Recently published data from Memorial Sloan Kettering show that most of the guidelines primary care physicians (PCPs) can turn to for advice about appropriate cancer survivorship care are vague and inconsistent. This lack of clarity reinforces a perceived need for specialty care and feeds patient anxiety and overtesting.
The study (1) looked at 41 guidelines, predominantly from professional organizations, published between January 1, 2010, and March 1, 2016, and found that 83 percent had ambiguous recommendations (i.e., modality not discussed or discussed without a clear recommendation).
This issue, along with other barriers to PCP ownership of the care of cancer survivors, is addressed in maintenance of certification and accredited continuing medical education (CME) workshops created by MSK in which our expert survivorship clinicians (both doctors and nurse practitioners) come to PCP practices to deliver practical education about survivorship care in an interactive small-group setting.
MSK is committed to partnering with PCPs to help them care for cancer survivors, and we are continuously researching and setting up evidence-based initiatives to support this burgeoning population.
A Growing Demographic
The aging of the population coupled with advances in cancer therapies and reduced cancer mortality has led to a massive increase in the number of cancer survivors. In the United States in 2016, there were 15.5 million cancer survivors; this number is expected to grow to more than 20 million by 2026. (2)Many survivors live for years after the completion of cancer therapy and may have complex healthcare needs related to their cancer, cancer therapies, and other comorbid conditions.
In its 2006 report entitled “From Cancer Patient to Cancer Survivor: Lost in Translation,” the Institute of Medicine (IOM) sought to raise awareness about the needs of cancer survivors and to highlight important components of care coordination among oncologists, PCPs, and other specialists for this population. (3)In more recent years, there has been growing recognition that PCPs have a central role to play in the care of these patients.
Four Components of Care
The IOM identified four essential components of survivorship care: prevention of cancer and late effects of cancer therapies, surveillance for cancer and physical and psychological late effects of therapy, treatment of problems related to cancer therapy (including psychological distress), and care coordination. The approach to these issues is similar to that in patients with other chronic conditions and thus falls squarely in the purview of PCPs. For example, most recommended preventive measures are achieved through optimizing lifestyle choices, such as diet and exercise. (4) Cancer survivors who return to their PCP for comprehensive care should have a survivorship care plan created by their cancer care team that provides the details of the cancer therapies received, describes potential harmful effects of those therapies, and makes recommendations about surveillance testing needs.
Overcoming Barriers
Despite its appropriateness, there are a number of barriers to PCP ownership of the care of cancer survivors related to both patient and clinician factors. Patients often form a strong emotional attachment to their cancer care team and may be fearful of relinquishing that relationship, feeling that a return to community-based care, without seeing an oncologist or other cancer specialist, may threaten their future health. Complicating these emotions is the presence of an underlying mood or anxiety disorder, both of which are prevalent in cancer survivors. (5)At the same time, PCPs may feel ill-prepared to provide high-quality care to cancer survivors or believe that survivors are best served by ongoing specialty oncology care. (6) They may also perceive that patients need much more testing than they actually do, since testing recommendations are often similar to cancer screening recommendations for the general population.
As well as our CME-accredited workshops, MSK experts have created web-based and paper-based information resources to serve as real-time references during clinical care. In addition, when our patients return to a community care setting, we provide every patient with a personalized survivorship care plan, as mentioned above, that describes the treatment received, possible long-term complications to look for, and recommended testing. We are also always available via phone or email to offer advice and answer questions and will expedite the return of patients if a new cancer-related need arises. Through these educational and care coordination efforts we believe that we can help our cancer survivors successfully traverse the gap from cancer treatment back to community-based primary care.