Shared Care For Hematologic Malignancy Survivors: Challenges Between Primary Care Physicians and Hematologist/Oncologists
Authors: Kadkhoda Haleh , Karten Clare , Van Laar Emily , Weiss Elisa , Oeffinger Kevin C. , Krauss John , Tonorezos Emily S. 
Published: October 2019

Abstract

Background
Many cancer patients are cured, or have a series of remissions interspersed with periods of re-treatment. In 2006, the Institute of Medicine's From Cancer Patient to Cancer Survivor: Lost in Transition recommended comprehensive treatment summaries and follow-up care plans for all cancer survivors. [Parry 2013] There were about 14 million cancer survivors in the US as of January 2012; this population is expected to be 18 million by 2022. [Siegel 2012] Among survivors, 64% have survived 5 years or more; 40% have survived 10 years or more; and 15% have survived 20 years or more after diagnosis. [de Moor 2013] Many survivors in this growing population experience physical, psychological, and/or financial long-term/ late effects. The complexities of managing cancer survivors suggest their care should not be conceived as a transition from the hematologist/oncologist to the primary care provider, but rather as an ongoing, flexible collaboration determined by individual survivor needs.

Methods
Polling surveys were conducted within the 2012 online education activity Sharing Care for Survivors of Hematologic Malignancies, developed by The Leukemia & Lymphoma Society and Medscape Oncology. Case-based education was delivered by an expert panel of hematologist/oncologists (Hem/Oncs) and primary care physicians (PCPs) to illustrate effective communication methods and critical communication points between (Hem/Oncs) and (PCPs).

Results
As of June 30, 116 Hem/Oncs and 171 PCPs overall responded to the polling surveys, which address current practices and barriers in shared care of cancer survivors. Responses were analyzed to identify gaps in continuity of care among specialties. A summary of responses shows the most significant barrier in effective management is the lack of survivorship care plans and treatment summaries (41% Hem/Oncs vs 51% PCPs). Only 8% and 5% of Hem/Oncs and PCPs, respectively, use survivorship care plans, although both Hem/Oncs and PCPs agreed that such plans and summaries are the most useful communication vehicle among professionals (73% Hem/Oncs vs 67% PCPs). PCPs used patient self-reported data more frequently to document cancer treatment, compared with Hem/Oncs (21% vs 7%, respectively); Hem/Oncs used caregiver reports more often than did PCPs (12% vs 3%, respectively). Similar numbers of Hem/Oncs and PCPs estimated that PCPs spend more than 4 hours of non-reimbursed time weekly researching issues related to patient care (47% Hem/Oncs vs 41% PCPs). Despite progress in electronic health records and widespread Internet access, these physicians most typically use the phone to communicate about the management of cancer survivors (64% Hem/Oncs vs 74% PCPs), followed by faxed/mailed letters, with email ranking as least used. Lack of prompt communication between Hem/Oncs and PCPs was the second highest barrier listed by respondents to effective management (22% and 27%, respectively).

Conclusion
Analysis of the Hem/Onc and PCP learner responses to the polling surveys point to clinical complexities and persistent challenges in the co-management of survivors of hematologic cancers. The challenges relate to communication, technological, healthcare system and healthcare coverage issues.Timely, ongoing communication of the right clinical information between Hem/Oncs and PCPs is essential for optimal management of the growing number of cancer survivors. Hem/Oncs and PCPs devote significant time each week to addressing the cancer survivors' needs; the lack of reimbursed time for PCPs may be an impediment to optimal care. Hem/Oncs and PCPs place a high value on the utility of survivorship care plans; however, they are not widely used. Phone calls are the current preferred communication mode. Until other technological solutions are more widely used to share clinical information, it is important to employ practical solutions, such as providing PCPs with information to help prioritize cancer survivors' follow-up care needs and providing patients/caregivers with brief cancer treatment summaries. Communication strategies to address potentially preventable causes of death, such as cardiac disease and second cancers, as well as acknowledgment and treatment for anxiety and depression related issues [Harrington 2010], which often accompany the uncertainty many cancer survivors live with, are critical.

Disclosures:
No relevant conflicts of interest to declare.