Who Will Care for the Growing Number of Ca Survivors?

NEW YORK—Who will watch over the burgeoning numbers of cancer survivors and provide the surveillance, general medical care, education, and psycho-social support that the upwards of 10 million survivors in America need and demand? Pilot programs and survivorship care guidelines may be shifting some responsibilities away from oncologists, according to Paul F. Engstrom, MD, medical director of the Fox Chase Cancer Center Partners, and Mary McCabe, RN, MA, director of the Cancer Survivorship Program at Memorial Sloan-Kettering Cancer Center, who spoke at the Second Annual Oncology Congress.

"Some 64% of our patients survive more than 5 years, so we must look past the acute management of the illness," Dr. Engstrom said. "And 75% of oncologists provide some or all of the health maintenance and preventive services for their patients past the acute management period." He noted that there is much to watch out for: recurrent disease, second primary tumors, fatigue, complications of treatment such as "chemo brain," cardiac problems, osteoporosis, fertility and reproductive problems, as well as psychosocial and genetic issues.

The growing numbers of cancer survivors and the complexity of their care suggests to many that the continuum of care has to change. Ms. McCabe said the time has come "to begin to pilot how we are going to work among specialties in this country. We have to think about where we want to go in terms of quality care and what that means." Memorial Sloan-Kettering is among seven cancer centers that are piloting different models of survivorship care, in conjunction with the Lance Armstrong Foundation.

All models, she explained, are built on a risk-stratified approach, understanding of respective roles, clear communication, confidence, and a supportive infrastructure that promotes easy transfer of medical records.

Some look to the pediatric oncology model of long-term follow-up. Many cancer centers have free-standing pediatric oncology follow-up programs with separate teams of nurse practitioners, oncologists, and social workers. "Pediatric oncology is also moving to more risk-based care in terms of who stays within the system and who has a coordinated hand-off back to community physicians," Ms. McCabe said.

Other centers are piloting a consultative model in which the patient has a one-time visit with a nurse practitioner who provides the patient a summary of care and plan for surveillance. The patient is then followed by the treating oncologist.

In a third model, a nurse practitioner leads a survivorship care clinic, either stand-alone or, as at a program being tested at Memorial Sloan-Kettering, connected with the treating team in the same building, so that the patient sees a clear continuation of care. The nurse practitioner sees the patient independently or in a shared visit with the physician. The patient always has the option of going back to the treating oncologist if a problem arises, Ms. McCabe said.

The nurse practitioner sees the patient after the risk of recurrence and immediate effects of toxicities of treatment have been reduced. Follow-up includes surveillance for recurrence, identification of late and long-term effects, ensuring that the patient continues to get all appropriate screenings, and ensuring that Memorial has a link with the health care provider in the community.

"I would suggest that in the clinical practice area there is no one size fits all," Ms. McCabe concluded. "If it is acceptable to patients and providers, it also must be financially do-able. And that is the biggest challenge we all face."