Evaluation of treatment completion note used by the BC Cancer Agency Centre for the North

Background
The BC Cancer Agency (BCCA) is the sole provider of radiotherapy (RT) in British Columbia and the Yukon and plays a major role in administering systemic therapy. The BCCA Centre for the North treats residents from all over Northern BC, which covers 600 000 km². In 2013 there were 613 cancer cases requiring radiotherapy in this area.

Cancer patients may undergo RT for curative or palliative purposes, and after treatment by an oncologist they usually return to the care of a family physician (FP). There are a number of reasons for this: it is generally more convenient for an FP to see a patient on a regular basis (especially if the patient resides in a rural location), the FP has likely already established rapport with the patient and family over a number of years, and returning a patient to an FP for care allows the radiation oncologist, a limited resource, to focus attention on patients who need the care of a specialist.[1] 

When a patient finishes undergoing RT, a treatment completion note (TCN) from the radiation oncologist is sent to the FP. In the past, TCNs have primarily served to document radiation treatment details. We hypothesized that including additional information would make these notes more useful to FPs following patients after RT and could improve communication during the transition from oncology back to primary care home. We proposed a study to evaluate the usefulness of TCNs prepared for referring FPs by radiation oncologists at the BCCA Centre for the North, which serves the largest geographic area in BC but has the smallest treatment population (Table 1).

The primary goal of this study was to determine the effectiveness of TCNs used in Northern BC, a jurisdiction where patients have identified unmet needs after cancer treatment.[2,3] Patients from rural communities often face significant barriers to obtaining follow-up at the cancer centre. This is particularly true for many First Nations patients.[2,3] Studies indicate patients in these communities feel their FPs work in isolation, are disconnected from the specialist cancer team, and lack information needed to provide follow-up care after radiotherapy.[2,3] 

The secondary goal of this study was to determine what information family physicians would like to see that was not in TCNs. We expected that FPs would have specific suggestions for improving the current radiation oncology TCN template used in Northern BC.

Methods
A mixed methods evaluation was used to assess the current BCCA Centre for the North radiation oncology TCN. The Cancer Agency Information System (CAIS) at the BCCA was used to obtain information regarding patients, their type of cancer treatment, and physician contact information. A questionnaire was developed and sent along with the TCN to all FPs caring for patients treated with RT at the BCCA Centre for the North between 1 November 2012 (when the centre opened in Prince George) and 31 August 2013. Family physicians who completed the questionnaire were reimbursed for their time. 

The questionnaire asked physicians to evaluate the clarity of information provided on the TCN regarding follow-up responsibility, follow-up schedule, side effects of treatment, when to contact the oncologist, and transition of care from oncology back to primary care home. These questions were scored on a 7-point Likert scale, with 1 being not clear and 7 being very clear. FPs were also asked to indicate which of the following they would find useful in a treatment completion letter: radiation therapy technique, dose, common side effects of treatment, rare but serious side effects of treatment, and contact information for the oncologist.

Responses were analyzed using SPSS (Statistical Package for the Social Sciences) version 14.0. ANOVA and Kruskal-Wallis tests were conducted for questions scored on the Likert scale.

This study was the first to evaluate TCNs used by BCCA radiation oncologists to communicate with FPs, and it was approved by the Research Ethics Board at the University of Northern British Columbia, the Research Review Committee at Northern Health, and the joint Research Ethics Board of BCCA and the University of British Columbia. Physician engagement aspects of the study and some staff support were provided by Northern Partners in Care, an initiative funded by the Shared Care Committee of Doctors of BC and the Ministry of Health.

Results
Of the 180 questionnaires mailed to family physicians, 121 were completed and returned, for a response rate of 67%. Two recurring themes were evident in survey responses: the need for information on side effects of treatment and the need for information on constructing a follow-up care plan.

Family physicians asked about the clarity of the current Centre for the North TCN rated the follow-up schedule information highest (mean 5.9) and the side effects of treatment information lowest (mean 3.5) (Table 2). Looking at all clarity scores from the survey (Figure 1), FPs ranked the information in order from most to least clear: follow-up schedule, follow-up responsibility, transition from oncology back to primary care home, when to contact the oncologist, and treatment side effects (P < .001).

When FPs were asked about specific information they would find useful (Figure 2), the majority indicated interest in common side effects of treatment (83%), treatment intent (75%), rare but serious side effects of treatment (59%), and contact information for the oncologist (55%), while a minority indicated interest in information about radiotherapy specifics, including treatment technique (42%) and dose (21%) (P < .001).

Side effects
FPs showed particular interest in knowing more about common side effects associated with radiotherapy: how often they occur, how to manage them, and when to refer the patient to the oncologist for management. Physicians said they would like to have a health care professional familiar with oncological practice available for consultation or a link on the BCCA website to resources that address knowledge gaps.

Follow-up plan
FPs stated that establishing a specific and detailed follow-up plan for patient care was essential. Such a plan would outline who is responsible for which aspects of care, what is required (including any investigations), and when follow-up should occur. Also, physicians indicated it would be helpful to know exactly what information had already been conveyed to patients by BCCA staff regarding treatment, follow-up, and prognosis.

Conclusions
In this study we found that FPs were moderately satisfied with the treatment completion note being used by the BCCA Centre for the North and wanted to see improvements regarding the following information: 
•    When family physicians should contact the oncologist.
•    Side effects of radiotherapy. 
•    Transition from oncology back to primary care home.

The lack of satisfaction with information supporting the transition from oncology back to primary care home may have been due to patients dying while undergoing treatment, as noted by respondents in the general comment section of the evaluation. 

Our finding that FPs were not satisfied with information in the TCN about when to contact the oncologist is seen in previous research in London, Ontario, by Wood, who found FPs were uncertain about contacting specialists regarding patient problems.[4] Wood felt this might be partially explained by FP concerns that they would lose specialist support through overuse, cause anxiety in patients with specialist referral for nonspecific symptoms, or not have adequate knowledge of oncological care.[4]

Our finding that most FPs wanted information about common and rare side effects and treatment intent rather than radiotherapy specifics is consistent with other study results showing TCNs lack information regarding potential side effects and pain management and focus too much on radiation treatment.[5,6] We suspect that FPs want more information on side effects so that they can identify and manage these themselves, which would improve the effectiveness and timeliness of care for patients. This might also reduce the burden on radiation oncologists and decrease wait times. Indicating in a TCN whether treatment intent is palliative or curative would help FPs manage patient symptoms more appropriately and provide emotional support to the patient and family.

Our finding that FPs want help establishing a detailed follow-up plan is consistent with other research.[4] The concern about follow-up was also seen in a study at the Royal Prince Alfred Hospital Department of Surgical Oncology in Australia, where researchers found that physicians generally regard information about diagnosis, further tests needed, prognosis, likely benefits of treatment, and possible side effects as essential in letters of referral and reply.[7] 

FPs in our study suggested addressing knowledge gaps by providing a contact person, either an oncology nurse or knowledgeable general practitioner, or supplying online educational resources. Similarly, FPs surveyed by Wood suggested setting up a contact person at the regional cancer centre to relay information, arranging for telephone consultation with the oncologist upon patient discharge, deciding on a follow-up plan and guidelines for each patient, and holding informal discussion groups with oncologists.[4]

In other research, cancer specialists identified the limited knowledge of FPs regarding cancer management as a problem.[8] Solutions suggested include establishing communication and collaboration at the time of initial consultation and at the end of cancer treatment, developing a shared follow-up plan, and holding informal educational seminars.[8-11]

Study strengths and limitations
This study should be interpreted in the context of its strengths and limitations. The TCN considered in this study may not be typical of TCNs in other parts of the province since each radiation oncologist provides a different amount of detail when treatment is complete. Delay in reporting on patients by radiation oncologists and delay in the time between discharge and presentation may have led to recall bias and misleading responses. However, our survey had a relatively high response rate that suggests the results are generalizable to Northern BC physicians, and the suggestions provided by FPs give us an opportunity to improve communication between specialists and family physicians.

Improving communication 
Results from this study highlight challenges faced by family physicians responsible for patients who have completed RT, and suggest strategies to improve communication and support more effective care of patients following treatment. As expected, northern FPs had specific recommendations for improvements to the current TCN. The improved TCN would describe RT side effects in more detail and explain what follow-up is required, when, and by whom. It would also clarify which side effects should lead the FP to contact the oncologist and provide clear contact instructions.

Based on family physician feedback, a new standardized treatment completion note template will be developed to include common and rare side effects of RT, treatment intent, and a clear follow-up plan. The research team is considering how this work could be used to address other forms of communication between specialists and FPs (consult letters, discharge summaries, etc.) and is also considering how such information could be incorporated into the patient’s electronic medical record to make follow-up more effective and efficient. 

Acknowledgments 
Dr Horvat’s work on this study was supported in part by a grant from the Shared Care Committee, a collaboration between Doctors of BC and the Ministry of Health to improve the flow of patients from primary to specialist care. 

Competing interests
None declared.

This article has been peer reviewed.

Ms Dang is a third-year medical student with the University of British Columbia’s Northern Medical Program. Dr Horvat is a family physician with experience in urban and rural settings and a co-leader of the Northern Partners in Shared Care initiative. He is also an assistant professor in the Northern Medical Program and a clinical assistant professor in the Faculty of Medicine at the University of British Columbia. Dr Klassen-Ross is a researcher at the University of Northern British Columbia and involved in medical student education. At the time of writing, Ms Collins was a research associate with Northern Partners in Care. Mr Graveline is the manager of Northern Partners in Care. Dr Olson is the department head of radiation oncology at the BC Cancer Agency Centre for the North, and an associate professor and the division head of radiation oncology and developmental radiotherapeutics at UBC.