Comorbid condition care quality in cancer survivors: role of primary care and specialty providers and care coordination

Primary care for cancer survivors: a review of national institutes of health-funded grants 2017-2022

PURPOSE

To describe the characteristics of National Institutes of Health (NIH) grants on primary care cancer research in cancer survivorship funded over the past 5 years.

METHODS

Research project grants (RPG) funded during Fiscal Year (FY) 2017 to 2022 focused on cancer survivorship were identified using a text mining algorithm of words from the NIH Research, Condition, and Disease Categorization (RCDC) thesaurus with survivorship-relevant terms. Grants were then reviewed and double-coded to identify those that were carried out in a primary care setting, targeted primary care providers, or had primary care providers in the study team.

RESULTS

A total of 24 grants were identified; 23 were funded by the National Cancer Institute and one was funded by the National Institute on Minority Health and Health Disparities. The majority were funded under the R01 mechanism (70.8%) and led by established investigators. Most were interventional design (91.7%), including both survivors and providers (79.2%), and focused care coordination or healthcare utilization (91.7%).

CONCLUSIONS

Grants focused on primary care cancer survivorship are uncommon in the NIH portfolio.

IMPLICATIONS FOR SURVIVORS

For the over 18 million cancer survivors in the USA, being cared for in a primary care setting is common. Yet, NIH-funded research on primary care cancer survivorship is sparse.

Primary Care Provider Visits Among Cancer Survivors 5-7 Years Postdiagnosis

PURPOSE

Cancer survivors experience better outcomes when primary care providers (PCPs) are engaged in their care. Nearly all survivors have a PCP engaged in their care in the initial 5 years postdiagnosis, but little is known about sustained PCP engagement. We assessed PCP engagement in survivors' care 5-7 years postdiagnosis and characterized survivors most vulnerable to loss to PCP follow-up.

METHODS

We linked electronic health record ambulatory care and cancer registry data from an National Cancer Institute-Designated Comprehensive Cancer Center to identify eligible survivors (≥18 years; diagnosed with breast, colorectal, or uterine cancer; had an in-network PCP). We used multiple logistic regression to assess associations between survivor demographics, clinical factors, and health care utilization and odds of sustained PCP engagement.

RESULTS

In 5-7 years postdiagnosis, PCPs were engaged in care for 43% of survivors. Survivors with sustained PCP-engagement were on average 4.6 years older than those without (P < .0001); survivors had 1.36 greater odds of having regular PCP visits for each decade increase in age on cancer diagnosis (P = .0030). Survivors were less likely to be lost to PCP follow-up if diagnosed at an earlier stage with odds at 0.57 and 0.10 for stage I and stage IV, respectively (P = .0005), and had 2.70 greater odds of engagement in care with at least one oncology visit annually 5-7 years postdiagnosis (P < .0001).

CONCLUSION

Sustained PCP engagement is endorsed as critical by survivors, PCPs, and oncologists. We found most survivors were lost to PCP follow-up 5-7 years postdiagnosis. Our study is among the first to contribute empirical evidence of survivors being lost in transition. Findings from this study demonstrate the need to bridge gaps in long-term care for cancer survivors.

Health Care Contact Days Among Older Cancer Survivors

PURPOSE

Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care.

METHODS

We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days.

RESULTS

We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad."

CONCLUSION

Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.

Pain management for post-treatment survivors of complex cancers: a qualitative study of opioids and cannabis

Aim: We aimed to understand experiences with opioids and cannabis for post-treatment cancer survivors. Patients & methods: We conducted seven focus groups among head and neck and lung cancer survivors, using standard qualitative methodology to explore themes around 1) post-treatment pain and 2) utilization, perceived benefits and perceived harms of cannabis and opioids. Results & conclusion: Survivors (N = 25) experienced addiction fears, stigma and access challenges for both products. Opioids were often perceived as critical for severe pain. Cannabis reduced pain and anxiety for many survivors, suggesting that anxiety screening, as recommended in guidelines, would improve traditional pain assessment. Opioids and cannabis present complex harms and benefits for post-treatment survivors who must balance pain management and minimizing side effects.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Oncologists' perceived confidence and attitudes toward managing pre-existing chronic comorbidities during patients' active cancer treatment

PURPOSE

To examine practicing oncologists' perceived confidence and attitudes toward management of pre-existing chronic conditions(PECC) during active cancer treatment(ACT).

METHODS

In December 2018, oncologists in the National Cancer Institute's Community Oncology Research Program (NCORP) were invited to complete a was pilot-tested, IRB-approved online survey about their perceived confidence in managing PECC. Pearson chi-square test was used to identify oncologists' differences in perceived confidence to manage PECC and attitudes toward co-management of patients' PECC with non-oncologic care providers. Perceived confidence and attitudes were analyzed as a function of medical specialty while controlling demographic and medical practice variables.

RESULTS

A total of 391 oncologists responded to the survey, 45.8% stated medical oncology as their primary specialty, 15.1% hematology oncology, 15.1% radiation oncology, 6.9% surgical oncology, and 17.1% other specialties such as gynecology oncology. Overall, 68.3% agreed (agree/strongly agree) that they were confident to manage PECC in the context of standard of care. However, only 46.6% and 19.7% remained confident when managing PECC previously managed by a primary care physician (PCP) and by a non-oncology subspecialist, respectively. Most oncologists (58.3%) agreed that patients' overall care was well coordinated, and 63.7% agreed that patients had optimal cancer and non-cancer care when PECC was co-managed with a non-oncology care provider.

CONCLUSION

Most oncologists felt confident to manage all PECC during patients' ACT, but their perceived confidence decreased for PECC previously managed by PCPs or by non-oncology subspecialists. Additionally, they had positive attitudes toward co-management of PECC with non-oncologic care providers. These results indicate opportunities for greater collaboration between oncologists and non-oncology care providers to ensure comprehensive and coordinated care for cancer patients with PECC.

Utilization of a primary care-based cancer survivorship clinic: patterns and patient characteristics

PURPOSE

The Johns Hopkins Primary Care for Cancer Survivors (PCCS) Clinic was established in 2015 to improve care delivery for the growing cancer survivor population. We aim to describe areas of care addressed by PCCS and factors associated with clinic utilization.

METHODS

We conducted a retrospective chart review of the first 301 patients' clinic visits. We used negative binomial regression models to identify factors associated with the rate of PCCS clinic visits overall and for cancer surveillance and treatment-related effects.

RESULTS

There were 1702 clinic visits across 301 patients during the study period (77% female, median age 61). The most common areas of care addressed were chronic medical problems (80%), preventive health care (62%), cancer surveillance (59%), treatment-related effects (50%), and new/acute problems (46%). Multivariate analyses found that age > 60 years (IRR = 1.9, 95% CI = 1.2-3.0, p = 0.007) and higher number of comorbidities (IRR = 1.2, 95% CI = 1.1 - 1.2, p < 0.001) were associated with more overall PCCS visits, while female gender was associated with fewer visits (IRR = 0.6, CI = 0.4 - 0.8, p = 0.001). Gastrointestinal cancer type, shorter length of survivorship, male gender, and higher number of comorbidities were associated with a higher rate of visits addressing both surveillance and treatment-related effects (p < 0.05).

CONCLUSIONS

The PCCS clinic addressed cancer and non-cancer related needs. Older patients and survivors with more comorbidities had significantly increased clinic utilization.

IMPLICATIONS FOR CANCER SURVIVORS

As the cancer survivor population grows, increasing access to survivorship clinics based in primary care may help meet these patients' diverse oncologic and general health needs.

Cardiometabolic Comorbidities in Cancer Survivors

There are nearly 17 million cancer survivors in the United States, including those who are currently receiving cancer therapy with curative intent and expected to be long-term survivors, as well as those with chronic cancers such as metastatic disease or chronic lymphocytic leukemia, who will receive cancer therapy for many years. Current clinical practice guidelines focus on lifestyle interventions, such as exercise and healthy eating habits, but generally do not address management strategies for clinicians or strategies to increase adherence to medications. We discuss 3 cardiometabolic comorbidities among cancer survivors and present the prevalence of comorbidities prior to a cancer diagnosis, treatment of comorbidities during cancer therapy, and management considerations of comorbidities in long-term cancer survivors or those on chronic cancer therapy. Approaches to support medication adherence and potential methods to enhance a team approach to optimize care of the individual with cancer across the continuum of disease are discussed.

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Cancer survivors are at increased risk for several chronic conditions, including hypertension, dyslipidemia, and diabetes.

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Determining optimal management of comorbidities for patients with cancer is critical.

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A multidisciplinary care approach is recommended throughout the continuum of active cancer treatment and survivorship.

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Survivorship research should focus on medication adherence and coordination of care.

Adherence to cardiovascular disease risk factor medications among patients with cancer: a systematic review

PURPOSE

The most common cause of mortality for many cancer survivors is cardiovascular disease (CVD). This requires a shift in thinking where control of CVD risk factor-related comorbidity is paramount. Our objective was to provide an understanding of adherence to medications for the management of CVD risk factor-related comorbidities among cancer survivors.

METHODS

We systematically searched for articles indexed in MEDLINE (via PubMed), Embase, Cochrane (Wiley), PsycINFO, and Scopus (via Elsevier) for articles published from inception to October 31, 2019, and updated the search on June 7, 2021. English language, original research that assessed medication adherence to common CVD risk factor-related comorbidities among cancer survivors was included. We assessed risk of bias using the Mixed Methods Appraisal Tool.

RESULTS

Of the 21 studies included, 57% focused on multiple cancer types. Seventy-one percent used pharmacy-based adherence measures. Two were prospective. Adherence was variable across cancer types and CVD risk factor-related comorbidities. Among the studies that examined changes in comorbid medication adherence, most noted a decline in adherence following cancer diagnosis and throughout cancer treatment. There was a focus on breast cancer populations.

CONCLUSIONS

CVD risk factor-related medication adherence is low among cancer survivors and declines over time. Given the risk for CVD-mortality among cancer survivors, testing of interventions aimed at improving adherence to non-cancer medications is critically needed.

IMPLICATIONS FOR CANCER SURVIVORS

For many cancer survivors, regularly taking medications to manage CVD risk is important for longevity. Engaging with primary care throughout the cancer care trajectory may be important to support cardiovascular health.

Adherence to Cancer Survivorship Care Guidelines and Health Care Utilization Patterns Among Nonmetastatic Breast Cancer Survivors in Singapore

Currently, limited information is available on care provided to breast cancer survivors in Singapore. This study aims to assess the quality of post-treatment cancer survivorship care among breast cancer survivors on the basis of compliance with international guidelines up to 5 years post-primary treatment.

We evaluated the adherence to international breast cancer survivorship care guidelines in Singapore.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

MEASURES

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

ANALYSES

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

RESULTS

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

CONCLUSIONS

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

Safety of opioid prescribing among older cancer survivors

BACKGROUND

Cancer survivors receive more long-term opioid therapy (LTOT) than people without cancer, but the safety of LTOT prescribing is unknown.

METHODS

Opioid-naive adults aged ≥66 years who had been diagnosed in 2008-2015 with breast, lung, head and neck, or colorectal cancer were identified with data from Surveillance, Epidemiology, and End Results cancer registries linked with Medicare claims. Survivors with 1 or more LTOT episodes (≥90 consecutive days) occurring ≥1 year after their cancer diagnosis and before censoring at hospice entry, another cancer diagnosis, 6 months before death, or December 2016 were included. The safety of prescribing during the first 90 days of the first LTOT episode was measured during follow-up. As a positive safety indicator, the proportion of survivors with concurrent nonopioid pain management was measured. Indicators of less safe prescribing were the proportion of survivors with a high average daily opioid dose (≥90 morphine milligram equivalents) and the proportion of survivors with concurrent benzodiazepine dispensing. Multivariable logistic regression analyses were conducted to identify clinical predictors of each safety outcome.

RESULTS

In all, 3628 cancer survivors received LTOT during follow-up (median duration, 4.9 months; interquartile range, 3.5-8.0 months). Seventy-two percent of the survivors received multimodal pain management concurrently with LTOT. Eight percent of the survivors had high-dose opioid prescriptions; 25% of the survivors received benzodiazepines during LTOT. Multivariable analyses identified variations in safety measures by multiple clinical factors, although none were consistently significant across outcomes.

CONCLUSIONS

To improve safe LTOT prescribing for survivors, efforts should focus on increasing multimodal pain management and reducing inappropriate benzodiazepine prescribing. Different clinical predictors of each outcome suggest different drivers of safe prescribing.

Low-value care and excess out-of-pocket expenditure among older adults with incident cancer - A machine learning approach

OBJECTIVE

To evaluate the association of low-value care with excess out-of-pocket expenditure among older adults diagnosed with incident breast, prostate, colorectal cancers, and Non-Hodgkin's Lymphoma.

METHODS

We used a retrospective cohort study design with 12-month baseline and follow-up periods. We identified a cohort of older adults (age ≥ 66 years) diagnosed with breast, prostate, colorectal cancers, or Non-Hodgkin's lymphoma between January 2014 and December 2014. We assessed low-value care and patient out-of-pocket expenditure in the follow-up period. We identified relevant low-value services using ICD9/ICD10 and CPT/HCPCS codes from the linked health claims and patient out-of-pocket expenditure from Medicare claim files and expressed expenditure in 2016 USD.

RESULTS

About 29 % of older adults received at least one low-value care procedure during the follow-up period. Low-value care differed by gender, and rates were higher in women with colorectal cancer (32.7 %) vs. (28.8 %) and NHL (40 %) vs. (39 %) compared to men. Individuals who received one or more low-value care procedures had significantly higher mean out-of-pocket expenditure ($8,726 ± $7,214) vs. ($6,802 ± $6,102). XGBOOST, a machine learning algorithm revealed that low-value care was among the five leading predictors of OOP expenditure.

CONCLUSION

One in four older adults with incident cancer received low-value care in 12-months after a cancer diagnosis. Across all cancer populations, individuals who received low-value care had significantly higher out-of-pocket expenditure. Excess out-of-pocket expenditure was driven by low-value care, fragmentation of care, and an increasing number of pre-existing chronic conditions.

POLICY STATEMENT

This study focuses on health policy issues, specifically value-based care and its findings have important clinical and policy implications for Centers for Medicare and Medicaid Services (CMS) which has issued a roadmap for states to accelerate the adoption of value-based care, with the Department of Health and Human Services (HHS) setting a goal of converting 50 % of traditional Medicare payment systems to alternative payment models tied to value-based care by 2022.

Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis

BACKGROUND

Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood.

METHODS

National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms).

RESULTS

In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively).

CONCLUSIONS

Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

Cancer screening and follow-up in general practice: A French nationwide cross-sectional study

BACKGROUND

The overall activity of general practitioners (GPs) related to cancer screening and follow-up is poorly documented.

OBJECTIVES

To describe cancer screening and follow-up activities carried out in general practice and analyse them according to the socio-economic characteristics of patients.

METHODS

We used data from a French nationwide, multicentre, cross-sectional study that described the distribution of health problems managed in general practice and the associated processes of care. Analyses were adjusted on age and gender when appropriate, using a multivariate, hierarchical, linear mixed-effects model.

RESULTS

Among 20,613 consultations recorded, 580 involved cancer screening (2.8%) and 475 cancer follow-ups (2.3%). The most frequent cancer screening procedures concerned colorectal cancer (38.6% of screening procedures), breast cancer (32.6%), cervical cancer (17.0%), and prostate cancer (9.3%). In consultations with female patients, the most frequent types of cancer followed up were breast (44.9%) and colorectal cancer (10.5%), and with male patients, the most frequent were prostate (37.3%) and skin cancer (10.3%). After adjustment on age and gender, consultations with cancer follow-up included a mean 1.9 health problems managed in addition to cancer. Consultations with cancer screening or follow-up issue less often involved a patient on low income than other consultations (2.4% vs. 4.2%, and 1.1% vs. 4.2%, respectively).

CONCLUSION

Around 5% of French general practice consultations include cancer screening or follow-up. Socio-economical inequalities demand further research.

Factors influencing treatment burden in colorectal cancer patients undergoing curative surgery: A cross-sectional study

OBJECTIVE

To describe the severity of treatment burden in surgically treated colorectal cancer (CRC) patients and examine associations between treatment burden and demographic and clinical variables.

METHODS

This cross-sectional study recruited 134 patients diagnosed with Dukes' stage A-C CRC between 2016 and 2018 who underwent curative surgery. The Patient Experience with Treatment and Self-management (PETS) questionnaire assessed treatment burden domains of 'workload', 'stressors' and 'impact' between 6 weeks and 18 months after primary surgery.

RESULTS

Highest scores were observed for difficulty with healthcare services (median score 33.3), physical and mental fatigue (median score 30.0) and medical information (median score 26.8). Younger age, low education level or no cohabitants were significantly associated with higher workload PETS scores (p < 0.05, 0.013, p = 0.047, respectively). Higher PETS stressors scores were significantly associated with younger age (p = 0.006), lower education level (p = 0.016), and high comorbidity (p = 0.013). Higher PETS impact scores were significantly associated with the female sex (p = 0.050), younger age (p = <0.001-0.003), lower education (p = 0.003), no cohabitants (p = 0.003), high comorbidity (p = 0.003) and cancer stage Dukes A (p = 0.004).

CONCLUSIONS

A seamless and supportive healthcare system beyond hospitalisation targeting CRC subpopulations in danger of high treatment burden may improve patients' self-management experience.

Cancer survivorship training in family medicine residency programs

PURPOSE

The objective of the study was to examine current family medicine residency education in cancer survivorship and barriers to cancer survivorship education in the residency curriculum.

METHODS

Family medicine residency program directors (n = 628) were surveyed electronically between September 2019 and November 2019 through the Council of Academic Family Medicine Educational Research Alliance (CERA) annual program directory survey. Respondents (n = 250) answered questions regarding eventual cancer survivorship curriculum in their residency program, including interest and barriers to implementation. Program characteristics were assessed using univariate and multivariate analyses.

RESULTS

Only 9.2% of family medicine residency program directors reported having a cancer survivorship curriculum. Sixty-nine percent of program directors reported they would implement a cancer survivorship curriculum if one was available. The most significant barrier to implementation of a cancer survivorship curriculum was insufficient time (39.6%) followed by lack of faculty expertise (26.9%). Respondents that reported lack of faculty expertise as a barrier to implementation of cancer survivorship training were more likely be report that they would be willing to implement a cancer survivorship curriculum (p < 0.01).

CONCLUSIONS

Despite the majority of primary care physicians providing care to cancer survivors, few family medicine residency programs have formal training in cancer survivorship care. There is interest in expanding family medicine residency training in cancer survivorship care among program directors.

IMPLICATIONS FOR CANCER SURVIVORS

Gaining insight into the current educational curriculum and barriers to cancer survivorship training will lead to opportunities to improve residency training, and ultimately provide better care to cancer survivors in primary care settings.

Cardiovascular Screening and Lipid Management in Breast Cancer Survivors

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death among breast cancer (BC) survivors. BC survivors are at increased risk of CVD due to a higher prevalence of risk factors. Current data are limited on the cardiovascular screening practices and lipid management in this population in primary care settings.

METHODS

A retrospective case control study was performed with 105 BC survivors and 210 matched controls (based on age and medical comorbidities of diabetes, hypertension, and hyperlipidemia). BC survivors were established with primary care practices within a large academic institution and had completed primary cancer treatment. Data on screening for CVD and lipid management were collected via a retrospective chart review.

RESULTS

The average BC survivor was 63 years old, with 9 years since diagnosis. Compared with matched controls, BC survivors had more cholesterol screening (88% vs 70%, P < .001) and active statin prescriptions (63% vs 40%, P < .05) if indicated by the Atherosclerotic Cardiovascular Disease Calculator. There were no differences in CVD screening in White and African American BC survivors. However, African American BC survivors were more likely to have hypertension (P < .01) and have a body mass index in the overweight and obese category (P < .001) than White BC survivors. Older BC survivors were more likely to receive cholesterol screening.

DISCUSSION

This study demonstrates that BC survivors who have an established primary care provider have improved cholesterol screening and statin therapy based on their risk of developing chronic diseases.

The Need for Accurate Risk Assessment in a High-Risk Patient Population: A NSQIP Study Evaluating Outcomes of Cholecystectomy in the Patient With Cancer

BACKGROUND

Cholecystectomy is considered a low-risk procedure with proven safety in many high-risk patient populations. However, the risk of cholecystectomy in patients with active cancer has not been established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify all patients with disseminated cancer who underwent cholecystectomy from 2005 to 2016. Postcholecystectomy outcomes were defined for patients with cancer and those without by comparing several outcomes measures. A multivariate model was used to estimate the odds of 30-d mortality.

RESULTS

We compared outcomes in 3097 patients with disseminated cancer to a matched cohort of patients without cancer. Patients with cancer had more comorbidities at baseline: dyspnea (10.5% versus 7.0%, P < 0.0001), steroid use (10.1% versus 3.0%, P < 0.0001), and loss of >10% body weight in 6-mo prior (9.3% versus 1.6%, P < 0.0001). Patients with cancer sustained higher rates of wound (2.3% versus 5.6%, P < 0.0001), respiratory (1.4% versus 3.9%, P < 0.0001), and cardiovascular (2.0% versus 6.8%, P < 0.0001) complications. In addition, patients with disseminated cancer experienced a longer length of stay and higher 30-d mortality. Multivariate modeling showed that the odds of 30-d mortality was 3.3 times greater in patients with cancer.

CONCLUSIONS

Compared to patients without cancer, those with disseminated cancer are at higher risk of complication and mortality following cholecystectomy. Traditional treatment algorithms should be used with caution and care decisions individualized based on the patient's disease status and treatment goals.

Setting the research agenda for living with and beyond cancer with comorbid illness: reflections on a research prioritisation exercise

BACKGROUND

People living with and beyond cancer are more likely to have comorbid conditions and poorer mental and physical health, but there is a dearth of in-depth research exploring the psychosocial needs of people experiencing cancer and comorbid chronic conditions. A patient partnership approach to research prioritisation and planning can ensure outcomes meaningful to those affected and can inform policy and practice accordingly, but can be challenging.

METHODS

We aimed to inform priorities for qualitative inquiry into the experiences and support needs of people living with and beyond cancer with comorbid illness using a partnership approach. A three-step process including a patient workshop to develop a consultation document, online consultation with patients, and academic expert consultation was carried out. The research prioritisation process was also appraised and reflected upon.

RESULTS

Six people attended the workshop, ten responded online and eight academic experts commented on the consultation document. Five key priorities were identified for exploration in subsequent qualitative studies, including the diagnostic journey, the burden of symptoms, managing medications, addressing the needs of informal carers, and service provision. Limitations of patient involvement and reflections on procedural ethics, and the challenge of making measurable differences to patient outcomes were discussed.

CONCLUSIONS

Findings from this research prioritisation exercise will inform planned qualitative work to explore patients' experiences of living with and beyond cancer with comorbid illness. Including patient partners in the research prioritisation process adds focus and relevance, and feeds into future work and recommendations to improve health and social care for this group of patients. Reflections on the consultation process contribute to a broadening of understanding the field of patient involvement.

Co-morbidities in a Retrospective Cohort of Prostate Cancer Patients

Objective

To characterize rates of co-morbidity among prostate cancer patients treated with radical prostatectomy and to examine the association between co-morbidity status and race, clinical factors, and health behaviors for cancer control.

Design/Study Participants

Retrospective cohort study among prostate cancer patients treated with radical prostatectomy.

Setting

Academic medical center located in the southeastern region of the United States.

Main Outcome Measure

Patients with at least one of five co-morbid conditions considered were categorized as having a co-morbidity, and those without any were categorized as not having a co-morbid condition. Co-morbid conditions considered were hypertension, diabetes, heart problems, stroke, and high cholesterol, which had been recorded in the electronic medical record as part of their past medical history.

Results

Fifty-one percent of participants had a co-morbidity, with hypertension being the most common. The average number of co-morbidities among study participants was .87. In a multivariate logistic regression analysis, being diagnosed with prostate cancer within the past four years was associated with an increased likelihood of having a co-morbidity (OR=4.71, 95% CI=2.69, 8.25, P=.0001) compared with diagnosis five or more years ago. Age was also associated with an increased likelihood of having a co-morbidity (OR=1.30, 95% CI=1.005, 1.68, P=.05). In this study cohort, race, stage at diagnosis, and PSA level were not statistically associated with co-morbidity status.

Conclusion

Better chronic disease management is needed among prostate cancer survivors through more effective survivorship care planning and interventions that promote health behaviors.

Understanding Long-Term Cancer Survivors' Preferences for Ongoing Medical Care

BACKGROUND

Due to risk for treatment-related late effects and concerns about cancer recurrence, long-term cancer survivors have unique medical needs. Survivors' preferences for care may influence adherence and care utilization.

OBJECTIVE

To describe survivors' preferences for care and factors associated with preferred and actual care.

DESIGN

Cross-sectional analysis of participants in a longitudinal study using mailed questionnaires.

PARTICIPANTS

Survivors of ten common cancers (n = 2,107, mean years from diagnosis 8.9).

MAIN MEASURES

(1) Survivors' preferences for primary care physician (PCP) and oncologist responsibilities across four types of care: cancer follow-up, cancer screening, preventive health, and comorbid conditions. (2) Survivor-reported visits to PCPs and oncologists.

KEY RESULTS

The response rate was 42.1%. Most long-term survivors preferred PCPs and oncologists share care for cancer follow-up (63%) and subsequent screening (65%), while preferring PCP-led preventive health (77%) and comorbid condition (83%) care. Most survivors (88%) preferred oncologists involved in cancer follow-up care, but only 60% reported an oncologist visit in the previous 4 years, and 96% reported a PCP visit in the previous 4 years. In multivariable regressions, those with higher fear of cancer recurrence were less likely to prefer PCP-led cancer follow-up care (OR = 0.96, CI = 0.93-0.98), as did survivors with advanced cancer stage (OR = 0.56, CI = 0.39-0.79). Those with higher fear of recurrence (OR = 1.03, CI = 1.01-1.04) or who preferred oncologist-led cancer follow-up care (OR = 2.08, CI = 1.63-2.65) had greater odds of seeing an oncologist in the last 4 years.

CONCLUSIONS

Most cancer survivors preferred PCPs and oncologists share care for cancer follow-up and screening, yet many had not seen an oncologist recently. Survivors preferred PCP-led care for other preventive services and management of comorbid conditions. These findings highlight the important role PCPs could play in survivor care, suggesting the need for PCP-oriented education and health system policies that support high-quality PCP-led survivor care.

Cancer care continuity: A qualitative study on the experiences of French healthcare professionals, patients and family caregivers

Introduction

Continuity of care has many positive outcomes. Yet, in oncology, it may rapidly be disrupted. It is therefore essential to investigate the perceptions of users. Our aim was thus to describe and compare the perceptions of cancer care continuity of patients, family caregivers and various healthcare professionals involved in cancer care in France, one of the countries most affected by cancer.

Methods

The urology and senology cancer departments of two hospitals, as well as community physicians, were involved: 54 hospital healthcare professionals including mainly physicians, nurses and medical secretaries; 12 city physicians; 41 patients and their family caregivers. We carried out a qualitative study using N-Vivo® and a deductive approach to code the interviews into the following dimensions of continuity: informational, organisational and relational.

Results

Three different perspectives were highlighted: hospital healthcare professionals primarily focused on organisational aspects (71% of their discourse), city physicians on their need for information from hospitals (40% of their discourse) and patients/caregivers on relational aspects with professionals (51% of their discourse). However, the three dimensions of continuity were intertwined, as the major focus of each type of participant impacted their perspective of the other spheres of coordination.

Discussion

Working on the main perspective of each category of person involved in cancer care could improve, in turn, the other spheres of continuity for these people. For example, dealing with organisational issues with hospital physicians could be an indirect and original way to enhance their relationships with patients, which are so important to the latter.

Health care services use among long-term breast cancer survivors: a systematic review

PURPOSE

Long-term breast cancer survivors are women surviving at least 5 years after diagnosis. This systematic review aimed to summarize the main characteristics and patterns of healthcare service use (frequency of visits, health providers visited, and preventive care performed) among long-term breast cancer survivors.

METHODS

We used standard Cochrane Collaboration methods and searched the MEDLINE and EMBASE databases up to January 2018. We included English language observational studies reporting health service use among long-term cancer survivors. The quality of the studies was appraised through the ROBINS-I assessment tool. Two independent reviewers performed both the study quality assessment and the data extraction.

RESULTS

A total of 23 observational studies were included that reported data on health services use by long-term breast cancer survivors. Despite heterogeneity among studies, about half of them reported that breast cancer survivors visited a medical provider at least once a year, as recommended by breast cancer survival guidelines. Although survivors visited medical providers with the recommended frequency, a substantial number used specialist care instead of primary care during follow-up. The results showed underuse of the recommended annual mammogram.

CONCLUSIONS

Long-term breast cancer survivors differ in their health services use with regard to the frequency of visits as well as the health providers seen. Our results indicate the need for active surveillance through primary care providers in coordination with specialized care.

IMPLICATIONS FOR CANCER SURVIVORS

This review could help to standardize the management of breast cancer survivors and decision-makers to adapt their guidelines and clinical protocols.

Living with and beyond cancer with comorbid illness: a qualitative systematic review and evidence synthesis

Purpose

To identify the qualitative evidence on the experience of cancer and comorbid illness from the perspective of patients, carers and health care professionals to identify psycho-social support needs, experience of health care, and to highlight areas where more research is needed.

Methods

A qualitative systematic review following PRISMA guidance. Relevant research databases were searched using an exhaustive list of search terms. Two reviewers independently screened titles and abstracts and discussed variations. Included articles were subject to quality appraisal before data extraction of article characteristics and findings. Thomas and Harden’s thematic synthesis of extracted findings was undertaken.

Results

Thirty-one articles were included in the review, covering a range of cancer types and comorbid conditions; with varying time since cancer diagnosis and apparent severity of disease for both cancer and other conditions. The majority of studies were published after 2010 and in high income countries. Few studies focused exclusively on the experience of living with comorbid conditions alongside cancer; such that evidence was limited. Key themes identified included the interaction between cancer and comorbid conditions, symptom experience, illness identities and ageing, self-management and the role of primary and secondary care.

Conclusions

In addition to a better understanding of the complex experience of cancer and comorbidity, the review will combine with research prioritisation work with consumers to inform an interview study with the defined patient group.

Implications for Cancer Survivors

Expanding this evidence base will help to illuminate developing models of cancer patient-centred follow-up care for the large proportion of patients with comorbid conditions.

Electronic supplementary material

The online version of this article (10.1007/s11764-019-0734-z) contains supplementary material, which is available to authorized users.

Health care use during cancer survivorship: Review of 5 years of evidence

Improvements in treatment strategies have resulted in increasing survival rates among patients diagnosed with cancer but also result in a growing population of individuals who have greater health care needs. These needs will persist from diagnosis throughout the continuing phase of care, or the survivorship phase. To better define models of survivorship care, there must be a strong evidence base in survivor health care use patterns. The objective of this review, which covers studies from 2012 to January 2018, was to evaluate the available evidence on patterns of health care visits among survivors of adult cancers and to understand what is known about the rate of health care visits, the physician specialties associated with these visits, and/or the types health care settings (eg, outpatient, emergency room). The findings underscore the importance of primary care, with the majority of studies reporting that >90% of survivors visited a primary care provider in the prior year. Visits to oncologists and/or other physician specialties were positively associated with receiving cancer screenings and obtaining quality care for noncancer-related conditions. High care density/low care fragmentation between physician specialties had lower costs and a lower likelihood of redundant health care utilization. The follow-up in almost all studies was 3 years, providing short-term evidence; however, as the survivorship period lengthens with improved treatments, longer follow-up will be required. The long-term patterns with which survivors of cancer engage the health care system are critical to designing long-term follow-up care plans that are effective in addressing the complex morbidity that survivors experience.

Cardiovascular Care Among Cancer Survivors in the United States

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of mortality among cancer survivors, but whether survivors receive routine cardiovascular monitoring and preventive care has not been well studied. This study uses a population-based dataset to examine this question.

METHODS

Data from the National Health Interview Survey were used to identify 13 266 cancer survivors who completed surveys from 2011 to 2015. Prevalence of CVD and associated risk factors, patterns of doctor visitation, and receipt of CVD preventive care were examined. We used multivariable logistic regression analysis to examine factors associated with the receipt of preventive care for survivors with and without CVD risk factors.

RESULTS

CVD risk factors were prevalent in older cancer survivors 65 years and older (56.9% with hyperlipidemia, 66.8% with hypertension) and younger survivors younger than 50 years (35.4% obese, 30.3% current smokers). Rates of blood pressure, cholesterol, and glucose monitoring were high, but rates of lifestyle modification were lower (54.8% moderate exercise, 47.1% smoking cessation attempts among smokers). Although 71.5% of survivors at 2 years or less from diagnosis saw both general and specialist doctors, only 51.6% of survivors at 5 or more years saw both, and 43.5% saw only a general doctor. On multivariable analysis, receipt of CVD preventive care was strongly associated with general doctor visitation for those with and without CVD risk factors.

CONCLUSIONS

CVD and associated risk factors are prevalent among both older and younger cancer survivors across the United States. This study identifies areas for improvement related to lifestyle modification in survivors, and also highlights the importance of care transition to the primary care provider for long-term survivors.

A diabetes pay-for-performance program and the competing causes of death among cancer survivors with type 2 diabetes in Taiwan

Objective

To examine associations between a diabetes pay-for-performance (P4P) program in Taiwan and all-cause of mortality and competing causes of death in cancer survivors with type 2 diabetes.

Design

A longitudinal observational intervention and comparison group study design.

Setting and participants

Cancer survivors with type 2 diabetes who enrolled in the P4P program compared with survivors who did not participate (non-P4P) under the Taiwan National Health Insurance program.

Intervention(s)

A nationwide diabetes P4P program.

Main outcome measures

The main outcome was a comparison of all-cause, diabetes-related and cancer mortality in P4P and non-P4P patients during a 5-year follow-up period. Total person-years and mortality rates per 1000 person-years for causes of death were calculated. Multivariate Cox proportional hazard models and competing risk regression were used in the analysis.

Results

Overall, our results indicate that P4P cancer survivors had lower risk of all-cause mortality and diabetes-related mortality than non-P4P survivors. Specifically, the hazard ratio (95% confidence interval) was 0.581 (0.447-0.756) for all-cause mortality; SHRs were 0.451 (0.266-0.765) for diabetes-related mortality and 0.791 (0.558-1.121) for cancer mortality.

Conclusions

Our empirical findings provide evidence of potential benefits of diabetes P4P programs in reducing risks of deaths due to diabetes or cardiovascular diseases among cancer survivors, compared with survivors who did not enroll in the P4P program. In consideration of recommended care for long-term survival, the diabetes P4P program can serve as a care model for cancer survivors for reducing mortality due to diabetes or cardiovascular diseases.

Most impactful factors on the health-related quality of life of a geriatric population with cancer

BACKGROUND

As the population of older adults with cancer continues to grow, the most important factors contributing to their health-related quality of life (HRQOL) remain unclear.

METHODS

A total of 1457 older adults (aged ≥65 years) with cancer participated in a telephone survey. Outcomes were measured using the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Survey (SF-12) from the Medical Outcomes Study (version 2). Statistical techniques used to identify factors in 4 domains (physical, psychological, social, and spiritual) most strongly associated with HRQOL included linear models, recursive partitioning, and random forests. Models were developed in a training data set (920 respondents) and performance was assessed in a validation data set (537 respondents).

RESULTS

Respondents were a median of 19 months from diagnosis, and 28.1% were receiving active treatment. The most relevant factors found to be associated with PCS were symptom severity, comorbidity scores, leisure-time physical activity, and having physical support needs. The most relevant factors for MCS were having emotional support needs, symptom severity score, and the number of financial hardship events. Results were consistent across modeling techniques. Symptoms found to be strongly associated with PCS included fatigue (adjusted proportion of summary score's variance [R² ] = 0.34), pain (adjusted R² = 0.32), disturbed sleep (adjusted R² = 0.16), and drowsiness (adjusted R² = 0.16). Symptoms found to be strongly associated with MCS included fatigue (adjusted R² = 0.23), problems remembering things (adjusted R² = 0.17), disturbed sleep (adjusted R² = 0.16), and lack of appetite (adjusted R² = 0.16).

CONCLUSIONS

The findings of the current study support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges. A long-term comprehensive approach is needed to ensure the well-being of older adults with cancer. Cancer 2018;124:596-605. © 2017 American Cancer Society.

Care Coordination and Transitions of Care

Care coordination and effective transitions of care are essential for high-quality care in cancer survivors. Aspects of care that require coordination include cancer surveillance, managing the effects of cancer and its treatment, and preventive care, including screening for new cancers, with the clinician responsible for each aspect of care clearly defined. There are many barriers to transitioning and coordinating care across cancer specialists and primary care physicians; possible solutions include survivorship care plans and certain care models. Improving these areas, along with survivorship care training and education, may lead to more effective care coordination and transitions in the future.

Defining cancer survivors, their needs, and perspectives on survivorship health care in the USA

More people are living after a diagnosis of cancer than ever before and now account for around 5% of the US population. The specialty of cancer survivorship has been developing and growing since the mid-1980s, but the term survivor is open to debate by people living with cancer and those caring for them. Regardless of the term used, many ongoing physical, psychological, and social needs affect quality of life for people who are living with cancer and those who have survived the disease. Survivors prefer to have these needs addressed by their oncologist but also want their primary care provider to have a role. However, survivors also believe there are communication and coordination barriers between care providers. The existing method for delivering cancer care is becoming unsustainable and is not adequately configured to deliver high-quality cancer care to this growing population in the USA, especially when confronted with projected health-care shortages by 2020. In this Series paper, we define the term cancer survivor, discuss survivors' ongoing needs and preferences for care over time, and consider the implications for delivering coordinated cancer care in the USA.

Experience of living with cancer and comorbid illness: protocol for a qualitative systematic review

INTRODUCTION

There are an increasing number of people living with and beyond cancer, whose experience is further complicated by additional long-term health conditions in the context of an ageing population. The supportive care needs of this growing patient group should be recognised and addressed. There is a need to explore the experience of living with cancer and comorbid illness in order to develop optimal models of patient-centred care. This protocol describes a systematic review that aims to identify the qualitative evidence relating to the experience of cancer and comorbid illness for patients, informal carers and professionals, and to highlight areas where more research is needed.

METHODS AND ANALYSIS

A systematic review following PRISMA guidance will be undertaken. Medline, Embase, CINAHL, PsycINFO, ASSIA, Sociological Abstracts, Web of Science, SCOPUS, OpenGrey and ProQuest Dissertations and Theses Global databases will be systematically searched for articles relevant to patient, carer and professional experiences. Two independent reviewers will screen articles for inclusion and evaluate them according to the Critical Appraisal Skills Programme tool. Extracted data will be combined using recognised methods of qualitative synthesis to offer new insights into the topic area and for a patient-centred model of care.

ETHICS AND DISSEMINATION

The review does not require formal ethical review as no direct patient contact or patient identifiable data is used. Conduct of the review has been approved internally by the University of Edinburgh Centre for Population Health Sciences Ethics Review Committee. Results of the review will be published in a generalist peer-reviewed journal and presented at a relevant conference in addition to informing subsequent empirical work by the authors on this topic area.

Optimizing endometrial cancer follow-up and survivorship care for rural and other underserved women: Patient and provider perspectives

OBJECTIVES

This study describes patient and provider attitudes on transitioning cancer surveillance visits and treatment of comorbid conditions to the primary care setting in a rural patient population as a strategy for minimizing financial and travel related barriers for patients while simultaneously enhancing quality and availability of health care options.

METHODS

Focus group discussions and telephone interviews were conducted with endometrial cancer (EC) survivors and primary care providers (PCPs) to provide insights into post-treatment follow-up practices and the acceptability of transitioning follow-up to primary care setting utilizing a cancer survivorship care plan model.

RESULTS

EC survivors expressed high levels of satisfaction with their oncology care and suggested that transitioning to PCPs for follow-up care would be convenient yet challenging. Challenges cited include: 1) patient perceptions of deficits in PCP's understandings of cancer surveillance; 2) inability to identify a personal PCP; and 3) lack of communication between oncologists and PCPs. PCP participants similarly identified the need for extensive EC training and effective communication strategies with oncologists as necessary factors for accepting responsibility for EC follow-up care. Both groups offered strategies to create a more team based approach to EC survivorship care.

CONCLUSIONS

Increasing the role of the PCP in the ongoing care of EC survivors was generally considered acceptable by both patients and providers in both rural and urban women. Successful coordination of care between cancer survivors, oncologists and PCPs will be a critical step in improving the cancer care delivery of our rural patient and provider population.

Follow-up after treatment for breast cancer: Practical guide to survivorship care for family physicians

OBJECTIVE

To offer FPs a summary of evidence-based recommendations to guide their follow-up survivorship care of women treated for breast cancer.

QUALITY OF EVIDENCE

A literature search was conducted in MEDLINE from 2000 to 2016 using the search words breast cancer, survivorship, follow-up care, aftercare, guidelines, and survivorship care plans, with a focus on review of recent guidelines published by national cancer organizations. Evidence ranges from level I to level III.

MAIN MESSAGE

Survivorship care involves 4 main tasks: surveillance and screening, management of long-term effects, health promotion, and care coordination. Surveillance for recurrence involves only annual mammography, and screening for other cancers should be done according to population guidelines. Management of the long-term effects of cancer and its treatment addresses common issues of pain, fatigue, lymphedema, distress, and medication side effects, as well as longer-term concerns for cardiac and bone health. Health promotion emphasizes the benefits of active lifestyle change in cancer survivors, with an emphasis on physical activity. Survivorship care is enhanced by the involvement of various health professionals and services, and FPs play an important role in care coordination.

CONCLUSION

Family physicians are increasingly the main providers of follow-up care after breast cancer treatment. Breast cancer should be viewed as a chronic medical condition even in women who remain disease free, and patients benefit from the approach afforded other chronic conditions in primary care.

[Not Available]

Objectif

Offrir aux médecins de famille un résumé des recommandations fondées sur les données probantes pour guider les soins aux survivantes traitées pour le cancer du sein.

Qualité des données

Une recherche documentaire a été effectuée dans MEDLINE entre 2000 et 2016 à l’aide des mots-clés anglais suivants : breast cancer, survivorship, follow-up care, aftercare, guidelines et survivorship care plans, en se concentrant sur la revue des lignes directrices publiées récemment par les organismes nationaux de cancérologie. Les données étaient de niveaux I à III.

Message principal

Les soins aux survivantes comportent 4 facettes : surveillance et dépistage, prise en charge des effets à long terme, promotion de la santé et coordination des soins. La surveillance des récidives ne se traduit que par une mammographie annuelle, et le dépistage d’autres cancers doit suivre les lignes directrices basées sur la population. La prise en charge des effets à long terme du cancer et de son traitement aborde des problèmes courants tels la douleur, la fatigue, le lymphœdème, la détresse et les effets indésirables des médicaments, de même que les préoccupations à long terme comme la santé du cœur et des os. La promotion de la santé met en relief les bienfaits de l’activité chez les survivantes du cancer, avec l’accent mis sur l’activité physique. Les soins aux survivantes sont de meilleure qualité lorsque divers services et professionnels de la santé participent aux soins, et le médecin de famille joue un rôle important dans la coordination des soins.

Conclusion

Les médecins de famille sont de plus en plus souvent les principaux fournisseurs de soins de suivi après le traitement du cancer du sein. Le cancer du sein doit être considéré comme une affection médicale chronique, même chez les femmes en rémission, et les patientes profitent de la même approche que celle utilisée pour les autres affections chroniques en soins de première ligne.

Relationship Between Quality of Comorbid Condition Care and Costs for Cancer Survivors

PURPOSE

To estimate the association between cancer survivors' comorbid condition care quality and costs; to determine whether the association differs between cancer survivors and other patients.

METHODS

Using the SEER-Medicare-linked database, we identified survivors of breast, prostate, and colorectal cancers who were diagnosed in 2004, enrolled in Medicare fee-for-service for at least 12 months before diagnosis, and survived ≥ 3 years. Quality of care was assessed using nine process indicators for chronic conditions, and a composite indicator representing seven avoidable outcomes. Total costs on the basis of Medicare amount paid were grouped as inpatient and outpatient. We examined the association between care quality and costs for cancer survivors, and compared this association among 2:1 frequency-matched noncancer controls, using comparisons of means and generalized linear regressions.

RESULTS

Our sample included 8,661 cancer survivors and 17,332 matched noncancer controls. Receipt of recommended care was associated with higher outpatient costs for eight indicators, and higher inpatient and total costs for five indicators. For three measures (visit every 6 months for patients with chronic obstructive pulmonary disease or diabetes, and glycosylated hemoglobin or fructosamine every 6 months for patients with diabetes), costs for cancer survivors who received recommended care increased less than for noncancer controls. The absence of avoidable events was associated with lower costs of each type. An annual eye examination for patients with diabetes was associated with lower inpatient costs.

CONCLUSION

Higher-quality processes of care may not reduce short-term costs, but the prevention of avoidable outcomes reduces costs. The association between quality and cost was similar for cancer survivors and noncancer controls.

A head and neck cancer intervention for use in survivorship clinics: a protocol for a feasibility study

BACKGROUND

Head and neck cancer survivors commonly experience severe long-term toxicities, late-occurring symptoms, and significant risks of the second primary malignancy and comorbid illnesses. With multiple simultaneous health issues, these complex cancer survivors often do not receive comprehensive health care that addresses their needs. A tool is needed to streamline and standardize comprehensive care for this cohort.

METHODS/DESIGN

We designed the Head and Neck Survivorship Tool: Assessment and Recommendations (HN-STAR) to address health care challenges for head and neck cancer survivors. HN-STAR is an electronic platform that aims to simplify the provision of personalized care in cancer survivorship clinics. It uses an algorithmic approach to integrate patient-reported outcomes, clinical details, and evidence-based guidelines to standardize comprehensive care provided in routine survivorship visits. It has four integrated components: (1) a simplified treatment summary, which pulls treatment details from a clinical database or can be completed manually using a streamlined form; (2) an online self-assessment for patients to report their own symptoms; (3) an interactive discussion guide presenting all relevant information to the provider during the clinic visit; and (4) a survivorship care plan generated at the end of each visit that reflects decisions made during the visit. By using a modifiable electronic platform, HN-STAR provides a method for incorporating survivorship care plans into clinical practice and for disseminating evidence on symptom management and preventive care. This is a study to assess the feasibility of a future multi-site, randomized clinical trial of HN-STAR. We will enroll head and neck cancer survivors who are followed in one of two nurse practitioner-led survivorship clinics. We will implement HN-STAR for one routine survivorship visits. We will assess (1) usability and feasibility outcomes of HN-STAR from the perspective of key stakeholders and (2) the planned outcomes intended for the larger trial. We will collect usability and feasibility data from online surveys of survivors and their providers. Our findings will inform whether it is feasible to advance HN-STAR to trial. If so, we will adapt HN-STAR and the study design of the trial in response to feedback from survivors and providers. The long-term goal is to determine if such an intervention will lead to improved and simplified comprehensive survivorship care.

DISCUSSION

This feasibility study will evaluate implementation of HN-STAR into clinical practice in terms of usability, practicality, and clinical flow in two distinct clinical settings. This study will also provide critical baseline data to characterize this vulnerable population. Findings from this study will inform a multicenter randomized trial of HN-STAR, aimed at standardizing and streamlining the delivery of evidence-guided comprehensive care for head and neck cancer survivors. Ultimately, if found effective, the modular structure of HN-STAR could permit its expansion to survivors of other complex cancers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02571673.

Moving survivorship care plans forward: focus on care coordination

After completing treatment for cancer, the coordination of oncology and primary care presents a challenge for cancer survivors. Many survivors need continued oncology follow-up, and all survivors require primary care. Coordinating the shared care of a cancer survivor, or facilitating an informed handoff from oncology to primary care, is essential for cancer survivors. Survivorship care plans are personalized documents that summarize cancer treatment and outline a plan of recommended ongoing care, with the goal of facilitating the coordination of post-treatment care. Despite their face validity, five trials have failed to demonstrate the effectiveness of survivorship care plans. We posit that these existing trials have critical shortcomings and do not adequately address whether survivorship care plans improve care coordination. Moving forward, we propose four criteria for future trials of survivorship care plans: focusing on high-needs survivor populations, tailoring the survivorship care plan to the care setting, facilitating implementation of the survivorship care plan in clinical practice, and selecting appropriate trial outcomes to assess care coordination. When trials meet these criteria, we can finally assess whether survivorship care plans help cancer survivors receive optimal oncology and primary care.