Addressing the Needs of Millions of Cancer Survivors

Host, Dr. John Sweetenham, associate director of Clinical Affairs at UT Southwestern Harold C. Simmons Comprehensive Cancer Center, and Dr. Keith Argenbright, medical director of the Moncrief Cancer Institute, a non-profit, community-based cancer prevention and support center, discuss models of survivorship care, and likely challenges in addressing the needs of a growing population of survivors.  Dr. Argenbright is also the chief of Community Health Sciences at UT Southwestern Medical Center.   Transcript:     Dr. John Sweetenham: Hello, I'm John Sweetenham the associate director for Clinical Affairs at UT Southwestern Harold C. Simmons Comprehensive Cancer Center and host of the ASCO Daily News Podcast. The number of cancer survivors in the United States is increasing each year, and this is a reflection of advances in cancer prevention and screening, as well as in cancer treatment. And the National Cancer Institute now estimates that there will be more than 22 million cancer survivors in the U.S. by the year 2030.     Joining us to discuss the future challenges of providing care for this growing population is Dr. Keith Argenbright. He is the director of the Moncrief Cancer Institute in Fort Worth, and a professor at the UT Southwestern Simmons Comprehensive Cancer Center, and a colleague and friend of mine.     My guest and I have no conflicts relating to our topic today. Our full disclosures are available in the show notes, and disclosures of all guests on the podcast can be found in our transcripts at asco.org/podcasts.     Keith, thanks for being on the podcast today.    Dr. Keith Argenbright: Thank you for having me, John.    Dr. John Sweetenham: So, the growing population of cancer survivors presents major challenges for providers, health care systems, and other stakeholders. Could you talk to us a little about models of survivorship care that you think could potentially meet the challenges of caring for millions of survivors in the future?    Dr. Keith Argenbright: Of course. I guess I'll start that response by recalling a meeting that I was at back in the 2008, 2009 timeframe, more than 10 years ago. And it was held in Washington D.C. and sponsored by Livestrong. And I think that that was the question that we were asking ourselves 10 plus years ago. What are these models going to look like to meet the challenge of the millions of cancer survivors in the future? And in some way, I think we've come a long way, and in other ways, I'm not so sure we have. Right now, I think we think of cancer survivorship maybe being delivered at an academic medical center and a structured model, maybe being delivered by a community physician in an informal way.    I think that 1 thing that is for certain is that the models of care are going to reflect the reality on the ground. And that there won't be 1 single model of survivorship, but there will be multiple models of survivorship that are created at the local level that understand the resources as well as resource limitations for any given community, for any given oncology practice, for any given group of survivors. And I think that that was probably a conclusion that we reached 10 years ago. And I think that that still holds true now as well as in the future.    Dr. John Sweetenham: Thanks, Keith. So obviously to your point, there are many models of survivorship and there clearly is not going to be a kind of 1 size fits all approach to how we address cancer survivorship. And maybe just to backtrack a little, 1 of the things that I should have said at the beginning of the podcast is that, although it's perhaps a little bit cliche to say this, I do think that now there is a widespread acceptance that cancer survivorship care begins from the day of diagnosis, and isn't something which kind of kicks in once cancer treatment is over. And to that point, I know that 1 of the models that you have adopted in Fort Worth has been to embrace primary care practice into the cancer center to assist with the survivorship and supportive care of patients. Could you just say a little bit about that model and talk to us a little about what you've experienced so far?    Dr. Keith Argenbright: Yeah, for sure. And to your earlier point, we've made great strides in actually recognizing the value of survivorship. And I don't want to dismiss that. I recall again thinking back 10, 15 years ago, I think that a lot of us thought, "Well if you're cured, that's great. And so that's the end of our responsibility." And I think that the medical community and the oncology community have realized that a lot of these cures come at a price and we're recognizing that price in the form of survivorship and survivorship care. So I don't want to neglect the fact that I think that we've come a long way in a very short period of time in embracing the idea of survivorship. What we are doing at Moncrief Cancer Institute is we're bringing in additional specialties into the survivorship milieu.   We talked about the numbers I think a little bit earlier in the podcast. Something like 17 million cancer survivors now with 13,000 practicing oncologists—there's just no way that our oncologists can or that they have the bandwidth, nor are they expected to be the only ones providing survivorship care.    What we did here at Moncrief and at UT Southwestern is we are bringing in different clinical specialties to assist in this team-based approach to survivorship care. And that's been led by our family and community medicine department which has established a primary care clinic in our cancer center for cancer survivors. Patients with cancer are introduced to these practitioners very early in their treatment cycles. Sometimes in their first or second visit with their oncologist here. We will also introduce them to the primary care physician who might be taking care of them at the end of their treatment, even though that might not be for another 6 to 12 months. It's been very well received. Cancer survivors a lot of times don't even have a primary care physician, to begin with. And so sometimes this is their first experience with a true primary care physician.    Oftentimes the primary care physician is able to look more comprehensively at some of the other issues that may or may not be cancer-related. It's been very well received. We bring in other specialties as well, physical medicine, rehabilitation, cardiology, psychiatry, and psychology. So it's something that we've been doing now for about a year. And we're very excited about the promise for a model like this in the future. Again, not all cancer centers or community practices have the ability to do this type of program but we're fortunate that we are. And hopefully, others will be able to take pieces of what we're doing and find them relevant and replicable in their situation.    Dr. John Sweetenham: Yeah. Thanks, Keith. And I do agree. I think it's a great innovation. And your comments pick up on another very important point and that's the workforce issue, which I think we're challenged with. Because of course, with an anticipated 22 million cancer survivors by the end of the decade, we are going to need a significantly expanded workforce of health care professionals of various types to work with these patients. And in addition to that, of course, we're going to need to be able to deliver care in community settings. It can't all be done in big health systems and academic oncology centers. So accepting that that will be the case and that we are going to need to develop community-based cancer survivorship services, what do you think are going to be the most challenging aspects of building those services and sustaining them out in the community rather than in big centers?    Dr. Keith Argenbright: Funding and reimbursement is always a challenge, right?    Dr. John Sweetenham: Right.    Dr. Keith Argenbright: A lot of these survivorship services, a medical visit with a practitioner, for instance, a visit with a psychologist or a psychiatrist regarding mental and behavioral health issues are reimbursable. But a lot of the things that we hear from our patients that they find most valuable in a survivorship program are not reimbursable. And I'm talking about things like nutritional programs, not just nutritional education, but an actual nutritional demonstration in cooking classes. Exercise programs are not currently reimbursable. The ability to speak with a financial counselor regarding the financial strain that has been placed on the patient with cancer and their family regarding the toxicity that they're left with after their cancer treatment. So these continue to be challenges for us, and I'm sure for the listeners of the podcast as well. These are challenges that are not easily overcome.    We are fortunate that we have some philanthropic partners who support a lot of our programs, not everyone is as fortunate as that. So that's one of the barriers. One of the things though, John, that I'm really encouraged about is the new and innovative ways that we've been able to use telemedicine and video conferencing throughout the pandemic. I personally have been amazed at how quickly our providers and our patients have adapted to telehealth, telemedicine, and video visits. In our survivorship care, we've taken that to the next level and have delivered a lot of our survivorship care services through Zoom and other video and electronic means. And this has just been a game-changer for us, as well as the patients. A lot of our patients travel a great distance to us to get cancer care chemotherapy, for example, and there's no way to deliver that remotely.    But we've become pretty adept at learning how to deliver a lot of this survivorship care by Zoom and a teleconference, and the patients just love it. They don't have to make the commute, they don't have to deal with our parking situation. So we're continuing to explore not only other ways and other cancer survivorship services to deliver through video and through remote means. But also, how to actually bring the team together so that it's not just the patient who is having a visit with a physician, but maybe the patient has a visit with the physician along with a nurse navigator, along with an exercise specialist altogether in real-time. And it's something that we're really excited about and exploring actively right now.    Dr. John Sweetenham: Yeah. Thanks, Keith. And in fact, that sort of dovetails into the next question I had for you. And I think you've partially answered that. But I'd just like to extend that theme, that sort of telehealth and new innovations theme a little bit further if we can. Obviously, as our patients are living longer, we need better supportive care strategies for them because of the many experiences that they're going to confront. And you've already mentioned a number of those; infections, neuropathy, depression, [and] the financial stresses that they're going to encounter. And I think, as you point out, the telehealth opportunities have really been a tremendous innovation in helping us to deliver that care. In addition to that though, there clearly are many other aspects of cancer survival, which can impact a patient's wellbeing and compromise their adherence to long-term cancer treatments and subsequent follow-up. And we need other ways of influencing wellness and healthy behaviors both during and after treatment.    So, in addition to the innovations that you've already mentioned of telehealth in our direct health care provider to patient interactions, do you see anything on the horizon in terms of technology or anything else, which is going to help us in the professional-to-professional communication space? And I guess what I'm thinking of particularly, is in making sure that our health care professional colleagues, let's say out in the community, are fully clued in, in terms of likely cancer recurrence, [and] what they should be looking for. They will all know which wellness and healthy behaviors they should be encouraging, but really in terms of providing some additional support and education for health care professionals in the community with respect to the needs of our cancer survivors.    Dr. Keith Argenbright: Yeah. Great question. And I want to circle back to what we spoke about earlier about this primary care physician clinic or this primary care clinic being embedded within our current cancer center. In working with our family medicine and internal medicine colleagues, when we developed this, we realized that not only is this a great opportunity for our survivorship patients, not only is a great opportunity for our current oncologist to offload some of the survivorship care to a primary care clinic, this is a great professional education opportunity. This is still a young program and it's got a long way to go before it matures. But pretty quickly, we're going to start bringing some of our medical students, some of our family medicine residents into this clinic, because they need to know more about the long-term effects of the medications. John, we're all learning about these new medications, right?    The CAR T therapies, the tyrosine kinase inhibitors, the antibody, we're all learning about this. And it's a focus of current oncology education so that the oncologist will understand these side effects and these late-term effects. We need to expand that education to our medical students, our residents, as well as in our community primary care physicians as well. As you know, I'm a primary care physician by training. And some of these drugs are very frightening to primary care providers because the oncologists are around these medications all the time, but not so much the primary care physicians.    And so, we need to educate our primary care physicians, both at the beginning of their training, as well as throughout their training to understand the medications better, understand the side effects better, understand what they are able to take care of themselves in their own primary care clinics, what they need to be able to refer back either to an oncologist or potentially a cardiologist. So I know that ASCO is very interested in working with some of the other professional family medicine and internal medicine and pediatric societies in order to expand this education into the providers. And I think we need to continue to look at that and continue to have that our focus.    Dr. John Sweetenham: Thanks, Keith. I think because as you were speaking, the other thing that does occur to me is, of course, that the communication piece, it's going to be so important that it's very much a two-way street. Because as you pointed out with a lot of these newer treatments, checkpoint inhibitors, and so on, we're going to see new toxicities, long-term toxicities emerge, one would anticipate, over the coming months and years. And making sure that there is two-way communication as community-based health care providers start to see some of these toxicities emerge, and making sure that we collect these data and ensure that we are keeping a very close eye on how this develops is going to be really important. So, I think two-way communication is going to be key.    So, Keith, we, I think are just about at the end of our time. Thank you very much for coming onto the podcast today and sharing your insights on models of care of cancer survivorship. I think although we have many challenges ahead, as we try to support our patients and design care models for them in the future, I think maybe the take-home message has to be that we are in, I think in many ways, the fortunate position of being able to have this discussion because we have so many more cancer survivors than we had some years back. So greatly appreciate your thoughts today. And thanks again for joining.    Dr. Keith Argenbright: My pleasure. Thank you, John.    Dr. John Sweetenham: And thank you to our listeners for your time today. If you enjoyed this episode, please take a moment to rate and review us wherever you get your podcasts.    Disclosures:  Dr. John Sweetenham:   Consulting or Advisory Role: EMA Wellness  Dr. Keith Argenbright: None disclosed.  Disclaimer:   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.