The number of cancer survivors continues to increase in the United States, which can be attributed to a growing and aging population, as well as recent advances in diagnosis and treatment. The Institute of Medicine advises that every cancer survivor receive a survivorship care plan summarizing his or her diagnosis, treatment, and recommendations regarding follow-up care. These plans play an important role as patients transition from their oncology care team to their primary care physician (PCP). Unfortunately, the inclusion of PCPs into survivorship care plans is often overlooked, despite the fact that these healthcare professionals remain key players in survivorship care delivery.
At the 2022 American Association for Cancer Research annual meeting, Kevin Oeffinger, MD, Founding Director, Duke Cancer Institute Center for Onco-Primary Care, and Director, Duke Cancer Institute Supportive Care and Survivorship Center, Durham, NC, discussed evolving models of survivorship care that incorporate PCPs, including a program at his institution.
Models of Survivorship Care
“Many survivorship initiatives are based on the shared-care model—the idea of including PCPs in the care of patients with cancer,” explained Dr Oeffinger.
The most efficient programs are those that risk-stratify survivors, that is, making sure the follow-up care is tailored to the needs of the individual patient based on his or her cancer history.
Dr Oeffinger described lessons learned from separate model programs at Memorial Sloan Kettering Cancer Center (a high-volume center) and Johns Hopkins (a low-volume center).
“From the perspective of the oncologist, he or she likes to see healthy survivors to balance out the day. Follow-up visits [with the survivor] add to the incredible bond of trust between the oncologist and survivor, and it can be a struggle to find a PCP to follow the patient. Without a survivorship program, survivorship care is not risk-stratified, and all survivors are treated the same way, although they have different needs,” Dr Oeffinger pointed out.
“From the PCP point of view, they see their primary care patients go into the ‘black hole’ of cancer care and emerge 5 years later back in primary care practice. There is often poor communication from the oncologist, and the oncology care plan uses jargon and terminology not easily understood,” he explained. “Unlike oncologists, PCPs do not consider survivorship a phase. Rather, they think of their patients in the context of the life continuum in which cancer was just one of the major events in their lives.”
Dr Oeffinger emphasized that survivorship care should be simplified and made more efficient. PCPs need to be informed about the type of care the patient needs and what the priorities are.
Onco-Primary Care at Duke
The Duke Cancer Institute for Onco-Primary Care program represents a partnership between oncology and primary care. The Duke Primary Care Network includes 300 PCPs across 40 medical sites in North Carolina. All of these practices share the same electronic health records.
An important goal is to avoid redundancy of care and transition to value-based care. The program encompasses the entire cancer continuum from prevention to survivorship/chronic cancer care and includes end-of-life care. The focus is on screening, ease of referrals, and managing patients on chemotherapy. Relationship-building is an important component of the program.
“With the help of researchers, we identify efficient and high-quality approaches to communication. We want to work in a timely fashion, with the underpinning of research and quality improvement,” Dr Oeffinger said.
“Training and education in survivorship care involves medical students, nursing students, residents, fellows, and post-docs. Think of the circle of care. After cancer, you go around the circle again to screening and prevention and primary care,” he said.
The shared-approach program at Duke Cancer Institute has yielded positive outcomes. Thus far, using electronic health records, the program has instituted a streamlined prostate-specific antigen screening effort to omit screening when not necessary and ensure patients at higher risk are screened more often; a cancer diagnostic service; and an alert system that flags cardiovascular problems for patients with chronic lymphocytic leukemia treated with ibrutinib (Imbruvica). These efforts have improved survivorship care, he said.
“Traditions change slowly. A multidisciplinary approach is essential for a program like this. It is a partnership between PCPs and oncologists. It is not a top-down approach. We pilot and pilot and pilot initiatives to identify those that are scalable and generalizable. And we implement risk stratification,” Dr Oeffinger concluded.