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Monday Feb 20, 2017

Better Cancer Care Demands That FPs, Oncologists Work Together

During a recent business trip, I logged in to my electronic health records system to catch up on my charts and was notified that one of my patients had died.

I was struck by the irony. I was in San Diego to participate in the Cancer Survivorship Symposium: Advancing Care and Research -- A Primary Care and Oncology Collaboration(survivorsym.org) and I was saddened by the thought that my patient, who was being treated for cancer, could have benefited from the type of collaborative approach being touted at the event.

Photo by © ASCO/Todd Buchanan 2017
Deborah Mayer Ph.D., A.O.C.N., right, and I participate during a panel discussion at the Cancer Survivorship Symposium: Advancing Care and Research -- A Primary Care and Oncology Collaboration.

Too often after a cancer diagnosis, our primary care patients disappear from our view. They move on to oncology. Sometimes they come back to us. Sometimes they don't.

At the symposium, which was co-sponsored by the AAFP, I was asked what kind of transition of care family physicians need when cancer survivors come back to our practices. My response surprised our oncology colleagues. I said that I don't want or need a transition. Instead, I want to be involved and informed as my patients are treated.

I explained that I often have cared for patients for years before their cancer diagnoses, and, I hope, I will care for them for years afterward. In many cases, I care for their loved ones, too.

That was the case with Lisa, the patient whose death I'd found out about when I checked my charts during that trip. I cared for her and her partner. They knew me and trusted me. Lisa had struggled with cognitive problems after an accident, and that may have complicated her cancer treatment and compliance, and lowered her odds for a good outcome.

As I sat there processing the news of her death, I lamented the fact that given the opportunity, I could have been of assistance. I could have made things easier for everyone, including the now grieving partner. But when Lisa died, I hadn't seen her for nearly 18 months. I wasn't included in her treatment, and I wasn't able to help. Attempts to reach her to re-establish contact were not successful.

I shared Lisa's story during a panel discussion at the symposium, and I also shared Robert's story. In the most basic way, their stories are the same. They both battled cancer and they both, in the end, succumbed to their illness. However, their stories diverge -- greatly -- in the fact that as Robert's primary care physician, I was there to support him, help him understand his options and allow him to make the decision that was best for him.

Robert's oncologists were excellent physicians. They provided top-notch care, knew the most up-to-date science and were ready to deploy new and aggressive treatments when earlier plans failed.

Robert, wonderful man that he was, didn't want to disappoint these doctors who were valiantly trying to save his life. But he was 73 years old, had survived other major health care crises, and he was ready to die. He knew what was coming, accepted it and wanted to stop treatment.

But he didn't know how to look these physicians in the eye and tell them that, no, he did not want their help any longer. So I told them for him, at his request. He wasn't depressed; he was realistic and wanted to spend his last few weeks without further medical intervention.

Family medicine is, in large part, about building relationships and trust over time. Robert had been my patient for 15 years, and his family asked me to speak at his funeral. He knew me and he trusted me.

Having primary care involved along the spectrum of cancer care is critical for patients. As family physicians, we don't make decisions about what type of medication or surgery our patients need after they transition to an oncologist's care, but we can ensure that their other medical and preventive care is provided appropriately. We make a difference in follow-up surveillance, and we can ensure that our patients are informed and involved in the decision-making process and that their wishes are respected.

During the symposium, Jonathan Sussman, M.D., associate professor in the Department of Oncology at McMaster University in Hamilton, Ontario, and clinical lead for survivorship at Cancer Care Ontario, presented preliminary findings of a study that showed that breast cancer survivors who transitioned to primary care had a better five-year survival rate and lower health care costs than patients in a control group. More in-depth analyses of that study are expected to be made public next month.

Roughly 900 people attended the symposium, and the majority of them were doctors, nurses and patient advocates from oncology. I talked to many people after the panel discussion, including one oncologist who admitted she hadn't really understood what family medicine was about or appreciated the scope of what we do. I would wager that in that audience, she wasn't alone. I think they learned that family physicians are strong patient advocates, that we provide comprehensive care and that patients have better outcomes when we are involved.

Oncologists told me they didn't know we wanted to stay involved as our patients went through cancer care. They thought that as busy primary care physicians we would be glad to not be "overburdened" with one more complex patient.

"It's nice to know we have partners," one oncologist told me.

So what does collaborative care look like?

Perhaps we should have a cup of coffee, or at least a phone call, with our oncologist colleagues to talk about how we can provide better care for our patients. Tell them if we want to stay involved and be informed about what tests are being ordered, what medications or radiation treatments are given, what follow-up care is needed now and over the lifetime, who will provide/order that care, and everything else we want to know. If the patient is seeing physicians from both specialties, communicate about what specific care each practice will be responsible for. It might also help to ensure that we understand their jargon and they understand ours.

Most importantly, open a conversation with your oncology colleagues to lower the barriers to good patient-centered care and improve communication all around.

Wanda Filer, M.D., M.B.A., is Board chair of the AAFP.

Posted at 12:35PM Feb 20, 2017 by Wanda Filer, M.D.

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