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Models of Care
Resolving the Impending Supply-Demand Imbalance in Cancer Survivorship Care: A Need for New Models Craig A. Bunnell, MD, MPH, MBA1; Lawrence N. Shulman, MD2 1 Assistant Professor, Associate Chief Medical Officer; 2Associate Professor, Chief Medical Officer, Dana-Farber Cancer Institute, Boston
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Physician and infusion visits per patient per year during first year of therapy
he future of cancer care is about to confront the laws of supply and demand—and the outcome remains uncertain. Although cancer incidence rates have fallen modestly over the past 15 years, the absolute number of people diagnosed with invasive cancer has continued to increase, owing largely to a growing population and its aging demographic. At the same time, early detection and improved therapies have resulted in declining mortality rates, leaving the absolute number of patients dying of cancer essentially unchanged, and the number of survivors increasing. Based on these trends, it is estimated that the number of living Americans with a history of cancer will increase by nearly 60%, from 11.4 million in 2005 to 18.2 million in 2020.1,2 Compounding the demands of this increasing number of cancer patients and survivors is the growing intensity and complexity of cancer care. Even previously worrisome estimates of the future projected number of cancer visits have failed to account for this increasing complexity, perhaps because these trends are difficult to predict and the data are not routinely collected or reported.2,3 The Dana-Farber Cancer Institute tracked these data and determined that from 2001 to 2009, the average number of physician visits per patient per year rose 28% during the first year of treatment and the number of infusion visits per patient during the first year of therapy increased by 147% [Lawrence N. Shulman, MD, personal communication, June 2010] (Figure). Given that ear-
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Physician visits
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Infusion visits
Craig A. Bunnell, MD, MPH, MBA
The expectation that ongoing follow-up care for cancer survivors might be transitioned to primary care physicians, allowing oncologists to care for patients undergoing active therapy, is grossly unrealistic. lier predictions that do not account for this increased complexity or intensity of care estimate an increase of more than 50% in the number of visits to medical oncologists by 2020, it seems likely that they underestimate future demand. Shortage of oncologists predicted Exacerbating the growing imbalance of demand is the impending diminished relative supply of medical oncologists to provide necessary cancer care. A study conducted by the Association of American Medical Colleges predicts a critical shortage of oncologists to care for patients within the next decade.4 Given that this estimate also did not account for
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the increasing complexity of oncologic care, it seems likely that the impending shortage will be realized earlier than expected. The expectation that ongoing follow-up care for cancer survivors might be transitioned to primary care physicians, allowing oncologists to care for patients undergoing active therapy, is grossly unrealistic. Much has been written about the current crisis in supply of primary care physicians and how the increasing demands and diminishing reimbursements are driving US medical students away from careers in family practice and internal medicine.5 Further, with US medical schools currently maintaining a near-zero growth rate in medical graduates, no coordinated strategy exists that is likely to produce a future supply of oncologists or primary care physicians sufficient to meet the needs of future cancer patients.6 Clearly, services currently provided by physicians will need to be provided by nonphysicians.7
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Year Adapted with permission from Dana-Farber Cancer Institute. Figure. Physician and Infusion Visits per Patient per Year During First Year of Therapy from 2001-2009
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Lawrence N. Shulman, MD
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Innovative models of care needed Novel, innovative models of care will need to be explored.8 Several cancer centers and practices are developing collaborative models of care using “physician extenders,” such as nurse practitioners, physician assistants, and clinical nurse specialists. Partnering with these extenders allows physicians to care for new patients and those with complex medical needs, while the extenders follow patients in treatment and provide survivorship care. Indeed in some centers, advanced practice nurses and physi-
cian assistants see patients independently and bill for their services. Such collaborative models are also being explored in survivorship clinics to assist in the transition from active treatment to follow-up care. Other areas of medicine, such as diabetes and cardiac care, have already explored such models. In these scenarios, patients meet with the extenders at the end of active treatment to receive a formal end-of-treatment summary and evidence-based follow-up care plan. These follow-up plans facilitate the transition from the oncologist to the primary care physician or to the longitudinal survivorship clinic and serve as a mechanism for the patient and the primary care provider to identify relevant issues and provide guidance regarding the appropriate follow-up for the patient’s specific cancer, its treatment, and the attendant medical risks. These and additional efforts to educate primary care physicians and primary care physician extenders about survivorship issues, and to cultivate relationships with primary care clinicians who have an interest in survivorship care, will also be critical to address the knowledge and coordination deficiencies accompanying the transition from active cancer treatment to ongoing follow-up. These efforts must eliminate duplicative care, increase efficiency, and maintain or improve medical outcomes. Only with forethought and the development of new and creative models of care, can we hope to provide for the needs and demands of future cancer patients. It will be critical, however, that these models be studied in a scientific manner to ensure that they accomplish their intended objectives. ● References 1. American Cancer Society. Cancer Facts & Figures 2010. Atlanta, GA: American Cancer Society; 2010. 2. Warren JL, Mariotto AB, Meekins A, et al. Current and future utilization of services from medical oncologists. J Clin Oncol. 2008;26:3242-3247. 3. Cooper RA. The medical oncology workforce: an economic and demographic assessment of the demand for medical oncologists and hematologist-oncologists to serve the adult population to the year 2020. November 2008. www.asco.org/ASCO/Downloads/Cancer%20 Research/Medical%20Oncology%20Workforce-Cooper %20Study.pdf. Accessed August 17, 2010. 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. Bodenheimer T. Primary care—will it survive? N Engl J Med. 2006;355:861-864. 6. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med. 2006;81:782-787. 7. Whitcomb ME. The shortage of physicians and the future role of nurses. Acad Med. 2006;81:779-780. 8. 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.
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