Improvements in cancer screening and therapy have resulted in a growing number of cancer survivors. The transition between initial therapy and surveillance has unique challenges [1]. Oncology visits often continue but focus on cancer issues and do not include screening for other malignancies or general health monitoring. Previous research suggests that when care is shared between specialists and primary care providers (PCPs), survivors receive better health care [2–4]. Yet, the role of the PCP in survivorship care is often unclear and communication is inadequate between the oncologist, PCP and patient [5–7].

The 2005 Institute of Medicine report on cancer survivorship, From Cancer Patient to Cancer Survivor: Lost in Transition called for the development of cancer survivor documents for survivors and their PCPs [8]. In 2015 the American College of Surgeons Commission on Cancer will require a survivorship care plan (SCP) for cancer survivors [9]. A SCP has the potential to facilitate communication about the oncology experience. Ideally, it provides a clear outline of the diagnosis, treatments received, plan for monitoring and clarifies the roles of the medical providers involved in the survivor’s care.

PCPs clearly favor the receipt of a summary of cancer diagnosis and care [6,10] and their perceptions of SCPs have been positive [11]. However, there is limited research evaluating how PCPs perceive SCPs developed for their own patients. It is also unknown whether the needs and preferences of PCPs in different practice settings differ regarding follow up care of cancer survivors. We evaluated PCPs’ understanding of and satisfaction with SCPs prepared for breast and colorectal cancer survivors in their practice. Additionally we examined whether PCP response to the SCPs varied according to characteristics of the practitioner and their practice.

SCPs were developed for breast and colorectal cancer patients and mailed to their PCPs at an urban and rural cancer center. In 2010, the urban area had a census of greater than 150,000, while the rural area had a population of approximately 31,000. All stage 0–3 breast cancer and stage 2–4 colorectal cancer patients who received intent to cure oncologic interventions between January 2011 and July 2011 were eligible to receive a SCP. A total of 89 patients were invited to participate in the study and 78 agreed (88%), including 61 with breast cancer and 17 with colorectal cancer.

Of the 55 surveys sent to PCPs, 39 were returned for a response rate of 70.9%. We received 22 surveys from PCP’s in the urban area and 17 from PCP’s in the rural area. Demographic characteristics of respondents are summarized in Table 1. The majority of respondents were female and family practice physicians. The demographic characteristics between rural and urban centers were similar other than a predominance of female providers in the rural area.

Nearly all PCP's reported that the SCP was easy to understand (97%), incorporated appropriate topics (97%) and was useful (90%). However 16% disagreed that the length of the SCP (which was on average 5 pages) was "just right". Written comments concurred that several PCPs felt the SCP was too long.

In general, PCP’s felt that SCPs developed for their patients contributed to their understanding of the cancer diagnosis and treatment and would improve communication with cancer treatment providers and survivors. However, we discovered differences between urban and rural PCPs and those in practice less than 18 years compared with those in practice longer. We also found that PCPs encounter substantial barriers in providing survivorship care.

Our survey results are consistent with a recent study based on semi-structured interviews of primary care providers receiving SCPs for their patients who felt SCPs increased their knowledge about their patient’s cancer history and recommendations for surveillance [11]. There were two notable exceptions regarding the agreement between the two studies: 1) the role of PCP and oncologist in survivorship care and; 2) division of responsibility for monitoring for recurrence and new primary cancers.

Despite receiving a SCP for a specific patient, many urban and rural PCPs remained unclear about their role in survivorship care and how primary care and oncology might share responsibility. The rural PCPs were significantly less likely to understand their role in follow up care and continuing education efforts should target them. There is not a defined time to transfer the care of a cancer survivor from oncology to primary care. Commonly patients continue to see both a PCP and an oncologist for an extended period making it difficult to clearly delineate who is responsible for follow up care. As a result, many aspects of survivorship follow up may remain ambiguous. Additionally, a majority of PCPs feel that primary care guidelines for adult cancer survivors are not well defined [14].

Significant differences have been reported between oncologists and PCPs in the attitudes, knowledge and practices for cancer survivor care [15]. PCPs express concern that they do not know what surveillance tests are needed or the appropriate duration of surveillance [5,11]. They are also more likely to endorse the use of non-recommended tests for follow up than are oncologists [15]. The SCP should clearly specify which physician is responsible for ordering which monitoring test. This will require clear guidelines from national professional organizations which incorporate input from oncologists and PCPs and define follow up monitoring and the role of the PCP in cancer survivor care. Oncology organizations should be encouraged to establishing clear guidelines delineating responsibility of cancer survivor care.

PCPs in practice a longer time expressed less understanding of the requirements for monitoring for late or chronic problems that result from cancer therapy. As cancer therapy has become more complex, primary care providers further from initial training may be unfamiliar with newer interventions and less aware of the current consequences of cancer therapy. Knowledge of the late and long term impact of cancer therapy is important for PCPs as patients may see them first about these symptoms and late and lingering effects may impact organ systems for which the patient is being monitored.

PCPs generally agreed that the detail in the SCP was adequate. However, PCP’s from the rural area were significantly less likely to agree that the SCP provided sufficient content to help them obtain tests for monitoring. Perhaps PCP’s in the urban area, who were often associated with an academic center, receive more cancer related education or presumed they had easier access to oncologists should questions arise. Additionally, actual monitoring recommendations may be less clearly defined than PCP’s anticipate and recommendations vary by cancer type which contributes to confusion about surveillance.

Insufficient knowledge of cancer survivor issues was a commonly identified barrier among PCPs and may partially explain why they felt the SCP provided insufficient detail. PCP uncertainty about late effects of cancer and follow up care recommendations has been identified by others [15]. Given the uncertainty PCPs have about late effects and what tests are needed for monitoring, continuing medical education should include more information about cancer therapy, long term and late effects of therapy, and surveillance of recurrence and new primary cancers.

Our findings have several limitations. The small sample size limits statistical power to detect small differences in responses by PCP characteristics. The use of a quantitative survey is also a limitation, as a qualitative approach may have provided a richer understanding of the complexities faced by PCPs when using information contained in a SCPs in a busy practice. While the response rate was high, non-respondents may have differed in their assessment of the SCPs. Despite including PCPs practicing in both urban and rural areas, the survey was administered in a geographically localized area which limits generalizability of the study results. Participating PCPs in the urban area may be more integrated with the academic cancer center where most of their patients would receive oncologic care. They may also have more education opportunities and greater access to oncologists thus alleviating concerns about monitoring.

SCPs have the potential to strengthen communication, facilitate care coordination, clarify roles, and lessen PCPs anxiety about providing adequate care, thus increasing the opportunity for more primary care of cancer survivors. PCPs in rural and urban areas appear to find SCPs developed for their patients understandable and the content sufficiently detailed for most topics. However, usefulness of SCPs can be enhanced. Given the time challenges PCPs face SCP should as short and precise as possible. Clear delineation of roles between PCPs and oncologists and specific information within the SCP regarding late and long term effects and monitoring tests are needed. Oncology organizations should be encouraged to develop well-defined follow up recommendations. Ideally a SCP could be updated as new information regarding impacts of cancer treatment and follow up recommendations evolve. A disease and care management model that empowers patients, which improves health care team collaboration and patient outcomes has been found to be beneficial for patient with chronic disease [16] and would likely enhance cancer survivor care. This approach would be a particular advantage in rural settings by helping facilitate appropriate testing and communication with specialists. At a minimum, continuing education regarding cancer survivor issues will help relieve the dissonance PCPs may feel about assuming a larger role in cancer survivor care and their perception of insufficient knowledge of survivor issues and follow up.