Oncologists and PCPs will have to team up to cope with patient influx.
Primary care and oncology services will need to integrate structures, systems, and approaches to care in order to manage the impending surge of cancer patients, a group projected to nearly double in the next two decades, a special Commission reported.
The Commission, an international mix of cancer specialists, primary care providers (PCPs), and policy researchers from several high-income countries, estimated that the need for cancer care will increase by 40% in the next 20 years, a demand that will not be met by the number of physicians entering the field; but a shared care model between the two specialties could help meet the increased demands, Professor Greg Rubin, FRCGP, of Durham University in the U.K., and colleagues, reported in The Lancet Oncology.
"With the continuous improvements in outcomes and outright cure made possible by steady scientific and clinical care advances across many types of cancers, the absolute number of survivors continues to climb," Clifford A. Hudis, MD, past president of the American Society of Clinical Oncology (ASCO), said in an email to MedPage Today. "A return to high quality, fully functional life is a key goal of care and it is explicitly incorporated into the earliest patient interactions by many specialists and high volume centers."
At some point after treatment, Hudis noted, a large and increasing number of patients no longer benefit from specialized oncology care, but would rather be equally well served closer to home, and at lower overall cost, by receiving care from an informed primary care provider.
"All patients, including cancer patients, need the trusted, healing relationship of a family physician to help them deal with the complex and frightening issues associated with modern cancer treatment," John Meigs, MD, president-elect of the American Academy of Family Physicians (AAFP), told MedPage Today in an interview. "It would be a great disservice to [cancer patients] to not have the involvement of a family physician who knows them, knows their unique situation, and can provide the comfort, care, and coordination of their sometimes very complex treatment regimens."
To handle the influx, Meigs proposed more family physicians. "Family physicians don't just treat diseases or organs, but treat the patient in the total context of their community, family, and life situation."
The Action Plan
The Commission proposed three points of integrated care -- clinical care coordination, including processes and roles; vertical structures and processes between primary care and oncology services for care delivery; and functional designs and protocols to enhance coordination between providers.
The Commission suggested several action points, and timelines, for integrating care between services, among which the highlights focused on expanding PCP education and cancer care in the primary care setting:
►Define education competencies for cancer care required for PCPs (1-3 years)
►Adapt evidence-based models and tools to improve integration between primary and specialist care for each phase of cancer control (1-5 years)
►Education programs to support integrated care, including pathways, systems, and quality improvement measures (1-5 year)
►Assess the role and optimal utilization of patient navigators (1-2 years)
►Boost effective patient engagement in physical activity and obesity reduction in the primary care setting (1-8 years)
►Prepare PCPs to use genomic information to individualize preventive strategies for patients (2-8 years)
►Generate pilot alternative models to improve access to diagnosis and assessment for children, teens, and young adults (1-3 years)
►Improve the referral process, especially for teens and young adults (1-3 years)
►Research priorities for the use of biomarkers for early diagnosis, in high-risk or symptomatic patients, in the primary care setting (2-10 years)
►Research the usefulness of electronic clinical decision support in the primary care setting, and implement if effective (1-5 years)
►Develop new models for cancer follow-up (1-5 years) and survivorship care plans (1-3 years)
►Integrate palliative-care services based on the WHO Public Health Strategy for palliative care (1-5 years)
As a matter of practice, these points of integrated care could be achieved through: communication, developing care pathways, cross-sector education, including development of systems and quality improvement measures, assessments of the role and integration of patient navigators, and adoption of evidence-based methods to boost integration for each phase of cancer control.
Furthermore, all of these models would need to be introduced with strategies for implementation, adoption, and sustainability. And weak points in the current systems, where failures and errors most likely occur, such as patient transitions, abnormalities detected during screenings, hospital discharges, and referrals, will also need attention.
"While the vast majority of cancers are diagnosed by primary care physicians, it has been the specialists who follow protocol and formulae to treat and cure these diseases," Marc I. Leavey, MD, of Mercy Medical Center in Lutherville, Md., said in an email to MedPage Today.
Leavey agreed with the Commission that in order for PCPs to be able to respond in an intelligent fashion, furthering the therapy and enhancing care, there needs to be clear and open lines of communication between primary care and specialty services, and that the process is more feasible than ever before with electronic medical record (EMR) technology.
And Carl R. Olden, MD, a member of the AAFP Board of Directors, agreed. "Cancer screening, shared cancer care, and survivorship care will be enhanced by [EMRs] that have true interoperability and data-sharing capabilities."
"With the help of technology, along with the abandonment of egos and posturing for position in the diagnostic hierarchy, physicians can then work together to carry the patient through the angst and trauma of a cancer diagnosis and treatment, to the comfort of a long term remission or cure among familiar practitioners," Leavey added.
The team-based care model of the patient centered medical home (PCMH) has already improved coordination and continuity of care resulting in better quality, safety, and patient satisfaction, complete with evidence-based recommendations for screening and prevention of cancer, John L. Bender, MD, MBA, a member of the AAFP Board of Directors, told MedPage Today.
Olden echoed Bender's assertion. "With family physician leadership, the multidisciplinary PCMH is ideally positioned to provide for lifelong evidence-based wellness, screening and health promotion services, and with the family-focused approach, to identify individuals who are candidates for enhanced cancer screening based on family history or personal risk factors," Olden said in an interview with MedPage Today.
"This should be a wake-up call," Bender said. "We need to recognize the importance of family medicine, even in cancer care, and make training more primary care physicians a national priority."
"We [family physicians] must be involved at the leadership level to ensure that every patient has access to advanced directives and that precious health care resources are focused on evidence-based approaches to cancer screening, with shared decision making an integral part of every screening and care decision," Olden added.
Rubin reported financial relationships with Medx and Eli Lilly. Crawford reported financial relationships with Boehringer Ingelheim and Celgene. Lyratzopoulos and Peake reported financial relationships with Eli Lilly.
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