5
Providers of Survivorship Care: Their Supply and Education and Training

With the number of cancer survivors in the United States at 10 million and expected to increase, concerns have arisen about the supply of adequately trained health professionals to provide survivorship care. This chapter enumerates providers of survivorship care and then reviews the inclusion of survivorship content in the educational and training programs of selected health professionals involved in survivorship care. Support for professional education and training in survivorship is then described. Finally, the committee puts forth its recommendations to improve the capacity of the survivorship workforce.

SUPPLY OF SURVIVORSHIP CARE PROVIDERS

Survivorship care is by nature multidisciplinary and ideally provided using a team approach. Physicians are the likely coordinators of survivorship care, but as a National Cancer Institute (NCI) Fact Sheet describing the cancer health care team informs consumers, “Your Doctor Is Only the Beginning” (NCI, 2000). Physicians and nurses are often links to many other important care providers, including those in the areas of social work, psychology, rehabilitation, and genetic counseling.

Using the best available data on the supply of health personnel, an attempt is made in Tables 5-1 and 5-2 to assess the availability of selected providers of survivorship care. Table 5-1 shows the numbers of physicians in various disciplines certified by the American Board of Medical Special-



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From Cancer Patient to Cancer Survivor: Lost in Transition 5 Providers of Survivorship Care: Their Supply and Education and Training With the number of cancer survivors in the United States at 10 million and expected to increase, concerns have arisen about the supply of adequately trained health professionals to provide survivorship care. This chapter enumerates providers of survivorship care and then reviews the inclusion of survivorship content in the educational and training programs of selected health professionals involved in survivorship care. Support for professional education and training in survivorship is then described. Finally, the committee puts forth its recommendations to improve the capacity of the survivorship workforce. SUPPLY OF SURVIVORSHIP CARE PROVIDERS Survivorship care is by nature multidisciplinary and ideally provided using a team approach. Physicians are the likely coordinators of survivorship care, but as a National Cancer Institute (NCI) Fact Sheet describing the cancer health care team informs consumers, “Your Doctor Is Only the Beginning” (NCI, 2000). Physicians and nurses are often links to many other important care providers, including those in the areas of social work, psychology, rehabilitation, and genetic counseling. Using the best available data on the supply of health personnel, an attempt is made in Tables 5-1 and 5-2 to assess the availability of selected providers of survivorship care. Table 5-1 shows the numbers of physicians in various disciplines certified by the American Board of Medical Special-

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From Cancer Patient to Cancer Survivor: Lost in Transition ties1 (ABMS) and the membership of related professional societies. For nurses, physical and occupational therapists, social workers, mental health professionals, and other nonphysician providers involved in survivorship care, Table 5-2 shows the number of licensed or certified personnel when applicable and the relevant professional societies.2 The professional societies of physicians, nurses, and other providers are often the main source of continuing medical education for their specialty and so are key to any effort to raise awareness of survivorship care. Important disciplines relevant to survivorship care are not represented in these tables. The expertise of cardiologists, neurologists, and endocrinologists, for example, may be needed to diagnose and manage cancer’s late effects. Although these estimates are incomplete and imprecise, they point to potential shortages of trained personnel given the size of the survivorship population. Concerns about the future supply of physicians, nurses, and other providers available to care for an older cancer patient population have been voiced since the early 1990s (Kennedy, 1994), but there are few studies of health personnel capacity to gauge the extent of the problem. The Association of American Medical Colleges (AAMC) and the American Society for Clinical Oncology (ASCO) are partnering to study whether the future supply of clinical oncologists will be sufficient to meet future health care needs (ASCO, AAMC to assess clinical oncology workforce, 2005). Better information on all survivorship-related health care personnel is needed to plan for health care delivery and education and training. STATUS OF PROFESSIONAL EDUCATION AND TRAINING Cancer survivorship care as a distinct phase of the cancer trajectory is a relatively new construct, and health professional schools’ curricula have generally not included much content in this area. This needs to change, but a larger task is providing continuing medical education to professionals who have completed their formal training and are encountering cancer survivors in their practices. The question of who to train is a complicated one because survivorship care encompasses both medical and psychosocial issues and a diverse set of providers can potentially be involved. The content of any survivorship curricula is also not straightforward. Providers need to be apprised of the risks of cancer treatments, the probabilities of cancer recurrence and second cancers, the effectiveness of surveillance and interventions for late effects, the need to address psychosocial concerns, the 1   By 2003, more than 85 percent of licensed physicians in the United States were certified by at least one ABMS Member Board (ABMS, 2004b). 2   Membership in a professional association is a very rough marker for supply of specific types of providers because an organization can include members from various professions.

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From Cancer Patient to Cancer Survivor: Lost in Transition TABLE 5-1 Estimates of the Supply of Selected Physicians Who Provide Survivorship Care Type of Physician Number of Physicians Physician specialist Medical oncology • Board certified 9,708   • American Society of Clinical Oncology 12,603 Radiation oncology • Board certified 4,005   • American Society for Therapeutic Radiology and Oncology 3,900 Hematology • Board certified 5,794   • American Society of Hematology 4,233 Surgery • Board certified 35,403   • Society for Surgical Oncology 1,700 Colorectal surgery • Board certified 1,317   • American Society of Colon and Rectal Surgeons 1,000 Thoracic surgery • Board certified 5,693   • Society of Thoracic Surgeons 4,200c Breast surgery • American Society of Breast Surgeons 1,900 Ear Nose & Throat (Otolaryngology) • Board certified 10,165 Urology • Board certified 10,512   • American Urological Association 9,738a Gynecologic oncology • Board certified 718   • Society of Gynecologic Oncologists 872 Physiatry • Board certified 6,604   • American Academy of Physical Medicine and Rehabilitation (AAPM&R) 6,849   • AAPM&R cancer special interest group 28 benefits to patients of prevention and lifestyle change, and the complexities of integrating survivorship concerns into care for a group of patients of generally advanced age with other chronic conditions. Education and training must also stress the need for multidisciplinary approaches, integrated and coordinated care, and effective use of community-based resources. Aspects of survivorship that could be considered essential content of survivorship training for health care providers are shown in Box 5-1.

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From Cancer Patient to Cancer Survivor: Lost in Transition Type of Physician Number of Physicians Primary care Family medicine • Board certified 64,701   • American Academy of Family Physicians 94,000 Internal medicine • Board certified 161,921   • American College of Physicians: Internal Medicine 118,000c Obstetrics and gynecology • Board certified 37,057   • American College of Obstetricians and Gynecologists 46,480b Geriatric medicine • Board certified 7,287 NOTE: Numbers are estimates based on the number of certifications issued, and may not accurately reflect the number of currently practicing physicians. aNumber includes resident members and excludes retired members. bNumber includes resident members. cNumber includes medical student and resident members. SOURCES: Number of Board-certified physicians comes from the American Board of Medical Specialties (ABMS, 2004a) and the American Board of Internal Medicine (ABIM, 2005); professional organization membership (limited to physicians of the specified type who may care for adult cancer survivors, in the United States, when possible) comes from: American Society of Clinical Oncology (Personal communication, D. Lopez, ASCO, June 22, 2005); American Society of Breast Surgeons (2005); American Society of Hematology (Personal communication, G. Aklilu, ASH, July 27, 2005); Society of Gynecologic Oncologists (Personal communication, R. Benkert, SGO, January 26, 2005); American Society of Therapeutic Radiation Oncologists (ASTRO, 2002, 2004); Society of Surgical Oncology (Personal communication, R. Slawny, SSO, April 15, 2005); American Urological Association (AUA, 2005); American College of Obstetricians and Gynecologists (Personal communication, C. Flood, ACOG, April 15, 2005); American Society of Colon and Rectal Surgeons (ASCRS, 2005); American College of Physicians (ACP, 2005a); American Society for Therapeutic Radiology and Oncology (Personal communication, S. Smith, ASTRO, June 21, 2005); Society of Thoracic Surgeons (Personal communication, A. Ticoalu, STS, June 23, 2005); American Academy of Family Physicians (AAFP, 2005). Education and training opportunities for selected physician and nonphysician providers of survivorship care are detailed in the following section. Most of these are oriented to a particular health care discipline, but it is likely that survivorship education and training could be developed for multiple audiences. A few continuing education resources are broadly applicable across professional disciplines. Forthcoming from NCI is a resource for clinicians on cancer survivorship (Personal communication, S. Wilcox, Office of Education and Special Initiatives, NCI, February 2,

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From Cancer Patient to Cancer Survivor: Lost in Transition TABLE 5-2 Estimates of the Supply of Selected Nonphysician Survivorship-Related Providers Type of Provider Number of Providers Registered nurses (RNs) • Licensed 2,201,813a   • Oncology certified nurse 19,132   • Advanced oncology certified nurse 1,514   • Oncology Nursing Society 32,000 Physical therapists • Licensed 120,433   • American Physical Therapy Association (APTA) 50,035   • APTA Oncology Section 600 Occupational therapists • Certified 111,151   • American Occupational Therapy Association 35,000b Social workers • Medical and public health social workers 107,000   • National Association of Social Workers 153,000 Oncology social workers • Association of Oncology Social Work 1,000 Mental health professionals Psychology • Licensed 85,000   • American Psychological Assocation (APA) 90,200   • APA, Health Division 2,947 Psychiatry • Board certified 34,114   • Focus on oncology 100 Pastoral counseling • Certified chaplains 9,100 Genetic counseling • Board certified 1,811   • National Society of Genetic Counselors 2,098c aNumber of RNs employed in nursing, including nurse practitioners. bAll members, including occupational therapy assistants and student members. cIncludes student members SOURCES: Number of RNs employed in nursing from the Health Resources and Service Administration (Spratley et al., 2000); number of professional chaplains from a white paper on chaplaincy (VandeCreek and Burton, 2001); number of licensed doctoral level clinically trained psychologists (Personal communication, K. Lewis, APA, July 12, 2005); professional organization membership (limited to U.S. professionals) comes from: Oncology Nursing Society (ONS, 2005); American Physical Therapy Association (Personal communication, K Gardner, APTA, April 27, 2005); American Occupational Therapy Assocation (AOTA, 2005); National Association of Social Workers (NASW, 2005a); National Board for Certification in Occupational Therapy (Personal communication, P. Grace, NBCOT, May 5, 2005); American Board of Genetic Counseling (ABGC, 2003); National Society of Genetic Counselors (Personal communication, L. Brodeur, NSGC, May 17, 2005); Association of Oncology Social Workers (Personal communication, B. Zebrack, AOSW, April 25, 2005); American Psychological Association (Personal communication, K. Cooke, APA, April 25, 2005).

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From Cancer Patient to Cancer Survivor: Lost in Transition BOX 5-1 Essential Content of Survivorship Training for Health Care Providers Prevention of secondary cancers General discussion of survivorship Long-term complications/sequelae of treatment Trends and statistics in health care access Health care systems/quality assurance/models of care Rehabilitation services Quality-of-life issues in survivorship Detection of recurrent and secondary cancers Pain management Palliative care/end-of-life care Short-term complications Treatment of recurrent cancer SOURCE: Ferrell et al. (2003). 2005).3 An educational opportunity available to a cross-section of health professionals is a cancer survivorship biennial conference sponsored by NCI’s Office of Cancer Survivorship and the American Cancer Society (ACS) (NCI and ACS, 2002, 2004). Physicians The status of undergraduate and graduate medical education is described in this section, followed by some examples of opportunities for continuing medical education on survivorship for practicing physicians.4 Given their educational potential, the availability of clinical practice guidelines related to cancer survivorship is included in this discussion. 3   An older, now out-of-date training program for health professionals, The Cancer Journey: Issues for Survivors, was developed by NCI in collaboration with the National Coalition for Cancer Survivorship and Ortho Biotech, Inc. It was designed to (1) raise awareness of cancer survivorship; (2) demonstrate how to provide effective support, accurate information, and useful referrals; and (3) promote the empowerment of survivors and their families to work effectively with their health care team, employers, and others concerning issues related to their cancer history (NCI, 1998). 4   The status of survivorship-related educational opportunities for psychiatrists are described later in the chapter in the section on psychosocial and mental health providers.

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From Cancer Patient to Cancer Survivor: Lost in Transition Undergraduate Medical Education Cancer survivorship has not yet been well represented in medical school curricula. Only a few schools were identified as having courses or clerkships pertaining to cancer survivorship when the online database on medical school curriculum maintained by the American Association of Medical Colleges was searched (AAMC, 2005a).5 Some medical schools have, however, incorporated survivorship issues into the curriculum by including cancer survivors as “standardized patients” in what are referred to as “structured clinical instruction modules” (Plymale et al., 1999). These instruction modules involve medical students interacting with cancer survivors who have been trained to describe their medical history, symptoms, and concerns in a standardized way. Students interview and assess cancer survivors in this simulated, but realistic, clinical setting under the supervision of the faculty. Both the faculty instructor and the cancer survivor provide feedback to the trainees about their performances and, as time allows, the cancer survivor shares additional personal experiences with the trainees. An evaluation of one of these programs found that this method of instruction was considered beneficial for trainees and faculty members alike (Plymale et al., 1999). Emory University has added an educational program, “Survivors Teaching Students: Saving Women’s Lives” to the third-year medical students’ 6-week gynecology and obstetrics rotation. Survivors from the Georgia Ovarian Cancer Alliance volunteer to discuss their experiences, giving students an opportunity to understand the diagnosis of cancer from the patient’s perspective (Emory University, 2004). A 4-year integrated curriculum in cancer survivorship is being developed under an NCI R25 grant for students at University of California Schools of Medicine (Los Angeles and San Francisco) and the Charles R. Drew University of Medicine and Science. Core competencies have been established and instructional material is being developed on topics such as the epidemiology of survival, risk assessment, treatment of late effects, psychosocial concerns, prevention strategies, and resources for cancer survivors (Box 5-2) (Stuber et al., 2003, 2004). Curricular materials include problem-based learning cases, multimedia web-based problems, a targeted preceptorship experience, and exercises to develop skills in behavior change 5   The online database maintained by the American Association of Medical Colleges is called the Curriculum Management and Information Tool (CurrMit®). The database was searched using the following terms: Cancer AND (rehab OR quality of life OR late-effects OR late effect OR long-term effect OR long term effect OR patient surveillance OR follow-up OR follow up OR surviv OR chronic). The names of required courses and clerkships are available for all medical schools, but only 60 percent of schools have provided additional detail about the coursework.

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From Cancer Patient to Cancer Survivor: Lost in Transition BOX 5-2 Cancer as a Chronic Disease: Curriculum for Survivorship Required Objectives for Medical School Core Curriculum Attitudes Comfortable prescribing medications for pain control, including opioids Comfortable asking new patients routinely about previous cancers Willing to ask oncologists for consultation when appropriate Considers general preventative issues as well as those related to cancer survivorship in cancer survivors Knowledge Understands that all cancer survivors are at increased risk for other cancers as well as recurrence of the original cancer, and need to avoid tobacco, eat right, and use sunscreen Understands basic mechanisms of genetic contribution to risk of cancer Understands common uses of the terms “cure”, “disease free survival”, and “cancer survivor” Understands differences in cancer survivorship by gender, ethnicity and socio-economic status Understands the variety of social consequences of cancer on survivors, including difficulty getting employment and insurance, stigma, and the impact on the family and friendships Knows the essential elements to obtain about a cancer history, how to get information the patient can’t give them, and how to interpret the health implications of the history Understands consequences of cancer treatment for different developmental stages, including impact on growth, osteoporosis, learning, sexual function and fertility Skills Able to use key screening guidelines to identify people at higher risk for cancer Able to provide appropriate and individualized recommendations for secondary prevention to cancer survivors regarding sunscreen, diet, obesity, exercise, alcohol, and tobacco Able to tailor pain medication and other interventions for pain to the source and type as well as the severity of pain Able to explain and help patients make decisions about a living will, do not resuscitate (DNR) orders, durable power of attorney, and advance health care directives Able to give bad news about second malignancy or relapse, and to move to a palliative approach when appropriate without saying “there is nothing we can do” Able to partner with patients in decision making, respecting what is important to the patient Able to work as the primary care provider with a specialty team, providing continuity of care, and working with family as well as patient Able to get current cancer information for cancer survivors at the appropriate reading level and language (e.g., from the Cancer Information Service and National Cancer Institute) SOURCE: UCLA (2005b).

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From Cancer Patient to Cancer Survivor: Lost in Transition and risk assessment (Personal communication, L. Wilkerson, David Geffen School of Medicine at University of California–Los Angeles, January 13, 2005). A survey on survivorship knowledge and experience has been designed as a needs assessment or program evaluation tool. The survivorship curriculum and materials will be available through the UCLA Cancer Education Project’s website (UCLA, 2005a) and the Health Education Assets Library (HEAL), an online, peer-reviewed health education repository (HEAL, 2005). As survivorship curricula and materials are developed, they can also be shared between medical schools through the MedEd Portal, a new online repository of education materials maintained by AAMC (2005b). Graduate Medical Education The curricula followed in graduate medical education is determined under the auspices of the American Council of Graduate Medical Education. According to a review of the curriculum for medical oncology, some of the 28 content areas listed are related to survivorship (e.g., knowledge of drug toxicity, rehabilitation, and psychosocial aspects of clinical management of the cancer patient), but no specific mention of cancer survivorship is made (Winn, 2002). The specific items to be included in the oncology fellowship training curriculum are not within the purview of the American Board of Internal Medicine and Accreditation Council for Graduate Medical Education. ASCO has assumed the task of creating a “Competence Comprising Curriculum” for medical oncology subspecialty training in 14 key areas, including supportive care and survivorship (Muss et al., 2005; ASCO, 2005a). For the primary care disciplines of internal medicine and family medicine, a review of curriculum guidelines found a lack of mention of cancer survivorship. A review of selected general oncology and disease-specific medical textbooks found only one text that addressed cancer survivorship specifically (i.e., Diseases of the Breast, Harris et al., 2004) (Winn, 2000). Most of the other textbooks had certain survivorship issues represented, but there was relatively little discussion of practical clinical management issues. Several standard primary care and internal medicine textbooks were reviewed from the perspective of whether a primary care physician wishing to learn about the management of cancer survivors could readily obtain an overview of the entire area. The texts were not comprehensive or detailed enough in their coverage to serve as primary sources of information for the clinician seeking to effectively manage these patients. Available texts may, however, serve a purpose in highlighting some of the major problem areas of cancer survivorship and alerting the caregiver of the need to consult additional sources for more comprehensive information.

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From Cancer Patient to Cancer Survivor: Lost in Transition Some specialty texts were found that were directly related to survivorship care. The text Cancer Patient Follow-Up (Johnson and Virgo, 1997) provides a comprehensive review of follow-up practices. The major focus is on surveillance testing, but treatment complications and their management are also covered. This text provides an excellent source for clinicians interested in the scientific rationale for many survivor issues. Another resource is Principles and Practice of Palliative Care and Supportive Oncology (Berger et al., 2002). This text has two relevant chapters, “Long-term survivorship: Late effects” (Aziz, 2002), and “Psychosocial aspects of cancer survivorship” (Leigh and Clark, 2002). In addition, many of the chapters about specific supportive care issues, such as sexuality and reproduction or depression and anxiety, are pertinent to survivorship. Integrated discussions of these palliative and supportive care topics provide an excellent orientation for the clinician wanting to become grounded in survivorship. A new certification program of the ABMS may provide opportunities for continuing education regarding survivorship care (ABMS, 2004b). Until recently, Board recertification testing occurred every 6, 7, or 10 years. A new program, called “Maintenance of Certification” (MOC), changed the specialty recertification process for physicians from periodic testing to a more continuous process. The new MOC program will require the assessment and improvement of practice performance by physician specialists. Examples of practice assessment and improvement approaches for MOC include, for internal medicine, Practice Improvement Modules in clinical preventive services and preventive cardiology, and, for pediatrics, web-based education improvement programs in pediatric asthma and attention deficit hyperactivity disorder. A module related to cancer survivorship could be developed to enhance specialists’ knowledge of survivorship-related care. Continuing Medical Education For practicing clinicians, continuing medical education provides opportunities to gain skills in this relatively new area. There appears to be a demand for such education, at least among oncologists. According to a recent survey, more than 75 percent of medical oncologists reported that they provide some follow-up care for cancer survivors, but a significant proportion wanted additional training (ASCO, 2004). Continuing medical education (CME) credits—attained through onsite meeting attendance, virtual meeting participation, or online CME venues—provide significant opportunities for clinicians to be exposed to issues related to survivorship. The Accreditation Council of Continuing Medical Education has accredited the major national societies to offer CME credit for certain sessions at their meetings. Examples of some recent CME opportunities at professional meetings are shown in Box 5-3.

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From Cancer Patient to Cancer Survivor: Lost in Transition BOX 5-3 Continuing Medical Education: Examples from Recent Professional Meetings American Society of Clinical Oncology (2005 Annual Meeting) Cancer Survivorship: Long-Term Complications of Treatment Breast Cancer Survivorship: Long-Term Issues in Women with Breast Cancer Supportive Oncology: Complementary and Alternative Medicine Assessing and Teaching Humanistic and Spiritual Aspects of Cancer Care Society of Gynecologic Oncologists (2005 Annual Meeting) Advances in Reproductive Health: Cancer and Conception Barriers to Sexual Health After Cancer: What Can Be Done? Ovarian Cancer Survivor’s Course (for survivors and nurses) The American Society for Therapeutic Radiology and Oncology (2004 meeting) raised awareness of cancer survivorship by creating a “Survivor Circle” exhibit in partnership with the Atlanta chapter of the American Cancer Society. Information on ACS support programs was featured (US Newswire, 2004). American Association for Cancer Education (2004 Meetings) Integration of Cancer Survivorship Coursework into First Year Medical School Curriculum Quality of Life: Native American Cancer Education for Survivors Exploring the Needs of Cancer Patients and Their Family Caregivers Through a Training Workshop Does Diet Modification Have Potential to Reduce Cancer Suffering and Extend Life? Partners in Survival National Training Program: Training Minority Men to be Effective Caregivers for Women with Cancer SOURCES: ASCO (2005c); SGO (2005); Journal of Cancer Education (2004). In some cases, professional societies have, or are planning, continuing medical education opportunities for their specialty group. Medical oncology To help oncologists better address the needs of cancer survivors, ASCO has formed a Survivorship Task Force to develop, implement, and manage ASCO survivorship programs related to physician education, survivorship guidelines, patient education, and research (ASCO, 2004). There are plans for the issuance of clinical practice guidelines on issues such as late effects and the development of a central online information resource on late and long-term effects of cancer and its treatment. At

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From Cancer Patient to Cancer Survivor: Lost in Transition TABLE 5-4 Professional Education Programs Supported by the Lance Armstrong Foundation Project Description Cancer Survivorship Education Initiative for Texas Nurses, Nurse Oncology Education Program of the Texas Nurses Foundation (www.noeptexas.org) The initiative, also funded by the Texas Cancer Council, aims to increase awareness among nurses of the unique psychological and physiologic problems faced by cancer survivors and to enable them to provide patients with accurate information, resources, and psychological support that will improve their quality of life. The initiative’s educational module, which targets the state’s practicing nurses and student nurses, includes a printed booklet, a PowerPoint presentation on CD (for use in presentations to nursing students or health professional groups), an audio CD, and a web-based independent study module. Four thousand Texas nurses will receive the booklet or audio CD, while additional nursing school faculty members will receive the booklet for presentation to nursing students. Survivorship Professional Education Program, The Leukemia and Lymphoma Society (LLS) (www.lls.org) The LLS, with the help of a 2003 LAF community grant, established the Survivorship Professional Education Program for oncology nurses and social workers who focus specifically on survivorship issues. The program educates participants on mind-body healing and integrative medicine options for patients during and beyond the treatment portion of their journey as cancer survivors. SOURCE: LAF (2005). The International Psycho-Oncology Society The International Psycho-Oncology Society provides information about fellowship opportunities to social workers and others (IPOS, 2005) in addition to the information available from APOS (APOS, 2005a). FINDINGS AND RECOMMENDATIONS Few cancer care and primary care health professionals have had formal education and training regarding cancer survivorship. Needed are efforts to update: (1) undergraduate curricula for those in training; and (2) continu-

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From Cancer Patient to Cancer Survivor: Lost in Transition ing education for practicing providers of survivorship care. Continuing education is needed across many disciplines, but in order to ensure the provision of quality survivorship care, it is especially important to reach (1) oncologists, hematologists, urologists, surgeons, and radiologists who initially treat cancer patients; (2) primary care physicians; (3) nurses; and (4) social workers and other providers of psychosocial services. To ensure the provision of comprehensive survivorship care, it is likely that additional health personnel will be needed, particularly nurses with advanced oncology training. Many methods are being used to provide continuing education in survivorship (Table 5-5). Online resources are increasingly available and appear to be an attractive means of reaching many providers, but the effectiveness of this and other approaches need to be assessed. There appear to be few educational programs aimed at multiple provider audiences (e.g., APOS psycho-oncology online course), but it is likely that survivorship continuing education would lend itself to such an approach. The American Association TABLE 5-5 Methods of Survivorship Continuing Education Educational Approach Example Meeting on survivorship NCI/ACS cancer survivorship biennial conference Session on survivorship at professional society meeting ASCO 2005 annual meeting session: Cancer Survivorship: Long-Term Complications of Treatment SGO 2005 annual meeting session: Barriers to Sexual Health After Cancer: What Can Be Done? Home study guides AAFP home study self-assessment cancer survivor monograph American Academy of Physical Medicine and Rehabilitation self-directed study guides and examinations are published annually as a Medical Education Supplement to the Archives of Physical Medicine and Rehabilitation Problem-based learning cases ACP online clinical problem-solving case on cancer follow-up Online course directed to one specialty AOSW/CancerCare course, Understanding Cancer: The Social Worker’s Role Online course directed to multiple specialties APOS psycho-oncology course Online repository of information, guidelines NCI’s Physician Data Query summaries on supportive care, genetics services, and complementary and alternative medicine AHRQ guideline clearinghouse

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From Cancer Patient to Cancer Survivor: Lost in Transition for Cancer Education (AACE) could play an important role. AACE is a multidisciplinary group that has included survivorship education in its annual meeting (AACE, 2005). Limited support is available through public and private sources for survivorship-related education and training. Recommendation 7: The National Cancer Institute (NCI), professional associations, and voluntary organizations should expand and coordinate their efforts to provide educational opportunities to health care providers to equip them to address the health care and quality of life issues facing cancer survivors. Immediate steps to facilitate the development of programs include: Establish a clearinghouse of available sources of survivorship education and training (and guidelines), with opportunity for feedback. Appoint an interdisciplinary consortium to review available resources, identify promising approaches, develop new programs, and promote cost-effective approaches. Increase support of model formal training programs (undergraduate and graduate levels, continuing medical education) that could be adopted by others. By specialty: Physicians Add more survivorship-related CME: The American Board of Medical Specialties’ new program, “Maintenance of Certification,” will require continuous assurance of professional skills for board-certified physicians. The development of a module on cancer survivorship as part of this program could facilitate the assurance of competence for these and other specialty providers. Improve online survivorship information aimed at health care providers: Expand PDQ to include more information on survivorship care. Centralize survivorship guidelines online. Encourage the development and adoption of evidence-based guidelines. Ease finding survivorship-related guidelines included in the Agency for Healthcare Research and Quality (AHRQ) sponsored guideline clearinghouse (e.g., add the term “survivorship” to the search engine to pick up surveillance guidelines for cancer).

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From Cancer Patient to Cancer Survivor: Lost in Transition Expand training opportunities to promote interdisciplinary, shared care. Nurses Increase survivorship content in undergraduate and graduate nursing programs. Expand continuing education opportunities on survivorship for practicing nurses. Increase the number of nursing schools that provide graduate training in oncology. Increase the number of nurses who seek certification in oncology (incentives are needed). Endorse activities of those working to ease the nursing shortage. Social workers and other providers of psychosocial services Support efforts of APOS to standardize and promote continuing education. Endorse activities of those working to maintain social services in cancer programs. It is important to verify the effectiveness of education programs because they may not always have the desired effect on practice. One such effort dealt with the provision of survivorship care to residents in rural areas, which can be problematic, especially if they live far away from providers of cancer treatment. In an effort to improve the cancer care provided to rural residents in Minnesota, Michigan, and Wisconsin, investigators tested multimodal, multidisciplinary set of interventions among 18 communities randomized to be in either an intervention or control group (Elliott et al., 2001a,b, 2002, 2004). Among the study’s interventions were efforts to involve community-based opinion leaders (physicians, nurses, and pharmacists), targeted education, quality improvement activities in rural hospitals and clinics, telecommunications via fax machines, clinical practice guidelines, and outreach oncology consultations. The interventions led to improvements in knowledge, but did not change practices, including appropriate post-treatment surveillance. Travel to health care was significantly reduced in the intervention communities, but there were no significant differences in satisfaction with care, economic barriers to care, or health-related quality of life.

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