'Share Care' Difficult for Ca Survivors and Their Oncologists

December 1, 2006

Just how are new plans to share care of cancer survivors being greeted by oncologists, primary care physicians, and patients? Some speakers on a cancer survivorship panel at the Second Annual Oncology Congress said it would be a big adjustment.

NEW YORK—Just how are new plans to share care of cancer survivors being greeted by oncologists, primary care physicians, and patients? Some speakers on a cancer survivorship panel at the Second Annual Oncology Congress said it would be a big adjustment.

"Cancer patients miss their oncologist so much, I think," said Paul F. Engstrom, MD, medical director of the Fox Chase Cancer Center Partners.

In the initial stages of survivorship, the first 5 years, he said, "people have developed such a bond with their team, they miss that interaction. They have a level of confidence with that group. They'll say, 'Yes, I'll go back to my primary care physician, but if anything develops, if there is anything related to my cancer, I want to see my oncologist.' This type of share care isn't going to work because of the psychological dependence patients have on their oncologist."

And what about the oncologists? "The treatment team has a bond with the individual and is very reluctant to share care because they are confident that they understand the disease and potential for recurrence and are worried about sending the patient back to the communities," said Mary McCabe, RN, MA, director, Cancer Survivorship Program, Memorial Sloan-Kettering Cancer Center. "So it's a change in culture for oncologists. But it can also be a relief."

For instance, she said, when medical oncologists who treat breast cancer patients really begin to provide all their care—checking for hypertension, for diabetes—at first it is difficult for them to think about sharing care. But afterwards, they're actually relieved because they feel they can't keep up with every antihypertensive agent. As long as they have confidence in the relationship, it can work."

Letting go of patients would be easier if their risk levels were clearer, said Scott M. Lippman, MD, professor and chair, Department of Thoracic Head and Neck Medical Oncology, M.D. Anderson Cancer Center "I think the better we get with individual risk assessment and patterns, the easier it will be to transition patients from an active cancer therapy." Trans-itioning the patient from the treating team makes sense on many levels, he said, especially since "the primary care physician may know more about other types of medical problems."

Patient Perspective

Douglas Ulman, chief of mission at the Lance Armstrong Foundation, represented the patient perspective on the panel. Mr. Ulman, 29, was diagnosed with chondrosarcoma at age 19 and later developed melanoma. "In my own case," he said, "I have a phenomenal primary care physician, but with the lack of guidelines for follow-up, it has been difficult. He was honest with me when I started my therapy. He said, 'I most likely will overprescribe diagnostics.' For me that's fine," Mr. Ulman said, "because I'd rather be more vigilant than less, but I think in lieu of specific guidelines, that could be a financial burden on some patients."

Dr. Engstrom also had something to say about primary care physicians. "Most primary care physicians whom I've worked with are kind of dichotomized on the issue. They want to be involved all the way along. They want reports to come back to them, and yet, when they are told they are going to take over the patient's care, they get quite anxious about what tests should be done."

He added that the patient may perceive the doctor's anxiety. "The patient may say, 'Well, I don't think this person really knows what's going on; I'm going back to my oncologist.' So I think we have a lot of training to do to understand the issues better. The patient also needs to understand what we are doing. You can't just tell the patient, 'We're not going to see you any longer; you have to go back to your primary care physician.'"