approach to translating evidence to care for cancer survivors · the survivorship care roundtable:...
TRANSCRIPT
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Integrating Agendas: A “Team Sports” Approach to Translating Evidence to Care for
Cancer Survivors
Catherine M. Alfano, PhDVice President, Survivorship
SBM Master Lecture April 2, 2016
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Estimated and projected number of cancer survivors in the United
States from 1977-2022 by years since diagnosis
0
2
4
6
8
10
12
14
16
18
20
1977 1982 1987 1992 1997 2002 2007 2012 2017 2022
Nu
mb
er i
n M
illi
on
s
Year
15+ years
10-<15 years
5-<10 years
1-<5 years
<1
de Moor et al, CEBP, 2013;22(4):561-70
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Cancer Survivorship Research &
Reports
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Cancer Survivors are at risk:
Chronic & Late Effects of Cancer
FatiguePain
LymphedemaSexual
Impairment
Incontinence
Depression, Anxiety
Uncertainty
Poor body image
Relationship changes
Job & Insurance problems
Financial burden
CVD
Recurrence/new cancers
Endocrine dysregulation
Obesity
Diabetes
Osteoporosis
Functional limitations
Disability
Poor Quality of Life
Neuropathy
+ Changes: purpose, priorities
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Oeffinger et al, N Engl J Med, 2006
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 5 10 15 20 25 30
Yrs. From Original Cancer Diagnosis
Cu
mu
lative
In
cid
en
ce Grade 1-5
Grade 3-5
Incidence of Chronic Health Conditions in 10,397
Adult Survivors of Childhood Cancer
Mean age of 26.6 years (18-48 years)
By 30 years post cancer:
• 73% survivors with at least one
chronic health condition
• 42% with a Grade 3-5 (severe,
life-threatening, death)
• 39% had >2 chronic health
conditions
Survivors – 8.2 times more likely to
have a severe or life threatening
condition compared to siblings
Childhood Cancer Survivor Study
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% with Limitations:
Survivors vs. General Population
Hewitt, Rowland, Yancik. J Gerontol. 58:82, 2003
Psych
Problems
1+
ADL/IADL
1+
Functional
Work
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Group Statistics Mask Individual
Differences
Vs…
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Projected Increase in US Cancer
Survivors by 2020
Parry et al, CEBP; 20(10) October 2011
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
18,000,000
20,000,000
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Nu
mb
er
of
ca
se
s
Year
65+
<65
42% ↑
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Baby Boomers & Expectations:
What a Difference a Generation Makes
THEN COMING SOON…
Old vs. New Definitions ofQuality of Life
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Delivering Survivorship Care
• Who should be responsible for survivorship
care?
Oeffinger & McCabe, JCO 2006
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Delivering Survivorship Care –Patient
Preferences
Hudson et al, Ann Fam Med 2012
• 52% survivors want follow-up care from cancer specialist
• Survivor concerns about PCPs:
• Lack of cancer expertise• Lack of involvement w
original cancer care• Lack of care continuity
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Delivering Survivorship Care
• Who should be
responsible for
survivorship care?
• Divergent perceptions
about who should
provide care for
survivors
Erikson et al., 2007, JOP
Potosky et al, JGIM 2011
Projected Shortage of Oncologists
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Delivering Survivorship Care
• Knowledge gaps among PCPs (& oncologists)
Potosky et al, JGIM 2011
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Costs of Cancer Care (US)
• $157.77 billion by 2020
• Survivorship excess medical costs: $25-48
billion
• Lost productivity among survivors: $8-16
billion
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Costs of Cancer Care (Survivors)
Survivors 2.65 X more likely to file bankruptcyRamsey, Medical Affairs, 2013
Bankruptcy among survivors: 1.79 X higher risk of mortalityRamsey, JCO, 2016
Yabroff, JCO, 2016
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Effective, Efficient Care
Doing the right things
Doing the right things right
Doing things
Doing things right
High EfficiencyLow Efficiency
Low Effectiveness
High EffectivenessEfficiency: Doing things rightEffectiveness: Doing the right things
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What Does “Doing the Right Things
Right” Look Like for Survivors?
• “Whole person” survivorship care focused on
creating healthy survivors
• Goal: Develop efficient pathways of care
– Keep people OUT of the healthcare system as much
as possible
– Intensity of care varies with need
– Prevent long-term problems to lighten load in primary
care
– Engage patients; Leverage technology
• Coordinate care
• Increase the VALUE of care (outcomes vs. cost)
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IOM 4 Pillars of Survivorship Care
• Surveillance
– Recurrence, 2nd cancers, late effects
• Intervention for treatment consequences
– Medical/psychosocial/economic
• Prevention of recurrence/new CAs, late
effects, new comorbidities, disability
• Coordination between PCP, ONC, and
specialists to ensure all needs are met
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• For comprehensive, patient-centered care
Screening, surveillance for new/recurrent cancers
Management of late/ long-term effects
Psychosocial, Rehabilitation, & Palliative Care
Specialist care (Cardiac, Endo, Ortho)
Prevention, lifestyle recommendations
Coordination of carePatient
&Family
Hematologist/Oncologist
ONC Nurse
Cancer Rehabilitation Team
Palliative Care Team
Psychologist/Psychiatrist
Social Worker
Pharmacist
Primary Care MD, PA, APRN
Dentist
Specialty providers (CV, Endo, Ortho)
Clinical Care Follow-up Guidelines
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• Prostate Cancer – Published online in CA Cancer J Clin on June 10, 2014.(www.bit.ly/ACSPrCa)
• Colorectal Cancer – Published online in CA Cancer J Clin on September 8, 2015. (bit.ly/acscolorc)
• Breast Cancer – Collaboratively developed and released with ASCO. Published online in CA Cancer J Clin and JCO on December 7, 2015. (bit.ly/BrCaCare)
• Head and Neck Cancer – Published online in CA Cancer J Clin March 22, 2016. (bit.ly/acsheadneck)
• Insufficient data to develop guidelines for other cancer sites at this time
Clinical Care Follow-up Guidelines
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Guidelines are Useless if We Cannot
Deliver Guideline-Consistent Care
Next Step:
How Do We DELIVER High-Quality
Survivorship Care?
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How Do We Get to the Future?
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Need Multi-modal, “Team Sport” Partnership Approach
Policy Makers
Clinical Educators
Healthcare Payers
Clinicians
Survivors & Families
Public Health, Community partners
Healthcare Administrators
Industry
ResearchersAdvocacy
Health IT, EHR vendors
Employers
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“Team Sport” Strategies to Improve Survivorship Care
Individualized Care Pathways
Legislative/Regulatory/Policy
Technology, Digital health, EHR innovation
Assessment, triage, & surveillance
Healthcare Delivery Innovation
Patient activation/empowerment
Provider Training
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1. Assessment, triage, and surveillance• “Precision medicine” Comprehensive Assessment of
Needs & Resources: Integrate molecular, genomic, cellular, physiological, clinical (w PROs), behavioral, and environmental data
• Risk-stratify into care pathways
•Modeling: supercomputer, systems science
• Repeat Assessments: Ongoing surveillance for survivors’ needs
WHO?
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2. Create individualized care pathways:
• Targeted: Identify what works for whom? Type & Dose? Especially older adults
• Feasible interventions (survivors & system)
• Assess outcomes: morbidity, referrals, costs, mortality; outcomes that matter to survivors
• Change the process of conducting research—improving communication, collaboration, evaluation, and feedback through partnerships w ALL stakeholders
WHO?: All
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Creating Better Research through Partnerships
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T3
T1
T2
T4
T0Technology
Multi-level
Analysis
Collaboration (Researchers,
Survivors, Clinicians,
Stakeholders)
The Translational Science Process for Survivorship
Modified from Lam et al; CEBP 2013; (22); 181-8
Survivor Population Health &
Disease Burden
Scientific Discovery
Promising Applications &Interventions
Evidence BasedRecommendations ,
Guidelinesor Policies
Programs in Practice,Organization, &
Community Settings
Describe
health outcomes& determinants
Mechanisms; Preclinical Studies;
Phase I & II trials
Evaluation of Interventions
(Phase III Trials)
Implementation &
Dissemination in real-world settings
Evaluating outcomes inreal-world settings
Knowledge
Integration
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Change our Thinking about “Outcomes” to Translate Science into Care• Differ with intended audience
• Providers: morbidity, mortality, referrals, clinic flow
• Survivors: morbidity, mortality, feasibility, out of pocket costs
• Payers: outcomes, costs, ROI
• Legislators & Regulators: new care model value & off-sets
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Collect Data to inform USPSTF*:• Intervention effects by symptoms, comorbidities
• Feasibility of referral from primary care
• Dose response for different outcomes
• Independent contribution of intervention components
• Adverse events/potential harms
• Use standardized measures to facilitate pooling
• Intervention effects on health outcomes, prognosis, intermediate markers
*Murray DM, Kaplan RM, Ngo-Metzger Q, et al. Enhancing Coordination Among the USPSTF, the AHRQ, and the NIH. American Journal of Preventive Medicine, 2015, Sept; 49 (3 Suppl 2), S166-73
*These same data will help make the case to other funders as well
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3. Patient Activation & Empowerment
• Help survivors self-manage health, become active participants in care = ↑ care efficiency, ↑ adherence, better outcomes
• mHEALTH tools, education, communication & decision making aids
• Workplace solutions
WHO?
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4. Provider Training
• Medical school education in survivorship (oncology, primary care, nursing, pharmacy)
• Hybrid practitioners (cardioncology, cancer rehabilitation, palliative care)
• Continuing education for existing workforce
WHO?
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E-Learning Series for Primary Care Providers
www.cancersurvivorshipcentereducation.org
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ASCO/Primary Care Training
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5. Healthcare Delivery Innovation
• Interventions: meet the IHI triple aim
• Improve referral, care coordination, & communication
• Develop tech, mHEALTH, EHR tools to facilitate guideline-consistent care delivery
WHO?
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6. Legislative, Regulatory, Policy Reform
• Legislative: Reform insurance coverage:
• Care coordination
• Care planning
• Survivorship care interventions
• Regulatory: Reform carrots & sticks
• CoC, ASCO QOPI
• Revise CMS Oncology Care Model (bundle) to optimize survivorship
WHO?
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6. Legislative, Regulatory, Policy Reform
WHO?
Policy
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Need Multi-modal, “Team Sport” Partnership Approach
How do we get everyone together?
Policy Makers
Clinical Educators
Healthcare Payers
Clinicians
Survivors & Families
Public Health, Community partners
Healthcare Administrators
Industry
ResearchersAdvocacy
Health IT, EHR vendors
Employers
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New National Initiative to Serve as “Coach”:
ACS & ASCO are founding:
The Survivorship Care Roundtable: •Bring together organizations with a stake in the care of cancer survivors
• Clinical groups, advocacy, industry, lifestyle change, payers, regulators, policy makers
•Overarching goal: enhancing delivery of survivorship care to meet survivors’ needs and keep them active and functional •Tackle agendas that no one organization can do alone
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The Survivorship Care Roundtable: Subgroups will tackle each of these collaborative agendas:• Assessment, triage, & surveillance• Individualized Care Pathways• Patient activation and empowerment• Provider training• Healthcare delivery innovation• Legislative, regulatory, policy reform
*All leveraging changing technology
New National Initiative to Serve as “Coach”:
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Understand Their Specific Motivators, Realities of their Business Model
• What will they get out of participation?
• ROI?
• Value added?
• Drivers are Different…
Engaging Stakeholders
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Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
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Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
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Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
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Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
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Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
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Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
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A Challenge Lies Before Us…
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THANK yOU,
DEB BOWEN
!!!!!!!
2016 SBM Distinguished Research Mentor Awardee
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CATHER INE. ALFANO@CANCER .ORG
THANK YOU !
CANCER.ORG 800-227-2345