Cancer Survivorship

Cancer Survivorship

Douglas W. Blayney, MD, FASCO

Mar 12, 2009

Last week, I participated in a panel on cancer survivorship, chaired by melanoma survivor Sam Donaldson, formerly the White House correspondent of ABC News, at the NCCN conference in Fort Lauderdale. I was one of two oncologists on the panel, which included Elizabeth Edwards (wife of the former North Carolina Senator and VP candidate), Ellen Stoval (founder of the National Coalition for Cancer Survivorship), old friend Mary McCabe of Memorial Sloan Kettering, Jane Brody (the New York Times health columnist and a breast cancer survivor), and others.

One of my purposes on the panel was to discuss ASCO's treatment plan and treatment summaries. As oncologists, our traditional approach to cancer survivorship (which we usually think of as beginning after the completion of active adjuvant or other potentially curative treatment) is to detect primary cancer recurrence, to detect second primary cancers or treatment-related cancers, and to manage any direct treatment-related complications. I sense that most oncologists follow their survivors almost indefinitely, or until they relocate to another city. Many of us are gratified to meet again and again our patients whom we've successfully helped through a difficult journey, and consequently are reminded of that many of our patients do indeed do well.

However, apart from the social interaction and some measure of re-assurance, it's fair to ask if our patients derive maximum value from these interactions. Can we deliver more?

For patients, transition into survivorship—after the intense medical interactions of surgery, chemotherapy, radiation—with its less intense visits, is often a confusing and troubling time. See if this part of the patient conversation rings true "Doctor, I had cancer and was in danger of dying. Then I had all of this treatment with people paying attention to me all the time. Now you're telling me that I won't see you or my nurses as often. It's almost as if you have given up on me, and don't care." No one patient has expressed the transition quite this succinctly, but I've paraphrased many of the discussions I've had over the years.

My colleagues at the University of Michigan, lead by Jennifer Griggs, M.D., Jon Wei, M.D., and Shiela Crowley, PhD. are developing a post-treatment survivorship treatment and research program. Dr. Griggs started by surveying all of us who take care of breast cancer at the U as to our survivorship practices. It's her story to tell, but it shouldn't surprise that our practices had great variation and duplication. She found that some patients were seeing their medical oncologist, radiation oncologist and surgeons at seperate visits within the same two weeks. Some of my colleagues reflected that their patient visits with long term survivors often were more valuable as social interactions than medical visits. In building their survivorship program, they are starting with pediatric cancer survivors, and on prostate and breast cancer adult surviviors.

They have developed the concept of the "transition visit," in which breast cancer survivors are transitioned away from the intense oncologist-centered treatment paradigm, and are prepared for self management. The visit's core components are emphasis on exercise, bone health and smoking cessation. In preparation for the visit, they are using a patient questionairre to explore the survivor's knowledge and knowledge gaps around diet, weight gain, sexual health, stress management, and other issues. During the visit, they use this pre-work to give the survivor "nudges" to open a conversation on these or other issues. In addition, adherence to routine health practices like colonoscopy screening, mammograms, etc, are also emphasized and scheduled. The survivorship clinic, which is staffed primarily by nurse practitioners with collaboration of a medical oncologists or a urologic oncologist, is not meant to replace the oncologist's role in rrecurrence detection; nor do we know if transition back to their primary care doc for routine care and cancer follow-up or continued follow-up by the oncologist or oncology nurse practitioner or physician's assistant, or some combination, is the best or most efficient model. These and other questions are the focus of the research my colleagues are undertaking. They are also exploring tailored health messaging, using internet and other telemedicine tools.

Which brings us back to the treatment summaries. ASCO has developed a series of templates to guide survivorship care planning. (They are available here.) The treatment summaries are a work in evolution, and it's not clear yet if they are in the best format, how they will be integrated into electronic health records, and how the effort to generate these summaries will be compensated. ASCO has ideas on all of these issues. Watch this space!

The conference proceedings and a video stream of the proceedings may appear here.


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