The Primary Care Team in Cancer Care Materials

THE ROLE OF THE PRIMARY CARE TEAM IN CANCER CARE

L. Austin Fredrickson, MD, FACP

L. Austin Fredrickson, MD, FACP, is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care.

Liz Fredrickson, PharmD, BCPS

Liz Fredrickson is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy.

Topic Overview

The role of the primary care team in cancer care is multifaceted and vital to patients' overall health and well-being. By fostering a holistic approach to cancer care, primary care teams can optimize their patients' physical and emotional well-being, ultimately leading to better health outcomes. Healthcare providers should have a comprehensive understanding of how to implement evidence-based screening protocols, promote lifestyle modifications, and facilitate timely referrals to oncology specialists. Additionally, care providers must understand how to address the psychosocial challenges faced by patients with cancer and their families. This continuing education activity will provide healthcare providers with information on key areas of cancer prevention, early detection, and screening recommendations. It will also discuss the complexities of managing comorbid conditions in cancer patients, emphasizing the importance of coordinated care to optimize treatment outcomes and improve quality of life. Finally, participants will learn effective communication techniques to educate patients and their families about cancer diagnoses, treatment options, side effect management, and self-care practices.

Accreditation Statement

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-24-139-H01-P

Pharmacy Technician  0669-0000-24-140-H01-T

Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $6.99

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation

Release Date: October 4, 2024 Expiration Date: October 4, 2027

Target Audience: This educational activity is for pharmacists and pharmacy technicians.

How to Earn Credit: From October 4, 2024, through October 4, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe the function of the primary care team in the context of cancer care

Identify key responsibilities of primary care providers in cancer prevention, early detection, and screening

Recognize the psychosocial challenges faced by cancer patients and their families and how to facilitate access to appropriate mental health and support service

Educate patients and their families about cancer diagnosis, treatment options, side effect management, and self-care practices

Disclosures

The following individuals were involved in developing this activity: L. Austin Fredrickson, MD, FACP, Liz Fredrickson, PharmD, BCPS, and Pamela Sardo, PharmD, BS. Pamela Sardo, L. Austin Fredrickson, MD, FACP, and Liz Fredrickson, PharmD, BCPS, have no conflicts of interest or financial relationships regarding the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

The Role of the Primary Care Team in Cancer Care Introduction

The role of primary care teams in cancer care is vital to the overall health and well-being of patients. By fostering a holistic approach to cancer care, primary care teams can optimize the physical and emotional well-being of their patients, ultimately leading to better health outcomes. Healthcare providers should have a comprehensive understanding of how to implement evidence-based screening protocols, promote lifestyle modifications, and facilitate timely referrals to oncology specialists. Additionally, it is important that care providers understand how to address the psychosocial challenges faced by patients with cancer and their families.

This continuing education activity will provide healthcare providers with information pertaining to key areas of cancer prevention, early detection, and screening. It will also discuss the complexities of managing comorbid conditions in cancer patients, with an emphasis on the importance of coordinated care to optimize treatment outcomes and improve quality of life. Finally, participants will learn effective communication techniques to educate patients and their families about cancer diagnoses, treatment options, side effect management, and self-care practices.

Value of the Primary Care Team in Cancer Care

The primary care team is crucial across the cancer continuum, from prevention and screening to navigating the healthcare field to survivorship and end-of-life care. Primary care providers are instrumental in initiating discussions about cancer risk factors, recommending appropriate screenings, and identifying potential signs and symptoms of cancer. As the number of cancer survivors, or those living with or beyond cancer, increases, the role of primary care teams with regard to the management of comorbidities and the provision of physical, psychological, and social resources becomes even more important.1 Because of this, care teams must understand how to recognize

and address the many challenges that patients with cancer and their families face, ensuring that they receive the necessary support and resources.

Optimizing Team-Based Care

Team-based care involves collaboration among health providers and patients to achieve shared goals and is essential for enhancing patient outcomes, care efficiency, and clinician well-being.2 Successful teams share common features such as shared leadership, well-defined roles, open communication, and mutual respect (Table 1).2,3 Effective teamwork requires that members contribute their unique expertise towards a common goal, and shared leadership enables teams to coordinate care seamlessly, ensuring continuity and quality during transitions.2

Table 1

Qualities of High Performing Teams2,3

Shared leadership has been defined as a team property that consists of shared responsibility and mutual influence.3 Shared leadership is a dynamic process and is critical, especially during transitions of care.2 Within this concept, multiple teams work together as a cohesive unit.3 For example, during the transition to survivorship, shared leadership is crucial in preventing, detecting, and managing cancer recurrence while addressing the psychosocial impacts of the disease.3 This approach involves collaborative sharing, where teams work together to ensure comprehensive care and leadership responsibilities are distributed across various clinical tasks over time.3 The benefits of shared leadership include improved patient outcomes, reduced care duplication, and enhanced trust among team members.3 However, challenges such as unclear roles and lack of communication can hinder effective leadership sharing, emphasizing the need for ongoing research and training to optimize this model of care.3

Tremblay, et al. (2016) have described various examples of individual and shared leadership.3 In their first example, physicians act as clinical leaders within a team. Their responsibilities include establishing and maintaining disease management objectives in alignment with the patient’s medical history and preferences.3 Physicians also interpret and frame the disease management plan for other team members while setting team objectives and specifying tasks, and they play a critical role in communicating expectations, guidelines, and recommendations.3

In another example, shared leadership within a team is emphasized.3 Physicians, while still acting as clinical leaders, share leadership responsibilities with team members and the patient-family.3 This collaborative approach builds mutual trust, fosters two-way communication patterns, and develops shared mental models, particularly around long-term follow-up and survivorship management.3 The team manages interdependent tasks, ensuring each member optimizes their contributions.3

Finally, a third example highlights shared leadership between patient- family, oncology, and primary care providers, forming a team-of-teams.3 Physicians lead this collaboration during transitions by clarifying the roles and resources of the oncology team, PCPs, and the patient-family.3 This coordinated effort ensures the fluid distribution of expertise across professional and organizational boundaries.3 The collaboration relies on mechanisms like mutual trust, shared mental models, and two-way communication patterns.3

Primary Care Team Members in Cancer Care

Physicians

Primary care providers are often the first point of contact for patients with regard to screening for cancer, evaluation of cancer-related symptoms, and initiation of referrals to specialists.4 Recently, the Division of Cancer Prevention at the National Cancer Institute (NCI) sponsored a roundtable with primary care providers to identify barriers and explore opportunities for integrating cancer prevention into primary care.5 One of the most challenging aspects of cancer prevention for primary care clinicians is establishing a baseline for a patient’s cancer risk, which includes evaluating risk factors such as tobacco use, diet, and family history.6 A family history of cancer is particularly important as it may indicate a genetic predisposition, but obtaining accurate family health information can be difficult. Many patients are unsure about their family history, often unaware of the specific types of cancer their relatives had.6 To improve accuracy, clinicians may ask patients to consult with their families and report back.6

To assist in cancer risk assessment, researchers have developed tools that calculate risk scores based on specific patient information, such as those used for assessing breast cancer risk.6 These tools help guide preventive measures for women at higher risk.6 However, studies show that these tools are not commonly used in everyday primary care, largely due to time constraints and the complexity of incorporating them into routine practice.6 Additionally, many tools have not been adequately tested in underrepresented populations, and some require genetic testing, which can be time-consuming for both patients and clinicians.6

Early detection through screening is one of the most effective strategies for improving cancer outcomes.6 Primary care providers are responsible for recommending and conducting routine cancer screenings based on current guidelines and the individual risk factors of their patients. Common screening tests include mammograms for breast cancer, colonoscopies for colorectal cancer, Pap tests for cervical cancer, and low-dose computed tomography. Screening recommendations are summarized in Table 2.6

Table 2

Cancer Screening Recommendations per American Cancer Society6

Primary care physicians also play essential roles in managing patients’ comorbid conditions. Over the past twenty years, the number of cancer survivors with comorbidities has dramatically increased, and this requires well-coordinated management to ensure optimized care for this patient population.7 Managing these comorbid illnesses can be challenging, as the treatment of different diseases can potentially complicate cancer treatments.7 Survivors of cancer are at risk for developing various diseases due to things such as smoking, physical inactivity, and obesity.8 Given these risks, the American Society of Clinical Oncology (ASCO) recommends that primary care physicians discuss smoking cessation, weight management, implementation of exercise regimens, and decreased alcohol consumption with survivors.8 A key aspect of optimizing non-cancer related cancer is ensuring routine follow- ups in the primary care setting and regular communication between primary care physicians and the oncology team.8

Various guidelines and educational resources are available pertaining to smoking cessation, nutrition, and exercise.9 With regard to nutrition and exercise, the American Cancer Society recommends the following:

Achieve and maintain a healthy weight

If overweight or obese, limit consumption of high-calorie foods and beverages and increase physical activity to promote weight loss.

Engage in regular physical activity

Avoid inactivity and return to normal daily activities as soon as possible following diagnosis

Aim to exercise at least 150 minutes per week

Include strength training exercises at least 2 days per week.

Achieve a dietary pattern that is high in vegetables, fruits, and whole grains.

Individualized nutritional advice can improve dietary intake and potentially reduce some of the toxicities associated with cancer treatments.9 For survivors facing issues like anorexia or early satiety, consuming smaller, more frequent meals with minimal liquids during meals can help increase food intake, with liquids consumed between meals to prevent dehydration.9 If nutritional needs cannot be met through food alone, nutrient-dense beverages, either commercially prepared or homemade, can improve energy and nutrient intake.9 In cases where these measures are insufficient, and malnutrition is a concern, other interventions such as appetite stimulants, enteral nutrition, or intravenous parenteral nutrition may be necessary.9

Pharmacists

Pharmacists practicing in numerous settings can assist patients with cancer in numerous facets. Community pharmacists are often the first point of contact with regard to healthcare for patients.10 By providing health education and disease awareness campaigns, community pharmacists are key in enhancing the overall health literacy and the well-being of the public.10 Their frequent interactions with patients make them well-suited to offer

consultations and advice that can significantly influence cancer management.10

Early detection is a vital strategy in reducing cancer morbidity and mortality.10 Screening both healthy and high-risk populations allows for early cancer detection, potentially reducing the need for more invasive treatments and improving survival outcomes.10 In some cases, pharmacists have been able to assist with cancer screening through physical tests and by offering laboratory referrals, such as prostate-specific antigen (PSA) tests for prostate cancer.10 In Kentucky, pharmacists who work under the authorization of a prescriber are able to screen, educate, and also order a noninvasive stool- based screening test for patients.11 Under this protocol, patients who meet criteria can see their pharmacist for a colorectal cancer screening but must agree to undergo a colonoscopy if their test is positive.11 These types of protocols have allowed pharmacists to fill gaps in care.11

From a clinical pharmacy specialist perspective, ambulatory oncology pharmacists play important roles in providing medication therapy management for patients with cancer from the time of diagnosis throughout their cancer journey and through survivorship.12 They may also practice under a collaborative practice agreement to adjust medications and provide patient education.12

Pharmacy Technicians

Pharmacy technicians support the work of pharmacists by assisting with the preparation and dispensing of medications, managing inventory, and providing basic patient education. They are also involved in ensuring that the pharmacy operates efficiently and that patients receive their medications in a timely manner.

Advanced Practice Providers

Advanced Practice Providers (APPs) include Physician Assistants (PAs) and Nurse Practitioners (NPs). These individuals are highly skilled members

of the healthcare team.13 APPs have been identified as key players in addressing the growing demand for oncology services amid an anticipated shortage of providers.13 Roles of APPs include cancer prevention, screening, diagnosis, supportive care during treatment, long-term follow-up, survivorship care, and end-of-life care.13 Additionally, APPs are involved in patient counseling about disease, treatment options, and prognosis, and they frequently participate in clinical research.13

APPs have successfully collaborated in both community and academic oncology settings, with high patient satisfaction reported in collaborative care models.13 The use of APPs in oncology has grown significantly, with 73.1% of ASCO practices reporting APP employment in 2015, up from 52% in 2014. Despite this growth, the total workforce capacity of oncology APPs remains uncertain.13 While there are over 115,000 certified PAs and 220,000 licensed NPs in the U.S., it is estimated that less than 5% of APPs practice in oncology.13

Psychosocial Challenges

Cancer patients and their families often face significant psychosocial challenges, including anxiety, depression, and financial stress. These challenges can affect the patient's overall well-being and ability to adhere to treatment regimens. The primary care team must be equipped to recognize these challenges and provide appropriate support, which may include counseling, referrals to mental health professionals, and assistance with accessing financial resources.

Cancer patients’ experiences with cancer can be divided into the stages of pre-diagnosis, post-diagnosis (before treatment), short-term after treatment, and long-term after treatment. Each stage comes with its own obstacles.14 These include challenges around deterioration of self-concept (or problems with self-esteem, body image, and self-appraisal), sexual dysfunction, trouble maintaining social relationships, and emotional distress.14 Primary care teams have numerous options for helping patients manage psychosocial issues, including referrals to mental health services and

recommending integrative therapies such as acupuncture, massage, self-care strategies, and mind-body therapies.15 In some cases, pharmacological interventions may be required as well.15 Primary care teams should ensure patients are appropriately screened for conditions such as depression and anxiety regularly.

Patient, Family, and Caregiver Education

Education is a critical component of cancer care, and primary care providers play a key role in educating patients, their families, and caregivers about the disease, treatment options, and self-care practices. This education helps patients make informed decisions about their care and empowers them to take an active role in managing their health.

Primary care physicians should use clear, simple language and ensure that patients understand the information being provided. It is also important to consider the emotional and psychological impact of a cancer diagnosis and to provide information in a compassionate and supportive manner. Two models for conveying bad news include the SPIKES protocol for breaking bad news (Table 3) and the SHARE model (Table 4).

Table 3

The SPIKES Protocol

Table 4

The SHARE Model

Primary care physicians also must educate patients and their caregivers about survivorship plans. The Institute of Medicine (IOM) recommends using survivorship care plans (SCPs) for all cancer survivors.16 SCPs are detailed, personalized documents that provide cancer survivors with a comprehensive summary of their cancer diagnosis, treatment, and follow-up care recommendations.16 These plans are typically developed in collaboration with oncology and primary care teams and are tailored to the specific needs of each patient.16 The goal of SCPs is to ensure continuity of care, empower survivors with knowledge about their health, and improve long-term health outcomes by fostering proactive management of potential health risks associated with their cancer and its treatment.16 A sample SCP from the American Society of Clinical Oncologists is detailed in Figure 1 below.16

Form: ASCO Treatment Summary and Survivorship Care Plan16

Pharmacists are key educators with regard to a patient’s medication regimen, including proper administration and storage of medications and how to manage potential side effects.10 Education and counseling by pharmacists have been shown to improve medication adherence among cancer patients and even reduce pain levels.10 Additionally, pharmacists can enhance cancer awareness and prevention efforts by offering promotional materials such as pamphlets and videos, which can raise public awareness about cancer screening and prevention.10 Pharmacists may also discuss risk reduction with vulnerable populations and offer guidance when dispensing high-risk medications.10

Summary

The primary care team plays an indispensable role in the comprehensive care of cancer patients, serving as the cornerstone for early detection, ongoing management, and holistic support throughout the cancer journey. The primary care team’s involvement is crucial in educating patients about their condition, guiding them through complex treatment decisions, and helping them navigate the healthcare system, all of which contribute to a more positive patient experience. The continuity of care provided by the primary care team is vital in fostering a trusting relationship with patients, empowering them to actively participate in their care, and ultimately improving long-term health outcomes.

Course Test

Which of the following principles of high-quality teams best matches its definition?

Shared goals: Team members trust one another and feel safe enough within the team to admit a mistake, ask a question, offer new data, or try a new skill without fear of punishment

Clear roles: Clear expectations for each team member's functions, responsibilities, and accountabilities to optimize team efficiency and effectiveness

Mutual trust: Reliable and ongoing assessment of team structure, function, and performance that is provided as actionable feedback to all team members to improve performance

Effective communication: The team establishes shared goals that can be clearly articulated, understood, and supported by all members

Which of the following best describes a model of shared leadership?

Providers, patients, and their families form a “team-of-teams” that focuses on strong communication and mutual trust

Physicians acting as the team leader and determining the roles of all other health care provider team members

Team members working independently to ensure well-defined deadlines meet patient and caregiver goals

Pharmacists assuming the role of team lead in order to prevent medication-related errors and adverse events

Based on American Cancer Society recommendations, at what age should primary care providers advise patients to begin regular screenings for colon and rectal cancer?

Age 30

Age 35

Age 45

Age 50

Which of the following is true regarding the role of the primary care team in cancer prevention?

Community pharmacists may regularly screen patients for all types of cancers

While tools are available to assess a patient’s risk of cancer, these may not be used in everyday primary care due to time constraints

Obtaining a patient’s family history of cancer is an easy task that can assist primary care physicians in determining a patient’s cancer risk

Primary care teams should only complete cancer screenings for patients with a high risk of cancer due to family history or genetic testing results

Which of the following is a recommendation of the American Cancer Society with regard to nutrition and exercise regimens for patients with cancer?

Aim to exercise for at least 30 minutes each week

Strength training should be implemented at least 2 days a week

Diets should be high in saturated fats and protein

Nutrient-dense beverages should be avoided for patients who cannot

If a pharmacist is at the Breast Cancer Relay for Life, which of the following is the most likely role the pharmacist can provide regarding cancer care counseling?

Educate patients through disease awareness campaigns

Prescribe and adjust doses of medications

Order stool test kits without the need for collaborative practice agreements

Provide referrals to psychologists and mental health professionals

Which of the following is a challenge that patients with cancer may face with regard to “self-concept”?

Self-esteem issues

Trouble maintaining social relationships

Emotional distress

Financial challenges

Which of the following is a part of the SPIKE protocol that assists providers in breaking bad news to patients?

S: setting (setting context and listening skills)

S: setting up a supportive environment for the interview

E: exploring medical options

I: inviting patients family members to discuss options

Which of the following is not a goal of survivorship care plans (SCPs) as recommended by the Institute of Medicine?

SCPs are recommended for all patients surviving with an oncology diagnosis

SCPs are detailed, personalized documents developed in collaboration

SCPs are only recommended for patients diagnosed with stage 3-4 conditions.

SCPs provide a comprehensive summary of the cancer diagnosis and treatment

Which of the following best matches the care team member with their role in providing cancer care?

Pharmacy technician: managing medication inventory and drug supply

Physician: providing screening while working under a collaborative practice agreement

Advanced care provider: dispensing medications and counseling patients on side effects

Pharmacist: planning and discussing survivorship plans

References

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Smith, C. D., C. Balatbat, S. Corbridge, A. L. Dopp, J. Fried, R. Harter,

S. Landefeld, C. Martin, F. Opelka, L. Sandy, L. Sato, and C. Sinsky. 2018. Implementing optimal team-based care to reduce clinician burnout. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201809c. Accessed October 3, 2024.

Tremblay D, Latreille J, Bilodeau K, et al. Improving the Transition From Oncology to Primary Care Teams: A Case for Shared Leadership. J Oncol Pract. 2016;12(11):1012-1019. doi:10.1200/JOP.2016.013771

Samimi G, Douglas J, Heckman-Stoddard BM, Ford LG, Szabo E, Minasian LM. Report from an NCI Roundtable: Cancer Prevention in Primary Care. Cancer Prev Res (Phila). 2022;15(5):273-278. doi:10.1158/1940-6207.CAPR-21-0599

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American Cancer Society. American Cancer Society Guidelines for the Early Detection of Cancer. November 1, 2023. https://www.cancer.org/cancer/screening/american-cancer-society- guidelines-for-the-early-detection-of- cancer.html#:~:text=No%20matter%20which%20test%20you,screene d%20is%20right%20for%20you. Accessed October 3, 2024.

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Egbewande OM, Abdulwasiu MA, Yusuf RO, Durojaye AB, Ashimiyu- Abdulsalam ZI. Roles of Community Pharmacists in Cancer

Management. Innov Pharm. 2022;13(3):10.24926/iip.v13i3.4946. Published 2022 Dec 12. doi:10.24926/iip.v13i3.4946

Wilkinson E. Pharmacy Colorectal Cancer Screening Protocol Shows Potential of Pharmacists in Preventative Health. Pharmacy Times. 2023. https://www.pharmacytimes.com/view/pharmacy-colorectal-cancer- screening-protocol-shows-potential-of-pharmacists-in-preventative- health . Accessed October 3, 2024.

Holle LM, Segal EM, Jeffers KD. The Expanding Role of the Oncology Pharmacist. Pharmacy (Basel). 2020;8(3):130. Published 2020 Jul 25. doi:10.3390/pharmacy8030130

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The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

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© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.