Transforming Cancer Care: Bringing PCPs “Back” into Cancer Care through Onco-Primary Care

The Problem

Comorbidities, particularly hypertension, in patients on active cancer therapy are inadequately managed due to the lack of communication between oncologists and primary care physicians(PCP).(1-3) With the substantial increase in cure rates for many cancers (e.g., breast cancer) and the extended life expectancy for patients with a chronic cancer (e.g., chronic lymphocytic leukemia, castrate resistant prostate cancer), the risk of death from a cardiovascular event exceeds that of death from the primary cancer.(4,5) It now appears that cardiovascular disease (CVD) risk factors, often unaddressed during active cancer therapy in the past, have an accelerating effect on the atherosclerotic process in the face of a cancer-induced cytokine storm. Thus, it is imperative that there is a redesign of the current cancer care model in order to incorporate the PCP as an active member of the cancer caring team. Indeed, this is the primary objective of the Duke Center for Onco-Primary Care, a collaborative effort between primary care and oncology. This innovative Center is one of the four programs highlighted in the 2018-2021 Duke Cancer Institute (DCI) Strategic Plan. The proposed demonstration project directly addresses three of the DIHI RFA priorities. First, we are redesigning the cancer care model to use a team-based approach that incorporates the expertise of the PCP. In the current model of care in the U.S. and at Duke, while some PCPs are actively involved in the care of their patients during cancer therapy, this is the exception rather than the rule. Instead, most PCPs follow patients socially during active cancer therapy and rarely make changes in the evaluation and management of CVD risk factors because (1) they are unclear if the cancer therapy adversely affects the risk factor (i.e., which chemotherapeutic agents cause hypertension or which antihypertensive medications interact with chemotherapy) and (2) there is a conventional implicit message to the patient and the PCP that management of CVD risk factors is ‘not really that important’ compared to the need to focus on the cancer. Our proposed project aims to minimize both of these barriers to optimal cancer care. Second, we propose to introduce a novel patient interaction through digital technologies. By integrating home blood pressure monitoring, via a blue tooth device that is directly uploaded into Maestro, automated EHR messaging will link the patient, the PCP, and the oncologist together with the common goal of improved blood pressure management. To date, we are not aware of any automated systems that upload blue tooth blood pressures into the EHR, much less integrate the blood pressures into a clinical pathway. Third, we aim to enhance the transition of cancer survivors back to the PCP. The seminal 2005 Institute of Medicine report on Cancer Survivors was subtitled, ‘Lost in Transition’.(6) Across the U.S. and internationally, there remain many barriers to the implementation of a standardized, systematic, and high quality transition of survivors from the cancer center to the primary care setting or the incorporation of a shared care model for high-risk cancer survivors.(7,8) We posit that involving PCPs during active cancer therapy will demystify what happens in the ‘black box’ of cancer care and will enhance the survivorship transition.

Our Solution

We propose to leverage new technology embedded in the iPhone iOS 12 HealthKit to automatically upload home blood pressures, using a well-validated blue tooth blood pressure monitor(iHealth BP5), directly into Maestro using SMART on FIHR. Further, we propose to develop an automated Maestro messaging system utilizing home blood pressure monitoring with alerts for abnormal weekly average pressures tobe sent to the patient’s Duke PCP, with copies to the patient and the primary oncologist.

References

1. Calip GS, Elmore JG, Boudreau DM. Characteristics associated with nonadherence to medications for hypertension, diabetes, and dyslipidemia among breast cancer survivors. Breast Cancer Res Treat. 2017;161(1):161-172.
2. Jiang L, Lofters A, Moineddin R, et al. Primary care physician use across the breast cancer care continuum: CanIMPACT study using Canadian administrative data. Can Fam Physician. 2016;62(10):e589-e598.
3. Worndl E, Fung K, Fischer HD, Austin PC, Krzyzanowska MK, Lipscombe LL. Preventable Diabetic Complications After a Cancer Diagnosis in Patients With Diabetes: A Population-Based Cohort Study. JNCI Cancer Spectr. 2018;2(1):pky008.
4. Bradshaw PT, Stevens J,Khankari N, Teitelbaum SL, Neugut AI, Gammon MD. Cardiovascular Disease Mortality Among Breast Cancer Survivors. Epidemiology. 2016;27(1):6-13.
5. Simon MS, Beebe-Dimmer JL, Hastert TA, et al. Cardiometabolic risk factors and survival after breast cancer in the Women’s Health Initiative. Cancer. 2018;124(8):1798-1807.
6. Hewitt M, Greenfield S, Stovall E (editors): From Cancer Patient to Cancer Survivor: Lost in Transition. Washington DC, The National Academies Press, 2005.
7. Long-Term Survivorship Care After Cancer Treatment: Proceedings of a Workshop. Washington DC, The National Academies Press, 2018.
8. Nekhlyudov L, O’Malley D M, Hudson SV. Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities. Lancet Oncol. 2017;18(1):e30-e38.