Navigating the Transition From Cancer Care to Primary Care: Assistance of a Survivorship Care Plan

40 Background: In our Institution, we started a survivorship care program that integrates survivors’ health care provided by the oncologist and the primary care physician (PCP).We present the follow-up analysis of the first cohort of patients (pts) enrolled from April to July 2015. Methods: We included adult pts affected by hematologic or solid tumors without evidence of disease from at least 5 years (yrs). They are referred to the PCP with a survivorship care plan. An online platform for cancer survivors (CS) and their PCPs will be available. Progression free survival (PFS), overall survival (OS) and treatment related clinical events were calculated after 17 months from the start of the project. Results: We analyzed data from 269 CS. The median age was 67 yrs, they were mainly females (77%). The most frequent histological types were breast (157), colorectal (37), and hematologic (30) tumors. 189 pts had an early stage disease. 161 pts received chemotherapy with 95 pts receiving anthracycline-based-chemotherapy (ABC), 86% at a cumulative dose > 240 mg/mq. 154 pts underwent radiation therapy (RT), 94% at a dose > 30 Gy. 58 pts received both ABC and RT. The 10-yr cumulative risk of secondary cancer (SC) was 4% with a median latency period from the first cancer diagnosis of 11.3 yrs. 15-yr OS was 98% (one patient died of myocardial infarction), and 15-yr PFS was 96%. The 10-yr cumulative risk of late cardiologic toxicity (LCT) was 11% and 37 pts developed cardiologic complications with a median latency period from treatment of 10.5 yrs. The adhesion to the survivorship care plan was 84%. 13% of pts returned to our Center. The main non-clinical reason for returning was the lack of confidence in PCP. No association was observed between ABC and/or RT exposure and LCT or SC development. Conclusions: In this cohort of patients a high risk of LCT was observed. The risk and latency of SC was similar to the ones reported in literature. The number of cardiac events and SC is too low to give solid conclusions about the association with therapeutic exposure. So far, the compliance of patients and PCPs with the program was high. More data and longer follow-up period are necessary to confirm the accuracy of this model of care.

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Leveraging the electronic health record (EHR) to support survivorship care planning for bone marrow transplant (BMT) survivors.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.7_suppl.57 ◽

2018 ◽

Vol 36 (7_suppl) ◽

pp. 57-57

Author(s):

Mandy Swiecichowski ◽

Amye Tevaarwerk ◽

Mark Juckett ◽

James Edward Haine ◽

Kirsten Norslien ◽

...

Keyword(s):

Primary Care ◽

Systems Engineering ◽

Information Needs ◽

Patient Data ◽

Care Plan ◽

Survivorship Care Plan ◽

Care Planning ◽

Survivorship Care ◽

Roles And Responsibilities ◽

Survivorship Care Planning

57 Background: BMT survivors are underrepresented in survivorship research, yet are at high risk for complications. Practice guidelines are vague, non-BMT clinicians are inadequately informed, and communication between BMT and non-BMT clinicians is inconsistent. Our objective is to develop EHR-integrated survivorship care planning that is user-centered, supports non-BMT clinician and survivor needs, but does not adversely impact clinical workflow. Methods: A multidisciplinary team of clinicians (primary care, oncology, BMT), engineers, and EHR analysts used a systems engineering approach to identify barriers and facilitators to BMT survivorship care planning. The team identified patient data categories to include in BMT survivorship care plan (SCP) templates, as well as examined tasks, technology, workflows and individual roles and responsibilities necessary to support care planning. Results: Facilitators include: potential for EHR to discretely capture individual diagnosis and treatment data to create accurate SCPs addressing survivor and primary care information needs. Barriers are: lack of EHR inter-operability which prevents sharing of patient data outside the BMT center’s EHR system, reliance on manual entry of critical data elements into the SCP (i.e. majority of the 88 patient data categories, identified by the team, are non-discrete in the EHR), inefficient or absent survivorship workflows, lack of resources (including time, dedicated clinical staff, space, SCP content), poorly defined roles and responsibilities for survivorship care provision, and lack of evidence-based BMT survivorship guidelines. Conclusions: Work system barriers impede use of the EHR to support survivorship care planning. Steps to overcome barriers: design discrete fields in the EHR to support patient-level data capture, re-engineer existing workflows to support survivorship care planning, obtain BMT program consensus on SCP content, and evaluate user-centeredness of SCPs. This research has the potential to improve feasibility and sustainability of survivorship care planning activities, resulting in improved communication and care coordination for BMT survivors.

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Developing a survivorship care plan (SCP) delivery process for patients and primary care providers serving poor, rural, and minority patients with cancer

Supportive Care in Cancer ◽

10.1007/s00520-021-06043-w ◽

2021 ◽

Author(s):

Bernard Tawfik ◽

Shoshana Adler Jaffe ◽

Lisa Mohler ◽

Jamina Oomen-Hajagos ◽

Inigo San Gil ◽

...

Keyword(s):

Primary Care ◽

Primary Care Providers ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care ◽

Care Providers ◽

Patients With Cancer

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Integrating the primary care physician into cancer follow-up.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.3_suppl.102 ◽

2016 ◽

Vol 34 (3_suppl) ◽

pp. 102-102 ◽

Cited By ~ 1

Author(s):

Andrew L. Salner ◽

Deborah Walker ◽

Amanda Seltzer ◽

SarahLena Panzer ◽

Carrie Stricker ◽

...

Keyword(s):

Breast Cancer ◽

Primary Care ◽

Primary Care Physician ◽

Care Physician ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care ◽

Care Plans ◽

Follow Up Care

102 Background: After a diagnosis of breast cancer, it can be difficult for patients to understand the role their primary care physician (PCP) should play in their follow up care. Methods: 65 women (mean age 60 years, SD = 10) with breast cancer (stage 0-III) were seen by a nurse practitioner for a 60-90 minute consultative survivorship visit and received a treatment summary and personalized survivorship care plan (SCP) utilizing Carevive Care Planning Systems software. The Carevive system incorporates patient-reported and clinical data to create tailored care plans with personalized recommendations for follow up care and supportive referrals, including direction to follow up with primary care for specific care and health maintenance activities. Approximately 6 weeks following their survivorship care visit, patients completed a survey assessing their use of and satisfaction with the SCP. Patients were advised that the SCP would be mailed to their referring oncologist and primary care physician. Results: Out of 65 sent, 35 surveys have been completed to date. Survivors were diagnosed approximately 10 months prior, and all were within 6 months following completion of treatment. All patients (100%) reported that they read, or planned to read, their survivorship care plan packet carefully. While all care plans included a recommendation to follow up with their PCP, only (71%) of survivors remembered receiving this recommendation. Of those who did, most (74%) had either seen or scheduled an appointment with their PCP. Patients who reported higher anxiety at the time of the survivorship visit were more likely to report that the follow up care plan helped them take action about seeing their PCP (p = .03). Conclusions: Coordination between primary and oncology care providers has previously been shown to improve the quality of care for cancer survivors. SCPs that emphasize the importance of and activities to be undertaken in primary care may help to improve this coordination. Continuation of this research will help to better understand how to integrate the primary care physician into cancer follow up care. Updated data will be shared at time of presentation.

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Rural Primary Care Offices and Cancer Survivorship Care: Part of the Care Trajectory for Cancer Survivors

Health Services Research and Managerial Epidemiology ◽

10.1177/2333392818822914 ◽

2019 ◽

Vol 6 ◽

pp. 233339281882291 ◽

Cited By ~ 1

Author(s):

Maresi Berry-Stoelzle ◽

Kim Parang ◽

Jeanette Daly

Keyword(s):

Primary Care ◽

Cancer Survivors ◽

Cancer Survivorship ◽

Research Network ◽

Care Plan ◽

Survivorship Care Plan ◽

Survivorship Care ◽

Female Physicians ◽

Skin Changes ◽

Care Plans

Background: A cancer diagnosis is a monumental event in a patient’s life and with the number of cancer survivors increasing; most of these patients will be taken care of by a primary care provider at some point after their cancer therapy. The purpose of this study is to identify primary care physician’s needs to care for a patient who has had cancer. Methods: A cross-sectional survey of the physician members of the Iowa Research Network was conducted. The survey was designed to measure physician confidence in cancer survivor’s care, office strategies regarding cancer survivorship care, and resources available for patients with cancer. Two hundred seventy-four Iowa Research Network members were invited to participate in this survey. Results: Eighty-two physicians (30%) completed the questionnaire with 96% reporting that they are aware of their patient’s cancer survivorship status. Seventy-one physicians reported they were aware of cancer survivorship status by an oncologist sending a note to the office, 68 being diagnosed in their office, 61 by the patient keeping the office apprised, and 15 receiving a survivorship care plan. Physicians reported the top changes in a cancer survivor’s physical health as fatigue (81%) and pain (59%). Sixty-two physicians reported not feeling confident for managing chemobrain, cardiotoxicity (71%), and skin changes (35%). Male physicians were significantly more confident managing patients’ skin changes ( P = .049) and musculoskeletal disturbances than female physicians ( P = .027), while female physicians were significantly more confident managing early-onset menopause than male physicians ( P = .027). Conclusion: Most respondents are aware of their patients who are cancer survivors and are mostly confident in the care they provide for them related to long-term effects and side effects of cancer therapies with limited receipt of cancer survivorship care plans.

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