Improvements needed to better integrate PCPs into cancer survivorship care

Several cancer survivorship care models are available to help integrate primary care providers into the long-term follow-up care of cancer survivors.

However, limited data exist on the effectiveness of these models, as well as the specific roles primary care providers actually play, according to a series of papers published in The Lancet Oncology.

Shawna V. Hudson

Shawna V. Hudson, PhD, associate professor and research division chief in the department of family medicine and community health at Rutgers Robert Wood Johnson Medical School, and colleagues assessed conceptual survivorship care models included in more than a dozen published studies, all of which were intended to integrate primary care providers into cancer survivorship care.

“We found a number of gaps in the literature, the most glaring being that — despite a number of proposed care models — there remains limited empirical evidence regarding clinical outcomes,” Hudson, also a research member at Rutgers Cancer Institute of New Jersey, said in a press release. “Models emphasize the use of communication tools and processes to assign care based on risk factors; however, there was little evidence on how effective these models are and scant description of the role primary care providers might assume.”

HemOnc Today spoke with Hudson about the findings, as well as how oncologists and primary care providers can work together to ensure coordinated long-term follow-up care of cancer survivors.

Question: What prompted you and your colleagues to conduct this study?

Answer: The study came about after a group of us worked together on a variety of projects looking at the state of primary care and the state of cancer survivorship in the United States. We all were aware of and read the 2009 study published in Cancer that discussed where long-term cancer survivors receive their care. The research team, led by Lori A. “Loria” Pollack, MD, MPH, looked at Medicare recipients, and one of the things that struck us about the findings was that the longer a patient is out from initial treatment into survivorship, the less likely they are to see their cancer treatment team. In the study, researchers found that about 75% of patients diagnosed with some of the most common cancer types — such as breast, colorectal and prostate cancers — were seen by primary care providers, and this was something that did not change over time. This was striking to all of us engaged in primary care. It prompted us to ask what the resources and models are for these patients who are in our care. It was sort of the confluence of looking at the increasing numbers of cancer survivors in general and knowing there are many of them in primary care, but not knowing the state of the research and the state of care being provided in these settings.

Q: What did the findings suggest?

A: There are a variety of different models, so no one survivor has the same experience as another in terms of long-term follow-up care in the primary care setting. The literature suggested there were a number of initiatives in the past 5 to 6 years that focused on developing cancer survivorship clinics. We found that, although those are wonderful resources, they are not readily available to the majority of patients because there are so few. We also found there are multiple types of relationships between primary care doctors and cancer treatment teams when it comes to managing long-term care. One of our diagrams in the study delineates six different groupings of care available across different care settings.

Q: What needs to change to improve the follow-up care model and get more primary care providers involved?

A: A number of things need to happen. First, survivorship care plans are wonderful resources for patients who are newly diagnosed and are coming out of treatment. However, the majority of our cancer survivors are longer-term survivors, and they are living with late and long-term effects of their treatment. We need to get resources for those individuals. Also, not all cancer survivors are the same. Some are long-term survivors who may have been treated for a locally diagnosed cancer and received a cure. For these patients, primary care management may be perfectly appropriate. For patients who had metastatic disease or have cancer recurrences that occur more frequently, they may be better managed by a shared care model between their primary care provider and oncologist, or they may need to have the majority of their care in an oncology setting. We need to stop talking about survivors as one monolithic group and start thinking of them as individuals who have different risk profiles based upon the types of cancers they had and types of treatments they received. We need more of a personalized approach to follow-up care.

Q : What are the benefits of this approach from the perspective of patients and oncologists?

A: There is a better continuity of care. If a patient has a primary care provider who is working with the cancer treatment team, that transition from survivorship to the end of the intense period of initial treatment is a little smoother. Being able to have this continuity of care is a huge benefit for patients. It also helps providers — both the oncologist and the primary care provider — because many patients tend to be older and have comorbid conditions. This impacts the treatment they are receiving and the long-term effects of those treatments. Having a more tightly coupled relationship between the oncologist and primary care provider allows for a better flow of information and a more complete picture of what is going on.

Q: How can oncologists work with primary care providers to ensure coordinated follow-up care?

A: Anything that has to do with initial treatment and cancer treatment clearly needs to stay within the realm of oncology. However, there are a number of late effects associated with therapies that primary care providers can track and monitor. For example, some treatments are associated with increased cardiovascular risk factors, and this is routinely checked in the primary care setting. In terms of preventive care, primary care providers can refer patients for appropriate screenings based on their age and risk profile. Anything preventive makes sense within the primary care setting, and anything that has to do with chemotherapy and surgical intervention are most appropriately managed in the oncology setting.

Q: If primary care providers do become more involved, what must happen to maximize their participation?

A: Increased training would be important. Many primary care providers do not feel they know what is going on because treatment summaries in survivorship care plans often focus on the types of regimens — eg, chemotherapy — a patient had. Although this is useful information, it is necessary to include a summary of what can be done after a patient had exposure to a specific treatment. We need to provide training, support and resources to primary care providers so they know what treatment a patient received and — because of that treatment — what risk factors a patient has and what monitoring is necessary. Additionally, having the support of the oncologist is equally important.

Q: Is there anything else that you would like to mention?

A: A patient’s history of cancer may or may not be the most salient issue for them years after cancer treatment. However, reverberations of their cancer care experience on their health and wellness are important and should be monitored. We need to equip patients and providers with nimble survivorship tools that meet their long-term screening and care needs. – by Jennifer Southall

References:

Nekhlyudov L, et al. Lancet Oncol. 2017;doi: 10.1016/S1470-2045(16)30570-8.

Pollack L, et al. Cancer. 2009;doi:10.1002/cncr.24624.

Disclosure: Hudson reports no relevant financial disclosures.

Several cancer survivorship care models are available to help integrate primary care providers into the long-term follow-up care of cancer survivors.

However, limited data exist on the effectiveness of these models, as well as the specific roles primary care providers actually play, according to a series of papers published in The Lancet Oncology.

Shawna V. Hudson

Shawna V. Hudson, PhD, associate professor and research division chief in the department of family medicine and community health at Rutgers Robert Wood Johnson Medical School, and colleagues assessed conceptual survivorship care models included in more than a dozen published studies, all of which were intended to integrate primary care providers into cancer survivorship care.

“We found a number of gaps in the literature, the most glaring being that — despite a number of proposed care models — there remains limited empirical evidence regarding clinical outcomes,” Hudson, also a research member at Rutgers Cancer Institute of New Jersey, said in a press release. “Models emphasize the use of communication tools and processes to assign care based on risk factors; however, there was little evidence on how effective these models are and scant description of the role primary care providers might assume.”

HemOnc Today spoke with Hudson about the findings, as well as how oncologists and primary care providers can work together to ensure coordinated long-term follow-up care of cancer survivors.

Question: What prompted you and your colleagues to conduct this study?

Answer: The study came about after a group of us worked together on a variety of projects looking at the state of primary care and the state of cancer survivorship in the United States. We all were aware of and read the 2009 study published in Cancer that discussed where long-term cancer survivors receive their care. The research team, led by Lori A. “Loria” Pollack, MD, MPH, looked at Medicare recipients, and one of the things that struck us about the findings was that the longer a patient is out from initial treatment into survivorship, the less likely they are to see their cancer treatment team. In the study, researchers found that about 75% of patients diagnosed with some of the most common cancer types — such as breast, colorectal and prostate cancers — were seen by primary care providers, and this was something that did not change over time. This was striking to all of us engaged in primary care. It prompted us to ask what the resources and models are for these patients who are in our care. It was sort of the confluence of looking at the increasing numbers of cancer survivors in general and knowing there are many of them in primary care, but not knowing the state of the research and the state of care being provided in these settings.

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Q: What did the findings suggest?

A: There are a variety of different models, so no one survivor has the same experience as another in terms of long-term follow-up care in the primary care setting. The literature suggested there were a number of initiatives in the past 5 to 6 years that focused on developing cancer survivorship clinics. We found that, although those are wonderful resources, they are not readily available to the majority of patients because there are so few. We also found there are multiple types of relationships between primary care doctors and cancer treatment teams when it comes to managing long-term care. One of our diagrams in the study delineates six different groupings of care available across different care settings.

Q: What needs to change to improve the follow-up care model and get more primary care providers involved?

A: A number of things need to happen. First, survivorship care plans are wonderful resources for patients who are newly diagnosed and are coming out of treatment. However, the majority of our cancer survivors are longer-term survivors, and they are living with late and long-term effects of their treatment. We need to get resources for those individuals. Also, not all cancer survivors are the same. Some are long-term survivors who may have been treated for a locally diagnosed cancer and received a cure. For these patients, primary care management may be perfectly appropriate. For patients who had metastatic disease or have cancer recurrences that occur more frequently, they may be better managed by a shared care model between their primary care provider and oncologist, or they may need to have the majority of their care in an oncology setting. We need to stop talking about survivors as one monolithic group and start thinking of them as individuals who have different risk profiles based upon the types of cancers they had and types of treatments they received. We need more of a personalized approach to follow-up care.

Q : What are the benefits of this approach from the perspective of patients and oncologists?

A: There is a better continuity of care. If a patient has a primary care provider who is working with the cancer treatment team, that transition from survivorship to the end of the intense period of initial treatment is a little smoother. Being able to have this continuity of care is a huge benefit for patients. It also helps providers — both the oncologist and the primary care provider — because many patients tend to be older and have comorbid conditions. This impacts the treatment they are receiving and the long-term effects of those treatments. Having a more tightly coupled relationship between the oncologist and primary care provider allows for a better flow of information and a more complete picture of what is going on.

Q: How can oncologists work with primary care providers to ensure coordinated follow-up care?

A: Anything that has to do with initial treatment and cancer treatment clearly needs to stay within the realm of oncology. However, there are a number of late effects associated with therapies that primary care providers can track and monitor. For example, some treatments are associated with increased cardiovascular risk factors, and this is routinely checked in the primary care setting. In terms of preventive care, primary care providers can refer patients for appropriate screenings based on their age and risk profile. Anything preventive makes sense within the primary care setting, and anything that has to do with chemotherapy and surgical intervention are most appropriately managed in the oncology setting.

Q: If primary care providers do become more involved, what must happen to maximize their participation?

A: Increased training would be important. Many primary care providers do not feel they know what is going on because treatment summaries in survivorship care plans often focus on the types of regimens — eg, chemotherapy — a patient had. Although this is useful information, it is necessary to include a summary of what can be done after a patient had exposure to a specific treatment. We need to provide training, support and resources to primary care providers so they know what treatment a patient received and — because of that treatment — what risk factors a patient has and what monitoring is necessary. Additionally, having the support of the oncologist is equally important.

Q: Is there anything else that you would like to mention?

A: A patient’s history of cancer may or may not be the most salient issue for them years after cancer treatment. However, reverberations of their cancer care experience on their health and wellness are important and should be monitored. We need to equip patients and providers with nimble survivorship tools that meet their long-term screening and care needs. – by Jennifer Southall

References:

Nekhlyudov L, et al. Lancet Oncol. 2017;doi: 10.1016/S1470-2045(16)30570-8.

Pollack L, et al. Cancer. 2009;doi:10.1002/cncr.24624.

Disclosure: Hudson reports no relevant financial disclosures.