Models of Cancer Survivorship Care: Overview and Summary of Current Evidence

Quality of Cancer Surveillance Clinical Practice Guidelines: Specificity and Consistency of Recommendations

Importance

Primary care clinicians, who are increasingly responsible for caring for the growing population of cancer survivors, may be unfamiliar with appropriate cancer surveillance strategies. Clinical practice guidelines can inform cancer follow-up care and surveillance testing. Vague recommendations and inconsistencies among guidelines can lead to overuse and underuse of health care resources and have a negative impact on cost and quality of survivorship care.

Objective

To examine the specificity and consistency of recommendations for surveillance after active treatment across cancer guidelines.

Design, Setting, and Participants

Retrospective cross-sectional analysis of national cancer guidelines from North America and Europe published since 2010 addressing posttreatment care for survivors of the 9 most common cancers. We categorized surveillance modalities into history and physical examinations, tumor markers, diagnostic procedures (eg, colonoscopy), and imaging. Within each guideline, we classified individual recommendations into 5 categories: (1) risk-based recommendation, (2) recommendation for surveillance, (3) addressed but no clear recommendation, (4) recommendation against surveillance, or (5) cases in which surveillance was not addressed. We reviewed each surveillance recommendation for frequency and a stop date, evaluated consistency among guidelines, and analyzed associations between the organizations proposing the guidelines and recommendation characteristics.

Main Outcomes and Measures

Description of guideline recommendations for cancer surveillance.

Results

We identified 41 guidelines published between January 1, 2010, and March 1, 2016. Eighty-five percent of guidelines (35) were from professional organizations. Ambiguous recommendations (ie, modality not discussed or discussed without a clear recommendation) were present in 83% of guidelines (34), and 44% (18) recommended against at least 1 test. European guidelines were more likely than North American guidelines to contain ambiguous recommendations (100% vs 68%; P < .01). Recommendations commonly specified testing frequency (from 88% [14 of 16] for tumor markers to 92% [24 of 26] for procedures and/or imaging) but infrequently provided a definitive stop time. Cross-sectional imaging recommendations varied among guidelines for each cancer. For example, among breast cancer guidelines, surveillance computed tomographic scans were recommended against in 2, discussed without a clear recommendation in 1, and not addressed in 3 guidelines.

Conclusions and Relevance

Guidelines addressing the care of cancer survivors have low specificity and consistency. As guidelines continue to be revised, developers should clarify recommendations with simple, nonambiguous, definitive language for or against the use of specific tests to optimize care quality and resource utilization.

Reprint of: Long-Term Survivorship after Hematopoietic Cell Transplantation: Roadmap for Research and Care

The number of survivors after hematopoietic cell transplantation (HCT) is expected to dramatically increase over the next decade. Significant and unique challenges confront survivors for decades after their underlying indication (malignancy or marrow failure) has been cured by HCT. The National Institutes of Health (NIH) Late Effects Consensus Conference in June 2016 brought together international experts in the field to plan the next phase of survivorship efforts. Working groups laid out the roadmap for collaborative research and health care delivery. Potentially lethal late effects (cardiac/vascular, subsequent neoplasms, and infectious), patient-centered outcomes, health care delivery, and research methodology are highlighted here. Important recommendations from the NIH Consensus Conference provide fresh perspectives for the future. As HCT evolves into a safer and higher-volume procedure, this marks a time for concerted action to ensure that no survivor is left behind.

Accuracy and Thoroughness of Treatment Summaries Provided as Part of Survivorship Care Plans Prepared by Two Cancer Centers

PURPOSE

Treatment summaries prepared as part of survivorship care planning should correctly and thoroughly report diagnosis and treatment information.

METHODS

As part of a clinical trial, summaries were prepared for patients with stage 0 to III breast cancer at two cancer centers. Summaries were prepared per the standard of care at each center via two methods: using the electronic health record (EHR) to create and facilitate autopopulation of content or using manual data entry into an external software program to create the summary. Each participant's clinical data were abstracted and cross-checked against each summary. Errors were defined as inaccurate information, and omissions were defined as missing information on the basis of the Institute of Medicine recommended elements.

RESULTS

One hundred twenty-one summaries were reviewed: 80 EHR based versus 41 software based. Twenty-four EHR-based summaries (30%) versus six software-based summaries (15%) contained one or more omissions. Omissions included failure to provide dates and specify all axillary surgeries for EHR-based summaries and failure to specify receptors for software-based summaries. Eight EHR-based summaries (10%) versus 19 software-based summaries (46%) contained one or more errors. Errors in EHR-based summaries were mostly discrepancies in dates, and errors in software-based summaries included incorrect stage, surgeries, chemotherapy, and receptors.

CONCLUSION

A significant proportion of summaries contained at least one error or omission; some were potentially clinically significant. Mismatches between the clinical scenario and templates contributed to many of the errors and omissions. In an era of required care plan provision, quality measures should be considered and tracked to reduce rates, decrease inadvertent contributions from templates, and support audited data use.

Long-Term Survivorship after Hematopoietic Cell Transplantation: Roadmap for Research and Care

The number of survivors after hematopoietic cell transplantation (HCT) is expected to dramatically increase over the next decade. Significant and unique challenges confront survivors for decades after their underlying indication (malignancy or marrow failure) has been cured by HCT. The National Institutes of Health (NIH) Late Effects Consensus Conference in June 2016 brought together international experts in the field to plan the next phase of survivorship efforts. Working groups laid out the roadmap for collaborative research and health care delivery. Potentially lethal late effects (cardiac/vascular, subsequent neoplasms, and infectious), patient-centered outcomes, health care delivery, and research methodology are highlighted here. Important recommendations from the NIH Consensus Conference provide fresh perspectives for the future. As HCT evolves into a safer and higher-volume procedure, this marks a time for concerted action to ensure that no survivor is left behind.

Exploration of return-to-work interventions for breast cancer patients: a scoping review

PURPOSE

Many women who have been diagnosed with breast cancer (BC) would like to return to work after undergoing cancer treatment. This review explores the nature of interventions addressing return to work (RTW) for this population.

METHOD

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in five bibliographic databases from 2005 to 2015 to identify intervention studies. Article selection and characterization were performed by two reviewers using systematic grids. Themes were identified to construct a narrative summary of the existing literature.

RESULTS

The literature search identified 17 articles published between 2005 and 2015. The interventions (n = 16) vary in terms of objectives, methodology, description of intervention activities, and period of deployment. Only one intervention referred to a theory linked to RTW. The results further show that nearly 44% of the interventions found provided only information on RTW (information booklet, individual meeting, group session). Only 38% of the interventions were work-directed and offered other activities, such as coordination of services and information, as well as instructions for drawing up an RTW plan. More than 80% of the interventions were provided by health care professionals. Interventions took place during the survivorship period (75%), at the hospital (44%), or an external rehabilitation center (38%).

CONCLUSION

The variability of interventions found indicates the need to clarify the concept of RTW after a BC diagnosis. Recommendations are made for the development of multicomponent interventions that include both the clinic and the workplace to meet the particular needs of this population.

Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities

Since the release of the Institute of Medicine report: From cancer patient to cancer survivor: lost in transition, in 2005, there has been a national call in the USA to provide coordinated, comprehensive care for cancer survivors, with an emphasis on the role of primary care. Several models of care have been described, which focus on primary care providers (PCPs) as receiving cancer survivors who are transferred after successful treatment, and who are given specific types of information from oncology-based care (eg, survivorship care plans), and not as active members of the cancer survivorship team. In this Series paper, we assessed survivorship models that have been described in the literature, with a specific focus on strategies that aim to integrate PCPs into the care of cancer survivors across different settings. We offer insights differentiating PCPs' level of expertise in cancer survivorship and how such expertise could be used. We provide recommendations for education, clinical practice, research, and policy initiatives that might advance the integration of PCPs in the care of cancer survivors in diverse clinical settings.

The experiences of cancer survivors while transitioning from tertiary to primary care

PURPOSE

In current fiscally constrained health care systems, the transition of cancer survivors to primary care from tertiary care settings is becoming more common and necessary. The purpose of our study was to explore the experiences of survivors who are transitioning from tertiary to primary care.

METHODS

One focus group and ten individual telephone interviews were conducted. Data saturation was reached with 13 participants. All sessions were audio-recorded, transcribed verbatim, and analyzed using a qualitative descriptive approach.

RESULTS

Eight categories relating to the main content category of transition readiness were identified in the analysis. Several factors affected participant transition readiness: how the transition was introduced, perceived continuity of care, support from health care providers, clarity of the timeline throughout the transition, and desire for a "roadmap." Although all participants spoke about the effect of their relationships with health care providers (tertiary, transition, and primary care), their relationship with the primary care provider had the most influence on their transition readiness.

CONCLUSIONS

Our study provided insights into survivor experiences during the transition to primary care. Transition readiness of survivors is affected by many factors, with their relationship with the primary care provider being particularly influential. Understanding transition readiness from the survivor perspective could prove useful in ensuring patient-centred care as transitions from tertiary to primary care become commonplace.

Military veteran cancer survivors' preferences for a program to address lifestyle change and psychosocial wellness following treatment

This study aimed to understand military veteran cancer survivors' preferences regarding the delivery of post-treatment wellness services. Thirty-three military veteran cancer survivors were interviewed about their perceptions of three models of health service delivery (home-, primary care-, and oncology-based services). Conventional qualitative content analysis revealed strengths and weaknesses of each service delivery model's content and structure (e.g., program location, inclusion of emotional support, access to clinical experts). All service delivery programs had strengths, with clinic-based programs offering the greatest breadth of services deemed important for wellness by cancer survivors.

Improving the Transition From Oncology to Primary Care Teams: A Case for Shared Leadership

This article discusses the case of a 47-year-old woman who underwent primary therapy with curative intent for breast cancer. The case illustrates a number of failure events in transferring information and responsibility from oncology to primary care teams. The article emphasizes the importance of shared leadership, as multiple team members, dispersed in time and space, pursue their own objectives while achieving the common goal of coordinating care for survivors of cancer transitioning across settings. Shared leadership is defined as a team property comprising shared responsibility and mutual influence between the patient and the patient’s family, primary care providers, and oncology teams, whereby they lead each other toward quality and safety of care. Teams, including the patient-family, should achieve leadership when their contribution is relevant in managing task interdependence during transition. Shared leadership fosters coordinated actions to enable functioning as an integrated team-of-teams. This article illustrates how shared leadership can make a difference to coordinate interfaces and pathways, from therapy with curative intent to the follow-up and management of survivors of breast cancer. The detailed case is elaborated as a clinical vignette. It can be used by care providers and researchers to consider the need for new models of care for survivors of cancer by addressing the following questions. Who accepts shared leadership, how, with whom, and under what conditions? What is the evidence that supports the answers to these questions? The detailed case is also valuable for medical and allied health professional education.

Unequal cancer survivorship care: addressing cultural and sociodemographic disparities in the clinic

The number of individuals diagnosed with cancer is growing worldwide. Cancer patients from underserved populations have widely documented disparities through the continuum of cancer care. As the number of cancer survivors (i.e., individuals who have completed cancer treatment) from underserved populations also continue to grow, these individuals may continue to experience barriers to survivorship care, resulting in persistent long-term negative impacts on health and quality of life. In addition, there is limited participation of survivors from underserved populations in clinical trials and other research studies. To address disparities and change practices in survivorship care, a better understanding of the roles of both socioeconomic status (SES) and of culture in cancer care disparities and the relevance of these to providing high-quality care is needed. SES and culture often overlap but are not identical; understanding the impact of each is especially relevant to survivorship care. To enhance health equity among cancer survivors, clinicians need to practice culturally competent care, address cultural beliefs and practices that may influence survivors' beliefs and activities, gain awareness of historical patterns of medical care in the survivor's community, and consider how barriers to cross-cultural communications may hinder communication in clinical settings. While the design and implementation of survivorship care programs emphasizing effectiveness and equity is complex and potentially time consuming, it is critical for providing optimal care for all survivors, including those from the most vulnerable populations.

National Institutes of Health Blood and Marrow Transplant Late Effects Initiative: The Healthcare Delivery Working Group Report

Hematopoietic cell transplantation (HCT) survivors are at risk for development of late complications and require lifelong monitoring for screening and prevention of late effects. There is an increasing appreciation of the issues related to healthcare delivery and coverage faced by HCT survivors. The 2016 National Institutes of Health Blood and Marrow Transplant Late Effects Initiative included an international and broadly representative Healthcare Delivery Working Group that was tasked with identifying research gaps pertaining to healthcare delivery and to identify initiatives that may yield a better understanding of the long-term value and costs of care for HCT survivors. There is a paucity of literature in this area. Critical areas in need of research include pilot studies of novel and information technology supported models of care delivery and coverage for HCT survivors along with development and validation of instruments that capture patient-reported outcomes. Investment in infrastructure to support this research, such as linkage of databases including electronic health records and routine inclusion of endpoints that will inform analyses focused around care delivery and coverage, is required.

Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care

PURPOSE

This study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models.

METHODS

Snowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators' summaries of care models. We used a multistep immersion/crystallization analytic approach, guided by a primary care organizational change model.

RESULTS

Innovative practice models included: (1) a consultative model in a primary care setting; (2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; (3) an oncology nurse navigator in a primary care practice; and (4) two subspecialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers.

CONCLUSIONS

Cancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors' needs.

IMPLICATIONS FOR CANCER SURVIVORS

Current models of primary care-based cancer survivorship care may not be sustainable. Innovative strategies to provide quality care to this growing population of survivors need to be developed and integrated into primary care settings.

Breast and prostate cancer survivors' experiences of patient-centered cancer follow-up care from primary care physicians and oncologists

PURPOSE

Patient-physician relationships impact health care seeking and preventive screening behaviors among patients. At the end of active treatment some cancer survivors report feeling disconnected from their care team. This study explores cancer survivors' experiences of patient-centered cancer follow-up care provided by primary care physicians (PCP) and oncologists (ONC).

METHODS

Three hundred five early stage, breast and prostate cancer survivors at least 2 years post treatment were surveyed from four community hospital oncology programs in New Jersey. Participants reported receipt of patient-centered care measured by care coordination, comprehensiveness of care, and personal relationship with PCPs and ONCs.

RESULTS

PCPs received higher ratings for coordination of care and comprehensive care than ONCs from all survivors (P < 0.01). However, prostate and breast cancer survivors rated strengths of their personal bonds with the physicians differently. While prostate cancer survivors rated PCPs significantly higher for all items (P < 0.028), breast cancer survivors rated ONCs significantly higher on four out of seven items including having been through a lot together, understanding what is important regarding health, knowing their medical history and taking their beliefs and wishes into account (P < 0.036).

CONCLUSIONS

Prostate and breast cancer survivors report different experiences with their PCPs and oncologists around the comprehensiveness and coordination of their cancer follow-up care in addition to the strength of their relationships with their physicians.

IMPLICATIONS FOR CANCER SURVIVORS

There are important differences in the experience of patient-centered care among cancer survivors that should be considered when planning care models and interventions for these different populations.

What They Want: Inclusion of Blood and Marrow Transplantation Survivor Preference in the Development of Models of Care for Long-Term Health in Sydney, Australia

Four hundred forty-one adult allogeneic blood and marrow transplantation (BMT) survivors participated in a cross-sectional survey to assess long-term follow-up (LTFU) model of care preference. Survey instruments included the Sydney Post BMT Survey, Functional Assessment of Cancer Therapy-BMT, Depression Anxiety Stress Scales 21, the Chronic GVHD Activity Assessment-Patient Self Report (Form B), the Lee Chronic GVHD Symptom Scale and the Post-Traumatic Growth Inventory. We found most BMT survivors (74%) would prefer LTFU with their transplantation physicians alone or in combination with transplantation center-linked services (satellite clinics or telemedicine) Over one-quarter indicated a preference for receiving comprehensive post-transplantation care in a "satellite" clinic staffed by their BMT team situated closer to their place of residence, with higher income, higher educational level, and sexual morbidity being significant social factors influencing this preference. Regular exercise was reported less often in those who preferred telemedicine, which may reflect reduced mobility. The factor most strongly associated with a preference for transplantation center follow-up was the severity of chronic graft-versus-host disease. Full- and part-time work were negatively associated with transplantation center follow-up, possibly implying decreased dependency on the center and some return to normalcy. This study is the first to explore the preferences of BMT survivors for long-term post-transplantation care. These data provides the basis for LTFU model of care development and health service reform consistent with the preferences of BMT survivors.

Wellness Beyond Cancer Program: building an effective survivorship program

BACKGROUND

The Wellness Beyond Cancer Program (wbcp) was launched in 2012, first accepting patients with colorectal cancer (crc) and, subsequently, those with breast cancer (bca), with the aim of standardizing and streamlining the discharge process from our cancer centre. Patients are discharged either to the wbcp nurse practitioner or to their primary care provider (pcp). The program incorporates survivorship care plans (scps) and education classes; it also has a rapid re-entry system in case of recurrence. The objective of this paper is to describe the process by which a cancer survivorship program was developed at our institution and to present preliminary evaluation results.

METHODS

Qualitative surveys were mailed to patients and pcps 1 year after patients had been referred to the wbcp. The surveys addressed knowledge of the program content, satisfaction on the part of patients and providers, and whether scp recommendations were followed. Questions were scored on the level of agreement with each of a list of statements (1 = strongly disagree to 5 = strongly agree).

RESULTS

From March 2012 to November 2014, 2630 patients were referred to the wbcp (809 with crc, 1821 with bca). Surveys were received from 289 patients and 412 pcps. Patients and pcps gave similar scores (average: 4) to statements about satisfaction; pcps gave scores below 4 to statements about communication with the wbcp.

CONCLUSIONS

At 1 year after discharge, patients and pcps were satisfied with program content, but there is an opportunity to improve on communication and provision of cancer-specific information to the pcps. Using the wbcp to ensure a safe transition to the most appropriate health care provider, we have standardized the discharge process for crc and bca patients.

Evidence-Based Cancer Survivorship Activities for Comprehensive Cancer Control

INTRODUCTION

One of six priorities of CDC's National Comprehensive Cancer Control Program (NCCCP) is to address the needs of cancer survivors within the local population served by individually funded states, tribes, and territories. This report examines cancer survivorship activities implemented in five NCCCP grantees, which have initiated evidence-based activities outlined in A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies (NAP).

METHODS

NCCCP action plans, submitted annually to CDC, from 2010 to 2014 were reviewed in February 2015 to assess implementation of cancer survivorship activities and recommended strategies consistent with the NAP. Four state-level and one tribal grantee with specific activities related to one of each of the four NAP strategies were chosen for inclusion. Brief case reports describing the initiation and impact of implemented activities were developed in collaboration with each grantee program director.

RESULTS

New Mexico, South Carolina, Vermont, Washington state, and Fond Du Lac Band of Lake Superior Chippewa programs each implemented activities in surveillance and applied research; communication, education, and training; programs, policies, and infrastructure; and access to quality care and services.

CONCLUSIONS

This report provides examples for incorporating cancer survivorship activities within Comprehensive Cancer Control programs of various sizes, demographic makeup, and resource capacity. New Mexico, South Carolina, Vermont, Washington state, and Fond Du Lac Band developed creative cancer survivorship activities that meet CDC recommendations. NCCCP grantees can follow these examples by implementing evidence-based survivorship interventions that meet the needs of their specific populations.

Views of family physicians about survivorship care plans to provide breast cancer follow-up care: exploration of results from a randomized controlled trial

BACKGROUND

The U.S. Institute of Medicine recommends that cancer patients receive survivorship care plans, but evaluations to date have found little evidence of the effectiveness of such plans. We conducted a qualitative follow-on study to a randomized controlled trial (rct) to understand the experiences of family physicians using survivorship care plans to support the follow-up of breast cancer patients.

METHODS

A subset of family physicians whose patients were enrolled in the parent rct in Ontario and Nova Scotia were eligible for this study. In interviews, the physicians discussed survivorship care plans (intervention) or usual discharge letters (control), and their confidence in providing follow-up cancer care.

RESULTS

Of 123 eligible family physicians, 18 (10 intervention, 8 control) were interviewed. In general, physicians receiving a survivorship care plan found only the 1-page care record to be useful. Physicians who received only a discharge letter had variable views about the letter's usefulness; several indicated that it lacked information about potential cancer- or treatment-related problems. Most physicians were comfortable providing care 3-5 years after diagnosis, but desired timely and informative communication with oncologists.

CONCLUSIONS

Although family physicians did not find extensive survivorship care plans useful, discharge letters might not be sufficiently comprehensive for follow-up breast cancer care. Effective strategies for two-way communication between family physicians and oncologists are still lacking.