Professionalism and Survivorship
A recent conversation on ACCCExchange goes right to the point on follow-up for patients with cancer. Dr. Dale Fuller should be commended for his practice of offering to follow up free of charge.
“Ever since I was in training back in the 1960s,” Dr. Fuller writes, “I have made a practice of seeing patients I have treated on an ongoing basis, and at no charge, because I have been interested in outcomes. What I have learned in over 40 years is that radiation is the gift that keeps on giving, and the “gifts” are often in ways not foreseen by the radiation oncologists who don’t see their patients over the long run of time.”
“One wants to be aware of early signs of recurrence, early evidence of post-irradiation complications (which, if addressed in a timely way can usually be ameliorated), early evidence of metastatic disease, evidence of second primary cancers (not all that uncommon), and evidence of other medical issues wrongly attributed to the patient’s history of irradiation. Benefits for the patient are that the radiation oncologist has knowledge and expertise to address these issues that, sadly, no other specialty has. One gets to know patients very, very well.”
Patients both need and desire to know what may happen in the future and to whom to go for follow-up care. Obviously, each specialty involved in cancer care should be responsible for determining the best source of follow-up. Cancer survivorship usually implies a life-long potential for recurrence as well as a continuing propensity for new cancers to develop. Some family physicians can handle this responsibility, but they are few and far between, especially considering the sensitivity needed to make a diagnosis, including adequate breast, pelvic, and prostate exams!
As a surgeon I followed my breast and colon cancers for life, and picked up the responsibility for making sure there was communication with the primary physician and the other specialists involved. Depending on the initial and subsequent courses of therapy, the other two specialties would be involved to a greater or lesser extent.
Dr. Fuller describes the truly professional approach because of what he describes as the “gift that keeps giving” with radiation therapy, but this gift can also be true for chemotherapy and surgery. On the other hand, the patient can be in a revolving door of repeat visits to all the specialists, which might not be necessary and is always a burden to the patient, both in terms of time and money.
Many physicians might offer free follow-up care, but there are problems with this approach. Some might get billed anyway despite the wishes of the physician. In addition, without adequate communication, the patient is often subjected to duplicative and unnecessary exams and lab work, for example.
The real answer should not be a hard and fixed date for follow-up. Instead, the schedule should fit the individual patient’s needs. For example, breast cancer patients need almost yearly follow-up for 10-15 years (if not a lifetime) to be, at least, vigilant of the opposite breast. I would say that the breast surgeon should be the designated hitter, so to speak. And each instance of cancer needs a separate and personal approach to survivorship. Hence, the need for all practitioners and cancer centers to provide a comprehensive survivorship plan. In this plan it is far more important to include what the patient should expect and to whom the patient should seek treatment than a lengthy and detailed summary of the courses of chemo, or the portals of radiation, or the extent of surgery.
“I have always kept other interested physicians informed about each visit,” said Dr. Fuller, “a courtesy that, in my experience, is seldom reciprocated, but I do it anyway, because I think it is in the patient’s interest. The practice has not been all that burdensome, as some patients move away, some die, and some, for their own reasons elect to discontinue the visits. Even as a retired doc, I tell patients that if they want to show up, I’ll show up, and 12 years on, it still happens once in a while. I’m grateful to my group that they have enabled me to continue that activity.”
We should all listen to the professionalism of Dr. Fuller and do what is best for the patient despite remuneration or personal desires to cut off care at some point in time.
Visit ACCC’s excellent resources at its Survivorship Education Project website.