Fmily Physicin Involvement in Cncer Cre Follow-up: The Experience of Cohort of Ptients With Lung Cncer Michèle Aubin, MD, PhD, CCFP, FCFP 1,2,3,4 Lucie Vézin, MA 4 René Verreult, MD, PhD, FCFP, CCFP 1,5 Lise Fillion, PhD 3,6 Éveline Hudon, MD, MSc, CCFP, FCFP 7 Frnçois Lehmnn, MD, CCFP, FCFP 7 Yvn Leduc, MD, PhD, CCFP, FCFP 2 Rénld Bergeron, MD, CCFP, FCFP 2,4 Dniel Reinhrz, MD, PhD 5 Dine Morin, PhD 6 1 Reserch Unit of the Quebec Center of Excellence on Aging, Quebec, QC, Cnd 2 Deprtment of Fmily Medicine nd Emergency Medicine, Université Lvl, Quebec, QC, Cnd 3 Mison Michel-Srrzin Reserch Tem in Pllitive Cre, Quebec, QC, Cnd 4 Lvl Fmily Medicine Unit, Université Lvl, Quebec, QC, Cnd 5 Deprtment of Socil nd Preventive Medicine, Université Lvl, Quebec, QC, Cnd 6 Fculty of Nursing, Université Lvl, Quebec, QC, Cnd 7 Deprtment of Fmily Medicine, Université de Montrél, Quebec, QC, Cnd Confl icts of interest: none reported CORRESPONDING AUTHOR Michèle Aubin, MD, PhD, CCFP, FCFP 2690, Chemin des Qutre-Bourgeois Quebec, QC G1V 0B7, Cnd michele.ubin@mf.ulvl.c ABSTRACT PURPOSE There hs been little reserch describing the involvement of fmily physicins in the follow-up of ptients with cncer, especilly during the primry tretment phse. We undertook prospective longitudinl study of ptients with lung cncer to ssess their fmily physicin s involvement in their follow-up t the different phses of cncer. METHODS In 5 hospitls in the province of Quebec, Cnd, ptients with recent dignosis of lung cncer were surveyed every 3 to 6 months, whether they hd metstsis or not, for mximum of 18 months, to ssess spects of their fmily physicin s involvement in cncer cre. RESULTS Of the 395 prticipting ptients, 92% hd regulr fmily physicin but only 60% hd been referred to specilist by him/her or collegue for the dignosis of their lung cncer. A mjority of ptients identified the oncology tem or oncologists s minly responsible for their cncer cre throughout their cncer journey, except t the dvnced phse, where mjority ttributed this role to their fmily physicin. At bseline, only 16% of ptients perceived shred cre pttern between their fmily physicin nd oncologists, but this proportion incresed with cncer progression. Most ptients would hve liked their fmily physicin to be more involved in ll spects of cncer cre. CONCLUSIONS Although ptients perceive tht the oncology tem is the min prty responsible for the follow-up of their lung cncer, they lso wish their fmily physicins to be involved. Better communiction nd collbortion between fmily physicins nd the oncology tem re needed to fcilitte shred cre in cncer follow-up. Ann Fm Med 2010;8:526-532. doi:10.1370/fm.1171. INTRODUCTION Mny uthors hve recognized the lck of continuity in cncer cre. 1-9 Ptients with cncer often need to consult mny helth professionls from multiple settings, leding to frgmented cre. At the tretment phse, fmily physicins my lose trck of their ptients with cncer, who re usully followed by oncology tems. It my be diffi cult for fmily physicins to tke over their ptients follow-up t the end of tretments if they hve not seen them for long time. 10-16 Mny helth uthorities promote collbortion of oncology tems with fmily physicins to keep them in the loop t ll phses of cncer. 9,17-19 Little is known on ctul fmily physicins prctices in cncer cre, however. Normn et l 12 hve described 3 ptterns of cre with incresing levels of fmily physicin involvement: (1) sequentil, with virtully no fmily physicin involvement nd ptients receiving most of their cre from the oncology tem, (2) prllel, with the fmily physicin still involved but minly for noncncer problems, nd (3) shred, with involvement of both 526
the fmily physicin nd the oncology tem in cncer cre. Informtion on fmily physicin ptterns of cre throughout the cncer cre trjectory is scrce. This study imed to describe the ctul nd expected role of fmily physicins t the different phses of cncer, mong cohort of ptients with lung cncer. METHODS Study Design nd Ptient Selection We conducted prospective longitudinl descriptive study between My 2005 nd July 2008 mong ptients with lung cncer from 5 hospitls in the Cndin province of Quebec. Ptients were eligible if they hd received dignosis of ny type of lung cncer, regrdless of stge nd tretment. We chose this specifi c cncer becuse of its high prevlence in men nd women, its vrible evolution depending on the cellulr type nd stging t dignosis, nd its diverse tretments. Given these ttributes, lung cncer provides the opportunity to document, from the ptient s perspective, the chnge in their fmily physicin s involvement when they move from one cncer phse to nother, while following them over certin period of time. Eligible ptients were informed of the study by the oncology tem. Those who greed to be contcted by the reserch tem were invited to prticipte nd signed n informed consent form. We kept bsic informtion on nonprticipnts to compre them with prticipnts. The study ws pproved by the Reserch Ethics Committee of Lvl University nd of ll study hospitls. Dt Collection nd Study Instruments At bseline, ptients prticipted in n interview lsting pproximtely 45 minutes, either t the oncology clinic or t their home, depending on their preference. They completed questionnires regrding their socil nd demogrphic chrcteristics; lung cncer history; functionl sttus ccording to the Estern Coopertive Oncology Group (ECOG) Performnce Sttus Scle (0 = norml ctivity; 1 = symptoms but mbultory; 2 = in bed <50% of time; 3 = in bed 50% of time; 4 = 100% bedridden) 20-22 ; number of visits to the fmily physicin in the prior yer; fmily physicin s, specilist s, nd oncology tem s responsibility for cncer cre; fmily physicin s involvement in their cre; perceived fmily physicin s ctul nd expected roles in vrious spects of cre (coordintion, emotionl support, informtion trnsmission, symptom relief); nd the fmily physicin pttern of cre (clssifi ed ccording to the previously mentioned ctegories of Normn et l 12 ). We dpted the questionnire on fmily physicins involvement from the vlidted primry cre ssessment tools of Sfrn et l 23 nd Strfi eld et l, 24 nd used 4-point Likert scles (1 = not involved; 2 = little involved; 3 = involved; 4 = very involved) tht we collpsed into dichotomous ctegories (not involved vs involved). We performed test-retest nlysis of this instrument on 20 ptients, nd concordnce testing showed no sttisticlly signifi cnt difference between the 2 sets of responses for ll vribles (P =.31 to.99). We reviewed ptients medicl records to complete informtion relted to lung cncer, tretment received, nd services used. Ptients were followed up for mximum of 18 months. To tke into ccount vribility in ptients survivl, we ressessed those with metstsis t 3-month intervls (mximum of 7 interviews) nd those without metstsis t 6-month intervls (mximum of 4 interviews). Subsequent interviews lsted 20 to 30 minutes nd took plce t the oncology clinic, t home, or by telephone, depending on ptients preference. Ech time, ptients completed the sme questionnires on the number of visits to their fmily physicin since the lst interview, ctul nd expected fmily physicin role in the sme spects of cre, nd the fmily physicin pttern of cre. We reviewed their medicl records ech time to determine if metstsis hd developed nd to scertin the cncer phse: primry tretment, stbility (primry tretment completed nd no sign of cncer progression or new metstsis), progression/relpse, or dvnced/ terminl. Determintion of ll phses of cncer ws bsed on medicl informtion from the records, except for the dvnced/terminl phse, which ws defi ned s hving score of 3 or 4 on the ECOG scle. We used this pproch to void misclssifi ction of ptients, considering the lck of consensus in the literture on defi ning this cncer phse from clinicl predictors. Anlyses We conducted sttisticl tests on mens (t tests) nd proportions (χ 2 tests) to compre prticipnts with nonprticipnts on their personl nd medicl chrcteristics. Ptients perceptions regrding their fmily physicin s role nd pttern of cre re presented for ech cncer phse. When ptients were questioned more thn once per phse (ie, if they hd n extended period of tretment or there ws no progression of cncer over time), single response per ptient per phse ws used in the nlyses. For continuous vribles, we clculted men score from ll responses provided by ptient per phse, for ech vrible, nd used this score in nlyses. For ctegoricl vribles (eg, fmily physicin pttern of cre for which the 4 ctegories no fmily physicin, sequentil, prllel, nd shred cre represent n 527
incresing level of fmily physicin involvement), we conducted nlyses lterntively using either the highest or the lowest score s the sole response per ptient per phse. Since we found the results to be equivlent using either of those scores, we rbitrrily decided to present results obtined with the highest score. Notbly, in most of these cses, ptients questioned repetedly in cncer phse reported the sme pttern of fmily physicin involvement over time. We used the Cochrn-Mntel-Henszel test to ssess the vrition, with the cncer phses, of ptients perceptions regrding their fmily physicin s involvement in cncer cre nd the fmily physicin pttern of cre. Anlyses of vrince were performed to compre, t ech phse, the men number of visits to the fmily physicin ccording to pttern of cre. An α level of.05 ws used s the signifi cnce threshold. All sttisticl nlyses were performed using SAS softwre, version 9.1 (SAS Institute Inc, Cry, North Crolin). RESULTS Ptient Disposition nd Chrcteristics Of the 695 eligible ptients with lung cncer, 395 were recruited for prticiption rte of 56.8%. Figure 1 shows ptients prticiption t ech cncer phse. Over the 18-month follow-up, individul ptients courses vried considerbly; in fct, we found 15 scenrios of evolution from one phse to nother. For exmple, 52 (13.2%) of the ptients continued receiving tretment during the whole study, 192 (48.6%) remined in the stbility phse throughout the followup, nd 20 (5.1%) went directly from dignosis to the progression/relpse or dvnced/terminl phses. Overll, 148 (37.5%) of the ptients died during the study, nd 44 (11.1%) withdrew, minly becuse their condition ws worsening nd they were overwhelmed fter receiving the bd news. Also, becuse of the slow recruitment pce, we extended the recruitment period 6 months longer thn originlly plnned, but the lst 95 recruited ptients were followed up for only 12 months. There ws no difference ccording to type of lung cncer between prticipnts nd nonprticipnts (P =.50). More women thn men declined the invittion to prticipte (P =.05). In ddition, prticipnts were slightly younger on verge thn nonprticipnts (63.4 vs 65.5 yers; P =.02). Ptients personl nd medicl chrcteristics t bseline re presented in Tble 1. Women were signifi - cntly younger thn men (61.7 vs 64.7 yers; P =.002) nd more frequently lived lone (30.6% vs 19.9%; P =.01). Most ptients hd been wre of their dignosis for lmost 3 months on verge. A lrge proportion of ptients (63.4%) hd positive lymph nodes t dignosis, nd cumultive 42% hd metstses t some point between dignosis nd the end of the 18-month follow-up. Almost ll ptients (92.9%) were offered tretment. At bseline, nerly one-third (30.6%) of ptients hd been hospitlized t lest once in reltion to their lung cncer, excluding the 75 ptients who were hospitlized for lung surgery. Only 16.7% of ptients hd visited the emergency deprtment for resons relted to their lung cncer, nd the mjority of ptients (77%) reported being ssisted in their cre trjectory by nurse nvigtor. Figure 1. Ptient prticiption in the study. 695 Eligible ptients 395 Ptients recruited t bseline (Dignosis phse) 25 Withdrew 50 Died Primry tretment phse: n = 118 52 Styed t this phse 6 Withdrew 29 Died Medin durtion of 6 months Stbility phse: n = 238 192 Styed t this phse 11 Withdrew 38 Died Medin durtion of 12 months Progression/relpse phse: n = 50 37 Styed t this phse 1 Withdrew 2 Died Medin durtion of 6 months Advnced/terminl phse: n = 39 9 Styed t this phse 1 Withdrew 29 Died Medin durtion of 3 months 528
Involvement of Fmily Physicins in Ptients Cncer Cre A totl of 364 ptients (92.1%) reported hving regulr fmily physicin. Among the 31 ptients who did not hve one, the mjority, 19 (61.3%), wnted to fi nd one, but 12 believed tht they should be followed by specilists. Approximtely two-thirds of ptients hd been followed by the sme fmily physicin for more thn 5 yers nd, on verge, they hd consulted him/ her 4 times in the prior yer (4.0 ± 4.5; rnge 0-52). Overll, mny ptients were unwre of their fmily physicin s prctice regrding home cre (48.4%) nd fter-hours cre (20.6%). Approximtely 60% of ptients were referred by Tble 1. Ptient Chrcteristics t Bseline (N = 395) Chrcteristic No. (%) or Men ± SD (Rnge) [Medin] Sex Femle 170 (43.0) Mle 225 (57.0) Functionl sttus Norml ctivity 178 (45.1) Symptoms but mbultory 150 (37.9) Confined to bed or chir 44 (11.1) <50% of wking hours Confined to bed or chir 20 (5.1) 50% of wking hours Completely disbled 3 (0.8) 100% bedridden Type of lung cncer Squmous cell crcinom 77 (19.5) Adenomtous crcinom 164 (41.5) Other non smll cell crcinom 67 (17.0) Smll cell crcinom 58 (14.7) Unknown 29 (7.3) Tretment Surgery with/without chemotherpy/rdition 113 (28.6) therpy Chemotherpy nd/or rdition 254 (64.3) therpy No tretment 28 (7.1) Metstses Present t bseline 128 (32.4) Found during follow-up 37 (9.4) None 230 (58.2) Cncer stge Stge I 56 (14.2) Stge II 33 (8.3) Stge III 119 (30.1) Stge IV 133 (33.7) Not confirmed 54 (13.7) Age, yers 63.4 ± 9.5 (31-88) [64] Eduction, yers 10.9 ± 3.9 (2-24) [11] Intervls in cre Investigtion to dignosis, weeks 5.6 ± 8.0 (0-78) [3] Dignosis to first tretment, dys 29.0 ± 26.6 (0-140) [21] their fmily physicin or collegue from the sme clinic to confi rm the dignosis of lung cncer; the remining 40% were referred either by physicin from the emergency deprtment (18%) or by specilist (22%). In most cses (80.3%), the fmily physicin ssisted ptients in mking the ppointment with the specilist. Among ptients referred by other physicins, the lrge mjority (83.1%) reported tht their fmily physicin ws informed of their dignosis. Most ptients reported being stisfied with the time their fmily physicin gve for discussion (93%) nd with his or her ptience in responding to questions (93%), bility to mke them t ese (96%), nd bility to ressure them (88%). A lrge proportion of ptients continued to see their fmily physicin throughout their cncer journey, but predominntly fter the end of tretment when their condition ws stble (88%) (P <.001) (Tble 2). At ll phses of cncer, mjority of ptients reported tht they discussed with their fmily physicin their visits to the oncology tem, but no more thn hlf of Tble 2. Extent of Fmily Physicin Involvement by Cncer Phse Extent of Involvement N (% of Ptients) P Vlue Contct with fmily physicin Dignosis 364 (58.8) <.001 Primry tretment 108 (60.2) Stbility 228 (88.2) Progression/relpse 48 (75.0) Advnced/terminl 37 (67.6) If contct with fmily physicin, discussion bout visits to oncologist Dignosis 214 (72.9).09 Primry tretment 65 (77.8) Stbility 197 (79.7) Progression/relpse 36 (91.7) Advnced/terminl 22 (83.3) Questions to sk of fmily physicin in reltion to cncer Dignosis 214 (32.7) <.001 Primry tretment 65 (43.1) Stbility 201 (44.3) Progression/relpse 36 (50.0) Advnced/terminl 25 (64.0) Fmily physicin involvement in tretment decisions b Dignosis c <.001 Primry tretment 53 (15.1) Stbility 107 (16.8) Progression/relpse 34 (20.6) Advnced/terminl 13 (53.9) From the Cochrn-Mntel-Henszel test; compres, cross cncer phses, the proportion of ptients who reported ech extent of fmily physicin involvement. b Only for ptients who hd tretment. c This question ws not sked t the dignosis phse; often, tretment hd lredy begun t the bseline interview. 529
ptients hd dditionl questions to sk to their fmily physicin in reltion to their lung cncer, except t the dvnced/terminl phse, where this sitution ws more common (64%) (P <.001). Similrly, t most cncer phses except the dvnced/terminl one, few ptients reported tht their fmily physicin ws involved in decisions regrding cncer tretment. Tble 3. Fmily Physicin Involvement in Vrious Aspects of Cre by Cncer Phse Aspect of Cre Actul Involvement N (% of Ptients) Expected Involvement N (% of Ptients) P Vlue Coordintion of cre Dignosis 357 (41.2) 362 (83.4) <.001 Primry tretment 102 (24.5) 107 (83.2) <.001 Stbility 227 (31.3) 228 (85.1) <.001 Progression/ 46 (37.0) 48 (75.0) <.001 relpse Advnced/terminl 37 (46.0) 37 (86.5) <.001 Emotionl support Dignosis 351 (36.8) 362 (83.4) <.001 Primry tretment 104 (44.2) 107 (86.9) <.001 Stbility 227 (54.6) 228 (88.2) <.001 Progression/relpse 46 (60.9) 48 (87.5).002 Advnced/terminl 37 (51.4) 37 (81.1).007 Trnsmission of informtion Dignosis 352 (17.3) 362 (62.0) <.001 Primry tretment 103 (18.4) 107 (59.8) <.001 Stbility 227 (29.1) 228 (72.4) <.001 Progression/ 46 (34.8) 48 (58.3).01 relpse Advnced/terminl 37 (37.8) 37 (73.0).002 Symptom relief Dignosis 332 (13.0) 361 (62.3) <.001 Primry tretment 100 (19.0) 107 (74.8) <.001 Stbility 225 (30.2) 228 (79.8) <.001 Progression/relpse 46 (30.4) 48 (72.9) <.001 Advnced/terminl 37 (43.2) 37 (78.4).002 From the χ 2 test; compres, t ech cncer phse, the ctul vs expected proportions for fmily physicin involvement in specific spects of cncer cre, s reported by ptients. Actul nd Expected Fmily Physicin Involvement in Cncer Cre Although fmily physicins contributed modestly to cncer cre follow-up, most ptients were stisfi ed in generl with their fmily physicin s involvement. Nevertheless, when questioned on specifi c spects of cncer cre, there ws signifi cnt gp between ptients perception of the ctul involvement of their fmily physicin nd their expecttions regrding his/ her contribution in coordintion of cre, emotionl support, informtion trnsmission, nd symptom relief (Tble 3). At ll phses of cncer, most ptients would hve liked their fmily physicin to be more involved thn he/she ctully ws in ll these spects of cre (P <.05). Tble 4 shows ptients perception of their fmily physicin s pttern of cre t the different phses of cncer. Although the proportion of ptients without regulr physicin did not vry signifi cntly with the evolution of cncer, the 3 other ptterns of cre differed from dignosis to the dvnced/terminl phse. Prllel cre ws the most frequent pttern reported t ll phses of cncer, except t the dvnced/terminl phse, where shred cre ws identifi ed more often. At dignosis, ptients reported men number of visits to their fmily physicin in the prior yer tht ws signifi cntly different ccording to their perceived fmily physicin s pttern of cre (P <.001). In prticulr, there ws incresing fmily physicin involvement from the sequentil pttern of cre (2.4 ± 2.5 visits) to the prllel pttern of cre (3.9 ± 3.6), nd lso from the prllel to the shred cre pttern (5.6 ± 7.3). The sme difference ws consistently seen between the ptterns of cre t ll other cncer phses (Tble 5). Finlly, when sked independently for ech type of helth cre professionl, more thn 90% of ptients considered oncologists to be the min professionls responsible for their cncer cre t ll phses but one. The exception ws the dvnced phse, where more thn 70% ptients gve this responsibility to their fmily physicin. Tble 4. Fmily Physicin Pttern of Cre by Cncer Phse Cncer Phse Pttern of Cre Dignosis (N = 395) Primry Tretment (n = 118) Stbility (n = 238) Progression/Relpse (n = 50) Advnced/Terminl (n = 39) P Vlue No fmily physicin 7.8 8.5 4.2 4.0 5.1.31 Sequentil 11.6 12.7 3.8 2.0 18.0 <.001 Prllel 64.6 54.2 55.9 62.0 23.1 <.001 Shred 16.0 24.6 36.1 32.0 53.8 <.001 Note: Vlues re percentges of ptients. From the Cochrn-Mntel-Henszel test; compres vrition of ech fmily physicin pttern of cre cross cncer phses. 530
DISCUSSION This study provides new knowledge regrding fmily physicins ctul nd expected involvement in cncer cre, s no other longitudinl study hs looked t these physicins role throughout the cncer cre trjectory, to the best of our knowledge. Recently, Cheung et l 25 hve documented ptients expecttions regrding some spects of cncer follow-up specifi clly for survivorship cre. This ltter study complements our results by lso providing comprison of ptients expecttions to the ones of fmily physicins nd oncologists. But their study ws cross-sectionl nd limited to cncer survivorship cre, compred with ours, which ddressed the evolution of ptients expecttions from dignosis to the dvnced/terminl phse of cncer. In our cohort, most ptients reported hving regulr fmily physicin, fi nding tht is concordnt with fi ndings from other studies with ptients of similr ge. 16,26 Throughout the cncer cre trjectory, less thn 50% of ptients reported high degree of fmily physicin involvement in most spects of cncer cre. These physicins were lest involved during the primry tretment phse of cncer, s reported by ptients. This study thus confi rms tht fmily physicins re lrgely cut off from cncer cre during the tretment phse, s hs been found in other studies. 10,16 From dignosis to the progression phse, the pttern of cre most frequently reported ws the prllel one, which corresponds to some fmily physicin involvement in follow-up, but minly for noncncer helth problems. Shred cre between fmily physicins nd the oncology tem ws mentioned incresingly s the cncer progressed, nd becme the most frequent pttern of cre t the dvnced/terminl phse. These results re consistent with findings of Sisler et l, 16 but they provide dditionl informtion by documenting the chnge in pttern of cre during the cncer cre trjectory. They seem to reflect ptients preference for FAMILY PHYSICIAN INVOLVEMENT IN CANCER CARE Tble 5. Ptient Visits to Their Fmily Physicin by Cncer Phse nd Pttern of Cre Cncer Phse Pttern of Cre No Fmily Physicin Sequentil Prllel Shred Cre P Vlue b Primry tretment 0.00 0.89 ± 1.38 2.25 ± 1.73 <.001 Stbility 0.00 1.28 ± 1.26 2.54 ± 2.52 <.001 Progression/relpse 0.72 ± 0.00 1.33 ± 1.48 3.21 ± 3.27.02 Advnced/terminl 0.67 ± 0.82 1.20 ± 1.81 2.37 ± 1.30.02 Note: Vlues re men ± stndrd devition number of visits. Vlues should not be compred from one cncer phse to nother since durtion of ech phse ws not equivlent. b From nlysis of vrince; compres, t ech cncer phse, the men number of visits to the fmily physicin ccording to fmily physicin ptterns of cre. shift in cre towrd specilists fter the dignosis of cncer until they rech the dvnced phse of their disese, t which point substntil proportion turn bck to their fmily physicin. In tht sense, the prllel pttern of cre my be perceived by ptients s providing better-defined roles for both fmily physicins nd oncologists, compred with shred pttern of cre tht requires good communiction between physicins to determine how best to interfce with ech other in delivering cre to ptients. These findings my lso explin why mjority of ptients were stisfied with their fmily physicin s overll level of involvement, even though few of them reported high level of fmily physicin involvement in their cncer cre. Nevertheless, s Cheung et l 25 concluded, the respective roles expected of fmily physicins nd oncologists need to be clrifi ed in order to provide continuous nd integrted cncer cre. Despite ptients high degree of stisfction with their fmily physicin s level of involvement overll, there ws significnt gp, t ll phses of cncer, between their perception of their fmily physicin s ctul follow-up nd wht they expected from them in specific spects of cncer cre. These contrsting results emphsize the importnce of ssessing specific domins of stisfction. The gp found between ptients experiences nd expecttions mirrors fi ndings of Miedem et l, 27 which showed tht 80% of surveyed cncer ptients wnted counseling from their fmily physicin bout the emotionl issues of cncer, but only 20% received it. There re some limittions to this study. First, the rther low prticiption rte combined with the high dropout rte my rise some concerns. But these rtes compre well with those of other studies conducted with such vulnerble popultion. 16,25,28 Moreover, the withdrwl rte ws quite low in this cohort, the min resons for dropping out being deth or cncer recurrence ssocited with poor functionl sttus, which were inevitble in this popultion. Second, becuse the study ws limited to ptients with lung cncer, it is uncertin if results my be generlized to ptients with other types of cncer. Since the cohort included ptients vried in ge, sex, stge t dignosis, nd tretments received, however, it gives insights into ptients preferences on cncer follow-up cre tht my lso pply to other cncers. Third, the clssifi ction of fmily physicin ptterns of cre relied on ptients perception, which my be considered imprecise. Nevertheless, there ws signifi cnt difference, t bseline nd for 531
ech cncer phse, in the men number of ptient visits to their fmily physicin ccording to this pttern of cre, supporting the vlidity of this clssifi ction originlly described by Normn et l. 12 Finlly, our fi ndings re bsed on self-reported dt, nd they must be interpreted with cution given the smll number of prticipnts in some phses of cncer, prticulrly t the progression/relpse nd dvnced/terminl phses. Despite these limittions, this study provides vluble informtion on how ptients with lung cncer experience fmily physicins contribution to their cre nd wht they expect from them, throughout their cncer journey. As highlighted by other uthors, 10,16,29-31 this reserch reinforces the importnce of good communiction nd collbortion between fmily physicins nd the oncology tem in order to keep the former involved t ll phses of cncer nd to promote shred cre in cncer follow-up. Future reserch should focus on developing nd evluting innovtive strtegies to increse interprofessionl collbortion to ultimtely improve continuity of cre for ptients with cncer. To red or post commentries in response to this rticle, see it online t http://www.nnfmmed.org/cgi/content/full/8/6/526. Key words: Cncer cre; fmily physicins; primry cre; ptient cre; ptient cre tem; multidisciplinry communiction; collbortion; continuity of cre; cncer follow-up Submitted December 14, 2009; submitted, revised, April 8, 2010; ccepted My 18, 2010. Funding support: This study ws supported by n operting grnt of the Cndin Institutes of Helth Reserch (CIHR), grnt MOP-68834. Acknowledgments: The uthors thnk Mr Serge Simrd, biosttisticin, for his dvice on dt nlyses, nd Mrs Lucie Misson nd Dnielle Mrleu for their role in ptient interviewing nd dt collection. References 1. Dudgeon D, Vitonis V, Seow H, King S, Angus H, Swk C. Ontrio, Cnd: using networks to integrte pllitive cre province-wide. 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