A primary care physician is important for cancer survivors for several reasons: 1) Primary care physicians can provide whole person care beyond just cancer, including preventative care, management of other health conditions, and annual checkups. 2) Oncologists focus narrowly on cancer care while primary care physicians take a broader view of patient health. 3) More patients have access to primary care physicians than oncologists, and primary care physicians can help coordinate care between specialists like oncologists. 4) Establishing care with a primary care physician and having a survivorship care plan facilitates smooth transitions in care after cancer treatment is completed.

1. Why do I Need a Primary
Care Physician?
Brian Sick, MD
Internal Medicine/Pediatrics
Medical Director, Primary Care Center
University of Minnesota

2. I have gotten excellent care from
my oncologist.
Why do I need a primary care
physician?

3. Objectives
• 1. Convince you of the need for a cancer
survivor to have a primary care physician.
• 2. Show you how to make that as smooth
a process as possible.

4. Why do I need a primary care
physician?
• Access to care
• Whole person care
• Preventative care

5. Whole Person Care
• Oncologists
– excellent cancer care
– narrow focus
• Primary Care Physicians
– excellent primary care
– broad focus

6. More patients have access to
primary care than oncology
• In 2010:
– 219,441 primary care physicians (family med,
internal med, med/peds)
– 12,743 heme/onc
• Or,
– 2,901 people per family med
– 2,834 people per internal med
– 24, 253 people per heme/onc
2012 Physician Specialty Data Book. Center for Workforce Studies. AAMC. November 2012.

7. Most common reasons for visit
1. Preventative physical examination
2. Hypertension
3. Preoperative evaluation
4. Diabetes
5. Low back pain
6. Depression
7. Abdominal pain
8. High cholesterol
9. Cough
10. Chest pain
Primary Care Center, University of Minnesota. September 2008.

8. Annual Preventative Check-Up
• Time to look at the whole person health
• Get to know the patient in more depth
• Directed physical exam
• Review meds
• Necessary blood work (there is no global
cancer blood test)
• Update preventative health screening
• Update cancer survivor follow-up

9. Non-cancer preventative health
• Abdominal aortic aneurysm screening
• Alcohol abuse screening
• Chlamydia screening
• Depression screening
• Domestic violence screening
• Immunizations – flu, pneumococcal,
shingles, hepatitis
• Osteoporosis screening

10. Oncology and Primary Care
Comparison of health maintenance in breast cancer survivors.
Neither PCP PCP only Oncology Both PCP
or oncology only and oncology
Mammogram 30.3 60.7 80.3 86.7
Influenza 28.1 62.6 59.1 70.1
Lipid 20.4 42.1 34.5 54.9
Cervical exam 3.2 24.7 12.3 38.8
Colon exam 1.4 12.6 10.8 21.2
Bone density 1.4 7.0 8.9 9.9
Earle, C, et al. Quality of non-breast cancer health maintenance among elderly breast cancer survivors.
J Clin Oncol 21(8):1447-1451. April 15, 2003.

11. Choosing a primary care
physician
• Make a list of
characteristics you would
like in a doctor
• Ask friends for referrals
• Look at logistics:
– ease of getting to
clinic, hours (including
after hours), location
of lab/imaging, etc.

12. Yelp.com
Based 100% on individual
reviews
Healthcare is a minor
category of reviews.
Only displays the reviews
of trusted reviewers

13. Annual Fee
Angie’s List Based 100% on reviews
Healthcare is minor part of the reviews
Wrong

14. HealthGrades
privately owned; data from
claims, state records,
medical boards, telephone
surveys, patient ratings
?
$12.95 for a more detailed report

15. Minnesota HealthScores
(www.mnhealthscores.org)
Data directly
submitted by clinics.
Cost, quality and
patient experience
data on clinics,
medical groups and
hospitals.

16. Transitioning Care

17. Patient Example
• 50yr old shows up with hypertension
• Remembers he had some sort of brain cancer as a
19yr old
• Knows he has a VP shunt and had radiation but
does not remember the details
• Family history of high blood pressure and
cholesterol

18. How to help the transition
• Partnership – oncology and primary care
• Patient – owner of their own health
• Plan – survivorship plan

19. Partnership
Breast cancer survivor rating of primary care
physician survivorship care
• General care 78%
• Psychosocial support 73%
• Health promotion 73%
• Knowledge about cancer follow-up 50%
• Late effects of cancer therapy 59%
• Symptoms from cancer or therapy 41%
Mao, J, et al. Delivery of Survivorship Care by Primary Care Physicians: The Perspective of Breast Cancer Patients.
J Clin Oncol 27(6): 933-8. Feb 20, 2009.

20. Partnership
28% felt their primary care physician
and oncologist communicated well

21. How to help the transition
• Partnership – oncology and primary care
• Patient – owner of their own health
• Plan – survivorship plan

22. Patient
• Healthy living
• Know own disease
• Medication list – bring meds or updated
list
• Portable health care record

23. Healthy Living
• Balanced diet
• Regular physical activity
– Relationship between
exercise and survival
– Obesity adversely
affects prognosis
– 30min five days a week
• No tobacco use
Irwin , M. Physical activity interventions for cancer survivors. British J Sports Med 43:32-8. Oct 23, 2008.

25. Patient
• Healthy living
• Know own disease
• Medication list – bring meds or list
• Portable health care record

26. Portable Medical Record
• Needs to be concise yet complete
• Used in transitions of care
– Home to ER/hospital
– Specialist to generalist
– Doctor to doctor
• Easily accessible – ideally web based
• Updated regularly

28. Portable Cancer Record
Cancer diagnosis
Treatments
http://www.survivorshipguidelines.org/pdf/GuidelinesAppendixI.pdf. Accessed March 28, 2009.

29. How to help the transition
• Partnership – oncology and primary care
• Patient – owner of their own health
• Plan – survivorship plan

30. Survivorship Plan
• Survivorship Guidelines
– www.survivorshipguidelines.org
– Patients and physicians need to know about
this resource

31. Preventative Care
Child to Adult Transition

32. Start the transition early

33. Transition Plan
Establish good
medical habits

34. Transition for Adults
Cancer diagnosis
Treatments
http://www.survivorshipguidelines.org/pdf/GuidelinesAppendixI.pdf. Accessed March 28, 2009.

35. Where does it all break down
• Lack of education
• Lack of insurance
• Lack of a plan
“I’ll have someone come in and
prep you for the bill.”

36. Patient Example
• 50yr old with brainstem glioma at 19yr
• Radiation and VP shunt
• Family history of high blood pressure and cholesterol
• Seen in Long Term Follow-Up Clinic for survivors of
childhood/adolescent cancer
– Identified risks: pituitary, skin cancers in field of
radiation, mild memory deficits, headaches

37. Patient Example
• Transition document clued me into increased risks
– MRI of brain done, pituitary hormones checked, detailed
skin exam yearly
• Age-related preventative screening
– Colonoscopy, PSA/DRE, lipids, glucose, skin exam
• I manage his hypertension, hyperlipidemia,
vaccines, acute visits
• Periodic visits with LTF clinic

38. What is a “cancer survivor”?

39. Definition
National Cancer Institute:
“In cancer, a person is considered to be a
survivor from the time of diagnosis until
the end of life.”
National Cancer Institute. http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=450125. Accessed March 28, 2009.

40. So, patients and providers need to
plan for survivorship
• Establish care with a primary care
physician
• Plan for the transition

41. Questions?