Value-driven colorectal cancer survivorship through partnership with primary care.
Authors: Chan Gloria Hui Jia , Ho Carol LF , Lin Zhaoting , Wu Jiaxuan , Chieng Jenny , Lieske Bettina , Yong Wei Peng , Sundar Raghav , Tan Hon Lyn , Ho Jingshan , Choo Joan RE , Walsh Robert John , Cheong Wai Kit , Tan Ker Kan , Chee Corissa , Liu Xin , Lim Fong Seng , Goh Shi Min , Chee Cheng Ean 
Published: June 2023

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Background: The risk of recurrence for colorectal cancer (CRC) is low after 5 years (<1.5% per year) hence, surveillance visits, CEA blood tests and annual CT scans are not recommended beyond this period (NCCN guidelines). Importantly, right-siting survivorship care to the community allows primary care providers (PCP) to focus on preventive health beyond cancer. The National University Cancer Institute, Singapore, a tertiary, academic cancer center developed a program to transition CRC survivorship care to the community after 5-years of active surveillance. Patients (Pts) are discharged to the community with a survivorship care plan and followed-up via phone calls. We hypothesize that by transitioning CRC survivors to the community, we can optimize healthcare resources by reducing specialist visits and tests at the cancer center without compromising outcomes. Methods: From July 2018, CRC pts beyond 5-years from diagnosis with no evidence of cancer recurrence were eligible for transition. Pts were followed prospectively to determine date of cancer recurrence, issues preventing transition to the community and a phone survey on pt satisfaction was conducted for those who transitioned to primary care. Data on healthcare utilization amongst pts who transitioned vs. pts who remained in tertiary care was collected. Data cutoff was June 2022. Statistical analysis was performed with IBM SPSS Statistics (v28.0). Results: Between July 2018 - June 2022, there were 791 CRC pts who were eligible for transition, of which 534 pts (67.5%) had no clinical issues preventing transition and included in this analysis. 54.3% (N= 290) were males and stage distribution of cancers were 14.2%, 34.0%, 47.1% and 4.7% for stages I, II, III and IV, respectively. The mean number of years since diagnosis was 6.88 (range: 5-16 years; SD 2.25). 380 pts (71.2%) were transitioned to the community. There was consistently higher utilization of healthcare resources in the group not transitioned vs. transitioned: mean number of consults (2.86 vs 1.02; p<0.001); CEA (1.23 vs 0.31; p<0.001); CT scans (0.08 vs 0.05; p=0.221) and colonoscopies (0.25 vs 0.16; p=0.031). Mean healthcare expenditure (mean gross bill per year) was consistently higher in pts across all categories for the group not transitioned vs. transitioned: consults ($158 vs $56; p<0.001); CT scans ($60 vs $39; p=0.273); CEA ($26 vs $7; p<0.001) and colonoscopies ($208 vs $126; p=0.018). Importantly, recurrence rates were low with no difference in both groups (0.8% vs 1.3%; p=0.629). 82% of CRC pts were satisfied or very satisfied with follow-up care provided by their PCPs on a subsequent survey. Conclusions: We have demonstrated value-driven survivorship care by right-siting CRC survivors into the community. Healthcare resources were optimized with reduction in specialist visits and tests which lead to lower costs while recurrence rates remain low. Pt satisfaction in the community was also high.