Download MODELS OF CANCER SURVIVORSHIP CARE Models of Cancer

Shared Care Models of Older
Survivors of Cancer
Beatriz Korc-Grodzicki, MD, PhD
Memorial Sloan-Kettering Cancer Center
Weill Cornel Medical College
New York, NY
MAY 14, 2015
OBJECTIVES
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Understand the shared role of the
geriatrician/primary care provider with the
cancer specialist in providing cancer care.
Identify gaps in knowledge about shared-care
Propose future studies to fill the gaps in
knowledge in shared-care.
Cancer Survivorship and Aging
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Survivorship is a relatively new way of thinking about cancer.
Improved survival rates
Cancer is a chronic disease
“Survivor” includes
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Those who have lived for an extended period of time after treatment
Newly diagnosed individuals
Those who are in treatment, have completed treatment or are in
remission
NCI defines survivor as anyone who has been diagnosed with
cancer
18 Million Cancer Survivors Projected in 2022
IOM.
Delivering
High Quality
Cancer Care:
Charting a
new course for
a system in
crisis.
http://www.io
m.edu/reports
/2013
The
Majority
of
Cancer
Survivors
are Older
Adults
CANCER SURVIVORSHIP AND AGING
Studies of Long-Term Diagnosed Older Patients
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Cancer survivors have more comorbidities and
poorer functioning (independent of comorbidities)
than non-cancer survivors
The effects of cancer due to age is more apparent
This may be the result of the late effects of cancer
and its treatment, underlying risk factors or
interaction of cancer and aging.
Avis et al. Cancer 2008;113 (12 suppl):3519-29
From Cancer Patient to Cancer Survivor: Lost in
Transition. IOM 2005
Report Recommendations: www.iom.edu
1.
…..should work to raise awareness of the
needs of cancer survivors, establish cancer
survivorship as a distinct phase of cancer
care, and act to ensure appropriate
survivorship care.
From Cancer Patient to Cancer Survivor: Lost in
Transition. IOM 2005
Cancer Survivor Care Planning
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Record of Care
Upon discharge from cancer treatment, including treatment of
recurrences, every patient should be given a record of all care received
and important disease characteristics
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Standards of Care
Upon discharge from cancer treatment, every patient and their primary
care provider should receive a written follow-up care plan incorporating
available evidence-based standards of care.
SURVIVORSHIPCARE PLAN (SCP)
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Treatment summery
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Contact information of providers
Tumor type, stage, grade
Hormonal/markers info
Rx provided: Surgeries,
chemotherapy (drugs, dates),
radiotherapy
Follow up care plan
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Surveillance of recurrences or
new cancer
Assessment and treatment of
persistent effects and their
management
Prevention of late effects
Coordination of care
Associations among SCPs, experiences of survivorship care, and functioning
in older breast cancer survivors: CALGB/Alliance 369901.
Faul et al. J Cancer Surviv (2014)8:627-637
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Only 35% of 328 women, >65, over 78 cooperative –group
sites, with invasive non-metastatic breast cancer received
SCPs.
For each one year increase in age there was a 5% lower odds
of receiving an SCP.
Besides age no other factors predicted SCPs.
SCP receipt was associated with greater knowledge and
understanding of requisite follow up
However it did not impact functioning one year post
treatment.
To impact functioning and other needs of older survivors,
SCP should be tailored to geriatric specific issues: exercise,
nutrition, polypharmacy, social support, comorbidities.
Survivorship Issues for an Aging Population
Rowland J and Bellizi K JCO 2014
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SCP format
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Tailoring the document to include coexisting health
problems
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Paper vs. electronic
Attention to survivor’s reading level
Attention to font size for the visually impaired
Inclusion of geriatric assessment?
Inclusion of the appropriate caregiver in SCP process
Staff training in order to provide patient education
that is culturally sensitive
Identification of the responsible individuals to deliver
care
MODELS OF CANCER SURVIVORSHIP CARE
Care of Breast Cancer Patients
Diagnosis
Treatment
Survivorship
Post Treatment
Follow-up
Early Follow
up
2-5 yrs post
treatment. The
patient is provided a
standardized care
plan
Long term
Post
Treatment
Follow-up
Nurse Practitioner provides
transition note to Internist :
• 10 yrs post treatment for
t1,2 NO;
• 5 yrs for t1,2 NO triplenegative;
• 5 yrs for DCIS
Recurrence
Community
Physician
MSKCC Breast Cancer Specialist (surgery,
chemotherapy, radiation)
MSKCC Survivorship
Nurse Practitioner
Community
Physician
.
Methods of Delivering
Survivorship Care
Oeffinger K C , McCabe M S JCO 2006;24:5117-5124
©2006 by American Society of Clinical Oncology
A Model for the Shared Care of Elderly Patients with Cancer
Harvey Jay Cohen, MD
J Am Geriatr Soc 57:S300-S302, 2009.
MODELS OF CANCER SURVIVORSHIP CARE
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Models of Cancer Survivorship Care: Overview and Summary of Current
Evidence Michael T. Halpern, MD, PhD, et al.
2014 AHRQ Publication No. 14-EHC011-EF
2015 JANUARY 2015 • jop.ascopubs.org
Conclusion: There is substantial variation in survivorship care models. The optimal
nature, timing, intensity, format, and outcomes of survivorship care models are
uncertain and require further research. Specific research questions need to be
addressed by the survivorship community to better understand the advantages
and limitations of survivorship models.
BARRIERS TO/CONCERNS ABOUT LONG-TERM CARE
FOR CANCER SURVIVORS
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Inadequate training of health care providers
Malpractice defense practice test ordering
Preventive care concerns
Lack of guidelines to address this population
Inadequate knowledge of long-term effects, e.g:
 Surveillance for recurrences
 Potential side effects of treatments
Unclear directions about providers’ responsibilities
Financial incentives/disincentives
Clinical information systems
Lack or organizational support
Lack of patient awareness
Lack of patient interest/adherence with survivorship care programs
Lack of provider knowledge regarding best processes for delivering coordinated
care.
GAPS IN KNOWLEDGE
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Unclear added value/improved outcomes of developing
“models of care” for older cancer survivors to add onto
complex health care delivery systems
Studies need to describe the model(s) being examined ,
providing detail information to assist comparing results of one
study with those of other studies and assessing the
generalizability of any one model
Studies of survivorship care need to provide data on longterm or late effects of treatment received by older adults
cancer patients
There is a gap in understanding survivors’ needs especially in
the aged and in the racial/ethnic minority populations
RESEARCH QUESTIONS
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What is a model of cancer survivorship care? How are they defined?
What should constitute usual survivorship care? Is it different for the different cancers? Stage? Other
patient characteristics?
Provide evidence of the advantage of using different models of care and effectiveness of different
approaches to surveillance, and other patient-centered outcomes
What are the key elements to include in the SCP?
Identify the organizational changes needed to deliver survivorship care. What contributes to
organizational culture change to support survivorship care? Should it be imbedded in cancer care or
provided as a separate service?
Determine patient morbidity associated with follow up appointments, overuse and underuse of health
care.
Development of evidence-based follow-up guidelines
Determine most effective ways to bridge the gap between oncologists and PCPs/Geriatricians
Determine the unmet needs of geriatric cancer survivors over time
How can awareness of survivorship programs be improved among survivors, caregivers, and clinicians?
Could a virtual patient navigator program facilitate transitions? What is the potential role of
telemedicine?
What is the role of financial incentives?
How to optimize wellness in older survivors? Is there a role for self-management?
What study designs are the most appropriate to evaluate survivorship programs? What are the key
outcomes or endpoints to be evaluated?
How should models be tailored to benefit the underserved, racial/ethnic minorities, low health literacy?
RESEARCH QUESTIONS
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What is a model of cancer survivorship care? How are they defined?

What should constitute usual care? Is it different for the different cancers? Stage? Other patient
characteristics?
Provide evidence of the advantage of using different models of care and effectiveness of different
approaches to surveillance, and other patient-centered outcomes


What are the key elements to include in the SCP?

Identify the organizational changes needed to deliver survivorship care. What contributes to
organizational culture change to support survivorship care? Should it be imbedded in cancer care or
provided as a separate service?
Determine patient morbidity associated with follow up appointments, overuse and underuse of health
care.
Development of evidence-based follow-up guidelines
Determine most effective ways to bridge the gap between oncologists and PCPs/Geriatricians
Determine the unmet needs of geriatric cancer survivors over time
How can awareness of survivorship programs be improved among survivors, caregivers, and clinicians?
Could a virtual patient navigator program facilitate transitions? What is the potential role of
telemedicine?
What is the role of financial incentives?
How to optimize wellness in older survivors? Is there a role for self-management?
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What study designs are the most appropriate to evaluate survivorship programs?
What are the key outcomes or endpoints to be evaluated?
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How should models be tailored to benefit the underserved, racial/ethnic minorities, low health literacy?
CURRENT GUIDELINES FOR SURVIVORSHIP CARE
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NCCN
Transitioning Patients With Cancer © JNCCN—Journal of the National Comprehensive Cancer Network |
Volume 12 Number 12 | December 2014
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ACS CA Cancer J Clin. 2014 Jul-Aug;64(4):225-49. doi: 10.3322/caac.21234. Epub 2014 Jun 10.
ASCO Cancer Survivorship Committee.
Society of Gynecologic Oncology
Calling for AGS involvement in the development of
geriatric-specific guidelines for survivorship care
Providing Care to the Older Cancer Survivor
Rao and Demark-Wahnefried. Critical Reviews in Hematology/Oncology 60 (2006) 131-143
“The older cancer patient/survivor may present us with an
exceptional opportunity to target primary, secondary and
tertiary prevention strategies, capable of effecting beneficial
outcomes for a broad spectrum of diseases and conditions
that not only include cancer, but cardiovascular disease,
osteoporosis, functional decline, cognitive decline,
psychological wellbeing and overall quality of life”.
THANK YOU