Primary care providers can play key role in delivering survivorship care in rural areas
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Cancer survivors living in rural settings often face unique challenges in terms of insurance coverage, access to healthy lifestyle choices and opportunities to receive guideline-concordant care.
In her presentation at Cancer Center Survivorship Research forum, Jennifer R. Klemp, PhD, MPH, MA, discussed these barriers to optimal survivorship, which she defined as extending from the time of diagnosis through the patient’s lifespan, including patients living with or through metastatic disease.
“One example would be a woman who has the option of doing a lumpectomy with radiation, but who lives 90 miles from a radiation facility or is busy with harvest,” Klemp, professor of medicine in the division of medical oncology and director of cancer survivorship at University of Kansas Cancer Center, told Healio. “We’ve had patients who’ve said, ‘I’m just going to have a mastectomy, because I don’t have to stay in town or travel back and forth for over a month to get radiation therapy.’”
KanSurvive: engaging rural primary care practices
Klemp discussed addressing these challenges through KanSurvive, an NCI grant-funded program evaluating shared care between primary care and oncology in managing rural cancer survivors.
The KanSurvive program helps participating practices assess gaps in care for cancer survivors, determine training and educational needs to help close these gaps, and map workflow and data capabilities using quality measures.
“Oncologists often experience challenges communicating with primary care, and primary care clinicians often get inundated with information or get no information,” Klemp said. “They don’t know their role. The thing that was most fascinating about our pilot work leading up to this grant was that many primary care clinicians often can’t even identify cancer survivors within their practices.”
Role delineation between primary care and oncology care teams is a valuable way to clarify the responsibilities that fall to each specialty, rather than assuming that clinicians automatically understand the scope of their job.
“Instead of saying, ‘Hey, primary care, just do your job — you already know what evidence-based care is; you should be doing colonoscopies on a patient with breast cancer,’” she said. “We’ve had primary care providers ask whether they really should be ordering these tests — they don’t want to step on oncology’s toes. So, role delineation is a very big issue.”
Defining guidelines
When asking rural primary care practices to help in providing guideline-concordant care, Klemp said it is important to define for clinicians which guidelines they should be following.
“There are guidelines from the American College of Radiology, from the National Comprehensive Cancer Network and the American Cancer Society,” she said. “Every single group has their set of guidelines. Primary care providers want to know which ones they should follow.”
For example, Klemp added, if a patient has a history of breast cancer treated with lumpectomy, then the primary care provider would need to know whether to do a screening or a diagnostic mammogram, how often to do this test, whether they should also do an MRI and whether the MRI should be contrast or noncontrast. Additionally, primary care providers can play a role in stratifying risk for cancer survivors, both in terms of cancer and in terms of comorbid conditions.
“If we have a colon cancer survivor, for example, who is 68 years old with three comorbid conditions, what is their biggest risk and priority in health care?” Klemp asked. “In oncology, they are focused on treating cancer. They don’t have the same level of awareness and expertise in managing patients with diabetes or arthritis. They may expect the primary care physician to do a bone density test or manage obesity, but then the primary care doctor doesn’t want to do something that would potentially impact the management of that colon cancer survivor.”
Klemp emphasized that when evaluating a cancer survivor, primary care physicians may find clarity in viewing cancer as they would any chronic condition.
“When we first talked to participating primary care physicians, we wanted them to start thinking about managing a cancer survivor just like they manage a patient with diabetes,” she said. “The patient is going to have diabetes disease management for the rest of their lives to control it. We want physicians to think about the cancer survivor using this chronic disease model. Whenever they are making those shared decisions with the patient, they should be thinking about cancer as one of that patient’s comorbid conditions.”
‘A pragmatic and stepwise process’
Klemp said part of the framework for the NCI KanSurvive grant takes the form of national quality measures that overlap with a Medicare well-person visit. She said these measures are helpful in establishing how a primary care clinician should consider a cancer survivor, including assessing for comorbid conditions and other health needs and recommending preventive screening.
“They should be talking to every patient about whether they smoke and offering smoking cessation if needed,” Klemp told Healio. “They should be asking patients about psychosocial issues once a year and talking about lifestyle. There are certain national quality measures that should be followed for every patient sitting in front of you. We wanted to look at how many patients with a history of cancer actually receive this level of quality care.”
After offering an educational intervention to primary care providers, Klemp and her team worked with the practices to develop a quality improvement project. Primary care physicians and clinics did chart reviews on their patients based on these quality measures.
“They then looked at those same quality measures a year and a half later, because we hoped that, over time, they would improve their adherence to guideline-concordant care,” she said. “We overlapped it with national quality measures that were tied to reimbursement, because behavior change in medicine is so hard. If we didn’t tie it to things they would already be reimbursed for, it would be hard to move the needle.”
Klemp said the quality measures did result in improvements in some of the primary care practices. Her group has recently written and submitted the next version of the KanSurvive project and is hopeful that this continuation of the initiative will continue to yield results.
“There are some commonalities as to what predicts a practice is going to make a change, such as having engaged providers and better utilization and control over the electronic health record,” she said. “We’re trying to highlight that this needs to be a practical, pragmatic and stepwise process that will allow for change, but also should use the appropriate infrastructure and incentives to facilitate, support and sustain the change.”
For more information:
Jennifer R. Klemp, PhD, MPH, MA, can be reached at Richard and Annette Bloch Cancer Care Pavilion, 2650 Shawnee Mission Parkway, Westwood, KS 66205; email: jklemp@kumc.edu.
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Klemp JR. Practical approaches in rural/urban settings. Presented at: Cancer Center Survivorship Research Forum; Sept. 11-12, 2023, Stanford, California.
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