When patients finish active treatment, do you schedule routine follow-ups to screen for recurrence and late effects? If these patients develop new symptoms, do you want them to call you or their primary care physician (PCP)?
Different oncologists handle post–treatment “survivorship” care differently. With no consensus on how to screen for late effects, and with only some PCPs up to date on survivorship, the question as to who should be primarily responsible for caring for survivors is up for grabs. For now.
Across America, researchers and clinical oncologists are working to develop standards for the prevention, screening, and treatment of recurrence and aftereffects. Meanwhile, legislators and insurers are implementing policies to standardize who delivers this care.
Today's turmoil creates an urgency to discuss the stewardship of survivorship and choose wisely for tomorrow's patients and clinicians. So I'd like to throw in my two cents—an opinion shaped by my perspective as a retired internist and survivor of many courses of treatment.
All other things being equal, patients who survive cancer are different from patients spared a “you-have-cancer” moment. For one thing, these patients sustained physiologic insults (many of which are unique to survivors) that can lead to long-term and late effects. For another, treatment-related changes can cause a loss of homeostatic reserves of one or more organ systems, leading to:
* The premature development of normal, age-related changes
* An atypical presentation of a common problem
* An increased risk of developing a common problem
* A poor response to treatment that is usually effective for that condition.
In addition to the medical considerations, psychosocial issues play a significant role in shaping survivors' needs and behaviors after completion of active cancer treatment.
Today's clinicians are caught in a paradox. Information about late effects obtained from long-term survivors of now obsolete therapies becomes meaningless with regard to newer therapies. And information about these newer therapies remains unavailable until adequate time has elapsed for patients to develop associated late effects.
Still, survivorship research has progressed enough to positively influence current practices. Clinicians' proficiency in survivorship leads to more accurate risk-benefit assessments regarding diagnostic tests and therapeutic interventions.
To explore which clinicians can best meet survivorship needs, let's begin by looking at what oncologists and primary care physicians do. It may seem odd, but a cursory comparison will help explain my position.
The Oncologist Approach
The oncologists I know are consummate internists. But however broad and deep their fund of knowledge, they look at patients through the lens of their specialty. So while oncologists certainly consider patients' co-morbid conditions and mitigating circumstances, they do so only to tailor their recommendations regarding patients' cancer care—and not to manage these conditions.
As for survivorship care, oncologists categorize patients by the type of cancer and/or the class of treatments received. If patients develop any late effects other than second malignant neoplasms, other specialists or PCPs address these new problems.
It's not that oncologists can't diagnose and treat vascular disease, renal insufficiency, pulmonary fibrosis, and so on. They can, if they want to change their practice to manage patients' non-malignant aftereffects.
The PCP Approach
In contrast to oncologists, PCPs view survivorship care in the context of an ongoing comprehensive wellness program. They are the principal clinicians to respond to all insults threatening patients' well-being from cradle to grave: infections, injuries, toxic exposures, genetically programmed pathologic conditions, chronic diseases, surgeries, medications, and psychosocial stresses.
Aside from responding to patients' acute and chronic problems, PCPs periodically assess modifiable risk factors for all diseases, promote a healthy lifestyle, and screen for early disease (not just cancer).
If trained in survivorship, PCPs would continue doing what they've always done. Only they'd do it better. For example, we know radiation therapy can lead to vascular disease. PCPs already screen for and manage patients' hypertension and all its consequences (e.g., MI, CVA, ischemic bowel), whatever the cause(s). Expertise in survivorship would merely fine-tune the care PCPs already provide.
Since PCPs determine when to call in specialists, health care wonks call them “gate-keepers.” I prefer the image of an orchestra conductor, leading the efforts of patients and all the players involved in patient care to a common goal: harmonious health care that optimizes each patient's outcome.
The Future of Cancer Care
To plead my case for PCPs, let's for a moment assume oncologists do all the survivorship care. The advantages may be obvious, such as continuity of care and patient access to cutting-edge interventions. But I have concerns to consider. I'd worry that chances are greater for patients to…
* Skip visits with their PCP, assuming visits with their oncologist are adequate.
* Experience delays in diagnosis if they go to their oncologist with symptoms or problems unrelated to their history of cancer.
* Undergo duplicative work-ups if their PCP orders the same or similar tests in the course of managing patients' comorbid conditions.
While I don't have data to support the above assertions, my bias toward PCPs is supported by logistic realities: With rare exceptions, oncologists are the only clinicians with the expertise and means to prescribe and administer cancer therapies, a situation unlikely to change in the foreseeable future. And looking to the future, demographic studies predict a dramatic increase in the pool of patients diagnosed with cancer.
Undoubtedly, oncologists will be at the heart of survivorship research and guidelines. But I'd like to see PCPs assume the mantle of patients' survivorship care. Not because it would be more cost-effective—which it would—but because patients would benefit: PCPs would be attentive to survivorship issues, and this structure would free oncologists to meet the needs of patients with active cancer.
Whatever happens, I hope oncologists and PCPs work together. Teamwork is necessary to ensure that the same expertise, energy, empathy, and support that are provided during the crises of diagnosis and treatment are provided throughout recovery and long-term survivorship.