Illustrative Case series
Care Options for Breast Cancer Survivors
By Jerome W. Yates, MD, Professor of Medicine, SUNY at Buffalo; Professor of Oncology, Roswell Park Cancer Institute, Buffalo, NY; Senior Clinical Research Scientist, Clinical Research Branch, NIA, NIH. Dr. Yates reports no financial relationships relevant to this field of study.
A 57-year-old postmenopausal librarian, who is 1-year post diagnosis of a stage II invasive cancer of the right breast, is found to be estrogen- and progesterone-receptor positive, and Her2neu negative with one positive axillary node. Following the completion of breast conserving tumor resection, adjuvant chemotherapy, and radiation treatment, she was given the option of being followed by her surgeon, medical oncologist, radiation therapist, primary care physician, or a nurse practitioner in the multidisciplinary clinic. She was not comfortable with the consultant medical oncologist and was favorably inclined toward the nurse practitioner, having been assured that she would see her at each follow-up visit. Her previous primary care physician retired during the course of her adjuvant chemotherapy. She elected to be followed by telephone conversations with a nurse practitioner and customary repeated mammograms.
CASE DISCUSSION
A recent paper using a survey methodology to explore various follow-up options for breast cancer survivors examined patient comfort with providers "most likely to decrease worry and increase survival."1 Included options were being seen by a medical oncologist, surgeon, radiation oncologist, nurse practitioner, primary care physician, or a virtual visit using either a telephone or internet interaction. This study included 218 breast cancer survivors and reaffirmed some of our knowledge about provider-patient relationships. Those surveyed favored follow-up visits from medical oncologists over the other options. They also favored being followed by their primary care physicians over nurse practitioners and were least interested in virtual visits. The authors note that other investigators found that psychosocial support for patients with cancer had been effectively provided through periodic telephone-based follow-up.2 Another study demonstrated that telephone conversations with trained nurses as opposed to appointments with specialists failed to demonstrate differences in patient satisfaction, anxiety, or the detection of recurrences.3
Although the results of this study appear consistent with most expectations, it has serious limitations. The survey inclusion rate was only 40% in what would normally be a highly motivated cancer population. The respondents were significantly younger than the overall population, were highly educated with 71% having completed college, and 51% had an annual household income of greater than $80,000. It could be expected that in the future, highly educated patients might be more receptive to virtual visits as was the case for the librarian mentioned above. However, in this study, technological expertise did not overcome survivor interest in direct interactions with their providers.
Was the librarian's selection of telephonic follow-up rational or merely based on her discomfort with the medical oncologist responsible for her adjuvant care and the loss of her primary care physician to retirement? As a trained librarian she was comfortable with electronic support services and perhaps more knowledgeable than others confronted with the selection of their survival management. In an effort to better understand why she would select the least personal interaction for her follow-up, some understanding of patient comfort and trust in caregivers deserves exploration.
Multiple factors contribute to patient confidence in their providers, and these include the following: trust in their provider to act in their best interests, their perception of the education and knowledge of the provider, the respect they derive from a patient-focused interaction, and their comfort with the personality and level of interest from the provider.4 Trust is generally more likely the result of interactions with individual providers, while distrust is often associated with impersonal institutional providers.5 This is true because the behavior of an individual is easier to predict then the less personal associations with an impersonal institution. The high-risk probability of a recurrence of disease puts the survivors in a vulnerable situation because of their inability to exercise medical control without their dependence on their knowledgeable health care provider. Patient satisfaction is based on past experiences, while confidence in providers is based on future expectations. This librarian had her confidence in the medical oncologist eroded because of past interactions. Lack of confidence translates into a lack of trust.
Provider characteristics that are important to patients include familiarity with their medical and social situation, the amount of time they spend with the patients, the information they provide, and their level of empathy in difficult situations. Patient characteristics that help providers relate favorably include loyalty, ethnicity, satisfaction, adherence to medical recommendations, and a willingness to participate in clinical trials.4 When patients with cancer entrust their future survival to providers, it is easy to understand why they expect positive interactions with trusted providers. It is also predictable that the results of the survey would reflect the importance of personal interactions with knowledgeable, compassionate, and trusted providers. The impersonal imposition of institutional solutions (clinics, telephone, or Internet support) to solve the shortages of oncologists, primary care physicians, and nurse specialists likely will result in less patient and provider satisfaction in the future. The availability of telephonic follow-up and web-based survivorship planning and general responses to questions may benefit some patients and their families, but it also may introduce confusion and misinterpretation for the most vulnerable patients. There also will be an increase in legal liability for the provider institution. The librarian elected to take control of the situation herself because of her comfort with technological answers and her mistrust or lack of empathy from her medical oncologist.
References
1. Mayer EL, et al. Breast cancer survivors' perceptions of survivorship care options. J Clin Oncol 2012;30:158-163.
2. Gotay CC, Bottomley A. Providing psycho-social support by telephone: What is its potential in cancer patients? Eur J Cancer Care (Engl) 1998;7: 225-231.
3. Beaver K, et al. Comparing hospital and telephone follow-up after treatment for breast cancer: Randomised equivalence trial. BMJ 2009;338:a3147.
4. Hillen MA, et al. Cancer patients' trust in their physiciana review. Psychooncology 2011;20:227-241.
5. Hall MA, et al. Trust in the medical profession: Conceptual and measurement issues. Health Serv Res 2002;37:1419-1439.
A 57-year-old postmenopausal librarian, who is 1-year post diagnosis of a stage II invasive cancer of the right breast, is found to be estrogen- and progesterone-receptor positive, and Her2neu negative with one positive axillary node.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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