low-up services concluded that there is insufficient primary empirical evidence on which to draw broad conclusions regarding best practice for breast cancer follow-up in terms of patient involvement in care, reductions in morbidity, and cost-effectiveness of service provision (Collins et al., 2004).

Some promising models of follow-up care have emerged, including a shared-care model that integrates oncology with primary care follow-up, a nurse-led model of care, and specialized multidisciplinary survivorship follow-up clinics. Relatively little is known regarding cancer survivors’ preferences for care, but there is a growing recognition of the need for flexible options for survivors who may have different needs and circumstances (Koinberg et al., 2002).

Shared-Care Model of Follow-up Care

Shared care has been defined as “care which applies when the responsibility for the health care of the patient is shared between individuals or teams who are part of separate organizations, or where substantial organizational boundaries exist” (Pritchard and Hughes, 1995). Such a model implies personal communication and organized transfer of knowledge from specialists to primary care practitioners as well as patient involvement (Nielsen et al., 2003). Cancer patients may face several care transitions, for example, from their active treatment phase, to survivorship care, to care for a recurrence, and finally to palliative and end-of-life care. With such transitions, the focus of care can shift toward specialty care or toward primary care. When the shift is toward primary care, a smooth transition is more likely when the primary care physician receives relevant and timely information from cancer specialists (Braun et al., 2003).

Primary care physicians are actively providing cancer-related care according to ambulatory care surveys of U.S. office-based and hospital-based physicians. Of all the cancer-related visits that were made to physicians’ offices in 2001 and 2002, nearly one-third (32 percent) were made to primary care physicians (Table 4-2). Relatively fewer such visits were made to oncologists (18 percent). Cancer-related primary care visits were somewhat more common when they were for prostate cancer and lung cancer, which may indicate primary care providers’ active role in symptom management, palliative care, and end-of-life care.

The role of the primary care clinician in the shared-care model is to ensure that all of the physical and emotional health needs of the patient are addressed, to assume responsibility for aspects of care of the chronic disease that are feasible in the primary care setting, to refer the patient to specialists for periodic reevaluations and to address issues that require focused expertise, and to consult with specialists on areas of uncertainty. The role of the



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