When the landmark report from the Institute of Medicine, From Cancer Patient to Cancer Survivor: Lost in Transition, was published in 2006, there were 10 million cancer survivors in the United States.1 Meant to raise awareness of the medical, functional, and psychosocial consequences of a cancer diagnosis, as well as the potential long-term side effects of its treatment, the report outlined 10 recommendations aimed at enhancing the health care and quality of life of cancer survivors following active treatment. Among the report’s recommendations was the development and dissemination of survivorship care plans to provide survivors with a summary of their diagnosis, treatments received, and guidance on follow-up surveillance as they transitioned back to the care of their primary care physician.
Although today the number of cancer survivors has grown to nearly 17 million—and that number is expected to increase to more than 22 million over the next decade2—studies consistently show that the implementation of survivorship care plans and their provision to primary care physicians remains abysmally low.3 This lack of clinical information to inform cancer survivors’ care after active treatment presents a critical challenge to the primary care physicians trying to address the myriad health challenges cancer survivors often confront. This has created what Kevin Oeffinger, MD, termed a “black hole” in medicine. He is Founding Director of the Duke Cancer Institute Center for Onco-Primary Care and Director of the Duke Supportive Care and Survivorship Center at Duke Cancer Institute and Duke University Medical Center, in Durham, North Carolina.
Kevin Oeffinger, MD
“Primary care providers are often the ones to screen for or diagnose cancers and make referrals to cancer specialists, and then they lose those patients to oncologists while patients are undergoing treatment. Eventually, many of those patients go back to their primary care physicians several years after completing their cancer treatment, uncertain about how the therapy might have affected their future health,” explained Dr. Oeffinger. “Studies have shown that half of primary care providers feel unprepared to manage patients’ late effects from cancer treatment or monitor them for cancer recurrence, because they rarely receive sufficient information about patients’ future medical needs from oncologists, thereby causing a black hole in patients’ survivorship care.”
To help ensure that cancer survivors do not fall into a medical care transition black hole, in 2017, Dr. Oeffinger launched the Duke Cancer Institute Center for Onco-Primary Care in partnership with the Duke University Health System. The goal was to unite primary care clinicians and cancer specialists to improve patient care both before and after a cancer diagnosis. The ASCO Post talked with Dr. Oeffinger about this innovative, patient-centric care model and how it is improving care for cancer survivors.
Coordinating Care Before a Cancer Diagnosis
Please talk about the critical role primary care physicians play in the coordination of the multispecialty care that cancer survivors may need from the end of active treatment and throughout the continuum of survivorship.
I am a family physician, and for most of my over 20-year career, my research focus has been on cancer screening and survivorship. For the past 30 years, cancer screening initiation has primarily been a one-size-fits-all approach based on a person’s age. For example, the American Cancer Society guidelines for the early detection of breast cancer call for women between the ages of 45 and 54 to have annual mammograms and for regular screenings for colorectal cancer to begin at age 45 for people at average risk.4 However, over the past few years, screening has become much more risk-stratified.
Over the next 10 years, cancer screening will become more personalized based on a patient’s specific risk for a particular cancer. So, instead of screening everyone for breast cancer at the same age, for example, risk will be determined by tests for genetic markers, tests that detect circulating tumor cells, or other predictive factors. Primary care physicians and oncologists will need to work together even before a patient is diagnosed with cancer. This change will coincide with a health-care delivery transformation that is taking medical care from its current volume-based system to one that is more value-based; that will give primary care and oncology providers another wonderful opportunity for close collaboration.
“Primary care physicians and oncologists will need to work together even before a patient is diagnosed with cancer.”— Kevin Oeffinger, MD
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Preventing Death From Manageable Comorbidities
How is the Duke Center for Onco-Primary Care bridging the gap in care for patients diagnosed with cancer?
The onco-primary care initiative is part of the Duke University Health System; within that system, we have more than 300 primary care providers across 40 medical sites in North Carolina. Our mission for the Duke Cancer Institute Center for Onco-Primary Care is threefold. One is to deliver evidence-based, patient-centered, personalized health care across the cancer continuum by enhancing the interface between cancer specialists and primary care physicians. Two is to conduct innovative research with cutting-edge technology that can be translated to the community setting. And, three is to train and educate the next generation of clinicians and researchers to extend the mission beyond our center.
Often after a cancer diagnosis, many patients lose contact with their primary care physician. When they do go back to their regular physician’s care, the physician has no idea how the cancer treatment may have affected the patient’s overall health or how comorbidities, such as high blood pressure or high cholesterol, were managed. We know, for example, that breast cancer survivors are more likely to die of a cardiac event years after their cancer was successfully treated—not because of the cancer therapies she received, but often because of undertreated hypertension or hypercholesterolemia. The focus of their care was on curing the cancer. If we don’t keep the primary care physician involved during or soon after the patient’s therapy, sometimes hypertension or lipid disorders can actually increase the risk of dying more than the breast cancer. In other words, we might cure the cancer but lose the patient to another disease.
How do we prepare primary care physicians for the potential health needs of a cancer survivor? We make them active members of the oncology team from day one of a patient’s cancer diagnosis.
Collaboration Among Patients, Oncologists, and Primary Care Physicians
How do you motivate patients to stay engaged with their primary care physicians after their cancer diagnosis?
We are piloting a systemwide messaging service to our patients with breast and prostate cancers to inform them that their primary care provider is a key member of the active cancer team and that comorbidities such as hypertension are no longer something we can ignore; they need to be appropriately managed. We are also in the process of implementing systemwide blood pressure guidelines for our patients with cancer, so they recognize what their blood pressure goals and targets are.
We are testing a blood pressure management tool that comes with a cuff and uses a Bluetooth interface that is downloaded onto patients’ smartphones. Patients push a button and the app measures and records their blood pressure and automatically sends the data to their electronic health records. If the reading is above our target level, the patient’s primary care physician and oncologist receive a message to address the issue with the patient.
With this system, we are accomplishing a few goals. One is we are drawing the primary care physician directly into the patient’s care, even though the physician may be miles away from the cancer center, and making the physician an active member of the oncology team. Through the patient portal, we are also emphasizing to patients the importance of getting their blood pressure under control. Thus, everyone involved—the patient and the patient’s medical team—is aware of what we are trying to accomplish.
This effort has taken a lot of relationship-building between our primary care physicians at Duke University Health Systems and our oncology providers at the Duke Cancer Institute. It also has taken a lot of time and financial investment, but obviously, it has been worth it because the beneficiaries of this collaboration are our patients.
DISCLOSURE: Dr. Oeffinger reported no conflicts of interest.
1. Hewitt M, Greenfield S, Stovall E: From cancer patient to cancer survivor: Lost in transition. The National Academies Press, Washington, DC, 2006. Available at https://www.nap.edu/read/11468/chapter/1#v. Accessed February 20, 2020.
2. Miller KD, Nogueira L, Mariotto AB, et al: Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin 69:363-385, 2019.
3. Donohue S, Sesto ME, Hahn DL, et al: Evaluating primary care providers’ views on survivorship care plans generated by an electronic health record system. J Oncol Pract e329-e335, 2015.
4. American Cancer Society: American Cancer Society guidelines for the early detection of cancer. Available at www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html. Accessed February 20, 2020.