Cancer Screening of Long-term Cancer Survivors
Cancer Screening of Long-term Cancer Survivors
Background: Although 64% of cancer survivors are expected to live at least 5 years beyond diagnosis, the receipt of cancer screening by this population is unclear. The objective of this study was to assess the relation between a cancer diagnosis and future cancer screening, exploring provider-, patient-, and cancer-specific factors that explain observed relationships.
Methods: The Wisconsin Longitudinal Study (WLS) and Wisconsin Tumor Registry were used to identify 2 participant groups: 415 patients diagnosed with nonmetastatic cancer between 1992 to 1993 (before cancer) and 2003 to 2004 (after cancer) and 4680 controls (no cancer). Adjusted average predicted probabilities of cancer screening were estimated with models that first did not include and then included, provider (provider relationship length), participant (depressive symptoms per the Center for Epidemiologic Studies Depression Scale), and cancer-specific (time since diagnosis) factors. Participants with a history of cancer associated with a given screening test were then excluded to assess whether relationships are explained by screening for recurrence versus second cancers.
Results: Female cancer survivors were more likely than no-cancer controls to undergo pelvic/Papanicolaou screening (survivors: 70%, 95% confidence interval [CI]: 63% to 76%; controls: 61%, 95% CI: 59% to 63%) and mammography screening (survivors: 86%, 95% CI: 78% to 90%; controls: 76%, 95% CI: 74% to 77%), though male cancer survivors were not more likely to receive prostate exams (survivors: 76%, 95% CI: 70% to 82%; controls: 69%, 95% CI: 67% to 71%). After excluding people with a history of the cancer being screened for, there were few significant differences in cancer screening between short- or long-term survivors (≥5 years) and no-cancer controls. Relationships were not sensitive to adjustment for provider or participant factors.
Conclusions: The significant positive differences in cancer screening between people with and without cancer can be explained by screening for recurrence. Long-term cancer survivors are not more likely to receive follow-up screening for second cancers. This information should be used by providers to ensure patients receive recommended follow-up preventive care.
Cancer detection and treatment advances have produced declining cancer death rates, with 64% of cancer survivors expected to live ≥5 years from diagnosis. Despite improvements, cancer survivors remain at risk of recurrence and second cancers. In recognition of these risks, the Institute of Medicine outlined a critical need to improve the long-term follow-up of cancer survivors, including cancer screening, to optimize health outcomes.
Given long-term health risks, there is reason to believe cancer survivors would be likely to undergo recommended cancer screening, but evidence of whether this occurs is mixed. Several studies show cancer survivors to be more likely to receive mammograms, Papanicolaou smear/pelvic examinations, and prostate-specific antigen tests than adults without a personal history of cancer. Other studies found either no difference or underutilization of certain services once people with a history of the cancer being screened for were excluded. These studies were largely analyses of administrative datasets (eg, Surveillance, Epidemiology and End Results Reporting [SEER]–Medicare) and focused on recently diagnosed breast and colorectal cancer survivors older than age 65. This limits the ability to control for a comprehensive set of patient-level factors or explore mechanisms through which a cancer diagnosis influences screening behavior.
The amount of time a person has lived with cancer may influence cancer screening behavior. Surviving 5 years is considered a "milestone" that represents a reduction in health risks, though many long-term survivors remain at risk of recurrence and second cancers. Studies using SEER-Medicare data suggest that mammography and cervical cancer screening decline after a diagnosis of breast and colorectal cancer. Cancer screening, however, has not been described in individuals surviving longer than 5 years or compared with trends in people without cancer. Studies addressing this gap have important clinical implications. As the number of cancer survivors continues to increase, providers will need to remain vigilant in screening for recurrent and new cancers.
Research exploring factors that affect cancer screening has focused primarily on provider type and patient mental health. After 5 years from diagnosis, nearly two-thirds of cancer survivors visit their primary care physician (PCP) exclusively, making a shared care model for the systematic long-term care of cancer survivors less feasible. In primary care, continuity of care generally fosters patient adherence to physician recommendations for cancer-specific services, though this has not been explored for cancer survivors. Depressive symptoms are commonly reported by cancer survivors and could be a modifiable mechanism by which a diagnosis impacts screening, though to our knowledge this has not been explored. Cross-sectional studies have yielded mixed results, with some studies associating depressive symptoms with underutilization and others with more primary care visits or better guideline adherence.
We address prior limitations with a unique dataset that combines a longitudinal study with a state tumor registry database. This linkage allowed for an investigation of the relationship between a cancer diagnosis and cancer screening and provider and patient factors that explain screening behavior.
Abstract and Introduction
Abstract
Background: Although 64% of cancer survivors are expected to live at least 5 years beyond diagnosis, the receipt of cancer screening by this population is unclear. The objective of this study was to assess the relation between a cancer diagnosis and future cancer screening, exploring provider-, patient-, and cancer-specific factors that explain observed relationships.
Methods: The Wisconsin Longitudinal Study (WLS) and Wisconsin Tumor Registry were used to identify 2 participant groups: 415 patients diagnosed with nonmetastatic cancer between 1992 to 1993 (before cancer) and 2003 to 2004 (after cancer) and 4680 controls (no cancer). Adjusted average predicted probabilities of cancer screening were estimated with models that first did not include and then included, provider (provider relationship length), participant (depressive symptoms per the Center for Epidemiologic Studies Depression Scale), and cancer-specific (time since diagnosis) factors. Participants with a history of cancer associated with a given screening test were then excluded to assess whether relationships are explained by screening for recurrence versus second cancers.
Results: Female cancer survivors were more likely than no-cancer controls to undergo pelvic/Papanicolaou screening (survivors: 70%, 95% confidence interval [CI]: 63% to 76%; controls: 61%, 95% CI: 59% to 63%) and mammography screening (survivors: 86%, 95% CI: 78% to 90%; controls: 76%, 95% CI: 74% to 77%), though male cancer survivors were not more likely to receive prostate exams (survivors: 76%, 95% CI: 70% to 82%; controls: 69%, 95% CI: 67% to 71%). After excluding people with a history of the cancer being screened for, there were few significant differences in cancer screening between short- or long-term survivors (≥5 years) and no-cancer controls. Relationships were not sensitive to adjustment for provider or participant factors.
Conclusions: The significant positive differences in cancer screening between people with and without cancer can be explained by screening for recurrence. Long-term cancer survivors are not more likely to receive follow-up screening for second cancers. This information should be used by providers to ensure patients receive recommended follow-up preventive care.
Introduction
Cancer detection and treatment advances have produced declining cancer death rates, with 64% of cancer survivors expected to live ≥5 years from diagnosis. Despite improvements, cancer survivors remain at risk of recurrence and second cancers. In recognition of these risks, the Institute of Medicine outlined a critical need to improve the long-term follow-up of cancer survivors, including cancer screening, to optimize health outcomes.
Given long-term health risks, there is reason to believe cancer survivors would be likely to undergo recommended cancer screening, but evidence of whether this occurs is mixed. Several studies show cancer survivors to be more likely to receive mammograms, Papanicolaou smear/pelvic examinations, and prostate-specific antigen tests than adults without a personal history of cancer. Other studies found either no difference or underutilization of certain services once people with a history of the cancer being screened for were excluded. These studies were largely analyses of administrative datasets (eg, Surveillance, Epidemiology and End Results Reporting [SEER]–Medicare) and focused on recently diagnosed breast and colorectal cancer survivors older than age 65. This limits the ability to control for a comprehensive set of patient-level factors or explore mechanisms through which a cancer diagnosis influences screening behavior.
The amount of time a person has lived with cancer may influence cancer screening behavior. Surviving 5 years is considered a "milestone" that represents a reduction in health risks, though many long-term survivors remain at risk of recurrence and second cancers. Studies using SEER-Medicare data suggest that mammography and cervical cancer screening decline after a diagnosis of breast and colorectal cancer. Cancer screening, however, has not been described in individuals surviving longer than 5 years or compared with trends in people without cancer. Studies addressing this gap have important clinical implications. As the number of cancer survivors continues to increase, providers will need to remain vigilant in screening for recurrent and new cancers.
Research exploring factors that affect cancer screening has focused primarily on provider type and patient mental health. After 5 years from diagnosis, nearly two-thirds of cancer survivors visit their primary care physician (PCP) exclusively, making a shared care model for the systematic long-term care of cancer survivors less feasible. In primary care, continuity of care generally fosters patient adherence to physician recommendations for cancer-specific services, though this has not been explored for cancer survivors. Depressive symptoms are commonly reported by cancer survivors and could be a modifiable mechanism by which a diagnosis impacts screening, though to our knowledge this has not been explored. Cross-sectional studies have yielded mixed results, with some studies associating depressive symptoms with underutilization and others with more primary care visits or better guideline adherence.
We address prior limitations with a unique dataset that combines a longitudinal study with a state tumor registry database. This linkage allowed for an investigation of the relationship between a cancer diagnosis and cancer screening and provider and patient factors that explain screening behavior.
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