1. Shared Care Models of Older Survivors of Cancer Beatriz Korc-Grodzicki, MD, PhD Memorial Sloan-Kettering Cancer Center Weill Cornel Medical College New York, NY MAY 14, 2015

2. OBJECTIVES Understand the shared role of the geriatrician/primary care provider with the cancer specialist in providing cancer care. Understand the shared role of the geriatrician/primary care provider with the cancer specialist in providing cancer care. Identify gaps in knowledge about shared-care Identify gaps in knowledge about shared-care Propose future studies to fill the gaps in knowledge in shared-care. Propose future studies to fill the gaps in knowledge in shared-care.

3. Cancer Survivorship and Aging Survivorship is a relatively new way of thinking about cancer. Survivorship is a relatively new way of thinking about cancer. Improved survival rates Cancer is a chronic disease Improved survival rates Cancer is a chronic disease “Survivor” includes “Survivor” includes Those who have lived for an extended period of time after treatment Those who have lived for an extended period of time after treatment Newly diagnosed individuals Newly diagnosed individuals Those who are in treatment, have completed treatment or are in remission Those who are in treatment, have completed treatment or are in remission NCI defines survivor as anyone who has been diagnosed with cancer

4. 18 Million Cancer Survivors Projected in 2022 The Majority of Cancer Survivors are Older Adults IOM. Delivering High Quality Cancer Care: Charting a new course for a system in crisis. http://www.io m.edu/reports /2013

5. CANCER SURVIVORSHIP AND AGING Studies of Long-Term Diagnosed Older Patients Cancer survivors have more comorbidities and poorer functioning (independent of comorbidities) than non-cancer survivors Cancer survivors have more comorbidities and poorer functioning (independent of comorbidities) than non-cancer survivors The effects of cancer due to age is more apparent The effects of cancer due to age is more apparent This may be the result of the late effects of cancer and its treatment, underlying risk factors or interaction of cancer and aging. This may be the result of the late effects of cancer and its treatment, underlying risk factors or interaction of cancer and aging. Avis et al. Cancer 2008;113 (12 suppl):3519-29 Avis et al. Cancer 2008;113 (12 suppl):3519-29

6. From Cancer Patient to Cancer Survivor: Lost in Transition. IOM 2005 Report Recommendations: www.iom.edu www.iom.edu 1. …..should work to raise awareness of the needs of cancer survivors, establish cancer survivorship as a distinct phase of cancer care, and act to ensure appropriate survivorship care.

7. From Cancer Patient to Cancer Survivor: Lost in Transition. IOM 2005 Cancer Survivor Care Planning Record of Care Record of Care Upon discharge from cancer treatment, including treatment of recurrences, every patient should be given a record of all care received and important disease characteristics Standards of Care Standards of Care Upon discharge from cancer treatment, every patient and their primary care provider should receive a written follow-up care plan incorporating available evidence-based standards of care.

8. SURVIVORSHIPCARE PLAN (SCP) Treatment summery Treatment summery Contact information of providers Contact information of providers Tumor type, stage, grade Tumor type, stage, grade Hormonal/markers info Hormonal/markers info Rx provided: Surgeries, chemotherapy (drugs, dates), radiotherapy Rx provided: Surgeries, chemotherapy (drugs, dates), radiotherapy Follow up care plan Follow up care plan Surveillance of recurrences or new cancer Surveillance of recurrences or new cancer Assessment and treatment of persistent effects and their management Assessment and treatment of persistent effects and their management Prevention of late effects Prevention of late effects Coordination of care Coordination of care

9. Associations among SCPs, experiences of survivorship care, and functioning in older breast cancer survivors: CALGB/Alliance 369901. Faul et al. J Cancer Surviv (2014)8:627-637 Only 35% of 328 women, >65, over 78 cooperative –group sites, with invasive non-metastatic breast cancer received SCPs. Only 35% of 328 women, >65, over 78 cooperative –group sites, with invasive non-metastatic breast cancer received SCPs. For each one year increase in age there was a 5% lower odds of receiving an SCP. For each one year increase in age there was a 5% lower odds of receiving an SCP. Besides age no other factors predicted SCPs. Besides age no other factors predicted SCPs. SCP receipt was associated with greater knowledge and understanding of requisite follow up SCP receipt was associated with greater knowledge and understanding of requisite follow up However it did not impact functioning one year post treatment. However it did not impact functioning one year post treatment. To impact functioning and other needs of older survivors, SCP should be tailored to geriatric specific issues: exercise, nutrition, polypharmacy, social support, comorbidities. To impact functioning and other needs of older survivors, SCP should be tailored to geriatric specific issues: exercise, nutrition, polypharmacy, social support, comorbidities.

10. Survivorship Issues for an Aging Population Rowland J and Bellizi K JCO 2014 SCP format SCP format Paper vs. electronic Paper vs. electronic Attention to survivor’s reading level Attention to survivor’s reading level Attention to font size for the visually impaired Attention to font size for the visually impaired Tailoring the document to include coexisting health problems Tailoring the document to include coexisting health problems Inclusion of geriatric assessment? Inclusion of geriatric assessment? Inclusion of the appropriate caregiver in SCP process Inclusion of the appropriate caregiver in SCP process Staff training in order to provide patient education that is culturally sensitive Staff training in order to provide patient education that is culturally sensitive Identification of the responsible individuals to deliver care Identification of the responsible individuals to deliver care

11. MODELS OF CANCER SURVIVORSHIP CARE

12. Community Physician Care of Breast Cancer Patients Community Physician MSKCC Breast Cancer Specialist (surgery, chemotherapy, radiation) MSKCC Survivorship Nurse Practitioner DiagnosisTreatment Early Follow up Survivorship Post Treatment Follow-up Long term Post Treatment Follow-up 2-5 yrs post treatment. The patient is provided a standardized care plan Recurrence Nurse Practitioner provides transition note to Internist : 10 yrs post treatment for t1,2 NO; 5 yrs for t1,2 NO triple- negative; 5 yrs for DCIS Nurse Practitioner provides transition note to Internist : 10 yrs post treatment for t1,2 NO; 5 yrs for t1,2 NO triple- negative; 5 yrs for DCIS

13. . Oeffinger K C, McCabe M S JCO 2006;24:5117-5124 ©2006 by American Society of Clinical Oncology Methods of Delivering Survivorship Care

14. A Model for the Shared Care of Elderly Patients with Cancer Harvey Jay Cohen, MD J Am Geriatr Soc 57:S300-S302, 2009.

15. MODELS OF CANCER SURVIVORSHIP CARE Models of Cancer Survivorship Care: Overview and Summary of Current Evidence Michael T. Halpern, MD, PhD, et al. Models of Cancer Survivorship Care: Overview and Summary of Current Evidence Michael T. Halpern, MD, PhD, et al. 2014 AHRQ Publication No. 14-EHC011-EF 2014 AHRQ Publication No. 14-EHC011-EF 2015 JANUARY 2015 jop.ascopubs.org 2015 JANUARY 2015 jop.ascopubs.org Conclusion: There is substantial variation in survivorship care models. The optimal nature, timing, intensity, format, and outcomes of survivorship care models are uncertain and require further research. Specific research questions need to be addressed by the survivorship community to better understand the advantages and limitations of survivorship models.

16. BARRIERS TO/CONCERNS ABOUT LONG-TERM CARE FOR CANCER SURVIVORS Inadequate training of health care providers Malpractice defense practice test ordering Preventive care concerns Lack of guidelines to address this population Inadequate knowledge of long-term effects, e.g: Surveillance for recurrences Potential side effects of treatments Unclear directions about providers’ responsibilities Financial incentives/disincentives Clinical information systems Lack or organizational support Lack of patient awareness Lack of patient interest/adherence with survivorship care programs Lack of provider knowledge regarding best processes for delivering coordinated care.

17. GAPS IN KNOWLEDGE Unclear added value/improved outcomes of developing “models of care” for older cancer survivors to add onto complex health care delivery systems Unclear added value/improved outcomes of developing “models of care” for older cancer survivors to add onto complex health care delivery systems Studies need to describe the model(s) being examined, providing detail information to assist comparing results of one study with those of other studies and assessing the generalizability of any one model Studies need to describe the model(s) being examined, providing detail information to assist comparing results of one study with those of other studies and assessing the generalizability of any one model Studies of survivorship care need to provide data on long- term or late effects of treatment received by older adults cancer patients Studies of survivorship care need to provide data on long- term or late effects of treatment received by older adults cancer patients There is a gap in understanding survivors’ needs especially in the aged and in the racial/ethnic minority populations There is a gap in understanding survivors’ needs especially in the aged and in the racial/ethnic minority populations

18. RESEARCH QUESTIONS What is a model of cancer survivorship care? How are they defined? What is a model of cancer survivorship care? How are they defined? What should constitute usual survivorship care? Is it different for the different cancers? Stage? Other patient characteristics? What should constitute usual survivorship care? Is it different for the different cancers? Stage? Other patient characteristics? Provide evidence of the advantage of using different models of care and effectiveness of different approaches to surveillance, and other patient-centered outcomes Provide evidence of the advantage of using different models of care and effectiveness of different approaches to surveillance, and other patient-centered outcomes What are the key elements to include in the SCP? What are the key elements to include in the SCP? Identify the organizational changes needed to deliver survivorship care. What contributes to organizational culture change to support survivorship care? Should it be imbedded in cancer care or provided as a separate service? Identify the organizational changes needed to deliver survivorship care. What contributes to organizational culture change to support survivorship care? Should it be imbedded in cancer care or provided as a separate service? Determine patient morbidity associated with follow up appointments, overuse and underuse of health care. Determine patient morbidity associated with follow up appointments, overuse and underuse of health care. Development of evidence-based follow-up guidelines Development of evidence-based follow-up guidelines Determine most effective ways to bridge the gap between oncologists and PCPs/Geriatricians Determine most effective ways to bridge the gap between oncologists and PCPs/Geriatricians Determine the unmet needs of geriatric cancer survivors over time Determine the unmet needs of geriatric cancer survivors over time How can awareness of survivorship programs be improved among survivors, caregivers, and clinicians? How can awareness of survivorship programs be improved among survivors, caregivers, and clinicians? Could a virtual patient navigator program facilitate transitions? What is the potential role of telemedicine? Could a virtual patient navigator program facilitate transitions? What is the potential role of telemedicine? What is the role of financial incentives? What is the role of financial incentives? How to optimize wellness in older survivors? Is there a role for self-management? How to optimize wellness in older survivors? Is there a role for self-management? What study designs are the most appropriate to evaluate survivorship programs? What are the key outcomes or endpoints to be evaluated? How should models be tailored to benefit the underserved, racial/ethnic minorities, low health literacy?

19. RESEARCH QUESTIONS What is a model of cancer survivorship care? How are they defined? What is a model of cancer survivorship care? How are they defined? What should constitute usual care? Is it different for the different cancers? Stage? Other patient characteristics? What should constitute usual care? Is it different for the different cancers? Stage? Other patient characteristics? Provide evidence of the advantage of using different models of care and effectiveness of different approaches to surveillance, and other patient-centered outcomes Provide evidence of the advantage of using different models of care and effectiveness of different approaches to surveillance, and other patient-centered outcomes What are the key elements to include in the SCP? What are the key elements to include in the SCP? Identify the organizational changes needed to deliver survivorship care. What contributes to organizational culture change to support survivorship care? Should it be imbedded in cancer care or provided as a separate service? Identify the organizational changes needed to deliver survivorship care. What contributes to organizational culture change to support survivorship care? Should it be imbedded in cancer care or provided as a separate service? Determine patient morbidity associated with follow up appointments, overuse and underuse of health care. Determine patient morbidity associated with follow up appointments, overuse and underuse of health care. Development of evidence-based follow-up guidelines Development of evidence-based follow-up guidelines Determine most effective ways to bridge the gap between oncologists and PCPs/Geriatricians Determine most effective ways to bridge the gap between oncologists and PCPs/Geriatricians Determine the unmet needs of geriatric cancer survivors over time Determine the unmet needs of geriatric cancer survivors over time How can awareness of survivorship programs be improved among survivors, caregivers, and clinicians? How can awareness of survivorship programs be improved among survivors, caregivers, and clinicians? Could a virtual patient navigator program facilitate transitions? What is the potential role of telemedicine? Could a virtual patient navigator program facilitate transitions? What is the potential role of telemedicine? What is the role of financial incentives? What is the role of financial incentives? How to optimize wellness in older survivors? Is there a role for self-management? How to optimize wellness in older survivors? Is there a role for self-management? What study designs are the most appropriate to evaluate survivorship programs? What are the key outcomes or endpoints to be evaluated? What study designs are the most appropriate to evaluate survivorship programs? What are the key outcomes or endpoints to be evaluated? How should models be tailored to benefit the underserved, racial/ethnic minorities, low health literacy?

20. CURRENT GUIDELINES FOR SURVIVORSHIP CARE NCCN Transitioning Patients With Cancer © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 12 Number 12 | December 2014 NCCN Transitioning Patients With Cancer © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 12 Number 12 | December 2014 ACS CA Cancer J Clin. 2014 Jul-Aug;64(4):225-49. doi: 10.3322/caac.21234. Epub 2014 Jun 10. ACS CA Cancer J Clin. 2014 Jul-Aug;64(4):225-49. doi: 10.3322/caac.21234. Epub 2014 Jun 10. CA Cancer J Clin. CA Cancer J Clin. ASCO Cancer Survivorship Committee. ASCO Cancer Survivorship Committee. Society of Gynecologic Oncology Society of Gynecologic Oncology Calling for AGS involvement in the development of geriatric-specific guidelines for survivorship care

21. Providing Care to the Older Cancer Survivor Rao and Demark-Wahnefried. Critical Reviews in Hematology/Oncology 60 (2006) 131-143 “The older cancer patient/survivor may present us with an exceptional opportunity to target primary, secondary and tertiary prevention strategies, capable of effecting beneficial outcomes for a broad spectrum of diseases and conditions that not only include cancer, but cardiovascular disease, osteoporosis, functional decline, cognitive decline, psychological wellbeing and overall quality of life”.. THANK YOU