Dr. Fredrick Ashbury, PhD and Kristina Michael, NP
Fred Ashbury (FA): Fortunately, many more people are surviving cancer as a result of earlier detection, optimizing treatment delivery, and innovations in cancer therapies, including the development and integration of immunotherapies and targeted treatments. Today, “survivorship”, is perhaps even more important than it has ever been. How would you characterize the management of survivorship thinking in today’s community oncology practice setting?
Kristina Michael (KM): During cancer treatment, the concept of “what comes next” is often overshadowed by a focus on the “present” treatment. Despite excellent training, many clinical oncologists and licensed providers in the clinical setting have had little formal training in post-treatment survivorship care management. Within the community oncology setting, we have a responsibility to patients and the future of medicine to adapt our mindset to prevention and management of other diseases, along with preventing cancer recurrence. It is important to integrate survivorship into the treatment process at the initial clinical visit, as well as throughout the treatment journey.
FA: How might community oncology practitioners support survivorship management as part of the care paradigm?
KM: One concept is utilizing an end of treatment summary with emphasis on a survivorship care plan in which the clinician and patient and/or support system work together to minimize additional clinic visits, excessive labs, duplicate imaging orders, active participation in cancer screening and positive lifestyle behaviors. Setting time-specific goals with prioritization to keep track of requested imaging, procedures, and routine follow up for wellness can assist with compliance. To date, there are no provider driven survivorship models that are standard in cancer programs. The presence of social support has been shown to be a protective factor in optimization of quality of life and improved health outcomes, therefore engaging patient’s social support during this time is optimal. Ensuring patients are provided with a copy of their treatment report(s) and provided appropriate education on expectations, will diminish barriers when patients return for routine clinic visits. Guidance on key issues to be aware of and when these should be reported, including changes in body weight, eating habits, energy, and the like, can facilitate more effective communication between the practice and the patient, especially if clinical rules are established and integrated to guide actions to take as a result of these changes the patients may report.
FA: What are some of the challenges in delivering survivorship care in the community oncology setting?
KM: Some challenges include actual monitoring of certain clinical aspects of care. For example, surveillance for recurrence, monitoring for secondary cancers, physical ailments secondary to treatment, management of psychological effects of treatment, and management of new or ongoing social disparities.
Another important issue within survivorship care is the transition of care to the primary care provider. Oncologists see their role as addressing cancer needs, and patients often have difficulty placing that trust and expectation for an elevated level of care to an additional provider. According to Coschi, Bainbridge & Sussman, 2021, “oncologists agreed that more patients could be shared/transitioned. Barriers include treatment-related toxicities (82% agree), tumor-specific factors (60–90% agree) and perception of PCP willingness to participate in survivorship care (47% agree)”. While most symptoms of treatment typically resolve after 6-12 months, there is a significant impact in quality of life and physical functioning that may be present for their lifetime. There is currently a system-wide preparation to support expanded use of nurse practitioners, physician assistants, and primary care providers. According to studies observing different framework models, “comprehensive cancer centers may be able to offer more extensive resources and services to their survivors than smaller, independent oncology providers. However, smaller programs may have fewer barriers in assessing and meeting those needs” (Nekhlyudov et. al, 2019).
In addition to the physical and psychosocial issues that can challenge survivorship care delivery, involves financial setbacks including employment and insurance concerns. Many patients continue to work throughout treatment, but due to the diagnosis or the selected treatment regimen working limitations may result. “Survivors who incurred $10,000 or more in debt were significantly more likely to report social and economic impacts. The most commonly reported financial sacrifices included cutbacks on household budgets, challenges with health insurance and costs, career constraints, reduction/depletion of assets, and inability to pay bills” (Banegas et. al, 2019).
Thirdly, there can be resource constraints in the community setting. For example, limited or no access to social work, psychologists, financial counseling, as well as the absence of digital health solutions, particularly in rural-remote patient populations and lower socio-economic status patients, can dramatically affect successful survivorship participation in care and outcomes. In the absence of the resources, community oncology programs might seek to establish relationship with resources in their communities and facilitate care coordination to ensure patients can participate actively.
While significant progress has been made in addressing survivorship needs, there are still areas of improvement to continue providing the highest level of comprehensive and evidence-based care in the community. Models of survivorship care are emerging in the published literature, and these will be discussed in a subsequent newsletter.
Fredrick D. Ashbury, PhD
Chief Scientific Officer, VieCure Professor (Adj), Department of Oncology University of Calgary Professor (Adj), DLSPH, University of Toronto
Kristina Michael, NP
Senior Clinical Associate, VIeCure