Impact of provider type and number of providers on surveillance testing among survivors of head and neck cancers

Abstract

BACKGROUND: Guidelines for follow-up after head and neck cancer (HNC) treatment recommend frequent clinical examinations and surveillance testing. Here, the authors describe real-world follow-up care for HNC survivors and variations in surveillance testing. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study examined a population-based cohort of HNC survivors between 2001 and 2011 Usage of cross-sectional head and neck imaging (CHNI), chest imaging (CI), positron emission tomography (PET), fiberoptic nasopharyngolaryngoscopy (FNPL), and, in irradiated patients, thyroid function testing (TFT) was captured over 2 consecutive surveillance years. Multivariate modeling with logistic regression analyses was used to assess variations by clinical factors, nonclinical factors, number and types of providers seen and their evolution over time. RESULTS: Among 13,836 HNC survivors, the majority saw a medical, radiation, or surgical oncologist and a primary care provider (PCP; 81.7%) in their first year of surveillance. However, only 58.1% underwent either PET or CHNI, 47.8% underwent CHNI, 64.1% underwent CI, 32.5% underwent PET scans, 55.0% underwent FNPL, and 55.9% underwent TFT. In multivariate analyses, patients who followed up with more providers and those who followed up with both a PCP and an oncologist were more likely to undergo surveillance testing (P < .007). However, adjusting for providers seen did not explain the variations in surveillance testing rates based on age, race, education, income level, and place of residence. Over time, there was a gradual increase in the use of PET scans and TFT during surveillance years. CONCLUSIONS: In this large SEER-Medicare data study, only half of HNC survivors received the recommended testing, and greater compliance was seen in those who followed up with both an oncologist and a PCP. More attention is needed to minimize variations in surveillance testing across sociodemographic groups.

Characterizing head and neck cancer survivors' discontinuation of survivorship care

“…Recent work on HNC survivorship utilization specifically has shown that care utilization can vary widely between patients, can be bolstered by a survivor's involvement (cancer-related or otherwise) with primary care, and frequently decreases over time. 16,17 This research reveals the patterns of those who engage in survivorship care but cannot provide insight into the experience of those who, for whatever reason, do not. As a complement to work on HNC survivorship care utilization, our findings are a first step toward a detailed understanding of how best to meet the needs of all HNC survivors.…”

“…This finding is concordant with those reported by others. Massa et al, 24 in a prospective cross‐sectional survey study, identified multidisciplinary care as a factor associated with a desire for more frequent follow‐up visits, and Yao et al, 16 in a retrospective study based on Surveillance, Epidemiology, and End Results–Medicare, found that the treatment received was associated with HNC patients' follow‐up care utilization. Multimodality cancer treatment correlates with higher stage cancer, greater treatment complexity, and more severe treatment toxicity—all of which are factors that reasonably might result in survivor needs that could be addressed through continued survivorship care.…”

Examination of risk factors for discontinuation of follow‐up care in patients with head and neck cancer

“…The BDI is a widely used and well-validated measure of depressive symptomatology consisting of 21 items scored 0-3, each assessing a unique category of depressive symptoms. 18 Cutoff scores have been established which suggest minimal (0-9), mild (10)(11)(12)(13)(14)(15)(16)(17)(18), moderate (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29), and severe (30-63) depression. 18 The BDI has been used in both nonclinical and clinical samples, including those with HNC.…”

“…While exploration of these factors is needed, research also demonstrates that utilization of follow‐up care declines with time. 10 , 12 One recent study found that only half of patients receive recommended surveillance testing over a 2‐year period posttreatment, for example. 12 Limited research to date suggests that factors such as marital status, treatment modality, and poor recognition of the recommended follow‐up period may be related to discontinuation in HNC, 8 , 9 but overall extremely little is known about those who discontinue follow‐up care.…”

“… 10 , 12 One recent study found that only half of patients receive recommended surveillance testing over a 2‐year period posttreatment, for example. 12 Limited research to date suggests that factors such as marital status, treatment modality, and poor recognition of the recommended follow‐up period may be related to discontinuation in HNC, 8 , 9 but overall extremely little is known about those who discontinue follow‐up care. This includes rates of discontinuation and which key demographic, disease, and behavioral factors may play a role, thus warranting further investigation.…”