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Transitioning to Primary Care After IO Treatment

By Regina Jacob, MD, MSCE, FACP

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Regina Jacob, MD, MSCE
Assistant Professor, Clinical Medicine;
Director, Social Determinants of Health Curriculum, Internal Medicine Residency Program
Lewis Katz School of Medicine at Temple University

Regina Jacob, MD, MSCE, is an assistant professor of Clinical Medicine at The Lewis Katz School of Medicine at Temple University in North Philadelphia.  She received her MD degree from The George Washington University in Washington, D.C., completed her internal medicine residency at Temple University Hospital, and earned a master’s degree in Clinical Epidemiology at The Weill Cornell Medical College of Cornell University in Manhattan, New York.

Dr. Jacob has two main research interests which both assess psychological adjustment and co-morbid medical conditions.  She conducted a study called Coping with Lymphoma to Enhance Adjustment and Reduce Stress, which assessed the psychological adjustments which may occur after a diagnosis of lymphoma.  She continues to grow her cancer survivorship expertise in education, designing curricula to educate internal medicine residents on how to appropriately tailor primary care for patients with a history of cancer. 

Her second research interest involves assessing co-morbid conditions that result from chronic and cumulative trauma exposure.  She is currently conducting a study called Trauma Alert! How Social Complexity Contributes to Medical Complexity, which assesses the prevalence of post-traumatic stress disorder (PTSD), adverse childhood experiences, depression, and co-morbidity in an underserved primary care population. While the effects of poverty on healthcare are known, there is still a large amount of work to be done with regards to how trauma associated with poverty results in negative health behaviors and subsequent poor medical and psychological outcomes.

  March 11, 2021

While immuno-oncology (IO) therapies have heralded significant advancements in cancer care, there are still many unknowns when it comes to the long-term side effects of these relatively new agents. Since ambulatory care typically involves long-term chronic disease management, these unknowns can often translate to management uncertainty. 

Nationwide, primary care clinicians report being interested in and willing to manage the long-term care of cancer survivors, although most say they feel ill-equipped to do so. For example, primary care providers who care for patients who have received traditional cancer therapies, including radiation and chemotherapeutic agents, report sometimes unreliable communication between primary care and oncology, which then translates to uncertainty in both cancer surveillance and management of potential long-term side effects of those therapies.1 With IO therapies, these gaps in communication hold much higher stakes. Unlike traditional cancer therapies, in which most side effects typically occur during or immediately after treatment, IO therapies can have long-term side effects that can resurface well beyond 90 days and sometimes even years after treatment. 

Consequently, communication between a patient’s cancer care team and primary care teams is imperative. It is crucial that both patients and primary care clinicians be provided sufficient information and instruction about the specific therapies used and what side effects may require urgent care. Many primary care clinicians state that if they are given adequate information about the therapies a patient has received, they are better equipped to be vigilant on their behalf. 

Screening for and managing the delayed side effects that may arise in IO patients is vital, particularly since specific guidelines for doing so are still being developed. As more primary care clinicians learn about the late-term side effects of IO therapies and monitor their patients for them, a more evidence-based approach to screening for such side effects will evolve and spread. Much like with traditional cancer therapies such as chemotherapy and radiation, screening for delayed IO side effects may simply require clinicians to conduct a detailed review of symptoms, since there is currently little evidence to support the use of surveillance imaging. 

Treatment information can be easily provided by the cancer care team to patients and primary care clinicians using a survivorship care plan, or the information can be conveyed via direct communication between the oncology team and the primary care team. While there is still much debate as to whether current survivorship care plans are sufficient for IO patients, limitations seem to be primarily related to the inconsistency and variability with which they are used. 

Regardless of the form it takes, with open communication between patients’ cancer and primary care teams, we can ensure IO patients do not “fall through the cracks” when their active treatment comes to an end. What’s more, patients generally feel more comfortable when all of their care providers are aligned and working together as a cohesive network. When it comes to IO therapies this is absolutely critical, as improved communication can empower patients to feel more confident in their long-term survivorship care. 

References

1. Nissen MJ, Beran MS, Lee MW, Mehta SR, Pine DA, Swenson KK. Views of primary care providers on follow-up care of cancer patients. Fam Med. 2006;39(7):477-482. http://www.ncbi.nlm.nih.gov/pubmed/17602321