Survivorship Care for Breast Cancer Patients: Exploring the Role of the Primary Care Physician 

Dr. Caudle:
While breast cancer survivors may find themselves in remission or cancer-free, developing a coordinated survivorship care plan between oncologists and primary care physicians remains a top priority. Welcome to Project Oncology on ReachMD. I’m your host Dr. Jennifer Caudle and joining me to explore the primary care physician’s role in survivorship care for breast cancer patients is Dr. Maryam Lustberg, Director of The Breast Cancer Center at the Smilow Yale Cancer Center and Chief of Breast Medical Oncology at Yale Cancer Center. Dr. Lustberg thanks so much for joining me today.

Dr. Lustberg:
Thank you for having me.

Dr. Caudle:
Of course. So, let’s begin with some background. Can you tell us what a survivorship care plan looks like for breast cancer survivors?

Dr. Lustberg:
Yes, of course. So, I think over time, we’ve learned that when patients who are undergoing curative intent treatments, so they have a very defined, duration of treatment; when treatment ends it’s often associated with a heightened sense of anxiety, distress, not knowing what roadmap to follow. So, several decades ago this was recognized by the Institute of Medicine that this was one of our gaps in care that essentially patients entering this end of treatment period or survivorship period really didn’t know who to turn to their doctors didn’t know what to follow, what to do. So the idea was that a truly well-integrated cancer care needed to include coordinated survivorship care that would follow patients over time even though acute treatment of cancer was over, there were still many active issues, including complications of the cancer treatment that patients continued to experience but also  many needs, including surveillance and health maintenance needs. So, in summary, a good survivorship care plan can take many forms, but at its main essence, there is some type of a thoughtful plan in terms of how we follow patients and communicate with them and take care of them after acute cancer treatment has ended.

Dr. Caudle:
Okay. And what type of role does the primary care physician typically have in these patients’ survivorship care plan?

Dr. Lustberg:
Primary care providers are such an integral part of good healthcare and this applies to cancer survivors. The quarterbacks, they’re the ones who can really have a bird’s eye view of the holistic health needs of cancer survivors, where as an oncologist my focus is on cancer-related issues. Whereas a primary care provider has the added advantage of having a broader, more global look at different ways that health can be optimized, and this can often be missed if a cancer survivor is only being followed by an oncologist. Things like vaccines, regular health maintenance procedures, making sure that cardiovascular risk factors are kept in check. Those things can really be best accomplished through partnership with a primary care provider that is integrated within the care of cancer survivors.

Dr. Caudle:
That makes a lot of sense. As we know, you recently conducted a questionnaire among primary care physicians to evaluate their role in survivorship care. Can you share some of your findings with us?

Dr. Lustberg:
Sure. So, this was a combination of a web-based questionnaire of PCPs who are taking care of cancer survivors, as well as some qualitative interviews to delve a bit deeper in terms of their experience. And what we found is not surprising or very different from what has been previously reported, unfortunately, in that many primary care  providers felt that communication between oncologists and themselves could be improved and that many of them did not have a clear hand-off in terms of the active survivorship issues that they needed to follow-up on. So, unfortunately, there was a lack of clarity and not a clear understanding of who was going to do what, which is a recurring theme in cancer survivorship care. In essence, it doesn’t matter who’s going to follow the bone density test, but if there’s lack of clarity, then sometimes it doesn’t get done because people think the other person is doing it. So, the role definitions and what the oncologists expected them to follow verus not was one of the biggest complaints.

Dr. Caudle:
For those of you who are just tuning in, you’re listening to Project Oncology on ReachMD. I’m your host, Dr. Jennifer Caudle and I’m speaking with Dr. Maryam Lustberg on primary care physician’s role in survivorship care for breast cancer patients

And now that we’ve reviewed some of your findings, Dr. Lustberg, what do you think are some of the main obstacles between oncologists and primary care physicians when it comes to survivorship care?

Dr. Lustberg:
So, it’s such a great question and probably does not have easy answers. I think it’s important that we’re talking about it, and I really appreciate that. I think, in many ways, healthcare has become fragmented over time as a function of a lot of different issues that have happened in our healthcare marketplace. So, all of us are experiencing, as healthcare workers, shorter time visits. So, there’s less time to really get to know our patients, to really have time to delve into issues. So, that’s one aspect of it.

The second is just when we look at the electronic medical record the ideal of the electronic medical record is that it should facilitate communication and it should actually improve how we’re delivering care to this diverse patient population. However, what has happened is that often, it has taken the place of what used to be, what we call a ‘warm hand-off.’ We used to pick up the phone and call our colleague and say, ‘Hey, I just saw this patient and I’m kind of worried about her, let’s say blood pressure is a little bit high in my oncology office. I would love for you to follow that up. I want to make sure I’m not missing anything.’ So, that has been often replaced with these templated notes that are pages and pages and pages long and sometimes we’re not just directly communicating with each other.

And then third is just how we use technology. I think there are smarter ways we can use our technology, electronic medical records, are of course here to  stay and they should stay. However, how can we leverage, smarter technologies to remind each other of things that need to be followed-up on? Not in an annoying, alert way that many physicians don’t enjoy. But there’s a lot of great research going on in terms of can we use different pathways or smart technology to let’s say, if you’re seeing a patient who has previously received cardiotoxic therapy, perhaps bringing up a well-integrated alert so that the primary care provider actually knows to maybe keep a closer eye on their heart function or blood pressure issues or cholesterol issues.

I think, in summary, it’s a very complex healthcare system and we’re all doing the best that we can. It’s not anybody’s fault. And I think in this complexity just some of that direct communication or smarter communication has been lost.

Dr. Caudle:
Keeping all of this in mind, how can we strengthen the coordination between physicians to help improve survivorship care plans for our breast cancer survivors?

Dr. Lustberg:
So, I think one, these discussions are super important bringing the issues into light. I really believe in that. I think, just as a functioning of doing  this research study, what we found at our center was that  the physicians who participated actually had a better understanding of what to do, just as a function of having participated in the study. So, just having discussions is important.

I think the use of technology there is a lot of great research in terms of how we can use that electronic medical record to our advantage. It may be that a PCP in their busy schedule does not want to read a five-page document of everything that has happened to the cancer survivor, but perhaps what they would be most interested in is relevant to that visit of the day, they would like  that part of that cancer history to be highlighted. So, these algorithms are currently being researched and worked out.

And third, but most importantly, I think this is an area that I do want to make sure we focus on is that we need to engage more with our patients and survivors themselves. Part of this dialogue has been ‘Well, what can oncologists and primary care providers do?,’ and I think it’s ultimately a triad of the patients are front-and-center and if we can envision this team as a patient-centered care model and really think about ways to engage our patients so that they’re aware of their survivorship needs that they know what risk factors they have and they are active participants in their care. And this is not to replace the physician or healthcare provider input, but I think engaging with our patients more, understanding better what type of integration of care that they’re looking for, I think that will go a long way. Additionally there’s a whole field developing called ‘self-management’ where we actually give our patients the tools so that they have a better understanding of how to manage certain symptoms and toxicities and also increase patient education so they’re better aware of their different risk factors. I think that will help a lot, as well.

Dr. Caudle:
Before we close, Dr. Lustberg, do you have any takeaways you’d like to share with our listeners?

Dr. Lustberg:
I think the team approach to healthcare is really key. I think thankfully we’ve come a long way from the old model, the hierarchical model of healthcare where, essentially, a physician would tell a patient what to do and I don’t think that was the best model. And what we’ve also learned is that physicians by themselves, whether it be oncologists or primary care providers, may not hold all the answers. And so, as we think about survivorship care, what I would leave you with, is that team-based approach that includes patients, that includes a lot of allied health professionals. We know, for example, oncologic rehab, physical therapists, occupational therapists, are such an important part of the care that we give in survivorship. So what I leave the listeners with is a broader look at what survivorship teas actually look like and they tend to be much more multi-disciplinary and if we can build these teams in each of our healthcare settings we will actually deliver better survivorship care.

Dr. Caudle:
Well with those considerations in mind, I’d like to thank my guest, Dr. Lustberg for joining me today to share her insights and discuss the role of primary care physicians in improving survivorship care for breast cancer patients. Dr. Lustberg, thank you so much for being here today.

Dr. Lustberg:
Of course. I enjoyed your questions. Thank you.

Dr. Caudle:
I’m Dr. Jennifer Caudle and to access this and other episodes in our series, please visit ReachMD.com/ProjectOncology, where you can be part of the knowledge. Thanks for listening.