Towards a personalised approach to aftercare: a review of cancer follow-up in the UK

Survivorship care plans: a work in progress

BACKGROUND

Health agencies across the world have echoed the recommendation of the U.S. Institute of Medicine (iom) that survivorship care plans (scps) should be provided to patients upon completion of treatment. To date, reviews of scps have been limited to the United States. The present review offers an expanded scope and describes how scps are being designed, delivered, and evaluated in various countries.

METHODS

We collected scps from Canada, the United States, Europe, the United Kingdom, Australia, and New Zealand. We selected for analysis the scps for which we could obtain the actual scp, information about the delivery approach, and evaluation data. We conducted a content analysis and compared the scps with the iom guidelines.

RESULTS

Of 47 scps initially identified, 16 were analyzed. The scps incorporated several of the iom's guidelines, but many did not include psychosocial services, identification of a key point of contact, genetic testing, and financial concerns. The model of delivery instituted by the U.K. National Cancer Survivorship Initiative stands out because of its unique approach that initiates care planning at diagnosis and stratifies patients into a follow-up program based on self-management capacities.

SUMMARY

There is considerable variation in the approach to delivery and the extent to which scps follow the original recommendations from the iom. We discuss the implications of this review for future care-planning programs and prospective research. A holistic approach to care that goes beyond the iom recommendations and that incorporates care planning from the point of diagnosis to beyond completion of treatment might improve people's experience of cancer care.

Cost-effectiveness of follow-up services for childhood cancer survivors outside the cancer setting

PURPOSE OF REVIEW

To provide a brief review of literature published since January 2012 on the subject of the cost-effectiveness of follow-up services for childhood cancer survivors. A pragmatic literature review was carried out to identify relevant literature.

RECENT FINDINGS

There is very little literature or evidence around the cost-effectiveness of follow-up services for the survivors of childhood cancer. The literature that is partially relevant focuses on the need for follow-up services to change to allow a more risk-based, personalized approach for survivors. There are implications in these changes for the costs and effectiveness of services. Some current literature also focuses on the economic impact of childhood cancer and treatment on the individual.

SUMMARY

There is considerable interest in understanding whether innovative approaches to follow-up care are cost-effective. There is little evidence currently but new models of care imply a potential shift in the resources required from the hospital setting to care provided outside hospitals. The rapid growth in numbers of survivors means that traditional hospital-based follow-up services will continue to experience high demand so it is important that new models of care are cost-effective.

The impact of supportive nursing care on the needs of men with prostate cancer: a study across seven European countries

Background:

Prostate cancer is for many men a chronic disease with a long life expectancy after treatment. The impact of prostate cancer therapy on men has been well defined, however, explanation of the consequences of cancer treatment has not been modelled against the wider variables of long-term health-care provision. The aim of this study was to explore the parameters of unmet supportive care needs in men with prostate cancer in relation to the experience of nursing care.

Methods:

A survey was conducted among a volunteer sample of 1001 men with prostate cancer living in seven European countries.

Results:

At the time of the survey, 81% of the men had some unmet supportive care needs including psychological, sexual and health system and information needs. Logistic regression indicated that lack of post-treatment nursing care significantly predicted unmet need. Critically, men's contact with nurses and/or receipt of advice and support from nurses, for several different aspects of nursing care significantly had an impact on men's outcomes.

Conclusion:

Unmet need is related not only to disease and treatment factors but is also associated with the supportive care men received. Imperative to improving men's treatment outcomes is to also consider the access to nursing and the components of supportive care provided, especially after therapy.

Sexuality is not a priority when disease and treatment side effects are severe: conceptions of patients with malignant blood diseases

AIMS AND OBJECTIVES

To describe how patients with malignant blood diseases conceive the influence of chemo- or chemoimmunotherapy on sexuality, and their need of support related to this issue.

BACKGROUND

Sexuality is often negatively affected in cancer patients with sex-specific diagnoses. For patients with malignant blood diseases, the research is limited with regard to the effect on sexuality. Knowledge about their need for support related to sexuality is also needed as nurses are found to often avoid this area of their responsibility.

DESIGN

Qualitative design.

METHODS

Twelve patients treated for malignant blood diseases were interviewed twice. Phenomenography was used for the analysis.

RESULTS

The analyses revealed an outcome space consisting of two main categories: 'Sexuality is overshadowed by the cancer experience' and 'No need of support but timely information might be helpful', both comprehensively related to three interrelated description categories 'Affected strength', 'Affected sexual desire' and 'Affected body image', which describe conceptions of how sexuality was affected.

CONCLUSION

Patients experienced negative effects on sexual function and sexual relationship during and after treatment period due to affected strength, sexual desire and negatively body image. However, when disease and side effects were experienced as severe, thoughts and interest of sexuality were overshadowed, and the need or wish for support related to this issue was very low. It is important to note that some patients expressed that pre- or post-treatment information might have been helpful.

RELEVANCE TO CLINICAL PRACTICE

It is acknowledged in the cancer care of today that cancer follow-up should address psychosocial support in which sexuality is an important area. Therefore, it is imperative that cancer care is organised in a patient centred way, with adequate time for nurses to provide continuity in the nurse-patient relation and supportive care also during cancer rehabilitation.

Development and qualitative evaluation of a self-management workshop for testicular cancer survivor-initiated follow-up

PURPOSE/OBJECTIVES

To describe the needs of testicular cancer survivors, develop a nurse-led workshop, and explore the experience of participation.

RESEARCH APPROACH

A systematic intervention development process was used to design a self-management workshop for cancer survivors, which then was evaluated qualitatively.

SETTING

Outpatient clinic in England.

PARTICIPANTS

26 healthcare professionals, charity workers, family members, and testicular cancer survivors participated in the intervention development process. Six testicular cancer survivors attended the workshop and participated in the postintervention focus group discussion.

METHODOLOGIC APPROACH

Ten participants, including four survivors, completed the initial needs assessment interviews. Twenty-six participants then rated the identified needs on two dimensions: importance to self-management and changeability via a self-management intervention. Literature review and expert consultation were used to identify potential workshop components. To explore the experience of attending the intervention, six testicular cancer survivors who participated in the nurse-led workshop were interviewed six weeks later.

FINDINGS

The workshop was well received by participants, who appreciated the goal-setting and information provision activities. The men also felt that they had benefited from the experience of being in the group.

CONCLUSIONS

Testicular cancer survivors had unmet post-treatment needs. The systematic intervention development method led to an evidence-based workshop to address those needs. Men reported benefits from attending the workshop, which may help maintain and improve health.

INTERPRETATION

Nurse-led workshops can address the current unmet needs of testicular cancer survivors.

KNOWLEDGE TRANSLATION

Testicular cancer survivors may require support with health information, maintaining psychological health, and monitoring cancer symptoms. Survivors also need help planning and maintaining an active lifestyle. In addition, a brief workshop approach to intervention delivery is acceptable to testicular cancer survivors.

Qualitative analysis of patients' feedback from a PROMs survey of cancer patients in England

OBJECTIVE

This study examined how free-text comments from cancer survivors could complement formal patient-reported outcome measures (PROMs), as part of the England PROMs survey programme for cancer.

DESIGN

A qualitative content analysis was conducted of responses to a single open-ended free-text question placed at the end of the cross-sectional population-based postal questionnaire.

SETTING

Individuals were identified through three UK Cancer Registries and questionnaires were posted to their home addresses.

PARTICIPANTS

A random sample of individuals (n=4992) diagnosed with breast, colorectal, non-Hodgkins lymphoma or prostate cancer at 1, 2, 3 and 5 years earlier.

RESULTS

3300 participants completed the survey (68% response rate). Of these 1056 (32%) completed the free-text comments box, indicating a high level of commitment to provide written feedback on patient experience. Almost a fifth (19%) related experiences of excellent care during the treatment phase, with only 8% reporting negative experiences. This contrasted with experiences of care after primary cancer treatment where the majority were negative. Factors impacting negatively upon patient-reported outcomes included the emotional impact of cancer; poor experiences of treatment and care; comorbidities, treatment side effects, social difficulties and inadequate preparation for a wide range of sometimes long-lasting on-going physical and psychological problems. Mediating factors assisting recovery incorporated both professional-led factors, such as quality of preparation for anticipated problems and aftercare services, and participant-led factors, such as learning from other cancer survivors and self-learning through trial and error. The support of friends and family was also a factor in participants' outcomes.

CONCLUSIONS

This analysis of free-text comments complements quantitative analysis of PROMs measure's by illuminating relationships between factors that impact on quality of life (QoL) and indicate why cancer patients may experience significantly worse QoL than the general population. The data suggest more systematic preparation and aftercare for individuals to self-manage post-treatment problems might improve QoL outcomes among cancer survivors.

Implementing improved post-treatment care for cancer survivors in England, with reflections from Australia, Canada and the USA

Increasing cancer incidence together with improved survival rates are contributing to the growing number of cancer survivors. Survivors may encounter a range of potential effects as a result of the cancer itself or cancer treatments. Traditionally, the major focus of follow-up care has been on detection of cancer recurrence; however, the efficacy of such strategies is questionable. Traditional follow-up frequently fails to identify or adequately address many survivors’ concerns. Aftercare needs to be planned to enable better outcomes for survivors, while using scarce health-care resources efficiently. This review focuses on provision of survivorship care, rather than on research. England’s National Cancer Survivorship Initiative has developed principles for improved care of those living with and beyond cancer. These include risk-stratified pathways of care, the use of treatment summaries and care plans, information and education to enable choice and the confidence to self manage, rapid re-access to specialist care, remote monitoring and well-coordinated care. Many of these principles are relevant internationally, though preferred models of care will depend on local circumstances.

Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia

PURPOSE

The purpose of this study was to examine colorectal cancer (CRC) follow-up care in Nova Scotia, Canada. More specifically, the objectives were to describe adherence to two elements of follow-up guidelines (colonoscopies and physician visits) and to identify factors associated with receiving at least guideline-recommended care.

METHODS

All patients with stage II or III CRC undergoing curative-intent surgery in Nova Scotia, Canada, were identified through the provincial cancer registry and anonymously linked to additional administrative health databases. For a 3-year follow-up period, beginning 1 year after the diagnosis date, descriptive statistics were calculated for physician visits and colonoscopies. Factors associated with receiving at least guideline-recommended care were identified using logistic regression.

RESULTS

Most patients received follow-up care from multiple physician specialties. In year 3, 58.1% of patients received oncologist follow-up care. Guideline adherence for colonoscopies was 52.4%, whereas guideline adherence for physician visits decreased from 41.9% to 25.4%. Receipt of at least guideline-recommended care was inversely associated with age and comorbidity for colonoscopy and inversely associated with age for physician visits.

CONCLUSION

Receipt of follow-up care from oncologists and primary care physicians, prolonged oncologist care, and receipt of care inconsistent with guideline recommendations suggest there may be potential issues with inefficient use of cancer system resources and integration of guidelines into follow-up care practices in Nova Scotia. Transitioning routine follow-up to primary care could potentially increase guideline adherence by improving access to and continuity of care. CRC may be well suited to targeted knowledge translation strategies to improve guideline adherence.

Reach for recovery: evaluating a pilot study of a colorectal cancer survivorship programme

PURPOSE

More people are living with and beyond a cancer diagnosis and new models of care are required which not only help cancer survivors meet their needs after cancer treatment but also offer guidance on how they might optimize their future quality of life.

METHODS

'Reach for recovery' is a programme of educational group support which was designed specifically for colorectal cancer patients on completion of treatment. This new initiative consisted of weekly sessions offering group support and information to promote recovery from treatment and transition into cancer survivorship. The first two programmes constituted a pilot study and were evaluated to inform future content and development.

RESULTS

A total of seventeen patients participated in the first two programmes. Completed evaluations (n = 13) revealed that the content of the programme was perceived to be beneficial, the sessions were rated as informative and relevant to individual needs and participants had enjoyed meeting others in a similar situation. While nearly all eligible patients expressed interest in the programme, less than half of those invited attended more than one session. Establishing the resources for the programme and recruiting participants to the programme proved resource-intensive and this may limit its sustainability.

CONCLUSION

This initiative was well received by both cancer survivors and clinicians and offered both support and education at a critical transition time in colorectal cancer patients entry into survivorship. Careful consideration must be given to the programme venue, frequency and timing for the successful delivery of such initiatives.

Consequences, control and appraisal: cues and barriers to engaging in self-management among people affected by colorectal cancer - a secondary analysis of qualitative data

BACKGROUND

Little is known about peoples' self-management experiences and their desires or expectations to engage in self-management. As such, there is little understanding about individuals' perceived cues and barriers to engagement in self-management, particularly in people affected by cancer.

OBJECTIVE

To understand cues and barriers to people's engagement in self-management during chemotherapy treatment for colorectal cancer.

DESIGN

Secondary analysis of qualitative data from mixed methods, longitudinal study.

SETTING AND PARTICIPANTS

Eleven participants undergoing treatment for colorectal cancer. Semi-structured interviews were conducted twice with each participant, at the start and end of a 6-month course of chemotherapy treatment in a Scottish cancer centre.

RESULTS

Cues and barriers to engagement in self-management appeared to stem from perceptions of the impact and associated severity of side effects experiences as well as the perceptions about the efficacy of chosen self-management activities and perceptions of control in minimizing the consequences of cancer treatment. Severe, episodic or unexpected side effects coupled with perceptions of uncertainty, lack of control and lack of adequate preparation to engage in self-management were identified as key barriers to engagement.

DISCUSSION AND CONCLUSION

Participants' reflection on, or appraisal of, their treatment-related experiences and personal abilities, confidence and preferences to manage the impact of these shaped their subsequent engagement in self-management. The findings highlight the importance of understanding individual's self-management experiences, perceptions, preferences, priorities and needs to help support, prepare and enable them to feel capable and confident to engage actively and effectively in self-management.

What happens now? Psychosocial care for cancer survivors after medical treatment completion

The growing population of adults living with a history of cancer in the United States mandates attention to quality of life and health in this group, as well as to the implementation of evidence-based interventions to address psychosocial and physical concerns at completion of medical treatments and beyond. The goals of this article are to document the need for attention to psychosocial domains during the re-entry and later phases of the cancer survivor trajectory, offer an overview of current evidence on efficacy of psychosocial interventions during those phases, and offer suggestions for application and research regarding post-treatment psychosocial care.