Promoting assessment and management of function through navigation: opportunities to bridge oncology and rehabilitation systems of care

Availability of cancer survivorship support services across the National Cancer Institute Community Oncology Research Program network

BACKGROUND

National cancer organizations recommend provision of nutrition, physical activity, and mental health supportive services to cancer survivors. However, the availability of these services across diverse community oncology settings remains unclear.

METHODS

The National Cancer Institute Community Oncology Research Program (NCORP) is a national network of community oncology practices engaged in cancer research. The 2022 NCORP Landscape Assessment (5UG1CA189824) assessed individual practices' establishment of survivorship clinics and nutrition, physical activity, and mental health services, resources, and/or referrals. Descriptive statistics summarized and logistic regression quantified the association between services, practice, and patient characteristics.

RESULTS

Of 46 NCORP community sites, 45 (98%) responded to the survey, representing 259 adult practice groups. A total of 41% had a survivorship clinic; 96% offered mental health, 94% nutrition, and 53% physical activity services, resources, and/or referrals. All 3 services were offered in various formats (eg, in-house, referrals, education) by 51% and in-house only by 25% of practices. Practices with advanced practice providers were more likely to have a survivorship clinic (odds ratio [OR] = 3.19, 95% confidence interval [CI] = 1.04 to 9.76). Practices with at least 30% Medicare patients (OR = 2.54, 95% CI = 1.39 to 4.66) and more oncology providers (OR = 1.02, 95% CI = 1.01 to 1.04) were more likely to have all 3 services in any format. Practices with at least 30% Medicare patients (OR = 3.41, 95% CI = 1.50 to 7.77) and a survivorship clinic (OR = 2.84, 95% CI = 1.57 to 5.14) were more likely to have all 3 services in-house.

CONCLUSIONS

Larger oncology practices and those caring for more survivors on Medicare provided more supportive services, resources, and/or referrals. Smaller practices and those without survivorship clinics may need strategies to address potential gaps in supportive services.

Occupational Therapists in Patient Navigation: A Scoping Review of the Literature

This review seeks to understand the literature on patient navigator programs (PNPs) that employ occupational therapists (OTs), including the role (conceptualization), functions (operationalization) of OTs who work as patient navigators (PNs) and the settings and populations they serve. This review also mapped the role of PNs to the 2021 Competencies for Occupational Therapists in Canada. Scoping review methodology by Arksey and O'Malley (2005) was employed. Data were analyzed thematically and numerically to identify frequent patterns. Ten articles were included. Within PNPs, OTs worked in hospitals and communities, but their role was rarely well-defined. Five competency domains (i.e., communication and collaboration, culture, equity and justice, excellence in practice, professional responsibility, and engagement with the profession) were evident in existing PNPs that included OTs. This review supports the increasing interest in OTs as PNs by demonstrating the alignment between the OT competencies and roles and functions of OTs working within PNPs.

Impact of Income on Physical Concerns, Help Seeking, and Unmet Needs of Adult Cancer Survivors

Purpose

Cancer treatment can have consequences for individuals which may have profound impact on daily living. Accessing assistance can be problematic. This study explores associations between income and concerns, help-seeking, and unmet needs related to physical changes following cancer treatment.

Method

A national survey was conducted with cancer survivors about experiences with follow-up care one to three years after treatment. We report a trend analysis describing associations between income and cancer survivors' concerns, help-seeking, and unmet needs related to physical changes after treatment.

Results

In total 5,283 cancer survivors between 18 and 64 years responded, of which 4,264 (80.7%) indicated annual household income. The majority of respondents were survivors of breast (34.4%), colorectal (15.0%), and prostate (14.0%) cancers. Over 90% wrote about experiencing physical changes following cancer treatment. Survivors with low annual household incomes of less than $25,000 (CAN) reported the highest levels of concern about multiple physical changes and were more likely to seek help to address them.

Conclusions

Cancer survivors can experience various physical challenges and unmet needs following cancer treatment and difficulty obtaining relevant help across all income levels. Those with low income are more severely affected. Financial assessment and tailored follow-up are recommended.

Development and pilot testing of a clinic implementation program delivering physical activity electronic referrals to cancer survivors

Provider physical activity referrals are recommended for cancer survivors, though barriers exist to clinical system integration. To develop and test ActivityChoice, an electronic referral (eReferral) clinic implementation program referring cancer survivors to physical activity programs of their choice. In Phase 1, we conducted semi-structured interviews with Cancer Center clinicians (n = 4) and cancer-focused physical activity program leaders (n = 3) assessing adaptations needed to implement an eReferral previously designed for another context. In Phase 2, we pilot-tested clinician-delivered referrals to survivors in two 12-week Plan, Do, Study, Act (PDSA) cycles. We examined feasibility using descriptive statistics (clinicians' adoption and engagement, patient referrals, and physical activity program enrollment) and acceptability through semi-structured interviews with enrolled clinicians (n = 4) and referred patients (n = 9). ActivityChoice included a secure referral webform, text message/email referral confirmations, clinician training/booster sessions, visual reminders, and referrals to in-person or virtual group physical activity programs. Results for each PDSA cycle respectively included: 41% (n = 7) and 53% (n = 8) of clinicians adopted ActivityChoice; 18 and 36 patients were referred; 39% (n = 7) and 33% (n = 12) of patients enrolled in programs, and 30% (n = 4) and 14% (n = 5) of patients deferred enrollment. Patients and clinicians appreciated the referrals and choices. A printed handout describing both programs was added to the clinic workflow for Cycle 2, which yielded more referrals, but lower program enrollment rates. Clinic-based eReferrals to choices of physical activity programs were feasible and acceptable by clinicians and patients. Added clinic workflow support may facilitate referrals.

Perspectives of Cancer Survivors with Low Income: A Content Analysis Exploring Concerns, Positive Experiences, and Suggestions for Improvement in Survivorship Care

The number of cancer survivors in Canada has reached 1.5 million and is expected to grow. It is important to understand cancer survivors' perspectives about the challenges they face after treatment is completed. Many factors create barriers to accessing assistance, and limited income may be a significant one. This study is a secondary analysis of data from a publicly available databank (Cancer Survivor Transitions Study) regarding the experiences of Canadian cancer survivors. The goal was to explore major challenges, positive experiences, and suggestions for improvement in survivorship care for low-income Canadian cancer survivors one to three years following treatment. A total of 1708 survey respondents indicated a low annual household income (<$25,000 CD). A content analysis was performed utilizing written comments to open-ended questions. The major challenges respondents described focused on physical capacity limits and treatment side effects; positive experiences emphasized support and attentive care; and suggestions for improvements highlighted the need for better support, information about self-care and side effect management, and timely follow-up care. The relationships between household income and the management of survivors' physical, emotional, and practical concerns require consideration. The design of follow-up care plans, programs, services, and financial assessments of patients may prepare survivors for predictable issues and costs in their transition to survivorship.

Cancer Survivors Living in Rural Settings: A Qualitative Exploration of Concerns, Positive Experiences and Suggestions for Improvements in Survivorship Care

In Canada, the number of cancer survivors continues to increase. It is important to understand what continues to present difficulties after the completion of treatment from their perspectives. Various factors may present barriers to accessing help for the challenges they experience following treatment. Living rurally may be one such factor. This study was undertaken to explore the major challenges, positive experiences and suggestions for improvement in survivorship care from rural-dwelling Canadian cancer survivors one to three years following treatment. A qualitative descriptive analysis was conducted on written responses to open-ended questions from a national cross-sectional survey. A total of 4646 individuals living in rural areas responded to the survey. Fifty percent (2327) were male, and 2296 (49.4%) were female; 69 respondents were 18 to 29 years (1.5%); 1638 (35.3%) were 30 to 64 years; and 2926 (63.0%) were 65 years or older. The most frequently identified major challenges (n = 5448) were reduced physical capacity and the effects of treatment. Positive experiences included family and friend support and positive self-care practices. The suggestions for improvements focused on the need for better communication and information about self-care, side effect management, and programs and services, with more programs available locally for practical and emotional support.

Implementing process improvements to enhance distress screening and management

INTRODUCTION

While distress is prevalent among individuals living with cancer, distress management has not been optimized across cancer care delivery despite standards for screening. This manuscript describes the development of an enhanced Distress Thermometer (eDT) and shares the process for deploying the (eDT) across a cancer institute by highlighting improvements at the provider, system, and clinic levels.

METHODS

Focus groups and surveys were used at the provider-level to outline the problem space and to identify solutions to improve distress screening and management. Through stakeholder engagement, an eDT was developed and rolled out across the cancer institute. Technical EHR infrastructure changes were implemented at the system-level to improve the use of the distress screening findings and generate automated referrals for specialty services. Clinic workflows were adapted to improve screening and distress management using the eDT.

RESULTS

Stakeholder focus group participants (n=17) and survey respondents (n=13) found the eDT to be feasible and acceptable for distress identification and management. System-level technical EHR changes resulted in high accuracy with patient identification for distress management, and 100% of patients with moderate to severe distress were connected directly to an appropriate specialty provider. Clinic-level workflow changes to expand eDT use improved compliance rates with distress screening from 85% to 96% over a 1-year period.

CONCLUSIONS

An eDT that provides more context to patient-reported problems improved identification of referral pathways for patients experiencing moderate to high distress during cancer treatment. Combining process improvement interventions across multiple levels in the cancer care delivery system enhanced the success of this project. These processes and tools could support improved distress screening and management across cancer care delivery settings.

Implementation of a Cancer Rehabilitation Navigation Program: a qualitative analysis of implementation determinants and strategies

BACKGROUND

Cancer rehabilitation navigation (CRNav) is a care delivery model that expedites identification and management of symptom-related functional morbidity for individuals undergoing cancer treatment. A CRNav program is unique in that it embeds a cancer rehabilitation professional in the cancer center for patient screening and assessment. The implementation of CRNav programs has not been studied and doing so could facilitate greater uptake of these programs.

METHODS

Using implementation science frameworks, we conducted a qualitative, post-implementation analysis of a CRNav program that was implemented in 2019. Semi-structured, 1:1 interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and a combination of deductive and inductive analyses, using a priori established codes, was used to assess the implementation context, and identify emergent themes of barriers and facilitators to implementation. Participant described implementation strategies were characterized and defined using the Expert Consensus Recommendations for Implementing Change (ERIC) taxonomy.

RESULTS

Eleven stakeholders including physicians, administrators, clinical staff, and patients, involved with program development and the implementation effort, participated in interviews. Predominant barriers to implementation included developing the program infrastructure, and lack of awareness of rehabilitation services among oncology professionals, predominant facilitators of implementation included; physical co-location of the navigator in the cancer center, individual characteristics of the navigator, and unique characteristics of the program. Strategies described that supported implementation included developing stakeholder interrelationships, evaluating and iteratively adapting the program, creating infrastructure, training and education, and supporting clinicians.

CONCLUSION

This analysis uses implementation science to methodically analyze and characterize factors that may contribute to successful implementation of a CRNav program. These findings could be used alongside a prospective context-specific analysis to tailor future implementation efforts.

IMPLICATIONS FOR CANCER SURVIVORS

Implementing a CRNav program expedites a patient's direct contact with a rehabilitation provider complementing the cancer care delivery team, and providing an additive and often missing service.

Racial disparity in breast cancer survivorship: themes from a series of four national healthcare provider live virtual forums

PURPOSE

Significant disparity exists in the diagnosis, treatment, and survivorship outcomes among Black breast cancer (BC) survivors. Black BC survivors have more significant survivorship issues and a greater burden of illness than White counterparts. Barriers to rehabilitation exist for all BC survivors but are magnified in Black BC survivors. The purpose of this qualitative research was to document patient, clinician, and researchers' perceptions surrounding contributing factors, lived experiences, and potential solutions to racial disparity in BC survivorship.

METHODS

A narrative approach was utilized to identify themes from a series of four virtual healthcare provider forums that explored lived personal and professional experiences, issues, and potential solutions surrounding racial disparity in BC survivorship. Forums included perspectives of patients, healthcare providers, researchers, and stakeholders in the BC field. An independent thematic analysis was performed by the investigators, all of whom have emic perspectives with respect to race and/or BC.

RESULTS

Three main themes were identified related to racial disparity in BC survivorship: (1) societal and cultural contributing factors, (2) contribution of healthcare providers and systems, and (3) models of care and research considerations.

CONCLUSIONS

The findings provide compelling documentation of lived personal and professional experiences of racial disparity in BC survivorship. Potential solutions exist and must be enacted immediately to ensure equitable survivorship outcomes for Black individuals following a BC diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Increased awareness related to racial disparity in BC survivorship among survivors, healthcare providers, and researchers will contribute to health equity and improved outcomes for Black individuals.

Relationship between income and concerns about physical changes and help-seeking by older adult cancer survivors: a secondary analysis

OBJECTIVE

Globally, the number of older adults surviving cancer is anticipated to grow rapidly over the next decades. Cancer and its treatment can leave survivors with a myriad of challenges including physical changes which impact independence and quality of life. This project explored the relationship of income level with concerns and help-seeking for physical changes following treatment in older Canadian survivors of cancer.

METHODS

A Canada-wide survey of community-dwelling survivors of cancer explored their experiences with survivorship care one to three years following completion of treatment. A secondary trend analysis examined the relationship of income with older adults' level of concern and help-seeking experiences regarding physical consequences they attributed to their cancer treatment.

RESULTS

In total, 7,975 people aged 65 years and older who survived cancer responded to the survey, of whom 5,891 (73.9%) indicated annual household income. Prostate (31.3%), colorectal (22.7%) and breast (21.8%) cancer accounted for the majority of respondents. Of those who reported household income data, over 90% wrote about the impact of physical changes following treatment, their concerns about the changes, and whether they sought help for their concerns. The most frequently identified physical challenge was fatigue (63.7%). Older survivors with low annual household incomes of less than $CA25,000 reported the highest levels of concern about multiple physical symptoms. 25% or more of the survey respondents across all income levels reported difficulty finding assistance for their concerns about the physical challenges, especially in their local communities.

CONCLUSION

Older survivors of cancer can experience a range of physical changes, amenable to intervention by physical therapy, yet experience challenges obtaining relevant help. Those with low income are more severely affected, even within a universal healthcare system. Financial assessment and tailored follow-up are recommended.

Examining the impact of physical function performance in predicting patient outcomes after lung-sparing surgery for malignant pleural mesothelioma

PURPOSE

The purpose of this study was to examine the impact of physical function performance and pulmonary function on patient outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM).

MATERIALS AND METHODS

A retrospective review of 54 patients with MPM from 2015 to 2020 was performed. The primary objective was to assess whether physical function, as measured by the Eastern Cooperative Oncology Group Performance Status (ECOG), and pulmonary function tests were predictive of postoperative patient outcomes (ventilator days, chest tube days, hospital length of stay). A secondary objective was to explore demographic and preoperative variables that best predict postoperative physical function and patient outcomes.

RESULTS

Data include 54 patients who underwent extended pleurectomy-decortication. Preoperative ECOG was a significant predictor of postoperative patient outcomes while preoperative lung function lacked predictive ability. Preoperative ECOG was also predictive of preoperative lung function. Age on the day of surgery was the best predictor of postoperative physical function, which was significantly reduced postoperatively.

CONCLUSIONS

Preoperative physical function performance was a significant predictor of postoperative outcomes. The results of our study highlight the importance of physical function in patients with MPM and support the need for early rehabilitation and further research to determine optimal rehabilitation interventions.IMPLICATIONS FOR REHABILITATIONPreoperative physical function can predict outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM).Physical function in patients with MPM should be carefully examined.To accurately reflect patients' abilities, patient assessment should include both patient-reported outcomes and performance-based measures.Patients with MPM should receive rehabilitation early after diagnosis and throughout the continuum of care.

CREATE Childhood Cancer Rehabilitation Program development: Increase access through interprofessional collaboration

BACKGROUND

Cancer and its treatment can lead to functional limitations affecting ongoing development in children and adolescents. We developed a pediatric cancer rehabilitation program that integrates evidence-based rehabilitative care into cancer treatment. The program utilizes the CREATE (collaboration, rehabilitation/research, education, assessment, treatment, evaluation) Childhood Cancer Rehabilitation model. We aim to describe the structural and process components of our rehabilitation program and provide an access and utilization analysis.

PROCEDURES

To evaluate the rehabilitation program, we identified new patients with oncologic diagnoses from 2002 to 2019 using our database. To evaluate rehabilitative care, descriptive data, including the timing and type of rehabilitation services utilized within 5 years of a child's diagnosis, were collected and reviewed. Statistical analysis focused on change over time.

RESULTS

Among 1974 children assessed, 1580 (80.0%) received care from at least one rehabilitation service. Between 2002 and 2018, the percentage of children receiving rehabilitation services grew significantly throughout all disciplines, except for outpatient speech-language pathology. Utilization differed by age and diagnosis. Integrating therapists in the clinic improved patient access, reduced the time to access outpatient services, and increased the number of attended visits. Additional factors supporting program growth included: identifying leaders, using a prospective surveillance model, education, and program evaluation.

CONCLUSION

A multimodal interprofessional approach, such as the CREATE model, improves access to and the efficiency of evidence-based rehabilitation services promoting recovery, ongoing development, and quality of life.

Empowering Oncology Nurses through Knowledge and Practice to Improve Transitions Following Treatment and Survivorship Care

Following cancer treatment, individuals can be left with physical, emotional, and practical consequences which influence their quality of life. Cancer survivors frequently require added knowledge and skills to handle the demands of everyday living after treatment. Oncology nurses are in an ideal position to address the needs of cancer survivors. This article describes an online interactive workshop for oncology nurses to introduce Canadian data on unmet needs of cancer survivors, highlight the contribution oncology nurses can make to survivorship care, and introduce a self-learning resource for survivor care. Didactic presentations and small group discussions were used and feedback from participants was positive. Online learning can be an effective approach for learning with international nursing colleagues and could be utilized for nurses with limited access to cancer nursing education.

Limitations of Current Rehabilitation Practices in Pediatric Oncology: Implications for Improving Comprehensive Clinical Care

OBJECTIVE

To identify the proportion of hospitals/clinics in the United States (US) that have a comprehensive pediatric oncology rehabilitation program and characterize current practices.

DESIGN

Cross-sectional survey of rehabilitation providers in the US and internationally.

SETTING

Electronic or telephone survey.

PARTICIPANTS

Rehabilitation or supportive care practitioners employed at a hospital, outpatient clinic, or medical university.

INTERVENTIONS

Electronic and telephone survey. The full electronic survey contained 39 questions, provided opportunities for open-ended responses, and covered 3 main categories specific to pediatric cancer rehabilitation: service delivery, rehabilitation program practices, and education/training. The short telephone survey included 4 questions from the full survey and was designed to answer the primary study objective.

MAIN OUTCOME MEASURES

Proportion of hospitals/clinics with a comprehensive pediatric oncology rehabilitation program.

RESULTS

This cohort (N=241) includes rehabilitation providers from 191 hospitals/clinics, 49 states within the US, and 5 countries outside of the US. Of hospitals/clinics represented from the full and short survey, 145 (76%) do not have an established pediatric oncology rehabilitation program. Nearly half of full survey respondents reported no knowledge of the prospective surveillance model (PSM) and 65% reported no education was provided to them regarding pediatric cancer rehabilitation. Qualitative survey responses fell into three major themes: variability in approach to rehabilitation service delivery, program gaps, and the need for additional educational opportunities.

CONCLUSIONS

There is evidence of limited comprehensive rehabilitation programming for children with cancer as demonstrated by the lack of programs with coordinated interdisciplinary care, variability in long-term follow-up, and the absence of education and training. Research is needed to support the development and implementation of comprehensive pediatric oncology rehabilitation programs.

Factors influencing the delivery of cancer pathways: a summary of the literature

PURPOSE

The study aims to summarise the literature on cancer care pathways at the diagnostic and treatment phases. The objectives are to find factors influencing the delivery of cancer care pathways; to highlight any interrelating factors; to find gaps in the literature concerning areas of research; to summarise the strategies and recommendations implemented in the studies.

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative approach and developed a causal loop diagram to summarise the current literature on cancer care pathways, from screening and diagnosis to treatment. A total of 46 papers was finally included in the analysis, which highlights the recurring themes in the literature.

FINDINGS

The study highlights the myriad areas of research applied to cancer care pathways. Factors influencing the delivery of cancer care pathways were classified into different albeit interrelated themes. These include access barriers to care, hospital emergency admissions, fast track diagnostics, delay in diagnosis, waiting time to treatment and strategies to increase system efficiency.

ORIGINALITY/VALUE

As far as the authors know, this is the first study to present a visual representation of the complex relationship between factors influencing the delivery of cancer care pathways.

A systematic review of rehabilitation and exercise recommendations in oncology guidelines

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management

Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.