BETHESDA, Md—“I went into community oncology to treat patients,” said Richard Kosierowski, MD, an oncologist in private practice outside Philadelphia, “but I have a responsibility to the community as well.”

Three-fourths of all cancer patients are treated in the community, not in tertiary care centers, as are a like proportion of clinical trials participants, he noted. In this setting, oncologists treat not only patients but families, Dr. Kosierowski said at the 22nd annual meeting of the American Society of Preventive Oncology.

The community oncologist’s responsibility, Dr. Kosierowski said, goes beyond treatment intervention. It includes primary cancer prevention such as smoking cessation, chemoprevention in breast cancer and prostate cancer, surveillance of high-risk patients, early cancer detection, and public education.

Like everything else in medicine, the world of community oncologists is in flux, he said. Once, community oncologists were tied to hospitals, but the advent of managed care has pushed more cancer treatment to outpatient services. This results in more paperwork and more administrative time for the physician’s staff. At the same time, Dr. Kosierowski said, it is harder for an individual physician to hire more people to deal with the extra paperwork than it might be for a large institution.

A Good Oncology Nurse

The same forces have also separated the doctor’s office from the social services that came with the hospital. “The staff becomes more important,” he said. “You need a good oncology nurse to communicate with patients.”

The job of educating the public takes on new importance, especially as nutrition is given more weight as a preventive strategy. But financial pressures militate against this role for physicians and their staffs. As valuable as disseminating the latest information on cancer to the public might be, it is not a reimbursable procedure. “There is no J-code for educating the public,” he said, “but this is a job that has to be done.”

Other changes may be in the wind. Stark II legislation regarding Medicare reimbursements could alter the landscape again, since proposed regulations to implement Stark II would restrict reimbursement for chemotherapy given in the office.

“Ten or 15 years ago, chemotherapy was part of hospital care,” he noted. “Then it moved to the doctor’s office to save money. Now, with the possibility that Stark II regulations will limit chemotherapy reimbursement, we don’t know where chemotherapy will be delivered in the future. Maybe it will move back to the hospital, meaning community oncologists will have to cut back on their staffs again.”

Community oncologists will have to coordinate their work with other institutions, services, and providers, Dr. Kosier-owski said. For example, since prevention programs are needed for hospital accreditation, there are incentives for hospitals and physicians to work together.

Community oncologists set high goals for caring for their patients and their families, for both their medical and their psychosocial needs, Dr. Kosierowski said. The next era in oncology will see an enhanced role for prevention, screening programs, early detection, and the value of educating the public to take advantage of these developments.