Survivorship Care and the Provider’s Role in Patient Support: Adriana Olivo, NP

Olivo Adriana, NP, who specializes in breast cancer survivorship at Memorial Sloan Kettering Cancer Center, spoke with The American Journal of Managed Care^® to highlight the importance of survivorship care and how current providers in the field are utilizing available tools to the best of their ability. Olivo is hopeful that community health care providers treating women who’ve finished their breast cancer treatment will advance their knowledge of survivorship to better address and treat survivors and alleviate some of the burden from oncologists and survivorship clinics.

This transcript has been lightly edited. Captions are auto-generated.

Transcript

What are the biggest challenges breast cancer survivors face during this transitional phase?

I think after treatment is when they feel like they've been dropped from their intense care. They're used to coming to the doctor and being seen frequently, and then all of a sudden that stops. I think there's a period of vulnerability where they don't have to be seen as frequently, and the appointments get more spaced out, and they feel like they're not being followed as closely.

That being said, there are long-term side effects that are still present and still need to be monitored over time; things like lymphedema can develop as a consequence of surgery. There are a lot of breast changes and sensations that are normal but sometimes unexpected or not either explained or that the patient may have forgotten what they were told about. Things that are happening after their treatment that they're bringing to the attention of the provider years later. The vulnerability, this fear of recurrence, this fear of not being followed as closely, and what are we doing to catch recurrence and distant, distant disease? Those are some primary factors that we see in survivorship clinics.

Why is improving survivorship support, including tools like the Breast Cancer Index—used to aid physicians on cancer therapy duration—so important for equity in breast cancer care?

I find oftentimes survivorship is kind of glazed over because after the patients are done with their active treatment, meaning chemotherapy or even surgery and radiation, they often feel, like I said, left in the dust and that they’re forgotten about. But there are so many issues that come up later in survivorship—like that fear, which I think never goes away. That fear of recurrence is always there, and that’s huge. Also, I think there are a lot of late side effects that may not be addressed initially or may have been forgotten.

Our job as survivorship, APPs [advanced practice providers], or whoever has seen these patients long-term, is to help them with their side effects, help them with their fear and anxiety, and just be there for them and be supportive of them. I really wish there were more resources for survivorship. We need more clinics because patients are getting diagnosed younger, which means they have many more years ahead of them for follow-up. Patients still need screening tests. We make sure all of their health maintenance is up to date, and if they’re still recommended to seek gynecology, we make sure that they’re doing that. There are other cancer screenings, such as colonoscopy. We're making sure that they’re getting blood work with their primary care physician and making sure things like thyroid function, cholesterol, and cardiovascular health are being looked at as well.

[We look at] the full picture of the person as a patient, in addition to their cancer history, and bring it all together. I think we need more providers specializing in survivorship, because it is a unique area, and I think often patients think, and sometimes outside communities and populations think, that once they’re done with treatment, they’re done. And really, it’s a lifetime of needs. And for some patients, they are on treatment for 10 years, so that’s a long time.

If you could change one thing about how survivorship care is delivered today, what would it be?

I think we need to focus on having more specialists for some of these patients. For example, a lot of times the sexual health clinics are overcrowded because they are seeing patients that are active in treatment or having inactive medications that affect their fertility or other side effects. Once again, I think if a patient is in survivorship, sometimes it's viewed as they're not on active treatment, they don't need to be seen, or that urgency is not there, that priority is not there for these patients, and it's just not the case. Everybody needs to be seen, and they do have long-standing needs that need to be addressed, and especially with breast cancer hormone-positive patients, because hormone replacement therapy is not an answer or a reliable improvement.

Other things we need are gynecologists. We need primary care doctors who actually understand breast cancer survivorship patients. They have to be able to perform a breast exam in addition to our clinics, or in conjunction with our clinics, and we need to be able to communicate with these doctors, because there are also a lot of post-surgical and post-radiation changes after breast cancer treatments. I think an accurate breast exam is very powerful for both primary care and gynecologists. Sometimes patients aren't seeing gynecologists anymore, so there just needs to be more education in the community to recognize symptoms and to know what the guidelines are in terms of how we're screening these patients and what's appropriate to order and what is not appropriate to order, and when it is appropriate to order it.

Also, in terms of guidelines, we're following them. Again, I said, I wish there were more providers, but there's not. A lot of times, patients are eligible to go back to their community doctors, but there's this disconnect between their knowledge and what we know, and so they defer to us. They say, “Go back to your oncologist or oncology provider,” and we're saying, “No, this could be handled in the community.” There's a disconnect there.

I think we need more education in the community and, hopefully with some of the new technologies, better communication across health care systems so we could collectively manage patients together.