From Cancer Patient to Cancer Survivor: Lost in Transition An American Society of Clinical Oncology and Institute of Medicine Symposium (2006) / Chapter Skim
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3 Morning Breakout Sessions with Invited Speakers
3 Morning Breakout Sessions with Invited Speakers
Pages 56-93
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From page 56... ...
Although I am a medical oncologist at Memorial Sloan-Kettering Cancer Center, in a sense, I am here representing ASCO and the NCCS on this initiative. Many of you in the room have participated in this initiative, and I welcome you to chime in.
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From page 57... ...
The transition to survivorship care plans, which you heard so much about from Dr. Ganz and others this morning, we conceive of as a more detailed and extensive type of this particular summary.
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From page 58... ...
· Disease-related symptoms · Physical manifestations · Radiologic · Tumor markers · Reasons for treatment discontinuation · Long-term sequelae of treatment · Planned next steps beginning. This is something that Ellen has been talking about for years and years.
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From page 59... ...
So, the short answer to your question is, at this point the Treatment Plan/ Summary is not pitched at the patient level. It is pitched at the primary care physician level.
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From page 60... ...
We think it makes sense in terms of how I, as a medical oncologist, communicate with you as a surgical oncologist, and with my colleague Dr. Ayanian as a primary care physician.
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From page 61... ...
When they are in a surveillance mode, are they following practice guidelines? As we elaborate tighter and tighter, more evidence-based, more knowledge-based, and more clinically relevant practice guidelines, we can continue to link what doctors are doing, what they say they are doing, to
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From page 62... ...
Dr. Ganz: Peter, if we wanted to develop a mechanism for having a visit that would focus on the survivorship care plan visit, which would be linked obviously to an end-of-treatment summary of some sort, would there be some potential for a demonstration that would create that visit, or could be coded as a specialized visit in that way?
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From page 63... ...
I would rather redefine the spectrum of what it is that oncologists and primary care providers do. Joan McClure, National Comprehensive Cancer Network (NCCN)
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From page 64... ...
In putting together my remarks this morning, I tried to meld my personal thoughts as a cancer survivor, with what I have learned professionally about how to measure quality. And on a personal basis, and thinking about the cancer survivorship plan, I want one.
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From page 65... ...
FIGURE 3-2 Measurement leads to improvement: Physicians achieving "Diabetes Physician Recognition" show substantial improvement in key clinical measures.
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From page 66... ...
I tried to think about the vehicles that we could use to begin to implement the cancer survivorship care plan. The NCQA has a program known as Physician Practice Connections.
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From page 67... ...
Does the primary care physician have a responsibility to think about what self-management resources they can provide to a patient based on their survivorship care plan?
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From page 68... ...
Dr. Jacobs: I am the Director of the Cancer Survivorship Program at the University of Pennsylvania Abramson Cancer Center which has been in existence for about five years.
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From page 69... ...
So, the notion that we can create a care plan and just hand it to individuals and expect that it will alleviate or reduce anxiety, or provide a higher quality of care I think is a little bit unrealistic. And so, I think we need to develop very complex educational
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From page 70... ...
So, the paper route, long-term, is probably not the most sustainable. But I think that we have to empower the survivors, and then build the necessary infrastructure in order to not only implement the care plan, but also to provide quality survivorship care.
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From page 71... ...
Dr. Bach: I agree, but I think there is an analogous research question that you would want to address, which is what is going on in the physician community, and the culture of medical caring that creates impediments for this kind of communication?
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From page 72... ...
Dr. Anna Meadows: When I was the director of the Office of Cancer Survivorship, who and when an individual was considered a survivor was up for argument.
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From page 73... ...
You can make up a specification, or something like that, that says within a year you will have at least had to offer a survivorship care plan. That would be a quality measure, something like this.
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From page 74... ...
Diana Jeffery, National Cancer Institute, Office of Cancer Survivorship: As I am listening, I am thinking of lots of research questions. But the number one question I have is, if this was instituted, whether in demonstration projects or a national kind of effort, would there be a difference at the end of the day or the end of the year, or at the end of 5 years or 10 years?
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From page 75... ...
And we have to decide whether we are going to do this as operations research, sort of quick and dirty. Let's try it, measure the impact, regroup, revise, and do it again.
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From page 76... ...
When you look at the acute care, preventive care, or overall care, the survivors that had a primary care physician and an oncologist were most likely to have recommended care (Figure 3-5)
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From page 77... ...
What I would like to emphasize though, is that most of the studies have focused on either the simple presence or absence of a healthcare provider, and have not systematically looked at whether there was shared care. I have illustrated in Figure 3-7 the distinct needs of oncologists, survivors, and primary care providers.
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From page 78... ...
The electronic health record has a key role to play in promoting survivorship care. The technology is currently available and the cancer care team can create an electronic health record and then populate the record with key elements of the cancer survivorship plan outlined earlier.
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From page 79... ...
Adaptation of 3-component "re-engineered" model Dietrich AJ. BMJ 2005 Survivor Prepared Practice Care Manager Oncologist Targeted education Nurse/Telephone Supervise care Implement system Educate manager process to Anticipate Informal/formal enable and consult with PCP Guide reinforce for Increase quality & Guidelines survivor care quantity of survivor Algorithm resources Healthcare organization FIGURE 3-8 Bridging through shared care.
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From page 80... ...
Pat Legant, Community-Based Medical Oncologist I have practiced medical oncology in the community for over 20 years, and I am pleased to report that I follow a great many cancer survivors. In this way, I think that my experience parallels that of most oncology specialists, in that most adult cancer survivorship care in this country is supervised by an oncology specialist who works in cooperation with a primary care provider, in some version of the model of shared care that is described in the report from the Institute of Medicine.
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From page 81... ...
We need both perspectives. The chief disadvantage of the shared care model, as cited in the IOM report, is a dwindling supply of oncology specialists in the face of an increasing population of cancer survivors.
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From page 82... ...
Insurers must offer adequate reimbursement, or else these activities cannot happen. The shared care model has served us well for many years, and will continue to be the predominant model in the foreseeable future.
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From page 83... ...
Another critical piece as we do the "hand off" or the shared care transitions is how we will make sure that primary care physicians and whoever is following these patients 15 years down the line have access to relevant cancer-related information? There are ways to build these communications in either through web sites or staying in contact in some way with an oncologist in the long-term.
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From page 84... ...
But until I went to do her annual pap smear and her breast exam did it occur to me, oh yes, this person has had breast cancer, and I need to start to followup on some things. And that is why recommendation number two is really important, that a survivorship care plan is needed.
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From page 85... ...
I think survivorship guidelines would really help us as primary care physicians very much. And the last thing that is important to me, because it is important to my entire medical career, has been access to adequate and affordable health insurance.
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From page 86... ...
Dr. Susan Weiner, Children's Cause for Cancer Advocacy: I would like to address some questions about this notion of a shared care model to the speakers.
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From page 87... ...
And whether that is a nurse within the cancer team, or whether it is a nurse in the prepared primary care practice that works as an intermediary, it is going to vary from practice to practice. The other thing that I want to highlight is we used the term "shared care," and I am going to be the devil's advocate, and say we do not know what shared care is.
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From page 88... ...
As a primary care physician, we often have this habit of looking across diseases, because we take care of multiple conditions. Some of the concerns you raised when I listened to you are specific to cancer survivorship.
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From page 89... ...
Dr. Woolf: Let's get a reaction to the panel on the issue of gaps in knowledge, and how the partnership between the primary care physician and the oncologist can help deal with those gaps in understanding.
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From page 90... ...
I would like to suggest that along with shared care, we focus on appropriate care, which brings in the expertise that is needed at the time that it is needed. If we look at the epidemiology chapter in this book, what really comes to my mind, and really was the impetus for the research I have done for years on this topic, is that for the major prevalent cancers, breast, colon, and prostate cancer, the majority of survivors are over 65.
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From page 91... ...
. This research illustrated how when cancer survivors see the family doctor, they receive recommended general preventive care, and when they see the oncologist, they receive the recommended cancer specific preventive care.
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From page 92... ...
So, my question would be what can we do, what will it take to bring the leading organizations of primary care physicians into this process? I think many primary care physicians are just grappling with the needs of cancer survivors in the ways as best they can as individuals.
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From page 93... ...
Dr. Benjamin: In the AMA and the Academy of Family Physicians we could take this report and present a resolution to the house of delegates in both organizations saying exactly what you just said.
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