You Survive Cancer. Now What?

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Kaiser Permanente is expanding its program that connects cancer survivors to comprehensive follow-up care, ensuring they stay healthy for the long haul. Pictured, Kaiser Permanente Northern California member Sam Wiley and his wife, Hazel Weiss.

Five years after a colon cancer diagnosis, Sam Wiley of Berkeley, California, got some great news. He is cancer free.

The word came from Kaiser Permanente oncologist Corey Schwartz, MD, who read the results of Wiley’s blood test and computed tomography, or CT scan. Dr. Schwartz declared Wiley a graduate of cancer treatment.

“I had a blood test on Sunday and saw my oncologist on Monday,” said Wiley, a retired City of Berkeley landscape supervisor who just turned 79. “He gave me a certificate saying I’m cancer free after 5 years.”

Wiley’s most recent reminder to get his blood test and CT scan originated with a team of nurses who send letters and secure emails to make sure cancer survivors are tracked for follow-up care.

Leslie Manace, MD, is one of the creators of a comprehensive cancer survivor tracking system for Northern California Kaiser Permanente members.

“We’re doing a great job of screening, diagnosing, and treating cancer, but when patients become survivors, we also want them to feel connected to their care team and to have warm, continued monitoring,” said Leslie Manace, MD, Kaiser Permanente’s regional director of the Precision Tracking program, who developed it with colleague Aileen De Mucha Flores, RN.

Since it launched in 2017, follow-up appointments completed for CT scans in colon cancer survivors increased from 47% to 92%, Dr. Manace said.

Follow-up care reminders were previously the work of individual oncologists, who now have more time to see patients. Reminders go to cancer survivors regardless of whether an oncologist retires, leaves the organization, or a member moves to another Kaiser Permanente service area.

“Members want to know we are still taking care of them after treatment,” said De Mucha Flores. “They don’t want the cancer to come back, so the question is, ‘How do we manage that?’”

Currently the team is working with about 2,500 Kaiser Permanente members in Northern California who survived colon, lung, testicular, head and neck, and skin cancers. The number is expected to grow to about 50,000 members with other kinds of cancer in the next 5 years, Dr. Manace said.

A Team of Caregivers

Dr. Manace said members get secure emails and mailed letters notifying them of follow-up tests that offer “a very personal touch on behalf of their care provider.” If a patient does not respond, more messages are sent at 2-week intervals and can be followed by a phone call from their oncologist.

The Northern California cancer tracking team that contacts cancer survivors for follow-up appointments includes from left to right, Norma Jones, RN; Blanca Moran, RN; Director Leslie Manace, MD; Rene Ryken, RN, and Aileen De Mucha Flores, RN.

The program is based on a highly successful, 25-year-old breast cancer screening program that similarly transferred follow-up notifications from oncologists to a team of nurses.

For Wiley, the fact that he’s cancer free after 5 years is proof that Kaiser Permanente is looking after him.

“I got the letters at home in the mail, and I would tape them up right here,” Wiley said, motioning to a kitchen cabinet in his Berkeley home. “And my wife would remind me, too. You go in once a year, they do a scan to look inside you, and then you do a blood test and see your oncologist.”

Dr. Manace said the new reminder program will keep patients connected with intensive survivorship surveillance so doctors can intervene at any sign of cancer recurrence.

“The idea is that our database will always remember them,” Dr. Manace said. “We want people to go back to their lives, and we are in the background making sure they do their follow-up care to stay well.”

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