2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Planning for the Future: The Role of Nurse
Practitioners and Physician Assistants in
Survivorship Care
By Mary S. McCabe, RN, MA, and Todd Alan Pickard, PA-C, MMSc
Overview: The number of cancer survivors in the United
States now approaches 12 million individuals, with an estimated
7.2% of the general population aged 18 years or older
reporting a previous cancer diagnosis. These figures highlight
a number of questions about the care of survivors—how
patients at risk for a known set of health problems should be
followed, by whom, and for how long. At the same time that
oncologists are developing strategies to provide services to
this growing population, there are economic and systems
challenges that have relevance to the previous questions,
including a predicted national shortage of physicians to provide
oncology services. Nurse practitioners (NPs) and physician
assistants (PAs) have been identified as members of the
AS A RESULT of the ongoing advances in early detection
and treatment, the number of cancer survivors in
the United States now approaches 12 million individuals,
with an estimated 7.2% of the general population aged 18
years or older reporting a previous cancer diagnosis. 1,2 The
5-year relative survival rate for adult cancer survivors has
reached 67%, with the largest number of survivors having
been treated for breast, prostate, and colorectal cancers. 2
These optimistic figures also highlight the challenges and
opportunities facing the oncology community as we work to
make survivorship a formal period of care. Such a focus
requires not only appropriate surveillance for recurrence,
but also the comprehensive rehabilitation of the posttreatment
patient: 1) follow-up medical care tailored to the
problems of specific populations, 2) psychosocial support,
and 3) health promotion education that includes diet, exercise,
and screening for new primary cancers. These core
services are coupled together with the imperative that we
share the care of these individuals with their community
primary care physician (PCP), thus assuring a coordination
of care that leads to effective communication and improved
quality of life for cancer survivors (Sidebar 1).
In 2005, the Institute of Medicine issued a seminal report,
From Cancer Patient to Cancer Survivor: Lost in Transition,
which served as an early guide to the development of
survivorship-specific services and models of care. 3 It was the
first comprehensive proposal detailing the follow-up care
needs of survivors and the novel provider arrangements that
could be implemented to provide these services. This report,
and others that followed, refocused our thinking about how
survivorship care can and should be delivered. Initially,
survivorship research focused on the long-term consequences
of cancer therapy in the pediatric cancer survivor,
in particular the serious morbidity and premature mortality
resulting from exposure to radiation and chemotherapeutic
agents in developing organs and normal tissue. And now,
over the past 10 years, research has increasingly focused on
the long-term and late effects experienced by individuals
treated for adult-onset cancers as well. 4,5,6 Traditionally,
the follow-up care of the survivor of an adult-onset cancer
was primarily focused on an evaluation of recurrence, but
this single focus is insufficient. We now know that survivors
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health care team who can help reduce the oncology supply and
demand gap in a number of ways. The ASCO Study of Collaborative
Practice Arrangements (SCPA) in 2011 concluded that
oncology patients were aware and satisfied when their care
was provided by NPs and PAs; there was an increase in
productivity in practices that utilized NPs and PAs; utilizing
the full scope of practice of NPs and PAs was financially
advantageous; and, physicians, NPs, and PAs are highly satisfied
with their collaborative practices. Increasingly, the
oncology and health policy literature contains evidence supporting
innovative provider models. There is still much work to
be done to move beyond pilot data to establish the true value
of these models.
face a variety of health risks that are dependent on treatment
exposures, genetic predisposition, comorbid health
conditions, and lifestyle behaviors and that the identified
issues cross multiple domains, including the medical, psychological,
and social. 7,8,9,10 Because breast cancer survivors
are the most widely studied group to date, they serve as an
excellent example of the range of late effects a survivor can
face. Medical late effects include anthracycline-related cardiomyopathy,
osteoporosis, cognitive dysfunction, and infertility;
psychological effects include fear of recurrence, sexual
dysfunction, and fatigue; and, social issues relate to return
to work and changes in role functioning. These examples
raise the question of how patients at risk for a known set of
health problems should be followed, by whom, and for how
long. At the same time that oncologists are developing
strategies to provide services to this growing population—
formally extending oncology care through the survivorship
period—there are other economic and systems challenges
that have relevance to the previous questions.
Drivers of Workforce Change
There are a number of factors in the U.S. health care
system today that will affect the ability for oncology physicians
to provide care for patients with cancer. The growing
population of individuals over the age of 65 with an increasing
incidence of cancer is a significant driver for an increasing
demand for oncology care. 11 The improvement in cancer
therapies and the resulting reduction in mortality rates
mean that there will be an increase in the number of years
that a patient will live with cancer through all phases of
the disease. Essentially, there will be a larger population of
individuals diagnosed with cancer, and they are likely to live
longer with the disease. This drives the increased demand
From the Memorial Sloan-Kettering Cancer Center and University of Texas M. D.
Anderson Cancer Center.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests Mary S. McCabe, 1275 York Avenue, New York, NY 10065;
email: mccabem@mskcc.org.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10