The March 11th report by the U.S. Centers for Disease Control and Prevention highlighted once again the growing number of cancer survivors—now approximately 12 million. This good news serves as a reminder to the oncology community of the need for formal care for this increasingly large group of individuals. How best to provide this is an international challenge, with physicians and nurses in countries such as Australia, Canada, Italy, Israel, Argentina, and the United Kingdom working together with their U.S. colleagues to share best practices so they can be instituted and evaluated in the various clinical settings where survivors are being followed.
To date, most models of care have been developed by academic medical centers, but increasingly, community practices, clinics, and hospitals are formulating plans for survivorship care. Regardless of setting and national health-care system, a number of key factors influence the type of program, including the patient population, type of services, and location of services to be provided. These characteristics drive the clinic structure and the type of health-care provider (eg, physician or nurse) for each model.
Variety of Care Models
In several countries, the pediatric multidisciplinary care model is being used for adult survivors. Because it is resource-intensive, it is most frequently used for the care of “complex patients” (eg, adult survivors of pediatric cancers, brain tumor survivors) requiring comprehensive care in a setting where specialists such as physicians, nurses, and psychologists come together for the visit.
Another specialized approach is the disease/treatment-specific clinic model, where the focus of the care is on patients with one disease (eg, breast cancer) or patients who have received one type of treatment (eg, stem cell transplant). This model is often a good way to begin and work out problems and practice logistics, but in the long run, it may limit care to a few categories of survivors and omit the survivors with the greatest need.
A clinic that is also frequently used as a starting point for survivorship programs is the consultative model, where a “one-time” visit serves as an opportunity to develop a treatment summary and care plan, and referrals are made for subspecialty care and supportive services. The advantage of this type of model is that it can serve an unrestricted survivor population, and only core services need be provided on-site. Other services, such as physical therapy, nutrition counseling, and cardiology, are provided by community/institutional groups. This model can be used to prepare survivors who are transitioning back to their primary care providers, with a summary plan for cancer-specific follow-up. For patients continuing follow-up with the oncology team, it can include the provision of a shared-care communication plan with the primary care provider, specifically delineating the responsibilities of each provider.
In the United States, a rapidly growing model of care is the integrated care model, where the survivorship provider is a nurse practitioner or physician assistant who is embedded in the oncology team where the patient was treated. This model offers an easy transition for survivors and the oncologist, since the patient continues to be cared for by the team but by someone with expertise in survivorship issues. Communication with the primary care provider using a treatment summary and care plan is a key component of this model.
Although survivorship follow-up care traditionally has been the responsibility of the treating oncologist, we now have a much greater appreciation for formal communication with other physicians. Today, sharing care with other specialists and the primary care provider is recognized as both necessary and optimal. In addition, there has been a rethinking about who the appropriate provider of care is during the follow-up period, and considerations about staffing the previously mentioned models with both primary care physicians and nonphysician providers (such as nurses and nurse practitioners), depending on the country.
Measuring Success
The variety of care models doesn’t signal confusion or chaos, but rather, it offers the oncology community the option of tailoring needed services to the survivor population and the clinical environment. We are beginning to answer critical questions about how cancer survivors should be followed, by whom, and for how long. As these models mature, each should be evaluated using key metrics to ensure that we are providing optimal care for this growing number of individuals. Success will be measured not merely in numbers, but in the quality of the lives of these survivors. ■
Financial Disclosure: Ms. McCabe reported no potential conflicts of interest.
