Who Should Lead the Shared-Care Cancer Survivorship Model?

With a growing number of cancer survivors in the United States (about 12 million by current estimates), there is increasing pressure on primary care physicians (PCPs) to share responsibilities of follow-up care with the patient’s oncologist. However, several studies, including one that was recently presented at the 2016 Cancer Survivorship Symposium hosted by the American Society of Clinical Oncology (ASCO), have found significant uncertainty on who is responsible for the care of cancer survivors, which can lead to care gaps that affect health outcomes.

Researchers at the University of Texas compared the attitudes and practices of PCPs and oncologists in an integrated healthcare system that shares a common electronic health record and clinical infrastructure. The hypothesis was that an integrated system might provide an adequate setup for clinicians to help coordinate survivor care responsibilities. The results, however, suggested otherwise.

Analyzing the results of their survey of 41 PCPs and 24 oncologists who were affiliated with the integrated system, the researchers found that 41% of PCPs preferred an oncologist-led care delivery model as compared with 21% of oncologists. Nearly 75% of PCPs believed in their ability to initiate cancer surveillance, while a majority (58%) of oncologists thought otherwise. Despite their belief in their own skills, PCPs preferred to take the back seat when it came to follow-up care of cancer survivors, with 56% advocating for the oncologist to lead the process, as opposed to 42% of oncologists wanting to do it.

“What we found is that both agree that primary care physicians have the skills to care for these patients. 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,” Bijal A. Balasubramanian, MBBS, PhD, lead author on the study, told Medscape Medical News. “We haven't yet figured out how to deliver this shared-care model, and clearly there are many problems associated with it.”

The 2 clinician groups also held distinct opinions on cancer surveillance practices, with oncologists consistently reporting that PCPs ordered tests for cancer surveillance, evaluated patients for cancer recurrence and for adverse physical and psychological effects of cancer or its treatment, as well as managed pain and adverse outcomes of cancer treatment. PCPs, however, did not agree on equivalent ordering of these services.

According to Balasubramanian, there is need to develop improved communication methods between the oncologists and PCPs to avoid the potential gap in care of survivors.

It’s important to note that the issues that the study has identified were observed within an integrated healthcare system. If one steps out into the community clinic arena, there is probably a bigger void between oncologists and PCPs that needs to be filled. With this in mind, ASCO and the American Cancer Society recently released guidelines (for breast cancer) to help PCPs better manage potential long-term and late effects and to provide timely and appropriate screening and surveillance to improve the overall health and QoL of survivors. Additionally, online training modules, such as the Cancer Survivorship Training (developed under guidance of the University of Kansas), are being offered to healthcare professionals to help transition survivors back to their PCPs.