It’s no secret that the U.S. cancer care delivery system is in crisis. But when primary care physicians are closely involved during a patient’s cancer treatment, quality of care can improve.
It’s no secret that the U.S. cancer care delivery system is in crisis. Care is often not patient-centered, appropriate palliative care is lacking, and medical decisions often are not evidence-based. But when primary care physicians are closely involved during a patient’s cancer treatment, quality of care can improve.
New cancer diagnoses are expected to rise by 45% by 2030, even as severe shortages of both oncologists and primary care physicians (PCPs) are projected. Costs in cancer care are rising faster than other areas of medicine-annual costs are projected to reach $173 billion by 2020, up from $104 billion in 2006, according to the American Society of Clinical Oncology (ASCO). Meanwhile, the rollout of the Affordable Care Act will bring more patients into the healthcare system.
Traditionally, the role of the PCP in treating cancer patients has been ill-defined, and PCPs might easily lose track of their patients with cancer during the treatment phase.
For example, in a study of 395 lung cancer patients, researchers found that only 16% of patients perceived a shared-care pattern between their family physician and oncologist, even though “most patients would have liked their family physician to be more involved in all aspects of cancer care,” according to the study in the November/December 2010 issue of the Annals of Family Medicine.
Recent research in the United Kingdom led to initiatives to help PCPs care for cancer patients in collaboration with their patients’ oncologists, pointing to a possible future model for the United States.
“For most cancer patients, the best model for care is likely the ‘shared-care model’ in which the patient is cared for by both oncologists and primary care provider. For this to work effectively, however, there needs to be good communication between providers. And that is where most of the problems develop,” says Amy Shaw, MD, medical director of the cancer survivorship program at the Annadel Medical Group in Santa Rosa, California.
Medical Economics asked leading oncologists and primary care doctors from institutions around the country to share their best practical advice on managing cancer patients within a primary care practice, from communication to treatment to survivorship care. Here’s what they said.
Next: Communication is critical
Communication is critical
The basic need for better communication between PCPs and oncologists is so desperate that many cancer centers are working on ways to enhance it.
Cleveland Clinic Taussig Cancer Institute has an initiative to improve communication with referring PCPs, which includes a pilot program to facilitate calls between doctors. Cancer Treatment Centers of America (CTCA) at Southeastern Regional Medical Center in Atlanta has a continuity of care program that includes assigning an onsite PCP to patients undergoing cancer treatment-for example, if a cancer patient with diabetes needs a short-term course of steroids.
“We need to get rid of the old practices where physicians practice in silos,” says Jeffrey Metts, MD, MPH, chief of medicine at CTCA.
PCPs can make similar efforts in their own practices by considering the following steps:
Get the records.
So often, errors happen. Even though there have been improvements in communications with electronic health records, many systems are not interconnected.
“The entire healthcare industry is faced with the problem of getting records in a streamlined way. There are so many opportunities for failure-it could be they were signed off but not sent, or the fax machine was down, or they were received but not read,” says Metts.
Make sure patients sign the appropriate documents so you can receive their records, and then take the time to read them.
Next: Schedule follow-ups in advance
Schedule follow-ups in advance.
Don’t let visits get lost in the shuffle.
“If Mr. Smith is going away for cancer treatment for two weeks, I make sure to have a follow-up scheduled for when he is home,” says Metts.
Get lab work done early.
“Lab challenges-they are real. Ideally, I have the patient go to the lab a couple of days before the appointment,” says Metts.
If your patient has high cholesterol, you’ll make more of an impact advising them to adjust their diet during a face-to-face encounter than by sending a letter later.
Chipping away at the never-ending process of streamlining communications will help optimize time with your patients.
Know your local oncologists.
Cultivate relationships with oncologists in your community.
“Know who you are referring to,” says Larissa Nekhlyudov, MD, MPH, a general internist at Harvard Vanguard Medical Associates and associate professor at Harvard Medical School. “Figure out who you like in your community-based on their interpersonal skills, professional skills, and their communication-and develop that relationship,” she says.
Oncologists notice when you stay involved with your patients. “They become better about consultation notes. The more involved I was, the more I learned. The oncologists recognized it-and that’s how I got referrals back,” adds Shaw.
You’ll also be better positioned to help newly-diagnosed patients determine whether to seek treatment in the community or at a cancer center. “For some of the commonly treatable cancers there is not much benefit in going to a cancer center, compared to seeing an oncologist in your own town who also shares the same electronic medical record system and knows the PCP,” says Nekhlyudov.
If it’s a 25-year-old diagnosed with bone cancer, she adds, “the data show that person would do better in a cancer center, while a 60-year-old with breast cancer probably would not have any different outcome being seen in the community.”
Phone your patients.
PCPs are certainly pressed for time, but Shaw suggests that they phone patients after surgery or upon their first chemo treatment. Though phone calls are not billable, a nurse practitioner or mid-level provider from the PCPs office could make the calls.
The patient feels cared for, rather than forgotten by the PCP. Often they have care coordination needs such as medicine refills or referrals to a specialist.
“Patients get so tired of going to the doctor, getting dressed, going to the car, being seen twice a week sometimes, getting their vitals checked. For them, a phone call is more helpful than yet another doctor visit,” says Shaw.
Improve communications with cancer centers.
Some PCPs assume that oncologists don’t want their input, when the opposite is true, especially as high-tech treatments require more complex management.
“These days, for a metastatic colorectal cancer patient, their treatment control is prolonged by a biologic treatment of Avastin, but we must involve the PCP in the management of hypertension, so the patient can stay on the Avastin that will prolong their survival,” says Anupama Acheson, MD, an oncologist at Providence Cancer Center Oncology and Hematology Care Clinic and chair of ASCO’s clinical practice committee.
“A lot of the drugs impact cardiac function or diabetes, and it’s very nuanced. I’m never comfortable when we have to make adjustments due to a patient’s blood sugars or appetite being affected, because I don’t typically prescribe these medicines,” says Michael McNamara, MD, a doctor of internal medicine and medical oncology at Taussig Cancer Institute. Some cancer centers make it a practice to copy the PCP on all notes, and would like to receive the same.
“We are concerned that PCPs may not understand that we want to stay informed about the patient,” says Acheson.
Next: Use suvivorship care plans
Use survivorship care plans.
With improvements in detection and treatment, the population of cancer survivors is expected to swell to 18 million by 2022, according to ASCO. Increasing numbers of patients will live for decades after treatment.
“Patients who are done with treatment may be under surveillance by their oncologist, but there are long-term effects that the PCP should be tagged back in on,” says Acheson.
Academic cancer centers have survivorship programs to guide post-treatment care, but in the community setting these are lacking-in part because there is no set reimbursement for them, according to ASCO.
One step PCPs can take is to ask the oncologist for a “Treatment Summary and Survivorship Care Plan” for each patient who completes cancer treatment. In a 2013 survey, only 20% of oncologists said they routinely provide them, while just 13% of PCPs routinely receive them.
Traditionally, PCPs may have found oncologists reluctant to refer patients back to them after active treatment is complete, whether due to lack of confidence in the PCP’s abilities or having formed a strong emotional bond with the patient. Yet, “as of 2013, no study has demonstrated any harmful effects of PCP-led cancer follow-up,” says Shaw, meaning PCPs do just as well with patient survival and quality of life.