COMMENTARY

Clinical Takeaways From the 2018 Cancer Survivorship Symposium

Survivorship Care Plans, Co-management With Primary Care Key Issues

Lidia Schapira, MD

Disclosures

March 09, 2018

In her opening remarks at the Cancer Survivorship Symposium in Orlando last month, Chicago physician Carol Rosenberg, MD, a self-described "survivorist" and the director of the NorthShore University cancer survivorship program, stressed that physicians who take an interest in caring for cancer survivors often feel a sense of isolation from the rest of the medical community. It is fitting, then, that this annual symposium, now in its third year, gives these physicians and healthcare providers the opportunity to network in person and address the special problems faced by people living with and beyond cancer.

The topic that received the greatest attention and podium time was the utility and implementation of Survivor Care Plans (SCPs). In a lecture honoring Ellen Stovall (one of the founding members of the National Coalition of Cancer Survivors and champion of the needs of this population), UCLA's Patricia Ganz, MD, reminded the audience that SCPs were intended to serve as tools in a process of coordination of care. She urged her oncology colleagues not to isolate patients from their primary care clinicians. Ganz reminisced about the origin of the term "survivor," initially coined in 1986 to refer to "the time since a cancer diagnosis and for the balance of life, and that includes the family" and served as a departure from terms such as "victims," which were often used to identify patients with cancer. Discussing models of shared care for patients at low risk for complications of cancer therapy and with excellent prognoses whose needs may be well met by their primary care clinicians, Ganz reflected on the fact that many of the current guidelines for follow-up were derived from follow-up practices for participants in clinical trials. Clearly, those populations required more frequent visits and testing than is likely necessary for patients receiving standard treatment for curable cancers.

Several presentations highlighted the struggles that accompany cancer therapies, with much attention given to financial hardship and its association with psychological hardship. In her remarks, Carolyn Messner, DSW, of CancerCare, noted that much of survivorship care revolves around the proper identification of problems related to cancer and cancer treatment, and which require specialized referrals to resolve lingering symptoms and address psychosocial concerns. Messner said that there are 1000 nonprofit organizations in the United States with multiple available resources and services, and that oncology clinicians and patients may not even know that they exist. She provided examples of what she called the "art and science of referral," which requires an assessment of need and patient readiness to accept a recommendation. She advised naming the resource for the patient, and gave the example of a food delivery service that she recommended to a patient who was not prepared to act on the suggestion until sufficient time passed and she recognized the value of this service. Messner reviewed the difficulties inherent in returning to work after cancer, stating that survivors may get into trouble by oversharing details of their cancer experience.

The organizers of the symposium represented family medicine, primary care, and oncology. In an interesting panel discussion, speakers from each discipline discussed how they use guidelines in clinical practice. A comprehensive list of available guidelines, issued by professional societies and task forces, illustrated that there are several options available that provide prescriptive approaches to care for survivors of common cancers. Panelists endorsed guidelines issued by the National Comprehensive Cancer Network and the American Society of Clinical Oncology. Dana-Farber Cancer Institute's Ann Partridge, MD, MPH, suggested that community physicians may benefit by focusing on clinical pathways rather than guidelines. Involving primary care clinicians in the process through co-location, or via sequential visits integrated into the oncology treatment pathway, may help ensure proper follow-up for patients completing cancer therapy.

The keynote address was delivered by Arti Hurria, MD, of City of Hope, and focused on the needs of older patients. Hurria began her remarks with a provocative question: Are cancer treatments creating a premature aging syndrome? In an elegant and data-filled lecture, Hurria reviewed the biological markers associated with aging and cancer treatments, such as increase in p16, resting cytokines, telomere length, and resting energy expenditure. She summarized research documenting the value of detailed geriatric assessments prior to cancer treatment. This process allows clinicians to identify individuals who are at risk for toxicity related to treatment and who may require special services or modifications of the intended cancer treatment.

Hurria discussed the need to understand the mechanisms of toxicity of cancer therapies in older individuals, as well as to focus on their psychological needs and personal goals. She reminded participants that drug studies approved by the US Food and Drug Administration over the past 10 years included few patients over the age of 75, despite demographic shifts that clearly show that the proportion of older individuals with cancer is on the rise. She commented that older patients may be more worried about becoming frail as a result of cancer therapy and are asking: Am I going to be hospitalized? What will happen to my memory and function? What does my family need to prepare for? What will be the quality of my survival? For those interested in learning more about available tools for performing short geriatric assessments and estimating chemotherapy toxicity, Hurria offered a link to www.mycarg.org.

Most presenters and participants at this meeting endorsed extending the concept of survivorship to include patients on chronic cancer therapies. An interesting panel discussion covered the health effects of hormonal therapies for women on antiestrogen therapies and men receiving androgen deprivation therapy (ADT). Northwestern Medicine's Alicia Morgans, MD, MPH, reminded the audience that hormonally driven cancers are the most common cancers in the United States and that understanding complications is necessary for optimal outcomes. Men undergoing ADT have more fat and less muscle which renders them less sensitive to insulin.[1] They are also at increased risk for fractures[2] and cognitive decline, although whether ADT increases the risk for dementia remains an area of controversy. For women with early-stage breast cancer taking aromatase inhibitors, the data are reassuring regarding risk for cardiovascular disease (CVD), although it is important to remember that more women with early-stage breast cancer will die of CVD than of cancer. We have long known about increases in fracture risk while taking aromatase inhibitors.[3] Effects on cognitive and executive function have remained difficult to sort out from the natural aging process.

More women with early-stage breast cancer will die of CVD than of cancer.

Research in cancer survivorship has focused on three areas of need: the late effects of cancer therapies, models of co-management and shared care between oncologists and primary care or family physicians, and the need to provide a clear summary and care plan upon completion of active cancer therapy. There was very little mention of new research on late toxicities, and limited attention was given to models of co-management. More emphasis was placed on discussing the fate of SCPs. Paul Jacobsen, PhD, of the National Cancer Institute, presented results of a recent systematic review of the impact of SCP on healthcare outcomes and healthcare delivery. This did not show a conclusive benefit. Proponents insisted that patients value having an opportunity to review their cancer treatment and plan their future care, while agnostics stressed the cost and time required to produce a document that may not only be unhelpful but potentially harmful.

Sarah Birken, PhD, of the University of North Carolina, provided a thoughtful final reflection on how to implement survivorship planning based on studying models of successful implementation in various practices. Birken remarked that practices that have successfully implemented SCPs saw these as opportunities to improve care and have phased in efforts to implement changes slowly and carefully by integrating changes into the workflow without taxing clinicians. By identifying champions and spreading the tasks among multiple members of the staff and multidisciplinary team, these practices produced the materials required to provide proper follow-up care, with the ultimate objective of keeping cancer survivors safe and preparing them for a healthy transition after completing care for cancer.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....