Survivorship Care: An Emerging Medical Need

TON - September 2011 Vol 4, No 6 — September 15, 2011

CHICAGO—The population of cancer survivors is growing rapidly. More than 12 million Americans are alive after a cancer diagnosis, with most living at least 5 years, and 16% living 20 years after their initial diagnosis.

This growing population of cancer survivors is at risk for many comorbid health conditions, especially as they age. A study of 10,397 childhood cancer survivors found this group to be 8 times more likely to have a severe or life-threatening condition than their siblings (Oeffinger K, et al. N Engl J Med. 2006;355:1572-1582).

Survivorship care, therefore, has become a topic of interest as oncologists aim to determine the best way to attend to these patients’ long-term needs. “Patients report feeling abandoned at the end of their cancer treatment, and many complete treatment with persistent problems. Planning for recovery is important!” said Julia Rowland, PhD, of the National Cancer Institute, speaking at a special session on survivorship care. Rowland cited several “lessons learned” recently about survivors and their need for personalized care:

  • The posttreatment survivorship phase brings its own set of unique needs and challenges—physical and medical, psychological, social, and existential/spiritual. • Intervening early, when problems arise, leads to better outcomes.
  • For many patients, cancer provides “a teachable moment.”

It is not only healthcare providers who are concerned, but also patients who are asking how they can reduce their risk of cancer recurrence and live healthier lives, she pointed out. It is important for healthcare providers to be prepared to answer their questions, she emphasized.

The Institute of Medicine and President’s Cancer Panel have recommended that survivors receive a summary record that includes important disease characteristics and the treatments received, and that they be provided with a follow-up care plan that incorporates evidence-based standards of care. “But we have little information as to how this is being done and its impact in real practice,” Rowland said.

Whose Job Is It?

A much debated issue is determining which healthcare provider should be in charge of survivorship care: the oncologist or the patient’s primary care physician (PCP). A recent survey suggests the primary care model may not be preferred. Paul Han, MD, of Maine Medical Research Institute, Scarborough, discussed the early findings of the Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS). One survey was administered to 1100 PCPs and a second one to 1100 oncologists.

“We wanted to examine the attitudes, knowledge, and practices of PCPs and oncologists regarding the care of cancer survivors,” Han said. “We focused on breast and colon cancer survivors, and we looked at how physicians perceived their roles and responsibilities in the care of cancer survivors vis-à-vis one another. We also looked at how much confidence they have in one another’s skills and the knowledge that is required to take care of this group of patients.”

The study found, in general, that PCPs had low confidence in their knowledge of appropriate surveillance and of the long-term and late effects of cancer treatment. PCPs rated their skills for caring for cancer survivors as low, and oncologists agreed. “These data could have implications, considering that many groups have argued that we should move toward a system of shared care between PCPs and oncologists, with PCPs demonstrating greater responsibility for cancer survivor care,” Han suggested.

Neither PCPs nor oncologists selected a PCP-led model as the ideal model for survivorship care, he reported. In addition, although oncologists said they provide treatment summaries or care plans to PCPs most of the time, the PCPs reported they rarely receive these. Oncologists also reported frequent communication with other physicians to clarify their respective roles in follow-up care, but PCPs reported that this communication occurred infrequently. Both specialties tended to overuse surveillance testing, especially PCPs.

“We need to explore models where there is greater sharing of care with PCPs, yet these findings show that PCPs have very low confidence, and oncologists also rate PCPs’ skills and knowledge as very low. It suggests we have a long way to go before physicians are comfortable with the proposed shared-care model,” Han said.

Cost-Effectiveness Not Proven

Certainly, survivorship care plans (SCPs) are well-meaning, but do they really improve health outcomes and are they cost-effective?

A research team from Canada concluded that the survivorship care plan adopted by their center had no impact on patient outcomes or adherence to follow-up guidelines and was not a cost-effective use of “scarce healthcare resources.”

In accordance with the Institute of Medicine’s recommendation for providing cancer survivors with formal SCPs, the multicenter study assessed the effect of such a program and its cost-effectiveness.

In a randomized trial, the re searchers first evaluated an SCP for breast cancer survivors transitioning to routine follow-up care with their family physician. The study enrolled 408 patients with early-stage breast cancer who had completed treatment at a tertiary cancer center. In the intervention group, 200 patients received an SCP consisting of a treatment summary, a patient’s version of the follow-up guidelines, and brochures and information about local relevant supportive care resources. These were compiled into a binder and reviewed with the patient in a nurse-led 30-minute educational session. The family physicians re ceived a copy of all documents plus the full guideline and a reminder table of recommended follow-up visits and tests. The control group of 208 patients received a discharge visit and their physicians received a discharge letter, according to usual practice.

The primary outcome was psycho social adjustment (measured on the Impact of Events Scale; IES) 12 months after intervention. The secondary outcomes were continuity of care, health-related quality of life (measured on the SF-36 health survey questionnaire), patient satisfaction, and adherence to guidelines. A shortterm study cannot adequately assess clinical outcomes, the investigators pointed out.

In spite of having received a formal SCP, the intervention group demonstrated no additional improvement in psychosocial adjustment or in any of the secondary outcomes studied, reported Eva Grunfeld, MD, of the University of Toronto.

The IES change from baseline was –2.9 points in the intervention group and –1.4 points in the control group, for a difference of 1.6 points that was not significant, she said. The analysts used data from the trial, derived utility values for the outcomes, and put these together with the costs incurred for each 3-month period from baseline to 24 months after discharge. Costs included physician visits, diagnostic tests, patient travel costs, lost productivity, and cost of recurrence. In the SCP analysis, costs included the cost of developing and, where necessary, revising the plan, which included labor, administrative support, materials, and postage, totaling approximately $60 per patient.

In the cost-effectiveness analysis, the base cost was $736.23 for the standard of care and $788.63 for the SCP. The analysis was performed from various perspectives, such as the healthcare system perspective, with inclusion and exclusion of lost productivity as measured by a human capital approach, and with exclusion and in clusion of recurrences. Standard care remained dominant over the SCP when costs and benefits were not discounted, when the analysis adopted the healthcare system perspective, when lost productivity was ex cluded, and when estimates of the costs were included, according to Doug Coyle, PhD, of the University of Ottawa.

“The results of this study clearly suggest that the SCP adopted was not a cost-effective use of scarce healthcare resources,” Coyle suggested. “Given the 22,500 new incident cases of breast cancer per year [in Canada], implementation of the SCP to all breast cancer patients would cost in excess of $1.3 million per year with no evidence of improved healthrelated outcomes.”

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