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

Exploring colorectal cancer survivors' perspectives on improving care delivery and the role of e-health technology: a qualitative study

PURPOSE

The purpose of this study was to gather insights from colorectal cancer (CRC) survivors on how to improve care for CRC survivors and how e-health technology could be utilized to improve CRC care delivery.

METHODS

Three semi-structured focus groups were held with sixteen CRC survivors. To initiate the discussion, an online registration form and two vignettes were used. The data was analyzed using the framework method.

RESULTS

Based on survivors' experiences, five themes were identified as opportunities for improving CRC care delivery. These themes include better recognition of complaints and faster referrals, more information as part of the care delivery, more guidance and monitoring of health outcomes, more collaboration between practitioners, and more attention for partners and relatives. In addition, survivors expressed opportunities for using e-health to facilitate information provision, improve communication, and monitor survivors' health conditions.

CONCLUSION

Several suggestions for improvement of CRC care delivery were identified. These often translated into possibilities for e-health to support or improve CRC care delivery. The ideas of survivors align with the vast array of existing e-health resources that can be utilized to enhance CRC care delivery. Therefore, the next step involves addressing the implementation gap between the needs of stakeholders, such as CRC survivors and healthcare providers, and the e-health tools currently available in clinical practice.

Using immersive technology and architectural design to assist head and neck cancer patients' recovery from treatment: A focus group and technology acceptance study

PURPOSE

Head and neck cancer patients can face debilitating treatment related side-effects, resulting in requirement for support and negatively impacting on care outcomes. This study aimed to develop a digital recovery support package and assess its acceptability with head and neck cancer patients to support their information needs and assist with their self-management. It provided additional support through development of a WebXR platform 'recovery' package, which allowed patients to live a 'virtual reality' experience, entering and moving inside a 'virtual room', accessing targeted resources and specific learning materials related to their cancer.

METHOD

A qualitative intervention development study consisting of three phases. This study followed the COREQ checklist for qualitative research. Phase 1- Focus groups with seven head and neck cancer patients and six healthcare professionals. Phase 2- Development of 'recovery' package based on the focus group data which informed the content and design of the WebXR recovery platform. Phase 3- Technology acceptance study. Once developed, the platform's acceptability of the experience lived inside the virtual room was assessed via qualitative interviews with six different patient participants.

RESULTS

Most participants felt comfortable using the virtual reality platform, finding it a realistic and useful support for identifying resources and signposting to relevant materials. Participants agreed the WebXR platform was a feasible tool for the head and neck cancer setting and helped reduce anxiety.

CONCLUSIONS

Head and neck cancer patients welcome specific targeted, information and advice to support their ability to self-manage their rehabilitation and thus focus their nursing care. The platform was implemented during the Covid-19 pandemic, demonstrating its versatility and accessibility in providing complementary support to head and neck cancer patients, to empower them to adjust to their 'new' normal as part of their ongoing cancer journeys.

Nurse-led consultations reinforced with eHealth technology: a qualitative study of the experiences of patients with gynecological cancer

BACKGROUND

During the last decade, the health care profession has moved toward personalized care and has focused on the diversity of survivorship needs after initial cancer treatment. Health care providers encourage empowering patients to participate actively in their own health management and survivorship. Consequently, we developed and piloted a new follow-up model for patients at a Norwegian hospital, referred to as the Lifestyle and Empowerment Techniques in Survivorship of Gynecologic Oncology (LETSGO) model. Using LETSGO, a dedicated nurse replaces the physician in every second follow-up consultation, providing patients who have undergone cancer treatment with self-management techniques that are reinforced with eHealth technology via a specially designed app. Encouraging behavioral change and evaluating the late effects of treatment and recurrence symptoms are central components of self-management techniques. In addition, the app encourages physical activity and positive lifestyle changes, helps identify recurrence-related symptoms, and provides reminders of activity goals. This study aims to investigate experiences with nurse-led consultations supported by eHealth technology among the patients who piloted the LETSGO intervention.

METHODS

Semi-structured qualitative interviews were conducted to analyze the participants' experiences with the LETSGO intervention after six to seven months.

RESULTS

The participants in the LETSGO pilot felt safe and well cared for. They thought the nurse was less busy than the doctors appear to be, which made it easy for them to share any cancer-related challenges. Many participants reported increased empowerment and confidence in recognizing symptoms of cancer recurrence, and participants who used the app regularly were motivated to increase their physical activity levels. However, the participants also experienced some limitations and technical errors with the app.

CONCLUSIONS

Generally, the participants positively received the nurse-led consultations and eHealth technology, but an intervention study is required for further evaluation. In addition, the reported technical app errors should be resolved and tested prior to eHealth application implementation. Regardless, this study may be useful in planning personalized survivorship care studies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03453788 . Registration March 5, 2018.

Electronic patient-reported monitoring of symptoms during follow-up of ovarian cancer patients: a feasibility study

Background

Ovarian cancer patients require monitoring for relapse. Innovative follow-up methods are increasingly being explored. An electronic patient-reported outcome (ePRO) follow-up pathway was developed for women treated for ovarian cancer. This feasibility study explored patient acceptability and compliance.

Methods

A single-arm non-blinded prospective feasibility study was undertaken at two hospitals. Participants were women who had completed treatment for ovarian cancer whose clinician was happy for them to be monitored remotely. Automated 3-monthly reminders were sent to participants to complete an ePRO questionnaire and obtain blood tests. Participants were reviewed over the phone by their clinical nurse specialist instead of attending clinic-based follow-up. The primary outcome was compliance (expected ePRO completions/blood tests) across the 12-month study period. Secondary outcomes were recruitment, attrition, resource use, symptom severity/alerts and patient acceptability.

Results

Twenty-four women consented (50% consent rate), and 13 remained on study at 12 months. Seven women relapsed, 3 chose to withdraw, and 1 withdrew for other clinical reasons. ePRO compliance was high and consistent at 75-82%, although the two hospitals differed. Adherence to the clinical protocol was evident for blood tests and contacts with staff (fewer visits, more phonecalls compared to an earlier audit). End-of-study feedback indicated high patient satisfaction.

Conclusions

Remote ePRO follow-up for ovarian cancer is feasible and acceptable to patients who are able and willing to participate. However, the low recruitment rate (ineligible + declined) indicate it is not suitable/acceptable to all patients immediately post-treatment. Further large-scale research and implementation work is required, especially in a post-COVID era.

Trial registration

ClinicalTrials.gov ID: NCT02847715 (first registered 19/05/2016).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09817-5.

Health care professionals' perspectives on shared decision making supported by personalised‐risk‐for‐recurrences‐calculations regarding surveillance after breast cancer

Objective

Breast cancer patients for whom less intensive surveillance is sufficient can be identified based on the risk for locoregional recurrences (LRRs). This study explores health care professionals' (HCPs) perspectives on less intensive surveillance, preferences for shared decision‐making (SDM) about surveillance and perspectives on the use of patients' estimated personal risk for LRRs in decision‐making about surveillance.

Methods

We conducted semi‐structured interviews with 21 HCPs providing follow‐up care for breast cancer patients in seven Dutch teaching hospitals (Santeon hospitals).

Results

HCPs were predominantly positive about less intensive surveillance for women with a low risk for recurrences. They mentioned important prerequisites such as clearly defined surveillance schedules based on risk categories, information provision and communication support for patients and HCPs. Most HCPs supported SDM about surveillance and were positive about using patients' estimated personal risk for LRRs. HCPs specified prerequisites such as clear visualisation and explanation of risk information, attention for fear of cancer recurrence (FCR) and defined surveillance schedules for specific risk groups.

Conclusion

Mentioned prerequisites for less intensive surveillance need to be accounted for. Information needs and existing misconceptions need to be addressed. Outcome information regarding risks for LRRs and FCR can enrich the SDM process about surveillance.

'We do need to keep some human touch'-Patient and clinician experiences of ovarian cancer follow-up and the potential for an electronic patient-reported outcome pathway: A qualitative interview study

Objective

This study aimed to explore experiences of follow‐up after treatment and views on an electronic patient‐reported outcome (ePRO) pathway among ovarian cancer patients and clinicians.

Methods

Semi‐structured qualitative interviews were conducted with clinicians and patients previously treated for ovarian cancer. Interviews explored experiences of the current follow‐up pathway, patients' needs and views on an ePRO pathway enabling patients to report symptoms online rather than attend clinic‐based appointments. Transcripts were analysed using framework analysis.

Results

Sixteen patients and 10 clinicians participated from four hospitals in England. Four key themes were identified: transition into follow‐up, key features of effective follow‐up, issues in follow‐up and views of ePRO. Both patients and clinicians saw benefits of an ePRO pathway alongside continued access to specialist support and discussed various practicalities (e.g., frequency, introduction and communication). Technology concerns and feelings of abandonment were highlighted as barriers. The proposed impact on clinical and individual patient outcomes was discussed.

Conclusion

Patient and clinician views on follow‐up and an ePRO pathway informed key recommendations on the development/introduction of ePRO follow‐up. Technology use in healthcare will continue to grow and may offer solutions to facilitate responsive and tailored care. Further research should explore the safety, experiences and acceptability of ePRO follow‐up.

Stratified follow-up for endometrial cancer: a move to more personalized cancer care

OBJECTIVE

Hospital based follow-up has been the standard of care for endometrial cancer. Patient initiated follow-up is a useful adjunct for lower risk cancers. The purpose of this study was to evaluate outcomes of endometrial cancer patients after stratification into risk groupings, with particular attention to salvageable relapses.

METHODS

All patients treated surgically for International Federation of Gynecology and Obstetrics (FIGO) stage I-IVA endometrial cancer of all histological subtypes, from January 2009 until March 2019, were analyzed. Patient and tumor characteristics, treatment details, relapse, death, and last follow-up dates were collected. Site of relapse, presence of symptoms, and whether relapses were salvageable were also identified. The European Society of Medical Oncology-European Society of Gynecological Oncology 2020 risk stratification was assigned, and relapse free and overall survival were estimated.

RESULTS

900 patients met the eligibility criteria. Median age was 66 years (range 28-96) and follow-up duration was 35 months (interquartile range 19-57). In total, 16% (n=144) of patients relapsed, 1.3% (n=12) from the low risk group, 3.9% (n=35) from the intermediate risk group, 2.2% (n=20) from the high-intermediate risk group, and 8.7% (n=77) from the high risk group. Salvageable relapses were less frequent at 2% (n=18), of which 33% (n=6) were from the low risk group, 22% (n=4) from the intermediate risk group, 11% (n=2) from the high-intermediate risk group, and 33% (n=6) from the high risk group. There were only three asymptomatic relapses in the low risk patients, accounting for 0.33% of the entire cohort.

CONCLUSIONS

Relapses were infrequent and most presented with symptoms; prognosis after relapse remains favorable. Overall salvageable relapses were infrequent and cannot justify intensive hospital based follow-up. Use of patient initiated follow-up is therefore appropriate, as per the British Gynaecological Cancer Society's guidelines, for all risk groupings.

Determinants of quality of life in women immediately following the completion of primary treatment of breast cancer: A cross-sectional study

Backgrounds

Many breast cancer patients experience significant distress immediately following the completion of primary treatment. Women who report low levels of quality of life (QOL) early in this phase of transitional survivorship tend to experience diminished long-term adjustment. However, since most of the prior studies on survivors were conducted on patients at various times, studies on QOL of women during the end of primary treatment have been insufficient. This study aimed to identify determinants of QOL in women with breast cancer immediately following the completion of treatment.

Methods

A cross-sectional study was conducted on 140 disease-free breast cancer patients who had completed therapy in the past 1 month at university hospitals. Functional Assessment of Cancer Therapy-Breast (FACT-B), Memorial Symptom Assessment Scale-Short Form (MSAS-SF), Self-Efficacy Scale for Self-Management of Breast Cancer (SESSM-B), and Interpersonal Support Evaluation List-12 (ISEL-12) scales were used to assess predictors and QOL. The data were analyzed using the Pearson correlation, t-test, ANOVA, and hierarchical multiple regression.

Results

The mean score of QOL for breast cancer survivors was 97.23 (±20.01). Chemotherapy and perceived economic status were significantly associated with QOL in terms of sociodemographic and disease/treatment-related characteristics. Physical and psychological symptoms and social support had a significant association with QOL. The regression analyses showed that physical and psychological symptoms and belonging support were statistically significant in predicting the QOL of breast cancer survivors.

Conclusions

The variables of symptom experience and social support must be acknowledged when improving women’s QOL immediately after their completion of primary breast cancer treatment. Greater focus on the reduction of symptom distress and increasing a sense of belonging could improve QOL among breast cancer survivors.

Trajectories of health-related quality of life and psychological distress in patients with colorectal cancer: A population-based study

BACKGROUND

The aim of this nationwide cohort study was to examine the course of symptoms and trajectories of health-related quality of life (HR-QoL) and psychological distress during follow-up and to identify vulnerable patients.

METHODS

Patients with pathological stage I-III colorectal cancer (CRC) between 2013 and 2018 were included. Baseline characteristics were collected from the Netherlands Cancer Registry, and patients completed the European Organisation for Research and Treatment of Cancer QLQ-C30/CR29, Hospital Anxiety and Depression Scale and low anterior resection syndrome (LARS) questionnaires at the baseline and subsequently at 3, 6, 12, 18 and 24 months. Latent class growth and multinomial logistic regression analyses were performed to outline 24-month trajectories in HR-QoL and distress and to identify predictive factors.

RESULTS

A total of 1535 patients with colon cancer or rectal cancer were included. Trajectory analysis of HR-QoL identified three patient classes: high HR-QoL (62.7%), improving HR-QoL (29.0%) and low HR-QoL (8.3%). The following patient groups were identified with having low distress (64.0%), moderate distress (26.9%) and high distress (9.1%). Around 13% of the total cohort had either persistent low HR-QoL or high psychological distress throughout follow-up. Patients belonging to this vulnerable group were significantly more likely to be female, to be younger aged, to have lower education, to have disease stage II-III or to have major LARS.

CONCLUSIONS

Although most patients treated for stage I-III CRC fared well, a small but significant proportion of around 13% did not recover during follow-up and reported low HR-QoL and/or high psychological distress levels throughout. This study's findings should be taken into account when organising and selecting patients for tailored follow-up.

Follow-up practice and healthcare utilisation of colorectal cancer survivors

OBJECTIVE

To examine healthcare utilisation and adherence to colorectal cancer (CRC) follow-up guidelines.

METHODS

A total of 2450 out of 3025 stage I-III CRC survivors diagnosed between 2000 and 2009 completed the Hospital Anxiety and Depression Scale, SF-12, EORTC QLQ-CR38 and Fatigue Assessment Score questionnaires, in December 2010. Multivariable regression analyses were performed to identify predictors for increased follow-up care (>1 visit than recommended by guidelines).

RESULTS

In the first follow-up year, the average number of cancer-related visits to the general practitioner and medical specialist was 1.7 and 4.2, respectively. More than 80% of the CRC survivors was comfortable with their follow-up schedule, and 49-72% of them received follow-up according to the guidelines. Around 29-47% was followed more than recommended. Simultaneously, around 4-14% of the CRC survivors received less follow-up care than recommended. Survivors of stage III disease treated with chemotherapy received the most follow-up care. In addition, lower socio-economic status stoma and fatigue were associated with increased follow-up care.

CONCLUSION

CRC survivors were predominantly followed according to national guidelines. Increased follow-up care is driven by advanced disease stage, chemotherapy, SES, stoma and fatigue. Future studies should investigate how increased follow-up care use can be reduced, while still addressing patients' needs.

Unmet supportive care needs of breast, colorectal and testicular cancer survivors in the first 8 months post primary treatment: A prospective longitudinal survey

Objectives

To explore the supportive care needs of cancer survivors, the characteristics of patients with high levels of unmet need, changes in unmet need after treatment ends and differences in unmet needs of breast, colorectal and testicular survivors.

Methods

The method used was a prospective longitudinal mailed survey. Unmet needs, measured by 25‐item modified Cancer Survivors Unmet Needs survey at baseline (immediately post‐treatment) and 8 months later, were analysed descriptively.

Results

Of 434 breast, 186 colorectal and 75 testicular patients responding at baseline, 56.2%, 65.6% and 50.7%, respectively, had no unmet needs, the top decile having ≥10 (breast) or seven (colorectal and testicular) different needs and seven different unmet needs. The most frequently reported unmet need (all groups) was fear of cancer recurrence. Unmet needs fell significantly at 8 months for breast patients. Some patients reported new needs. Needs were lowest amongst colorectal survivors and differed between the three groups. Higher levels of unmet needs (breast and colorectal) were associated with having had chemotherapy.

Conclusion

Most survivors reported few unmet needs, but a small proportion have persisting or emerging needs. Routine or regular monitoring of unmet needs is required so that healthcare professionals can deliver personalised care based on individual needs, preferences and circumstances.

Patients' and healthcare professionals' views on a pre- and post-operative rehabilitation programme (SOLACE) for lung cancer: A qualitative study

AIMS AND OBJECTIVES

To explore patients' and healthcare professionals' views and experiences of a pre- and post-operative rehabilitation intervention (SOLACE), for patients undergoing surgery for early-stage lung cancer.

BACKGROUND

Considerable post-operative complications can occur after surgery. A specialist lung cancer service (SOLACE) was developed to optimise health and fitness levels prior to and following lung cancer resections, as well as reducing morbidity and mortality, and improving the physical and psychological well-being of patients.

DESIGN

The design was an exploratory, descriptive qualitative interview study.

METHODS

Seventeen lung cancer patients and eight healthcare professionals were recruited from a large teaching hospital in South England. Data were collected through semi-structured telephone and face-to-face interviews. Transcribed interview data were analysed thematically. The COREQ checklist was used to report on the study process.

RESULTS

The SOLACE service was positively perceived by patients and healthcare professionals. Patients valued the provision of tailored support/advice and peer support and reported benefits to their health and well-being. Barriers to patient uptake of the classes included time constraints, motivation and access for patients who lived at a distance.

CONCLUSIONS

There is benefit in providing a personalised approach through a pre- and post-operative rehabilitation service for lung cancer patients. Virtual support may address equality of access to service for those who live at a distance from the hospital.

RELEVANCE TO CLINICAL PRACTICE

Introduction of a pre- and post-operative rehabilitation service provided by specialist peri-operative rehabilitation nurses and practitioners can yield positive outcomes for patients undergoing surgical treatment of early-stage lung cancer. Engagement of key healthcare professionals, consideration of virtual follow-up services and making patients aware of services could maximise patient uptake. Further consideration is needed of the best way to promote patient self-management and long-term continuation of patient rehabilitation in the community.

Self-management and adherence to recommended follow-up after gynaecological cancer: results from the international InCHARGE study

OBJECTIVE

To assess the relationship between self-management skills and adherence to follow-up guidelines among gynecological cancer survivors in the Netherlands, Norway, and Denmark, and to assess the relationship between adherence to follow-up programs and use of additional healthcare services.

METHODS

For this international, multicenter, cross-sectional study, we recruited gynecological cancer survivors 1-5 years after completion of treatment. Information on follow-up visits, use of healthcare resources, self-management (measured by the Health Education Impact Questionnaire), clinical characteristics, and demographics were obtained by validated questionnaires. Participants were categorized as adherent if they attended the number of follow-up visits recommended by national guidelines, non-adherent if they had fewer visits than recommended, or over-users if they had more visits than recommended.

RESULTS

Of 4455 invited survivors, 2428 (55%) returned the questionnaires, and 911 survivors were included in the analyses. Survivors with high self-management most frequently adhered to recommended follow-up. Non-adherent survivors showed lower self-management in the health-directed activity domain (OR 1.54, 95% CI 1.03 to 2.32) than adherent survivors. No other associations between self-management and follow-up adherence were revealed. Non-adherent survivors tended to have endometrial cancer, surgical treatment only, be older, and be Danish residents. Over-users reported more follow-up visits and also used additional healthcare services more frequently than adherent survivors.

CONCLUSION

Low self-management appears to reduce the likelihood of adherence to national guidelines for gynecological cancer follow-up. Focusing on patient education for survivors at risk of low self-management to ensure adherence to recommended follow-up may improve personalization of follow-up.

Survivorship care for cancer patients in primary versus secondary care: a systematic review

Background

Cancer survivorship care is traditionally performed in secondary care. Primary care is often involved in cancer management and could therefore play a more prominent role.

Purpose

To assess outcomes of cancer survivorship care in primary versus secondary care.

Methods

A systematic search of MEDLINE and EMBASE was performed. All original studies on cancer survivorship care in primary versus secondary care were included. A narrative synthesis was used for three distinctive outcomes: (1) clinical, (2) patient-reported, and (3) costs.

Results

Sixteen studies were included: 7 randomized trials and 9 observational studies. Meta-analyses were not feasible due to heterogeneity. Most studies reported on solid tumors, like breast (N = 7) and colorectal cancers (N = 3). Clinical outcomes were reported by 10 studies, patient-reported by 11, and costs by 4. No important differences were found on clinical and patient-reported outcomes when comparing primary- with secondary-based care. Some differences were seen relating to the content and quality of survivorship care, such as guideline adherence and follow-up tests, but there was no favorite strategy. Survivorship care in primary care was associated with lower societal costs.

Conclusions

Overall, cancer survivorship care in primary care had similar effects on clinical and patient-reported outcomes compared with secondary care, while resulting in lower costs.

Implications for cancer survivors

Survivorship care in primary care seems feasible. However, since the design and outcomes of studies differed, conclusive evidence for the equivalence of survivorship care in primary care is still lacking. Ongoing studies will help provide better insights.

Health care provider and patient preparedness for alternative colorectal cancer follow-up; a review

Follow-up after curative treatment for colorectal cancer (CRC) puts pressure on outpatient services due to the growing number of CRC survivors. The aim of this state-of-the-art review was to evaluate setting, manner and provider of follow-up. Moreover, perceptions of CRC survivors and health care providers regarding standard and alternative follow-up were examined. After a comprehensive literature search of the PubMed database, 69 articles were included reporting on CRC follow-up in the hospital, primary care and home setting. Hospital-based follow-up is most common and has been provided by surgeons, medical oncologists, and gastroenterologists, as well as nurses. Primary care-based follow-up has been provided by general practitioners or nurses. Even though most hospital- or primary care-based follow-up care requires patients to visit the clinic, telephone-based care has proven to be a feasible alternative. Most patients perceived follow-up as positive; valuing screening and detection for disease recurrence and appreciating support for physical and psychosocial symptoms. Hospital-based follow-up performed by the medical specialist or nurse is highly preferred by patients and health care providers. However, willingness of both patients and health care providers for alternative, primary care or remote follow-up exists. Nurse-led and GP-led follow-up have proven to be cost-effective alternatives compared to specialist-led follow-up. If proven safe and acceptable, remote follow-up can become a cost-effective alternative. To decrease the personal and financial burden of follow-up for a growing number of colorectal cancer survivors, a more acceptable, flexible and dynamic care follow-up mode consisting of enhanced communication and role definitions among clinicians is warranted.

Exploring Strategies for Using Social Media to Self-Manage Health Care When Living With and Beyond Breast Cancer: In-Depth Qualitative Study

Background

As breast cancer survival rates improve and structural health resources are increasingly being stretched, health providers require people living with and beyond breast cancer (LwBBC) to self-manage aspects of their care.

Objective

This study aimed to explore how women use and experience social media to self-manage their psychosocial needs and support self-management across the breast cancer continuum.

Methods

The experiences of 21 women (age range 27-64 years) were explored using an in-depth qualitative approach. The women varied in the duration of their experiences of LwBBC, which facilitated insights into how they evolve and change their self-management strategies over time. Semistructured interviews were analyzed inductively using a thematic analysis, a polytextual analysis, and voice-centered relational methods.

Results

The use of multiple social media platforms, such as YouTube, Facebook, WhatsApp, and Twitter, enabled women to self-manage aspects of their care by satisfying needs for timely, relevant, and appropriate support, by navigating identities disrupted by diagnosis and treatment and by allowing them to (re)gain a sense of control. Women described extending their everyday use of multiple platforms to self-manage their care. However, women experienced social media as both empowering and dislocating, as their engagement was impacted by their everyday experiences of LwBBC.

Conclusions

Health care professionals (HCPs) need to be more aware, and open to the possibilities, of women using multiple social media resources as self-management tools. It is important for HCPs to initiate value-free discussions and create the space necessary for women to share how social media resources support a tailored and timely self-managed approach to their unique psychosocial needs.

Exploring health care professionals views on alternative approaches to cancer follow-up and barriers and facilitators to implementation of a recovery package

PURPOSE

To meet the long-term needs of cancer survivors the focus of recent cancer care reform in the United Kingdom (UK) has been the implementation of alternative follow-up strategies to relieve the growing pressures threatening to overwhelm cancer services. In 2013, the UK's National Cancer Survivorship Initiative recommended an integrated package of care called the Recovery Package to meet cancer survivors' psychosocial and information needs and supported self-management.

METHOD

We aimed to explore health care professionals' views of alternative strategies for follow-up care, and perceived barriers and facilitators to implementation of the Recovery Package for patients who had completed treatment for cancer. Semi-structured interviews with 19 participants sought views and experiences of key aspects of cancer care follow-up and aspects of the Recovery Package implementation.

RESULTS

Seven themes emerged from the data; sustainability and capacity, cost implications, primary care, self-management, recovery package, resistance to change, and visions for the future. Traditional hospital follow-up was considered suitable for patients with complex needs, rarer forms of cancer and/or a poorer prognosis. Risk stratification was considered a vital element of any future strategy as was interoperability of digital communication systems between health care providers. Charitable funding had enabled one site to introduce all elements of the recovery package for patients with common cancers.

CONCLUSION

Charitable funding had enabled implementation of elements of the Recovery Package. However, new approaches require services to be commissioned and funded appropriately with effective communication between patients and primary and secondary care facilitated by interoperability of health care records.

Endometrial cancer patients' preferences for follow-up after treatment: A cross-sectional survey

PURPOSE

Alternatives to hospital follow-up (HFU) following treatment for cancer have been advocated. Telephone follow-up (TFU) and patient-initiated follow-up are being implemented but it is unclear if these approaches will meet the preferences and needs of patients. This study aimed to explore the preferences of endometrial cancer patients and their levels of satisfaction with HFU and nurse-led TFU.

METHODS

A cross-sectional survey design was utilised and a questionnaire was administered to 236 patients who had participated in a randomised controlled trial comparing HFU with TFU for women diagnosed with Stage I endometrial cancer (ENDCAT trial).

RESULTS

211 (89.4%) patients returned the questionnaire; 105 in the TFU group and 106 in the HFU group. The TFU group were more likely to indicate that appointments were on time (p < 0.001) and were more likely to report that their appointments were thorough (p = 0.011). Participants tended to prefer what was familiar to them. Those in the HFU group tended to prefer hospital-based appointments while the TFU group tended to prefer appointments with a clinical nurse specialist, regardless of locality.

CONCLUSIONS

To provide patient centred follow-up services we need to ensure that patient preferences are taken into account and understand that patients may come to prefer what they have experienced. Patient initiated approaches may become standard and preferred practice but TFU remains a high-quality alternative to HFU and may provide an effective transition between HFU and patient-initiated approaches.

Follow-up strategies following completion of primary cancer treatment in adult cancer survivors

BACKGROUND

Most cancer survivors receive follow-up care after completion of treatment with the primary aim of detecting recurrence. Traditional follow-up consisting of fixed visits to a cancer specialist for examinations and tests are expensive and may be burdensome for the patient. Follow-up strategies involving non-specialist care providers, different intensity of procedures, or addition of survivorship care packages have been developed and tested, however their effectiveness remains unclear.

OBJECTIVES

The objective of this review is to compare the effect of different follow-up strategies in adult cancer survivors, following completion of primary cancer treatment, on the primary outcomes of overall survival and time to detection of recurrence. Secondary outcomes are health-related quality of life, anxiety (including fear of recurrence), depression and cost.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases and two trials registries on 11 December 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised trials comparing different follow-up strategies for adult cancer survivors following completion of curatively-intended primary cancer treatment, which included at least one of the outcomes listed above. We compared the effectiveness of: 1) non-specialist-led follow-up (i.e. general practitioner (GP)-led, nurse-led, patient-initiated or shared care) versus specialist-led follow-up; 2) less intensive versus more intensive follow-up (based on clinical visits, examinations and diagnostic procedures) and 3) follow-up integrating additional care components relevant for detection of recurrence (e.g. patient symptom education or monitoring, or survivorship care plans) versus usual care.

DATA COLLECTION AND ANALYSIS

We used the standard methodological guidelines by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC). We assessed the certainty of the evidence using the GRADE approach. For each comparison, we present synthesised findings for overall survival and time to detection of recurrence as hazard ratios (HR) and for health-related quality of life, anxiety and depression as mean differences (MD), with 95% confidence intervals (CI). When meta-analysis was not possible, we reported the results from individual studies. For survival and recurrence, we used meta-regression analysis where possible to investigate whether the effects varied with regards to cancer site, publication year and study quality.

MAIN RESULTS

We included 53 trials involving 20,832 participants across 12 cancer sites and 15 countries, mainly in Europe, North America and Australia. All the studies were carried out in either a hospital or general practice setting. Seventeen studies compared non-specialist-led follow-up with specialist-led follow-up, 24 studies compared intensity of follow-up and 12 studies compared patient symptom education or monitoring, or survivorship care plans with usual care. Risk of bias was generally low or unclear in most of the studies, with a higher risk of bias in the smaller trials. Non-specialist-led follow-up compared with specialist-led follow-up It is uncertain how this strategy affects overall survival (HR 1.21, 95% CI 0.68 to 2.15; 2 studies; 603 participants), time to detection of recurrence (4 studies, 1691 participants) or cost (8 studies, 1756 participants) because the certainty of the evidence is very low. Non-specialist- versus specialist-led follow up may make little or no difference to health-related quality of life at 12 months (MD 1.06, 95% CI -1.83 to 3.95; 4 studies; 605 participants; low-certainty evidence); and probably makes little or no difference to anxiety at 12 months (MD -0.03, 95% CI -0.73 to 0.67; 5 studies; 1266 participants; moderate-certainty evidence). We are more certain that it has little or no effect on depression at 12 months (MD 0.03, 95% CI -0.35 to 0.42; 5 studies; 1266 participants; high-certainty evidence). Less intensive follow-up compared with more intensive follow-up Less intensive versus more intensive follow-up may make little or no difference to overall survival (HR 1.05, 95% CI 0.96 to 1.14; 13 studies; 10,726 participants; low-certainty evidence) and probably increases time to detection of recurrence (HR 0.85, 95% CI 0.79 to 0.92; 12 studies; 11,276 participants; moderate-certainty evidence). Meta-regression analysis showed little or no difference in the intervention effects by cancer site, publication year or study quality. It is uncertain whether this strategy has an effect on health-related quality of life (3 studies, 2742 participants), anxiety (1 study, 180 participants) or cost (6 studies, 1412 participants) because the certainty of evidence is very low. None of the studies reported on depression. Follow-up strategies integrating additional patient symptom education or monitoring, or survivorship care plans compared with usual care: None of the studies reported on overall survival or time to detection of recurrence. It is uncertain whether this strategy makes a difference to health-related quality of life (12 studies, 2846 participants), anxiety (1 study, 470 participants), depression (8 studies, 2351 participants) or cost (1 studies, 408 participants), as the certainty of evidence is very low.

AUTHORS' CONCLUSIONS

Evidence regarding the effectiveness of the different follow-up strategies varies substantially. Less intensive follow-up may make little or no difference to overall survival but probably delays detection of recurrence. However, as we did not analyse the two outcomes together, we cannot make direct conclusions about the effect of interventions on survival after detection of recurrence. The effects of non-specialist-led follow-up on survival and detection of recurrence, and how intensity of follow-up affects health-related quality of life, anxiety and depression, are uncertain. There was little evidence for the effects of follow-up integrating additional patient symptom education/monitoring and survivorship care plans.

End-of-life cost and its determinants for cancer patients in urban China: a population-based retrospective study

OBJECTIVE

This study aimed to define the end-of-life (EOL) healthcare utilisation and its cost and determinants for cancer patients and to proactively inform related strategies in mainland China.

DESIGN

A population-based retrospective study.

SETTING AND PARTICIPANTS

Data from 894 cancer patients were collected in urban Yichang, China from 01 July 2015 to 30 June 2017.

OUTCOME MEASURES

Emergency department (ED) visits, outpatient and inpatient hospitalisation services, intensive care unit (ICU) admission and total costs were used as the main outcomes.

RESULTS

In this study, 66.8% of the 894 patients were male, and the average age was 60.4 years. Among these patients, 37.6% died at home, and patients had an average of 4.86 outpatient services, 2.23 inpatient hospitalisation services and 1.44 ED visits. Additionally, 5.9% of these patients visited the ICU at least once. During the EOL periods, the costs in the last 6 months, 3 months, 1 month and 1 week were US$18 234, US$13 043, US$6349 and US$2085, respectively. The cost increased dramatically as death approached. The estimation results of generalised linear regression models showed that aggressive care substantially affected expenditure. Patients with Urban Employee Basic Medical Insurance spent more than those with Urban Resident-based Basic Medical Insurance or the New Rural Cooperative Medical Scheme. The place of death and the survival time are also risk factors for increased EOL cost.

CONCLUSION

The findings suggested that the EOL cost for cancer patients is associated with aggressive care, insurance type and survival time. Timing palliative care is urgently needed to address ineffective and irrational healthcare utilisation and to reduce costs.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571). All the data used in this study were de-identified.

A qualitative study of home visiting as a palliative care strategy to follow-up cancer patients by nurses in clinical setting in a developing country

AIMS

The aims are to examine the effect of home visiting and resources for instituting the programme as a follow-up strategy in integration of palliative care in daily clinical practice by nurses caring for cancer patients in Nigeria, and on how it can be used to improve care for cancer patients.

BACKGROUND

Home visiting by nurses has been used as a follow-up option in maternal and child health care globally. Most cancer patients default after diagnosis, home visiting offers potential as a strategy for follow-up of these patients too.

METHODS

This was a qualitative study which employed a focus group discussion with nurse managers and interviews with cancer in-patients in two teaching hospitals in Nigeria. It utilised an interpretive paradigm to reach the best understanding of the problem. A total of 19 nurse managers who were directly involved with the care of cancer patients and 11 cancer patients participated in the study between July and September 2016. A qualitative content analysis was employed to analyse the data.

FINDINGS

Nine major themes were identified in relation to perceived benefits of home visiting services and six in relation to needed resources in instituting the programme. Similar findings emerged from both the focus group discussions and the interviews with patients. Participants agreed that visiting cancer patients would ease many problems commonly encountered by patients following diagnosis of cancer, including psychological, financial, and emotional problems. Needed resources included hospital policies, adequate staff strength, staff commitment and funding.

CONCLUSIONS

Viable home visiting requires palliative care teams to carry out the service and hospital policy to direct their activities. Putting this into practice will be in line with World Health Organisation (WHO) advocacy of integrated palliative care for chronic diseases.

Partnership between patients, nurse leaders and researchers: Outcomes of a web-based KT strategy for hospital discharge planning and care transitions in oncology

A research project brought together patient partners, nurse leaders from six clinical settings in Quebec and researchers to develop and test a web technology, the Forum for Knowledge Exchange (FKE), in order to improve discharge planning practices and oncological care transitions. The project led to the creation of a FKE accessible to the oncology sector of the Francophonie. It revealed an innovative strategy of knowledge transfer (KT) based on the FKE and was fed by collaborative work among partners, where the patient partners played a vital role. The results highlighted the importance, for health research, of giving a voice to patient partners in close collaboration with clinicians and researchers so that clinical practices are better adapted to the actual needs of patients and of their relatives.

Telephone follow-up after treatment for endometrial cancer: A qualitative study of patients' and clinical nurse specialists' experiences in the ENDCAT trial

PURPOSE

Endometrial cancer is the sixth most common female cancer worldwide. There is little evidence that routine hospital surveillance increases survival or decreases morbidity following treatment. Gynaecology Oncology clinical nurse specialists (CNSs) are ideally placed to provide the care, information and support to enable women with a gynaecological cancer to self-manage and live well. A multi-centre randomised controlled trial (RCT) compared hospital follow-up (HFU) with telephone follow-up (TFU) by CNSs. The structured telephone intervention focused on information provision to meet patients psychosocial and information needs. This study aimed to explore the views of women who had received TFU and the CNS's who had delivered the service.

METHOD

A qualitative study to complement the RCT using semi-structured interviews was conducted. Twenty-five patients were randomly selected from participants in the TFU arm stratified by study site. Seven CNSs were interviewed.

RESULTS

Patient and CNS regarded TFU positively; Three themes emerged from the patient interviews; Convenient Care, Discrete Personalised Care, Confidence and Reassurance. Themes arising from the CNS interviews were Patient Centred Care, Holistic Care and, Confidence and Skills. Patients found that TFU with CNS's was convenient and enabled discussion of issues and information provision at time-points relevant to them. The CNS's found the structured format of TFU enabled them to utilise their skills and knowledge to identify and meet patients holistic needs.

CONCLUSIONS

Alternative models of care such as TFU provided by CNSs provides the care, information and support to enable women treated for endometrial cancer to self-manage and live well.

A Snapshot of Community Engagement in Research in the Context of an Evolving Public Health Paradigm: Review

BACKGROUND

Community engagement is a work in process. Researchers continue to refine the process of collaboration and look to best practice and lessons learned for guidance in this relatively new model.

OBJECTIVE

The aim of this study was to provide a snapshot of whether community engagement has been included in the design and implementation of research initiatives in Australia, Canada and the United Kingdom. The secondary aim is to identify the underlying themes present, to identify theories and tools that drive research.

METHODS

A literature search was performed to identify studies that have been conducted to reduce the weight of the general population.

RESULTS

The results of the study, which focused on the field of weight loss, indicate that scientific and technological advancements are the primary drivers of research. However, these new research initiatives have largely been undertaken in the absence of community engagement.

CONCLUSIONS

The study concludes that initiatives need to adapt to a wider range of stakeholders, develop equitable community engagement platforms and take into consideration.

A train the trainer program for healthcare professionals tasked with providing psychosocial support to breast cancer survivors

BACKGROUND

The objective of this study is to develop, implement, and evaluate a training program for healthcare providers to improve ability to provide psychosocial support to breast cancer survivors in Korea.

METHODS

Based on a needs assessment survey and in-depth interviews with breast cancer survivors, a multidisciplinary team developed two-day intensive training program as well as education materials and counseling notes. Participants' overall satisfaction was evaluated after the training.

RESULTS

The training program included a total of 16 lectures held over the course of seven sessions. Forty-one nurses and 3 social workers participated in the training program. Mean age was 37.5(± 6.4) years, and on average, they had 11.1 (± 5.6) years of experience. Participants' overall satisfaction was good as following: program contents (4.04), trainee guidebook (3.82), location and environment (4.10), and program organization (4.19). Among the participants, 31 (70.4%) received certification after submitting real consultation cases after the training.

CONCLUSION

Two day intensive training can provide a comprehensive and coordinated education to healthcare professionals for implementing survivorship care with an emphasis on psychosocial support. Furthermore, the program should resume as a periodic continuing education course for healthcare providers. Similar education for graduate students in oncology nursing would be beneficial.

Follow-up care after treatment for prostate cancer: protocol for an evaluation of a nurse-led supported self-management and remote surveillance programme

BACKGROUND

As more men survive a diagnosis of prostate cancer, alternative models of follow-up care that address men's enduring unmet needs and are economical to deliver are needed. This paper describes the protocol for an ongoing evaluation of a nurse-led supported self-management and remote surveillance programme implemented within the secondary care setting.

METHODS/DESIGN

The evaluation is taking place within a real clinical setting, comparing the outcomes of men enrolled in the Programme with the outcomes of a pre-service change cohort of men, using a repeated measures design. Men are followed up at four and 8 months post recruitment on a number of outcomes, including quality of life, unmet need, psychological wellbeing and activation for self-management. An embedded health economic analysis and qualitative evaluation of implementation processes are being undertaken.

DISCUSSION

The evaluation will provide important information regarding the effectiveness, cost effectiveness and implementation of an integrated supported self-management follow-up care pathway within secondary care.

Integrated Care in Prostate Cancer (ICARE-P): Nonrandomized Controlled Feasibility Study of Online Holistic Needs Assessment, Linking the Patient and the Health Care Team

Background

The potential of technology to aid integration of care delivery systems is being explored in a range of contexts across a variety of conditions in the United Kingdom. Prostate cancer is the most common cancer in UK men. With a 10-year survival rate of 84%, there is a need to explore innovative methods of care that are integrated between primary health care providers and specialist teams in order to address long-term consequences of the disease and its treatment as well as to provide continued monitoring for recurrence.

Objective

Our aim was to test the feasibility of a randomized controlled trial to compare a model of prostate cancer continuing and follow-up care integration, underpinned by digital technology, with usual care in terms of clinical and cost-effectiveness, patient-reported outcomes, and experience.

Methods

A first phase of the study has included development of an online adaptive prostate specific Holistic Needs Assessment system (HNA), training for primary care-based nurses, training of an IT peer supporter, and interviews with health care professionals and men with prostate cancer to explore views of their care, experience of technology, and views of the proposed intervention. In Phase 2, men in the intervention arm will complete the HNA at home to help identify and articulate concerns and share them with their health care professionals, in both primary and specialist care. Participants in the control arm will receive usual care. Outcomes including quality of life and well-being, prostate-specific concerns, and patient enablement will be measured 3 times over a 9-month period.

Results

Findings from phase 1 indicated strong support for the intervention among men, including those who had had little experience of digital technology. Men expressed a range of views on ways that the online system might be used within a clinical pathway. Health care professionals gave valuable feedback on how the output of the assessment might be presented to encourage engagement and uptake by clinical teams. Recruitment to the second phase of the study, the feasibility trial, commenced March 2017.

Conclusions

To our knowledge, this study is the first in the United Kingdom to trial an online holistic needs assessment for men with prostate cancer, with data shared between patients and primary and secondary care providers. This study addresses recommendations in recent policy documents promoting the importance of data sharing and enhanced communication between care providers as a basis for care integration. We anticipate that this model of care will ultimately provide important benefits for both patients and the National Health Service.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 31380482; http://www.isrctn.com/ISRCTN31380482 (Archived by WebCite at http://www.webcitation.org/6s8I42u5N)

Patients' expectations and preferences regarding cancer follow-up care

INTRODUCTION

Most survivors of cancer enter a follow-up routine after their treatment, the aim of which is to detect recurrence, provide psychological support, monitor treatment-related side-effects, and to evaluate care. Due to rising numbers of people with cancer and better survival of these patients, current follow-up routines are under pressure. We reviewed the literature on patients' expectations and preferences regarding this care.

METHODS

We systematically searched the databases of Pubmed, CINAHL, and PsychInfo. Studies were screened and data extraction was double performed by three authors. Data were collected from quantitative and qualitative studies and described thematically.

RESULTS

After screening, 12 full-text articles were included, comprising 849 patients aged from 28 to 90 years. Patients expect follow-up visits to detect recurrence of cancer. They want to undergo extensive testing to get reassurance. Furthermore, patients expect relevant information to be provided and to get advice about different aspects of their illness. Psychosocial support is also expected. Patients express a desire for consistency of care as well as continuity of care, and prefer long and intensive follow-up.

DISCUSSION AND CONCLUSION

After cancer, patients appear to lose confidence in their bodies and fear cancer recurrence after the end of treatment, which may lead to intensive screening wishes. This is not desirable, since care for cancer is already under pressure due to rising numbers of survivors. We have to ensure that follow-up routines are sustainable and effective. Patients should receive good information about the need for follow-up tests. Doctors should be trained to give this information.

Determining cancer survivors' preferences to inform new models of follow-up care

BACKGROUND

Specialist-led cancer follow-up is becoming increasingly expensive and is failing to meet many survivors' needs. Alternative models informed by survivors' preferences are urgently needed. It is unknown if follow-up preferences differ by cancer type. We conducted the first study to assess British cancer survivors' follow-up preferences, and the first anywhere to compare the preferences of survivors from different cancers.

METHODS

A discrete choice experiment questionnaire was mailed to 1201 adults in Northeast Scotland surviving melanoma, breast, prostate or colorectal cancer. Preferences and trade-offs for attributes of cancer follow-up were explored, overall and by cancer site.

RESULTS

668 (56.6%) recipients (132 melanoma, 213 breast, 158 prostate, 165 colorectal) responded. Cancer survivors had a strong preference to see a consultant during a face-to-face appointment when receiving cancer follow-up. However, cancer survivors appeared willing to accept follow-up from specialist nurses, registrars or GPs provided that they are compensated by increased continuity of care, dietary advice and one-to-one counselling. Longer appointments were also valued. Telephone and web-based follow-up and group counselling, were not considered desirable. Survivors of colorectal cancer and melanoma would see any alternative provider for greater continuity, whereas breast cancer survivors wished to see a registrar or specialist nurse, and prostate cancer survivors, a general practitioner.

CONCLUSIONS

Cancer survivors may accept non-consultant follow-up if compensated with changes elsewhere. Care continuity was sufficient compensation for most cancers. Given practicalities, costs and the potential to develop continuous care, specialist nurse-led cancer follow-up may be attractive.

A Holistic Model of Care to Support Those Living with and beyond Cancer

BACKGROUND

Globally, the burden of cancer continues to increase and it is well-documented that while not a homogeneous population, cancer patients and cancer survivors face many physical, psychological, social, spiritual, and financial issues. Cancer care is shifting from a disease-focused to a patient-centered approach resulting in an increased need to address these concerns.

METHODS

Utilizing a quality improvement approach, this paper describes an integrated cancer care model at Bloomhill Cancer Center (BCC) in Queensland, Australia that demonstrates the ability to meet the holistic needs of patients living with and beyond cancer and to identify opportunities for better practice and service provision.

RESULTS

Survey results indicate that 67% and 77% of respondents were very satisfied and 27% and 17% were satisfied with their first contact and very satisfied with their first meeting with a nurse at BCC. Clients also reported being very satisfied (46%) or satisfied (30%) with the emotional support they received at BCC and over 90% were very satisfied or satisfied with the touch therapies that the received.

CONCLUSION

Due to the early success of the interventions provided by BCC, the model potentially offers other states and countries a framework for supportive cancer care provision for people living with and beyond cancer.

Survivorship care and support following treatment for breast cancer: a multi-ethnic comparative qualitative study of women's experiences

BACKGROUND

As the number of breast cancer survivors continues to rise, Western populations become more ethnically and socially diverse and healthcare resources become ever-more stretched, follow-up that focuses on monitoring for recurrence is no longer viable. New models of survivorship care need to ensure they support self-management and are culturally appropriate across diverse populations. This study explored experiences and expectations of a multi-ethnic sample of women with breast cancer regarding post-treatment care, in order to understand potential barriers to receiving care and inform new models of survivorship care.

METHODS

A phenomenological qualitative research design was employed. In-depth interviews were conducted with women from diverse socio-demographic backgrounds in England, who completed treatment for breast cancer in the 12 months prior to the study. Data were analysed using Framework Analysis.

RESULTS

Sixty-six women participated and reported expectations and needs were unmet at follow-up. Whilst there were more commonalities in experiences, discernible differences, particularly by ethnicity and age, were identified relating to three key themes: emotional responses on transition to follow-up; challenges communicating with healthcare professionals at follow-up; and challenges finding and accessing information and support services to address unmet needs.

CONCLUSIONS

There are cultural differences in the way healthcare professionals and women communicate, not necessarily differences in their post-treatment needs. We do not know if new models of care meet survivors' needs, or if they are appropriate for everyone. Further testing and potential cultural and linguistic adaptation of models of care is necessary to ensure their appropriateness and acceptability to survivors from different backgrounds. New ways of providing survivorship care mean survivors will need to be better prepared for the post-treatment period and the role they will have to play in managing their symptoms and care.

eHealth for Breast Cancer Survivors: Use, Feasibility and Impact of an Interactive Portal

Background

MijnAVL is an interactive portal including patient education, overview of appointments, access to the electronic medical records (EMR), patient-reported outcomes, plus feedback and physical activity support.

Objective

With this study we aimed to evaluate the use, feasibility, and impact of MijnAVL among breast cancer survivors.

Methods

We included survivors currently or recently treated with curative intent, who completed questions on sociodemographics, patient activation (PAM), quality of life (SF-36), and physical activity (IPAQ). MijnAVL could be used noncommittally for four months. Log data were collected retrospectively and participants completed questions on acceptability, satisfaction, and the PAM, SF-36 and IPAQ.

Results

Ninety-two women (mean age 49.5 years, 59% on-treatment) participated, with a mean number of logins of 8.7. Overview of appointments (80% of participants) and access to the EMR (90%) were most frequently used and most highly valued. Average website user satisfaction was 3.8 on a 5-point scale. Although participants reported having more knowledge and experiencing more control of their situation after using MijnAVL, PAM scores did not change significantly. Three domains of the SF-36 (role functioning - emotional, mental health, and social functioning) and median vigorous physical activity improved significantly over time. The burden of MijnAVL for professionals was limited.

Conclusions

User experiences were positive and exposure to MijnAVL was accompanied by improvements in three quality of life domains and vigorous physical activity. Tailored features may be needed to enhance the usefulness and efficacy of MijnAVL. Research with a controlled design is needed to confirm our findings.

Comparing the costs of three prostate cancer follow-up strategies: a cost minimisation analysis

PURPOSE

Prostate cancer follow-up is traditionally provided by clinicians in a hospital setting. Growing numbers of prostate cancer survivors mean that this model of care may not be economically sustainable, and a number of alternative approaches have been suggested. The aim of this study was to develop an economic model to compare the costs of three alternative strategies for prostate cancer follow-up in Ireland-the European Association of Urology (EAU) guidelines, the National Institute of Health Care Excellence (NICE) guidelines and current practice.

METHODS

A cost minimisation analysis was performed using a Markov model with three arms (EAU guidelines, NICE guidelines and current practice) comparing follow-up for men with prostate cancer treated with curative intent. The model took a health care payer's perspective over a 10-year time horizon.

RESULTS

Current practice was the least cost efficient arm of the model, the NICE guidelines were most cost efficient (74 % of current practice costs) and the EAU guidelines intermediate (92 % of current practice costs). For the 2562 new cases of prostate cancer diagnosed in 2009, the Irish health care system could have saved €760,000 over a 10-year period if the NICE guidelines were adopted.

CONCLUSIONS

This is the first study investigating costs of prostate cancer follow-up in the Irish setting. While economic models are designed as a simplification of complex real-world situations, these results suggest potential for significant savings within the Irish health care system associated with implementation of alternative models of prostate cancer follow-up care.

Empowerment of Cancer Survivors Through Information Technology: An Integrative Review

BACKGROUND

Patient empowerment may be an effective approach to strengthen the role of cancer survivors and to reduce the burden on health care. However, it is not well conceptualized, notably in oncology. Furthermore, it is unclear to what extent information technology (IT) services can contribute to empowerment of cancer survivors.

OBJECTIVE

We aim to define the conceptual components of patient empowerment of chronic disease patients, especially cancer survivors, and to explore the contribution of existing and new IT services to promote empowerment.

METHODS

Electronic databases were searched to identify theoretical and empirical articles regarding empowerment. We extracted and synthesized conceptual components of patient empowerment (ie, attributes, antecedents, and consequences) according to the integrated review methodology. We identified recent IT services for cancer survivors by examining systematic reviews and a proposed inventory of new services, and we related their features and effects to the identified components of empowerment.

RESULTS

Based on 26 articles, we identified five main attributes of patient empowerment: (1) being autonomous and respected, (2) having knowledge, (3) having psychosocial and behavioral skills, (4) perceiving support from community, family, and friends, and (5) perceiving oneself to be useful. The latter two were specific for the cancer setting. Systematic reviews of IT services and our additional inventory helped us identify five main categories: (1) educational services, including electronic survivorship care plan services, (2) patient-to-patient services, (3) electronic patient-reported outcome (ePRO) services, (4) multicomponent services, and (5) portal services. Potential impact on empowerment included knowledge enhancement and, to a lesser extent, enhancing autonomy and skills. Newly developed services offer promising and exciting opportunities to empower cancer survivors, for instance, by providing tailored advice for supportive or follow-up care based on patients' input.

CONCLUSIONS

We identified five main components of empowerment and showed that IT services may especially contribute to empowerment by providing knowledge. The components of empowerment could be used to develop IT services for cancer survivors. It is important to take into account patients' needs, follow up on these needs, and create a service that is attractive and easy to use.

Knowledge and awareness of long-term and late treatment consequences amongst colorectal cancer survivors: A qualitative study

PURPOSE

To describe patient knowledge and awareness of long-term and late onset treatment consequences amongst colorectal cancer survivors.

METHODS

Semi-structured qualitative interviews were conducted with 19 colorectal cancer survivors at least 12 months post-treatment. Interviews were audio-recorded, transcribed into NVivo 10 software and analysed using the framework method.

RESULTS

Participants were aware of disease recurrence but not many other treatment consequences; change in bowel habit and impact on diet were common and had significant impact, yet many felt they had not received 'warning', considering it a gap in both information and support. Participants expressed preference to know about possible consequences early on and were willing to engage in education and support if offered. Information overload, timing of information provision and unequipped health care professionals were considered barriers to awareness.

CONCLUSION

Improvement in information provision, management of expectations and support around bowel function would facilitate patient self-empowerment and could improve holistic management of health and well-being after cancer.

Economic Considerations on the Follow-Up Practice in Gynecologic Cancers: Few Lights and Many Shadows From a Literature Review

Objective

The aim of this review was to analyze the existing literature on the cost of follow-up in gynecology oncology.

Methods/materials

We performed a literature search in Medline and NHS CRD (University of Oxford) databases. Research strings were mainly based on MESH terms referring to economic studies and to neoplasms follow-up/aftercare and cancer recurrences. Two independent searches were performed for ovarian neoplasm and uterine neoplasm. Some studies were also identified among the references of the selected articles. Potentially relevant studies were identified based on the title and abstract by 2 independent readers.

Results

Finally, the reviewing process selected 2 studies on gynecologic cancers in general, including uterine and ovarian cancers, 3 specific on ovarian cancer, 7 on endometrium, and 9 on cervix. The identified economic literature on economic evaluation of gynecologic cancer follow-up procedures showed to be based on weak evidence of effectiveness and to lack formal methodological approaches. In general, such literature is quite recent, relies on small sample observational studies, and suffers from a lack of financial support.

Conclusions

There are few available lights in economic considerations on gynecologic cancer follow-up, represented by all the published studies, and many shadows that require to be clarified by properly designed randomized trials including cost-effectiveness analysis.

Exploring patient perception of success and benefit in self-management of breast cancer-related arm lymphoedema

PURPOSE

The aim of this study was to identify factors influencing patient perception of success and benefit with self-management of breast cancer-related lymphoedema (BCRL) and explore how patients decide whether their swollen limb has improved or deteriorated.

METHODS

This qualitative study used a Grounded Theory approach. Twenty-one women in the BCRL self-management phase participated in one in-depth interview exploring their experience and perspective on self-managing their BCRL.

FINDINGS

Seven enablers and blocks to self-management were identified: routine, recognising benefit of self-management and consequences of non-treatment, owning treatment, knowledge and understanding, problem-solving, time required for treatment and aesthetics of hosiery. Women determined treatment outcome by monitoring size, appearance, texture and internal sensations within the affected arm.

CONCLUSIONS

Women who participated in this study showed varying degrees of acceptance and adjustment to life with lymphoedema. This appears to directly impact their ability to self-manage lymphoedema. Lymphoedema practitioners and oncology nurses have a valuable role providing knowledge and support to patients transitioning to independent self-care. A better understanding of factors facilitating patients to become experts in their condition may improve longer term outcomes and reduce cost pressures on lymphoedema services.

Using mixed methods to identify and answer clinically relevant research questions

The need for mixed methods research in answering health care questions is becoming increasingly recognized because of the complexity of factors that affect health outcomes. In this article, we argue for the value of using a qualitatively driven mixed method approach for identifying and answering clinically relevant research questions. This argument is illustrated by findings from a study on the self-management practices of cancer survivors and the exploration of one particular clinically relevant finding about higher uptake of self-management in cancer survivors who had received chemotherapy treatment compared with those who have not. A cross-sectional study generated findings that formed the basis for the qualitative study, by informing the purposive sampling strategy and generating new qualitative research questions. Using a quantitative research component to supplement a qualitative study can enhance the generalizability and clinical relevance of the findings and produce detailed, contextualized, and rich answers to research questions that would be unachievable through quantitative or qualitative methods alone.

Integrated care pathways for cancer survivors - a role for patient-reported outcome measures and health informatics

Modern cancer treatments have improved survival rates and changed the nature of cancer care. The acute and long-term physical and psychosocial comorbidities associated with treatment place increasing demands on healthcare services to provide suitable models of follow-up care for the survivor population.

AIM

We discuss the value and challenges of incorporating patient-reported outcome measures (PROMs) and eHealth interventions into routine follow-up care. We draw on our 15 years' experience of developing electronic systems for capturing patient-reported data in oncology settings, with particular reference to eRAPID a new online symptom reporting system for cancer patients. THE REDESIGN OF HEALTHCARE PATHWAYS: New stratified care pathways have been proposed for cancer survivors with an emphasis on supported self-management and shared care. THE POTENTIAL ROLE OF PROMS IN SURVIVORSHIP CARE PATHWAYS: PROMs can be used to evaluate rehabilitation services, provide epidemiological 'Big Data' and screen patients for physical and psychological morbidities to determine the need for further support. In addition, electronic PROMs systems linked to electronic patient records (EPRs) have the capability to provide tailored self-management advice to individual patients. INTEGRATION OF PROMS INTO CLINICAL PRACTICE: The successful clinical utilisation of PROMs is dependent on a number of components including; choosing appropriate questionnaires, developing evidence-based scoring algorithms, the creation of robust electronic platforms for recording and transferring data into EPRs, and training staff and patients to engage effectively with PROMs.

DISCUSSION

There is increasingly positive evidence for using PROMs and eHealth approaches to support cancer patients' care during treatment. Much of what has been learnt can be applied to cancer survivorship. PROMs integrated into eHealth platforms and with EPR have the potential to play a valuable role in the development of appropriate and sustainable long-term follow-up models for cancer survivors.

Treatment and outcomes of head and neck oedema referrals to a hospital-based lymphoedema service

A retrospective review of all head and neck cancer-related lymphoedema (HNCRL) referrals from 1 October 2009 to 30 September 2013 was undertaken. HNCRL referrals significantly increased over a 4-year period. Lymphoedema clinic records were manually examined for the presentation of HNCRL, treatments provided, and outcomes. Some 207 HNCRL referrals were received, increasing by 251% from 2009 to 2013. A total of 110 men and 50 women were assessed and treated over the 4 years; 67% were discharged, 26% continued treatment/monitoring by clinic; 8% are deceased. The average time to discharge reduced from 16 to 5 months. From the results, it seems that self-management with exercise and counter-pressure/compression is very effective and the requirement for manual lymph drainage is reduced. There is increased patient engagement with effective self-care. Provision of appropriate education and information facilitated simple, effective self-management. This reduced treatment time, shortened time to discharge and released valuable practitioner time to treat patients with complex oedema.

Internet-based support programs to alleviate psychosocial and physical symptoms in cancer patients: a literature analysis

In this review the effect of internet-based support programs on psychosocial and physical symptoms resulting from cancer diagnosis and treatment is analyzed. Selection of studies was based on the following criteria: (non-)randomized controlled trials, performed in adult cancer patients, comparing quantitative psychosocial and/or physical outcomes of an internet-based support program with (a) comparison group(s). Literature search yielded 2032 studies of which 16 fulfilled the eligibility criteria. Three different internet-based support programs were identified: social support groups, online therapy for psychosocial/physical symptoms, and online systems integrating information, support, and coaching services. Outcomes improved by these programs in nine studies. Especially fatigue, social support, and distress improved, regardless of the program type. All online systems showed positive effects, mainly for social support and quality of life. This analysis indicates that internet-based support programs are effective in improving psychosocial and physical symptoms in cancer patients.