Breast Cancer Survivors: Transition to PCP Leads to Savings

Roxanne Nelson, RN, BSN

February 22, 2018

ORLANDO — Breast cancer survivors who participated in a transition program where they switched from management by an oncologist to a primary care provider (PCP) used fewer health system resources and had lower health system costs compared with controls.

The findings from this new study provide "real-world evidence" to inform transition policies for cancer survivors, according to the authors.

"Most breast cancer survivors do continue follow up care with their oncologists for several years after treatment has been completed, but there has been a growing practice of transitioning these women to follow-up care with PCPs," said study author Soo Jin Seung, BSc (Hon), from Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

"This has been shown to be safe and often acceptable by patients," explained Seung, who presented the results of the study during the Cancer Survivorship Symposium (CSS) 2018: Advancing Care and Research.

Seung was reporting results from the Well Follow-up of Care initiative (WFCI),  a model of care to transition breast cancer survivors from oncologists to PCPs that was introduced into Cancer Care Ontario, the largest provincial cancer agency in Canada. From 2010 to 2013, this model was implemented at 14 cancer centers.

Uncertainty Over Transition 

There has been uncertainty about who should be managing and assuming responsibility for the care of cancer survivors: the oncologist, a PCP, or a shared model. But at least for prostate cancer, PCPs have received guidance —  the American Cancer Society issued it in 2014 to assist PCPs in the management of prostate cancer survivors.

Seung noted that there has been concern that this transition might be associated with higher costs because the PCPs might be ordering more diagnostic tests, and patients might be using the emergency department more frequently and requesting additional office visits.

"In our study, we decided to compare the health system resources and costs used by the women in the WFCI group as compared to those who hadn't transitioned to primary care," said Seung.

Lower Costs, Fewer Office Visits

Cases were identified in the WFCI, and controls were identified from the Ontario Cancer Registry. Both cases and controls were required to have the exact same year of cancer diagnosis and live in the same region.

A propensity score–matched, quasi-experimental approach was used to compare the healthcare resource utilization and costs between breast cancer survivors in the model of care program (cases) and those receiving usual care (controls). The primary study outcome was overall health system utilization and mean cost during the follow-up period.

There were 2324 women in transition group, and they were matched with an equal number of controls. The majority had stage I/II disease (about 60%). Demographic characteristics, including age, region, and stage, were well balanced between the groups.

Seung and colleagues found that compared with the controls, women in the transition model had a lower rate of hospitalizations (20.1% vs 24.4%; P < .05), made fewer cancer clinic visits (6.0% vs 15.1%; P < .05) and fewer medical oncologist visits (0.39 vs 1.29; P < .05), and underwent fewer diagnostic imaging tests (computed tomography, MRI, ultrasonography, radiography) during an average follow-up of 25 months.

The number of mammograms was higher for women in the transition group (0.83 scans per patient-year for cases vs 0.75 for controls), but this trend was reversed for other types of diagnostic imaging.

There was a trend for fewer family practice visits (7.35 vs 7.91; P = .08) and internal medical and hematology visits (0.81 vs 1.03; P = .08) in the transition group than in the control group. The number of annual emergency visits, however, was similar between the two groups (0.76 vs 0.82; P = .2).

Treatment costs were lower for the transition group, with a $4257 ($CAN) difference in the mean annual cost per patient between the transition group and the control group: $6575 vs $10,832.

When the researchers looked at the median annual cost per patient, the costs were $2261 for the transition group and $2903 for the control group, for a difference of $642.

The survival probability between cohorts was statistically significant, favoring the transition group, noted Seung,. "However, this was likely due to selection bias, as the highest-functioning survivors tended to be enrolled in WFCI," she said.

Resource-wise, WFCI cases had fewer oncology visits, fewer diagnostic scans, and the same number of PCP visits, explained Seung. "Cost-wise, WFCI cases had lower overall health system costs."

She pointed out that an initial investment across cancer centers could result in cost savings across the health system, depending on how many survivors transition to follow-up care with PCPs.

"The next steps include ongoing monitoring and evaluation of survivorship models as well as endorsement and engagement by patients, healthcare providers and stakeholders," she said. "These results will inform policy in Ontario and other regions in the development and implementation of survivorship models."

Moving to a Triage Model

Discussant Deborah Mayer, PhD, RN, an advanced practice oncology nurse at the University of North Carolina at Chapel Hill School of Nursing, feels that this study is important because of its design in using propensity scoring. "It shows that not everything needs to be done by a prospective randomized trial and then having to wait for that data," she said. "Especially if you have rich data sets like they had for this study."

She noted that while the authors did identify selection bias for this low-risk group, "that is a very important place to start."

It is important to consider which patients are the best candidates to transition to primary care, which would generally be those at low risk, and then "this will free up the oncology team to see the higher-risk patients," Mayer said. "So identifying the patients who will do well with this transition, as well as identifying the costs, is a significant contribution."

For future studies, Mayer recommends capturing the out-of-pocket expenses for this population. "We also don't have a sense for what their own transition was like," she said.

"From a clinical point of view, I would like to know how this transition occurred, because in the US it is very difficult to do this type of transition from the oncologist to the PCP. And patients are saying they are willing to do it, but they really need more education upstream as to how this will occur."

Mayer added that these data are also important because it can help convince other providers and stakeholders that there is a need to move to a triage model of care. "And that it can be as good if not better than our current system of doing this," she said.

Seung disclosed a relationship with Roche. Mayer disclosed a relationship with Carevive.

Cancer Survivorship Symposium (CSS) 2018: Advancing Care and Research. Abstract 1. Presented February 17, 2018.

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