Coordination of care in breast cancer survivors: an overview.

Abstract

The number of breast cancer survivors in the United States is increasing. With longer survival, there has been an increase in the complexity and duration of posttreatment care. Multidisciplinary care teams are needed to participate across the broad spectrum of issues that breast cancer survivors face. In this setting, the need for well-established patterns of communication between care providers is increasingly apparent. We have created a multidisciplinary approach to the management of breast cancer survivors to improve communication and education between providers and patients. This approach could be extended to the care and management of survivors of other types of cancer.

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H O WW E D OI T
Coordination of Care in Breast Cancer
Survivors: An Overview
Kimberly S. Peairs, MD; Antonio C. Wolff, MD, FACP; Sharon J. Olsen, PhD; Elissa T. Bantug, MHS;
Lillie Shockney, RN, BS, MAS; Melinda E. Kantsiper, MD; Elisabeth Carrino-Tamasi, MSW, LGSW; and
Claire F. Snyder, PhD
Abstract
The number of breast cancer survivors in the United States is increasing. With longer
survival, there has been an increase in the complexity and duration of posttreatment care.
Multidisciplinary care teams are needed to participate across the broad spectrum of issues that
breast cancer survivors face. In this setting, the need for well-established patterns of com-
munication between care providers is increasingly apparent. We have created a multidisci-
plinary approach to the management of breast cancer survivors to improve communication
and education between providers and patients. This approach could be extended to the care
and management of survivors of other types of cancer.
Case
A 65-year-old woman with stage II breast cancer,
mild hypertension, and obesity recently completed
treatment for her estrogen/progesterone receptor–pos-
itive, HER 2–negative breast cancer. She was
treated with lumpectomy, radiation therapy, and ad-
juvant chemotherapy with doxorubicin and cyclo-
phosphamide followed by paclitaxel. She remains on
an aromatase inhibitor and is experiencing arthral-
gias, numbness in her extremities, fatigue, and ap-
prehension about cancer recurrence. She has not seen
her primary care physician since the start of her
cancer treatment but is concerned that her “heart”
and bones may be affected by her therapy.
Scope of the Challenge
As of January 2007, the National Cancer In-
stitute estimated that there are 11.7 million can-
cer survivors in the United States, which repre-
sents approximately 4% of the population. Breast
cancer survivors comprise the largest proportion
at 22% of all survivors; and with the aging of the
general population, the majority of breast cancer
survivors are currently 65 years of age or older.1
As these numbers expected to grow in the next
decade, attention has turned toward the care of
this group of patients. These patients, many hav-
ing completed local and adjuvant cancer treat-
ment with no evidence of recurrent cancer, pres-
ent a unique set of health-care issues.2Often,
they are faced with long-term and/or late-onset
physical and psychosocial effects from their can-
cer and its treatment. They may also suffer from
chronic comorbid conditions, such as hyperten-
sion or diabetes, that are not actively addressed
during their acute cancer treatment. The path
which leads the patient to the next step of their
medical journey, transitioning from active cancer
treatment to posttreatment care, is not always
clear to the patient or the practitioners involved.
In 2006, the Institute of Medicine’s (IOM)
report From Patient to Cancer Survivor: Lost in
Transition acknowledged and outlined the gaps in
comprehensive and coordinated care for these
patients as well as the complexity of their care.3
In addition to increasing the awareness of the
consequences of cancer and its treatment, the
report identified several areas that were consid-
ered “essential components” of survivorship care.
These include prevention and surveillance for
new or recurrent cancers, treatment of long-term
Manuscript submitted March 3, 2011; accepted June 18,
2011.
Correspondence to: Kimberly S. Peairs, MD, Assistant Pro-
fessor of Medicine, Division of General Internal Medicine,
The Johns Hopkins School of Medicine, Suite 325, 10753
Falls Road, Lutherville, MD 21093; telephone: (410) 583-
2774, ext. 8; fax: (410) 583-2883; e-mail: kpeairs@jhmi.edu
J Support Oncol 2011;9:210–215
doi:10.1016/j.suponc.2011.06.008
© 2011 Elsevier Inc. All rights reserved.
Dr. Peairs is from the
Johns Hopkins School
of Medicine, Baltimore,
Maryland.
Dr. Wolff is from the
Johns Hopkins School
of Medicine, Johns
Hopkins Sidney Kimmel
Comprehensive Cancer
Center, Baltimore,
Maryland.
Dr. Olsenis from the
Johns Hopkins School
of Nursing, Baltimore,
Maryland.
Dr. Bantugis from the
Johns Hopkins School
of Medicine, Baltimore,
Maryland.
Dr. Shockney is from
the Johns Hopkins
School of Medicine,
Johns Hopkins Sidney
Kimmel Comprehensive
Cancer Center,
Baltimore, Maryland.
Dr. Kantsiper is from
the Johns Hopkins
School of Medicine,
Baltimore, Maryland.
Dr. Carrino-Tamasi is
from the Johns Hopkins
Sidney Kimmel
Comprehensive Cancer
Center, Baltimore,
Maryland.
Dr. Snyder is from the
Johns Hopkins School
of Medicine, Baltimore,
Maryland.
210
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Page 2

and late effects of cancer treatment, and coordination of care
between oncology care providers and primary care providers
(Table 1). The importance of patient and provider education
and communication was highlighted as a means to enhance
the transition phase from acute cancer treatment to long-term
health. However, many hurdles exist in the present health-
care structure, often making the delivery of optimal care for
these patients difficult.
For a variety of reasons, the care of the breast cancer
survivor no longer singularly can fall into the hands of the
oncologist. With the aging population and increase in cancer
survivors, the demand for oncologists will continue to in-
crease at a much higher pace than the number of oncologists
available.4In order to continue to evaluate newly diagnosed
cancer patients, oncologists must partner with other health-
care providers to manage the cancer survivor. Surveillance,
Epidemiology, and End Results (SEER)–Medicare analyses on
patterns of preventive care among breast cancer survivors
have shown that breast cancer survivors observed by both a
primary care practitioner and oncology specialist are more
likely to receive appropriate care,5,6supporting the integra-
tion of practitioners for improving outcomes. The patient-
centered medical home model has been proposed as an ap-
proach to improve the quality and cost of health care by
enhancing communication. In this primary care physician
(PCP)–led initiative, there is to be coordinated, evidence-
based care between health-care professionals, with patient
involvement.7,8Breast cancer survivorship care could be en-
hanced if this type of model is effective; however, improved
coordination will require clarification of each practitioner’s
role in care provision.
Patients and practitioners have concerns about the present
communication between providers. In a survivor/physician
survey, there were differences in expectations of care delivery
between patients and their physicians as well as between
PCPs and oncologists,9with PCPs expecting more involve-
ment in survivorship care than patients had perceived. Both
PCPs and oncologists felt they should be prominently in-
volved in cancer surveillance and screening as well as pre-
ventive health care, making it less clear who was to complete
the task. In a cross-sectional survey of breast cancer patients,
while survivors’ perceived confidence in PCPs’ survivorship
care increased with the frequency of office visits, most pa-
tients felt the communication between PCPs and oncologists
was poor.10Similarly, many PCPs consider the transfer of care
and information provided from the treating oncologist as fair
or poor.11–13
Primary care providers may also have reservations about
survivorship care and about their ability to successfully inte-
grate care for an already complex medical patient. In a survey
of community- and academically based internal medicine
physicians, 47% of respondents lacked formal training in
cancer survivorship and felt inadequately prepared. Eighty-
two percent felt that primary care guidelines for adult cancer
survivors were not well defined.13Despite this uncertainty,
there is evidence suggesting that noncancer physicians are
able to deliver appropriate long-term care to breast cancer
survivors. Studies by Grunfeld et al.14comparing PCP fol-
low-up with oncologist follow-up of survivors of early-stage
breast cancer in Canada demonstrated no difference in recur-
rence-related serious clinical events or health-related quality
of life. Patient satisfaction was better and health service costs
were lower with PCP delivery of long-term follow-up.15,16
A specific recommendation of the IOM report to improve
the transition period for the cancer survivor is the completion
of a comprehensive care summary and follow-up plan termed
a “Survivorship Care Plan.”3The goals of a treatment sum-
mary should be to improve communication between care
providers as well as to serve as educational material for future
care of the breast cancer survivor by all providers. It should
involve a written consolidation of the cancer treatment his-
tory with specifics on cancer type, surgeries, radiation treat-
ment, chemotherapy, as well as any additional therapy
planned. The physicians involved in the patient’s care and
their contact information should be included to streamline
communication. The survivorship care plan would be an
individualized assessment of the posttreatment and long-term
effects of the cancer treatment.17–19A care-plan template
proposed by the American Society of Clinical Oncology in-
cludes follow-up care testing recommendations for care pro-
vider visit frequency, mammography, breast exam, pelvic ex-
amination, and genetic counseling. It also addresses the
importance of coordination of care between providers to clar-
ify appropriate follow-up. Available evidence-based clinical
practice guidelines should be reviewed and shared with other
health-care providers involved in the patient’s care. The care
plan should delineate responsibilities of all care providers in
an effort to facilitate seamless coordination and communica-
tion. The timing of the completion of a care summary may be
patient-dependent but often occurs at a point when surgery,
chemotherapy, and/or radiation are completed. Some have
suggested that these discussions occur during a dedicated
clinic visit or some other protected time.
In addition to reviewing and documenting the patient’s
cancer treatment and coordinating health-care providers, this
visit or protected time is an opportunity to refocus the patient
on other health-care issues. Often, comorbidities are an af-
terthought to patients and practitioners during cancer treat-
ment, but the implications can be just as serious. Recent
studies of postmenopausal breast cancer survivors show higher
risks of death from cardiovascular disease than from breast
Table 1
Components of Care for Cancer Survivors3
1. Surveillance for recurrence of cancer
2. Surveillance and treatment of long-term and late effects of cancer
treatment
3. Screening and prevention for second cancers
4. Assessment of psychosocial issues
5. Care of comorbid conditions
6. Preventative health including immunizations, diet, and exercise
7. Coordination between care providers
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cancer,20,21especially for those diagnosed with early-stage
breast cancer. Obesity and diabetes have also been linked to
worse outcomes in breast cancer patients.22,23Other known
or newly-identified comorbidities should be discussed to en-
sure a follow-up care plan is in place and routine preventative
health measures such as exercise, diet, immunizations, and
cancer screening are reviewed.
Optimizing Care Delivery
In addition to instituting a care plan and treatment sum-
mary, the relationship between treating providers should be
examined. The most common model that exists in practice is
that in which a newly diagnosed cancer patient’s care is
assumed by an oncologist during the active treatment phase
and years thereafter for monitoring of recurrence or long-term
side effects of therapy. The role of the PCP is unclear during
this time, and the dissemination of treatment information is
limited. While oncologists are trained in internal medicine,
the noncancer medical issues of the patient may be given
lower priority. After acute cancer treatment is completed, the
role of the PCP may still be unclear. Patients may feel an
intense relationship with their oncologists and express anxi-
ety about leaving their care. PCPs may not receive enough
information regarding the cancer patient’s treatment course
and long-term cancer-related side effects.12
A shared-care model of health-care delivery involves a
more coordinated effort between practitioners with regard to
communication and delineation of responsibilities and has
been proposed as a model that may enhance survivorship care
for breast cancer patients.24In this model, the roles of the
oncologist and the PCP would be clarified and complement
one another. At the time of cancer diagnosis, the primary
responsibilities for treatment would be with the oncologist
but the management of comorbid illnesses and health main-
tenance would be handled by the PCP. Primary responsibility
for patient care would then shift back to the PCP at a
transition point in the patient’s cancer care. The oncologist’s
role would entail short- and mid-term surveillance of cancer,
treatment of acute- and short-term complications, and screen-
ing for second cancers. The primary care domain would in-
volve preventive services, screening for second cancers, long-
term surveillance, and treatment of long-term complications.
Implicit in the shared-care model is ongoing exchange of
information between care providers with the oncologist avail-
able and accessible for consults and dissemination of new
surveillance recommendations or information on long-term
side effects from treatments.
Completion and utilization of a cancer treatment summary
and survivorship care plan could be a pivotal accessory for the
physical and psychological transfer of care responsibilities
between practitioners. However, the timing and completion
of the document may be more complex. A risk-stratified
approach for the timing of transition has been implemented
for the care of pediatric cancer survivors and involves an
individualized assessment for risk of recurrence or late effects
as well as patient preferences.25A similar model for breast
cancer survivors could be employed with those having the
lowest risk of cancer-related health problems transitioning at
the completion of active treatment and patients with a higher
risk of side effects or recurrence remaining closely linked with
their cancer care provider but having continued involvement
of their PCP.24
Models of Care
The mechanism to complete survivorship care plans and
optimize the shared-care model for cancer survivors may de-
pend on the resources available. At large academic centers
there often exist many resources for cancer survivors, but
coordinating their efforts may be difficult. The use of elec-
tronic health records can improve communication between
providers within an institution and may help facilitate the
transfer of information beyond a single care setting.
Models of survivorship care are evolving within programs
designed to utilize the expertise of multidisciplinary teams to
deliver or coordinate long-term care for the cancer survivor.24
The first model of long-term cancer survivorship care origi-
nates from the pediatric cancer survivor population. These
programs typically follow the pediatric cancer survivor longi-
tudinally and are comprised of a team of practitioners, includ-
ing an oncologist, and often coordinated by an oncology nurse
practitioner. They may also utilize pediatric and adult medi-
cine specialists, social workers, and psychologists.26Annual
visits include surveillance for recurrence, evaluation of long-
term side effects, counseling for symptom management, and
patient education.
From this paradigm, some cancer centers are developing
programs that involve the survivorship care of multiple can-
cer groups and are more diverse than the pediatric survivor-
ship population. The unifying goal is to bring physicians,
nurses, social workers, mental health-care providers, and
other relevant experts in cancer survivorship together to
maximize the available services for the cancer survivor.
Within these programs, various care-delivery patterns exist,
such as that of a one-time consultative visit with a practitio-
ner with survivorship expertise in which the cancer treatment
summary and care plan are completed.
Another type of care is a survivorship clinic led by a nurse
practitioner. Here, cancer patients who have completed acute
treatment are followed for a period of time by the nurse
practitioner with cancer expertise and then transitioned back
to their PCP, with the nurse practitioner acting as the liaison
in the shared-care model to maximize support of long-term
care.
A third type of care delivery for comprehensive survivor-
ship programs is similar to the pediatric long-term follow-up
clinic and entails a multidisciplinary team of care providers
involved in the assessment of the patient’s needs, including
oncology nurse experts, mental health-care providers, social
workers, physical therapists, oncologists, and consultants.
Physicians, sometimes nononcologists, who are not involved
in active treatment assume the role of survivorship care and
long-term follow-up.
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Other centers have chosen to focus efforts on disease-
specific survivorship programs, coordinating efforts of disci-
plines relevant to treatment issues and side effects of an
individual cancer such as breast cancer. These often serve as
the springboard to coordinate larger survivorship initiatives
within an institution.
How We Do It
At our institution, the evolution of the care delivery for
breast cancer survivors has involved a multidisciplinary team
identifying distinct areas of need for improvement in imple-
menting survivorship care. We established a collaborative
relationship across the schools of nursing, medicine, and pub-
lic health and received funding from Susan G. Komen of
Maryland to develop a multifaceted program. Our working
group consists of a breast oncologist, general internists, ad-
vanced-practice oncology nurses, social worker, breast cancer
survivors, and researchers with expertise in nursing and
health-care outcomes. Goals for improving the transition of
care for breast cancer survivors included implementing a
multidisciplinary approach to survivorship care planning and
education of survivors and care providers.
The development of risk-adjusted individualized care strat-
egies was paramount to coordination of care between oncol-
ogy providers including medical oncologists, surgeons, and
radiation oncologists, as well as identifying the appropriate
time to initiate a transition of care. This approach was de-
veloped to avoid overlap of care services between oncology
providers and to offer a guide for practitioners and patients on
care expectations. Development of these strategies was com-
plicated by varying expectations from the oncology practitio-
ners and their desire for continued follow-up for even low-risk
patients. Provider expectations and concerns regarding survi-
vorship care delivery were clarified through focus groups con-
ducted with patients, oncologists, and PCPs.12The limita-
tions of the use of established survivorship care plan templates
were identified and led to modifications that would be piloted.
Educational endeavors for stakeholders involved in opti-
mizing breast cancer survivorship care were developed. A
Web site was created for patients as well as practitioners,
addressing issues such as symptom management, follow-up
care, survivorship care planning, side effects of therapy, re-
ducing risk of recurrence, fertility issues, and genetic coun-
seling. Videos of breast cancer survivors discussing their ex-
periences are accessible on the site, and further patient
specific-materials were developed to complement the sum-
mary care plan.27Within the school of nursing, an oncology
student interest group was established with a focus on lectures
promoting cancer survivorship issues. Several nursing initia-
tives to increase the exposure of students to breast cancer
survivor issues were implemented, including clinical place-
ments in oncology settings. To increase the awareness of
PCPs and oncology providers to the unique needs of breast
cancer survivors, a wide range of educational seminars were
given at the local and national levels. These included multi-
disciplinary panel presentations involving advanced nurse
specialists, internists, oncologists, gynecologists, and a health
services researcher.
The timing, content, and method of a transition experi-
ence from acute oncology treatment to long-term follow-up
care and coordination with primary care was determined by
several factors at our institution. Practitioner availability,
location, and reimbursement parameters factored into the
development of our care model. Many of our clinical resources
are not physically or operationally centralized, and simplifying
this for patients was a consideration. The model in existence
had breast cancer survivors maintaining a long-term relation-
ship with either their oncologist or an oncology nurse prac-
titioner with little coordination of care between nononcology
providers for long-term survivorship issues or general medical
health care. There existed no formalized mechanism to insti-
tute a transition visit or complete a survivorship care plan.
Initially, and during the piloting phase of the cancer sur-
vivorship care plan template, we envisioned the transition
visit would be best handled between the oncology physician
and patient. The presumed benefits would be the familiarity of
the relationship and the physician’s knowledge of cancer
treatment. The appropriate timing would be determined
based on the individual’s risk of recurrence and comfort with
transition. Practitioners, while supportive of the concept
of the visit and coordination of care, found it difficult to
utilize the oncology appointment solely for this purpose and
found the completion of the care summary time-consuming.
We tested a model for referral of patients who were com-
pleting the active treatment phase to an internal medicine
provider with experience in breast cancer survivorship care
for a consultative one-time evaluation. The physician was
linked with oncology providers by an electronic medical re-
cord facilitating the review of prior cancer treatment but was
in a separate clinical care area. Benefits of this approach were
the psychological and physical shift of focus from acute cancer
treatment to survivorship care issues. Attention to comorbid
illnesses and health prevention was emphasized in addition to
identification of side effects from treatment. This approach
had several limitations, including practitioner availability, as
many patients then wished to continue their long-term pri-
mary care with this care provider after the completion of the
visit. Most important, we wanted to maintain the established
relationships many patients may have had with their PCPs
prior to their cancer treatment and had concerns this model
might undermine those relationships. Additionally, the treat-
ment care summaries were not being completed by a cancer
care provider and the perspective of an oncology care pro-
vider was being lost. The financial feasibility of the model was
also of concern as insurance reimbursements for a consulta-
tive survivorship visit delivered by a PCP were variable.
To maintain the relationship of the patient with the on-
cology center yet coordinate transition of long-term care to
the PCP, we then considered utilizing the expertise of the
oncology advanced-practice nurses (nurse practitioners and a
clinical nurse specialist) embedded in the cancer center.
These providers had already established relationships with
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many of the breast cancer patients during their active treat-
ment phase and were intimate with the nuances of the on-
cology care and symptom management. Their nursing back-
grounds also included a focus on health promotion and
supportive care. Our multidisciplinary group met to outline
and clarify the expectations, goals, and best practices of a
survivorship care transition visit for these clinicians. Integral
to the mission was patient and staff education, patient self-
care guidance, resource identification to address the unique
physical and psychosocial referral needs of the survivors, and
the development and communication of treatment summaries
and survivorship care plans for PCP follow-up.
Patients are identified for the transition visit by either their
breast cancer physician or oncology nurse practitioner based
on an individualized risk-adjusted stratification, as well as by
patient interest. A distinct appointment is made for this
coordination of care visit, establishing it as a unique counsel-
ing appointment. After completion of the visit, a treatment
summary and care plan are provided for the patient and her
care providers. Patient-directed educational resources are also
made available.
Discussion
With the growing population of breast cancer survivors,
the importance of coordinated care to foster improved long-
term follow-up for these patients is paramount. The IOM’s
report on cancer survivorship has identified gaps in care
delivery and provider awareness of the issues unique to these
patients. As models of care are developed, mechanisms for
assessment must follow to continue to refine efforts aimed at
improving care delivery and patient outcomes. In the context
of our program, short-term feedback from patients completing
cancer treatment summaries and survivorship care plans dur-
ing the transition visit with an advanced nurse practitioner
will be obtained with regard to patient expectation, achieve-
ment of stated goals, and satisfaction with the process. Edu-
cational materials will be developed as areas of further need
are clarified. Similar feedback from other clinicians involved
in the care of the patient will be incorporated into the process
and dissemination of care plans. Our experience in develop-
ing a survivorship care model for breast cancer is paving the
way for other cancer types, such as prostate and colon, that
also continue to have a growing survivor population.
At our institution, the coordination of care for breast
cancer survivors has demonstrated the complexities of the
multidisciplinary approach to patient care. Identifying, engag-
ing, and organizing the various stakeholders involved in care
delivery can be both challenging and rewarding. Physicians’
and patients’ attitudes toward a shared-care model have been
varied, but all agree communication between providers is
essential. Patient-specific recommendations from oncologist
to PCP can alleviate some of the uncertainties of care,28and
summary information should be adapted to the needs of the
care provider so as not to make care plans so complex that
they are not practical. Clarifying the timing of a transition
visit in the trajectory of breast cancer care must be individ-
ualized, and this is best accomplished by the oncology care
providers. The transition of care goals should be patient-
centered, with the patient’s symptoms and concerns clearly
identified and triaged appropriately. The utilization of ad-
vanced-practice oncology nurses to meet the multifaceted
needs of the breast cancer survivor and coordinate commu-
nication between the oncology and primary care settings has
been an effective model. Adequate training for these profes-
sionals in the area of cancer survivorship should be expanded
and refined as more evidence-based guidelines are developed.
Identification of referral bases for physical therapy, psycho-
logical support, social work, or gynecological care is necessary
to expand survivorship resources.
We present our experience from a large tertiary care facil-
ity, but there are components that are adaptable to clinical
care settings in the community. First, the education of oncol-
ogy and noncancer practitioners on the importance and spe-
cifics of care relevant to the breast cancer survivor can be
achieved through continuing medical education, Web-based
educational modules, and treatment summaries with evi-
dence-based guidelines. Limited practitioner time and avail-
ability may dictate the flexibility for survivorship visits but
with the implementation of a cancer treatment summary and
survivorship care plan, clinicians may engage their nononcol-
ogy counterparts in a shared-care model and refocus their
efforts on acute care management. Through patient educa-
tion and information sharing, the cancer survivor may also
better navigate the health-care system. Access to Web-
based educational material for patients and providers that
is developed and curated by reputable organizations, such
as cancer.net by the American Society of Clinical Oncol-
ogy, offers the opportunity to reach out to patients and
PCPs whenever convenient.
While some of the medical or psychological implications of
cancer treatment are related to the particular cancer type,
many of the survivorship issues patients face are similar re-
gardless of their specific cancer. Patients with early-stage
cancers that are amenable to treatment with a curative intent
and have a favorable prognosis may have few long-term on-
cologic needs, but appropriate screening and surveillance
planning as well as assessment of long-term side effects is
warranted. Similarly, patients undergoing cancer treatments
that have more debilitating side effects may benefit from the
multidisciplinary services identified in a survivorship program,
including nutrition, physical therapy, pain management, and
psychological support. While the timing or need for a transi-
tion visit may be different for other cancers, the concepts of
patient education and consolidation of a treatment summary
still apply as ways to enhance communication with the pa-
tients’ primary care provider.
Conclusion
The patient case presented is emblematic of a course for an
early-stage breast cancer survivor. She is experiencing side
effects from her therapy that are common with treatments
that may be managed by her oncologist or her PCP. She has
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been disengaged from her PCP during her acute cancer treat-
ment and may be unsure of who should address her physical
and psychological concerns including the long-term and la-
tent side effects that may remain. In a model of survivorship
care, she could be evaluated by an oncology nurse specialist or
care provider with survivorship expertise, who would identify
her ongoing symptoms and put them in the context of her
cancer treatment. A care plan would be devised to include
appropriate follow-up with the clinicians best suited for her
needs, including listing contact information of oncology pro-
viders and her PCP. Educational information in the form of
printed materials and Web-site resources detailing the eval-
uation and treatment options for her symptoms such as neu-
ropathy and fatigue would be provided, and consideration of
referrals for other services such as physical therapy or a mental
health-care provider may be discussed. A printed copy of
coordination of clinician visits, screening guidelines, and
surveillance of long-term side effects from therapy that is
individualized would be provided for the patient and phy-
sicians. By engaging the patient as a health advocate and
improving lines of communication and education between
providers, the care of breast cancer survivors will continue
to improve.
Acknowledgments: This work was made possible in part by
a grant from Susan G. Komen for the Cure Maryland.
Conflicts of interest: All authors have completed and submitted the ICMJE
Form for Disclosure of Potential Conflicts of Interest. Dr. Shockney reported
receiving payment for lectures including service on speakers bureaus from
ONS and for royalties from Jones & Bartlett Publishing. All other authors
had no potential conflicts of interest to report.
References
PubMed ID in brackets
1. National Cancer Institute. Cancer Survivor-
ship Research. http://cancercontrol.cancer.gov/
ocs/prevalence/index.html. Accessed February
20, 2011.
2. Grunfeld E, Earle C. The interface between
primary and oncology specialty care: treatment
through survivorship. J Natl Cancer Inst Monogr
2010;40:25–30.
3. Hewitt M, Greenfield S, Stovall E. From Pa-
tient to Cancer Survivor: Lost in Transition.
Washington DC: National Academies Press;
2006.
4. Erikson C, Salsberg E, Forte G, et al. Future
supply and demand for oncologists: challenges
to assuring access to oncology services. J Oncol
Pract 2007;3:79–86.
5. Snyder C, Frick K, Kantsiper M, et al. Pre-
vention, screening and surveillance care for
breast cancer survivors compared with controls:
changes from 1998 to 2002. J Clin Oncol 2009;
27:1054–1061.
6. Snyder C, Frick K, Peairs K, et al. Comparing
care for breast cancer survivors to non-cancer
controls: a five-year longitudinal study. J Gen
Intern Med 2009;24:469–474.
7. Sinsky C. The patient-centered medical
home neighbor: a primary care physician’s view.
Ann Intern Med 2011;154:61–62.
8. Yee H. The patient-centered medical home
neighbor: a subspecialty physician’s view. Ann
Intern Med 2011;154:63–64.
9. Cheung W, Neville B, Cameron D, et al.
Comparisons of patient and physician expecta-
tions for cancer survivorship care. J Clin Oncol
2009;27:2489–2495.
10. Mao J, Bowman M, Stricker C, et al. De-
livery of survivorship care by primary care phy-
sicians: the perspective of breast cancer pa-
tients. J Clin Oncol 2009;27:933–938.
11. Nissen M, Beran M, Lee M, et al. View of
primary care providers on follow-up care of can-
cer patients. Fam Med 2007;39:477–482.
12. Kantsiper M, McDonald E, Geller G, et al.
Transitioning to breast cancer survivorship: per-
spective of patients, cancer specialists and pri-
mary care providers. J Gen Intern Med 2009;24:
S459–S466.
13. Bober S, Recklitis C, Campbell E, et al.
Caring for cancer survivors: a survey of primary
care physicians. Cancer 2009;115:4409–4418.
14. Grunfeld E, Levine M, Julian J, et al. Ran-
domized trial for long-term follow-up for early-
stage breast cancer: a comparison of family phy-
sician versus specialist car. J Clin Oncol 2006;24:
848–855.
15. Grunfeld E, Fitzpatrick R, Mant D, et al.
Comparison of breast cancer patient satisfaction
with follow-up in primary care versus specialist
care: results for a randomized controlled trial.
Br J Gen Pract 1999;49:705–710.
16. Grunfeld E, Gray A, Mant D, et al. Fol-
low-up of breast cancer in primary care versus
specialist care: results of an economic evalua-
tion. Br J Cancer 1999;79:1227–1233.
17. Ganz P, Hahn E. Implementing a survivor-
ship care plan for patients with breast cancer.
J Clin Oncol 2008;26:759–767.
18. Grunfeld E. Optimizing follow-up after
breast cancer treatment. Curr Opin Obstet Gy-
necol 2009;21:92–96.
19. Khatcheressian J, Wolff A, Smith T, et al.
American Society of Clinical Oncology 2006 up-
date of breast cancer follow-up and manage-
ment guidelines in the adjuvant setting. J Clin
Oncol 2006;24:5091–5097.
20. Giordano S, Hortobagyi G. Time to re-
move the subspecialty blinders: breast cancer
does not exist in isolation. J Natl Cancer Inst
2008;20:230–231.
21. Chapman J, Meng D, Shepherd L, et al.
Competing causes of death from a randomized
trial of extended adjuvant endocrine therapy for
breast cancer. J Natl Cancer Inst 2008;20:252–
260.
22. Peairs K, Barone B, Snyder CF, et al. Dia-
betes mellitus and breast cancer outcomes: a
systematic review and meta-analysis. J Clin On-
col 2011;29:40–46.
23. Ewertz M, Jensen M, Gunnarsdottir K, et
al. Effect of obesity on prognosis after early-
stage breast cancer. J Clin Oncol 2011;29:25–31.
24. Oeffinger KC, McCabe MS. Models for de-
livering survivorship care. J Clin Oncol 2006;24:
5117–5124.
25. Oeffinger KC, Eshelman DA, Tomlinson
GE, et al. Programs for adult survivors of child-
hood cancer. J Clin Oncol 1998;16:2864–2867.
26. Wallace WH, Blacklay A, Eiser C, et al.
Developing strategies for long term follow-up of
survivors of childhood cancer. BMJ 2001;323:
271–274.
27. Johns Hopkins Medicine. Breast Cancer
Survivor Care. http://www.hopkinsmedicine.org/
avon_foundation_breast_center/treatments_
services/survivor_care.Accessed
2011.
28. Del Giudice E, Grunfeld E, Harvey B, et al.
Primary care physicians’ view of routine fol-
low-up care of cancer survivors. J Clin Oncol
2009;27:3338–3345.
February 28,
Peairs, Wolff, Olsen, et al.
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