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More cancer survivors, fewer cancer specialists point to challenge in meeting care needs

February 19, 2019

An aging population, a growing number of cancer survivors, and a projected shortage of cancer care providers will result in a challenge in delivering the care for cancer survivors in the United States if systemic changes are not made, according to a commentary in the Journal of the National Cancer Institute.

Compounding the problem is the growing number of cancer survivors age 65 years or older, who are more likely to have multiple health issues in addition to cancer-related medical needs, said Deborah K. Mayer, PhD, RN, AOCN, FAAN, director of cancer survivorship at the University of North Carolina Lineberger Comprehensive Cancer Center and the interim director of the National Cancer Institute's Office of Cancer Survivorship, who co-authored the commentary with Catherine M. Alfano, PhD, vice president of survivorship at the American Cancer Society.

"The number of new patients diagnosed with cancer is relatively flat, which is good news, and the number of survivors is growing exponentially which is also good news," said Mayer, who is also the Frances Hill Fox Distinguished Professor of Nursing at the UNC School of Nursing. "However, we are now faced with the challenge of how to create 'right-sized' follow-up care in oncology. How do we transition survivors in a rational way that ensures they receive the proper follow-up care in the most appropriate setting by the most appropriate providers?"

Studies have shown that people are waiting longer to receive cancer care in the United States, and research suggests it will continue to be an issue in the years ahead if changes are not made. An American Society of Clinical Oncology report in 2014 estimated there would be a shortage of 2,200 oncologists, or approximately a 10 percent gap in providers, by 2025.

To address this supply and demand gap, Mayer and Alfano recommend the development of risk-stratified cancer follow-up care, an approach others put forward a decade ago, and one that has been demonstrated to be effective in Australia, Canada and the United Kingdom.

"The goal of the risk-stratification model is to provide the best possible follow-up care for cancer survivors in the most appropriate setting," said Mayer. "This will reduce demand pressures on oncology practices by allowing the cancer specialists to focus on those who are most in need of their expertise."

Risk-stratification involves assigning a person to a level of care management, or a "clinical pathway," based on a health assessment of current and projected complexity of their medical needs and the type of healthcare provider their care requires. The pathways are developed using evidence-based care guidelines, an approach informed by clinical study outcomes. The health assessment covers a range of issues, including overall prognosis, likelihood of cancer recurrence and new secondary cancers, the potential risk and impact of cancer treatment side-effects - both chronic and late-stage, psychosocial and socio-economic challenges, and the person's ability to navigate the healthcare system and manage their own health needs.

Patients deemed to have a low-risk of immediate or late-stage complications would receive follow-up care from their primary care provider. Patients experiencing moderate and ongoing problems would be followed by advanced practice providers focusing on survivors or "shared care" with both primary care and oncology expertise. Patients with complex care issues, or who were expected to experience significant cancer-related issues in the future, would receive their follow-up care from a multi-disciplinary team of care givers, including an oncologist.

"For this approach to be successful, it needs to be shaped by the perspectives of patients and their families, clinicians, insurers, advocates and health policy experts," said Mayer. "We have research data that can help us determine the appropriate level of care intensity, but that alone doesn't paint the full picture."

Mayer said while no one care delivery model is perfect, doing nothing to address the systemic shortfall while waiting for the development of the ideal solution is not an option.

"We are facing a significant issue that will adversely affect access to care and the quality of care we provide cancer survivors," said Mayer. "The commentary identifies next steps in addressing this this growing care gap, which will become more complicated in time if we don't address now."
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UNC Lineberger Comprehensive Cancer Center

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