September 25, 2017
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Comprehensive cancer survivorship services lacking in primary care

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New data have demonstrated an absence of comprehensive care for cancer survivors integrated into primary care practices.

“Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors,” Ellen B. Rubinstein, PhD, from the Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J., and colleagues wrote in their study published in JAMA Internal Medicine.

Rubinstein and colleagues conducted a comparative case study of 12 advanced primary care practices in the United States to determine why comprehensive services targeting long-term cancer survivors have not been widely integrated into primary care. These practices were selected between March 2015 and February 2017 from a national registry of 151 workforce innovators.

The researchers selected diverse practices in regard to policy context and organizational structure. The practices also came from multiple states and had a combination of physicians trained in family or internal medicine. Most practices (nine out of 12) were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes.

For each practice, the researchers collected ethnographic data, including interviews with practice personnel and patient pathways with cancer survivors, for 10 to 12 days. Participating practices were asked about barriers to care innovation, knowledge of survivorship care guidelines and how patients are referred to cancer care.

Comprehensive survivorship care included favorable conditions and infrastructure, as well as the implementation of disease registries, care coordination and communication with specialists. The researchers identified prominent themes within and across cases by analyzing fieldnotes, transcripts and practice documents.

Results showed that comprehensive cancer survivorship services of any kind were not provided by any of the practices. Rather, patients received care comparable to that of nonsurvivors. The researchers found three interdependent explanatory factors: a lack of a distinct clinical category of survivorship in primary care; the absence of accessible strategies to treat the population; and information systems incapable of supporting survivorship care.

Comprehensive cancer survivorship care is not happening in advanced [patient-centered medical homes],” Rubinstein and colleagues concluded. “The absence of this care is from the lack of concrete solutions to needs that precede the development and implementation of models of care. ... By correcting [the three identified] deficiencies, comprehensive cancer survivorship services could more easily integrate into current primary care transformation efforts.”

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In a related commentary, Emily S. Tonorezos, MD, MPH, from Memorial Sloan Kettering Cancer Center, New York, and Joseph Conigliaro, MD, MPH, from Northwell Health, Manhasset, N.Y., wrote that the findings by Rubinstein and colleagues offer great insight into primary care cancer survivorship and highlight opportunities for future research.

“Next steps in this work should include building cancer diagnosis and stage into a searchable field in the medical record, developing clinical decision aids that incorporate evidence-based follow-up guidelines at the point of care, and creating communication facilitators that allow for reimbursable and expedited exchanges between primary care and oncology clinicians,” Tonorezos and Conigliaro wrote.

“Rubenstein and colleagues have engaged innovative and high-quality methods to produce the first step in this process: describing the current primary care environment for cancer survivors,” they added. “Although there is still much that can be studied to understand the reasons for the observed breakdowns, it is not too early for testing creative and innovative approaches to enrich this care.” – by Alaina Tedesco

Disclosures: The researchers, Conigliaro and Tonorezos report no relevant financial disclosures.