Cancer as a Chronic Condition Implications for Practice

Articles on cancer as a chronic condition often include an account of a patient's journey from diagnosis to present day. The patient describes a range of emotions--from disbelief, to helplessness, to outright panic--upon hearing the word "cancer," which has often been equated with a death sentence. A poor prognosis adds insult to injury, as the patient attempts to grasp the reality of a future laid out in terms of 5-year survival rates. Life then becomes focused solely on the fight ahead, as the patient and his or her loved ones deal not only with the disease and its life-and-death implications but also with the adverse effects of treatment. As one treatment fails, another becomes available, and hope and empowerment give way to helplessness and despair, and again to hope.

The account ends not with a cure or with death but with a "new normal" the patient hadn't expected: namely, the realization that his or her cancer, while not curable, has become a chronic condition to be managed and controlled.

While this may not be the case for all cancers, the scenario described above represents a growing subset of patients whose disease has become largely manageable over the long term. Indeed, the past 10 to 20 years has witnessed a very real acceleration in the advances that are rendering many forms of cancer as chronic conditions manageable with continuing surveillance and/or treatment. This is allowing patients to live months or years longer than was the case only a generation ago.

To the patient, this "new normal" is nothing less than life changing. But what does it mean to the oncologist and to the practice of oncology today and in the future?

The New Normal Explained

While no one would argue that a cure remains the ultimate goal for oncologists and their patients, "there's no question that long-term control of cancer is becoming a reality," said Edward Partridge, MD, National Volunteer President for the American Cancer Society and director of the UAB Comprehensive Cancer Center in Birmingham, Alabama. This is true especially for solid metastatic colorectal, breast, and head and neck cancers, and, to some extent, lung and ovarian tumors, he said.

Those wanting to understand how this upward trend in survivorship and the resulting conversion to chronic status affect the practice of oncology must first comprehend the reasons for the phenomenon, which are both varied and interrelated. Thanks to a growing number of clinical trials, patients with metastatic disease have access to more therapeutic options than ever before, with secondand third-line treatments now available for cancers where only single therapy was offered a few years ago. This has broadened the field of effective agents available to a wider patient population, while providing individual patients with more opportunities to achieve disease control after standard treatments fail. Described as the hitchhiker model,¹ this phenomenon essentially buys time for the patient, who lives longer by undergoing 1 treatment until its effectiveness wanes and then moving on to another. (See "The Hitchhiker Model at Work" sidebar.) The hope is that the patient will live long enough to benefit from the approval of another effective treatment, enrollment in a promising trial, or even a cure.

The hitchhiker model also can be seen at work in the new and more effective agents that make their way from research into clinical practice. The advent of these agents can be attributed directly to a rapidly expanding knowledge of cancer's molecular roots.¹ Targeted therapies, such as the tyrosine kinase inhibitors, serve as an excellent example and are now playing a critical role in the management of many cancers. Because these agents, which interfere with specific molecular pathways to cancer, are less toxic and better tolerated than traditional chemotherapeutic agents, they can be administered for longer durations, allowing patients to reap the benefits of newer and more effective treatment modalities that come down the pipeline. Similarly, the proteasome inhibitor bortezomib, approved in 2003, has produced complete remission in some patients with multiple myeloma, once again buying the time needed to take advantage of additional treatment options as they become available.

With these ongoing advances and their improved symptom control, a patient's life can be extended for a number of years without achieving a complete cure. "With intermittent or ongoing treatment, patients can live with either persistent or stable disease, or can undergo new and potentially more effective treatment upon relapse--turning malignancy into a chronic process," said Partridge.

The Oncologist's-Eye View: A Welcome Problem

Despite this good news, the reality of cancer as a chronic condition poses some very real challenges to the practitioners caring for the growing population of cancer survivors. Oncology practices have always had a steady stream of new patients arriving at the "front end" for initial treatment. Historically, there have been 2 ways in which a practice's patient numbers could be reduced to make room for new patients: treatment is successful and patients deemed "cured" are referred back to their primary care physicians, or patients succumb to their disease during treatment. More recently, however, oncologists have been faced with the new and welcome "problem" of how best to manage the needs of the growing number of patients who, while not cured of their cancer, still require ongoing oncologyrelated services.

As a gynecologic oncologist in practice for 30 years, Partridge noted that he typically has a good sense of which patients will fall into this category after the initial visit. "Once a treatment plan has been agreed upon, we"re generally able to assign a statistical probability to the likelihood that a particular treatment will be curative for a particular patient group," he said. This, Partridge explained, is based on the oncologist's understanding that newly diagnosed patients will typically fall into 1 of 3 groups. The first group consists of patients who are likely to emerge from treatment free of clinical disease and remain so for the rest of their lives. It is, however, those in the second and third groups whose cancers have the potential to be converted into chronic processes. These are patients whose initial treatment is successful but for whom there is a reasonable probability of recurrence and need for further treatment, and patients who still have clinical disease despite initial treatment.

The patients whose disease is most likely to become manageable long-term are those whose cancer recurs 1, 2, or even 5 years after successful initial treatment, said Partridge. "These individuals can often be retreated with some reasonable expectation that such retreatment will lead them back to remission or to a 'quiet stage' marked by nonproliferation of cancer cells." At some later point, these patients might be treated with nontoxic therapies, such as biologic-response modifiers, or might simply be followed and retreated only if necessitated by a recurrence. "Conversion to a chronic process is more difficult in patients who emerge from initial treatment with clinical evidence of disease, putting us in the position of needing to play catch-up," said Partridge. "But once that conversion takes place, patients require a new and comprehensive set of services."

The Case for Physician Extenders

The emergence of cancer survivorship programs is testament to the importance of addressing the needs of the more than 11 million cancer survivors in the United States today, and of effectively following and caring for the growing number of patients who are not on active treatment but still require oncology-related services. Thanks to a $4.25 million Centers for Disease Control grant, the American Cancer Society and the GW Cancer Institute have teamed up to establish the National Cancer Survivorship Resource Center.² The 5-year grant will enable the 2 groups to "collaboratively guide national progress toward improved health outcomes for cancer survivors and to develop a strategic plan for enhancing nationwide surveillance of cancer survivors." A key element of the initiative is to identify gaps in survivorship and to identify indicators and criteria to assess the effectiveness of survivorship programs and activities already in place.

According to Partridge, a critical component to the success of these survivorship programs is the use of nonphysician clinicians, known as physician extenders. "For patients who are not currently undergoing active treatment but who are dealing with major treatment-related issues (eg, difficulty swallowing, colostomies, pulmonary fibrosis, neuropathy, etc.), care would be referred to nononcologist physicians and nonphysician practitioners already well trained and equipped to deal with these issues." The same would be true of patients who may not be experiencing ill effects from treatment but may require ongoing surveillance. This, he explained, would essentially allow oncologists to make room for the continuing influx of new patients while putting long-term management in the hands of those best qualified to provide needed services. "As oncologists, our main areas of expertise are those that relate to primary treatment of new cancers and recurrences rather than the management of treatment-related issues," he said. "Physician extenders such as nurse practitioners and physician assistants are already well positioned to take on these roles, often with no more than a bit of on-the-job training. The oncologist's expertise isn't needed again unless and until there's a recurrence."

Nurse practitioners already conduct newpatient intake and perform much of the posttreatment follow-up at UAB's Cancer Center, where a comprehensive program employing physician extenders for long-term cancer survivors is in the planning stages. Moreover, many of the larger cancer centers already have such services in place for palliative and supportive care.

"Our hope is to eventually have a program in which every patient who has completed initial therapy and is either experiencing complications or is complication-free will then enter a supportive and palliative program manned by specially trained physicians and physician extenders," said Partridge. Such a program would be equipped to deal not only with the management of major medical symptoms, but also with a broad range of quality-of-life and psychosocial issues, offering everything from yoga and massage to music therapy.

Despite the proposed changes outlined above, Partridge noted that there are some tasks that should remain the domain of the oncologist. Chief among these tasks--or, more appropriately, privileges--are the end-of-life discussions so familiar to oncologists, who are uniquely qualified to see patients and their loved ones through the series of difficult decisions. "Oncologists have been having these discussions with their patients for hundreds of years," said Partridge. "And while we now have more and better tools at our disposal than ever before, treatments still fail and heart-wrenching decisions need to be made."

Future Outlook: Promise and Challenges

The use of physician extenders is not new to medicine in general but is relatively new to the practice of oncology. "I can't conceive of another solution," said Partridge, "especially when you consider all the factors that are currently converging together." Among the factors that appear set for a collision course are the nation's aging population, the increasing number of patients living with cancer as a chronic condition, and the infusion into the system of new patients when and if healthcare reform becomes a reality. This last factor not only promises to add another 30 million individuals to the ranks of the insured (and, therefore, to those able to access needed care), it also places unprecedented importance on prevention and early detection, much of which can be accomplished by nonphysician practitioners. To this equation Partridge added a shortage of oncologists, further underscoring the need for a model that places emphasis on the use of physician extenders.

Viewing the matter from a financial viewpoint, Partridge noted that it is primary treatment, not follow-up care, that is the oncologist's main source of income. Not surprisingly, issues related to reimbursement are, and will likely remain, at the forefront of the challenges faced by those attempting to implement such programs. Currently, reimbursement for nonphysician services is inconsistent across the country. In some states, for example, nurse practitioners and physician assistants are able to perform somewhat independently, while in others, services performed by nonphysicians, such as placement of a central line or insertion of a chest tube, are reimbursed only when performed under the supervision of a physician and within the same facility. "At UAB, roughly half of these services are billable and half aren't" said Partridge. Until reimbursement policies start to compensate physician practices for the follow-up services they provide to cancer survivors, many cancer centers are now viewing philanthropic funds as a critical and substantial need to support their operating costs.

Despite the unresolved reimbursement issues, Partridge remains optimistic. He said, "It's difficult today to find anyone who hasn't been touched by cancer in some way. This unfortunate reality has a positive side effect in that most people are willing to support causes that have the potential to improve the lives of those affected by the disease." As budgets continue to tighten, this is good news for cancer centers that must now rely on philanthropy to a greater extent than ever before, and provides some incentive for adopting new and creative approaches toward making the changes needed to meet upcoming challenges.

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Laura Bruck is a Cleveland, Ohio-based freelance writer and editor who has specialized in healthcare reporting since 1987.

References

1. Witter DC, LeBas J. Cancer as a chronic disease. OncoLog; 2008. April;53(4):1-3.

2. American Cancer Society and GW Cancer Institute awarded federal grant to establish National Cancer Survivorship Resource Center [press release]. Washington, DC: PRNewswire; October 1, 2010.

Published in Oncology & Biotech News. February 2011.