Survivorship Care Challenges: Navigating Changing Concerns.

Advanced practitioners are often in charge of planning and implementing care for cancer survivors, as noted by Carrie Tompkins Stricker, PhD, RN, ANP-BC, during JADPRO Live Virtual 2021. During a session at the conference, Dr. Stricker reviewed quality measures, best practices, and exciting innovations to draw on to improve survivorship care delivery.

With a growing population of more than 17 million cancer survivors in the United States, survivorship care is more important than ever. During JADPRO Live Virtual 2021, Carrie Tompkins Stricker, PhD, RN, ANP-BC, of Thomas Jefferson University, in Pennsylvania, described the evolving demographic, epidemiologic, workforce and reimbursement trends that will influence cancer survivorship care delivery and discussed the vital role played by advanced practitioners along the entire continuum of care. Dr. Stricker also explained how care delivery innovations could improve the quality of care for cancer survivors.

KEY CONCEPTS AND STATISTICS

As Dr. Stricker explained, an individual is considered a cancer survivor from the time of diagnosis through the balance of life. Thus, there are many types of survivors, including those living with cancer and those free from cancer. Advanced practitioners should also be aware, however, that not all patients with cancer want to be called a survivor.

“This term is meant to capture a population of those with a history of cancer rather than to provide a label that may or may not resonate with individuals,” said Dr. Stricker, who noted that the term “meta-vivorship” was recently introduced to capture the condition of living with advanced or metastatic disease.

“The survivorship care continuum is no longer just considered post treatment but during treatment into either post-treatment recovery or into end-of-life care for those individuals who are meta-vivors,” Dr. Stricker added.

Cancer survivors comprise approximately 5% of the US population. What's more, of the more than 17 million cancer survivors currently in the US, two thirds are living 5 or more years post-diagnosis, and almost half are living more than 10 years post diagnosis. The 5-year survival rate of cancer is nearly 70%.

This massive population also continues to grow. Over the next 10 years, the number of cancer survivors is expected to increase 31% (to 22 million).

“This is an enormous population of individuals who are at risk of a variety of different psychologic, psychosocial, physical, economic and financial impacts,” said Dr. Stricker. “As advanced practitioners, we need to be well educated about these risks and educate others who are involved with their care.”

ONCOLOGY WORKFORCE TRENDS

The oncology workforce is struggling to keep pace with the growth of cancer survivors. Of the 13,146 medical oncologists practicing in the US, approximately one fifth are nearing retirement, and a small percentage are early career oncologists (“2021 Snapshot: State of the Oncology Workforce in America”). What's more, only about 600 oncology fellows graduate from an oncology program per year.

“By 2025, ASCO estimates a 40% growth in demand but only a 25% growth in the supply of physicians, which translates to a shortage of approximately 1,500 oncologists,” said Dr. Stricker. “The trends in radiation oncology are similar.”

Estimates of the number of oncology advanced practice providers range from 5,350 to 7,000 (Bruinooge et al., 2018). Approximately 1% of nurse practitioners and 2% of physician assistants specialize in oncology, said Dr. Stricker, who noted that around 500 new advanced practitioners enter oncology per year.

“There is going to be a big gap, in the thousands, in the next 4 years,” said Dr. Stricker. “Advanced practitioners have a huge role to play here, and this has enormous implications for survivorship.”

CANCER SURVIVORSHIP CHALLENGES

Survivorship care models and mandates will also play a role in mitigating challenges and improving how care is delivered to this burgeoning population.

In 2018, a workshop sponsored by the National Academy of Sciences, Engineering, & Medicine recommended enhanced technology efforts and support to improve care delivery while recognizing that these efforts are part of the solution—not the solution itself (Kline et al., 2018). The authors of the report also recognized the need for a living document that is modified over time.

In an expert perspective piece from 2021, Deborah Mayer, PhD, RN, AOCN®, FAAN, of the University of North Carolina at Chapel Hill School of Nursing, wrote about the gaps in survivorship care: “We have made tremendous progress in helping people live longer after a diagnosis of cancer because of the many discoveries regarding early detection and more refined treatment…However, we have not done as well in addressing the impact of this disease and its treatment on survivors’ physical and emotional wellbeing, as well as on their families.”

According to Dr. Mayer, providers must help cancer survivors understand the chronic nature of survivorship. Living with cancer or the sequelae of cancer, if one is a longer-term or post-acute treatment of a curative cancer survivor, does not mean that you can “kiss the cancer experience goodbye,” she said. Even survivors who are lucky enough to not have enduring psychosocial or significant physical effects still require ongoing care, and there are risks to attend to in the future (Mayer, 2021).

“Survivors tell us that they don't expect us to be their only support and source of empowerment and resource, but we do need to play a role as health systems and as providers in connecting them to their peers, to mental health support, and to practical resources to manage care,” said Dr. Mayer. “Survivors need access to transitional and continuous care, particularly as they transition between different phases in the continuum of care, and they deserve to have access to coordinated and integrated systems, which are so problematic in our fragmented cancer care delivery system.”

According to Dr. Stricker, more research is needed to drive practice forward in the surveillance and management of physical effects, but care delivery needs to be improved as well. Advanced practitioners may be aware of best practices, she said, but there are obstacles that stand in the way of optimal care. Dr. Stricker listed the following barriers to overcome: lack of clinical time available to address survivors’ needs; lack of provider training in how to address these needs; access and affordability issues, including unequal access; and need for improvement in enabling technologies.

“We are accomplished and high-quality care-delivering advanced practitioners, but we are also human beings working in an incredibly challenging context,” said Dr. Stricker. “With the pandemic, the time demands on professionals in health care having been stretched to the max on top of all of our already burgeoning challenges.”

SURVIVORSHIP CARE MODELS, MANDATES, AND BEST PRACTICES

According to Dr. Stricker, however, adopting certain survivorship care models of care may be able to help. The American College of Surgeons Commission on Cancer (CoC), for example, recently updated their Cancer Survivorship Standards (Blaes et al., 2020).

“The CoC still recommends and encourages patients to receive a survivorship care plan, but it states very clearly that delivery of such is inefficient and is not a required component but can be one among many components,” said Dr. Stricker. “The goal of the original standard was to facilitate and enhance care delivery by engaging patients and primary care providers alike in knowing the treatments that they received and the risks for the potential late effects…but there may have been an overemphasis on delivering the document rather than delivering actual survivorship care.”

“The new emphasis of the standards is on the actual survivorship program and the process of delivering that care by a team of providers managed by a designated coordinator,” Dr. Stricker continued. “Someone must be designated as a coordinator, often a nurse or an advanced practitioner, but flexibility is given to that program in the specific tactics needed to accomplish the goal.”

Per the CoC, the center must document a minimum of three services offered each year, including seminars for survivors and rehabilitation, nutritional, and psychological services.

AP SURVIVORSHIP CARE PROGRAM

Reorganizing clinical practice could also lead to improved survivorship care. After piloting several models, Penn Medicine has chosen to rely on advanced practitioners in independent clinics, both physician assistants and nurse practitioners, to provide follow-up care to cancer survivors. According to Dr. Stricker, this approach has led to “fabulous outcomes,” including decreased wait times, improved timeliness of care, and better care from the survivors’ perspective.

Dr. Stricker emphasized that this model requires both provider and administration buy-in and support. The advanced practitioners in this model run the follow-up care, which occurs within the oncology practice but is separate from the acute care practice.

“These are independent follow-up clinics and can occur within medical, surgical, or radiation oncology,” she explained. “It is recognized that good survivorship care is good ongoing follow-up care that includes all those elements.”

Penn Medicine has also integrated patient-reported outcomes into post-treatment care at every visit to enable this risk stratification and follow-up care, said Dr. Stricker, who noted that most of these survivorship visits moved from in-person to telemedicine-based during the COVID-19 pandemic.

“We must continue to leverage technology along with solutions like risk-stratified pathways to help our survivors have access to transitional and continuous care,” she concluded.