The population of cancer survivors is rapidly growing. More than 12 million Americans are alive after a cancer diagnosis: most are living at least 5 years and 16% are alive 20 years after diagnosis.
This growing population of cancer survivors is at risk for many comorbidities, especially as they age. A study of 10,397 childhood cancer survivors showed that group is 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 patients’ long-term needs. One session at the recent annual meeting of the American Society of Clinical Oncology (ASCO) was devoted to survivorship care.
“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.
Dr 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 individuals, cancer provides “a teachable moment”
- It’s not only healthcare providers who are concerned, but patients themselves are asking how they can reduce their risk of cancer recurrence and live healthier lives; it is important for healthcare providers to be prepared to answer their questions
- The Institute of Medicine (IOM) has recommended that survivors receive a summary record that includes important disease characteristics and the treatments they received, and that they be provided with a follow- up care plan that incorporates evidence-based standards of care.
ASCO has adopted this as a quality initiative, “but we have little information as to how this is being done and its impact in real practice,” Dr Rowland said. What care should be provided and to whom? Who should provide this care, and where and when should it be given? What impact does this care-planning have on patient behavior, physician behavior, practice costs, payer investments, and patient health outcomes? All these questions remain to be answered, she noted.
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).
Paul Han, MD, of Maine Medical Research Institute, in 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, showing that the primary care model may not be preferred.
“We wanted to examine the attitudes, knowledge, and practices of PCPs and oncologists regarding the care of cancer survivors,” Dr 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.”
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,” Dr Han suggested.
Neither PCPs nor oncologists selected a PCP-led model as the ideal model for survivorship care. In addition, although oncologists said they provide treatment summaries or care plans to PCPs most of the time, 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,” Dr Han said.
Survivorship programs are wellmeaning, but do they really improve health outcomes and are they costeffective? 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 health care resources.”
In accordance with the IOM’s recommendation for providing cancer survivors with a formal survivorship care plan (SCP), the multicenter study assessed the effect of such a program and its cost-effectiveness.
A randomized trial 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 received 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 psychosocial adjustment 12 months after intervention. The secondary outcomes were continuity of care, health-related quality of life, patient satisfaction, and adherence to guidelines. A short-term study cannot adequately assess clinical outcomes, the investigators noted.
Despite 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.
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, and with exclusion and inclusion 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 excluded, and when estimates of the costs were included, according to Doug Coyle, PhD, of the University of Ottawa, Canada.
In the probabilistic analysis, the most likely finding was that standard care was more effective and less costly. For all threshold values of a qualityadjusted life-year <$100,000, the probability that the SCP was cost-effective was <30%.
“The results of this study clearly suggest that the SCP adopted was not a cost-effective use of scarce healthcare resources,” Dr 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 health-related outcomes.”