As I approach my 25th year in oncology practice, I think back to when I started and the remarkable expansion since then of treatment options for patients with advanced cancer. In castration-resistant prostate cancer, we have gone from a single chemotherapy option to 13 different approved treatment options representing 8 distinct mechanisms of action. Not surprisingly, patients with castration-resistant prostate cancer are now routinely living 5 years or longer, compared with just 2 years on average when I entered the field. Now that even patients presenting with metastatic castration-sensitive prostate cancer have an average survival of nearly 5 years, one can see how prostate cancer can be considered a chronic disease in its most advanced stages. This is all good news, right? Except that . . .
Such an exponential increase in survivorship is profoundly changing my patient population, and I am sure it is changing yours, too. If I keep seeing all my surviving patients, I will run out of time and space to see new patients. In fact, I already have.
Let’s look at the numbers. As of January 2022, the National Cancer Institute estimates that there are 18.1 million cancer survivors in the United States, representing approximately 5.4% of the population. By 2032, this number is projected to increase by 24.4% to 22.5 million. Over the next decade, the NCI projects that the number of people living 5 or more years after their cancer diagnosis will increase by 30%, to 16.3 million. When we look at the number of patients surviving for many years after a cancer diagnosis, the percentages are staggering. In 2022, nearly 70% of patients were alive 5 years after their diagnosis, 47% were alive 10 years after their diagnosis, and 18% were alive 20 years after their diagnosis. These numbers are especially surprising given that 67% of cancer survivors are older than 65 years. So, there is much good news, but what effect does all this survivorship have on our health care system?
In addition to the monetary costs, which are exponentially rising, this increase creates a burden on health systems that is borne largely by the health care providers. I am referring to us: the doctors, nurses, advanced practice practitioners, pharmacists, hospitalists, and everyone else who provides services to aid in the care of these patients. Each incremental improvement in outcome from each new line of therapy over the lifetime of a patient means more clinic visits, patient calls, hospitalizations, family discussions, and referrals for palliative support. Although we tend to focus on the moment, managing our work by the day or the week, data analytics can provide some insights into this increased burden.
Looking at data from our genitourinary medical oncology group at Duke, I was surprised to learn that 90% of our clinic visits are with established patients of the practice, meaning that only 10% of our clinic appointments are with new patients. This trend leaves little capacity for the new patients who need to be added, which taxes the entire system. Unlike primary care doctors, hematologist/oncologists generally do not close our practices to new patients. How can we, when patients in our communities turn to us at such a vulnerable time in their life? On the other hand, how do we protect ourselves and our staff from the stress of having too many patients? It’s not like we can just graduate our cancer survivors . . . or can we?
Survivorship clinics have been growing in academic centers for the past 20 years. At first, they focused on pediatric and young adult patients who had survived harrowing experiences with toxic chemotherapies and were considered cured but were dealing with the consequences and sequelae of these treatments. Over time, the clinics have evolved to serve more adult patients, including those with long-term remissions. Breast cancer tops the list, making up 22% of cancer survivors (4.1 million), followed by prostate cancer, at 20% of cancer survivors (3.5 million).
Cancer survivorship clinics, staffed by primary care physicians, advanced practice practitioners, and a host of allied health professionals, can offer practical and personalized advice to patients whose cancer is no longer the focus of treatment. Many of the issues for these patients pertain to aging and the ways cancer therapies complicate age-related health issues. Encouraging these patients to transition their care to specialists in cancer survivorship not only can help our patients but can free up our clinic space for a new generation of patients who need our immediate services. Patients are wary of change, especially when they feel a connection with us, but cultivating transitions to survivorship specialists may be more than a luxury, it may be essential to our own survival.
Daniel J. George, MD