Evidence-Based Oncology

The Quest for Better Survivorship: Guidelines Promote More Accountable Cancer Care | Page 2

Published Online: December 13, 2013
Peter Page
In fact, when Gamble detailed COA’s effort to develop 19 standards of cancer on October 30, 2013, at the meeting Value-Based Oncology Management in Chicago, Illinois, he noted that payers were the first to ask that survivorship be included in the standards.

Ira Klein, MD, chief of staff to the chief medical officer for Aetna and active in the Oncology Medical Home Initiative, said survivorship programs will succeed by empowering patients with  information they can both understand and apply, while providing metrics for evaluating the costs and benefits of various treatments.

“We are looking for where what makes the most sense financially is what’s best for the patient. We want to arrange things so we encourage health, because being healthiest is what is cheapest, and when we have illness we pay for what works and not just everything people do,’’ Klein said.

“As we move from the very individualistic model of health care to population health care, the people who pay for the service recognize continuity of care is important,’’ he continued. “Once cancer patients are in remission they need a navigator to help with selfmanagement, help organizing records of their treatment, access to information on how to improve their health, how to manage long-term side effects. Maybe anxiety and depression will be issues; they may still be obese; they may not exercise and still smoke.’’ Dexter Shurney, MD, is chief medical director for Cummins, Inc, a leading global corporation headquartered in Columbus, Indiana, designing, manufacturing, selling, and servicing diesel engines and related technology. The company’s healthcare system covers 110,000 people and is about equally divided between employees and their families, Shurney said. The company is lending its perspective to the Oncology Medical Home Initiative because it already follows that mode for coordinated primary and cardiac care.

“We have a lifestyle approach to primary and cardiac care that encourages wellness. We know foods that contribute to heart disease contribute to obesity and diabetes,’’ Shurney said. “We would expect the oncologists to have a lifestyle approach to survivorship, particularly making sure patients don’t get a second cancer or it is caught early if they do. Our population will include children, some very young who require long-term follow up, and employees who want to get back to work as much we want them back. “Once people are in remission, what are the lifestyle adoptions they need to make? That is the conversation we are looking to measure, to see if that haphappens,” he said. “We don’t want people discharged without looking at what they might be doing that contributed to their cancer.’’

Moving Mountains—of Data

Lack of information is not the obstacle to writing a survivorship care plan. The biggest barriers are logistical and institutional; they include the technical challenge of coordinating the specifics of patient treatment with established best practices and documented side effects of medicines and treatment, and then paying care providers for it. “There is no reimbursement for putting together a plan the patient can take away. ... Physicians aren’t paid for it, so it just doesn’t happen,’’ said Shelley Fuld Nasso, chief executive officer of the National Coalition for Cancer

Survivorship. “For this to be common practice, we have to compensate physicians for their time.’’

Avery, of LIVESTRONG, said it takes about 3 hours per patient to assemble their survivorship care plan. “How can you get this done and get reimbursed for it?’’ she asked. “We have tools, the jewel being our free patient navigation services. We can help cancer clinics meet the needs of survivors.”

Nasso pointed to Journey Forward, a project to integrate data from cancer registries to speed plan preparation for 2 audiences, the patient and the primary care physician (PCP) who will care for the survivor once the cancer is in remission. “We need the NCCN guidelines to reach primary care physicians who are treating cancer survivors, and we need patients to get something, understandable to them, that says, ‘This is what you are facing; these are the side effects you should expect; this is when you need to call us,’’’ Nasso said. “I think it will get easier to create survivorship care plans as electronic record keeping improves.’’

Care Without Cure

In 1959 the British Medical Journal published a study that found cancer patients did better when doctors told them the truth about their diagnosis.7 Today, cancer is not always the disease doctors sometimes hide from doomed patients, but, even with better results from oncology, it remains perhaps the most dreaded diagnosis. A new IOM report issued this year, Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis,8 tempers optimism nurtured by increasingly effective treatments. The nation can anticipate 1.6 million new cancer cases annually with more than half striking people older than 65 years, with comorbidities common in this population. Treatment, already costly, is skyrocketing with each new therapy. The 2013 IOM report found that living with cancer is frequently grueling mentally, emotionally, and financially for patients and their families.8

Screening programs have led to more overdiagnosis than cures while encouraging overtreatment of patients faced with bewildering and scary choices.9 For all the progress, cancer will likely surpass heart disease as the nation’s leading cause of death this decade.10  “We are in a new payment environment that presents a great opportunity to raise the quality floor,’’ said Amy Berman, a senior program officer at the John A. Hartford Foundation. Her focus is on the health and healthcare of older adults, evaluating both the cost and effectiveness of care.

Berman has become her own best case study. Three years ago she was diagnosed with stage IV inflammatory breast cancer. The first oncologist she consulted recommended aggressive treatment including surgery, chemotherapy, and radiation that he conceded would not cure her. She declined, pursued palliative care, and remains at her job. During her keynote address in Baltimore, Maryland, at Patient-Centered Oncology Care 2013, sponsored by The American Journal of Managed Care, Berman told a rapt audience about visiting the Great Wall of China and staying active as an advocate for palliative care.

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