always
0 10 16 42 26 75 19 17 76 1 57 37 14 79 1 1 4 14 75
general % 0 10.6 17 44.7 27.7 79.8 20.2 18.1 80.8 1.1 60.6 39.4 14.9 84 1.1 1.1 4.2 14.9 79.8
N: number; GO: geriatric oncology; GOC: GO consultation; CME: continuing medical education.
Age range (years)
Type of practice
<30 30–39 40–49 50–59 >60 Total Urban Rural Total
of
the
geriatric
Yes N (%)
No N (%)
0 8 (14) 23 (40.4) 17 (29.8) 9 (15.8) 57 (100) 46 (82.1) 10 (17.9) 56 (100)
0 8 (21.6) 19 (51.4) 9 (24.3) 1 (2.7) 37 (100) 29 (76.3) 9 (23.7) 38 (100)
Total N (%) 0 16 42 26 10 94 75 19 94
oncology p (Fischer test) 0.15
(17) (44.7) (27.7) (10.6) (100) (79.8) (20.2) (100)
0.6
GOC: geriatric oncology consultation; N: number.
trained in GO. Finally, 75 GPs (79.8%) systematically referred elderly patients with cancer to an organ specialist. As concerns knowledge of the GOC, there was no significant difference for age (p = 0.15) and the type of practice (p = 0.6) among responder GPs (Table 2). The most frequent cancer locations were gynecological, which concerned 40.7% of GOC; among these 82.6% were breast cancer. The second leading cancer was digestive cancers in 24.8% of cases, including 57.2% colon-rectum, 25% gastric, 10.7% pancreatic and 7.1% esophageal cancers. Other cancers were lung neoplasia (3.7%), hematological cancers (3.7%), prostate cancer (2.6%), renal neoplasia (2.6%), urinary bladder cancer (2.1%), ear, nose and throat cancer (1.1%), and thyroid cancer (0.5%). Concerning the GOC report, 69.8% of GPs (88) declared they had received it. Among these, 92% (81) were (very) satisfied regarding the delivery time, and 94.3% (83) had read it in full. The main reason for not reading the whole GOC report mentioned by the GPs was its length for 3 of 5 GPs. Finally, among the 88 patients for whom GPs said they had received the GOC report, the report had affected the management of 63 patients. A care plan resulting from the GOC was proposed in 83 cases (Table 3); the response was missing in 29 of 126 cases. The GPs were satisfied with the care plan in 96.4% of cases. This care plan was applied by GPs in 74.7% of cases (62). The main reasons for not applying the care plan (22.9% of cases, N = 19) were death or loss of contact with the patient in 11 cases and the lack of a specialist doctor in 2 cases. There was no significant relationship between the application of the care plan proposed after the GOC and the GP's type of practice (p = 1.00) on the one hand, or the cancer type (p = 1.00) on the other hand. As concerns the phone contact, in 20 cases (16%), GPs were called by a member of the GO team. Among the 91 cases (72.2%) for which GPs had not received a phone call, they would have liked to have been called in 34 cases. There was no significant relationship between the desire or not to have phone contact and the cancer location (p = 0.52). However, there was a significant relationship between the desire or not to have phone contact and satisfaction with the GOC as a whole: the less the GP was satisfied, the more he or she wanted phone contact (p = 0.02) (Table 4).
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Table 3 – Care plan proposed by the geriatrician after the geriatric oncology consultation. Responses of general practitioners to the 126 questionnaires. Variable Care plan proposed by geriatrician
GPs' satisfaction with the care plan among the 83 positive responders Application of care plan by GPs among the 83 positive responders Limiting factor(s) when care plan not applied (N = 19)
Too many recommendations Lack of a specialist physician Patient's death or loss of contact
Response
N (%)
Yes No Not precise ⁎ Yes No Not precise ⁎ Yes No Not precise ⁎ Yes No Yes No Yes No
83 (65.9) 14 (11.1) 29 (23) 80 (96.4) 2 (2.4) 1 (1.2) 62 (74.7) 19 (22.9) 2 (2.4) 0 (0) 19 (100) 2 (10.5) 17 (89.5) 11 (57.9) 8 (42.1)
N: number; GP: general practitioner. ⁎ Lack of precision concerning the existence or not of a care plan proposal, or satisfaction level regarding it, or its application by GP.
Among the 87 (of 126) cases for which there was an overall assessment of the GOC, in 82 cases, the GPs considered the GOC very satisfactory (39) or good (43), while for 5 cases, the GP reported that the GOC was of little help or unsatisfactory. There was no relationship between GPs' overall level of satisfaction with the GOC and their knowledge of GO (p = 0.58) (Table 5). In 100 of the 108 questionnaires in which this item was answered, GPs wanted a future GOC. The GPs who did not want a future GOC significantly corresponded to those who had not received a report after the GOC (p = 0.001). Indeed, in 97.6% of the cases for which the GP had received a GOC report, the GP expressed the wish to have a GOC in the future, while the rate was 75% for cases in which the GP had not received a GOC report. No difference was noted for age range (p = 0.94) or the GP's type of practice regarding the desire or not to have a GOC in the future (p = 0.34).
Table 4 – Wish for phone contact among the general practitioners not called. Wish for phone contact
Cancer location
Gynecological Digestive Other Not precise ⁎ Total Satisfaction None or little with the GOC Good/Very good Not precise ⁎ Total
Yes N (%)
No N (%)
12 (35.3) 8 (23.5) 10 (29.4) 4 (11.8) 34 (100) 4 (11.8) 20 (58.8)
23 (51.1) 9 (20) 11 (24.4) 2 (4.5) 45 (100) 0 (0) 36 (80)
10 (29.4) 9 (20) 34 (100) 45 (100)
Total N (%)
p (Fisher test)
35 (44.3) 0.52 17 (21.5) 21 (26.6) 6 (7.6) 79 (100) 4 (5.1) 0.02 56 (70.9) 19 (24) 79 (100)
N: number; GOC: geriatric oncology consultation. ⁎ Lack of precision concerning cancer location or satisfaction level regarding the GOC.
Table 5 – Global level of satisfaction among general practitioners according to the knowledge of GO. Satisfaction level Knowledge of GO
Yes No Total
Very good/Good N (%)
Little/No N (%)
41 (71.9) 16 (28.1) 57 (100)
4 (80) 1 (20) 5 (100)
Total N (%) 45 (72.6) 17 (27.4) 62 (100)
P (Fisher test) 0.58
N: number; GO: geriatric oncology.
Finally, as concerns training in GO, 60 of the 89 GPs who responded to this item (67.4%) wanted to benefit from training in GO.
4. Discussion The objective of our study was to assess the interest of GOC for GPs. To our knowledge, very few studies have been published in the international literature on this subject, hence the originality of our paper.8 The response rate (44.4%) of GPs in our study was satisfactory and comparable with those for most surveys of this type. Indeed, this response rate is similar to that found in the study by Kurtz et al. (46.9%),8 and better than the mean response rate reported in the literature for this kind of study.9 We regret the fact that the chase-up phone call (following our paper questionnaire) did not improve the response rate among GPs.10 Responder and non-responder GPs were similar concerning their sex, type of practice and the location of the cancer in their patients. However, it was not possible to compare GPs with regard to age because this information was unavailable for non-responder GPs. The typical profile of a responder GP is a man, aged 55 years, working in an urban environment. Only 20% of the GPs had particular skills in geriatrics and only 15% had been trained in GO. This low rate of training in geriatrics is out of step with the current reality of the aging population.1 Our study showed that the majority (4/5) of responder GPs systematically referred elderly patients with cancer to an organ specialist. Thus, the patient's age, unlike the patient's refusal or the presence of several comorbidities, did not appear to be a barrier to such referrals. Our result is in accordance with studies conducted in Alsace (France),8 Aquitaine (France)11 or Canada.12 However, contradictory results have been reported, as in the meta-analysis of Delva et al., in which chronological age was the main barrier to referring patients to an organ specialist.13 In this study, whereas breast cancer was the most represented cancer, prostate cancer was surprisingly underrepresented. We believe that is due to recruitment bias. Indeed, the Urology Department of our network, which receives most of the patients, especially elderly patients, suffering from prostate cancer, rarely referred patients for a GOC at the time of this study. As concerns the GOC report, 30% of GPs reported that they had not received one. This relatively high rate can be in part explained by the fact that some GOC took place while patients
J O U RN A L OF GE RI A TR IC O N CO LOG Y 7 ( 20 1 6 ) 4 7 –52
were in hospital and did not result in a specific report for the GP because the result was filed in the patient's hospital record and not necessarily sent to the GP. An improvement in this area is necessary because communication between practitioners is a major criterion for quality care. This important aspect is underlined in French, Scandinavian, English and American Studies.14–17 Furthermore, in our study, almost all GPs read the GOC report in its entirety. These results are encouraging because they demonstrate the confidence that GPs have in the GOC. This confidence is underlined by the fact that almost all GPs were satisfied with the care plan proposed after the GOC, and ¾ of GPs applied it. This rate would have been higher without the loss of contact with and death or hospitalization of patients. Our result concerning satisfaction with the care plan is comparable to that in the study of Dagada et al., conducted in Aquitaine, which showed that 94% of GPs considered the information provided satisfactory.18 The main factors limiting the application of the recommendations mentioned in other studies are the excess of recommendations, the difficulties in applying them and the lack of a specialist doctor to whom patients could be referred. To our surprise, no difference was noted between GPs according to their type of practice (urban vs. rural) with regard to the application of the proposed care plan. Indeed, we would have thought that GPs with a rural practice would find it more difficult to implement certain measures of the proposed care plan, in view of the medical and paramedical “desertification” of most rural areas in France. Few GPs (16%) were called by a member of the GO team to discuss patients' files directly, though 37.4% of GPs not called would have liked to have taken part in the discussion. In France, the sharing of medical information is a real public health preoccupation, and is thus included among the measures of the national cancer plan. The mutual oncology file could be part of a strategy to foster information sharing, but it is still far from being implemented in real life. Among the responder GPs, 66% wanted to receive training in GO to improve their knowledge. The need for training is also stressed in other surveys. In the study conducted in Alsace (France), 56.3% of GPs said that they needed CME in GO.8 In the study carried out in Champagne Ardennes (France), most GPs wanted CME in GO.14 In France, the wish to create specific courses in GO during the medical studies seems to be an interesting way to meet this need. One bias of this study is its geographical distribution. Indeed, the GPs surveyed were those in Burgundy and some of the neighboring areas. They are therefore probably not representative of French GPs in general. However, the aim of this study was to assess the feelings of GPs relative to the GOC proposed by GOCUB, which has a regional dimension. The overall assessment of GOCUB activity since its establishment shows that all of the specialties confronted with cancer in the elderly are becoming increasingly aware of the GOCUB and thus the number of referrals is growing. The annual number of assessments of elderly people suffering from cancer performed in the context of GOC has almost quadrupled in 8 years of existence. In addition, the GOCUB has also initiated research projects and participates in many collaborative studies involving various GO coordination units. Finally, the GOCUB has implemented several training programs and a major annual seminar
51
for physicians, including GPs and/or caregivers. In the future, in order to constantly improve the management of elderly patients with cancer, the GOCUB intends to propose: 1) to GPs, the follow-up of patients, which will be either clinical or by phone, and 2) the establishment of multidisciplinary meetings devoted to examining the files of elderly patients with cancer. These will be extended to all Burgundy hospitals through video conferencing; and 3) the elaboration of a secure email system allowing physicians, including GPs involved in the management of these patients, to access their medical information in real time. In pedagogical terms, the GOCUB will reinforce CME cycles on GO throughout Burgundy. Finally, the GOCUB wishes to foster the introduction of a GO module in the 2nd cycle of medical studies in France. However, this decision requires a reform by the Ministry of Higher Education. To conclude, this study, concerning the activity of the GOCUB, had an original purpose, to assess the interest and feelings of GPs with regard to the GOC. Indeed, in addition to oncologists and GOC, GPs play a central role in the management and follow-up of elderly patients with cancer, as highlighted in the last cancer plan (2014–2019), deployed by the French authorities. Our results show that GPs are mostly satisfied with the GOC and do not seem to have any major difficulties in applying the care plan proposed after the GOC. The main obstacle to overcome is still communication with the geriatricians who perform the GOC, which is considered relatively insufficient by GPs. This was illustrated by the lack of a GOC report in some cases. This may weaken the concept of shared care, which aims to improve the management of these patients. This study also highlighted the fact that GPs expressed a wish for CME in the management of elderly patients with cancer.
Disclosures and Conflict of Interest Statements The authors have no conflicts of interest to disclose.
Author Contributions Study concepts: C. Charbonnier, S. Marilier, V. Quipourt. Study design: C. Charbonnier, S. Marilier. Data acquisition: C. Charbonnier. Quality control of data and algorithms: S. Dabakuyo, A. Cueff, V. Quipourt, P. Manckoundia. Data analysis and interpretation: C. Charbonnier, S. Marilier, P. Manckoundia. Statistical analysis: S. Dabakuyo, A. Cueff. Manuscript preparation: C. Charbonnier, S. Marilier, P. Manckoundia. Manuscript editing: C. Charbonnier, S. Marilier, P. Manckoundia. Manuscript review: C. Charbonnier, S. Marilier, V. Quipourt, P. Manckoundia.
Acknowledgments The authors are grateful to Mr. Philip Bastable.
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Assessment of the interest of the geriatric oncology consultation among French general practitioners Claire Charbonniera,1 , Sophie Mariliera,1 , Sandrine Dabakuyob , Adèle Cueff b , Valérie Quipourta , Patrick Manckoundiaa,c,⁎ a
Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France Côte d’Or Breast and Gynaecological Cancer Registry, Centre George François Leclerc, 1 rue du Professeur Marion, BP 77980, Dijon Cedex, France c Inserm/U1093 Cognition, Action and Sensorimotor Plasticity, University of Burgundy Franche-Comté, Dijon, France b
AR TIC LE I N FO
ABS TR ACT
Article history:
Objective: We assessed the interest of the geriatric oncology (GO) consultation (GOC) among
Received 25 June 2015
general practitioners (GPs).
Received in revised form
Materials and Methods: We conducted a survey among GPs whose patients had had a GOC in
14 September 2015
2012. A questionnaire was sent to GPs. The 1st part collected GPs' characteristics including
Accepted 14 October 2015
medical education in geriatrics and GO, and knowledge of GOC. The following parts
Available online 26 October 2015
concerned the GOC and included the cancer type, GOC report and care plan. Results: One-hundred twenty-six questionnaires corresponding to 94 GPs were collected.
Keywords:
Concerning the GPs' characteristics, age range 50–59 (44.7%), men (62.8%) and urban practice
Elderly patients
(79.8%) were the most represented, 80.8% had no expertise in geriatrics, 60.6% knew of the
General practitioners
existence of GOCs, and 14.9% had received medical education in GO. The most frequent
Geriatric oncology consultation
cancer location was gynecological (40.7%) (82.6% were breast cancers). Of the GPs, 69.8% had received a GOC report and 92% were (very) satisfied with the delivery time. A care plan was proposed after the GOC in 83% of cases. It was satisfactory in 96.4% of cases, and applied by 74.7% of GPs. Sixteen percent of GPs were called by the GO team. The less the GP was satisfied with the GOC, the more he or she wanted phone contact (p = 0.02); 94% of GPs considered the GOC (very) satisfactory. Sixty-seven percent of GPs wanted to be trained in GO. Conclusion: Very few GPs had been trained in geriatrics and/or GO. They were mostly satisfied with GOC and expressed a wish to be trained in GO. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction In parallel with the aging of world population, the incidence of cancer in the elderly will increase; over 30% of cancers occur in people aged 75 and over.1 Thus, geriatric oncology
(GO), which came into being in the late 1980s under the leadership of Balducci and Monfardini, is a medical discipline that brings together geriatrics and oncology.2–5 It is a global approach to the management of elderly patients suffering from cancer with the aim to offer them the most appropriate
⁎ Corresponding author at: Service de Médecine Interne Gériatrie, Hôpital de Champmaillot CHU BP 87 909, 2, rue Jules Violle, F21079 Dijon Cedex, France. Tel.: +333 80 29 39 70; fax: +333 80 29 36 21. E-mail address: [email protected] (P. Manckoundia). 1 Because of each of these authors contributed equally, all should be considered first authors.
http://dx.doi.org/10.1016/j.jgo.2015.10.184 1879-4068/© 2015 Elsevier Ltd. All rights reserved.
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therapeutic strategy, so as to improve their health and quality of life.6,7 In France, in 2003, the fight against cancer and the management of elderly people became health priorities. Thus, the establishment of GO results from a request from the National Cancer Institute (Institut National du Cancer: INCA, created in 2004) and the authority responsible for providing care (Direction Générale de l’Offre de Soins: DGOS) in 3 successive cancer plans: 2003–2009, 2009–2013 and 2014–2019. The objective of this INCA initiative was to improve the management of elderly people with cancer by reinforcing clinical research targeting this population.4 This led to the creation of GO Coordination Units in 2011, including the GO Coordination Unit of Burgundy (GOCUB). These units replaced pilot units created in 2006. The main objective of GO Coordination Units is to improve the management of elderly people suffering from cancer by fostering cooperative decisions between oncologists and/or organ specialists and/or surgeons and/or radiotherapists on the one hand and geriatricians on the other hand. In this system, the role of general practitioners (GP), who are automatically informed of all therapeutic proposals and decisions by letter or email or phone calls from the different specialists, remains crucial in the coordination of patient care. In addition to improving the quality of care provided to patients aged 75 and over with cancer, and developing a clinical research program, the GOCUB promotes education on GO. We thus conducted a survey among French GPs to evaluate their opinions regarding the GO consultation (GOC) proposed by the GOCUB. The GOC is conducted by a geriatrician trained in GO in order to assess elderly patients with cancer before oncological management.
2. Method 2.1. Population In June 2013, a questionnaire validated by the scientific committee of the GOCUB was sent to all GPs for whom one or several patients aged 75 and more had had a GOC between January 1st and December 31st 2012, in the GOCUB context. A follow-up phone call was made in July 2013 to improve the response rate. Elderly people suffering from cancer are referred for a GOC (conducted by the geriatrician) by the oncologist, radiotherapist, surgeon or organ specialist before the oncological treatment is started. The aim is to finalize therapeutic decisions in the management of this specific population. The GOC took place in either a geriatrics day hospital, or the Anticancer Centre, or within the framework of the mobile GO unit in the departments of our university hospital or in private practice. The GOC should lead to a personalized care plan sent to all physicians involved in the management of the patient, including GPs. General practitioners who followed several patients received one questionnaire for each patient. Because this was an observational survey among voluntary GPs, with no modification in the usual management of patients, no written consent of the participants (GP) was necessary. In addition, the Ethics Committee of our institution was
consulted; however, its approval was not necessary for the same reasons.
2.2. Recorded Data The questionnaire consisted of 21 questions, either binary choice (yes/no) or multiple choice questions, and was divided into 3 parts: – The first part concerned the GPs: 1) identification of the GP; 2) age range: 30–39, 40–49, 50–59, and ≥ 60 years; 3) type of practice: urban or rural; 4) geriatric education: skills in GO, university diploma or diploma in complementary specialized studies; 5) knowledge of the existence of a GOC; 6) continuing medical education (CME) in GO; and 7) referral or not to the specialist during the management of cancer in a subject aged 75 and over. Indeed, in France, there are several levels of training in GO for GPs, in particular, ranging from simple awareness courses to a formal qualification. – The 2nd part concerned the result of the GOC: 8) type of cancer managed; 9 to 12) GOC report: received or not by the GP, delivery time, reading the report in full and impact on the management of the patient; 13 to 16) care plan: proposed or not by the specialist in GO, GP's satisfaction or not with the care plan proposed, application or not of care plan by the GP, reasons for not applying of the care plan (several reasons were possible for each patient); 17) phone contact with the GO team during the GOC in order to discuss patients' files directly with the GOC team. The care plan proposed recommendations to GPs for the management of their elderly patients with cancer. These included therapeutic modifications, physiotherapy and nutrition management, for example. – The last part concerned the synthesis of the GOC: 18) level of GP's satisfaction with the GOC as a whole; 19 to 20) wish for a future GOC or collaboration with the GO team, and 21) wish for training in GO. We chose to distinguish between “satisfaction with the care plan proposed” and “satisfaction with the GOC as a whole”, as GPs could be satisfied with the GOC as a whole, but not completely satisfied with the care plan established at the end of the GOC, or vice versa.
2.3. Data Analysis First, the population of responder GPs was compared with the non-responder GPs concerning sex, type of practice and cancer location, in order to ensure the absence of bias linked to non-response. Then, the characteristics of the responder GP population were described and analyzed.
2.4. Statistical Analysis Qualitative variables were described as numbers (N) and percentages. Statistical analyses were performed using the chi-square test or Fisher's exact test. Results were considered statistically significant for p < 0.05. Statistical analyses were performed using Stata software (version 11).
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Table 2 – Knowledge consultation.
3. Results
Knowledge of GOC
3.1. Number of Questionnaires Analyzed A total of 287 patients had a GOC in 2012, but the names of 3 GPs were not recorded. Thus, 284 questionnaires were sent to 218 different GPs. We received 133 questionnaires from 99 GPs, representing an initial response rate of 46.8%. Among these 133 questionnaires, 126, corresponding to 94 GPs, were exploitable. Indeed, 4 corresponded to 3 GPs who no longer followed the patient and 3 questionnaires corresponded to 2 GPs who had died. Finally, the response rate was 44.4%.
3.2. Comparison of Responder and Non-responder General Practitioners The comparison between responder GPs, whose questionnaires were exploitable (94), and non-responder GPs (119) revealed no significant difference for sex (p = 0.14), type of practice (urban vs. rural) (p = 0.63) or the cancer type (gynecological, digestive or other) (p = 0.80). The comparison regarding the age was not possible because this information was unavailable for non-responder GPs.
3.3. Description of Responder General Practitioners This description concerns 126 questionnaires from 94 GPs. Table 1 shows the characteristics of responder GPs. The age range of 50–59 was the most represented with 42 GPs, i.e. 44.7%. No GP was aged below 30. Of the responder GPs, 59 (62.8%) were men and 35 (37.2%) women, and 79.8% (75) worked in an urban environment. A total of 76 GPs (80.8%) had no particular skills in geriatrics, and 57 GPs (60.6%) knew about the existence of a GOC. Only 14 GPs (14.9%) had been
Table 1 – Characteristics practitioners.
of
Variable Age range (years)
Type of practice Geriatric education
Knowledge of GOC GO CME
Referral to specialist
responder N = 94
<30 30–39 40–49 50–59 >60 Urban Rural Yes No Missing data Yes No Yes No Missing data Never Sometimes Often Always
0 10 16 42 26 75 19 17 76 1 57 37 14 79 1 1 4 14 75
general % 0 10.6 17 44.7 27.7 79.8 20.2 18.1 80.8 1.1 60.6 39.4 14.9 84 1.1 1.1 4.2 14.9 79.8
N: number; GO: geriatric oncology; GOC: GO consultation; CME: continuing medical education.
Age range (years)
Type of practice
<30 30–39 40–49 50–59 >60 Total Urban Rural Total
of
the
geriatric
Yes N (%)
No N (%)
0 8 (14) 23 (40.4) 17 (29.8) 9 (15.8) 57 (100) 46 (82.1) 10 (17.9) 56 (100)
0 8 (21.6) 19 (51.4) 9 (24.3) 1 (2.7) 37 (100) 29 (76.3) 9 (23.7) 38 (100)
Total N (%) 0 16 42 26 10 94 75 19 94
oncology p (Fischer test) 0.15
(17) (44.7) (27.7) (10.6) (100) (79.8) (20.2) (100)
0.6
GOC: geriatric oncology consultation; N: number.
trained in GO. Finally, 75 GPs (79.8%) systematically referred elderly patients with cancer to an organ specialist. As concerns knowledge of the GOC, there was no significant difference for age (p = 0.15) and the type of practice (p = 0.6) among responder GPs (Table 2). The most frequent cancer locations were gynecological, which concerned 40.7% of GOC; among these 82.6% were breast cancer. The second leading cancer was digestive cancers in 24.8% of cases, including 57.2% colon-rectum, 25% gastric, 10.7% pancreatic and 7.1% esophageal cancers. Other cancers were lung neoplasia (3.7%), hematological cancers (3.7%), prostate cancer (2.6%), renal neoplasia (2.6%), urinary bladder cancer (2.1%), ear, nose and throat cancer (1.1%), and thyroid cancer (0.5%). Concerning the GOC report, 69.8% of GPs (88) declared they had received it. Among these, 92% (81) were (very) satisfied regarding the delivery time, and 94.3% (83) had read it in full. The main reason for not reading the whole GOC report mentioned by the GPs was its length for 3 of 5 GPs. Finally, among the 88 patients for whom GPs said they had received the GOC report, the report had affected the management of 63 patients. A care plan resulting from the GOC was proposed in 83 cases (Table 3); the response was missing in 29 of 126 cases. The GPs were satisfied with the care plan in 96.4% of cases. This care plan was applied by GPs in 74.7% of cases (62). The main reasons for not applying the care plan (22.9% of cases, N = 19) were death or loss of contact with the patient in 11 cases and the lack of a specialist doctor in 2 cases. There was no significant relationship between the application of the care plan proposed after the GOC and the GP's type of practice (p = 1.00) on the one hand, or the cancer type (p = 1.00) on the other hand. As concerns the phone contact, in 20 cases (16%), GPs were called by a member of the GO team. Among the 91 cases (72.2%) for which GPs had not received a phone call, they would have liked to have been called in 34 cases. There was no significant relationship between the desire or not to have phone contact and the cancer location (p = 0.52). However, there was a significant relationship between the desire or not to have phone contact and satisfaction with the GOC as a whole: the less the GP was satisfied, the more he or she wanted phone contact (p = 0.02) (Table 4).
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Table 3 – Care plan proposed by the geriatrician after the geriatric oncology consultation. Responses of general practitioners to the 126 questionnaires. Variable Care plan proposed by geriatrician
GPs' satisfaction with the care plan among the 83 positive responders Application of care plan by GPs among the 83 positive responders Limiting factor(s) when care plan not applied (N = 19)
Too many recommendations Lack of a specialist physician Patient's death or loss of contact
Response
N (%)
Yes No Not precise ⁎ Yes No Not precise ⁎ Yes No Not precise ⁎ Yes No Yes No Yes No
83 (65.9) 14 (11.1) 29 (23) 80 (96.4) 2 (2.4) 1 (1.2) 62 (74.7) 19 (22.9) 2 (2.4) 0 (0) 19 (100) 2 (10.5) 17 (89.5) 11 (57.9) 8 (42.1)
N: number; GP: general practitioner. ⁎ Lack of precision concerning the existence or not of a care plan proposal, or satisfaction level regarding it, or its application by GP.
Among the 87 (of 126) cases for which there was an overall assessment of the GOC, in 82 cases, the GPs considered the GOC very satisfactory (39) or good (43), while for 5 cases, the GP reported that the GOC was of little help or unsatisfactory. There was no relationship between GPs' overall level of satisfaction with the GOC and their knowledge of GO (p = 0.58) (Table 5). In 100 of the 108 questionnaires in which this item was answered, GPs wanted a future GOC. The GPs who did not want a future GOC significantly corresponded to those who had not received a report after the GOC (p = 0.001). Indeed, in 97.6% of the cases for which the GP had received a GOC report, the GP expressed the wish to have a GOC in the future, while the rate was 75% for cases in which the GP had not received a GOC report. No difference was noted for age range (p = 0.94) or the GP's type of practice regarding the desire or not to have a GOC in the future (p = 0.34).
Table 4 – Wish for phone contact among the general practitioners not called. Wish for phone contact
Cancer location
Gynecological Digestive Other Not precise ⁎ Total Satisfaction None or little with the GOC Good/Very good Not precise ⁎ Total
Yes N (%)
No N (%)
12 (35.3) 8 (23.5) 10 (29.4) 4 (11.8) 34 (100) 4 (11.8) 20 (58.8)
23 (51.1) 9 (20) 11 (24.4) 2 (4.5) 45 (100) 0 (0) 36 (80)
10 (29.4) 9 (20) 34 (100) 45 (100)
Total N (%)
p (Fisher test)
35 (44.3) 0.52 17 (21.5) 21 (26.6) 6 (7.6) 79 (100) 4 (5.1) 0.02 56 (70.9) 19 (24) 79 (100)
N: number; GOC: geriatric oncology consultation. ⁎ Lack of precision concerning cancer location or satisfaction level regarding the GOC.
Table 5 – Global level of satisfaction among general practitioners according to the knowledge of GO. Satisfaction level Knowledge of GO
Yes No Total
Very good/Good N (%)
Little/No N (%)
41 (71.9) 16 (28.1) 57 (100)
4 (80) 1 (20) 5 (100)
Total N (%) 45 (72.6) 17 (27.4) 62 (100)
P (Fisher test) 0.58
N: number; GO: geriatric oncology.
Finally, as concerns training in GO, 60 of the 89 GPs who responded to this item (67.4%) wanted to benefit from training in GO.
4. Discussion The objective of our study was to assess the interest of GOC for GPs. To our knowledge, very few studies have been published in the international literature on this subject, hence the originality of our paper.8 The response rate (44.4%) of GPs in our study was satisfactory and comparable with those for most surveys of this type. Indeed, this response rate is similar to that found in the study by Kurtz et al. (46.9%),8 and better than the mean response rate reported in the literature for this kind of study.9 We regret the fact that the chase-up phone call (following our paper questionnaire) did not improve the response rate among GPs.10 Responder and non-responder GPs were similar concerning their sex, type of practice and the location of the cancer in their patients. However, it was not possible to compare GPs with regard to age because this information was unavailable for non-responder GPs. The typical profile of a responder GP is a man, aged 55 years, working in an urban environment. Only 20% of the GPs had particular skills in geriatrics and only 15% had been trained in GO. This low rate of training in geriatrics is out of step with the current reality of the aging population.1 Our study showed that the majority (4/5) of responder GPs systematically referred elderly patients with cancer to an organ specialist. Thus, the patient's age, unlike the patient's refusal or the presence of several comorbidities, did not appear to be a barrier to such referrals. Our result is in accordance with studies conducted in Alsace (France),8 Aquitaine (France)11 or Canada.12 However, contradictory results have been reported, as in the meta-analysis of Delva et al., in which chronological age was the main barrier to referring patients to an organ specialist.13 In this study, whereas breast cancer was the most represented cancer, prostate cancer was surprisingly underrepresented. We believe that is due to recruitment bias. Indeed, the Urology Department of our network, which receives most of the patients, especially elderly patients, suffering from prostate cancer, rarely referred patients for a GOC at the time of this study. As concerns the GOC report, 30% of GPs reported that they had not received one. This relatively high rate can be in part explained by the fact that some GOC took place while patients
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were in hospital and did not result in a specific report for the GP because the result was filed in the patient's hospital record and not necessarily sent to the GP. An improvement in this area is necessary because communication between practitioners is a major criterion for quality care. This important aspect is underlined in French, Scandinavian, English and American Studies.14–17 Furthermore, in our study, almost all GPs read the GOC report in its entirety. These results are encouraging because they demonstrate the confidence that GPs have in the GOC. This confidence is underlined by the fact that almost all GPs were satisfied with the care plan proposed after the GOC, and ¾ of GPs applied it. This rate would have been higher without the loss of contact with and death or hospitalization of patients. Our result concerning satisfaction with the care plan is comparable to that in the study of Dagada et al., conducted in Aquitaine, which showed that 94% of GPs considered the information provided satisfactory.18 The main factors limiting the application of the recommendations mentioned in other studies are the excess of recommendations, the difficulties in applying them and the lack of a specialist doctor to whom patients could be referred. To our surprise, no difference was noted between GPs according to their type of practice (urban vs. rural) with regard to the application of the proposed care plan. Indeed, we would have thought that GPs with a rural practice would find it more difficult to implement certain measures of the proposed care plan, in view of the medical and paramedical “desertification” of most rural areas in France. Few GPs (16%) were called by a member of the GO team to discuss patients' files directly, though 37.4% of GPs not called would have liked to have taken part in the discussion. In France, the sharing of medical information is a real public health preoccupation, and is thus included among the measures of the national cancer plan. The mutual oncology file could be part of a strategy to foster information sharing, but it is still far from being implemented in real life. Among the responder GPs, 66% wanted to receive training in GO to improve their knowledge. The need for training is also stressed in other surveys. In the study conducted in Alsace (France), 56.3% of GPs said that they needed CME in GO.8 In the study carried out in Champagne Ardennes (France), most GPs wanted CME in GO.14 In France, the wish to create specific courses in GO during the medical studies seems to be an interesting way to meet this need. One bias of this study is its geographical distribution. Indeed, the GPs surveyed were those in Burgundy and some of the neighboring areas. They are therefore probably not representative of French GPs in general. However, the aim of this study was to assess the feelings of GPs relative to the GOC proposed by GOCUB, which has a regional dimension. The overall assessment of GOCUB activity since its establishment shows that all of the specialties confronted with cancer in the elderly are becoming increasingly aware of the GOCUB and thus the number of referrals is growing. The annual number of assessments of elderly people suffering from cancer performed in the context of GOC has almost quadrupled in 8 years of existence. In addition, the GOCUB has also initiated research projects and participates in many collaborative studies involving various GO coordination units. Finally, the GOCUB has implemented several training programs and a major annual seminar
51
for physicians, including GPs and/or caregivers. In the future, in order to constantly improve the management of elderly patients with cancer, the GOCUB intends to propose: 1) to GPs, the follow-up of patients, which will be either clinical or by phone, and 2) the establishment of multidisciplinary meetings devoted to examining the files of elderly patients with cancer. These will be extended to all Burgundy hospitals through video conferencing; and 3) the elaboration of a secure email system allowing physicians, including GPs involved in the management of these patients, to access their medical information in real time. In pedagogical terms, the GOCUB will reinforce CME cycles on GO throughout Burgundy. Finally, the GOCUB wishes to foster the introduction of a GO module in the 2nd cycle of medical studies in France. However, this decision requires a reform by the Ministry of Higher Education. To conclude, this study, concerning the activity of the GOCUB, had an original purpose, to assess the interest and feelings of GPs with regard to the GOC. Indeed, in addition to oncologists and GOC, GPs play a central role in the management and follow-up of elderly patients with cancer, as highlighted in the last cancer plan (2014–2019), deployed by the French authorities. Our results show that GPs are mostly satisfied with the GOC and do not seem to have any major difficulties in applying the care plan proposed after the GOC. The main obstacle to overcome is still communication with the geriatricians who perform the GOC, which is considered relatively insufficient by GPs. This was illustrated by the lack of a GOC report in some cases. This may weaken the concept of shared care, which aims to improve the management of these patients. This study also highlighted the fact that GPs expressed a wish for CME in the management of elderly patients with cancer.
Disclosures and Conflict of Interest Statements The authors have no conflicts of interest to disclose.
Author Contributions Study concepts: C. Charbonnier, S. Marilier, V. Quipourt. Study design: C. Charbonnier, S. Marilier. Data acquisition: C. Charbonnier. Quality control of data and algorithms: S. Dabakuyo, A. Cueff, V. Quipourt, P. Manckoundia. Data analysis and interpretation: C. Charbonnier, S. Marilier, P. Manckoundia. Statistical analysis: S. Dabakuyo, A. Cueff. Manuscript preparation: C. Charbonnier, S. Marilier, P. Manckoundia. Manuscript editing: C. Charbonnier, S. Marilier, P. Manckoundia. Manuscript review: C. Charbonnier, S. Marilier, V. Quipourt, P. Manckoundia.
Acknowledgments The authors are grateful to Mr. Philip Bastable.
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