Roxanne Nelson, BN, RN

January 18, 2016

SAN FRANCISCO — Is the ideal model of care for cancer survivors one led by oncologists, one led by primary care physicians (PCPs), or a shared model?

Unfortunately for the patients, that question remains largely unresolved. There are still mixed views and uncertainty about who should assume responsibility for survivorship care, even in an integrated healthcare system, according to a study presented here at the inaugural Cancer Survivorship Symposium Advancing Care and Research.

For example, none of the PCPs surveyed preferred a model led by the PCP, and instead preferred that the oncologist take primary responsibility for follow-up care. In contrast, oncologists preferred a model of shared responsibility.

As a result, oncologists might be assigning more responsibility of survivorship care to the PCPs than the PCPs recognize, and patients might not be getting their recommended care, explained lead author Bijal A. Balasubramanian, MBBS, PhD, assistant professor in the division of epidemiology, human genetics, and environmental science at the University of Texas School of Public Health in Dallas.

"What we found is that both agree that primary care physicians have the skills to care for these patients," she told Medscape Medical News. "There is agreement there, but it's still a new problem for the health system. But when you ask about the preferred model, the PCPs do not want a primary-care-led model."

Of the physicians who participated in the survey, 30% of oncologists and 23% of PCPs expressed an interest in a shared model. "It makes sense, because primary care physicians are experts in chronic problems and oncologists are experts in cancer-related issues," Dr Balasubramanian explained. "But we haven't yet figured out how to deliver this shared-care model, and clearly there are many problems associated with it."

Previous research using nationally representative data showed significant differences between the attitudes of PCPs and oncologists and their practices with respect to the care of cancer survivors. It called for more effective communication and coordination to improve care.

For example, in one large nationally representative sample of PCPs and oncologists, findings suggested that oncologists have an "unfavorable view" of giving PCPs a central role in caring for cancer survivors. PCPs also expressed mixed views about assuming increased responsibility for survivorship care. The majority of oncologists favored a model led by oncologists, but almost half of all PCPs preferred a shared-care model or one led by PCPs.

But another issue is the growing number of cancer survivors, which is estimated to be about 12 million in the United States. In 2014, the American Cancer Society published new guidelines to help PCPs get up to speed in the management of prostate cancer survivors, as reported by Medscape Medical News. The guidelines note that the care of these men is increasingly falling to PCPs because oncologists cannot keep up with this rapidly expanding population.

Agreement and Disagreement

In their study, Dr Balasubramanian and her colleagues compared the attitudes and practices of PCPs and oncologists related to follow-up cancer care in an integrated health system that shared electronic health record and clinical infrastructure. They examined whether the integrated setting facilitated communication and coordination between PCPs and oncologists.

"The uniqueness of our study is that it is an integrated health system with community-oriented primary care clinics. They serve a very vulnerable population and serve as a safety net funded by county dollars," she explained. "All of the patients are uninsured and they receive care in the safety-net setting."

"Nationally, there hasn't been agreement on this issue," Dr Balasubramanian continued. However, "our situation is more unique because of the setting of an integrated safety-net hospital."

In their study, 41 PCPs and 24 oncologists who were affiliated with the healthcare system completed a validated survey; the response rate was 52%. The survey assessed preferred models for delivering care, attitudes toward follow-up care, and cancer surveillance practices in this setting.

Overall, the oncologist-led care delivery model was preferred by 41% of PCPs and 21% of oncologists.

Despite the fact that more PCPs than oncologists agreed that PCPs have the necessary skills to initiate cancer surveillance (73% vs 58%), PCPs were less likely than oncologists to agree they should have primary responsibility for providing cancer follow-up care in this population (56% vs 42%).

PCPs and oncologists also expressed significant differences about cancer surveillance practices. Oncologists more consistently reported that PCPs ordered tests for cancer surveillance, evaluated patients for cancer recurrence and for the adverse physical and psychologic effects of cancer or its treatment, and managed pain and the adverse outcomes of cancer treatment. PCPs, however, differed in that view, and did not report equivalent ordering of these services.

"This research has prompted us to write a grant so that we can take the next step and bring them to the table to actually develop the shared-care model," she said. "We need to work on communication and figure out what should be the responsibility of the PCP and what should be the responsibility of the oncologist. How do we actually share the responsibility?"

Dr Balasubramanian emphasized that the "epidemiology of survivorship is changing and the system has to catch up."

"In this system, we can make a difference by having patients transition to primary care, but we have to develop primary care in a much stronger way than in the past," she added.

Although most physicians believe that survivorship care after cancer treatment is important, it remains unclear how best to provide it, said Merry Jennifer Markham, MD, associate professor in the division of hematology and oncology at the University of Florida in Gainesville.

"This study demonstrates one of the fundamental dilemmas in survivorship care — whether the primary care provider or the oncologist should provide the care," Dr Markham told Medscape Medical News. "This study highlights the fact that more work is needed to clarify the logistics of provision of survivorship care, both on a local level and at a more global level."

"Methods to improve communication between oncologists and primary care providers, such as treatment summaries and personalized survivor care plans, may help bridge this potential gap in care," she added.

Dr Balasubramanian and Dr Markham have disclosed no relevant financial relationships.

Cancer Survivorship Symposium (CSS) Advancing Care and Research: Abstract 105. Presented January 15, 2016.

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