Summing it up: an integrative review of studies of cancer survivorship care plans (2006-2013)

A pilot randomized controlled trial to evaluate a survivorship care planning intervention for head and neck cancer survivor-caregiver dyads

PURPOSE

Head and neck cancer (HNC) survivors and caregivers face significant challenges after treatment. This study's objective was to evaluate the effects of a dyadic survivorship care planning (SCP) intervention on survivor and caregiver outcomes.

METHODS

This randomized controlled trial enrolled HNC survivors and caregivers within 18 months post-treatment, randomized dyads to SCP (one-session with written SCP and follow-up telephone call) or usual care and administered baseline and 6-month surveys. Multivariable linear regression examined intervention effects on depression and unmet needs in dyads and burden on caregiverss and a set of secondary outcomes. Rating scales and open-ended questions assessed acceptability.

RESULTS

We randomized 89 survivor-caregiver dyads (42 usual care, 47 SCP dyads). Fidelity to SCP was high for most survivorship domains except discussing care barriers (13%). The most commonly discussed referrals included nutrition (83%) and behavioral medicine (38%), but referral uptake was low. The SCP intervention did not improve depression or unmet needs among dyads or burden among caregivers at 6 months relative to usual care (p's > .05). Nurses and dyads rated SCP favorably with > 80% positive ratings for session length and care plan content. Qualitative findings highlighted that SCP helped consolidate complex clinical information and strengthened survivor-caregiver-clinician relationships.

CONCLUSIONS

An HNC SCP intervention was acceptable but ineffective in improving dyads' outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

Post-treatment SCP in HNC dyads was ineffective in improving outcomes in survivors and caregivers as delivered in this study. More research is needed to understand how to capitalize on the acceptability of the SCP approach and enhance its effectiveness to support dyads.

Oncological healthcare providers' perspectives on appropriate melanoma survivorship care: a qualitative focus group study

BACKGROUND

The increasing group of melanoma survivors reports multiple unmet needs regarding survivorship care (SSC). To optimise melanoma SSC, it is crucial to take into account the perspectives of oncological healthcare providers (HCPs) in addition to those of patients. The aim of this study is to gain an in-depth understanding of HCPs' perspectives on appropriate melanoma SSC.

METHODS

Four online focus groups were conducted with mixed samples of oncological HCPs (dermatologists, surgeons, oncologists, oncological nurse practitioners, support counsellors and general practitioners) (total n = 23). A topic guide was used to structure the discussions, focusing on perspectives on both SSC and survivorship care plans (SCPs). All focus groups were recorded, transcribed verbatim, and subjected to an elaborate thematic content analysis.

RESULTS

Regarding SSC, HCPs considered the current offer minimal and stressed the need for broader personalised SSC from diagnosis onwards. Although hardly anyone was familiar with SCPs, they perceived various potential benefits of SCPs, such as an increase in the patients' self-management and providing HCPs with an up-to-date overview of the patient's situation. Perceived preconditions for successful implementation included adequate personalisation, integration in the electronic health record and ensuring adequate funding to activate and provide timely updates.

CONCLUSIONS

According to HCPs there is considerable room for improvement in terms of melanoma SSC. SCPs can assist in offering personalised and broader i.e., including psychosocial SSC. Aside from personalisation, efforts should be focused on SCPs' integration in clinical practice, and their long-term maintenance.

Re-engineering Survivorship Care Plans to Support Primary Care Needs and Workflow: Results From an Engineering, Primary Care and Oncology Collaborative for Survivorship Health (EPOCH)

Maintaining the health of survivors requires communication, collaboration and care coordination between oncology and primary care. Primary care clinicians have been acknowledged as important recipients of survivorship care plans (SCPs); however, current SCP templates have not been evaluated for usefulness in the primary care context. We surveyed and interviewed primary care clinicians from a rural research network regarding SCP content, format and layout (phase 1), and potential use and clinical workflows around SCPs (phase 2). Based on these data, an existing SCP template was iteratively redesigned to better support survivorship care in the primary care setting. A total of 13 clinicians (9 MDs, 4 APPs) participated. Interviewees advocated for maintaining a single SCP document shared by survivors and clinicians. Changes to the SCP template included prioritizing follow-up over summary of treatment and removing or down-playing screening recommendations not impacted by cancer or cancer treatment. The re-engineered SCP was regarded as highly relevant for survivors, but clinicians noted the significant effort to "disassemble" SCPs in order to enter the information into on the receiving health record. Primary care clinicians value the information in SCPs but had important recommendations regarding content, layout, and format. Additionally, a significant effort appears to be required by recipients in order to extract SCP information for future use.

ESMO Expert Consensus Statements on Cancer Survivorship: promoting high-quality survivorship care and research in Europe

BACKGROUND

The increased number of cancer survivors and the recognition of physical and psychosocial challenges, present from cancer diagnosis through active treatment and beyond, led to the discipline of cancer survivorship.

DESIGN AND METHODS

Herein, we reflected on the different components of survivorship care, existing models and priorities, in order to facilitate the promotion of high-quality European survivorship care and research.

RESULTS

We identified five main components of survivorship care: (i) physical effects of cancer and chronic medical conditions; (ii) psychological effects of cancer; (iii) social, work and financial effects of cancer; (iv) surveillance for recurrences and second cancers; and (v) cancer prevention and overall health and well-being promotion. Survivorship care can be delivered by structured care models including but not limited to shared models integrating primary care and oncology services. The choice of the care model to be implemented has to be adapted to local realities. High-quality care should be expedited by the generation of: (i) focused and shared European recommendations, (ii) creation of tools to facilitate implementation of coordinated care and (iii) survivorship educational programs for health care teams and patients. The research agenda should be defined with the participation of health care providers, researchers, policy makers, patients and caregivers. The following patient-centered survivorship research areas were highlighted: (i) generation of a big data platform to collect long-term real-world data in survivors and healthy controls to (a) understand the resources, needs and preferences of patients with cancer, and (b) understand biological determinants of survivorship issues, and (ii) develop innovative effective interventions focused on the main components of survivorship care.

CONCLUSIONS

The European Society for Medical Oncology (ESMO) can actively contribute in the efforts of the oncology community toward (a) promoting the development of high-quality survivorship care programs, (b) providing educational material and (c) aiding groundbreaking research by reflecting on priorities and by supporting research networking.

The Association between Survivorship Care Plans and Patient-Reported Satisfaction and Confidence with Follow-Up Cancer Care Provided by Primary Care Providers

Survivorship care plans aim to facilitate a smooth transition from tertiary to primary care settings after primary cancer treatment is completed. This study sought to identify the sociodemographic factors associated with receiving a survivorship care plan and examine the relationship between receiving a plan and confidence in follow-up care delivered by primary care providers. A cross-sectional analysis of the Canadian Partnership Against Cancer's Experiences of Cancer Patients in Transition Study was conducted (n = 9970). Separate adjusted multinomial logistic regression models assessed the relationship between survivorship care plans and follow-up care outcomes. Proportion of survivors more likely to receive a survivorship care plan varied by numerous sociodemographic and medical factors, such as cancer type (colorectal and prostate), gender (male), and education (high school or less). In unadjusted and adjusted models, individuals who received a Survivorship Care Plan had significantly higher odds of: having felt their primary care providers were involved; agreeing that their primary care providers understood their needs, knew where to find supports and services, and were able to refer them directly to services; and were confident that their primary care provider could meet their follow-up care needs.

Quality of Life and Survivorship in Lymphoma

PURPOSE OF REVIEW

With an increasing number of long-term lymphoma survivors, there has been emphasis on optimizing quality of life and identifying survivorship challenges. This review summarizes the latest advancements pertaining to health-related quality of life and survivorship in lymphoma.

RECENT FINDINGS

Quality of life can vary from diagnosis through survivorship though some physical, social, and emotional effects may be persistent. Incorporation of patient reported outcomes enables recognition of factors that significantly impact quality of life. A greater understanding of quality of life and survivorship issues has generated momentum for practice change, improving education, and designing behavior related interventions. Patients with lymphoma face many challenges as they navigate their cancer experience. There is a tremendous opportunity to build upon this work through well-designed prospective longitudinal studies aimed at identifying vulnerable patient groups and impactful points of intervention during survivorship.

[Survivorship care plans for cancer patients: the importance of risk stratification, self-management and health literacy in the age of digital care]

In Deutschland wie allen anderen Industrieländern weltweit nimmt mit einer älter werdenden Bevölkerung und einer verbesserten Krebsfrüherkennung, Diagnostik und onkologischen Behandlung die Zahl der Patienten, die geheilt werden oder lange Zeit mit der Erkrankung leben, deutlich zu (Cancer Survivors). Ein Leben mit und nach einer Krebserkrankung bedeutet für viele Patienten ein Leben mit körperlichen und psychosozialen krankheits- und behandlungsbedingten Langzeit- und Spätfolgen. Angesichts des demografischen Wandels, der steigenden Krebsprävalenz sowie des medizinischen Fortschritts ist eine der dringenden Fragen, wie eine qualitativ hochwertige individualisierte und gleichzeitig finanzierbare Krebsversorgung für älter werdende, häufig multimorbide Patienten sichergestellt werden kann.

Diese Entwicklungen erfordern neben einer Stärkung der Krebsprävention die Erforschung und Umsetzung einer individualisierten Nachsorge im Rahmen von Survivorship-Care-Programmen (SCP). Übergreifende Zielsetzung von SCP ist es, den körperlichen wie psychosozialen Langzeit- und Spätfolgen vorzubeugen bzw. diese zu minimieren, die Mortalität zu senken sowie die Lebensqualität von Patienten zu verbessern. Die Evidenz zur Wirksamkeit von SCP hinsichtlich der Verbesserung patientenberichteter Endpunkte ist bislang nicht eindeutig. Die Bereitstellung von maßgeschneiderten Informationen sowie von risikomodifizierenden und bedarfsorientierten Angeboten auf der Basis einer Risikostratifizierung wird als zentraler Bestandteil bei der Implementierung von SCP angesehen. Dabei nimmt die Förderung von Selbstmanagement- und Gesundheitskompetenzen der Patienten, insbesondere vor dem Hintergrund der Zunahme von digitalen Gesundheitsanwendungen, einen hohen Stellenwert ein.

Oncology and Primary Care Provider Views on Cancer Survivorship Care: Mind the Gap

CONTEXT

Coordination between oncology and primary care practices in cancer survivorship is lacking.

OBJECTIVE

To identify cancer care coordination perceptions, knowledge, and practices in a sample of Oklahoma oncology care providers (ONCs) and primary care providers (PCPs) regarding post-treatment care of adult cancer survivors.

DESIGN

Cross-sectional, statewide survey by mail/web link in 2014/5.

SETTING

PCPs identified through a primary care research network, primary care organization membership lists; ONCs identified through www.Healthgrades.com.

PARTICIPANTS

Contacts who were clinically active and seeing cancer patients were eligible. The final sample size included 101 ONCs and 58 PCPs who reported actively seeing cancer patients.

MEASURES

Responses to predominately Likert scale or ranked-order questions derived from the Survey of Physician Attitudes Regarding the Care of Cancer Survivors.

ANALYSES

Chi square and t tests were performed to test bivariate associations between provider type and survey measures.

RESULTS

Statistically significant differences (P < .05) between ONC and PCP perceptions were observed for several questions on communication between the 2 provider types, ONC perceptions of PCP ability to address survivorship care, and responsibilities for post-treatment care.

CONCLUSIONS

Highly discrepant perspectives between ONCs and PCPs regarding communications and responsibilities for survivorship care may lead to adverse health outcomes. Interventions aimed at improving care coordination for cancer survivors should define each provider group's responsibilities in survivorship care, and create structures and processes that foster clear channels of communication between ONC and PCP practices.

Barriers and facilitators to the use of survivorship care plans by hematopoietic stem cell transplant survivors and clinicians

PURPOSE

Survivors of hematopoietic stem cell transplants (HSCT) have complex care needs for the remainder of their lives, known as the survivorship period. Survivorship care plans (SCPs) have been proposed to improve care coordination and ultimately survivorship outcomes. We explored the barriers and facilitators of SCP use among HSCT survivors and their clinicians in order to develop more useful SCPs for the HSCT context.

METHODS

Analogous surveys regarding perceived barriers to and facilitators of SCP use based on a sample SCP for a female allogenic HSCT survivor were administered to HSCT survivors and non-transplant oncology and primary care clinicians.

RESULTS

Twenty-seven HSCT survivors and 18 clinicians completed the survey. The main barriers to SCP use were lack of awareness of SCP existence, uncertainty regarding where to find SCP, unclear roles and responsibilities among healthcare teams, length of SCP, and difficultly understanding SCPs. The facilitators of SCP use were increased understanding of survivorship care needs, clarified roles and responsibilities of survivors and clinicians, SCPs that are readily available and searchable in electronic health record, increased awareness of SCP existence and provision to all survivors, and if the SCP is survivor-specific and up-to-date.

CONCLUSIONS

Much of the work regarding SCPs has looked at barriers to creation and provision; however, our study examines factors influencing use of SCPs. By determining the barriers and facilitators surrounding SCP use for HSCT survivors and their clinicians, we can create SCP templates and clinical workflows to optimize SCP use, ideally leading to better outcomes for HSCT survivors.

Cancer survivorship care for young adults: a risk-stratified, multicenter randomized controlled trial to improve symptoms

PURPOSE

Young adult (YA) cancer survivors have high rates of adverse health and psychosocial outcomes. This risk-stratified, multicenter, randomized controlled trial (RCT) compared a self-management survivorship intervention to usual care in YA survivors with symptoms of cancer-related distress, insomnia, fatigue, pain, and/or depression.

METHODS

Eligibility included age 18-39 at diagnosis with an invasive malignancy in the previous 1-5 years. Baseline assessment determined "high need" participants, with 2-5 elevated targeted symptoms. We randomized high need participants to intervention or usual care and offered intervention participants a survivorship clinic visit, which included mutually decided action plans for symptoms. Follow-up calls at 1 and 3 months after the clinic visit reviewed action plan progress. Outcomes compared rates of improved symptoms for intervention vs usual care at 6 months and 12 months.

RESULTS

N = 344 completed baseline assessment, with n = 147 (43%) categorized as high need and randomized. Of n = 73 randomized to the intervention, n = 42 (58%) did not attend their survivorship clinic visit. In intent-to-treat analyses, aggregate symptom scores did not differ between arms, though distress improved for 46% in the intervention arm at 6 months compared to 18% in usual care (p = 0.03) among those with elevated distress at baseline.

CONCLUSIONS

Distress improved for YAs who received self-management survivorship care. However, the study demonstrates a need for alternative strategies for providing YA survivorship care.

TRIAL REGISTRATION

NCT02192333 IMPLICATIONS FOR CANCER SURVIVORS: While YA survivors demonstrate some improved distress when provided survivorship care, to make care accessible and effective, they require options such as remote delivery of care.

Survivorship Care Plan Preferences and Utilization Among Asian American Breast Cancer Survivors

PROBLEM IDENTIFICATION

The survivorship care plan (SCP) is an individualized document with cancer diagnosis, treatment, surveillance, and health promotion recommendations. This integrative review synthesizes the extant literature to understand preferences and utilization of SCPs among Asian American survivors.

LITERATURE SEARCH

The CINAHL®, Embase®, PsycINFO®, and PubMed® databases were searched for articles about Asian American women with breast or cervical cancer and SCPs.

DATA EVALUATION

Two independent reviewers evaluated 481 titles and abstracts according to inclusion and exclusion criteria. Of those 481 titles and abstracts, 14 articles were selected for inclusion.

SYNTHESIS

There was little evidence surrounding utilization of SCPs. Articles identified addressed only survivors of breast cancer, predominately of Southeast Asian descent. Asian American women with breast cancer reported preferences surrounding their survivorship needs. Barriers to delivery of the SCP were related to socioeconomic factors.

IMPLICATIONS FOR RESEARCH

There is a paucity of information guiding evidence-based delivery of SCPs in the vastly heterogenous population of Asian American survivors. More work is needed to provide high-quality care to these survivors.

The Head and Neck Survivorship Tool (HN-STAR) Trial (WF-1805CD): A protocol for a cluster-randomized, hybrid effectiveness-implementation, pragmatic trial to improve the follow-up care of head and neck cancer survivors

Survivors of head and neck cancer (HNC) can have multiple health concerns. To facilitate their care, we developed and pilot-tested a clinical informatics intervention, HN-STAR. HN-STAR elicits concerns online from HNC survivors prior to a routine oncology clinic visit. HN-STAR then presents tailored evidence-based clinical recommendations as a clinical decision support tool to be used during the visit where the oncology clinician and survivor select symptom management strategies and other actions. This generates a survivorship care plan (SCP). Online elicitation of health concerns occurs 3, 6, and 9 months after the clinic visit, generating an updated SCP each time. HN-STAR encompasses important methods of improving survivorship care (e.g., needs assessment, tailored interventions, dissemination of guidelines) and will be evaluated in a pragmatic trial to maximize external validity. This hybrid type 1 implementation-effectiveness trial tests HN-STAR effectiveness while studying barriers and facilitators to implementation in community oncology practices within the National Cancer Institute Community Oncology Research Program. Effectiveness will be measured as differences in key survivorship outcomes between HNC participants who do and do not use HN-STAR over one year after the clinic visit. The primary endpoint is HNC-specific quality of life; other outcomes include patient-centered measures and receipt of guideline-concordant care. Implementation outcomes will be assessed of survivors, providers, and clinic stakeholders. The hybrid design will provide insight into a dose-response relationship between the extent of implementation fidelity and effectiveness outcomes, as well as how to incorporate HN-STAR into standard practice outside the research setting.

[Cancer survivorship care programs and self-management]

BACKGROUND

Survivorship care programs (SCP) are increasingly being implemented in order to ensure long-term and comprehensive care of physical and psychosocial cancer-related sequelae among survivors. In this article, we provide a short overview of SCP and the importance of health-related self-management.

RESULTS

The broad definition of "survivorship" and the high diversity of impairments among cancer survivors warrants a personalized and multidimensional approach. This in turn requires both interdisciplinary and integrated care. To date, the state of knowledge on the efficacy of SCP is limited. A central aim of SCP is to increase health-related self-management, which in turn requires the ability to correctly evaluate and apply health-related information in order to resolve health-related problems (health literacy). Due to the technological developments, additional skills are needed to stay health literate (digital health literacy).

CONCLUSION

Further research on the efficacy of SCP is warranted. Both advantages and risks of digital health programs need to be carefully weighed to avoid inequalities in health care ("digital divide"). Specific education programs to improve digital health literacy may help to minimize such risks.

Testicular cancer follow-up costs in Germany from 2000 to 2015

Purpose

Advances in testicular cancer screening and therapy increased 10-year survival to 97% despite a rising incidence; eventually expanding the population of survivors requiring follow-up. We analyzed 10-year follow-up costs after testicular cancer treatment in Germany during 2000, 2008, and 2015.

Methods

Testicular cancer follow-up guidelines were extracted from the European Association of Urology. Per patient costs were estimated with a micro-costing approach considering direct and indirect medical expenses derived from expert interviews, literature research, and official scales of tariffs. Three perspectives covering costs for patients, providers, and insurers were included to estimate societal costs. Cost progression was compared across cancer histology, stage, stakeholders, resource use, and follow-up years.

Results

Mean 10-year follow-up costs per patient for stage I seminomatous germ-cell tumors (SGCT) on surveillance declined from EUR 11,995 in 2000 to EUR 4,430 in 2015 (p < 0.001). Advanced SGCT spending shrank from EUR 13,866 to EUR 9,724 (p < 0.001). In contrast, expenditure for stage II SGCT increased from EUR 7,159 to EUR 9,724 (p < 0.001). While insurers covered 32% of costs in 2000, only 13% of costs were reimbursed in 2015 (p < 0.001). 70% of SGCT follow-up resources were consumed by medical imaging (x-ray, CT, ultrasound, FDG-PET). Spending was unevenly distributed across follow-up years (years 1–2: 50%, years 3–5: 39%, years 5–10: 11%).

Conclusions

The increasing prevalence of testicular cancer survivors caused German statutory insurers to cut per patient cost by up to 80% by budgeting services and decreasing reimbursement rates. The economic burden was gradually redistributed to patients and providers.

Development of cancer support services for patients and their close ones from the Cancer Society of Finland's perspective

Purpose: This study examined what support cancer patients and their close ones need and how this support should be organized when developing cancer care pathways. The study focused on the opinions of professionals of the Cancer Society of Finland (CSF), who play a central role in presenting the third sector’s perspective on care pathways.

Method: Six semi-structured group interviews were carried out with counselling nurses (n = 12) and managers (n = 9) of the CSF during summer 2017. The results were analysed using content analysis.

Results: Both patients and their close ones need more information, psychosocial support and financial counselling after diagnosis, during rehabilitation and follow-up, at relapse and during the palliative care phase; additionally, close ones require support after the patient’s death. Participants emphasized close collaboration between public healthcare and the CSF to meet the needs of patients and their close ones.

Conclusion: Psychosocial support can—and should—be provided as part of the care pathway. This support can be provided by organizations in the third sector, such as the CSF, which have resources in this area.

Prostate cancer follow-up costs in Germany from 2000 to 2015

Purpose

The main objective of this study is to estimate and evaluate 10-year follow-up costs after prostate cancer treatment with curative (surgery, radiotherapy) and non-curative intent (hormone, androgen deprivation) per patient in Germany in 2000, 2008, and 2015.

Methods

Prostate cancer follow-up recommendations were extracted from the European Association of Urology guidelines from 2000 to 2015. Per patient costs were calculated with a detailed micro-costing approach considering direct and indirect medical expenses. Input parameters were derived from expert interviews, literature research, and official scales of tariffs. Costs for insurers, providers, and payers were included to estimate societal costs.

Results

Mean 10-year follow-up costs per patient after treatment with curative intent amounted to EUR 4415 in 2000, EUR 4224 in 2008 (p < 0.001), and EUR 5159 in 2015 (p < 0.001). Costs after hormone therapy with metastasis cumulated to EUR 10,846 in 2000, EUR 9818 in 2008 (p < 0.001), and EUR 11,978 in 2015 (p < 0.001). While insurers covered 37% of costs in 2000 (EUR 1664), only 23% of costs were reimbursed in 2015 (EUR 1195; p < 0.001). Cost sources mainly included consultations (55%), transportation (18%), and imaging (27%).

Conclusion

Early detection and advances in prostate cancer treatment increased 10-year survival rates beyond 80% in Germany, ultimately expanding the number of survivors requiring follow-up. Statutory insurers reacted by decreasing the reimbursement rates to reduce per patient cost by up to 46%. Consequently, the economic burden was mainly shifted to payers and providers.

Implications for Cancer Survivors

Equitable and effective follow-up schedules covered by insurance funds are necessary to care for prostate cancer patients.

Thyroid cancer patients satisfaction at the management outcome: an analysis of the results of a nationwide survey in 485 subjects

BACKGROUND

We aimed to measure satisfaction of patients with thyroid cancer concerning different aspects of healthcare.

METHODS

We developed a web-based survey. Questions focused on patient satisfaction with specialists, the health centers and departments, and the information received about their disease. Level of satisfaction was quantified using a scale of 1 to 5. Values ≥4 were considered a high degree of satisfaction.

RESULTS

Four hundred eighty-five patients (aged 43.4 ± 9.9 yrs., 88% females) completed the survey. A high overall satisfaction with the specialists was reported by 52.5% of patients. The most highly valued specialists were surgeons, oncologists, and endocrinologists. 56.5% of respondents reported a high overall satisfaction with the health centers and departments. Lastly, the proportion of patients who were highly satisfied with the information received was only 42.5%. The presence of complications was indirectly related with satisfaction with specialists and information. Satisfaction with health centers and services was directly related with the level of education and inversely related to the time of evolution of the disease.

CONCLUSION

Our results show a high degree of overall satisfaction of thyroid cancer patients. However, satisfaction can be improved in some areas, such with regards to the information provided to patients.

A Multidisciplinary Approach to Implement Personalized Breast Cancer Treatment and Care Plans

Implementation of survivorship care plans remain a challenge. This quality improvement initiative aims to integrate personalized treatment plans (PTP) and care plans (PCP) into the existing workflow for breast cancer (BC) patients. Methods: Phase 1 was to identify multidisciplinary team members to generate and deliver PTP and PCP. Concurrently, Phase 2 was to deliver PTP and PCP to newly diagnosed invasive BC patients at chemotherapy initiation and completion, respectively. Iterative plan, do, study, act (PDSA) cycles were applied to refine the process. The proportion of information completed for PTP and PCP generation and its delivery by the care team were measured. Patient and provider satisfaction were also assessed. Implementation Process and Results: The care transfer facilitator (CTF) was identified to complete and deliver PTP, and their data entry increased from 0% to 76%, 80%, 92% consecutively during the last 4 PDSA cycles. PTP and PCP were provided to 85% of eligible BC patients. Patients agreed that PTP helped them to actively participate in their care (88%) and communicate with the oncology care team (86%). Primary care physicians agreed that PTP and PCP had the information needed to “stay in the loop” (80%), and oncologists agreed they should be incorporated into oncology clinics (100%). Conclusions: Integrating PTP and PCP generation and delivery into existing workflow has led to an increase in uptake, sustainability and provider buy-in. With limited resources, it remains difficult to find care team members to complete the forms. A dedicated personnel or survivorship clinic is required to successfully implement PTP and PCP as the standard of care.

Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review protocol

INTRODUCTION

Transitions in Care (TiC) are vulnerable periods in care delivery associated with adverse events, increased cost and decreased patient satisfaction. Patients with cancer encounter many transitions during their care journey due to improved survival rates and the complexity of treatment. Collectively, improving TiC is particularly important among patients with cancer. The objective of this scoping review is to synthesise and map the existing literature regarding TiC among patients with cancer in order to explore opportunities to improve TiC among patients with cancer.

METHODS AND ANALYSIS

This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review Extension and the Joanna Briggs Institute methodology. The PubMed cancer filter and underlying search strategy will be tailored to each database (Embase, Cochrane, CINAHL and PsycINFO) and combined with search terms for TiC. Grey literature and references of included studies will be searched. The search will include studies published from database inception until 9 February 2020. Quantitative and qualitative studies will be included if they describe transitions between any type of healthcare provider or institution among patients with cancer. Descriptive statistics will summarise study characteristics and quantitative data of included studies. Qualitative data will be synthesised using thematic analysis.

ETHICS AND DISSEMINATION

Our objective is to synthesise and map the existing evidence; therefore, ethical approval is not required. Evidence gaps around TiC will inform a programme of research aimed to improve high-risk transitions among patients with cancer. The findings of this scoping review will be published in a peer-reviewed journal and widely presented at academic conferences. More importantly, decision makers and patients will be provided a summary of the findings, along with data from a companion study, to prioritise TiC in need of interventions to improve continuity of care for patients with cancer.

Clinical Preventive Services and Self-Management Practices Among Adult Cancer Survivors in the United States Over Time

The objective of this research was to determine if the engagement/participation in health promotion activities of cancer survivors in the United States (US) changed between 2006 and 2015. We pooled two independent cross-sectional data of cancer survivors using Medical Expenditure Panel Surveys from 2006 (N = 791; weighted N = 9,532,674) and 2015 (N = 1067; weighted N = 15,744,959). Health promoting activities consisted of past year influenza immunization, routine physical examination, and dental visit. Self-care included maintaining normal weight, not smoking, and engagement in recommended vigorous physical activity. We conducted unadjusted and adjusted logistic regression analyses to examine the change in engagement in health promoting activities over time. We found rates of annual influenza immunization (66.8% vs 70.3%), dental visit (71.8% vs 70.3%), and normal weight (33.9% vs 33.5%) did not change from 2006 to 2015. The percent with physical examination (90.8% vs 93.8%; P = .03) and non-smokers increased (87.9% vs 91.2; P = .04). Between 2006 and 2015, despite guidelines and recommendations for personalized cancer survivorship health plans, health promoting activities among cancer survivors did not change significantly.

Exploring Interactive Survivorship Care Plans to Support Breast Cancer Survivors: Protocol for a Randomized Controlled Trial

Background

Breast cancer is the most common form of cancer among American women, accounting for 23% of all cancer survivors nationally. Yet, the availability of adequate resources and tools for supporting breast cancer survivors has not kept up with the rapid advancement in treatment options, resulting in unmet supportive care needs, particularly among low-income and minority populations. This study explores an alternative means of delivering breast cancer survivorship care plans (SCPs), with the aim of improving survivor morbidity, patient knowledge, and self-management of treatment-related symptoms, as well as addressing inconsistencies in follow-up care visits.

Objective

The overall goal of this study is to improve the uptake of SCP recommendations via an educational intervention for breast cancer survivors, to improve treatment-related morbidity, patient knowledge, self-management, and adherence to follow-up visits. The specific aims of the study are to (1) evaluate the feasibility of the online SCP, and (2) assess the impact of the online SCP on survivorship outcomes.

Methods

We will enroll 50 breast cancer survivors who have completed initial breast cancer treatment into a 2-armed, randomized, waitlist-controlled pilot trial, and collect data at baseline and 6 months. For the first aim, we will use mixed methods, including surveys and personal interviews among the intervention group, to determine the feasibility of providing an online, interactive SCP (called ACESO) based on the survivors’ online user experience and their short-term adoption. For the secondary aim, we will compare the 2 groups to assess the primary outcomes of survivor knowledge, self-efficacy for self-management, perceived peer support, and adherence to SCP-recommended posttreatment follow-up visits to oncology and primary care; and the secondary outcomes of treatment-related morbidity (body weight, fatigue, depression, anxiety, sexual function, distress, and sleep quality). We assess these outcomes by using measurements from validated instruments with robust psychometric properties.

Results

We have developed and refined the online breast cancer survivorship plan, ACESO, with consultation from breast cancer oncologists, nurses, and survivors. Approval for the study protocol has been obtained from the Institutional Review Board. An advisory board has also been established to provide oversight and recommendations on the conduct of the study. The study will be completed over a period of 2 years.

Conclusions

The results of this pilot study will inform the feasibility and design of a larger-scale pragmatic trial to evaluate the impact of an online breast cancer SCP on treatment-related morbidity and self-efficacy for self-management.

International Registered Report Identifier (IRRID)

PRR1-10.2196/23414

Improvement of the experience of colorectal cancer patients in Sweden with a regional cancer plan

AIM

The Stockholm-Gotland Regional Cancer Plan was launched in 2012 to improve cancer care. A personal contact nurse (CN), an individual written care plan (IWCP) and a standardized care pathway (SCP) were introduced. The aim of the current study was to evaluate whether these efforts have resulted in an improved experience for patients treated for colorectal cancer.

METHOD

Patients treated with bowel resection for colorectal cancer in the Stockholm-Gotland region between 1 January 2013 and 31 December 2017 were identified through the Swedish Colorectal Cancer Registry. Six to eight months postoperatively, the patients received a patient-reported experience questionnaire. Patients were classified as 'satisfied' or 'not satisfied'.

RESULTS

The questionnaire was sent to 4465 patients, and 3154 (70.64%) responded. The proportion of patients assigned a CN increased over time (79.84%-88.44%) and so did the proportion of patients receiving an IWCP (39.36%-70.00%). The waiting times were significantly shortened during the study period. In multivariable analysis, access to a CN and an IWCP was independently associated with increased patient satisfaction (OR 3.03, 95% CI 2.28-4.02 and OR 1.64, 95% CI 1.38-1.94). Patients with a long waiting time were significantly less satisfied than patients with a short waiting time (OR 0.72, 95% CI 0.60-0.88).

CONCLUSION

Implementation of a CN, IWCP and SCP has been successful, measured by a higher proportion of patients gaining access to these assets and shortened waiting times. This has led to an improved patient experience in patients treated for colorectal cancer in the Stockholm-Gotland region.

Cancer survivor's perspectives on the major challenge in the transition to survivorship

OBJECTIVES

To understand cancer survivors' perspectives regarding the major challenge in transitioning from cancer treatment to follow-up care. Identification of major issues should inform survivorship care and help reduce suffering.

METHODS

A national survey was conducted to identify experiences with follow-up for cancer survivors one to three years post-treatment. The survey included open-ended questions for respondents to add topics of importance and details that offer deeper insight into their experiences. This publication presents analysis of the open-ended question about the major challenge faced by adult cancer population.

RESULTS

Of 13,534 unique adult survey respondents, 8706 respondents identified major challenges. Of those reporting challenges, 4727 (54.3 %) named a single challenge but 3979 (45.7 %) identified more than one. In total, 15,351 challenges were identified. Responses to open-ended questions are summarized under significant themes: major concerns are often more than singular issues; recovery and fear of recurrence; and information needs.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Results indicate significant numbers of adult survivors have multiple concerns about physical, emotional, and practical issues but are not receiving assistance and/or appropriate information to help manage these concerns. It is important to determine how health care can be proactive in identifying and addressing needs of survivors.

Development of a Survivorship Care Plan (SCP) Program for Rural Latina Breast Cancer Patients: Proyecto Mariposa-Application of Intervention Mapping

Latina breast cancer survivors are less likely to receive a comprehensive Survivorship Care Plan (SCP) than non-Latina Whites. Evidence-based and theory driven interventions are needed to promote a culturally and linguistically responsive SCP. This paper describes the application of Intervention Mapping (IM) in the development of Proyecto Mariposa, a comprehensive SCP program targeting Latina breast cancer survivors living in a rural U.S.–Mexico border region. We conducted a needs assessment using focus groups (n = 40) and individual interviews (n = 4) with stakeholders to elicit their needs and preferences relating to SCPs and SCP aid (Step1). Content analysis of transcripts was conducted using Atlas.ti. The findings informed the development of a matrix of change objectives where we selected specific behavioral theories to ground the practical application of the SCP program (Step 2). We identified behavioral theories and the practical application of behavioral change (Step 3) and designed and developed a comprehensive SCP program which consisted of a culturally—and linguistically—adapted SCP document and animated video as an SCP aid (Step 4). The systematic application of the IM framework resulted in the development of a comprehensive and culturally tailored SCP intervention. Stakeholder active involvement in the cultural tailoring of the program was imperative and strengthens the SCP intervention.

Enhancing survivorship care planning for patients with localized prostate cancer using a couple-focused web-based, mHealth program: the results of a pilot feasibility study

PURPOSE

To examine the feasibility of an enhanced survivorship care plan (ESCP) that integrated the web-based program Patient Education Resources for Couples (PERC) into a standardized survivorship care plan (SCP) and estimated the outcomes of ESCPs versus SCPs.

METHODS

In this randomized pilot trial, localized prostate cancer (PC) patients and partners (i.e., couple) were randomly assigned to ESCP that contained a link to PERC or to SCP that contained a link to general PC information on the National Cancer Institute website. Couples completed assessments measuring quality of life (QOL), appraisal of symptoms, and coping resources at baseline (T1) and 4-6 months later (T2). We examined feasibility (e.g., recruitment and retention) using descriptive statistics. Linear mixed models examined changes in couples' outcomes over time and Poisson regression examined differences in patient healthcare utilization.

RESULTS

Sixty-two couples completed T1 surveys (recruitment rate 41.6%) and were randomly assigned to receive ESCP (n = 31) or SCP (n = 31). Twenty-eight (ESCP) and 25 (SCP) couples completed T2 surveys (retention rates = 90.3% vs. 80.7%). ESCP participants (70%) reviewed webpages consistent with patients' symptoms. ESCP patients reported greater program satisfaction (p = 0.02) and better urinary symptom scores (p < 0.01) than SCP patients.

CONCLUSIONS

Delivering ESCPs that embed a web-link to a couple-focused, tailored program is feasible and can potentially improve patient outcomes. The promising results need to be validated in a larger definitive trial using a diverse sample.

IMPLICATIONS FOR CANCER SURVIVORS

SCPs, enhanced using a web-based intervention (e.g., PERC), may help PC cancer survivors better manage their urinary symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04350788.

The use of survivorship care plans by female racial and ethnic minority breast cancer survivors: a systematic review

PURPOSE

Racial/ethnic breast cancer survivorship disparities persist as minority breast cancer survivors (MBCSs) report fragmentation in survivorship care, namely in the access and delivery of survivorship care plans (SCPs). To better understand care coordination of MCBS, this review elucidated concerns of female MBCS about their preparation for post-treatment survivorship care, the preferred practices for the delivery of a SCP, and the associated content to improve post-treatment survivorship care understanding.

METHODS

A systematic search of articles from PubMed, Ovid-Medline, CINAHL databases, and bibliographic reviews included manuscripts using keywords for racial/ethnic minority groups and breast cancer survivorship care coordination terms. Salient themes and article quality were analyzed from the extracted data.

RESULTS

Fourteen included studies represented 5,854 participants and over 12 racial/ethnic groups. The following themes of post-treatment MBCS were identified from the review: (1) uncertainty about post-treatment survivorship care management is a consequence of sub-optimal patient-provider communication; (2) access to SCPs and related materials are desired, but sporadic; and (3) advancements to the delivery and presentation of SCPs and related materials are desired.

CONCLUSIONS

Representation of only 14 studies indicates that the MBCSs' perspective post-treatment survivorship care is underrepresented in the literature. Themes from this review support access to, and implementation of, culturally tailored SCP for MBCS. There was multi-ethnic acceptance of SCPs as a tool to help improve care coordination.

IMPLICATIONS FOR CANCER SURVIVORS

These findings highlight the importance of general education about post-treatment survivorship, post-treatment survivorship needs identification, and the elucidation of gaps in effective SCP delivery among MBCS.

Engaging hematopoietic cell transplantation patients and caregivers in the design of print and mobile application individualized survivorship care plan tools

PURPOSE

INSPIRE (INteractive Survivorship Program with Information and REsources) is an online health program that includes a mobile app, website, health action plan, and individualized survivorship care plans for adult hematopoietic cell transplant (HCT) survivors. The INSPIRE program integrates two previously effective randomized control trials that tested an internet-based program and patient-centered survivorship care plans for HCT survivors.

METHODS

Three focus groups were conducted with a total of 22 participants (20 patients, 2 caregivers/patient advocates) to explore patient and caregiver preferences and to optimize the patient-centered emphasis of INSPIRE. Adult (age > 18 years at the time of study entry) HCT recipients had to be at least 1-year post-HCT to participate; caregivers/patient advocates were also eligible. Participants had to be able to communicate in English, could have any diagnosis, transplant type, or donor source, and could have had multiple transplants.

RESULTS

All patient participants received an allogeneic HCT; average time since HCT was 8 years (range 2-22 years). The majority of participants were female (77.3%). Overall, the tools were well received by participants in this study, particularly the personalized features of all the tools. Major themes included interest in having the ability to tailor features to individual needs, and an interest in tracking information over time.

DISCUSSION

Engaging patients and caregivers is invaluable to optimize tools designed to improve HCT survivorship care. Print, online, and mobile-based tools, tailored to individual patients' treatment history and requisite follow-up care, can provide otherwise unavailable expertise and guidelines for care.

A structural equation modeling approach to understanding pathways linking survivorship care plans to survivor-level outcomes

PURPOSE

Several high-profile organizations have mandated the delivery of survivorship care plans (SCPs) despite mixed evidence regarding the effectiveness of SCPs on key survivor-level outcomes. There is a need to understand the types of survivor-level outcomes the SCPs are likely to change. Informed by existing frameworks and the literature, the objective of this study was to understand the pathways linking the receipt of a SCP to key survivor-level outcomes including patient-centered communication (PCC), health self-efficacy, changes in health behaviors, and improvements in overall health.

METHODS

We used structural equation modeling to test the direct and indirect pathways linking the receipt of an SCP to patient-centered communication (PCC), health self-efficacy, and latent measures of health behaviors and physical health in a nationally representative sample of breast and colorectal cancer survivors from the Health Information National Trends Survey.

RESULTS

The receipt of an SCP did not have a significant effect on key survivor-level outcomes and was removed from the final structural model. The final structural model fit the data adequately well (Chi-square p value = 0.03, RMSEA = 0.07, CFI = .88, and WRMR = 0.73). PCC had a significant direct effect on physical health but not on health behaviors. Health self-efficacy had a significant direct effect on physical health and health behaviors.

CONCLUSION

The receipt of an SCP alone is unlikely to facilitate changes in PCC, health self-efficacy, health behaviors, or physical health.

IMPLICATION FOR CANCER SURVIVORS

A SCP is a single component of a larger model of survivorship care and should be accompanied by ongoing efforts that promote PCC, health self-efficacy, and changes in health behaviors resulting in improvements to physical health.

Healthcare provider perspectives on pediatric cancer survivorship care plans: a single institution pilot study

PURPOSE

Survivorship care plans (SCPs) are used to facilitate communication between oncology and primary care providers (PCPs) after cancer treatment and to assist cancer survivors with healthcare decisions. We evaluated pediatric oncology providers' experiences creating and delivering SCPs. We also evaluated PCPs' opinions of SCPs.

METHODS

Together, oncology nurses and oncologists created individualized SCPs for leukemia patients treated at a children's hospital in Utah, with nurses in charge of inputting the majority of SCP content. We surveyed providers after each SCP was completed. We also mailed SCPs to PCPs with a survey on SCP content and their knowledge and comfort level caring for cancer survivors. Descriptive statistics were used to summarize survey content.

RESULTS

A total of 6 nurses and 8 oncologists created 21 SCPs. On average, nurses assisted with 3.5 SCPs and spent 209 min (range 100-600 min) on completing their sections of each SCP, whereas oncologists assisted with 2.6 SCPs and spent 47.4 min (range 15-120). For most SCPs, there was agreement that they should be shared with PCPs (nurse surveys 71.4%, oncologist surveys 100%). Of the 15 participating PCPs, only 28% felt prepared to manage long-term effects in pediatric cancer survivors. They agreed that the SCP would improve communication with their patient's oncologist (80%) and their knowledge for future care (100%).

CONCLUSIONS

SCPs require substantial clinician time to create, but are seen as useful by PCPs. PCPs require specific guidelines and resources concerning ongoing care for pediatric cancer survivors.

After Ringing the Bell: Receptivity of and Preferences for Healthy Behaviors in African American Dyads Surviving Lung Cancer

PURPOSE

To explore receptivity of and preferences for risk-reducing health behavior changes among African American survivors of early-stage lung cancer and their family members.

PARTICIPANTS & SETTING

26 African American non-small cell lung cancer survivor-family member dyads were recruited from two cancer programs in the southeastern United States.

METHODOLOGIC APPROACH

Social cognitive theory principles guided the design and implementation of focus groups. Descriptive statistics were used to summarize the data, and thematic analysis was used to interpret the transcripts from the focus groups.

FINDINGS

The following four themes were identified.

IMPLICATIONS FOR NURSING

Participants emphasized the need for improved provider communication. Pragmatic communication interventions for providers, survivors, and family members may facilitate behavior change and improve outcomes among underserved populations.

Accuracy and acceptability of survivorship care plans: results of a pilot study

Survivorship treatment summaries and care plans are increasingly incorporated into cancer care but there are limited data on their accuracy and acceptability. We have evaluated written care plans developed as part of a once-off, nurse-led survivorship consultations across four medical oncology clinics in South Australia as part of a state-wide pilot. While the accuracy of treatment summaries was high, level of detail in care plans was moderate to low, as was survivors' perception of plans' utility.

Impact of treatment summaries for cancer survivors: a systematic review

PURPOSE

As a treatment summary (TS) documents information for follow-up care, it is believed to be an important communication tool for the patient, their GP, and other health professionals. The aim of this systematic review (SR) was to evaluate the impact of receiving a TS for cancer survivors when compared to receiving standard care and to identify knowledge gaps to inform future research.

METHODS

A systematic search of electronic databases and grey literature was undertaken from August 2018 to October 2018. Studies were included if participants (cancer survivors) were over 18 years of age and had received a TS, and if outcomes for TS could be separated from other survivorship interventions. The McMaster Critical Appraisal Tool was used to evaluate the methodological quality of the included studies. A narrative synthesis of the study outcomes was then conducted.

RESULTS

Seven studies (one prospective cohort and six cross-sectional studies) met the inclusion criteria. The impact of TS was assessed using widely varied outcomes in these studies. Overall, receipt of a TS was related to greater patient understanding and perception of the quality of care provided. However, caution is required when interpreting these results due to methodological limitations.

CONCLUSIONS

This systematic review found that TS may have a positive impact on patient understandings about and perceptions of cancer care. However, more robust research including perspectives of cancer survivors is required.

IMPLICATIONS FOR CANCER SURVIVORS

TS could play an important role for cancer survivors especially in terms of knowledge of cancer care.

Evaluation of a Technology-Based Survivor Care Plan for Breast Cancer Survivors: Pre-Post Pilot Study

Background

As of 2016, almost 16 million individuals were cancer survivors, including over 3.5 million survivors of breast cancer. Because cancer survivors are living longer and have unique health care needs, the Institute of Medicine proposed a survivor care plan as a way to alleviate the many medical, emotional, and care coordination problems of survivors.

Objective

This pilot study for breast cancer survivors was undertaken to: (1) examine self-reported changes in knowledge, confidence, and activation from before receipt to after receipt of a survivor care plan; and (2) describe survivor preferences for, and satisfaction with, a technology-based survivor care plan.

Methods

A single group pretest-posttest design was used to study breast cancer survivors in an academic cancer center and a community cancer center during their medical visit after they completed chemotherapy. The intervention was a technology-based survivor care plan. Measures were taken before, immediately after, and 1 month after receipt of the survivor care plan.

Results

A total of 38 breast cancer survivors agreed to participate in the study. Compared to baseline levels before receipt of the survivor care plan, participants reported increased knowledge both immediately after its receipt at the academic center (P<.001) and the community center (P<.001) as well as one month later at the academic center (P=.002) and the community center (P<.001). Participants also reported increased confidence immediately following receipt of the survivor care plan at the academic center (P=.63) and the community center (P=.003) and one month later at both the academic center (P=.63) and the community center (P<.001). Activation was increased from baseline to post-survivor care plan at both the academic center (P=.05) and community center (P<.001) as well as from baseline to 1-month follow-up at the academic center (P=.56) and the community center (P<.001). Overall, community center participants had lower knowledge, confidence, and activation at baseline compared with academic center participants. Overall, 22/38 (58%) participants chose the fully functional electronic survivor care plan. However, 12/23 (52%) in the community center group chose the paper version compared to 4/15 (27%) in the academic center group. Satisfaction with the format (38/38 participants) and the content (37/38 participants) of the survivor care plan was high for both groups.

Conclusions

This study provides evidence that knowledge, confidence, and activation of survivors were associated with implementation of the survivor care plan. This research agrees with previous research showing that cancer survivors found the technology-based survivor care plan to be acceptable. More research is needed to determine the optimal approach to survivor care planning to ensure that all cancer survivors can benefit from it.

Preferences for breast cancer survivorship care by rural/urban residence and age at diagnosis

PURPOSE

Preferences for survivorship care among recently treated breast cancer survivors may vary by rural-urban residence and age, but potential differences have not been examined.

METHODS

We conducted a cross-sectional survey of survivorship preferences among women treated for non-metastatic breast cancer 6-24 months prior to recruitment.

RESULTS

We surveyed 203 women (66% response) with American Joint Committee on Cancer Stage I or II breast cancer. Rural residents comprised 36.5% of respondents (82.7% White, non-Hispanic; 52.5% < college education) and 29.6% were ≥ 65 years. More than 95% indicated that checking for recurrence, receiving additional treatment, evaluation of side effects, and identification of late effects were "very important" reasons for follow-up care. The most common topics identified as "very important" for survivorship care discussions were recommendations for healthy behaviors (65.3%), best sources for breast cancer information (65.3%), and effects on family (53.3%) and job (53.8%). Women 65 years and older preferred to discuss follow-up care at the time of diagnosis (p = 0.002), with younger women preferring during (32%) or after treatment (39.1%). Rural survivors were significantly more likely to identify follow-up care reasons not related to the initial breast cancer as "very important" than urban survivors, including screening for other cancers, and examinations or tests for non-cancer diseases (both p = 0.01).

CONCLUSIONS

Survivorship care in accordance with national recommendations will likely be accepted by breast cancer survivors. Tailoring breast cancer survivorship care by timing, integration of primary care services, and specific psychosocial topics may best meet the needs of different ages and demographics.

Neighborhood Characteristics and Colorectal Cancer Survivors' Quality of Care

Purpose: Quality cancer care entails receipt of a Survivorship Care Plan (SCP). The purpose of this study was to determine differences in SCP delivery by patient-level and neighborhood characteristics.

Methods: We obtained California cancer registry data on individuals who were diagnosed with stage I, II, or III colorectal cancer (CRC) between 2012 and 2015 and resided in predetermined geographic areas. We then mailed them a questionnaire, which queried about receipt of a SCP and its content. SCP was defined by content, as summary of cancer treatment, cancer surveillance recommendations, and/or an individualized preventive care. Using logistic regression modeling, each measure of SCP, as well as the summary measure (none vs. any), was evaluated by person-level characteristics. Subsequently, neighborhood-level characteristics were added to the model to explore their additional value.

Results: Overall 80% of CRC survivors received a SCP. Receipt of SCPs was associated with person-level characteristics, while neighborhood characteristics did not make an additional contribution. Young, male employed survivors and those with more recent diagnoses or later cancer stages had greater odds of receiving a SCP.

Conclusion: When providing SCPs, health care providers prioritize patient groups who they may perceive as vulnerable or likely to benefit from SCPs.

Moving forward after cancer: successful implementation of a colorectal cancer patient-centered transitions program

PURPOSE

Cancer survivors transitioning between academic comprehensive cancer systems and community general practice settings are vulnerable to discontinuity, inconsistency and variation in care, inappropriate surveillance testing, and a sense of isolation and loss. Though these issues have been well recognized for over a decade and a half in the survivorship, oncologic, and health services literature, there remains a dearth of positive examples of models that have been well received by both the transitioned patient and the providers on either side of the handoff. We herein describe a sustained positive example of a transitions program. This program centers on standardized and personalized survivorship care plans (SCP) to guide follow-up care and recovery.

METHODS

Following the province-wide introduction of a transitions program for treated stages II and III colorectal cancer (CRC) patients, a post-implementation survey was mailed to transitioned patients with the primary outcome evaluated the patients' perception of improved continuity of care and the main instrument used the Patient Continuity of Care Questionnaire. This was compared against a previously published pre-implementation historical control.

RESULTS

The data presented comparing pre- and post-implementation patient cohorts reflect significantly improved patient-reported perceptions regarding the enhanced continuity and coordination of their follow-up and survivorship care after the province-wide introduction of a formal transitions process. This SCP intervention has been sustained post implementation.

CONCLUSIONS

Using, as a starting-point, a standardized electronically SCP, CancerCare Manitoba has successfully facilitated a jurisdiction-wide implementation of a scalable, reproducible, and adaptable transitions program.

IMPLICATIONS FOR CANCER SURVIVORS

This intervention at the time of transition back to the community has enhanced CRC survivor perception of continuity and coordination of follow-up care.

Survivorship Care Plans in Cancer: A Meta-Analysis and Systematic Review of Care Plan Outcomes

BACKGROUND

The Institute of Medicine recommends that survivorship care plans (SCPs) be included in cancer survivorship care. Our meta-analysis compares patient-reported outcomes between SCP and no SCP (control) conditions for cancer survivors. Our systematic review examines the feasibility of implementing SCPs from survivors' and health care professionals' perspectives and the impact of SCPs on health care professionals' knowledge and survivorship care provision.

METHODS

We searched seven online databases (inception to April 22, 2018) for articles assessing SCP feasibility and health care professional outcomes. Randomized controlled trials comparing patient-reported outcomes for SCP recipients versus controls were eligible for the meta-analysis. We performed random-effects meta-analyses using pooled standardized mean differences for each patient-reported outcome.

RESULTS

Eight articles were eligible for the meta-analysis (n = 1,286 survivors) and 50 for the systematic review (n = 18,949 survivors; n = 3,739 health care professionals). There were no significant differences between SCP recipients and controls at 6 months postintervention on self-reported cancer and survivorship knowledge, physical functioning, satisfaction with information provision, or self-efficacy or at 12 months on anxiety, cancer-specific distress, depression, or satisfaction with follow-up care. SCPs appear to be acceptable and potentially improve survivors' adherence to medical recommendations and health care professionals' knowledge of survivorship care and late effects.

CONCLUSION

SCPs appear feasible but do not improve survivors' patient-reported outcomes. Research should ascertain whether this is due to SCP ineffectiveness, implementation issues, or inappropriate research design of comparative effectiveness studies.

IMPLICATIONS FOR PRACTICE

Several organizations recommend that cancer survivors receive a survivorship care plan (SCP) after their cancer treatment; however, the impact of SCPs on cancer survivors and health care professionals is unclear. This systematic review suggests that although SCPs appear to be feasible and may improve health care professionals' knowledge of late effects and survivorship care, there is no evidence that SCPs affect cancer survivors' patient-reported outcomes. In order to justify the ongoing implementation of SCPs, additional research should evaluate SCP implementation and the research design of comparative effectiveness studies. Discussion may also be needed regarding the possibility that SCPs are fundamentally ineffective.

Randomized Trial of the Impact of Empowering Childhood Cancer Survivors With Survivorship Care Plans

Background

A survivorship care plan (SCP), that is, individualized treatment summary and schedule of off-therapy surveillance, will be mandated by January 2019. It is unclear whether SCPs improve adherence to recommended follow-up care in the community. In this trial, we evaluated the impact of randomly assigning childhood cancer survivors to 1) SCPs to be taken to their primary care physician (PCP) to implement or 2) survivorship clinic (SC) on health care quality measures.

Methods

Eligibility included cancer diagnosis younger than age 18 years (2000-2012), cancer free, one or more years off therapy, and no prior survivorship clinic attendance. At 12 months, the random assignment groups were compared (SCP+PCP vs SC) by intent-to-treat analysis with two-sided statistical tests in terms of patient adherence to guideline-recommended surveillance tests (eg, echocardiogram) and number of newly identified late complications of therapy.

Results

From 2011 to 2013, 96 participants (46.9% female, mean age = 15.9 ± 6.1 years) were randomly assigned. Adherence to 14 evaluated guideline-recommended surveillance tests ranged from 0% to 46.9% in the SCP+PCP group (n = 47) and from 50.0% to 86.4% in the SC group (n = 47). Adherence to 10 tests was statistically significantly different between the groups (all P < .05). One mild new late complication was identified in the SCP+PCP group compared with 21 late complications, ranging from mild to severe, identified in 11 patients in the SC group (2.1% vs 23.4% of patients, respectively, P = .003).

Conclusions

Our randomized trial suggests that empowering childhood cancer survivors with SCPs to be implemented by their PCPs is not sufficient to meet consensus follow-up recommendations.

The survivorship experience for patients with metastatic melanoma on immune checkpoint and BRAF-MEK inhibitors

PURPOSE

Immune checkpoint inhibitors (ICI) and BRAF and MEK inhibitors (BMi) have improved survival in metastatic melanoma (MM). However, the experience of long-term responders remains undescribed. This study characterised survivorship issues faced by long-term responders to ICI or BMi.

METHODS

Patients with MM, aged ≥ 18 years old, ≥ 6 months post-ICI or BMi initiation with an objective response or stable disease. A 72-question survey assessed physical and psychological effects, impact on lifestyle, access to information, satisfaction with care, and availability of supports.

RESULTS

One hundred and five of 120 (88%) patients completed the survey (ICI 69/BMI 36). For the ICI cohort, 39 (57%) were receiving ongoing treatment, 17 ceased due to toxicity and 13 due to a sustained response. For the BMi cohort, 31 (85%) were receiving ongoing treatment, 4 ceased due to toxicity and 1 due to a sustained complete response. At data cut-off on 18 December 2018, median PFS (range) was 2.5 years (1.3-8.5) for ICI and 3.1 years (0.6-7.3) for BMi. Long-term toxicities included dry/itchy skin (ICI 51, 74%/ BMi 25, 69%), arthralgias (ICI 30, 58%/ BMi 23, 64%) and fatigue (ICI 62, 90%/ BMi 33, 92%). Psychological morbidity was common, including anxiety awaiting results (ICI 50, 72%/ BMi 29, 81%), fear of melanoma recurring or progressing (ICI 56, 81%/ BMi 31, 86%) or death (ICI 44, 64%/ BMi 26, 72%).

CONCLUSION

MM survivors experience chronic treatment toxicities and frequently report psychological concerns.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors may benefit from discussions regarding long-term toxicities and tailored psychological supports.

Comorbidities, treatment-related consequences, and health-related quality of life among rural cancer survivors

PURPOSE

We explored how lifetime comorbidities and treatment-related cancer symptoms were associated with quality of life (QOL) in rural cancer survivors.

METHODS

Survivors (n = 125) who were rural Illinois residents aged 18+ years old were recruited from January 2017 to September 2018. We conducted 4 multivariable regressions with QOL domains as outcomes (social well-being, functional well-being, mental health-MHQOL, physical health-PHQOL); the number of physical and psychological comorbidities (e.g., arthritis, high blood pressure, stroke) and treatment-related cancer symptoms (e.g., worrying, feeling sad, lack of appetite, lack of energy) as predictors; and, cancer-related and demographic factors related to these variables as covariates.

RESULTS

The number of comorbidities and number of treatment-related symptoms were inversely associated with functional well-being (Std β = - 0.36, p < 0.0001 and - 0.18, p = 0.03), and MHQOL (Std β = - 0.30, p = 0.001 and Std β = - 0.25, p = 0.004). Comorbidities were associated inversely with social well-being (Std β = - 0.27, p = .003). Comorbidities and treatment-related symptoms were not associated with PHQOL (p = 0.20-0.24). Sensitivity analyses suggested that psychological comorbidities, treatment-related psychological symptoms, and physical comorbidities were associated with social well-being, functional well-being, and MHQOL.

CONCLUSIONS

Our study highlights the utility of risk-based survivorship care plans to address the negative, additive impact of comorbidities and the treatment-related symptoms to improve the health-related QOL among rural survivors. Future research should assess how contextual factors (e.g., geographic distance to oncologists and other providers) should be incorporated in survivorship care planning and implementation for rural survivors.

Implications for patient-provider communication and health self-efficacy among cancer survivors with multiple chronic conditions: results from the Health Information National Trends Survey

PURPOSE

Cancer survivors with multiple chronic conditions experience significant challenges managing their health. The six core functions of patient-centered communication (PCC)-fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management-represent a central component to facilitating a survivor's confidence to manage their health that has not been investigated in cancer survivors with multiple chronic conditions.

METHOD

Nationally representative data across two iterations of the Health Information National Trends Survey (HINTS) were merged with combined replicate weights using the jackknife replication method. Adjusted linear regression examined the association between PCC and health self-efficacy in a sample of breast, colorectal, and prostate cancer survivors and by multiple chronic conditions.

RESULTS

53.9% reported that providers did not always respond to their emotions and 48.9% reported that they could not always rely on their providers to help them manage uncertainty. In the adjusted linear regression models, there was a significant positive association between PCC and health self-efficacy (β = 0.2, p = 0.01) for the entire sample. However, the association between PCC and health self-efficacy was attenuated in cancer survivors with multiple chronic conditions (β = 0.1, p = 0.53).

CONCLUSION

PCC alone is not enough to improve a cancer survivor's confidence in their ability to manage their health in the presence of multiple chronic conditions.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors with multiple chronic conditions need ongoing support, in addition to PCC, that render them prepared to manage their health after cancer.

Assessing Key Stakeholders' Knowledge, Needs, and Preferences for Head and Neck Cancer Survivorship Care Plans

Cancer survivorship care plans (SCPs) are endorsed to support quality care for cancer survivors, but uptake is slow. We assessed knowledge, needs, and preferences for SCP content and delivery from a wide variety of stakeholders. We focused SCP content for head and neck cancer as it is a disease prone to long-term side effects requiring management from multiple providers. We conducted telephone-based, qualitative interviews. We purposively sampled head and neck cancer survivors (n = 4), primary care physicians in the community (n = 5), and providers affiliated with a large academic medical center (n = 5) who treat head and neck cancer, cancer specialists (n = 6), and nurse practitioners/supportive care staff (n = 5). Interviews were recorded, transcribed, and analyzed using direct content analysis. Few participants reported personal experience with SCPs, but most supported the concept. Several key themes emerged: (1) perceived ambiguity regarding roles and responsibilities for SCPs, (2) a need to tailor the content and language based on the intended recipient, (3) documentation process should be as automated and streamlined as possible, (4) concerns about using the SCP to coordinate with outside providers, and (5) that SCPs would have added value as a "living document." We also report SCP-related issues that are unique to serving patients diagnosed with head and neck cancer. Effort is needed to tailor SCPs for different recipients and optimize their potential for successful implementation, impact on care outcomes, and sustainability. Many cancer survivors may not receive a SCP as part of routine care. Survivors could engage their health care team by requesting a SCP.