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Proceedings of a Workshop
Pages 1-58

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From page 1...
... She added that many of the clinicians and institutions caring for people with cancer and cancer survivors face substantial challenges in identifying and addressing complex care needs, keeping pace with the high level of demand for care given workforce shortages and gaps in access to specialized expertise, and forming and sustaining effective care teams across specialties and clinical practices. 1 This workshop was organized by an independent planning committee whose role was limited to identification of topics and speakers.
From page 2...
... More people are living with and beyond cancer, due in part to an increase in cancer diagnoses and better survival rates brought about by medical advancements and innovative therapies, said Lawrence Shulman, director of the ­Center for Global Cancer Medicine at the University of ­Pennsylvania Abramson Cancer Center, who outlined the goals of the workshop. He explained that many people with a history of cancer are now living decades past their initial diagnosis, are in older age groups, and have one or more comorbidities, often related to the effects of their cancer treatment.
From page 3...
... Speaker presentations and the workshop recordings have been archived online.2 IMPROVING MULTIDISCIPLINARY AND MULTISPECIALTY CARE IN THE CANCER CARE CONTINUUM The workshop examined the challenges that cancer survivors face in managing health issues related to their cancer and cancer treatment and how multidisciplinary, multispecialty care can address these issues across the life­ span. Drawing upon research findings, patient experiences, and perspectives from specialists in a variety of areas, speakers discussed key gaps, opportunities, and considerations to lay the groundwork for improving the provision and coordination of survivorship care.
From page 4...
... Challenges with interdisciplinary care collaboration for cancer survivors • Even medical centers that have access to specialists face chal lenges in integrating them into an effective, collaborative care team focused on survivorship. (Jacobs, Mayer)
From page 5...
... They are not intended to reflect a consensus among work shop participants. BOX 2 Suggestions from Individual Workshop Speakers Regarding Ways to Improve the Provision of Multispecialty, Multidisciplinary Care for Cancer Survivors Enhancing patient outcomes through innovative technology and interventions • Use risk stratification to guide coordinated, multispecialty inter­ventions and integrate specialist care into treatment and follow-up decisions.
From page 6...
... (Thomson) • Include primary care clinician in patients' multidisciplinary care teams, and work with caregivers to implement survivorship plans that center whole-person care.
From page 7...
... • Recognize care inequities as a human rights issue and spur investment in building dedicated programs to address dispari ties. (Allicock, Cates, Fuld Nasso, Irwin, Ma)
From page 8...
... More recently, she has begun to feel more confident with a survivorship plan, a trusted primary care clinician, and a team of specialists who understand and address her multiple, layered health issues. In her view, the two most critical improvements needed in cancer care are to implement survivorship plans and include primary care clinicians on the care team and in every decision, from diagnosis to posttreatment.
From page 9...
... During this first cancer experience, he had access to multi­ disciplinary team care, which is common in pediatric cancer. In treatment for recurrences during adulthood, however, he has found the care to be very different.
From page 10...
... Carlson and Jacobs pointed out that problems can mount over time and comorbidities become more common with age. Moreover, the challenges of survivorship care grow more complex as an increasing number of cancer survivors live for decades past their diagnosis and often well into old age (see Figure 1)
From page 11...
... '" The Role of Specialty Care and the Need for Coordination Because many cancer survivors face a range of long-term health issues related to their cancer and cancer treatment, they often require care involving many medical specialties, from reproductive health and fertility to endocrinology and cardiology, and dozens of other areas. For example, Jeremy Pivor, senior program coordinator of Planetary Health Alliance at Harvard University, said that his care requires a large multispecialty and multidisciplinary team including expertise from primary care, cardiology, medical and radiation oncology, physical therapy, occupational therapy, psychiatry, acupuncture, neurosurgery, rheumatology, neurology, and a therapist who specializes in treating young adults with cancer (see Box 3)
From page 12...
... To delve deeper into some of the common health issues survivors face, the need for specialty care, and potential opportunities to enhance care coordination, many speakers shared experiences and models from the perspective of a range of medical specializations. While not comprehensively inclusive of the full spectrum of areas relevant to cancer survivorship care, speakers discussed a sampling of approaches to enhance multidisciplinary, multispecialty care.
From page 13...
... . Ky observed that despite this known risk, which increases with age, many cancer survivors with CVD are underdiagnosed and undertreated and face a higher risk of death than the general population (Paterson et al., 2022; Strongman et al., 2022; Sun et al., 2021)
From page 14...
... . Rehabilitation Medicine Rehabilitative care models that are co-located and embedded with cancer care delivery can play a crucial role in addressing the high burden of postcancer disability, noted Nicole Stout, associate director of the survivorship PREPUBLICATION COPY -- Uncorrected Proofs
From page 15...
... . She attributed the success of these models to the fact that they were implemented within cancer care, were aligned with systemwide strategies, and had a high level of institutional support.
From page 16...
... Psychosocial Health Gaps in the provision of mental health care and the role of psychosocial health in collaborative cancer care were discussed by William Pirl, vice chair for psychosocial oncology, and Kelly Irwin, director of the Collaborative Care and Community Engagement Program at Dana-Farber Cancer Institute and Harvard Medical School. They explained that psychosocial health affects every aspect of life, including mental health, physical functioning, finances, and even mortality.
From page 17...
... Pirl offered a few guiding principles for improving psychosocial health as part of collaborative cancer care. He said there will never be adequate numbers of mental health clinicians, so it is essential to integrate mental health care within medical care.
From page 18...
... . He also cautioned that patients will not benefit equally until other factors that affect patient outcomes can be addressed, such as a lack of transportation, gaps in health or digital literacy, and the high cost of cancer care.
From page 19...
... Endocrinology Describing the role of endocrinologists in cancer survivorship care, Meacham pointed out that the endocrine system is easily damaged by cancer PREPUBLICATION COPY -- Uncorrected Proofs
From page 20...
... She referred to Project ECHO5 as an informative resource for sharing best practices and knowledge with communities that are rural and/or underserved, while providing specialty care when facilities lack endocrinologists or other experts. Pulmonology Including pulmonologists as a part of multidisciplinary cancer care teams can improve patient outcomes in several ways, explained Patrick Nana-Sinkam, professor of medicine at Virginia Commonwealth University.
From page 21...
... , but barriers have hindered full integration into cancer survivorship, including a dearth of nutritionists in some areas, limited specialized training in nutri-oncology, a lack of reimbursement for medical nutritional therapy, and low funding for nutri-oncology research (Trujillo et al., 2019)
From page 22...
... He cautioned against losing sight of the imperative to ensure that people get the treatments they need. He posited that CHCs could take a much bigger role in this, saying "we have a tool that was supposed to be the undergirding in the United States for our most vulnerable, and we have in some ways ignored what was put in place." Describing his work to incorporate research, specialist care, and survivorship into a Chicago FQHC's traditional care model and public health focus, Winn said that academic cancer centers and CHCs should collaborate on aligning their communities, programs, services, and strategic directions to achieve greater equity in cancer and survivorship care.
From page 23...
... Because many CHCs do not have oncologists on staff, another participant suggested that cancer centers could partner with CHCs to improve their scope of practice and handle more survivorship care in these settings. Advancing Multidisciplinary, Multispecialty Care Many speakers highlighted a variety of approaches that could be leveraged to help facilitate multidisciplinary, multispecialty care.
From page 24...
... She explained that although technological advances would be welcome to help West Virginia's underfunded CHCs integrate their EHR data, the real need is for PCPs and CHCs to have a better understanding of cancer care and navigation, and to better help patients optimize self-­management skills and overcome negative health beliefs, she said (Azriful et al., 2021)
From page 25...
... She said this would be especially important for CHC clinicians and PCPs who may not have access to academic institutions or cancer centers. Gracia agreed and noted that cancer survivorship has been integrated into reproductive fellowships.
From page 26...
... . Heflin and Weaver said that implementation is necessary at various levels, including patient care, clinician practices, leadership, education, policy, administration, and within academic–CHC clinical partnerships (Bogossian et al., 2023; Interprofessional Education Collaborative, 2016)
From page 27...
... PREPUBLICATION COPY -- Uncorrected Proofs FIGURE 4  Conceptual schematic illustrating an example of a multiteam framework for collaborative cancer care. 27 SOURCES: Weaver presentation, July 17, 2023; Chollette et al., 2020.
From page 28...
... The majority of patients with a new cancer diagnosis are older adults,9 but Klepin said the cancer care delivery system is not set up to provide them with quality care (Bluethmann et al., 2016; IOM, 2013) .These patients have complex needs and multiple constraints, but there is a lack of evidence from clinical trials on how they respond to cancer therapies, as well as a lack of geriatric clinicians, training, coordination, advocacy, and dedicated resources (Bertagnolli and Singh, 2021; Williams et al., 2020)
From page 29...
... Project ECHO: Capacity Building for PCPs in Cancer Survivorship Care Hilary Ma, associate professor at the University of Texas MD Anderson Cancer Center, described how Project ECHO (Extension of Community Health Outcomes) brings clinicians together to improve survivorship care.
From page 30...
... . Supporting Training to Prioritize Access to Care Many speakers underscored the relationship between the priority placed on improving access to care and the willingness of health systems and clinicians to invest time and resources in education and training programs to facilitate multidisciplinary, multispecialty care.
From page 31...
... They discussed opportunities to focus attention on the need to improve cancer survivorship care in general and optimize the effectiveness and efficiency of delivering this essential care at the level of health care systems in particular. The Impetus and Challenge of System-Level Interventions to Support Survivorship Tevaarwerk and David Dougherty, deputy director of clinical services at the Abramson Cancer Center at the University of Pennsylvania, discussed challenges and opportunities for health systems to deliver multidisciplinary, multispecialty cancer care to the right patient, at the right time, and the right location -- and to do so at scale -- in the context of a continually evolving cancer care landscape.
From page 32...
... ­Tevaarwerk highlighted opportunities for health systems to establish system-level accessible and supportive structures and processes through efforts focused on quality integration, service site optimization, expanded advanced care access, and clinical disease teams, and by more effectively leveraging data. At Penn Medicine, for example, multiple structures provide patients at every site in the health system with patient-centered multidisciplinary, multispecialty care pathways to foster cancer survivorship.
From page 33...
... from efforts to improve survivorship care can be assessed across the health system. 33 SOURCES: Alfano presentation, July 17, 2023; Alfano et al., 2022.
From page 34...
... Brasfield stressed that the health care sector needs more innovative approaches like this care coordination system and enhanced payment ­models for telehealth, greater investment in integrated health care technology, more workforce training in oncology and cancer survivorship, long-term post­ treatment studies, and strategies to retain oncologists. She also suggested replacing board exams, which quickly become outdated, with more frequent and structured learning modules that can incorporate emerging research and best practices.
From page 35...
... . By contrast, structured and standardized EHR data can be more quickly and easily shared, searched, extracted, and analyzed to improve care delivery (Hassett et al., 2022; Häyrinen and Saranto, 2005; Osterman et al., 2020)
From page 36...
... "If all we're going to do is tweak the system and add something on top of it, it won't work," he stated. "We need to change the basic rules of the system." Learning from Other Fields of Medicine The cancer care community could learn from the standards of care for other diseases, Alfano suggested.
From page 37...
... Alfano stated that her system hires community members who speak the languages of the community, which creates "cancer cultural ambassadors" who can help with complex conversations. Reid and Gramatges suggested that survivorship programs should find ways to partner more effectively with PCPs, who are often the only local resource for cancer survivors and help them identify the appropriate survivorship guidelines or care pathways.
From page 38...
... population cannot afford basic health care, much less the multidisciplinary, multispecialty care that cancer survivors need. The much higher spending on cancer care in the United States compared with most developed nations does not translate into a lower cancer mortality rate, noted Robin Yabroff, scientific vice president of health services research at the American Cancer Society (Chow et al., 2022)
From page 39...
... Closing Gaps in Insurance Coverage for Survivorship Care Although the overall number of uninsured people in the Unites States has declined since the implementation of the Affordable Care Act (ACA) , Dusetzina noted that programs still need significant improvements to support better access to health care in general and cancer survivorship care in particular.
From page 40...
... Uninsured Rates for the Nonelderly by Age | KFF Timeframe: 2019 40 WA MT ME ND OR MN VT ID NH SD WI NY MA MI WY RI CT IA PA NJ NE NV OH DE UT IL IN MD CA CO WV DC KS MO VA KY NC TN AZ OK NM AR SC AL GA MS TX LA AK FL HI PREPUBLICATION COPY -- Uncorrected Proofs 4.4%- 8.3% 8.7%- 11.7% 12.2%- 16.0% 16.7%- 24.5% FIGURE 7  Percentage of adults aged 19–64 years without health insurance coverage by state in 2019. SOURCES: Yabroff presentation, July 18, 2023; Kaiser Family Foundation, 2023.
From page 41...
... Ideas and Efforts to Improve Payment and Service Delivery Models Yabroff pointed out that smarter, more efficient health care spending is needed to address the health and financial issues all patients face -- whether insured or uninsured. Several approaches have been employed to address payment and policy barriers and improve cancer care and survivorship care delivery.
From page 42...
... Survivorship care is now more of a priority at cancer centers, but Shulman cautioned that it is too early to tell how much progress has been made. Emily Tonorezos, director of the Office of Cancer Survivorship at NCI, discussed work that the office is doing to support survivorship care.
From page 43...
... She added that the EOM covers care planning, but a new, cancer-specific billing code18 is necessary for coordinated patient navigation through traditional Medicare. Fuld Nasso also advocated for passage of the Comprehensive Cancer Survivorship Act,19 which would provide coverage for cancer care planning and navigation and support clinician training for survivorship care.
From page 44...
... Christopher Friese, the Elizabeth Tone Hosmer professor of nursing at the University of Michigan, expressed optimism that various care models discussed at the workshop could inspire reimbursement policy changes to cover new services and expand cancer care team capabilities while controlling costs but noted that the support of institutions and health systems will also be essential for success. The Power of Perceptions of Value on Patient-, Clinician-, and System-Level Decisions Stout expressed frustration that clinicians are asked to work more efficiently and justify their costs, whereas new, expensive therapies are routinely reimbursed, even when they provide little survival benefit.
From page 45...
... Cavanagh said that daily or weekly team huddles may improve patient navigation and better meet patients' complex medical and psychosocial needs. Perkins said that cancer centers that co-locate care improve the patient experience, especially those with patient navigators, whose ability to take on clinicians' "invisible workload" make the biggest difference.
From page 46...
... Winn observed that health care in the United States is not only dysfunctional but disconnected. The pieces -- CHCs, academic research centers, and comprehensive cancer centers -- are not structurally connected.
From page 47...
... Carlson commented that these should be based on evidence from multiple large clinical trials with very high concordance levels and that "value" has different meanings, such as care efficacy, relationships, cost effectiveness, or care quality, so it is important to determine specify which definition is being used. Roy Jensen, vice chancellor and director of the University of Kansas ­Cancer Center, observed that many speakers lamented the lack of a coordi nated U
From page 48...
... 2022. Engaging team medicine in patient care: Redefining cancer survivorship from diagnosis.
From page 49...
... 2023. Effectiveness and implementation of models of cancer survivorship care: An overview of systematic reviews.
From page 50...
... 2020. Identifying cancer care team competencies to improve care coordination in multiteam systems: A modified Delphi study.
From page 51...
... 2002. Mental health service use among adult cancer survivors: Analyses of the National Health Interview Survey.
From page 52...
... 2019. Follow-up strategies following completion of primary cancer treatment in adult cancer survivors.
From page 53...
... 2022. Workforce caring for cancer survivors in the United States: Estimates and projections of use.
From page 54...
... 2017. Integrating primary care providers in the care of cancer survivors: Gaps in evidence and future opportunities.
From page 55...
... 2022. Examining guidelines and new evidence in oncology nutrition: A position paper on gaps and opportunities in multimodal approaches to improve patient care.
From page 56...
... Journal of Cancer Survivorship. Stout, N
From page 57...
... 2015b. Reviewing cancer care team effectiveness.
From page 58...
... 2021. Annual report to the nation on the status of cancer, part 2: Patient economic burden associated with cancer care.


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