Models of Care for Cancer Survivors UICC World Cancer Congress - - PowerPoint PPT Presentation

Models of Care for Cancer Survivors

Kevin C. Oeffinger, MD Departments of Medicine and Pediatrics Chair-Elect, ASCO Cancer Survivorship Committee

UICC World Cancer Congress August 30, 2012

Questions and Issues

• Risk-based survivorship health care
• Risk-based survivorship health care
• Who, where, how?
• Health care system and setting

– Hospital specialist vs GP outpatient – Tertiary cancer centers vs community

• ncologists
• Are resources allocated where they

are most needed? Does one size fit all? are most needed? Does one size fit all?

Es#mated)Number)of)Cancer)Survivors)in)the)United) States)from)1971)to)2007)

NCI Office of Cancer Survivorship, based on SEER data, 2009

2'000'000 4'000'000 6'000'000 8'000'000 10'000'000 12'000'000 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007

Number

Over)14)million)) cancer)survivors)

Traditional Model

• Oncologist follows survivor for ‘lifetime’
• Focus is on surveillance for recurrence and

persistent toxicity

• Disconnect from other health care needs and lost in

transition back to general health care needs

The average number of outpatient visits per year among 104,895 long-term cancer survivors

(SEER-Medicare 1997-2003)

Pollack LA, et al. Cancer 2009

10 years after cancer

• 8 physician visits per year
• 1.6 visits with cancer doctor
• 2.8 visits with primary care

Proportion of 5-year breast cancer survivors (N=1,961) receiving recommended preventive care (SEER-Medicare)

Snyder CF, et al. JGIM, 2009 10 20 30 40 50 60 70 80 90 100 Neither Onc PCP Both

Flu Vaccine Cholesterol CRC Screen DXA Mammogram

Long-Term and Late Effects

• Second malignant neoplasms (SMN)

– 16% of incident cancers are SMNs – Heightened risk from genetic factors, treatment exposures (radiation), lifestyles (smoking), aging, and multi-interactions

• Cardiovascular disease

– Cardiotoxic chemotherapy or radiation, lifestyles, aging ….

• Other organ dysfunction / senescence
• Aging and frailty

Conceptual Model: Frailty

5 6 4

Cancer

Adapted from Fried LP, J Gerontol 2001 1 2 3

Long-Term and Late Effects

• Psychological outcomes

– Anxiety and depression – Sense of uncertainty, fear of recurrence

• Social outcomes

– Changes in relationships – Economic / work / education impact

Long-Term and Late Effects

• Psychological outcomes

– Anxiety and depression – Sense of uncertainty, fear of recurrence

• Social outcomes

– Changes in relationships – Economic / work / education impact

• Suboptimal care of non-cancer

comorbidities

Cancer Survivor’s Risks

• Risk of recurrence
• Severity of long-term effect (toxicity)

– Pulmonary dysfunction – Job loss, inability to return to work – Ongoing need for rehabilitation

• Risk of late effect

– Radiation-related second cancer – Anthracycline-related cardiomyopathy – Post traumatic stress or fears of recurrence

Risk-based survivor health care

• Monitor for recurrence
• Surveillance for second

cancers and late effects

[Early diagnosis and intervention]

• Prevention

[Tobacco use, physical activity, diet, calcium intake]

• Counseling and targeted

education

• Specialized services

[cancer rehabilitation]

Potential Barriers

• 14 M increasing to 20 M by 2020
• Unclear patient desires and understanding
• f future health care needs
• Shortage of oncologists
• Shortage of primary care physicians
• Individual financial incentives vs fixed (or

shrinking) system resources

• Lack of communication, education, and

trust

Primary Care and Oncology

Potosky AL, et al. J Gen Intern Med, 2011

Primary Care and Oncology

Potosky AL, et al. J Gen Intern Med, 2011

• Different model preferences
• Lack of trust
• Difference in confidence levels

Levels of Risk

• Low risk

– 54-year-old breast cancer survivor 3 yrs post lumpectomy and radiation [cancer surveillance]

• Moderate risk

– 54-year-old breast cancer survivor also treated with adjuvant chemo including doxorubicin and sequential trastuzumab [above plus heart and brain]

• High risk

– 45-year-old leukemia survivor treated with allogeneic hematopoietic stem cell transplant following total body irradiation

Low-Moderate Risk Models

Eva Grunfeld Studies – transition of early stage breast cancer survivors to PCPs

• Surveillance and detection of serious
• utcomes: PCP = Oncologist

BMJ 1999 and J Clin Oncol 2006

• Survivorship care plan did not improve

patient-reported outcomes [J Clin Oncol 2011]

– Low vs moderate risk – Longitudinal assessment of surveillance mammography and late effects in moderate risk group

Low-Moderate Risk

Moderate Risk

• Initiation and counseling about surveillance
• Targeted counseling during ‘teachable’ moment

regarding physical activity and diet

• Transition back to the community

Pa#entDCentered)Medical)Home)

Developed by the MaColl Institute

Improved Outcomes

High Risk

• Multi-organ toxicity
• Unusual (non-intuitive) late effects, such as metabolic

derangements following bone marrow transplant

• On going need for physical and psychosocial cancer

rehabilitation

Several international studies in progress:

• Further elucidate patient, oncologist,

primary care physician preferences

• Study the transition process from
• ncologist to PCP – what is needed
• Randomized clinical trials to test in other

health care systems and patient populations

Future Directions

• Test the utility of electronic health record

and patient/physician portals

• Determine the incidence of late effects

(and mechanisms)

• Develop risk prediction models to assist

decision making (intensity, frequency, and setting of care)

Future Directions

Bridging Primary Care and Oncology

External Advisory Committee [K05CA160724]

• Roland Goertz, MD, MBA AAFP President
• J. Fred Ralston, Jr., MD

ACP President

• Douglas W. Blayney, MD

ASCO President 2009-2010

• Peter C. Adamson, MD

COG President

• Joseph V. Simone, MD

IOM 2003 Editor

• Eva Grunfeld, MD, Dphil

Knowledge Translation Network

• Ellen Stovall

IOM 2006; Editor, NCCS

Future Directions