Empowering primary care
physicians to handle survivorship
needs
DR. JULIA USATINSKY
DR. NIJAL PATEL
Who are the survivors?
 A cancer survivor is an individual from
the time of cancer diagnosis, through
the balance of his/her life
 National
Cancer Institute definition
Epidemiology
Epidemiology of Breast Cancer
 An estimated 226,870 new cases of invasive breast
cancer are expected to occur among women in the US
during 2012; about 2,190 new cases are expected in men.
 Excluding cancers of the skin, breast cancer is the most
frequently diagnosed cancer in women.
 The breast cancer incidence rate began to decline in
2000 after peaking at 142 per 100,000 women in 1999.
 The dramatic decrease of almost 7% from 2002 to 2003
has been attributed to reductions in the use of hormone
therapy
Epidemiology of Breast Cancer
 The 5-year relative survival rate for female breast cancer
patients has improved from 63% in the early 1960s to
90% today.
 The 5-year relative survival for women diagnosed with
localized breast cancer is 99%; if the cancer has spread to
nearby lymph nodes (regional stage) or distant lymph
nodes or organs (distant stage), the survival rate falls to
84% or 23%, respectively.
 For all stages combined, relative survival rates at 10 and
15 years after diagnosis are 82% and 77%, respectively
Epidemiology of Colon Cancer
 An estimated 103,170 cases of colon and 40,290
cases of rectal cancer are expected to occur in 2012.
 The third most common cancer in both men and
women.
 Incidence rates have been decreasing for most of the
past two decades, which has largely been attributed
to increases in the use of screening tests that allow
the detection and removal of polyps before they
progress to cancer.
Epidemiology of Colon Cancer
 The 1- and 5-year relative survival rates for persons
with colorectal cancer are 83% and 64%,
respectively.
 When colorectal cancers are detected at an early,
localized stage, the 5-year survival is 90%
Cancer Survivors
 Distribution of cancer survivors in the U.S. by site,
2002.
Survivors
.
 The number of cancer survivors in the United States
increased steadily during the past three decades:
CDC/NCI. MMWR 2004;53:526-529.
 Increased from 3.0 million (1.5% of the U.S.
population) in 1971 to 9.8 million (3.5%) in 2001,
and expected to double by 2050
CDC. Cancer Survivorship–United States 1971-2001.
MMWR. 2004: 53:526-529
Survivorship Care
 …increasing (survivors) population
combined with predicted shortages of PCPs
and oncologists will present unique
challenges to making sure that cancer
survivors receive high-quality cancer
survivorship care.”
 ~Katherine Virgo, PhD, MBA, managing director of
health services research at the American Cancer
Society's
Survivorship Care
 “People with histories of cancer have the
right to continued medical follow-up with
basic standards of care that include the
specific needs of long-term survivors.”
(Principle 6)
 ~National Coalition for Cancer Survivorship, 12
principles
What are the needs of the survivors?
 Monitor for early complications after treatment
 Detect late effects of treatment
 Detect recurrences early
 Address general health issues (might have
higher propensity for other health-related
issues)
 Address psychological health
 Health maintenance
Some other areas
 Care for the family members
 Ensure compliance with adjuvant therapies
 Direct exercise and nutrition
 Address quality-of-life issues
 Most importantly: return to normal life
Who should follow?
 Journal of Clinical Oncology, 2009: PCPs are
willing to assume exclusive responsibility for
routine follow-up care after completion of active
treatment.
 The following modalities were felt to be most
useful to assist PCPs in assuming responsibilities:
A
patient-specific letter from the specialist
 Available guidelines
 Expedited routes of referral and access to investigations for
suspected recurrence
Who does better job?
 Lack of evidence supporting advantages of long-term
follow-up care in Oncology clinics
 No significant difference in:
 Time to detection of disease recurrence
 Frequency of serious clinical events related to recurrence
 Health-related quality of life of cancer survivors

Data from BMJ, J Clin Oncol, Br J Cancer, Eur J Cancer Prev
What are the barriers?
 “Inadequate training” and “uncertainty” who is
providing what care are concerns

Journal of General Internal Medicine, 2011 (breast, colon)
 “CME initiatives” and “an enhanced cooperative
effort between those delivering and
coordinating…care” are needed

Supportive Care in Cancer, 2010
 “Inadequate preparation and lack of formal training”
 Cancer, 2009 (any cancer)
What do our patients think?
 Survey of 300 breast cancer survivors:


PCPs do great job at general care, psychosocial support, and
health promotion
However:
 Knowledgeable
about cancer follow-up- 50%
 PCPs and oncologists communicate well- 28%

Journal of Clinical Oncology, 2009
Common themes:
 Fragmentation of care
Fragmentation of care
 One major barrier to successful transition is
fragmentation of care

Many cancer patients choose to receive treatment
at hospitals where their primary care physicians
aren't affiliated.
 Cancer
center may not be coordinated
electronically with the PCP’s office
Fragmentation of care
 An average of 3 specialists/patient, with treatments
across time and space…outpatient, inpatient,
specialized treatment facilities….
Increasing with aging of the population
 Limited communication among treating physicians,
multiple medical records
Common themes:
 Lack of adequate knowledge/training
Not enough training for PCPs in Medical School
 Cancer survivorship has yet to be well represented in
undergraduate medical school curriculum and only a
few schools currently offer courses or clerkships
pertaining to cancer survivorship
Not enough training!
 Pheochromocytoma: annual incidence is
approximately 0.8 per 100,000 person years


Hours of medical school and residency curriculum
Oddly dominates lectures on hypertension
 Cancer survivor: one in every 25 Americans
 Review of curriculum guidelines of internal medicine and
family medicine found a lack of mention of cancer survivorship
Not enough guidelines for PCP
 Many guidelines address only the first five
years post-treatment when patients are
followed by their oncologist, but not for the
period after that, when patients are being
returned to their primary care physicians
What do we do to fix it?
Overcoming barriers
 Patients can be given a comprehensive care
summary and follow-up plan that is clearly
and effectively explained
 Frequent communication between the
oncologist and PCP
Cancer Treatment Plan and Summary
Follow up care plan
Overcoming barriers
 Improving medical schools/residency curricula
 Including cancer survivors as “standardized patients” by
some medical schools
 Developing integrated curriculum on cancer survivorship


Problem-based learning cases
Multimedia web-based problems
 Introducing various CMEs for practicing physicians
Overcoming Barriers
 Educating primary care physicians and oncology
providers, as well as empowering patients, are key
components
 Increasing the availability of evidence-based
guidelines on cancer survivorship; existing
guidelines should be refined
Follow up
guidelines
Breast Cancer Follow Up
Breast Cancer Follow Up
Breast Cancer Follow Up
Breast Cancer Surveillance
Not Recommended
Routine Blood Tests
CBC and LFTS not recommended
Imaging Studies
CXR, Bone scans, liver U/S, CT scans,
PET scans and Breast MRI not
recommended
Tumor Markers
CA 15-3, CA 27.29 and CEA are not
recommended
Colon Cancer
Lung Cancer
 CXR or CT is recommended every 6 months for 2
years and then annually
 Use of blood tests, PET scan, sputum cytology, tumor
markers, and fluorescence bronchoscopy is not
currently recommended for surveillance
 Patients who smoke should be strongly encouraged
to stop smoking
ACS Guidelines on Nutrition and
Physical Activity for Cancer Survivors
Achieve and maintain a healthy weight.
•If overweight or obese, limit consumption of high-calorie foods
and beverages and increase physical activity to promote weight
loss.
Engage in regular physical activity.
•Avoid inactivity and return to normal daily activities as soon as possible
following diagnosis.
•Aim to exercise at least 150 minutes per week.
•Include strength training exercises at least 2 days per week.
Achieve a dietary pattern that is high in vegetables, fruits,
and whole grains.
• Follow the American Cancer Society Guidelines on Nutrition and Physical
Activity for Cancer Prevention.
Use of Supplements
 All attempts should be made to obtain needed
nutrients through dietary sources.
 It may be counterproductive
 take
folate supplements when receiving antifolate
therapies such as methotrexate.
When to supplement
 Only if a nutrient deficiency
biochemically (eg, low plasma vitamin D levels, B12
deficiency)
 clinically (eg, low bone density)

 If nutrient intakes fall persistently below two-thirds of
the recommended intake levels
Consult a registered dietitian
 avoid ingesting supplements that exceed more than 100%
of the Daily Value

CASE
Clinical Case
 AR is a 40 year old female with history of left sided



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breast cancer in which per patient she received
chemotherapy and radiation and had a lumpectomy.
Further information is unknown as patient just moved
from out of state and her oncologist is retired, and she is
unsure what hospital he was affiliated with.
CC- progressively worsening SOB over the last 2 weeks
PMH- breast cancer, HTN, and hyperlipidemia
SH- not currently working, denies alcohol, smoking and
drugs
PE- Bibasilar crackles, 2+ lower extremity edema,
lymphedema of the left arm
Issues for the Patient
 Did my cancer spread to my lungs
 How do I make sure my 3 daughters and 2 sisters do
not have breast cancer
 What further tests need to be done to make sure I do
not have another cancer




Colonoscopy
Pap Smear
Lung Cancer
Skin Cancer
Issues for the PCP
 Is this SOB secondary to CHF from
 Previous medical problems
 Radiation
 Chemotherapy

Anthracycline, traztuzamab
 What chemotherapy regimen did the patient receive
 What follow up tests have been done for the patient
and what needs to be done
Possible Answers for Patients Issues
 Cancer spread to lungs- Unlikely because symptoms
most consistent with CHF
 Genetics- Need to go over the recommendations for
genetic referral
 Other cancers- Patient needs to be screened as any
other patient; close monitoring of skin for
malignancy
Possible Answers for PCP issues
 Why SOB- will need further testing including ECHO,
CXR to look for cause of SOB
 What regimen- not available at this point but this is
where summary is helpful
 What tests need to be done- CHF workup,
mammogram
Conclusions
 With improvements in medical education and
coordination of care, primary care will offer a safe,
cost-effective method in providing routine (and often
exclusive) follow-up care for cancer survivors
 Discharging cancer survivors from oncology
programs will reduce the load of well patients on
already busy cancer clinics
 Refining guidelines, risk-stratifying patients, as well
as providing patients with follow-up care plans, will
make this process better structured and coordinated.
Available Resources
Available resources
 Up to Date- now a small section on cancer survivorship, and
more chapters are being written focusing on the topic
 ACP's online decision support tool, PIER (Physicians'
Information and Education Resource) includes information
on follow-up care organized by type of cancer
 The American Society of Clinical Oncology houses
information on cancer survivorship on its website
 The American Cancer Society and the National Cancer
Institute jointly co-sponsor a cancer survivorship conference
every two years that allows the research community to come
together to discuss the issue
Questions?
Thank You!