Transitioning Breast Cancer Survivors Back to Primary Care

After being treated for breast cancer at Memorial Sloan Kettering Cancer Center (MSK), individuals then move on to the nurse practitioner-led breast cancer survivorship program. But eventually, they must be transitioned back to their primary care providers, explained Kathleen Keenan, NP, of MSK.

Survivors are stratified by risk of recurrence to determine when they will be moved over to their general practitioners, but it is important to establish expectations with both the patient and the provider about length of time they will be at seen at MSK, as well as their plan of care and other important notes.

TRANSCRIPTION

So what happens is we get a report every week in our nurse practitioner-led clinic. We see who is eligible for transition. It's a data-line report that's generated by looking at the rosters of our patients. We realize that these patients are eligible. We actually exclude the patients who are not eligible, based on second cancers, or genetic mutations. But then offer the patient transition.

We realized that what happens is on the first time of seeing these patients, it's best to actually lay the groundwork to say, "You're going to be seeing us for 4 more years, and then you're going to be transitioned," and actually making it much much easier to transition the patients back to their primary care doctors. On the first visit, we also send notes back and forth to their primary care doctors, making them aware of exactly what's going on, how long we're planning on following them, and what the plan of care is.