Executive Summary There is a gap in the literature regarding the key areas that measure the success of navigation programs—patient experience (PE), clinical outcomes (CO), and business performance or return [ Read More ]
February 2017 VOL 8, NO 2
Cancer Survivorship in Primary Care: Barriers and Recommendations for Improving Care and Outcomes
Katherine C. Chin, RN; Margarita B. Rabinovich, RN
Columbia University School of Nursing
New York, NY
Background: Due to advances in early cancer detection and treatment, more adults are surviving cancer and living long past the end of treatment. The growing population of cancer survivors exceeds the number of cancer specialists or oncologists required to maintain their health, and cancer survivors need a healthcare system with primary care providers (PCPs) who can address the symptoms associated with a history of cancer treatment, monitor patients for recurrent or secondary malignancies, and help survivors maintain a high quality of life.
Objective: This case report aims to discuss the obstacles in our current healthcare system for healthcare delivery to cancer survivors and presents possible guidelines to improve quality of care for this group. This case report also proposes a protocol for a clinical site to educate providers about the resources and guidelines to optimize healthcare for cancer survivors in a primary care setting.
Discussion: Barriers to survivorship care such as lack of communication between oncologists and PCPs, lack of cancer survivorship education for PCPs, and lack of adequate financial compensation for survivorship services may prevent PCPs from adapting to cancer survivorship guidelines. Models of care, such as shared care plans, that encourage communication between oncologists and PCPs can be paired with survivorship plans that detail individualized screening and tests needed for maintaining the health of cancer survivors.
Conclusion: With our proposed guideline emphasizing educating PCPs and providing survivorship plans, cancer survivors will receive better and more individualized healthcare that meets their needs of health maintenance and prevention of recurrent cancers.
Age: 59 years old
Race: White, non-Hispanic
Marital status: Single
Occupation: Retired, not currently working
Place of residence: Manhattan, NY
Preferred language: English
This is a 59-year-old single Caucasian male who currently resides alone in Manhattan, NY.
The patient is the source of information. He is reliable.
“I need my prescriptions refilled.”
History of Present Illness
A 59-year-old male presents to an adult internal medicine primary care clinic with a chief complaint of “I need my prescriptions refilled.” Patient reports his previous primary healthcare provider who initiated all his current medications recently retired, so he has come in today to establish care. Patient has not had blood work done in over a year and would like to get annual blood work done at this visit as well. Patient does not report any other health issues or reasons for coming to the clinic today. He endorses that his hypothyroidism, hypertension, and hyperlipidemia are managed well on current medications and denies any side effects to medications. He also reports taking all medications as directed and making sure that he obtains refills as needed. Patient denies any other complaints or symptoms related to current diagnoses listed below in PMH. Patient reports only being followed by an ophthalmologist and no other specialists at this time.
Past Medical History
Childhood Diseases: None reported
Adult Medical Diseases:
Gastroesophageal reflux disease (GERD)
Secondary hypertension (HTN)
Coronary artery disease (CAD; secondary to history of radiation requiring placement of 4 cardiac stents in 2011)
Hypothyroidism (secondary to history of radiation in 1986)
Hepatitis C infection (received treatment November 2015; resolved)
Pituitary adenoma behind L optic nerve (year of diagnosis unknown and patient not experiencing any related symptoms; previous evaluations recommend not operating on mass)
Hodgkin lymphoma (diagnosed in 1986; resolved)
Acute nonlymphocytic leukemia (diagnosed in 1987; resolved)
Diagnosis and treatment of hepatitis C, November 2015
Cardiac stent placement (4) in 2011
External radiation in 1986 as treatment for Hodgkin lymphoma
Psychiatric History: None reported
Injuries and Accidents: None reported
Current Health Status
- Amlodipine besylate 5 mg PO QD
- Aspirin 81 mg PO QD
- Cabergoline 0.5 mg PO QW
- Fenofibrate 145 mg QD
- Levothyroxine 75 mcg PO QD
- Losartan-HCTZ 100-12.5 mg PO QD
- Metoprolol tartrate 25 mg PO BID
- Omeprazole 20 mg PO BID
- Ranitidine 300 mg PO QD
- Simvastatin 20 mg PO QD
- Vitamin D3 5000 IU PO QD
Allergies: Eggs (reaction: arm became swollen and red).
Habits: Denies smoking, alcohol use, and other drug use.
Screening Tests: Last colonoscopy done 3 years ago, negative study.
Immunizations: Patient does not receive influenza vaccination because of egg allergy. Patient does not remember his other immunizations.
Sleep Patterns: “I sleep well; I have no issues with sleeping.”
Exercise/Leisure Activities: “I walk everywhere.”
Diet: Patient reported diet is well balanced; tries to stay away from sugar and fatty foods.
Environmental Hazards: None reported.
Use of Safety Measures: Patient uses seat belts; has working smoke detectors and carbon monoxide detectors at home. Patient does not have any pets.
Father (age unknown) – Kidney failure; deceased
Mother (age unknown) – Myocardial infarction (MI), HTN; deceased
No other family history reported
There is a family history of HTN, kidney failure of unknown origin, and MI. Patient could not provide family history for further generations.
The patient, a 59-year-old retired male, was born and raised in the NY metropolitan area. He currently lives in an apartment alone. He does not have any children or a spouse/partner. He walks everywhere or takes public transportation.
Review of Systems
General State of Health: “I feel fine.” Patient denies fever, chills, sweats, fatigue, weakness, decreased activity level.
Skin: Reports anal itching in the wintertime due to external hemorrhoids. Denies rash, skin lesions, changes in hair distribution and quality, changes in nail quality, changes in skin condition.
Head: Patient denies headaches, trauma/injury to the head.
Eyes: +Eyeglasses. Denies visual deficits, eye pain or discharge. Denies itchiness, eye pain, blurry vision, double vision, glaucoma, or cataract. Last eye exam 6 months ago.
Ears: Denies tinnitus, vertigo, pain, swelling, discharge, use of hearing devices.
Mouth/Oral/Throat: +Poor dentition secondary to history of radiation, denies difficulty eating. Patient denies dentures. Denies oral sores and lesions, bleeding gums, sore throat, voice changes, or dry mouth.
Neck/Nodes: Denies swelling, stiffness, lumps, tenderness, or enlargement.
Respiratory: Denies shortness of breath, cough, sputum production, asthma history, or TB history.
Cardio: Denies chest pain, palpitations, dyspnea, orthopnea, edema, syncope, heart murmur.
GI: +External hemorrhoids. Reports intermittent GERD managed effectively with medication, reports intermittent epigastric burning pain and increased belching. Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
GU: Denies polyuria, dysuria, hematuria, burning, urgency, frequency, and incontinence.
Musculoskeletal: Reports intermittent tingling in calves when it is cold outside; this does not bother him very much, and he has not received treatment to resolve the symptom despite having it evaluated by several providers. +Back spasms during cold weather; denies radiation to lower extremities. Denies pain, tenderness, weakness, stiffness, deformities, and loss of ROM.
Neurology: Denies tremors, paralysis, paresthesia, altered gait, sensory loss.
Psych: Denies depression, anxiety, suicidal ideations, hallucinations, memory loss.
Vascular: Denies edema, claudication, or cyanosis.
Endocrine: +Confirms hypothyroidism. Denies weight gain/loss, heat/cold intolerance, excessive sweating.
Vital Signs: Blood pressure, sitting (150/90); temperature (oral) (98.8F); heart rate (69); pulse (regular); SpO2 (96%); height (5 ft 3 in); weight (164 lb); BMI (29.05).
General: Male appearing to be stated age in no acute distress, cooperative, neatly groomed, and well nourished.
Head: Hair is thin and starting to have male balding pattern. No lesions, lacerations, rash, lumps, tenderness. Face symmetric with no weakness or involuntary movements.
Eyes: PERRLA, EOMI. No swelling, discharge, nystagmus, or redness.
Ears: TM intact bilaterally, nonerythematous, no exudate, no cerumen impaction.
Mouth/Oral/Throat: Pharynx pink, no exudate, dentition in poor repair – missing several teeth on upper and lower jaw.
Neck: Supple. No JVD, no thyromegaly or adenopathy.
Lungs: Clear to auscultation bilaterally throughout; no adventitious sounds; respirations unlabored.
CV: S1 S2; +grade III uniform nonradiating systolic murmur in right sternal border at pulmonary valve.
Abdomen: Nondistended, BS x4; soft, no organomegaly, nontender.
Ext: No claudication and edema, no varicosities. Pulses palpable, 2+ bilaterally in upper and lower extremities.
Back: Normal ROM. No scoliosis, nontender.
Neurology: Alert and oriented x3; CNII-XII normal.
59-year-old male with PMH of Hodgkin lymphoma at age 28 with secondary acute nonlymphocytic leukemia treated with external radiation, currently in remission, developed CAD secondary to radiation requiring 4 cardiac stents in 2011, and active, stable pituitary adenoma. Presents today with stable hypothyroidism, HTN, hyperlipidemia, and GERD to establish care and obtain medication refills. NYP documentation from previous hospital visits reviewed.
HTN, hyperlipidemia, hypothyroidism, GERD – stable. Plan
I. HTN well controlled
- A. Diagnostic: none at this time
- B. Therapeutic
- Continue metoprolol tartrate 25 mg tab PO BID
- Continue losartan-HCTZ 100-12.5 mg tab PO QD
- C. Education
- Continue to follow a low-sodium diet
- Continue to increase walking or other forms of low-impact exercise as tolerated
- Look for signs of hypotension as an adverse effect of antihypertensives
- D. Follow-up
- 1. Patient is currently at goal of ≤150/<90, continue to monitor
II. Hyperlipidemia well controlled
- A. Diagnostic
- Labs – lipid profile
- B. Therapeutic
- Continue simvastatin 20 mg tab PO QD
- Continue fenofibrate 145 mg tab PO QD
- C. Education
- Follow a low-fat diet and avoid fried and fatty foods, as well as refined carbohydrates
- Increase walking or other forms of low-impact exercise as tolerated
- D. Follow-up
- Patient is currently at goal of LDL <160, continue to monitor
- Follow up in 1 week for lab results
III. Hypothyroidism well controlled
- A. Diagnostic
- Labs: TFT (TSH, Free T4)
- B. Therapeutic
- Continue levothyroxine 75 mcg tab PO QD
- C. Follow-up
- Follow up in 1 week for lab results
IV. Establish Care
- A. Diagnostic
- CBC, SMAC, Vit D, Iron, UA, FOBTx3, Hep C
- B. Follow-up
- Follow up in 1 week to review lab results
V. GERD well controlled
- A. Diagnostic
- None at this time
- B. Therapeutic
- Continue omeprazole 20 mg tab PO BID
- Continue ranitidine 300 mg tab PO QD
- C. Education
- Eat small, frequent meals
- Do not eat several hours before going to bed
- Do not lie down after eating
- Avoid foods that trigger heartburn
VI. Pituitary adenoma, PMH of Hodgkin lymphoma and acute nonlymphocytic leukemia
- A. Diagnostic
- None at this time
- B. Therapeutic
- Continue cabergoline 0.5 mg tab PO QW
- C. Education
- Important to be followed by PCP for routine health maintenance screening and recurrent malignancies
- D. Referrals
- Referral given to oncologist for consultation of monitoring pituitary adenoma and guidance on proper screening for recurrent malignancies
VII. Vitamin D Deficiency
- A. Diagnostic
- Vitamin D blood level
- B. Therapeutic
- Continue vitamin D3 5000 IU PO QD
- C. Follow-up
- 1. Return in 1 week for lab results
Background and Statistics of Cancer Survivorship
Because of implementation of early cancer detection and new and more effective treatments, more adults are surviving cancer and living long past the end of treatment.1 Over the next 10 years, the rate of cancer survivors is expected to increase by 31%.1 Moreover, we are seeing higher survival rates in the most prevalent cancers, including breast and prostate cancers.2 In 2015, only 6.8% of new cases of breast cancer resulted in death, and 4.7% of new cases of prostate cancer resulted in death.2
The large and growing population of cancer survivors requires a healthcare system that can address the symptoms associated with a history of cancer treatment, monitor patients for recurrent or secondary malignancies, and help survivors maintain a high quality of life.3 Survivors need to be monitored periodically for signs and symptoms of returning disease.3 For example, mammograms should be ordered for breast cancer survivors and blood work ordered for leukemia survivors at appropriate intervals.3 Furthermore, patients with a history of any kind of cancer are at greater risk for developing second cancers and should be screened frequently for new malignancies.4 Cancer treatments are associated with impairments in all systems and can cause acute and chronic conditions that are very serious.4 Cancer treatment involving steroid use is associated with soft tissue atrophy, fibrosis, bone death, cataracts, and visual changes.4 Treatment with cisplastin, methotrexate, and nitrosoureas are associated with hypertension and impaired renal function.5 The patient in our case study developed hypothyroidism, GERD, heart disease, and impaired dentition as a result of radiation treatment for past medical history of Hodgkin lymphoma. Cancer survivors also live with symptoms of treatment that alter their quality of life, including chronic pain, dyspnea, sleep disturbance, diminished bowel and bladder control, and infertility.5 Living with such side effects and fear of returning disease can also cause psychological symptoms such as anxiety, depression, and posttraumatic stress disorder.5
Barriers to Primary Care Providers Providing Survivorship Care
In our current healthcare system, managing potential serious complications and risk of returning disease unique to cancer survivors is mostly in the hands of PCPs.1 Oncologists primarily follow patients who are undergoing treatment, and once treatment is completed patients may be followed short-term by their oncologist before care is transferred back to the PCP.1 The increase in cancer survivors along with the decreasing number of students specializing in oncology will result in an insufficient number of oncologists to manage cancer survivors long-term.1 In our clinical case, the new patient with a medical history of 2 types of cancer had not been followed by an oncologist or monitored for recurrent disease by a PCP despite his advancing age.
Cancer survivors are more vulnerable to developing chronic conditions as they age; therefore, they require more intensive healthcare maintenance in the primary care setting.3 For example, smoking cessation is a critical topic of counseling for cancer patients because smoking increases risk of recurrence.3 It is estimated that about 20% of cancer survivors still smoke, and smoking rates are higher among young cancer survivors than in those without a history of cancer.5 Because proper nutrition and maintaining a healthy weight can reduce the risk of cancer recurrence, nutritional counseling is very important for cancer survivors as well.5 Staying up to date with immunizations, counseling on limiting sun exposure, and education on maintaining bone health are just a few of the important preventive measures for cancer survivors.3
Given the greater comprehensive medical needs of cancer survivors that PCPs will be responsible for, recommendations have been made to ensure a high quality of care is available to this population. The Institute of Medicine (IOM) developed the concept of a survivorship care plan to promote complete, high-quality care for survivors.5 The elements of the plan include a record of care, a document detailing the patient’s disease and treatment specifics to be provided to future providers, a standard of care plan, and a follow-up care plan written by the patient’s oncologist to be given to the PCP detailing recommended cancer screenings and possible side effects from treatment, among other details.5 Since half of cancer survivor patients are managed by both PCPs and oncologists, the IOM recommends having guidelines in place in which PCPs ensure that all physical and emotional health needs of the patient are addressed, and that cancer specialists communicate with PCPs to provide guidance and treatment in their area of expertise.5 The National Comprehensive Cancer Network (NCCN) has developed an extensive compilation of guidelines aimed at addressing all the symptoms and conditions faced by cancer survivors, including sleep disturbances and chronic pain, as well as guidelines for communication between oncologists and PCPs.3 These guidelines have been updated annually since 2011 and include questionnaires to help PCPs assess the level of impairment in each domain.3 In addition, these guidelines can be used as a resource to help PCPs develop their understanding of the multitude of risks and conditions associated with cancer and cancer treatment.3 Outpatient primary care practices may not be equipped to care for this population, especially as this population continues to grow.6
Despite awareness of cancer survivors’ needs and recommendations derived from evidence-based practice, barriers exist to providing cancer survivors the care they need because this patient population is still new to the primary care setting. Our case study shows several of these barriers. The new patient did not have records from his previous cancer treatments and had not received recent survivorship care or primary care health maintenance screenings. His previous PCP retired without referring him to another primary care practice, preventing the patient from receiving continuous healthcare. As per clinic protocol, we gave the patient a consent form for release of medical records from his previous primary care doctor, but he did not have much confidence we would be able to get his records because of his previous doctor’s retirement. We also referred the patient to an oncologist as part of the care plan for the visit because he had not had a cancer screening in many years, and we were unsure of what screenings he should undergo at this time. Furthermore, as an adult internal medicine primary care clinic, our only onsite resources for managing cancer survivors include phlebotomy for routine blood tests, electrocardiograms, and an onsite cardiologist and gastroenterologist.
Based on this case, we can identify a lack of coordination of care between oncologists who follow patients during treatment and primary care once treatment is finished.6 Many PCPs have little or no communication with a patient’s oncologists during and after treatment, and many survivors are not followed by oncologists.7 Oncologists are crucial in providing counseling to patients who finish treatment about what side effects and late effects they may develop as a result of their treatment that can be addressed and treated by the PCP.2 PCPs and oncologists together can provide complete care to survivors, as oncologists can address cancer-specific issues and PCPs can address chronic and health maintenance issues.7 Currently, there is still a wide variety of care of cancer survivors, and little research and evaluation have been done on those models. Furthermore, there is no system to financially reimburse healthcare providers for the massive amount of time spent developing a plan to coordinate care.8 There are several proposed models: physician-led, nurse-led, and shared care plans.8 Shared care plans dictate that the responsibility for the healthcare of the patient is shared between professionals of different organizations, such as the oncologist and the PCP.5 Patients have indicated that they prefer a shared care plan in which the oncologist is still involved.8 The American College of Surgeons Commission on Cancer Survivorship Standard 3.3 endorses shared care plans and promotes the practice of survivor care plans being prepared by the treating oncologist with input from patient’s other providers.9 The commission advocates for the implementation of cancer survivorship plans to all eligible patients by January 1, 2019, to solve the issue of lack of communication between oncologists and PCPs.9 Unfortunately, at this time, even with the IOM recommendations and call for coordinated care for cancer survivors back in 2006, there is still little information available on current “usual” practices.8
Another barrier is the lack of education and training for PCPs that prepare them to care for cancer survivors.7 Although we do have current patients undergoing cancer treatment and many cancer survivors at our clinic, little is known about the side effects from their cancer and treatment, as well as how to provide them the best healthcare. Although guidelines for treating survivors exist, optimal management of survivors is a relatively new body of knowledge that has not reached many providers yet. Lack of knowledge about managing this population may cause PCPs to shy away from treating these patients, leading to unnecessary referrals, delay of treatment, and complicating these patients’ ability to get healthcare. PCPs report low familiarity with cancer survivorship care in pediatric cancer survivors but express an interest in continuing education and participating in a shared care plan.10 There are various resources available in continuing education such as Cancer SurvivorLink, a web-based tool for patients and healthcare providers.10 The National Cancer Institute (NCI), LIVESTRONG, CancerCare, the American Cancer Society, the Intercultural Cancer Council, Living Beyond Breast Cancer, and the National Coalition for Cancer Survivorship offered telephone workshops on various topics about cancer survivorship from 2003 to 2012.4 The NCI Office of Cancer Survivorship website provides a vast array of resources on cancer survivorship specifically directed at healthcare professionals.3 The NCCN provides a continuing education workshop, Supportive Oncology Care, for healthcare professionals that includes survivorship topics such as identification of needs and assessing for long-term effects.11 Medscape also has a continuing education opportunity, Increasing Role of Primary Care in Cancer Treatment, that addresses survivorship in primary care.12
A third barrier in this case is the lack of compensation for cancer survivorship services, which may drive the lack of interest in investing time and effort toward attending continuing education and developing guidelines or cancer survivorship plans. One of the recommendations from the IOM involves insurers and payers of healthcare creating a reimbursement mechanism to cover cancer survivorship care.5 Currently, however, there is no defined package of cancer survivorship billable codes. Possible codes that may be used are Level 3-5 codes, team conference codes, and Current Procedural Terminology (CPT) care coordination codes such as 99495 and 99469.13 Preventive medicine codes such as 99401-99404, 99411-99412 may be used.14 Counseling for smoking cessation (99406-99407), alcohol and substance abuse intervention services (99408-99409), medical nutrition therapy (97802-97804), and medical genetics counseling (96040) may all be used in cancer survivorship counseling.13 Health and behavior assessment (96150-96155) can also be used in assessing the cancer survivors’ psychosocial well-being.14
In regard to the barriers shown by our case study, we propose a protocol for our clinical site aimed at educating providers about the resources and guidelines regarding optimal healthcare for cancer survivors in a primary care setting. Given the lack of provider knowledge and absence of site guidelines regarding management of cancer survivors, we feel we could implement such a protocol to alleviate this barrier. Currently, the American Cancer Society provides several cancer survivorship guidelines available for breast, colorectal, prostate, and head and neck cancers.15 These guidelines, along with NCCN’s clinical practice guidelines on survivorship covering topics such as late or long-term psychosocial and physical problems and preventive health, will be compiled into a survivorship binder to be kept in the clinic.3 The binder will serve as an available resource for clinicians to refer to when treating a cancer survivor patient. We would also propose to hold an in-service training for the healthcare providers at the clinic in regard to common late or long-term psychosocial and physical problems listed in the NCCN’s clinical practice guideline and cover the billing codes that could be used in a survivorship visit.3,14 This would have to receive clearance from the chief physician and would take place in the clinic after hours for an allotted 2-hour period over 2 sessions. Existing and new providers would be encouraged to attend the in-service training and use the resource binder as needed. To remedy the barrier of lack of communication between oncologists and primary care, we would provide cancer survivor patients with a blank Cancer Survivorship Plan document if they do not have one already to take back to the oncologist to complete, or fax it to the oncologist with a request for release of health information. The American Society of Clinical Oncology has a sample Cancer Survivorship Plan that we would implement in this situation.16
Limitations to Proposal
There are several potential barriers to the implementation of our protocol. Most importantly, we would need the final approval of the clinic’s supervising physician. However, even if the protocol was approved, we would still face the systemic barriers that were discussed earlier (ie, the lack of communication between oncologists and PCPs and the lack of reimbursement for our services). These barriers could only be remedied on a broader scale, such as by creating shared care plans with a designated oncologist and by creating a CPT code specifically for cancer survivorship counseling, as echoed in the IOM’s report.5 Also, if there are few survivor patients who receive care at the clinic, the in-service training and resource binder may not be implemented as much in the future because other in-office education may be considered more necessary, and the protocol would not be upheld at the site.
Need for Future Research
Despite the topic of cancer survivorship receiving newfound attention in the medical community, there are several areas that would benefit from further research. There is little information about the outcomes of survivorship-focused care plans being implemented. The guidelines were formulated on research targeted at addressing needs and concerns of survivors, but it is unknown if these guidelines are achieving their goals and how patients are responding to them.
Another area that would benefit from more research would be a better understanding of how providers bill for survivorship care, because there are no specific CPT codes for cancer survivorship but rather a group of codes that could be used for topics covered within survivorship. Information about how survivorship-focused visits are coded would determine if the creation of survivor-specific codes would be useful in promoting survivor-specific care and counseling. Such information would be necessary for a Relative Value Scale Update Committee when considering the creation of such codes.
Implications/Role for Navigation
Studies have shown that patients with nurse navigators involved in early cancer care had better experiences and were less likely to encounter barriers such as coordination of care, psychosocial issues, education about their condition, etc, compared with patients without nurse navigators.17 However, because patient navigation in survivorship care is a new addition to the field, there is limited research available on the topic and little evidence showing the impact of patient navigators in cancer survivorship.18 The role of patient navigators or oncology nurse navigators is to help cancer survivors access services, assist with care coordination, provide general survivor information and resources, encourage cancer survivors to optimize time with clinicians, and prevent loss to follow-up.18 Such services would allow the PCP to focus primarily on late-effect symptom management and healthcare maintenance.18 In this case study, a nurse navigator would have been useful in mitigating barriers to high-quality survivor-focused care, such as facilitating communication between past providers and the current one, providing education on survivorship care, and preventing loss to follow-up.
As the number of cancer survivors continues to grow, cancer survivors will become a larger patient population managed in primary care.1 Given the high prevalence of late-term effects associated with cancer treatments, increased risk of chronic disease, and recurrent primary and secondary malignancies in cancer survivors, it is essential that cancer survivors receive survivorship-focused primary care. Although evidence-based guidelines outlining such care have been published and are updated annually, several barriers inhibit their utilization.3 These barriers include lack of coordination of care and communication between oncologists and PCPs, lack of PCP education on survivorship care, and lack of reimbursement of survivorship services and counseling, causing resistance to the incorporation of survivor-specific care in primary care. As an initial step to alleviate these barriers in our primary care setting, we propose holding an in-service to educate providers about survivor-specific care and providing a resource binder for providers to easily access as needed. We believe such a protocol along with continued research on the role of nurse navigators and outcomes of guidelines in survivor care are important steps for integrating survivorship care into primary care.
- de Moor JS, Mariotto AB, Parry C, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomarkers Prev. 2013;22:561-570.
- Ganz P. Survivorship: adult cancer survivors. Prim Care. 2009;36:721-741.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Survivorship. Version 2.2016. www.nccn.org/professionals/physician_gls/f_guidelines.asp#survivorship. Published March 30, 2016. Accessed September 11, 2016.
- National Cancer Institute. Division of Cancer Control & Population Sciences. Office of Cancer Survivorship. For Healthcare Providers. http://cancercontrol.cancer.gov/ocs/resources/healthcare.html. Updated January 11, 2016. Accessed September 11, 2016.
- Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2008;1-534.
- Shulman LN, Jacobs LA, Greenfield S, et al. Cancer care and cancer survivorship care in the United States: will we be able to care for these patients in the future? J Oncol Pract. 2009;5:119-123.
- Grunfeld E, Earle CC, Stovall E. A framework for cancer survivorship research and translation to policy. Cancer Epidemiol Biomarkers Prev. 2011;20:2099-2104.
- Halpern MT, Viswanathan M, Evans TS, et al. Models of cancer survivorship care: overview and summary of current evidence. J Oncol Pract. 2015;11:e19-e27.
- Ferris LW, Takanishi D, Shulman L, et al. Accreditation committee clarifications for Standard 3.3 survivorship care plan. American College of Surgeons. www.facs.org/publications/newsletters/coc-source/special-source/standard33. September 9, 2014. Accessed November 15, 2016.
- Meacham LR, Edwards PJ, Cherven BO, et al. Primary care providers as partners in long-term follow-up of pediatric cancer survivors. J Cancer Surviv. 2012;6:270-277.
- National Comprehensive Cancer Network. Cancer survivorship defined, identification of patient needs at survivorship visit, and Commission on Cancer’s requirements for survivorship care plans. National Comprehensive Cancer Network Continuing Education. https://education.nccn.org/node/79498. Published August 31, 2016. Accessed September 11, 2016.
- Davenport L. Increasing role of primary care in cancer treatment. Medscape. www.medscape.org/viewarticle/852911. Published October 29, 2015. Accessed September 11, 2016.
- The George Washington University Cancer Institute. Guide for delivering quality survivorship care. https://smhs.gwu.edu/gwci/sites/gwci/files/Guide_for_Delivering_Quality_Survivorship_Care_FINAL.pdf. Published November 2013. Accessed September 11, 2016.
- Parman C. Billing challenges for survivorship services. Compliance. www.accc-cancer.org/oncology_issues/articles/MJ13/MJ13-Billing-Challenges-for-Survivorship-Services.pdf. Published May 2013. Accessed September 11, 2016.
- American Cancer Society. American Cancer Society Prevention, Early Detection, and Survivorship Guidelines. www.cancer.org/healthy/informationforhealthcareprofessionals/acsguidelines/index. Published 2016. Accessed September 11, 2016.
- American Society of Clinical Oncology. ASCO Treatment Summary and Survivorship Care Plan. http://cancercontrol.cancer.gov/pdf/ASCO-Survivorship-Care-Plan.pdf. Published 2016. Accessed September 11, 2016.
- Wagner EH, Ludman EJ, Aiello Bowles EJ, et al. Nurse navigators in early cancer care: a randomized, controlled trial. J Clin Oncol. 2014;32:12-18.
- Pratt-Chapman M, Simon MA, Patterson AK, et al. Survivorship navigation outcome measures: a report from the ACS patient navigation working group on survivorship navigation. Cancer. 2011;117:3575-3584.