Guest Editorial

Cancer Survivors Need FPs, Subspecialists to Collaborate

January 04, 2017 02:52 pm Kevin Oeffinger, M.D.

There are more than 15 million cancer survivors living in the United States, and within the next five years, this number will exceed 20 million. Five-year cure rates for all cancers combined now approach 70 percent.

[Kevin Oeffinger, M.D.]

Kevin Oeffinger, M.D.

Needless to say, family physicians are often the ones to screen for or diagnose cancers, make the referral to the cancer specialists and then … wait. Yes, that is what family physicians and general internists often complain about: Our patients go into a black hole, and eventually they come back -- after having had some concoction of treatment -- uncertain how the therapy might affect their future health.

At the same time, cancer specialists contend that primary care physicians are not interested in or equipped to take care of cancer survivors.

This disconnect between primary care and subspecialty care leaves patients confused, questioning who is responsible for what and simply hoping to move forward with their lives.

This dilemma was well described in the seminal 2005 Institute of Medicine report From Cancer Patient to Cancer Survivor: Lost in Transition.(www.nationalacademies.org) Since then, several groups and organizations have tried to remedy the suboptimal care that frequently results from this disconnect. Notably, in 2011, the American Society of Clinical Oncology (ASCO) established the Cancer Survivorship Committee and tasked the multidisciplinary group (which includes family physicians) to develop initiatives that would lead to improved care of cancer survivors and facilitate communication and collaboration between cancer specialists and primary care clinicians.

Through the efforts of this committee, ASCO reached out to the AAFP and the American College of Physicians (ACP) to co-sponsor an annual symposium with a goal of bridging the oncologic and primary care worlds. Members of the AAFP, ACP and ASCO formed the steering and planning committees for this event. In January 2016, more than 800 individuals across many different disciplines and specialties attended the inaugural symposium in San Francisco.

On Jan. 27-28, the second annual Cancer Survivorship Symposium: Advancing Care and Research -- A Primary Care and Oncology Collaboration(survivorsym.org) will be held in San Diego.

This year's steering and planning committees for the symposium were both chaired by family physicians. Topics for the meeting will include dealing with genetic findings in survivorship; addressing gaps in health professional education about survivorship; basics in survivorship health care; community-based and international models of survivorship care; unique issues affecting adolescent and young adult cancer patients, as well as those affecting elderly cancer patients; reducing disparities in cancer survivorship; and learning from the insights of health care professionals who are cancer survivors.

This is just a starting point for dialogue and collaboration. There is exciting research being conducted in the United States and around the globe that is focused on optimizing the care of cancer survivors and incorporating the primary care physician into each step.

But, as many family physicians recognize, survivorship is simply one of the many aspects of the care of their patients, along with diabetes, heart disease, mental health issues, etc. Indeed, perhaps the best way to think about survivorship is to understand how the cancer and cancer therapy, modified by the patient's genetics, lifestyle behaviors and comorbid health conditions, influence the function and aging of the various organ systems -- and indeed, the whole patient. To optimize the health and quality of life of our cancer survivors, it is imperative that we, as family physicians, stay involved in the care of our patients and avoid the black hole mentioned above.

Several groups have developed useful tools to help us accomplish this goal. The American College of Surgeons' Commission on Cancer has established a set of standards to promote patient-centered care of cancer patients.(www.facs.org) Included is a hospital accreditation requirement for cancer specialists to provide a survivorship care plan (SCP) to all cancer patients and their primary care clinicians. Intended as a tool to aid communication among health care professionals, the SCP is a summary of the key aspects of the cancer, the cancer therapy, future health risks related to the cancer therapy and surveillance recommendations.

Working with leaders in this area, ASCO developed several templates for SCPs(www.cancer.net) -- one for any type of cancer and then disease-specific plans for several types of cancer. These SCPs are easily modified and can be adapted to different practice settings.

ASCO also is working with electronic health record vendors to develop easy-to-use electronic SCPs. ASCO,(www.asco.org) the American Cancer Society(www.cancer.org) (ACS) and the National Comprehensive Cancer Network(www.nccn.org) (NCCN) have developed a number of guidelines for the care of cancer survivors; these can be downloaded from their respective websites. (NCCN requires free registration to access its guideline.) The George Washington Cancer Institute, in collaboration with the ACS, developed an excellent 10-module cancer survivorship e-learning series for primary care health professionals.(gwcehp.learnercommunity.com)

In summary, it is our responsibility as family physicians to stay involved in the care of our patients as they progress through cancer therapy and into the survivorship phase. Moreover, although there are a number of family physicians who are leading research, developing new curricula for medical students, residents and fellows, or creating guidelines and tools to help in the care of cancer survivors, there is a critical need for considerably more involvement from our members.

Family physician Kevin Oeffinger, M.D., is the director of the Cancer Survivorship Center at Memorial Sloan Kettering Cancer Center. In March, Oeffinger will move to Duke University to serve as the director of the Duke Cancer Supportive Care and Survivorship Center and to establish the Duke Center for Onco-Primary Care, an innovative program within Duke Cancer Institute in partnership with the Duke University Health System.