Mary S. McCabe

Survivorship Care Planning

National Directions• Focus on recurrence• Increasing

expectations by patients and families• Identification of late effects• Development of evidence based/consensus guidelines• Focus on evaluation› Process› Outcomes

GeneticFactors

ComorbiditiesLifestyle

Behaviors

Exposures• Surgery• Chemotherapy• Radiation

LongTermandLate

Effects

Cancer SurvivorsRisk of Health Outcomes

• Focus › Surveillance for recurrence of the primary

cancer› Monitoring and managing medical and

psychosocial late effects› Providing screening recommendations for

second cancers› Health education about survivorship issues and

availability of community resources› Health promotion, including smoking cessation,

diet and exercise› Review of treatment summary and care plan› Communication with community physician› Empowering survivors to advocate for their

own health care needs

Elements of Survivorship Care

Conceptual Framework for Survivorship Care Planning

Parry, et al, JCO, 31 (21), July 20, 2013, pg. 2651 - 2653

Models of Survivorship Care Delivery

• Oncologist Specialist Care• Multi-disciplinary Clinic• Disease/treatment Specific Clinic• General Clinic• Consultative Clinic• Integrated Clinic• Community Generalist Clinic• Shared-Care of Survivor

Community Model of CareCoordination of Services

• Coordination among:› Oncologists› Hospitals › Primary Care

• Complementary roles:› Cancer focused surveillance› General medical care› Patient education and support› Care plans

Models of CareAuthor Comparison Population QOL PT

SatisfactionPsych Function

Recurrence Complications

Kimman 2010 NurseOncologist

Breast No report No difference No report No report

Grunfeld 2006

PCPOncologist

Breast No difference No report No report No difference

Wattchow 2006

PCPSurgeon

Colon No difference No difference No difference No difference

Koinberg 2004

NurseOncologist

Breast No difference No difference No difference (HADS)

No difference

Moore 2002

NurseOncologist

Lung No difference Higher for nurses

↑ nurses No difference

Baildam 2002 Nurse Oncologist

Breast No report Higher for nurses

↓ distress nurses

No difference

Brown 2002

ConventionalOn-demand

Breast No difference No difference No difference(HADS)

No difference

Helgeson 2000

NurseOncologist

Prostate No report No difference No difference No difference

Guillford 1997

More/LessFollow-up

Breast No report Preferred less follow-up

No report No ↑ Services/cost

Grunfeld 1996

PCPOncologist

Breast No difference Primary care No Difference anxiety

No difference

• Clinic/service structure and type of provider depend on:

» Type of services to be provided• Medical • Psychological• Social• Rehabilitation• Financial

» Timing of the services• Transition visit at the end of therapy• Specified time after completion of treatment• Ongoing care

Providers of Care

Follow Up Care of Cancer Survivors

Diagnosis TreatmentEarly

Follow Up (FU)

SurvivorshipPost-Tx FU

Long Term Post-Tx FU

SHARED CARE

Oncologist

Community Physician

MSK Nurse Practitioner

• CA Recurrence• Screening other cancers• Sequelae of treatment

McCabe, Seminars in Oncology 2013

Continuum of Care

Diagnosis Treatment Early Follow up

Survivorship Post

Treatment Follow-up

Long-term Post

Treatment Follow-up

Community Physician

MSK Cancer Specialist (surgery, chemotherapy,

radiation)

MSK Survivorship

Nurse Practitioner

Community Physician

Recurrence

Treatment Summary and Care Plans:Survivor Responses (253)

Form Yes No Unsure

Overall

Keep 185 (89%) 9 13

Discuss 109 (53%) 40 55

Clear & easy to understand 195 (93%) 2 13

Screening

Understood information 158 (93%) 77 5

Plan to follow recommendation 160 (94%) 77 3

Health Maintenance

Understood information 186 (74%) 59 7

Plan to follow recommendation 176 (72%) 57 10

Amount of Information Just Right More Less

166 (67%) 21 62

Treatment Summary and Care Plans:

Primary Care Responses (86) Yes No Unsure

Clearly explained screening, health behavior follow-up 82 (95%) -- 2

New information 60 (70%) 14 9

Comprehensive 84 (98%) 0 0

Keep in chart 85 (99%) 0 0

Discuss with patient 76 (88%) 4 5

Change plans 28 (33%) 39 18

Help co-manage care 78 (91%) 5 2

Continue updates 83 (97%) 0 1

Follow-up Care GuidelinesService Cancer

typeInterval Visit Testing Stage/Primary Provider

Thoracic Lung Year 1 Every 3- 6 months

CT scan w/contrast Surgeon

Year 2 Every 6 months CT scan w/contrast Nurse Practitioner

≥ Year 3 Annual CT scan w/out contrast

Urology Prostate Year 1-2 Every 6 months PSA Every 6 months Year 1- Surgeon≥ Year 1- Nurse Practitioner

Year 3 -5 Annual PSA Every 6 months

> Year 5 Annual PSA Annual

Breast Breast surgery, medicine & rad onc

Year 1-2 Every 6-12 months

Clinical breast exam, Annual mammogram Physician

>Year 2 Every 6-12 months

Clinical breast exam, Annual mammogram Physician or Nurse Practitioner

Colo-rectal

Colon Year 1-2 Every 3-6 months

CEA/scope depending on tumor site and CT scan depending on stage

Year 1- Surgeon> Year 1- Nurse Practitioner

Year 3-5 Every 6 months CEA/scope depending on tumor site and CT scan depending on stage

Nurse Practitioner

Year >5 Annual Scope Nurse Practitioner

Rectal Year 1-2 Every 3-6 months

CEA/scope Surgeon

Year 3- 5 Every 6 months CEA/scope Year 3- Surgeon>Year 3- Nurse Practitioner

Year >5 Annual Scope Nurse Practitioner

Quality Guidelines and Metrics for Survivorship

Quality Guidelines and Metrics for Survivorship

American Cancer Society Prostate Cancer Survivorship Care Guidelines

bit.ly/ACSPrCa

20

Growth of Adult Survivorship Clinics (Visits)

1497

3459

4562

6252

75898486

9480 9640

11071

2006 2007 2008 2009 2010 2011 2012 2013 2014

Percent

Physician Participation (78) 85-100%

Patient Referral 40-94%

Patient Acceptance 95-98%

Adult Survivorship Clinics Participation

Transition to Primary Care Summary

BREAST2011-2013

LYMPHOMA2011-2013

PROSTATE2007-2013

N % N % N %

Eligible for transition 3065 663 - -

Offeredtransition 2204 72% 505 76% 998

Transitioned to outside PCP 1050 48% 281 56% 797 80%

The Future of Survivorship Care

• Implement and evaluate models of care across diverse health care settings› Optimize communication between providers

• Care plans• Patient portals

› Apply a risk-based approach to care• Provide services to diverse survivor populations

› Race/ethnicity› Education

• Disseminate established practice standards• Move to a rehabilitation concept of care

› Integrate survivorship with health promotion and disease prevention strategies

MetricsHow Are We Doing?

• Process measuresAssess the activities carried out by health care professionals to

deliver servicesOften guided by evidence-based clinical guidelines

– Compliance with screening for anxiety and depression– Compliance with pain assessment and palliative care referral

when appropriate• Outcome measuresChange in the health of an individual, group of people or population

which is attributable to an intervention or series of interventions– Number of patients successfully treated for anxiety and

depression– Number of survivors who are pain free after consult with

palliative care

MetricsHow Are We Doing?

• Evaluate at System Level– Communication• Treatment Summary and Care Plans– Provision to survivors and primary

care providers– Practice patterns• Consistency across oncology providers

– Efficiency• Resource utilization, time and cost

– Value• Quality and cost

Actions Needed

• Increase policy makers awareness of survivorship as a growing public health issue• Increased support for research• Expand educational opportunities for providers and survivors› Cancer survivors› Medical and nursing trainees› Generalist providers› Oncology providers

We’re In This Together