Onco-primary care networks prevent ‘benign neglect’ through collaboration
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Primary care physicians often are best positioned to detect cancers and provide essential monitoring of treatment-related adverse events during cancer survivorship.
However, the focus on treating a patient’s cancer can have the unintended effect of alienating primary care providers and disrupting the continuity of primary care services, according to a presenter at Cancer Center Survivorship Research Forum.
“The screening rates for our five screenable cancers are low across the board, and very low in some areas,” Kevin C. Oeffinger, MD, professor in the department of medicine and a member of the Duke Cancer Institute (DCI), founding director of the DCI Center for Onco-Primary Care and director of the DCI Supportive Care and Survivorship Center, told Healio.
“If you look at most cancers diagnosed today in the U.S., patients will not die of their cancer, but they’ll die of a heart attack or stroke,” Oeffinger added. “That’s not because we are causing harm with their therapy, but because we have benign neglect of their hypertension, diabetes or lipid disorders for the 5 or 6 years around the time of their cancer diagnosis. We can do much better across the board.”
Oeffinger discussed the challenges around keeping primary care clinicians involved in patient care throughout the cancer continuum.
Applying the cardio-oncology model
The DCI Center for Onco-Primary Care is a primary care network consisting of 44 primary care clinics and 300 primary care providers within DCI. The primary care network and cancer centers are part of the same health care system located across seven counties and includes three hospitals and several outpatient facilities, Oeffinger said.
“We take care of a very demographically diverse population,” he said. “We work on tools that will enhance communication using things like the electronic health record auto reminders and auto messaging.”
The DCI Center for Onco-Primary Care — established in 2017 — was founded using some of the same concepts applied to Duke’s Cardio-Oncology program, Oeffinger said.
“In cardio-oncology, when we started the movement, our intent was not to train cardiologists to be oncologists — nor do we try to train oncologists to be cardiologists,” Oeffinger said. “Instead, we try to make sure that both are paying attention to the cardiovascular system of patients who are either going through or completed their cancer therapy. The same idea applies to primary care.”
Value-based care
Oeffinger discussed the value-based care that can be delivered through the collaboration between primary care and oncology across the cancer continuum.
He highlighted ways in which primary care clinicians and oncologists can collaborate on cancer prevention, screening, early diagnosis, comorbidity management, chronic cancer care, survivorship and end-of-life care.
Oeffinger cited an example of this care trajectory from Duke’s genitourinary oncology group.
“We have multiple projects that include everything from increasing our screening rates for prostate cancer — especially among our most vulnerable populations — to enhancing the transition of patients with elevated PSAs,” he said.
Oeffinger discussed his group’s virtual elevated PSA clinic, which is staffed by advanced practice providers.
Primary care providers refer patients with elevated PSAs of 10 ng/mL or lower to the virtual clinic. Those with PSA levels higher than 10 ng/mL are fast-tracked to the urology group.
Duke also offers a navigator program for individuals with elevated PSAs who have difficulty getting into the urology group.
“Then we have a study that is looking at managing hypertension, diabetes or lipid disorders among men with either newly diagnosed prostate cancer or men who are on androgen deprivation therapy, because both are associated with elevated risk for cardiovascular disease,” Oeffinger said. “The idea is for primary care and oncology to collaborate from cancer screening all the way to either active therapy with curative intent or chronic cancer care.”
‘Sit at the table together’
Another way in which the DCI Center for Onco-Primary Care will be patterned after its successful cardio-oncology program is in the use of research and clinical models, Oeffinger said.
“We have had research studies to identify when agents are causing cardiotoxicity, studies for prevention and treatment, and efforts aimed at the training and education of cardiology fellows and oncology fellows,” he said. “Just in the way that we have succeeded in many ways in cardio-oncology, we are emulating this model with the Center for Onco-Primary Care within the Duke University Health System.”
Even in the absence of a dedicated onco-primary care program, oncologists and primary care clinicians can do a great deal to encourage and support collaboration, Oeffinger said.
“Rather than having a finger-pointing situation where oncologists say, ‘I can’t find a PCP,’ or when a PCP says, ‘I can’t get the oncologist to send me information,’ the idea is to sit at the table together and determine a workflow and a method of communication for each part of the care continuum.”
Because much of medicine is now provided within the context of health care systems, providers can use these systems as an opportunity to forge constructive partnerships, Oeffinger said.
“By working collaboratively within the health care system, we can improve value,” he said. “We can move toward a value-based model, which we all think is important, and take it from a population-level or a health care system-level approach.”
For more information:
Kevin C. Oeffinger, MD, can be reached at Duke Cancer Institute, 2424 Erwin Drive, Suite 601, Durham NC 22705; email: kevin.oeffinger@duke.edu.
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Oeffinger KC. Duke’s oncoprimary care program. Presented at: Cancer Center Survivorship Research Forum; Sept. 11-12, 2023, Stanford, California.
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