Melanie Cole (Host):  Today’s topic is breast cancer survivorship and the future of cancer survivorship, in general.  My guest today, is Dr. Smita Bhatia.  She’s an Oncologist and the Director of the Institute for Cancer Outcomes and Survivorship in the School of Medicine at UAB.  Welcome to the show, Dr. Bhatia.  Explain a little bit about breast cancer survivorship, the program at UAB.  Tell us a little bit about the evolution of it and some of the overall past feelings about prognosis and what’s different now?

Dr. Smita Bhatia (Guest):  Thank you, for giving me this opportunity.  Good morning.  Breast cancer is the most common cancer for women in the United States.  With the treatments that patients have received, survival rates have improved tremendously.  After completing treatment, many breast cancer survivors have questions about how cancer may affect their lives going forward.  The UAB Medicine Breast Cancer Survivorship Clinic will answer these questions by helping survivors navigate these complex issues they face after treatment has ended.

Each survivor has unique needs and concerns while they find their new normal and the Breast Cancer Survivorship stands by, ready to assist them with these changes.

Melanie:  What do you think has been accomplished in cancer survivorship over the last decade?  Was there even survivorship back even a decade ago?

Dr. Bhatia:  Well, survivorship was always the goal when oncologists treat.  That has always been the goal, but increasingly, with these new treatments, with the improvements in supportive care strategies, there is increasing hope and longevity associated with breast cancer or with other cancers as well.  As individuals – these women – live longer, they realize that they can now return to what they are calling their new normal.  As part of that, they are also realizing that there are complications that result as a result of the treatment they received or the result of breast cancer.  These survivorship clinics that we have developed, including the Breast Cancer Survivorship Clinic, offer them this unique opportunity for a single place to be able to assess, evaluate, and help manage all of the complications that they might be anticipating or having at that time.

Melanie:  How are you identifying the needs of these cancer survivors, and what are some of the late and long-term effects that breast cancer survivors have?

Dr. Bhatia:  Sure.  The Breast Cancer Survivorship Clinic at the UAB is for patients who have a diagnosis of breast cancer who have reached at least twelve months since diagnosis and are not receiving active treatment, i.e., any chemotherapy or radiation.  They could be receiving hormonal therapy.  In this setting, we provide care – a nurse practitioner, who has expertise in breast cancer care and survivorship issues, leads these efforts.  There is a yearly follow-up in this clinic, and this gives the patients an opportunity to discuss their cancer treatment, its impact on their health, and ways to stay as healthy as possible.  

What do the Breast Cancer Survivorship Clinic patients receive?  They receive monitoring for long-term effects of breast cancer treatment – and I’ll discuss those in a minute.   They receive referrals for management of the problems that are identified if that is needed.  And a survivorship care plan is given to the patent, which includes a personalized record of the details of cancer treatment, the guidelines for continued monitoring, recommendations for preventative care, and then information regarding available resources and services.  

The survivorship care is done in collaboration with each patients’ primary treatment team, and that’s the most important thing.  There’s communication – seamless communication between the primary oncologist, the radiation oncologist, and the survivorship clinic team.  Now, what are the long-term effects that could possibly happen in this setting?  The treatment needed for breast cancer can result in thinning of bone.  If there is radiation, it can result in thyroid involvement, so that’s hypothyroidism or lower functioning thyroid gland.  That can happen several years after the treatment.  It can result in vitamin D deficiency.  Sometimes, the treatment that is used can result and even have an effect on the heart.  

What we do in the Survivorship Clinic is offer tailored evaluations or screening tests, which are needed in order to detect these complications early.  The patients, we review their history and symptoms, we do a physical exam, we give health education, we review the survivorship care plan, and then we do these tests.  These include the blood work, or the bone density scans, or the echocardiogram, that is needed only if they have received specific treatments that would place them at risk for these complications.  And then, if there are abnormalities that are detected, we create referrals to specialists or resources or services based on their individual needs.  Then we give them a summary to both the patient as well as the primary health provider if the patient requests that.  That’s the summary of what we do in Survivorship Clinic.

Melanie:  Speak about the coordination of care, Dr. Bhatia, because you mentioned a few of the other healthcare providers that might be involved.  Who is involved, and how do you coordinate that care?  Speak about some of the key elements of the program.

Dr. Bhatia:  Right, the coordination of care is the key topic of this – a key element of this survivorship clinic.  That coordination is provided by the nurse practitioner as well as the clinic coordinator.  The survivorship clinic nurse practitioner identifies who the primary oncologist is – the radiation oncologist, the surgical oncologist, the primary healthcare practitioner – she summarizes all of the treatments that the patient has received.  She creates a survivorship plan for the patient, and then sets up – schedules all of the screening evaluations for the patients, reviews the results, and then creates the referral to the various specialists as needed, but then communicates all of these results back to the primary oncologist – the surgical oncologist, the radiation oncologist, and the primary healthcare provider.  Essentially, she is coordinating the care of the patient after completion of therapy in order to make sure the patient leads as healthy a life as possible.

Melanie:  So, what about some of the challenges for adherence?  If someone is a candidate for this program at UAB, how do you approach those challenges to adherence to those healthy lifestyles, to possibly prevent new cancer diagnoses, or keep track of the surveillance for recurrence, and that sort of thing?

Dr. Bhatia:  Right, and that’s a very good question.  What our hope is that inviting patients back for annual visits, and health education, and ensuring that they understand what is needed for health promotion, as well as having social services available, so that can remove the barriers to the best of our ability, so that the patients can adhere to these recommendations that we have and their primary oncologists have to help them adhere to these recommendations.

Quite often, the barriers are pretty tangible.  The barriers could be lack of transportation.  The barriers could be issues related to insurance.  The social worker we have is at hand in order to help them navigate those issues.

Melanie:  How are you evaluating the impact of these kinds of programs, and monitoring those barriers on the outcomes?

Dr. Bhatia:  You ask fantastic questions.  Our goal here is multifold.  First, we’re looking to see are the patients satisfied with their care?  Are they perceiving that they are getting additional benefits from this survivorship clinic?  We ask them to help us understand if there are issues, so they can complete a satisfaction survey and give us comments about what they would like improved in this survivorship clinic.  That’s one way of dealing with it.

The second thing that we are doing is we are very closely following whether we are identifying any new complications as a result of our screening efforts and whether we are making referrals and closing the loop in terms of making sure that the patients get the necessary care for the new complications that are identified.  Those are the outcomes that we are monitoring.  Are we picking up low bone density?  Are we picking up low vitamin D3 levels?  Are we picking up heart problems, or lung problems, or thyroid problems, which would go undetected if they had not visited the Survivorship Clinic?  We are keeping very close tabs on that in order to see what benefits the patients are getting from this clinic.

Melanie:  In summary, Dr. Bhatia, tell other physicians what you would like them to know about the Breast Cancer Survivorship Program at UAB, and where do you see the future of cancer survivorship going from here and when they should refer?

Dr. Bhatia:  Right.  Right, Breast Cancer Survivorship Clinic is at the Kirkland Clinic at UAB Hospital.  We have a referral -- for more information or to schedule an appointment, the phone number is 205-801-0080.  There’s convenient parking located near the clinic, and the patients can be referred either self-referred, or the physicians are taking care of them can refer the patients.

What’s important to know is that the patients have to have a diagnosis of obviously, breast cancer.  They have to have reached at least twelve months since diagnosis, and they have to be not receiving active treatment other than hormonal therapy.  

Where is survivorship efforts going from here on?  By 2025, over 20 million individuals in the US will be cancer survivors.  Cancer survivors carry a substantial burden of morbidity that is related to the treatments that were used to treat their primary cancer.  In order to prevent fragmentation of care because of these cancer treatment-related complications, it is important for multidisciplinary efforts, such as the Survivorship Clinic that we are running, where there is expertise related to survivorship care issues as well as the ability to coordinate the care of the patient.  We believe that the patients’ health would be tremendously improved if they were to attend such clinics.

Melanie:  Tell us about your team.  Why is UAB so great to work with?

Dr. Bhatia:  UAB is the best place ever.  That is my summary.  We have a very strong collaborative team.  We have a Nurse Practitioner, we have a social worker, a clinic coordinator, a chief Nurse Practitioner who manages – who directs the clinical services, and then I offer the content expertise in terms of survivorship-related issues.  The breast oncologists partner with us so that if the Nurse Practitioner has issues, she has Dr. Andres Forero ready and at hand in order to address those issues if needed.  It’s just a tremendous collaborative environment, and patients feel very welcomed and do believe that they gain something out of the Survivorship Clinic.

Melanie:  Thank you so much, Dr. Bhatia, for being with us today.  A physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST.  That’s 1-800-822-6478.  You’re listening to UAB Med Cast.  For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician.  This is Melanie Cole.  Thanks so much for listening.