Treatment summaries, follow-up care instructions, and patient navigation: could they be combined to improve cancer survivor’s receipt of follow-up care?

Surveillance after childhood cancer: are survivors with an increased risk for cardiomyopathy regularly followed-up?

BACKGROUND

We aimed to study adherence to cardiac screening in long-term childhood cancer survivors (CCS) at high risk of cardiomyopathy.

METHODS

This study involved 976 5-year CCS at high risk for cardiomyopathy from the French Childhood Cancer Survivor Study. Determinants of adherence to recommended surveillance were studied using multivariable logistic regression models. Association of attendance to a long-term follow-up (LTFU) visit with completion of an echocardiogram was estimated using a Cox regression model.

RESULTS

Among participants, 32% had an echocardiogram within the 5 previous years. Males (adjusted RR [aRR] 0.71, 95% CI 0.58-0.86), survivors aged 36-49 (aRR 0.79, 95% CI 0.64-0.98), Neuroblastoma (aRR 0.53, 95% CI 0.30-0.91) and CNS tumour survivors (aRR 0.43, 95% CI 0.21-0.89) were less likely to adhere to recommended surveillance. Attendance to an LTFU visit was associated with completion of an echocardiogram in patients who were not previously adherent to recommendations (HR 8.20, 95% CI 5.64-11.93).

CONCLUSIONS

The majority of long-term survivors at high risk of cardiomyopathy did not adhere to the recommended surveillance. Attendance to an LTFU visit greatly enhanced the completion of echocardiograms, but further interventions need to be developed to reach more survivors.

"This Graft-vs.-Host Disease Determines My Life. That's It."-A Qualitative Analysis of the Experiences and Needs of Allogenic Hematopoietic Stem Cells Transplantation Survivors in Germany

Background: Allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative treatment modality for many patients affected by hematologic malignancies. However, it can cause debilitating long-term effects. Understanding the impact of alloHSCT on all aspects of the patients' life is required for optimal survivorship management. Aim: To explore in-depth HSCT-survivors' experiences and needs post-transplant. Partners were included to provide further information on survivors' needs and how care could be improved in this area. Methods: We conducted semi-structured face-to-face and phone interviews with alloHSCT-survivors and their partners referred to a survivorship clinic in Germany. Theoretical sampling was used to recruit participants. Data were analyzed using framework analysis. Results: Thirty-two survivors (consent rate: 100%, response rate: 100%) and eighteen partners (consent rate: 84%, response rate: 72%) participated. Survivors were aged between 25 and 68 years (Median: 48, IQR: 25.3) and partners were aged between 26 and 64 years (Median: 54, IQR: 16, SD: 12.8). The themes emerging from the data involved survivors' needs included (i) the diversity of long-term treatment side-effects; and (ii) time post discharge as a dynamic process with individual peaks of burden. Survivors and their partners also suggested strategies for mitigating these unmet needs, i.e., (iii) transparent communication and patient empowerment; and (iv) improvement in continuity of care system and help with claiming social benefits as cornerstones of optimal survivorship care. Conclusion: To our knowledge, this is one of the first qualitative studies focused on the views of German alloHSCT-survivors on the long-term effects of alloHSCT and the first study integrating the view of their partners. Healthcare providers could better support survivors with managing their symptoms and adhering to their prescribed care by ensuring comprehensive, transparent communication that helps increase survivors' understanding and involvement in their care. Further efforts should be made to provide patient-centered, continuous survivorship care that involves additional support with navigating the healthcare and social service system. Intervention studies are required to test the effectiveness of the suggested strategies.

Impact of treatment summaries for cancer survivors: a systematic review

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR CANCER SURVIVORS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR PRACTICE

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

Interventions to improve adherence to surveillance guidelines in survivors of childhood cancer: a systematic review

PURPOSE

Many survivors of childhood cancer are at high risk of late effects of their cancer therapy, including cardiac toxicity and subsequent malignant neoplasms (SMN). Current North American guidelines recommend periodic surveillance for these late effects. We conducted a systematic review of the literature to estimate rates of adherence to recommended surveillance and summarize studies evaluating interventions intended to increase adherence.

METHODS

We searched MEDLINE, Embase, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and September 2018 that reported adherence to surveillance for cardiac toxicity and SMN (breast and colorectal cancer) and interventions implemented to improve completion of recommended testing. Risk of bias was assessed using relevant Cochrane checklists. Due to heterogeneity and overlapping study populations, we used narrative synthesis to summarize the findings. This review was registered in PROSPERO: CRD42018098878.

RESULTS

Thirteen studies met our inclusion criteria for assessing adherence to surveillance, while five assessed interventions to improve rates of surveillance. No studies met criteria for low risk of bias. Completion of recommended surveillance was lowest for colorectal cancer screening (11.5-30.0%) followed by cardiomyopathy (22.3-48.1%) and breast cancer (37.0-56.5%). Factors such as patient-provider communication, engagement with the health care system, and receipt of information were consistently reported to be associated with higher rates of surveillance. Of five randomized controlled trials aimed at improving surveillance, only two significantly increase completion of recommended testing-one for echocardiography and one for mammography. Both involved telephone outreach to encourage and facilitate these tests.

CONCLUSION

The majority of childhood cancer survivors at high risk of cardiac toxicity or SMN do not receive evidence-based surveillance. There is paucity of rigorous studies evaluating interventions to increase surveillance in this population.

IMPLICATIONS FOR CANCER SURVIVORS

Robust trials are needed to assess whether tailored interventions, designed based on unique characteristics and needs of each survivor population, could improve adherence.

The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review

Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.

Disparities in ovarian cancer survival in the United States (2001-2009): Findings from the CONCORD-2 study

BACKGROUND

Ovarian cancer is the fifth leading cause of cancer death among women in the United States. This study reports ovarian cancer survival by state, race, and stage at diagnosis using data from the CONCORD-2 study, the largest and most geographically comprehensive, population-based survival study to date.

METHODS

Data from women diagnosed with ovarian cancer between 2001 and 2009 from 37 states, covering 80% of the US population, were used in all analyses. Survival was estimated up to 5 years and was age standardized and adjusted for background mortality (net survival) using state-specific and race-specific life tables.

RESULTS

Among the 172,849 ovarian cancers diagnosed between 2001 and 2009, more than one-half were diagnosed at distant stage. Five-year net survival was 39.6% between 2001 and 2003 and 41% between 2004 and 2009. Black women had consistently worse survival compared with white women (29.6% from 2001-2003 and 31.1% from 2004-2009), despite similar stage distributions. Stage-specific survival for all races combined between 2004 and 2009 was 86.4% for localized stage, 60.9% for regional stage, and 27.4% for distant stage.

CONCLUSIONS

The current data demonstrate a large and persistent disparity in ovarian cancer survival among black women compared with white women in most states. Clinical and public health efforts that ensure all women who are diagnosed with ovarian cancer receive appropriate, guidelines-based treatment may help to decrease these disparities. Future research that focuses on the development of new methods or modalities to detect ovarian cancer at early stages, when survival is relatively high, will likely improve overall US ovarian cancer survival. Cancer 2017;123:5138-59. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Provider perspectives on barriers and facilitators to adjuvant endocrine therapy-related symptom management

PURPOSE

Adjuvant endocrine therapy (AET) utilization is linked to improved clinical outcomes among breast cancer survivors (BCS); yet, AET adherence rates remain suboptimal. Little is known about provider perspectives regarding barriers and facilitators to AET-related symptom management (SM). In this study, we examined provider perspectives on the barriers and facilitators to AET-related SM among BCS and opportunities for improvement.

METHODS

We conducted three focus groups (FGs) with a multidisciplinary group of healthcare providers (n = 13) experienced in caring for BCS undergoing AET. We utilized semi-structured discussion guides to elicit provider perspectives on AET-related SM. FGs were audiotaped, transcribed, and analyzed using qualitative software to identify key themes.

RESULTS

Providers described patient-, provider-, and system-level barriers and facilitators to AET-related SM. At the patient-level, barriers included competing demands, limited time/resources, and possible misattribution of some symptoms to AET, while family/social relationships and insurance emerged as important facilitators. Discomfort with SM, limited time, and challenges distinguishing AET-related symptoms from other conditions were key provider-level barriers. Provider-level facilitators included routine symptom documentation and strong provider relationships. Care fragmentation and complexity of the cancer care delivery system were described as system-level barriers; however, survivor clinics were endorsed by providers.

CONCLUSIONS

Provider perspectives on AET-related SM can shed light on SM barriers and facilitators spanning multiple levels of the cancer care delivery system. Strategies for improving AET-related SM in BCS include increasing patients' knowledge and engagement in SM, equipping providers with efficient SM strategies, and improving coordination of symptom-related services through survivorship programs.

Race is a Strong Predictor of Receipt of a Written Survivorship Care Plan: Results from the National Health Interview Survey

The purpose of this study is to investigate the prevalence of receipt of written documentation of follow up care and of cancer treatments and to examine the predictors of receipt of such written documentation. Data from the 2010 National Health Interview Survey was used to identify individuals 18 years or older with a history of cancer. Binary and multinomial logistic regression were used to investigate patient-level variables associated with receipt of written documentation of cancer treatment, written advice about follow-up care, or both written documents. Patient-level variables included in the analysis were age, gender, region of residence, race/ethnicity, marital status, education level, insurance coverage, cancer type, employment status, and psychosocial support. Of the 1185 responses to the questions used to access receipt of a SCP, the prevalence of any receipt of a written documentation was 68%, where 30% obtained written advice only and 8% were provided a written treatment summary only; only 31% received both. Non-white race, cancer type, and psychosocial services were associated with increased odds of receiving written documentation. Patient-level characteristics are associated with receipt of care plan documentation. Further work needs to investigate the interaction of provider and patient-level characteristics. Understanding patient-level characteristics associated with receipt of written documentation may help uncover strategies for improved survivorship care plan implementation.

Adherence of Primary Care Physicians to Evidence-Based Recommendations to Reduce Ovarian Cancer Mortality

Ovarian cancer is the deadliest gynecologic cancer. Receipt of treatment from a gynecologic oncologist is an evidence-based recommendation to reduce mortality from the disease. We examined knowledge and application of this evidence-based recommendation in primary care physicians as part of CDC gynecologic cancer awareness campaign efforts and discussed results in the context of CDC National Comprehensive Cancer Control Program (NCCCP). We analyzed primary care physician responses to questions about how often they refer patients diagnosed with ovarian cancer to gynecologic oncologists, and reasons for lack of referral. We also analyzed these physicians' knowledge of tests to help determine whether a gynecologic oncologist is needed for a planned surgery. The survey response rate was 52.2%. A total of 84% of primary care physicians (87% of family/general practitioners, 81% of internists and obstetrician/gynecologists) said they always referred patients to gynecologic oncologists for treatment. Common reasons for not always referring were patient preference or lack of gynecologic oncologists in the practice area. A total of 23% of primary care physicians had heard of the OVA1 test, which helps to determine whether gynecologic oncologist referral is needed. Although referral rates reported here are high, it is not clear whether ovarian cancer patients are actually seeing gynecologic oncologists for care. The NCCCP is undertaking several efforts to assist with this, including education of the recommendation among women and providers and assistance with treatment summaries and patient navigation toward appropriate treatment. Expansion of these efforts to all populations may help improve adherence to recommendations and reduce ovarian cancer mortality.

Racial and ethnic differences in patient navigation: Results from the Patient Navigation Research Program

BACKGROUND

Patient navigation was developed to address barriers to timely care and reduce cancer disparities. The current study explored navigation and racial and ethnic differences in time to the diagnostic resolution of a cancer screening abnormality.

METHODS

The authors conducted an analysis of the multisite Patient Navigation Research Program. Participants with an abnormal cancer screening test were allocated to either navigation or control. The unadjusted median time to resolution was calculated for each racial and ethnic group by navigation and control. Multivariable Cox proportional hazards models were fit, adjusting for sex, age, cancer abnormality type, and health insurance and stratifying by center of care.

RESULTS

Among a sample of 7514 participants, 29% were non-Hispanic white, 43% were Hispanic, and 28% were black. In the control group, black individuals were found to have a longer median time to diagnostic resolution (108 days) compared with non-Hispanic white individuals (65 days) or Hispanic individuals (68 days) (P<.0001). In the navigated groups, black individuals had a reduction in the median time to diagnostic resolution (97 days) (P<.0001). In the multivariable models, among controls, black race was found to be associated with an increased delay to diagnostic resolution (hazard ratio, 0.77; 95% confidence interval, 0.69-0.84) compared with non-Hispanic white individuals, which was reduced in the navigated arm (hazard ratio, 0.85; 95% confidence interval, 0.77-0.94).

CONCLUSIONS

Patient navigation appears to have the greatest impact among black patients, who had the greatest delays in care. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2715-2722. © 2016 American Cancer Society.