Closing Cancer’s Posttreatment Care Gap: Bhavana Bhatnagar, DO

As cancer treatments improve and patients are living longer, answering the question of who takes charge of care once active treatment ends has become an urgent matter. Bhavana Bhatnagar, DO, says survivors often feel “homeless” after treatment, still facing physical, emotional, and psychological effects with no clear owner for their care.

In this interview with The American Journal of Managed Care^® (AJMC^®), Bhatnagar discusses gaps in survivorship care, from the decline of formal care plans to uncertainty over whether oncology or primary care should lead. She also outlines how payers could help, including support for transportation, housing, and caregiver needs tied to access to novel therapies; registries that expose care gaps between academic and community settings; and coverage for financial and psychological support programs.

This transcript has been lightly edited.

AJMC: As cancer treatments continue to improve and more patients are living longer, what do you see as the biggest unmet needs in cancer survivorship care?

Bhatnagar: Survivorship is one of those topics that’s incredibly important, but also uniformly difficult to execute, particularly outside of major academic medical centers, and within academic medical centers sometimes, because there’s not a lot of clarity on what it is, first of all. Recently, it was defined as from the time of diagnosis to whatever happens—that period is considered survivorship. But it’s not just that phase after cancer treatment is over and you have survived the cancer. It’s sort of the entire continuum, and there are a lot of gaps.

First of all, I think within the medical community, we don’t really have feasible ways to address who and what needs to be addressed for survivorship. I’ve attended various conferences and spoken to lots of different people. Should the onus of working on survivorship be on the oncology office? Is this something that the primary care physician should participate in? Who is going to quarterback survivorship care? Oftentimes it lands in the realm of oncology, but if you have a patient who’s a long-term survivor of a cancer, are they going to continually be seen in the oncology clinic? Not always. I think that’s one of the biggest gaps. We’ve moved away from care plans. They used to be there, and they outlined everything that patients should have completed to ensure that there’s no late toxicities following their cancer treatment. But again, the care plans were not always adhered to and, again, there was this issue of who’s going to be doing what.

In my mind, that’s kind of the biggest thing. I think the patients would tell you, too, that they kind of feel like they’re in a little bit of an abyss because they feel like they get a lot of attention and a lot of care as they’re going through their actual cancer treatments. However, when the treatments are over, they often feel kind of homeless, for lack of a better term; they’re not seeing their oncologist as often, but they are still experiencing either psychological, mental, physical, or emotional effects of the cancer therapy itself, and the question is, where do they go and how do we adequately address that and who should be addressing that?

At some places, there are very robust survivorship programs that are ready to address the needs of individuals, whatever they may be, because everybody’s needs are different. Some people have physical adverse effects that last for the rest of their lives. Other people struggle mostly from the emotional and psychological toll of having gone through a cancer treatment. Everybody’s needs post cancer treatment are different, and the question is, how do you capture that? How do you adequately address that? Who addresses that? Because it takes time.

I certainly see patients who are not actively on therapy, but have gone through chemotherapy, and sometimes those visits are the longest, even though we’re not talking about anything pertaining to the actual cancer. We’re talking about everything that happened afterward, and I don’t always have very good answers for it. I’m not really trained on that. So, who do I refer patients to?

I think that the survivorship plans, how do you manage survivorship, it’s going to become an even bigger issue in the future because the treatments are getting so much better and people are living longer, and while they're grateful for that, they’re not without their war wounds, and we have to address those, too.

AJMC: Of the levers you have highlighted for payers—funding community-based research, covering services tied to social determinants of health, supporting shared registries—which do you think would have the biggest near-term impact on patient care?

Bhatnagar: I think all of them could, but if I had to pick one, it would be leveraging resources that are directed towards equity and addressing some of these social determinants of health. For example, as of right now, if I want to send somebody for chimeric antigen receptor T-cell therapy, I can’t do it where I currently work. If I have an interested patient who has to travel to a center where they are able to do it, it would be great for the payers to sort of provide resources to make that happen, whether it’s transportation support, housing support, maybe even caregiver support if needed, so that people do have access to some of these novel therapies. Funding directed toward supporting the cost of some of these more expensive medications, I think would be key. A close second would be the support of a registry so that we’re better able to identify gaps in care between major academic medical centers and the local surrounding community hospitals so that patients are not at a disadvantage for not being at the academic medical center.

AJMC: What changes in survivorship care do you believe would have the greatest impact on helping cancer survivors maintain their quality of life?

Bhatnagar: The financial toxicity of cancer treatments is something that people have been talking about now for quite some time. It isn’t something that even comes front of mind when you’re going through a cancer treatment as the treating physician. But then, my patients will often voice, how much is that going to cost? Especially for younger patients, the financial toxicity is even greater because they sometimes are not working or they’re sort of in the early stages of their career. They haven’t reached the apex of where they’re trying to go. And so, yes, I think all of that is incredibly important. I think it would be great to inform policy changes that support survivorship.

I think that if we can get some policies enacted that allow for more intentional survivorship care, I think that could make a really big change for our patients. Coverage for those services that patients need, whether it’s for financial support or whether it’s for psychological support programs that are intended maybe to get especially younger cancer patients back into the job market and functioning the best they can post cancer diagnosis, I think are critically important.

I think it’s upon us to make sure that not only that people survive their cancer diagnosis, but that they thrive post cancer diagnosis and that they’re able to live their life in a meaningful way, and that the cancer didn’t just sort of bring everything to a halt. I think any policy changes that enable that to happen, like the ones I’ve listed, would be very helpful.

Editor’s note: At the time of this interview, Bhatnagar was associate professor of medicine at West Virginia University Cancer Institute at Wheeling Hospital. She is now director of acute lymphoblastic leukemia at Allegheny Health Network.