Alternate models may address ‘need to better tailor survivorship care’
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Advances in cancer treatment during the past half-century have achieved one of the fundamental goals of oncology: longer survival.
However, with more cancer survivors living longer, the medical profession must be prepared to navigate these patients through the long-term risks, comorbidities and complications of survivorship.
Source: Erica Reist Bass/Michigan Medicine Rogel Cancer Center.
“A solely oncologist-led model of care is no longer sustainable in the U.S. due to the increasing number of survivors, as well as workforce shortages,” Lauren P. Wallner, PhD, MPH, associate professor in the departments of internal medicine and epidemiology at University of Michigan, said in an interview with Healio | HemOnc Today. “We need to better tailor survivorship care to patients’ care needs.”
Wallner and other experts discussed proposed alternative models of survivorship care — including nurse-led, shared care and primary care-led models — as well as patient and provider preferences, during a session at the Association of Community Cancer Centers Annual Meeting and Cancer Center Business Summit in March.
“By better aligning care with patients’ needs, we can take advantage of these different models and deploy those that best fit the care delivery setting and meet the needs of patients,” she said.
Current models of care
Oncologist- or specialist-led survivorship care is the traditional approach and most prevalent model in the United States, according to Wallner. Other survivorship care models include those that involve shared or team-based collaboration between oncology and primary care, primary care physician-led models and nurse-led approaches, which usually include specialized oncology nurses.
Some of these less common survivorship care models have shown results comparable to those of the more widely adopted oncologist-led models.
Wallner cited research by Chan and colleagues, published in Journal of Cancer Survivorship, that showed no difference in overall effectiveness across survivorship care models for managing physical and psychosocial outcomes. The evaluation of 12 systematic reviews that captured 53 primary studies also revealed benefits of the PCP- and nurse-led models vs. the oncologist-led models with regard to cost and health promotion activities, such as diet, lifestyle and exercise, as well as patient and caregiver experience, she said.
“The research to date shows that the models are comparable in terms of a number of important outcomes, including morality, risk for recurrence, and management of both physical and psychosocial effects of treatment,” Wallner told Healio | HemOnc Today. “Nonspecialist-led models are also associated with improved care coordination and greater patient and caregiver satisfaction with their care — and may also have more economic benefits and utilize fewer health care resources.”
Wallner noted that most of the studies to date have been conducted outside of the U.S. “Therefore, the effectiveness of these different models in the U.S. delivery system is less clear,” she said.
Preferences of patients, providers
To better understand patient preferences for survivorship care, Wallner and colleagues surveyed 2,372 women who had received treatment for early-stage breast cancer.
“We asked them their preferences for provider roles and survivorship care — would they prefer that a PCP or an oncologist direct certain services that we know are key to high-quality care,” she said. “What we found was that for the two top services, comorbidity care and general preventive care, most patients preferred that their PCP direct care, which makes sense. These are things that PCPs are typically involved in.”
In terms of mammography screenings and ongoing surveillance for other cancers, however, most women preferred that their oncologists direct care.
Wallner noted that these preferences varied based on patient demographics.
“The preference for an oncology-led model of care was more common among Black and Latina women and those with the lowest level of educational attainment,” she said. “We have been doing a lot of subsequent work in this space to try to understand how best to clarify these roles for patients and survivors.”
Although research has shown that patients are open to PCPs managing their survivorship care, they frequently report concerns that these clinicians may not have the specialized knowledge and confidence to do so, Wallner said. She mentioned a study published earlier this year in Journal of Cancer Survivorship that showed 25% of survivors across multiple cancer types were comfortable with PCP-directed survivorship care and 50% were comfortable with a multidisciplinary clinic. These preferences differed by race, time to treatment and insurance coverage.
“Similar to our study, most of the patients preferred that oncologists manage things like late-term effects and recurrence monitoring, but they were OK with their PCP managing their general health,” Wallner said.
In terms of PCP preference, Wallner discussed the landmark study Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS), which evaluated the views of various clinicians regarding the delivery of survivorship care.
“In this survey, PCPs seem to prefer a shared model of care,” Wallner said. “This was conducted almost 10 years ago, and they endorsed that they want to be involved in cancer care but did not feel informed enough about what happens during treatment to effectively take on that role in survivorship.”
According to Barbara L. McAneny, MD, FASCO, MACP, medical oncologist and former president of the AMA, PCPs do not necessarily have the incentive to manage long-term cancer survivorship.
“Primary care seems to be a vanishing breed,” McAneny told Healio | HemOnc Today. “It’s difficult to justify a person busting their tail as a primary care doctor and taking home about $180,000 a year on [evaluation and management] Codes when they can go be a hospitalist and work one week on, one week off for $250,000 a year. Not as many people are choosing primary care.”
McAneny discussed the “treat and street” approach to primary care, which involves fast and efficient treatment and discharge.
“Primary care doctors don’t want patients with cancer in their panels. If you’re a 25-year-old with bronchitis, you can walk in, I can listen to your lungs, and I can say ‘Here’s a prescription — call me if you’re not better next week,’” she said. “The last thing they want is someone who says ‘I have bronchitis, I’m 55 years old and I just finished treatment for breast cancer 5 years ago. I’m really worried this cough could be something in my lungs. Can we check to see if it’s cancer?’”
Oncologists’ preferences for survivorship care tend to differ among studies, according to Wallner. In the SPARCCS study, oncologists reported that they preferred an oncologist-led model of care. However, in her own research, Wallner found a third of oncologists reported difficulty determining whether oncologists or PCPs should manage general preventive care during treatment.
“Another recent study suggests most oncologists now endorse that more survivors could be transitioned out of oncology clinics for follow-up care,” she said. “So, I think there is an evolving movement now in which oncologists are becoming more open to the idea of these alternate care models.”
However, oncologists also expressed concerns about barriers to continuity in the transition to survivorship care. Wallner said they cited obstacles such as treatment-related toxicities, tumor-specific factors and oncologists’ perception of PCPs’ willingness to participate in survivorship care. Most oncologists also reported patient preferences and anxiety as key to their transition decisions.
“Interestingly, decreased remuneration and fewer longitudinal relationships were not [key factors in decision-making],” Wallner said. “So, there is some misalignment or discordance in their views.”
Wallner said most PCPs reported a desire for additional training in survivorship care and management of late effects of cancer treatment, along with more resources to help them effectively participate in survivorship care.
“There are a number of great resources, including online training and CME activities for PCPs,” she said. “Many cancer centers also offer programs for PCPs that include updates on cancer screening, treatment and survivorship care guidelines.”
Risk-stratified care
Many clinicians endorse a risk-stratified survivorship care model as a means of directing patients toward care that best meets their needs and the providers’ expertise.
“Patients are stratified into care pathways based on the complexity of their needs and the types of providers that their care requires,” Wallner said. “This provides a great framework for thinking about when we might use some of these different delivery models. You can imagine that a patient with metastatic cancer might have quite a different delivery model than a patient with a very low-risk prostate cancer.”
Wallner discussed the ways her own center has been routing patients to appropriate survivorship care programs based on their cancer type and risk level.
“We have a number of nurse-led models by cancer type at our center, typically run by nurse practitioners,” she said. “We also have a small PCP-led clinic for very low-risk breast cancer [ductal carcinoma in situ].”
University of Michigan also has a multidisciplinary adolescent and young adult (AYA) oncology program, as well as a prostate cancer survivorship program focused primarily on symptom management and sexual health.
“There is a heavy social worker presence in this model, as well,” she said. “That has led us to step back and think about ways we can create efficiencies and centralization of some services, and try to minimize some redundancies in what we offer our patients. We are in the process of strategically planning and putting resources toward a more comprehensive survivorship program to address the needs of the growing population of survivors.”
The PCP-led care experience
Other cancer centers have introduced new models of survivorship care and reported promising results.
Internal medicine specialist Kimberly S. Peairs, MD, spoke during the session about her experience working in a PCP-led model at Johns Hopkins University.
“I have no formal oncology training, but I’ve worked very closely with our oncologists at Johns Hopkins,” Peairs said. “I came into this space about 20-plus years ago when our breast oncology surgeon reached out to internal medicine and said, ‘I’ve been treating a lot of my patients’ hypertension and diabetes, and that probably isn’t a good idea.’”
Peairs began working closely with this surgeon to develop a shared care model for survivors. In the ensuing years, she developed a consortium of other internists with an interest in cancer survivorship.
However, Peairs didn’t want to treat these individuals solely as cancer survivors.
“There are other comorbidities and medical issues that we were concerned weren’t being addressed fully,” she said. “So, working closely with our oncologists, I came up with the Primary Care for Cancer Survivorship Group.”
The group sought not only to coordinate care and learn from one another, but also to disseminate education and increase awareness beyond their institution.
“We didn’t want to be taking patients away from their providers in the community,” she said. “We thought we needed to extend the education to other primary care providers so they could facilitate similar care patterns. Also, we wanted to standardize assessment of the patients we were seeing in the clinic.”
Peairs and colleagues began to see survivors with various needs and risk levels, from low-risk survivors who needed surveillance for comorbidities to survivors with genetic predisposition to multiple cancer types.
“We’ve been taking snapshots in time of the volumes of patients we’ve seen, the type of referrals, and the patterns that subsequently came from that,” she said. “Our first 250 patients or so were primarily breast cancer survivors.”
Although Peairs said she and her colleagues expected to primarily see early-stage cancers, it surprised them to discover a more even distribution across cancer stages, including about 10% metastatic cancer cases.
“That has held true in our referral patterns,” she said. “That’s interesting and it speaks to the spectrum of care we’ve been delivering.”
Peairs and her colleagues also gave patients an assessment form, which asked them about the physical, emotional and social concerns that caused them to seek survivorship care.
“Not surprisingly, the emotional needs were quite high, but that was primarily due to fear of recurrence of their cancer,” she said. “Fatigue was also a leading concern.”
The comorbidities of these patients, most of whom were white and had insurance, closely resembled those of patients in the general medical clinic and included hypertension, hyperlipidemia and diabetes.
A hybrid payment model
Peairs also discussed the financial factors involved in running a PCP-led survivorship clinic. She said because the practice is embedded in a primary care clinic, it has benefited from changes to evaluation and management codes that include time-based billing.
“Even before that, the complexity of these patients caused us to have higher new and return billing codes for them compared with our regular medical patients who don’t have cancer,” Peairs said. “So, we were able to do this just based on our clinical care billings.”
Peairs said the program also benefited from some philanthropy to support the clinicians’ time for assessment and management. She added that in Maryland, a program called MD PCP is modeled after national programs directing funds toward primary care Medicare patients.
“As you can imagine, these patients have higher [hierarchical condition category] codes — they’re just sicker in general,” she said. “So, those wraparound services that go with those dollars can benefit our patients, because they are embedded in our primary care practice. When we have those dollar distributions from the state level, we’re able to support them with things like health, behavioral specialists, dieticians and pharmacy services in our clinic.”
Peairs said there is capitation in this model, but it is only partial.
“So really, we have a hybrid payment model within our clinic,” she said. “That has been very helpful.”
Continuity and access
Peairs said a qualitative assessment of survivors’ experience in the survivorship clinic showed, overall, they appreciated having their PCP monitor long-term and latent side effects.
“It gave them peace of mind to know that their PCP could manage this, and that they were still connected to their oncologist,” she said. “They could reach their oncologists easily if they had questions, and then work in conjunction with both providers.”
Peairs added that she has worked with her oncology colleagues to identify which patients would be best served by the survivorship program. She said they have tried to narrow down referral patterns, with a focus on patients who are older or at high risk for long-term or late effects from their treatment.
“We’ve had close interactions with our oncology counterparts, and I can’t overstate the benefit of being in a single EHR,” she said. “So, that leads back to the benefits of the shared care model. We don’t live in a silo — we work closely with oncology and manage as much as we can.”
- References:
- Attai DJ, et al. J Cancer Surviv. 2022;doi:10.1007/s11764-022-01177-0.
- Chan RJ, et al. J Cancer Surviv. 2021;doi:10.1007/s11764-021-01128-1.
- Potosky AL, et al. J Gen Intern Med. 2011;doi:10.1007/s11606-011-1808-4.
- Radhakrishnan A, et al. J Clin Endocinol Metab. 2020;doi:10.1210/clinem/dgaa437.
- Radhakrishnan A, et al. J Gen Intern Med. 2019;doi:10.1007/s11606-018-4690-5.
- Wallner LP, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2017.73.1307.
- Wallner LP, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2016.67.8896.
- For more information:
- Barbara L. McAneny, MD, FASCO, MACP, can be reached at New Mexico Cancer Center, 4901 Lang Ave. NE, Albuquerque, NM 87109; email: mcaneny@nmohc.com.
- Kimberly S. Peairs, MD, can be reached at Johns Hopkins Hospital, 10753 Falls Road Pavilion II, Timonium, MD 21093.
- Lauren P. Wallner, PhD, MPH, can be reached at University of Michigan School of Public Health, North Campus Research Complex, Bldg. 16, Room 409E, 2800 Plymouth Road, Ann Arbor, MI 48109; email: lwallner@med.umich.edu.
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