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From Cancer Patient to Cancer Survivor: Lost in Transition (2006)

Chapter:5 Providers of Survivorship Care: Their Supply and Education and Training

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Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
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5
Providers of Survivorship Care: Their Supply and Education and Training

With the number of cancer survivors in the United States at 10 million and expected to increase, concerns have arisen about the supply of adequately trained health professionals to provide survivorship care. This chapter enumerates providers of survivorship care and then reviews the inclusion of survivorship content in the educational and training programs of selected health professionals involved in survivorship care. Support for professional education and training in survivorship is then described. Finally, the committee puts forth its recommendations to improve the capacity of the survivorship workforce.

SUPPLY OF SURVIVORSHIP CARE PROVIDERS

Survivorship care is by nature multidisciplinary and ideally provided using a team approach. Physicians are the likely coordinators of survivorship care, but as a National Cancer Institute (NCI) Fact Sheet describing the cancer health care team informs consumers, “Your Doctor Is Only the Beginning” (NCI, 2000). Physicians and nurses are often links to many other important care providers, including those in the areas of social work, psychology, rehabilitation, and genetic counseling.

Using the best available data on the supply of health personnel, an attempt is made in Tables 5-1 and 5-2 to assess the availability of selected providers of survivorship care. Table 5-1 shows the numbers of physicians in various disciplines certified by the American Board of Medical Special-

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

ties1 (ABMS) and the membership of related professional societies. For nurses, physical and occupational therapists, social workers, mental health professionals, and other nonphysician providers involved in survivorship care, Table 5-2 shows the number of licensed or certified personnel when applicable and the relevant professional societies.2 The professional societies of physicians, nurses, and other providers are often the main source of continuing medical education for their specialty and so are key to any effort to raise awareness of survivorship care.

Important disciplines relevant to survivorship care are not represented in these tables. The expertise of cardiologists, neurologists, and endocrinologists, for example, may be needed to diagnose and manage cancer’s late effects. Although these estimates are incomplete and imprecise, they point to potential shortages of trained personnel given the size of the survivorship population. Concerns about the future supply of physicians, nurses, and other providers available to care for an older cancer patient population have been voiced since the early 1990s (Kennedy, 1994), but there are few studies of health personnel capacity to gauge the extent of the problem. The Association of American Medical Colleges (AAMC) and the American Society for Clinical Oncology (ASCO) are partnering to study whether the future supply of clinical oncologists will be sufficient to meet future health care needs (ASCO, AAMC to assess clinical oncology workforce, 2005). Better information on all survivorship-related health care personnel is needed to plan for health care delivery and education and training.

STATUS OF PROFESSIONAL EDUCATION AND TRAINING

Cancer survivorship care as a distinct phase of the cancer trajectory is a relatively new construct, and health professional schools’ curricula have generally not included much content in this area. This needs to change, but a larger task is providing continuing medical education to professionals who have completed their formal training and are encountering cancer survivors in their practices. The question of who to train is a complicated one because survivorship care encompasses both medical and psychosocial issues and a diverse set of providers can potentially be involved. The content of any survivorship curricula is also not straightforward. Providers need to be apprised of the risks of cancer treatments, the probabilities of cancer recurrence and second cancers, the effectiveness of surveillance and interventions for late effects, the need to address psychosocial concerns, the

1  

By 2003, more than 85 percent of licensed physicians in the United States were certified by at least one ABMS Member Board (ABMS, 2004b).

2  

Membership in a professional association is a very rough marker for supply of specific types of providers because an organization can include members from various professions.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

TABLE 5-1 Estimates of the Supply of Selected Physicians Who Provide Survivorship Care

Type of Physician

Number of Physicians

Physician specialist

Medical oncology

• Board certified

9,708

 

• American Society of Clinical Oncology

12,603

Radiation oncology

• Board certified

4,005

 

• American Society for Therapeutic Radiology and Oncology

3,900

Hematology

• Board certified

5,794

 

• American Society of Hematology

4,233

Surgery

• Board certified

35,403

 

• Society for Surgical Oncology

1,700

Colorectal surgery

• Board certified

1,317

 

• American Society of Colon and Rectal Surgeons

1,000

Thoracic surgery

• Board certified

5,693

 

• Society of Thoracic Surgeons

4,200c

Breast surgery

• American Society of Breast Surgeons

1,900

Ear Nose & Throat (Otolaryngology)

• Board certified

10,165

Urology

• Board certified

10,512

 

• American Urological Association

9,738a

Gynecologic oncology

• Board certified

718

 

• Society of Gynecologic Oncologists

872

Physiatry

• Board certified

6,604

 

• American Academy of Physical Medicine and Rehabilitation (AAPM&R)

6,849

 

• AAPM&R cancer special interest group

28

benefits to patients of prevention and lifestyle change, and the complexities of integrating survivorship concerns into care for a group of patients of generally advanced age with other chronic conditions.

Education and training must also stress the need for multidisciplinary approaches, integrated and coordinated care, and effective use of community-based resources. Aspects of survivorship that could be considered essential content of survivorship training for health care providers are shown in Box 5-1.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

Type of Physician

Number of Physicians

Primary care

Family medicine

• Board certified

64,701

 

• American Academy of Family Physicians

94,000

Internal medicine

• Board certified

161,921

 

• American College of Physicians: Internal Medicine

118,000c

Obstetrics and gynecology

• Board certified

37,057

 

• American College of Obstetricians and Gynecologists

46,480b

Geriatric medicine

• Board certified

7,287

NOTE: Numbers are estimates based on the number of certifications issued, and may not accurately reflect the number of currently practicing physicians.

aNumber includes resident members and excludes retired members.

bNumber includes resident members.

cNumber includes medical student and resident members.

SOURCES: Number of Board-certified physicians comes from the American Board of Medical Specialties (ABMS, 2004a) and the American Board of Internal Medicine (ABIM, 2005); professional organization membership (limited to physicians of the specified type who may care for adult cancer survivors, in the United States, when possible) comes from: American Society of Clinical Oncology (Personal communication, D. Lopez, ASCO, June 22, 2005); American Society of Breast Surgeons (2005); American Society of Hematology (Personal communication, G. Aklilu, ASH, July 27, 2005); Society of Gynecologic Oncologists (Personal communication, R. Benkert, SGO, January 26, 2005); American Society of Therapeutic Radiation Oncologists (ASTRO, 2002, 2004); Society of Surgical Oncology (Personal communication, R. Slawny, SSO, April 15, 2005); American Urological Association (AUA, 2005); American College of Obstetricians and Gynecologists (Personal communication, C. Flood, ACOG, April 15, 2005); American Society of Colon and Rectal Surgeons (ASCRS, 2005); American College of Physicians (ACP, 2005a); American Society for Therapeutic Radiology and Oncology (Personal communication, S. Smith, ASTRO, June 21, 2005); Society of Thoracic Surgeons (Personal communication, A. Ticoalu, STS, June 23, 2005); American Academy of Family Physicians (AAFP, 2005).

Education and training opportunities for selected physician and nonphysician providers of survivorship care are detailed in the following section. Most of these are oriented to a particular health care discipline, but it is likely that survivorship education and training could be developed for multiple audiences. A few continuing education resources are broadly applicable across professional disciplines. Forthcoming from NCI is a resource for clinicians on cancer survivorship (Personal communication, S. Wilcox, Office of Education and Special Initiatives, NCI, February 2,

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

TABLE 5-2 Estimates of the Supply of Selected Nonphysician Survivorship-Related Providers

Type of Provider

Number of Providers

Registered nurses (RNs)

• Licensed

2,201,813a

 

• Oncology certified nurse

19,132

 

• Advanced oncology certified nurse

1,514

 

• Oncology Nursing Society

32,000

Physical therapists

• Licensed

120,433

 

• American Physical Therapy Association (APTA)

50,035

 

• APTA Oncology Section

600

Occupational therapists

• Certified

111,151

 

• American Occupational Therapy Association

35,000b

Social workers

• Medical and public health social workers

107,000

 

• National Association of Social Workers

153,000

Oncology social workers

• Association of Oncology Social Work

1,000

Mental health professionals

Psychology

• Licensed

85,000

 

• American Psychological Assocation (APA)

90,200

 

• APA, Health Division

2,947

Psychiatry

• Board certified

34,114

 

• Focus on oncology

100

Pastoral counseling

• Certified chaplains

9,100

Genetic counseling

• Board certified

1,811

 

• National Society of Genetic Counselors

2,098c

aNumber of RNs employed in nursing, including nurse practitioners.

bAll members, including occupational therapy assistants and student members.

cIncludes student members

SOURCES: Number of RNs employed in nursing from the Health Resources and Service Administration (Spratley et al., 2000); number of professional chaplains from a white paper on chaplaincy (VandeCreek and Burton, 2001); number of licensed doctoral level clinically trained psychologists (Personal communication, K. Lewis, APA, July 12, 2005); professional organization membership (limited to U.S. professionals) comes from: Oncology Nursing Society (ONS, 2005); American Physical Therapy Association (Personal communication, K Gardner, APTA, April 27, 2005); American Occupational Therapy Assocation (AOTA, 2005); National Association of Social Workers (NASW, 2005a); National Board for Certification in Occupational Therapy (Personal communication, P. Grace, NBCOT, May 5, 2005); American Board of Genetic Counseling (ABGC, 2003); National Society of Genetic Counselors (Personal communication, L. Brodeur, NSGC, May 17, 2005); Association of Oncology Social Workers (Personal communication, B. Zebrack, AOSW, April 25, 2005); American Psychological Association (Personal communication, K. Cooke, APA, April 25, 2005).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-1
Essential Content of Survivorship Training for Health Care Providers

  • Prevention of secondary cancers

  • General discussion of survivorship

  • Long-term complications/sequelae of treatment

  • Trends and statistics in health care access

  • Health care systems/quality assurance/models of care

  • Rehabilitation services

  • Quality-of-life issues in survivorship

  • Detection of recurrent and secondary cancers

  • Pain management

  • Palliative care/end-of-life care

  • Short-term complications

  • Treatment of recurrent cancer

SOURCE: Ferrell et al. (2003).

2005).3 An educational opportunity available to a cross-section of health professionals is a cancer survivorship biennial conference sponsored by NCI’s Office of Cancer Survivorship and the American Cancer Society (ACS) (NCI and ACS, 2002, 2004).

Physicians

The status of undergraduate and graduate medical education is described in this section, followed by some examples of opportunities for continuing medical education on survivorship for practicing physicians.4 Given their educational potential, the availability of clinical practice guidelines related to cancer survivorship is included in this discussion.

3  

An older, now out-of-date training program for health professionals, The Cancer Journey: Issues for Survivors, was developed by NCI in collaboration with the National Coalition for Cancer Survivorship and Ortho Biotech, Inc. It was designed to (1) raise awareness of cancer survivorship; (2) demonstrate how to provide effective support, accurate information, and useful referrals; and (3) promote the empowerment of survivors and their families to work effectively with their health care team, employers, and others concerning issues related to their cancer history (NCI, 1998).

4  

The status of survivorship-related educational opportunities for psychiatrists are described later in the chapter in the section on psychosocial and mental health providers.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×
Undergraduate Medical Education

Cancer survivorship has not yet been well represented in medical school curricula. Only a few schools were identified as having courses or clerkships pertaining to cancer survivorship when the online database on medical school curriculum maintained by the American Association of Medical Colleges was searched (AAMC, 2005a).5 Some medical schools have, however, incorporated survivorship issues into the curriculum by including cancer survivors as “standardized patients” in what are referred to as “structured clinical instruction modules” (Plymale et al., 1999). These instruction modules involve medical students interacting with cancer survivors who have been trained to describe their medical history, symptoms, and concerns in a standardized way. Students interview and assess cancer survivors in this simulated, but realistic, clinical setting under the supervision of the faculty. Both the faculty instructor and the cancer survivor provide feedback to the trainees about their performances and, as time allows, the cancer survivor shares additional personal experiences with the trainees. An evaluation of one of these programs found that this method of instruction was considered beneficial for trainees and faculty members alike (Plymale et al., 1999). Emory University has added an educational program, “Survivors Teaching Students: Saving Women’s Lives” to the third-year medical students’ 6-week gynecology and obstetrics rotation. Survivors from the Georgia Ovarian Cancer Alliance volunteer to discuss their experiences, giving students an opportunity to understand the diagnosis of cancer from the patient’s perspective (Emory University, 2004).

A 4-year integrated curriculum in cancer survivorship is being developed under an NCI R25 grant for students at University of California Schools of Medicine (Los Angeles and San Francisco) and the Charles R. Drew University of Medicine and Science. Core competencies have been established and instructional material is being developed on topics such as the epidemiology of survival, risk assessment, treatment of late effects, psychosocial concerns, prevention strategies, and resources for cancer survivors (Box 5-2) (Stuber et al., 2003, 2004). Curricular materials include problem-based learning cases, multimedia web-based problems, a targeted preceptorship experience, and exercises to develop skills in behavior change

5  

The online database maintained by the American Association of Medical Colleges is called the Curriculum Management and Information Tool (CurrMit®). The database was searched using the following terms: Cancer AND (rehab OR quality of life OR late-effects OR late effect OR long-term effect OR long term effect OR patient surveillance OR follow-up OR follow up OR surviv OR chronic). The names of required courses and clerkships are available for all medical schools, but only 60 percent of schools have provided additional detail about the coursework.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-2
Cancer as a Chronic Disease: Curriculum for Survivorship Required Objectives for Medical School Core Curriculum

Attitudes

  1. Comfortable prescribing medications for pain control, including opioids

  2. Comfortable asking new patients routinely about previous cancers

  3. Willing to ask oncologists for consultation when appropriate

  4. Considers general preventative issues as well as those related to cancer survivorship in cancer survivors

Knowledge

  1. Understands that all cancer survivors are at increased risk for other cancers as well as recurrence of the original cancer, and need to avoid tobacco, eat right, and use sunscreen

  2. Understands basic mechanisms of genetic contribution to risk of cancer

  3. Understands common uses of the terms “cure”, “disease free survival”, and “cancer survivor”

  4. Understands differences in cancer survivorship by gender, ethnicity and socio-economic status

  5. Understands the variety of social consequences of cancer on survivors, including difficulty getting employment and insurance, stigma, and the impact on the family and friendships

  6. Knows the essential elements to obtain about a cancer history, how to get information the patient can’t give them, and how to interpret the health implications of the history

  7. Understands consequences of cancer treatment for different developmental stages, including impact on growth, osteoporosis, learning, sexual function and fertility

Skills

  1. Able to use key screening guidelines to identify people at higher risk for cancer

  2. Able to provide appropriate and individualized recommendations for secondary prevention to cancer survivors regarding sunscreen, diet, obesity, exercise, alcohol, and tobacco

  3. Able to tailor pain medication and other interventions for pain to the source and type as well as the severity of pain

  4. Able to explain and help patients make decisions about a living will, do not resuscitate (DNR) orders, durable power of attorney, and advance health care directives

  5. Able to give bad news about second malignancy or relapse, and to move to a palliative approach when appropriate without saying “there is nothing we can do”

  6. Able to partner with patients in decision making, respecting what is important to the patient

  7. Able to work as the primary care provider with a specialty team, providing continuity of care, and working with family as well as patient

  8. Able to get current cancer information for cancer survivors at the appropriate reading level and language (e.g., from the Cancer Information Service and National Cancer Institute)

SOURCE: UCLA (2005b).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

and risk assessment (Personal communication, L. Wilkerson, David Geffen School of Medicine at University of California–Los Angeles, January 13, 2005). A survey on survivorship knowledge and experience has been designed as a needs assessment or program evaluation tool. The survivorship curriculum and materials will be available through the UCLA Cancer Education Project’s website (UCLA, 2005a) and the Health Education Assets Library (HEAL), an online, peer-reviewed health education repository (HEAL, 2005). As survivorship curricula and materials are developed, they can also be shared between medical schools through the MedEd Portal, a new online repository of education materials maintained by AAMC (2005b).

Graduate Medical Education

The curricula followed in graduate medical education is determined under the auspices of the American Council of Graduate Medical Education. According to a review of the curriculum for medical oncology, some of the 28 content areas listed are related to survivorship (e.g., knowledge of drug toxicity, rehabilitation, and psychosocial aspects of clinical management of the cancer patient), but no specific mention of cancer survivorship is made (Winn, 2002). The specific items to be included in the oncology fellowship training curriculum are not within the purview of the American Board of Internal Medicine and Accreditation Council for Graduate Medical Education. ASCO has assumed the task of creating a “Competence Comprising Curriculum” for medical oncology subspecialty training in 14 key areas, including supportive care and survivorship (Muss et al., 2005; ASCO, 2005a). For the primary care disciplines of internal medicine and family medicine, a review of curriculum guidelines found a lack of mention of cancer survivorship.

A review of selected general oncology and disease-specific medical textbooks found only one text that addressed cancer survivorship specifically (i.e., Diseases of the Breast, Harris et al., 2004) (Winn, 2000). Most of the other textbooks had certain survivorship issues represented, but there was relatively little discussion of practical clinical management issues. Several standard primary care and internal medicine textbooks were reviewed from the perspective of whether a primary care physician wishing to learn about the management of cancer survivors could readily obtain an overview of the entire area. The texts were not comprehensive or detailed enough in their coverage to serve as primary sources of information for the clinician seeking to effectively manage these patients. Available texts may, however, serve a purpose in highlighting some of the major problem areas of cancer survivorship and alerting the caregiver of the need to consult additional sources for more comprehensive information.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

Some specialty texts were found that were directly related to survivorship care. The text Cancer Patient Follow-Up (Johnson and Virgo, 1997) provides a comprehensive review of follow-up practices. The major focus is on surveillance testing, but treatment complications and their management are also covered. This text provides an excellent source for clinicians interested in the scientific rationale for many survivor issues. Another resource is Principles and Practice of Palliative Care and Supportive Oncology (Berger et al., 2002). This text has two relevant chapters, “Long-term survivorship: Late effects” (Aziz, 2002), and “Psychosocial aspects of cancer survivorship” (Leigh and Clark, 2002). In addition, many of the chapters about specific supportive care issues, such as sexuality and reproduction or depression and anxiety, are pertinent to survivorship. Integrated discussions of these palliative and supportive care topics provide an excellent orientation for the clinician wanting to become grounded in survivorship.

A new certification program of the ABMS may provide opportunities for continuing education regarding survivorship care (ABMS, 2004b). Until recently, Board recertification testing occurred every 6, 7, or 10 years. A new program, called “Maintenance of Certification” (MOC), changed the specialty recertification process for physicians from periodic testing to a more continuous process. The new MOC program will require the assessment and improvement of practice performance by physician specialists. Examples of practice assessment and improvement approaches for MOC include, for internal medicine, Practice Improvement Modules in clinical preventive services and preventive cardiology, and, for pediatrics, web-based education improvement programs in pediatric asthma and attention deficit hyperactivity disorder. A module related to cancer survivorship could be developed to enhance specialists’ knowledge of survivorship-related care.

Continuing Medical Education

For practicing clinicians, continuing medical education provides opportunities to gain skills in this relatively new area. There appears to be a demand for such education, at least among oncologists. According to a recent survey, more than 75 percent of medical oncologists reported that they provide some follow-up care for cancer survivors, but a significant proportion wanted additional training (ASCO, 2004).

Continuing medical education (CME) credits—attained through onsite meeting attendance, virtual meeting participation, or online CME venues—provide significant opportunities for clinicians to be exposed to issues related to survivorship. The Accreditation Council of Continuing Medical Education has accredited the major national societies to offer CME credit for certain sessions at their meetings. Examples of some recent CME opportunities at professional meetings are shown in Box 5-3.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-3
Continuing Medical Education: Examples from Recent Professional Meetings

American Society of Clinical Oncology (2005 Annual Meeting)

  • Cancer Survivorship: Long-Term Complications of Treatment

  • Breast Cancer Survivorship: Long-Term Issues in Women with Breast Cancer

  • Supportive Oncology: Complementary and Alternative Medicine

  • Assessing and Teaching Humanistic and Spiritual Aspects of Cancer Care

Society of Gynecologic Oncologists (2005 Annual Meeting)

  • Advances in Reproductive Health: Cancer and Conception

  • Barriers to Sexual Health After Cancer: What Can Be Done?

  • Ovarian Cancer Survivor’s Course (for survivors and nurses)

The American Society for Therapeutic Radiology and Oncology (2004 meeting) raised awareness of cancer survivorship by creating a “Survivor Circle” exhibit in partnership with the Atlanta chapter of the American Cancer Society. Information on ACS support programs was featured (US Newswire, 2004).


American Association for Cancer Education (2004 Meetings)

  • Integration of Cancer Survivorship Coursework into First Year Medical School Curriculum

  • Quality of Life: Native American Cancer Education for Survivors

  • Exploring the Needs of Cancer Patients and Their Family Caregivers Through a Training Workshop

  • Does Diet Modification Have Potential to Reduce Cancer Suffering and Extend Life?

  • Partners in Survival National Training Program: Training Minority Men to be Effective Caregivers for Women with Cancer

SOURCES: ASCO (2005c); SGO (2005); Journal of Cancer Education (2004).

In some cases, professional societies have, or are planning, continuing medical education opportunities for their specialty group.


Medical oncology To help oncologists better address the needs of cancer survivors, ASCO has formed a Survivorship Task Force to develop, implement, and manage ASCO survivorship programs related to physician education, survivorship guidelines, patient education, and research (ASCO, 2004). There are plans for the issuance of clinical practice guidelines on issues such as late effects and the development of a central online information resource on late and long-term effects of cancer and its treatment. At

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

its 2005 annual meeting, ASCO examined prevention strategies for survivors at high risk for second cancers. ASCO also has a series of continuing education publications that are related to survivorship, for example, “Optimizing Cancer Care: The Importance of Symptom Management” and “Cancer Care in the Older Population” (ASCO, 2005d).


Primary care A comprehensive review of cancer survivorship is available through an American Academy of Family Physicians (AAFP) Home Study Self-Assessment monograph (Hamblin and Schifeling, 2001).6 The following areas are covered in this 60-page monograph:

  • Risk of recurrence or second malignancy

  • Follow-up regimens for breast, colorectal, prostate, acute leukemia, lymphoma

  • Late effects of treatment

  • Evaluation of common problems in survivors, such as depression and anxiety, sexual dysfunction

  • Diet, physical exercise, tobacco

  • Complementary and alternative medicines

  • Disability, discrimination, and related issues

  • Internet resources

Approximately 6,200 physicians received this monograph in May 2001 as part of their subscription to the Home Study Self-Assessment program, but there are no plans for any other distribution (Personal communication, P. Dove, AAFP, March 9, 2005).

One state-based continuing education project directed at primary care providers is noteworthy: the development of a CME module on surveillance of cancer patients by the Physician Oncology Education Program (POEP) with support from the Texas Cancer Council. The module was first developed in 1999 as a slide set and short booklet describing the role of the primary care physician in caring for cancer patients following diagnosis and treatment (POEP, 1999). The POEP plans to revise the module as part of a web-based online CME program with support from a Small Business Innovation Research (SBIR) grant from NCI (Personal communication, G. Weiss, MD, POEP, April 22, 2004).

The American College of Physicians (ACP) has 48 online clinical problem-solving cases that provide CME credits upon their completion.

6  

The monograph contains pre-and post-test forms, and the user is qualified for up to five Category I CME credits.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

Three of the cases are about cancer, and one of these involves a 52-year-old woman who seeks advice about follow-up cancer care. To complete the program, physicians use interactive software to review patient assessments, order tests, prescribe treatments, respond to outcomes, and receive expert feedback on decisions (ACP, 2005b).


Physical medicine and rehabilitation Topical self-directed study guides and examinations are published annually as a Medical Education Supplement to the Archives of Physical Medicine and Rehabilitation. These guides have included cancer rehabilitation as a focus (Roig et al., 2004; AAPM&R, 2005). CME credit for completion of the study guides may be obtained for up to 3 years from the date of publication.

Other Sources of Information on Cancer Survivorship

The ideal situation for a clinician who cares for cancer survivors would be to have immediate access to comprehensive clinical practice guidelines (CPGs) based on high-quality evidence where available that included a full range of recommendations for the many clinical decisions that might be encountered in the post-treatment phase of care (see discussion of CPGs in Chapter 3). As mentioned earlier, ASCO has plans for an online service to include information on late and long-term effects of cancer and its treatment. ASCO currently has guidelines available on its website on the post-treatment surveillance of individuals with breast and colorectal cancer for cancer recurrence (ASCO, 2005b). Guidelines on certain aspects of survivorship care are available online from other groups. For example, guidance on the management of cancer-related fatigue and psychosocial distress are available from the National Comprehensive Cancer Network (NCCN) (NCCN, 2005). The National Guidelines Clearinghouse is a searchable database of guidelines that includes guidelines for cancer patient follow-up when searched using the search terms “cancer” and “surveillance or follow-up” (AHRQ, 2004).

The NCI’s PDQ (Physician Data Query) contains peer-reviewed summaries on supportive care, genetics services, and complementary and alternative medicine (NCI, 2005d). Although they are not formal CPGs, PDQ’s supportive care summaries provide descriptions of the pathophysiology and treatment of common physical and psychosocial complications of cancer and its treatment (Box 5-4). PDQ cancer genetics summaries provide information about risk factors related to family history, major genes and syndromes associated with cancer, interventions specific to individuals at high risk, and the ethical, legal, and social issues related to cancer risk counseling and gene testing. PDQ also includes summaries of complementary and

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-4
Selected Examples of Survivorship-Related PDQ Summaries on Supportive Care (Coping with Cancer)

Symptoms

  • Cardiopulmonary syndromes

  • Fatigue

  • Fever, sweats, and hot flashes

  • Gastrointestinal complications

  • Hypercalcemia

  • Lymphedema

  • Oral complications of chemotherapy and head/neck radiation

  • Pain

  • Pruritus (itching sensation)

  • Radiation enteritis

  • Sexuality and reproductive issues

  • Sleep disorders

Psychosocial Issues

  • Anxiety disorder

  • Depression

  • Normal adjustment, psychosocial distress, and the adjustment disorders

  • Post-traumatic stress disorder

Lifestyle Issues

  • Nutrition in cancer care

  • Smoking cessation and continued risk in cancer patients

  • Spirituality in cancer care

  • Substance abuse issues in cancer

  • Transitional care planning

SOURCE: NCI (2005c).

alternative treatments commonly used by cancer survivors. Summaries are available for both physicians and patients.

Journal review articles provide good opportunities for learning. Two issues of Seminars in Oncology, for example, focused on post-treatment surveillance for potentially curable malignancies (Doll et al., 2003) and late effects of treatment and survivorship issues in early-stage breast cancer (Shapiro and Winer, 2003). However, most such articles are based on expert opinion, due to a lack of high-quality evidence. Opinions of equally qualified experts often can conflict.

The European Journal of Cancer Care has a continuing professional education in oncology program, the Forum for Applied Cancer Education

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

and Training (FACET) that includes a module called “After Treatment—Who Cares?” that addresses issues related to survivorship care (FACET, 2004).

Registered Nurses

Nursing represents the largest segment of the nation’s health care workforce and has a significant role on the “front lines” of cancer care, both in hospitals and ambulatory settings (McCorkle et al., 1998; Ferrell et al., 2003). In 2000, an estimated 2.2 million registered nurses (RNs) were employed full- or part-time nationwide (Spratley et al., 2000). Relative to the number of RNs, there are relatively few with specialized training in oncology. Specialization in nursing is recognized through certification by the Oncology Nursing Certification Corporation (ONCC). As of early 2005, there were 19,132 basic-level Oncology Certified Nurses (OCNs®) and 1,514 Advanced Oncology Certified Nurses (AOCN®) (ONCC, 2005a). Some oncology nurse specialists have completed training as nurse practitioners, allowing them to assume more independent clinical roles (Mooney, 2000). In 2003, ONCC conducted a role delineation study of advanced practice nurses that identified significant differences between the work responsibilities of oncology clinical nurse specialists and nurse practitioners in oncology. Based on the results of that study, beginning in January 2005, two different advanced oncology nursing certifications became available: Advanced Oncology Certified Nurse Practitioner (AOCNP®) and Advanced Oncology Certified Clinical Nurse Specialist (AOCNS®). To be eligible for either certification, a nurse must have an RN license, a master’s or higher degree in nursing, and a minimum of 500 hours of supervised clinical practice in oncology nursing; AOCNP® candidates must also have completed an accredited nurse practitioner program (ONCC, 2005b). Advanced practice nurses provide models for clinical practice, education, and advocacy. The professional society representing oncology nurses, the Oncology Nursing Society (ONS), has more than 32,000 registered nurses as members, and 127 members are enrolled in a survivorship special interest group (ONS, 2005) (Personal communication, D. Gutaj, Coordinator, ONS survivorship special interest group, January 23, 2005).

Information on the settings in which nurses practice suggests that the role of nursing in the provision of survivorship services may have lessened, in the sense that relatively few nurses work in ambulatory and community-based settings, the places where most cancer care is delivered. In 2000, only 9 percent of RNs worked in ambulatory settings, according to a large federally sponsored survey (Spratley et al., 2000). Substantially more oncology RNs (37 percent) work in ambulatory settings, according to a survey of

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

the ONS membership conducted in 2000 (Lamkin et al., 2001, 2002).7 Access to nurses in ambulatory care settings is limited by staff shortages that reduce the time available to assess or respond to other than acute care needs. Outpatients making cancer-related visits encounter nurses in just over one-quarter of visits, according to surveys of ambulatory care providers (see Chapter 4, Table 4-4). A belief that there are too few RNs specializing in oncology nursing in the United States and that RN staffing short-falls will continue over the decade was reported by most of the oncologists, executives, and oncology RNs surveyed in 2000 about the adequacy of the nursing supply (Buerhaus et al., 2001). Executives who reported unfilled positions for oncology RNs said that the lack of qualified applicants was the largest reason for unfilled positions. Despite reported shortages, many oncologists’ offices and some surgeons’ offices have an oncology nurse, so that, for patients in these settings, the oncology nurse plays a critical role in survivorship care.

Education and Training

Undergraduate nursing education rarely includes didactic training in oncology, according to a review of the content of basic nursing education (McCorkle et al., 1998; Ferrell et al., 2003).8 Nurses generally receive some exposure to cancer care through coursework related to surgical and medical care of chronic diseases. Cancer centers have worked with local nursing training programs to increase the number of students who rotate in oncology in an effort to attract students to oncology nursing positions upon graduation (Erikson, 2000).

Nurses with advanced training in oncology can assume important roles in providing survivorship care (see Chapter 4) but, even among nurses belonging to the ONS, there are relatively few with advanced training—only 11 percent reported having a certificate or degree as an advanced practice nurse9 in a 2000 survey (Buerhaus et al., 2001). It is of some concern that a diminishing number of nursing graduate programs offer a special oncology focus. The number of programs offering an oncology specialty has decreased from approximately 45 programs in 1990 to only 26 programs in 2002 (Ferrell et al., 2003). Increased budgetary concerns

7  

A sample of members of the Oncology Nursing Society was surveyed. A limitation of this survey is the low response rate (40 percent).

8  

Relatively few RNs have a master’s or doctoral degree—an estimated 10 percent in 2000, according to a federally sponsored study (Spratley et al., 2000). The highest level of preparation for most RNs was a diploma/associate degree (57 percent) or baccalaureate degree (33 percent).

9  

The following were defined as advanced practice nurses: nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, or clinical nurse practitioner.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

have led to the consolidation of specialty programs into more generalized tracks (e.g., chronic illness, medical-surgical). This finding holds important implications for the quality of care provided to cancer survivors. Generalized master’s education tracks are less likely to provide adequate attention to the specific nursing care of cancer survivors. The preservation of oncology nursing as a specialty is central to efforts to assure quality cancer care, according to some nurse educators (Satryan, 2001).

A review of the curricula of available graduate nursing programs offering an oncology focus suggests that the survivorship content could be strengthened (Ferrell et al., 2003). Information gathered from 17 of these programs indicated that 11 of the 17 programs had curricula that covered quality-of-life and survivorship issues, 9 of the 17 programs had curricula that covered detection of recurrent and secondary cancers, and 3 of the 17 programs had curricula that covered rehabilitation services. Enhancing the survivorship-related content in these advanced training programs could generate more nurses with the training needed to assume active roles in survivorship care. Certified oncology nurses are expected to master cancer patient survivorship skills. A review of the examination content for certification as an oncology nurse suggested that survivorship issues were well represented (Ferrell et al., 2003). The authors of this review recommended that cancer centers encourage nurses to be certified in oncology. There appear to be limited incentives for nurses to obtain certification—only one-third of nurses working in oncology settings reported that nurses receive a salary increase or bonus for obtaining oncology nursing certification when surveyed in 2000 as part of a workforce survey (Lamkin et al., 2001).

Continuing Nursing Education

ONS provides opportunities for continuing education on cancer survivorship through its “Institutes of Learning” added to its annual congress. In addition, more than 200 chapters of ONS provide cancer education at the local level (Mooney, 2000). Strategies for effective nursing continuing education have been outlined and include a focus on participants’ goals, examples of successes, inclusion of patients and families, and participatory learning (Ferrell et al., 2002).

The Nurse Oncology Education Program (NOEP) provides continuing education on cancer prevention, early detection, treatment, and survivorship to nursing professionals in Texas (NOEP, 2005). Continuing education credits are available through NOEP via workshops, online programs, and independent studies in print. The program is funded by the Texas Cancer Council and provided through the Texas Nurses Association and Foundation. Statewide surveys are conducted periodically to assess the continuing education needs of nurses (Meraviglia et al., 2003).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

A continuing education supplement to the American Journal of Nursing on nursing and cancer survivorship will be published based on a symposium on long-term cancer survivorship at the University of Pennsylvania (Mason and Burke, 2005).

Other Sources of Information on Cancer Survivorship
  • American Cancer Society has published A Cancer Source Book for Nurses that includes information on advances in symptom control and issues related to survivorship (Varricchio et al., 2004).

  • Journal articles that describe the population of cancer survivors and review the roles of nurses in providing survivorship care are important sources of continuing education (Thaler-DeMers, 2001; Rowland et al., 2001) (see also Chapter 4 for a description of nursing roles in survivorship)

Rehabilitation Specialists

Rehabilitative care is multidisciplinary and may involve physicians trained in rehabilitation and physical medicine (physiatrists), nurses, and other specialists. In this section, three important professional groups that often provide rehabilitative care are described: physical therapists, occupational therapists, and speech and language pathologists. Of these three professional groups, physical therapists are the most commonly encountered providers of rehabilitation services.10 An estimated 13 percent of cancer survivors report using the services of a physical therapist, occupational therapist, or other therapist in the past year (Hewitt et al., 2003). Such therapists are used more frequently (18 percent) among cancer survivors reporting one or more functional limitations.

Physical Therapists

Physical therapists (PTs) provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of patients suffering from injuries or disease (BLS, 2004b). PTs also restore, maintain, and promote overall fitness and health. Cancer survivors may be referred to a physical therapist to manage late effects such as

10  

Most outpatient rehabilitation therapy services provided to Medicare beneficiaries (with and without a history of cancer) are provided by physical therapists (PTs) (Ciolek and Hwang, 2004). In 2002, 8 percent of beneficiaries used PT services, 2 percent used occupational therapy services, and 1 percent used speech-language pathology services.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

lymphedema, pain, and fatigue. PT interventions for cancer survivors may include exercise, heat, therapeutic massage, gait training, and prosthetics to assist the patient in becoming as functional as possible (Mellette and Blunk, 1994). PTs focus on building lower body strength, dexterity, and flexibility. Nearly all hospital cancer programs provide PT services (see Chapter 4) and PT services may also be obtained through their independent practices. There were an estimated 37,000 PTs working in the United States as of 2002; however, the Oncology Section of the American Physical Therapy Association (APTA) has only about 600 members (Ries, 2004). Of the small number of physical therapists identified as specializing in oncology in the APTA database, most work in acute care hospitals and health systems, hospital-based outpatient facilities, private outpatient offices, or group practices (Personal communication, S. Miller, APTA, February 2, 2005).

The extent of coverage of cancer care in PT training programs is not well documented, but anecdotal evidence suggests that in many programs, oncology is integrated across the curriculum (Ries, 2004).11 A survey of physical therapy programs conducted in the late 1990s shows that most physical therapy programs cover topics in lymphedema management (Augustine et al., 1998), and previous National Physical Therapy Examinations have included questions on the treatment of cancer patients (Personal communication, M. Lane, Federation of State Boards of Physical Therapy, February 15, 2005).

Continuing education opportunities are offered through the APTA as in-person training sessions and online audio/video or text-based courses. Some courses are cancer specific, such as a session at the 2005 annual meeting entitled “Exercise Training Guidelines for Individuals with Cancer: Endurance, Strength, Flexibility & Adherence” (Oncology Section, 2005). One course, “Physical Therapy Treatment for the Breast Cancer Patient” addresses functional limitations associated with the late effects of treatment (R3 Programs, 2005). Other courses cover topics such as lymphedema, osteoporosis, and urinary incontinence, which, although not specific to cancer, may be relevant to cancer survivors (APTA, 2005b). The APTA publishes the journal Physical Therapy, which periodically publishes articles on cancer care. The comprehensive “Guide to Physical Therapist Practice,” published in Physical Therapy, includes a section on lymphedema diagnosis and management (APTA, 2001). The Oncology Section of the APTA publishes its own journal, Rehabilitation Oncology, and has also produced a series of monographs on developing oncology rehabilitation programs and training program curriculums.

11  

In the United States, 80 training programs offer master’s degrees in physical therapy, and 125 programs offer doctoral physical therapy degrees (APTA, 2005a).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×
Occupational Therapists

Occupational therapists (OTs) help people improve their ability to perform tasks in their daily living and working environments. They also help individuals develop, recover, or maintain daily living and work skills (BLS, 2004b). Cancer survivors may be referred to OTs for assistance with mobility impairments, pain, fatigue, shortness of breath, insomnia, auditory or visual impairment, and cognitive deficits (Penfold, 1996; COT, 2001). OTs can help by teaching various adaptive techniques, energy conservation, how to make the home or workplace more accessible, and how to use adaptive equipment (Mellette and Blunk, 1994). OTs focus on building upper body strength, dexterity, and flexibility. OTs work in cancer centers, community hospitals, ambulatory care settings, and independent practices (COT, 2001; BLS, 2004b). There were an estimated 111,151 certified OTs in the United States as of 2005, but virtually no information is available on the extent to which they provide cancer-related rehabilitation services.12

Speech-Language Pathologists

Speech-language pathologists, also known as speech therapists, are trained to treat problems with speech, voice, language, swallowing, and other related disorders (BLS, 2004c).13 They often work with survivors of head and neck cancers who may develop speech or swallowing problems as a result of surgery or radiation. Speech-language pathologists may teach muscle exercises or head postures to help overcome swallowing problems, or modifications of mouth movements to help patients adapt to differences in size and shape of the mouth to speak clearly (ASHA, 2005a,b). Speech therapists typically meet with patients before surgery or radiation, to discuss possible changes in speech and swallowing, and after medical treatment, to assess and treat any problems that may have arisen.

Psychosocial and Mental Health Providers

Cancer may cause psychosocial distress, so referrals to social service and mental health professionals may be indicated. Psychosocial services may be provided by cancer caregivers, such as nurses, primary care physicians, surgeons, or oncologists, or by professionals with special training in social work, psychology, psychiatry, or pastoral counseling. Services might

12  

A bachelor’s degree in occupational therapy is the minimum requirement for entry into the field, but beginning in 2007 a master’s degree or higher will be required (BLS, 2004b).

13  

Nearly all states require that speech therapists have a master’s degree and be licensed (BLS, 2004c).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

be conceptualized as basic, that is, provided as part of routine care by sympathetic and supportive physicians, nurses, and clinical and hospital staff who come in contact with the cancer patient. Services might be more extensive, supplemented by others such as social workers, support groups, and clergy as needed and, for more serious problems, specifically trained mental health professionals such as psychiatrists, psychologists, and clinical social workers.

This section briefly describes the education and training of some of the most frequently encountered providers of psychosocial services and mentions sources of survivorship-related continuing education that are available within the various disciplines. Several sources of continuing education are available to the full range of psychosocial providers, and these are described following the specific offerings of the various disciplines.

Social Workers

Social workers assist cancer patients in several ways: by providing help with concrete services, such as assisting with insurance and benefits; by serving as case managers to coordinate care and help patients navigate health care systems; by leading peer support groups; and by referring patients and families to community services (Box 5-5).

Social workers are the primary providers of psychosocial services in hospitals and many cancer centers and are trained to facilitate patient and family adjustment to a cancer diagnosis, its treatment, and rehabilitation (Smith et al., 1998). Social workers may also refer cancer patients and family members who show signs of distress or who have significant family or social problems to psychologists or psychiatrists. In small oncology practices, social workers may be the only professionals available for handling psychosocial problems occurring with cancer. As more cancer patients survive and continue to work, some social workers are providing workplace consultations to help with the employment adjustments of survivors and their colleagues (Tolley, 1994).

Social work services have been strained in recent years by hospital cutbacks, in some cases leading to the elimination of entire departments of social work. Although there have been advances in psycho-oncology research of relevance to social workers assisting cancer survivors, reductions in staffing and increased caseloads have made it difficult for social workers to translate these findings into their practices (IASWR, 2003; NASW, 2003). As of 2003, there were an estimated 103,000 medical and public health social workers in the United States, most of them employed in hospitals (BLS, 2004a).

Most oncology social workers have a Master of Social Work (MSW) degree and receive training in chronic illness issues in graduate school.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-5
Oncology Social Work: Scope of Practice

  • Clinical Practice: Complete psychosocial assessments; develop multidisciplinary care plans; provide therapeutic interventions and case management; assist with financial, transportation, lodging, and other needs; advocate to remove barriers to care and address gaps in service; advance knowledge through research.

  • Within Cancer Centers/Institutions: Provide education and consultation to professionals and staff regarding psychosocial and other factors affecting cancer care; collaborate in the delivery of psychosocial care, education, and research; develop programs and resources to address the needs of cancer survivors.

  • Within the Community: Increase awareness of psychosocial needs of cancer survivors, families, and caregivers; collaborate with community agencies to remove barriers to care; collaborate in the development of special programs and resources to address community-based needs; consult with voluntary agencies to provide community education and develop programs.

  • Within the Social Work Profession: Teach in the classroom or in clinical settings; supervise and evaluate practitioners; consult with colleagues; participate in research.

SOURCE: AOSW (2005).

There is no formal accreditation in oncology available for social workers. However, the Association of Oncology Social Work (AOSW), with a membership of nearly 1,000 social workers, defines oncology social workers’ scope of practice (Box 5-4), sets standards of practice, and serves as an educational resource (AOSW, 2004) (Personal communication, L. Behar, Membership Chair, AOSW, July 2004). Psychiatric social workers who have additional training in psycho-oncology are particularly valuable as mental health professionals in oncology.

There are several continuing education opportunities for social workers. A web-based continuing education course, Understanding Cancer: The Social Worker’s Role, is available through the National Association of Social Work and CancerCare, an organization providing psychosocial services (NASW, 2005b). The Journal of Psychosocial Oncology is the official journal of the AOSW and reports research findings and clinical observations relevant to the social workers involved in oncology. The book Social Work in Oncology: Supporting Survivors, Families, and Caregivers provides an overview of issues faced by social workers within various patient populations and practice settings (Lauria et al., 2001).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×
Psychologists

Psychologists are the mental health professionals who, after social workers, are most likely to be available for clinical consultation and management of psychosocial concerns in patients with cancer and their families.14 They also represent the discipline that contributes predominantly to psycho-oncology research. As of 2005 there were approximately 90,200 U.S.-based members, fellows, and associates of the American Psychological Association (APA), the professional association that represents psychologists, of which nearly 3,000 belonged to the health division (Personal communication, K. Cooke, APA, April 25, 2005).

Undergraduate psychology programs do not routinely include training in psycho-oncology, except as it might occur in conjunction with clinical rotations. Some health psychology graduate programs have faculty members who do research in psycho-oncology, and graduate students in these programs can choose dissertations dealing with oncology issues. Psychology internships are not available in the specialized area of oncology. However, many 2-year post-doctoral fellowships exist that permit training in either research or clinical work alone, or a combination of both. A large number of members of the Society of Behavioral Medicine have their career emphasis in some area of psychosocial or behavioral oncology. They have made major contributions in cancer prevention, cancer control, and lifestyle change, such as smoking cessation.

The APA offers continuing education opportunities for psychologists, although cancer-related offerings are somewhat limited. Of the 60 continuing education courses offered at the 2005 APA meeting, only one deals with cancer (APA, 2005). Although psychologist-specific continuing education in cancer may be sparse, many continuing education offerings that are aimed at psychosocial care providers from other organizations are available, as discussed below.

Psychiatry

Psychiatrists with an interest in diagnosis and treatment of comorbid psychological problems and psychiatric disorders are known as consultation-liaison psychiatrists. A subspecialty certification of psychiatry in the care of the medically ill has been established, with the first specialty examinations in psychosomatic medicine as a subspecialty to be adminis-

14  

Psychologists receive a PhD in clinical or health psychology or a PsyD, Doctorate of Psychology.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

tered in 2005. Among the 1,000 U.S. psychiatrists who work primarily with the medically ill, approximately 100 identify oncology as a significant focus of their clinical work, and work with cancer patients either on a full-time basis or as a part of their clinical care or research. Control of symptoms that reduce quality of life, such as severe anxiety, depression, and delirium, often requires management with psychopharmacologic interventions and awareness of drug–drug interactions in the context of complex oncologic treatment.

Psychiatric residents must rotate for a period of time, after internship, through the inpatient and outpatient units, where they learn the common psychiatric disorders of chronically medically ill patients and their psychological and psychopharmacological management. Post-residency clinical fellowships of 1 or 2 years can be taken in psychiatric and psychosocial oncology at a few major academic cancer centers. There are several formal psycho-oncology training programs that offer fellowships to physicians (e.g., Memorial Sloan-Kettering Cancer Center, Mount Sinai Ruttenberg Cancer Center, Dana-Farber Cancer Institute, University of Pennsylvania).

Rehabilitation and Employment-Based Counseling

Master’s-level counselors trained in specialized areas of counseling who work outside of oncology settings may be of assistance to cancer survivors. Rehabilitation counselors may help cancer survivors deal with the personal, social, and vocational effects of cancer-related disabilities. They may assist cancer survivors as they go back to work or reassess career options. Counseling may be available at worksites through corporate Employment Assistance Programs (EAPs). EAPs often employ social workers and other professional counselors who can provide short-term counseling and appropriate referrals to community resources. A demonstration project called the Individual Cancer Assistance Network (ICAN), sponsored by Bristol-Myers Squibb Foundation, trained 141 community-based counselors and EAP providers in Florida in a “face-to-face” and distance-learning program in psychosocial oncology. Efforts are underway to expand the program and use the core curriculum, developed by CancerCare, and the American Psychosocial Oncology Society (APOS), to train professionals who already have counseling skills to be oncology sensitive (Alter, 2005).

Marriage, Family, and Sex Counseling

Marriage and family therapists may work with individuals, couples, or families in dealing with cancer in the context of the family system. Marriage and family therapy is short-term, solution-focused therapy, and usually

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

includes fewer sessions than individual therapy.15 Sex counselors or therapists knowledgeable about the sexual side effects of cancer treatment (e.g., reduced libido, problems with sexual performance) can counsel individuals and their partners in both the psychological/psychosexual and practical issues arising from these difficulties.16

Pastoral Counseling

A diagnosis of cancer continues to be regarded as a threat to life, bringing the possibility of death into focus. Cancer survivors may seek assistance in coping with illness and its meaning from religious or spiritual counselors. Professional health care chaplains provide supportive spiritual care and may help educate the health care team on the relationship of religious and spiritual issues to aspects of clinical care (VandeCreek and Burton, 2001). Some of the 9,100 chaplains certified by the Association of Professional Chaplains (or other certifying organizations) work in hospitals, long-term care units, rehabilitation centers, hospices, or other specialized settings. Nearly all hospital cancer programs provide pastoral care (see Chapter 4). Pastoral care training and courses are available at some cancer centers (Roswell Park Cancer Institute, 2005), and certified chaplains may meet their continuing education requirements through such programs. The HealthCare Chaplaincy serving the New York metropolitan area is such a resource (The HealthCare Chaplaincy, 2005). Several journals cover the overlapping area of medicine and clergy (e.g., Journal of Health Care Chaplaincy, Journal of Religion and Health, The Journal of Pastoral Care and Counseling). Issues of Psycho-Oncology have been devoted to spiritual and religious aspects of psychosocial oncology (Russak et al., 1999) and the chaplain’s experience in a cancer center (Flannelly et al., 2003).

Continuing Education Programs for Psychosocial Care Providers

A common source of continuing education for the multidisciplinary psychosocial providers described in this section is an online core curriculum in psychosocial oncology developed by APOS (APOS, 2005b). Lectures, accompanied by slides and a bibliography, are given by experts on topics

15  

Therapists have master’s or doctoral degrees or other clinical post-graduate training. Certified marriage and family therapists can be located through the American Association for Marriage and Family Therapy on the web (AAMFT, 2005).

16  

Sexuality counselors, accredited by the American Association of Sex Educators, Counselors, and Therapists (AASECT), can be located through the Association (AASECT, 2004).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-6
The American Psychosocial Oncology Society Online Education Program: Survivorship

Symptom Detection and Management

  • Delirium

  • Depression and Suicide

  • Central Nervous System Effects of Drugs Used in Cancer Treatment

  • Distress Management in Cancer: Standards and Clinical Practice Guidelines

  • Cancer-Related Fatigue

  • Substance Abuse in the Oncology Setting

  • Anxiety and Adjustment Disorders

  • Psychosocial Screening Goes Mainstream: A Prospective Problem-Solving System

Interventions

  • Online Support Groups for Women with Breast Cancer: A Pilot Study of Effectiveness

  • Maximizing Psychosocial Health & Making a Therapeutic Connection: Counseling Cancer Patients and Their Caregivers

  • Cognitive and Behavioral Strategies for Cancer Patients

  • Psychiatric Emergencies in the Oncology Setting

Population-Specific Issues

  • Cancer Survivorship: Psychosocial Issues

Program Administration

  • Establishing a Psychosocial Program: Challenges and Strategies

Introduction to Oncology

  • Oncology for Psycho-Oncologists

SOURCE: APOS (2005b).

including survivorship (Box 5-6). The course provides a core of knowledge about psychosocial oncology that is relevant to many disciplines.

Professionals who complete the curriculum and examination are added to the APOS Referral Directory that will serve as a national registry of psychosocial oncologists. Founded in 1986, APOS is attempting to network all disciplines that provide psychosocial services to patients with cancer. Its goal is to become a nationally recognized organization that advocates for improvement of psychosocial care for these patients and their families. APOS also offers continuing education through its annual meetings. In addition to this opportunity available through APOS, continuing education opportunities in psycho-oncology are provided by several professional organizations: International Psycho-Oncology Society, Academy of Psychosomatic Medicine, Society of Behavioral Medicine, American Psychological Association, and American Psychiatric Association.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

A textbook in psycho-oncology has provided comprehensive reviews of relevance to cancer survivorship (Holland and Rowland, 1989; Holland, 1998), and the journals Psycho-Oncology and Psychosocial Oncology provide relevant reviews of research of clinical relevance.

Clinical practice guidelines and standards have been developed by the NCCN to assist health care providers in the management of psychosocial distress among patients and families with cancer (see Chapter 3) (NCCN, 2004a).

Genetic Counseling

As knowledge of the genetic basis for some cancers has expanded and tests for genetic susceptibility to cancer have become available, genetic counseling and testing have become more important to cancer survivors and their families (see Chapter 4, Appendix D). In some cases, genetic services are provided directly by doctors or nurses, but patients are often referred to genetic counselors, master’s-level trained professionals with expertise in medical genetics and counseling.17 They provide risk assessment, help patients weigh the risks and benefits of genetic testing, interpret results of genetic tests, and review prevention, screening, and treatment options (NSGC, 2004). Genetic counselors also provide supportive counseling and refer patients to appropriate support services.

The National Society of Genetic Counselors regularly provides continuing education opportunities to members, including an annual meeting. The American College of Medical Genetics annual meeting also includes sessions of interest to cancer genetic counselors, as well as other medical professionals who are involved in genetic risk assessment or refer patients for genetic counseling. Continuing education in genetics is also available for oncology nurses and other health professionals who do cancer risk assessment and counseling, such as the “Advance Nurses’ Training Course in Cancer Risk Counseling” developed at the Fox Chase Cancer Center with NCI support (NCI, 2005a). The Journal of Genetic Counseling and the journal Genetics in Medicine both publish articles relevant to the practice of cancer genetic counseling. Both ASCO and the NCCN have published guidelines on genetic testing, and several NCI PDQ publications address the genetics of breast, colorectal, prostate, and thyroid cancers (NCCN, 2004b; ASCO, 2005b; NCI, 2005d).

17  

There are 27 master’s programs in genetic counseling in the United States and 3 in Canada that are accredited by the American Board of Genetic Counseling (ABGC) (ABGC, 2004a). Instruction in cancer genetics is required for accreditation, and many genetic counseling students have rotations in cancer genetics clinics (ABGC, 2004b).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

SUPPORT FOR SURVIVORSHIP EDUCATION AND TRAINING PROGRAMS

Relatively few professionals are trained specifically to care for cancer survivors. It is therefore imperative that education and training programs be established to improve the cancer care workforce’s ability to provide such care. Support for training professionals in survivorship is available from the NCI and from a few private voluntary organizations.

Federal

National Cancer Institute

NCI offers a number of training, career development, and education opportunties. The Cancer Education Grant Program (R25), for example, provides support to develop and sustain innovative educational approaches (NCI, 2005e). The program is flexible and can support short courses, the development of new curricula in academic institutions, national forums and seminar series, and hands-on workshop experiences for the continuing education of health care professionals, biomedical researchers, and the lay community. This funding mechanism is well suited to the education and training needs in the area of survivorship. For example, an NCI R25 grant is supporting the development of undergraduate medical school curricula in cancer survivorship as described above. Other recent R25 grants of relevance to cancer survivorship include those related to cancer genetics training for nurses and physicians, and cancer nursing training, including training that targets minority nurses and nurses working with minority groups (Box 5-7). Grants may not exceed $300,000 in direct costs for any single year. A plan for how the proposed education program will be evaluated is required.

SBIR grants are also available through NCI to support educational programs. For example, the online module on cancer survivorship described earlier is being developed by the program called POEP in Texas and is being supported through an SBIR grant.

Support for an individual’s career development is also available through NCI. A variety of K grants are available to support scientists at all stages of their careers, from mentored researchers to senior scientists (NIH, 2005). These grants can be used by physicians, nurses, and other scientists to train for a career in survivorship research, or to support established survivorship researchers.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

BOX 5-7
Examples of National Institutes of Health Program Education Grants Related to Cancer Survivorship

  • Oncology Nursing PhD Using Distance Education Technology (R25-CA938313): To expand the scientific base for cancer prevention and control, including survivorship, by implementing and evaluating an innovative approach to preparing PhD oncology nurse scientists utilizing distance learning technology.

  • Cancer as a Chronic Disease: Curriculum for Survivorship (R25-CA969753): Develop, implement, evaluate, and disseminate a coordinated 4-year multidisciplinary medical school curriculum on cancer as a chronic disease.

  • Native American Cancer Education for Survivors (NACES) (R25-CA1019381): Implement and evaluate a culturally relevant quality-of-life education intervention designed to improve the lives of Native American breast cancer survivors.

  • Essential Clinical Cancer Genetics Internet Curriculum (R25-CA092357): To produce a unique electronic-based cancer genetics medical school curriculum to help train students in medicine, nursing, genetic counseling, genetics and other related fields.

  • Graduate Education in Oncology Nursing for Minorities (R25-CA056689): To provide training in advanced practice oncology nursing for minority students; expand clinical sites that provide students with opportunities to care for African-Americans, Hispanic, and Asian populations; and facilitate opportunities to mentor minority advanced practice oncology nurses after graduation.

SOURCE: NCI (2005b).

Private

American Cancer Society

The ACS provides several kinds of support for professional education and training for physicians, social workers, and nurses (Table 5-3). Although they are not specific to survivorship, all of the programs could enhance knowledge and skills related to survivorship. ACS also offers a number of fellowships that allow social workers to gain experience in palliative and end-of-life care.

Lance Armstrong Foundation

The Lance Armstrong Foundation supports a number of professional education programs (Table 5-4).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

TABLE 5-3 Selected ACS Professional Education and Training Programs

Professional Group

Kind of Award

Amount of Award

Primary care physicians

Cancer Control Career Development Award

Awards are made for 3 years with progressive stipends of $50,000, $55,000, and $60,000 per year.

Social work

Doctoral Training Grant in Clinical Oncology Social Work

Awards are for up to 3 years with annual funding of $20,000 (trainee stipend of $15,000, and $5,000 for faculty/administrative support).

 

Master’s Training Grants in Clinical Oncology Social Work

Awarded to institutions to support the training of second-year master’s-degree students to provide psychosocial services to persons with cancer and their families. The 1-year awards are for $12,000 (trainee stipend of $10,000, and $2,000 for faculty/administrative support).

Nurses

Doctoral Degree Scholarships in Cancer Nursing

Awarded to graduate students pursuing doctoral studies in the fields of cancer nursing research, education, administration, or clinical practice. Awards are for up to 4 years, with a stipend of $15,000 per year.

 

Master’s Degree Scholarships in Cancer Nursing

Awarded to graduate students pursuing master’s degrees in cancer nursing. Awards are $10,000 annually for up to 2 years.

SOURCE: ACS (2005).

Susan G. Komen Breast Cancer Foundation

The Komen Foundation established a Professor of Survivorship Award in 1999 to advance research and awareness on the issues surrounding long-term survivorship of breast cancer. An award of $20,000 is made to two recipients a year (Komen Foundation, 2005).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

TABLE 5-4 Professional Education Programs Supported by the Lance Armstrong Foundation

Project

Description

Cancer Survivorship Education Initiative for Texas Nurses, Nurse Oncology Education Program of the Texas Nurses Foundation (www.noeptexas.org)

The initiative, also funded by the Texas Cancer Council, aims to increase awareness among nurses of the unique psychological and physiologic problems faced by cancer survivors and to enable them to provide patients with accurate information, resources, and psychological support that will improve their quality of life. The initiative’s educational module, which targets the state’s practicing nurses and student nurses, includes a printed booklet, a PowerPoint presentation on CD (for use in presentations to nursing students or health professional groups), an audio CD, and a web-based independent study module. Four thousand Texas nurses will receive the booklet or audio CD, while additional nursing school faculty members will receive the booklet for presentation to nursing students.

Survivorship Professional Education Program, The Leukemia and Lymphoma Society (LLS) (www.lls.org)

The LLS, with the help of a 2003 LAF community grant, established the Survivorship Professional Education Program for oncology nurses and social workers who focus specifically on survivorship issues. The program educates participants on mind-body healing and integrative medicine options for patients during and beyond the treatment portion of their journey as cancer survivors.

SOURCE: LAF (2005).

The International Psycho-Oncology Society

The International Psycho-Oncology Society provides information about fellowship opportunities to social workers and others (IPOS, 2005) in addition to the information available from APOS (APOS, 2005a).

FINDINGS AND RECOMMENDATIONS

Few cancer care and primary care health professionals have had formal education and training regarding cancer survivorship. Needed are efforts to update: (1) undergraduate curricula for those in training; and (2) continu-

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

ing education for practicing providers of survivorship care. Continuing education is needed across many disciplines, but in order to ensure the provision of quality survivorship care, it is especially important to reach (1) oncologists, hematologists, urologists, surgeons, and radiologists who initially treat cancer patients; (2) primary care physicians; (3) nurses; and (4) social workers and other providers of psychosocial services. To ensure the provision of comprehensive survivorship care, it is likely that additional health personnel will be needed, particularly nurses with advanced oncology training.

Many methods are being used to provide continuing education in survivorship (Table 5-5). Online resources are increasingly available and appear to be an attractive means of reaching many providers, but the effectiveness of this and other approaches need to be assessed. There appear to be few educational programs aimed at multiple provider audiences (e.g., APOS psycho-oncology online course), but it is likely that survivorship continuing education would lend itself to such an approach. The American Association

TABLE 5-5 Methods of Survivorship Continuing Education

Educational Approach

Example

  1. Meeting on survivorship

  • NCI/ACS cancer survivorship biennial conference

  1. Session on survivorship at professional society meeting

  • ASCO 2005 annual meeting session: Cancer Survivorship: Long-Term Complications of Treatment

  • SGO 2005 annual meeting session: Barriers to Sexual Health After Cancer: What Can Be Done?

  1. Home study guides

  • AAFP home study self-assessment cancer survivor monograph

  • American Academy of Physical Medicine and Rehabilitation self-directed study guides and examinations are published annually as a Medical Education Supplement to the Archives of Physical Medicine and Rehabilitation

  1. Problem-based learning cases

  • ACP online clinical problem-solving case on cancer follow-up

  1. Online course directed to one specialty

  • AOSW/CancerCare course, Understanding Cancer: The Social Worker’s Role

  1. Online course directed to multiple specialties

  • APOS psycho-oncology course

  1. Online repository of information, guidelines

  • NCI’s Physician Data Query summaries on supportive care, genetics services, and complementary and alternative medicine

  • AHRQ guideline clearinghouse

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

for Cancer Education (AACE) could play an important role. AACE is a multidisciplinary group that has included survivorship education in its annual meeting (AACE, 2005).

Limited support is available through public and private sources for survivorship-related education and training.

Recommendation 7: The National Cancer Institute (NCI), professional associations, and voluntary organizations should expand and coordinate their efforts to provide educational opportunities to health care providers to equip them to address the health care and quality of life issues facing cancer survivors.

Immediate steps to facilitate the development of programs include:

  • Establish a clearinghouse of available sources of survivorship education and training (and guidelines), with opportunity for feedback.

  • Appoint an interdisciplinary consortium to review available resources, identify promising approaches, develop new programs, and promote cost-effective approaches.

  • Increase support of model formal training programs (undergraduate and graduate levels, continuing medical education) that could be adopted by others.

By specialty:

Physicians

  1. Add more survivorship-related CME:

    • The American Board of Medical Specialties’ new program, “Maintenance of Certification,” will require continuous assurance of professional skills for board-certified physicians. The development of a module on cancer survivorship as part of this program could facilitate the assurance of competence for these and other specialty providers.

  1. Improve online survivorship information aimed at health care providers:

    • Expand PDQ to include more information on survivorship care.

    • Centralize survivorship guidelines online.

    • Encourage the development and adoption of evidence-based guidelines.

    • Ease finding survivorship-related guidelines included in the Agency for Healthcare Research and Quality (AHRQ) sponsored guideline clearinghouse (e.g., add the term “survivorship” to the search engine to pick up surveillance guidelines for cancer).

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×
  1. Expand training opportunities to promote interdisciplinary, shared care.

Nurses

  1. Increase survivorship content in undergraduate and graduate nursing programs.

  2. Expand continuing education opportunities on survivorship for practicing nurses.

  3. Increase the number of nursing schools that provide graduate training in oncology.

  4. Increase the number of nurses who seek certification in oncology (incentives are needed).

  5. Endorse activities of those working to ease the nursing shortage.

Social workers and other providers of psychosocial services

  1. Support efforts of APOS to standardize and promote continuing education.

  2. Endorse activities of those working to maintain social services in cancer programs.

It is important to verify the effectiveness of education programs because they may not always have the desired effect on practice. One such effort dealt with the provision of survivorship care to residents in rural areas, which can be problematic, especially if they live far away from providers of cancer treatment. In an effort to improve the cancer care provided to rural residents in Minnesota, Michigan, and Wisconsin, investigators tested multimodal, multidisciplinary set of interventions among 18 communities randomized to be in either an intervention or control group (Elliott et al., 2001a,b, 2002, 2004). Among the study’s interventions were efforts to involve community-based opinion leaders (physicians, nurses, and pharmacists), targeted education, quality improvement activities in rural hospitals and clinics, telecommunications via fax machines, clinical practice guidelines, and outreach oncology consultations. The interventions led to improvements in knowledge, but did not change practices, including appropriate post-treatment surveillance. Travel to health care was significantly reduced in the intervention communities, but there were no significant differences in satisfaction with care, economic barriers to care, or health-related quality of life.

Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

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Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
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Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
×

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Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
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Suggested Citation:"5 Providers of Survivorship Care: Their Supply and Education and Training." Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. doi: 10.17226/11468.
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With the risk of more than one in three getting cancer during a lifetime, each of us is likely to experience cancer, or know someone who has survived cancer. Although some cancer survivors recover with a renewed sense of life and purpose, what has often been ignored is the toll taken by cancer and its treatment—on health, functioning, sense of security, and well-being. Long lasting effects of treatment may be apparent shortly after its completion or arise years later. The transition from active treatment to post-treatment care is critical to long-term health.

From Cancer Patient to Cancer Survivor focuses on survivors of adult cancer during the phase of care that follows primary treatment. The book raises awareness of the medical, functional, and psychosocial consequences of cancer and its treatment. It defines quality health care for cancer survivors and identifies strategies to achieve it. The book also recommends improvements in the quality of life of cancer survivors through policies that ensure their access to psychosocial services, fair employment practices, and health insurance.

This book will be of particular interest to cancer patients and their advocates, health care providers and their leadership, health insurers, employers, research sponsors, and the public and their elected representatives.

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