Survivorship Care Plan Is Important Part of Cancer Care

Zosia Chustecka

June 12, 2007

June 12, 2007 — With many more patients now surviving cancer, drawing up a survivorship care plan and a treatment summary for these individuals has become increasingly important, and yet this "posttreatment phase is a neglected phase of the cancer care trajectory," says Patricia Ganz, MD, from the University of California, Los Angeles Jonsson Comprehensive Cancer Center.

Speaking last week at a "meet-the-expert" session during the American Society of Clinical Oncology (ASCO) 43rd Annual Meeting, in Chicago, Illinois, Dr. Ganz commented that the point at which cancer patients complete their treatment offers the ideal opportunity to lay down some guidelines for patients to follow to foster their recovery — "this is a teachable moment," she said. However, cancer care is often not very well coordinated between all the specialists involved (surgeons, radiation specialists, medical oncologists) and liaison with the family physician is often poor, and so in many cases that "teachable moment" is lost. In Los Angeles, where she is based, these specialists can be geographically some distance apart, and the family physician is often not involved in the cancer treatment but then needs to take over when the patients has completed the treatment course.

There is no blueprint for cancer survivorship care, Dr. Ganz added. "This is new territory, and those of us running these centers are finding our way." Models exist for other chronic diseases, such as diabetes and asthma, but cancer is different from these diseases and follows a different tempo, she commented. With cancer, there is a crisis at the beginning, right after diagnosis, and then a flurry of activity, with treatment being quick, prompt, and intensive. The treatment is also complex, involving multidisciplinary teams, and it is very toxic and extremely expensive, she continued.

It is essential that all the details of the cancer treatment that have been delivered be recorded in a treatment care summary, Dr. Ganz emphasized. This should record details of the cancer type, with specific details of the tissue involved and stage at diagnosis. It should also contain exact details of the treatment that was delivered, with details of the type and dose of chemotherapy and radiation used, the timing of the schedules that were followed, and all toxicities that were encountered during treatment. In addition, there should be some information on the expected toxicities that may be encountered in the future and advice on how to monitor for late toxicity, as well as recommendations for surveillance for recurrence of the primary cancer or development of a second cancer.

The recommendation for such treatment summary plans was first made in 2005 by the Institute of Medicine in its "From Cancer Patient to Cancer Survivor: Lost in Transition" report and prompted ASCO to work on templates for such plans. The first of these, the colon cancer adjuvant chemotherapy treatment plan and summary template, has recently been completed and was unveiled during the Chicago meeting. Work is in progress now on a similar template for breast cancer, and there are plans to develop templates for many other cancers in the near future.

The new colon cancer template can be accessed online. ASCO notes that format is modifiable, allowing oncologists to customize and adapt it to suit their own practices.

Who Should Take Responsibility for the Plan?

Ideally, the "last treater" should take responsibility for completing a treatment plan summary, Dr. Ganz told the meeting, but with cancer there are many different pathways of treatment, and usual pathways of referral are sometimes circumnavigated. For example, when a patient is admitted for emergency surgery and a tumor is found, that patient may pass straight onto an oncologist without any referral from the family physician, who is then left out of the loop, she said. In somecancers, the last treater may be the surgeon or the radiation oncologist, but in most cases where there is treatment with a curative intent, the last treater is the medical oncologist, and usually this is the physician who should take on the responsibility. "However, this is a problem, as many oncologists tell us that they do not have the time to take on this additional task," Dr. Ganz commented, "but we need to educate them, and to use a carrot — maybe offer a new payment for this task." This may be possible, she added, as healthcare plans are realizing the benefit of having such summary plans. "I have been billing in my practice for years for this — this is not insurance fraud, this is cognitive delivery rather than doing procedure," she added.

"It takes about 40 minutes to go through the treatment plan and summary with a patient," Dr. Ganz said. This is also the ideal moment at which to advise on diet and behavioral changes, such as losing weight, as patients are motivated into looking after their health. The process can be delegated to a nurse — in fact, at the Sloan Kettering Center, this is carried out by practice nurses, she noted. However, in many instances patients want to see the physician they credit with "saving their life," whereas those physicians may feel that a better use of their time is to see new patients with cancer, rather than review the ones who have survived.

The number of cancer survivors has been steadily increasing as a result of the "remarkable improvement in prolonging survival in adult patients, especially those between 50 and 80 years of age," Dr. Ganz commented. Currently, there are an estimated 22.4 million cancer survivors globally, and more than 10 million in the United States.


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