Risk-stratified follow-up care may benefit cancer survivors, reduce costs
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A personalized, risk-stratified approach to follow-up care could better meet the needs of cancer survivors while helping to control costs for the U.S. health care system, according to a commentary published in Journal of the National Cancer Institute.
The authors — Deborah K. Mayer, PhD, RN, AOCN, FAAN, director of cancer survivorship at UNC Lineberger Comprehensive Cancer Center and interim director of NCI’s Office of Cancer Survivorship, and Catherine M. Alfano, PhD, vice president for survivorship at American Cancer Society — noted three key challenges require a more innovative approach to survivorship care: an aging population, a rapidly increasing number of cancer survivors and a projected shortage of oncologists.
“We need to take a deep breath, step back and rethink how we are doing our follow-up care for people who have no evidence of disease,” Mayer told HemOnc Today. “In doing so, we will be doing a better job for all of our patients.”
Other countries have implemented an approach that triages patients to personalized follow-up care pathways based on the level and nature of resources necessary for their long-term care.
ASCO and American Cancer Society organized a summit in January 2018, from which a multipronged strategy to implement such an approach in the United States emerged.
HemOnc Today spoke with Mayer about why a risk-stratified approach is necessary, as well as the benefits it could offer patients, clinicians and the health care system.
Question: Can you provide some context about the challenges associated with meeting the care needs of cancer survivors?
Answer: Cancer is a disease of aging and, with longer life expectancies for individuals with cancer, a tsunami of survivors has arrived. Even though we have made progress in cancer treatment and the mortality rate has declined, cancer survivors remain at risk for developing additional malignancies or experiencing long-term or late effects from their treatments. This creates a larger group of people who need providers who are knowledgeable about cancer and can help direct their care. Although the number of individuals with cancer has increased, the number of oncologists has not grown in the same proportion. The growing need for treatment is outpacing the ability to meet it. However, it is not only about oncologists. A shortage of primary care providers also is anticipated, so everybody in the health care system will have to see more patients than they may be capable of seeing. We need to develop strategies to address this problem, and we cannot solely focus on increasing the number of providers. We need to get smarter about what we are doing and how we are doing it throughout the entire cancer continuum.
Q: What factors contributed to this challenge?
A: I have been working in oncology since 1975, and I have witnessed the progress we have made. But at my institution, I must figure out how to deal with the challenges of trying to fit new patients into our existing framework. We usually develop programs around the number of new patients we are going to see and how it is expected to grow. However, this does not account for the number of actual visits, because patients who are doing well continue to count toward the volume during their follow-up visits. We have seen the tsunami of survivors coming for a while, but we were not correctly assessing all components of the total volume. I noticed new cancer facilities often ran out of space within the first few years because they counted the number of patients being seen, not the number or type of visits. The current dashboard in most of our electronic health records tells us how many patients are seen and how many total visits occur, but it does not show the granular detail we need to develop facilities, resources and programs to serve our cancer population. For example, you might have 80,000 visits, but you cannot break it down to explore how many of those are 10 years after diagnosis, how many have no evidence of disease and can be transitioned to their PCP, or how many are being treated for metastatic disease.
Q: An ASCO-commissioned study in 2007 predicted a shortfall of oncologists by 2020, and the threat persist s . How does this contribute to the challenge?
A: Although this surge in patients and survivors has been anticipated, not a lot has been done to lessen the gap. We have seen more advanced practice providers (nurse practitioners and physician assistants) enter this space, so it has partially softened the blow, but it has not caused us to step back to rethink how we are delivering care. When you are a busy clinician, it is very difficult to lift your head and look for different approaches while you are consumed with the work in front of you. We have been talking about this for over a decade, but we really haven’t changed what we are doing or how we are doing it. I believe ASCO is updating its workforce study so we will look forward to its report. Additionally, the National Cancer Policy Forum recently held a workshop on the oncology careforce addressing these issues.
Q: How can a risk-stratification model help?
A: We need to recognize that one size does not fit all for survivorship or follow-up care, and we cannot or do not need to do everything for every patient. We need to be more strategic about what we are doing. We want to be able to predict who might be at a lower risk for problems or recurrence, and potentially transition them fully to their PCP with supported self-management about when to call, when to come in or when to be concerned. This allows both the PCP and the patient to feel well-informed about how to manage treatment in a cooperative manner. This frees up space in the oncologist’s clinic, and it also helps return the patient to a more normal life that does not revolve around a cancer center or program.
We need to make this decision early in the process. If somebody has an early-stage cancer that should respond well to standard therapy, a provider can start talking to them about their options while they are receiving treatment. When treatment ends, it is time to talk about what the transition will look like and when it will happen. Patients want a roadmap. So do their PCPs. If oncologists do not provide it and act as if we do not trust PCPs to play a role in the treatment process, patients are not going to feel comfortable following through on this option.
Q: Are there evidence-based guidelines that determine risk level?
A: There are no evidence-based guidelines about risk yet. We need to develop a way to look at patients’ comorbid conditions and their functional ability to think about risk in a broader sense that isn’t based solely on recurrence. My colleagues at UNC are studying this model in breast cancers to see if we can better predict which patients fit into the low-risk group. It doesn’t mean this is going to be a good fit for all patients or all disease groups, but we have to start somewhere.
Q: How effective has this personalized, risk-stratified model been in other countries?
A: The data — particularly from the United Kingdom — have shown this approach reduced costs and also reduced the wait times for a newly diagnosed patient to see an oncologist. Outcome data look promising, and patient satisfaction is equivalent to that of someone who is still seeing an oncologist. We must figure out how we can adapt this for use in the United States. A focus on the large volume of low-risk patients would be a good place to start. This would mean focusing on breast, colon and prostate cancer survivors as the largest volume of survivors. High-risk patients may never fully stop being followed by the oncologist, but they may be receiving more shared care from the oncologist and the PCP. Patients with cancer have a number comorbid conditions that are not really being addressed by the oncologist. Shared care is probably an appropriate model for longer-term survivors who are at higher risk. There also needs to be better communication between the oncologist and PCP to ensure we do not duplicate or fail to provide services.
Q: If this issue is not addressed so on, what will the consequences be?
A: If the framework for managing follow-up for survivors does not change, oncologists could practice 24/7 and still not be able to fit in everybody who needs to be seen. We will start experiencing longer delays for appointments for patients. Survivors may be seen less often or in a different way. We do have some standards that determine how fast a newly diagnosed patient should be seen, but we do not have metrics to see how well we are accomplishing that or how well we are adhering to what we think are the right surveillance schedules. We are sitting on these electronic health records, and they really need to be better corralled to give us more granular data so we can see how well we are doing in measuring quality metrics and for planning our facilities, programs and resources. – by Joe Gramigna
References:
Alfano CM, et al. CA Cancer J Clin. 2019;doi:10.3322/caac.21558.
Mayer DK and Alfano CM. J Natl Cancer Inst. 2019;doi:10.1093/jnci/djy232.
For more information:
Deborah K. Mayer, PhD, RN, AOCN, FAAN, can be reached at UNC School of Nursing, Carrington Hall #7460, Chapel Hill, NC 27599-7460; email: dmayer@unc.edu.
Disclosure: Mayer reports an advisory board role with and stock ownership in Carevive.