Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

Surveillance After a Previous Cutaneous Melanoma Diagnosis: A Scoping Review of Melanoma Follow-Up Guidelines

INTRODUCTION

Cutaneous melanoma accounts for more than 70% of all skin cancer deaths. Follow-up surveillance is an integral part of melanoma patient care, to facilitate early detection of recurrences and subsequent primary melanomas. The purpose of this scoping review is to provide an overview of recently published melanoma surveillance guidelines from regional and national melanoma working groups.

METHODS

A systematic search for relevant studies in MEDLINE and Embase was conducted in September 2022 and was limited to publications from 2010 or later.

RESULTS

A total of 1047 articles were retrieved, and after abstract and full text review, 26 articles from 19 different organizations met inclusion criteria. Life-long annual skin surveillance with a physician was recommended by 53% (9/17) of guidelines. Routine laboratory investigations were recommended by 7/19 guidelines. Regional lymph node ultrasound was recommended by 9/16 guidelines, most often in stage IB or higher, and was optional in 7/16 for patients who met specific criteria. Surveillance with PET-CT or CT and MRI was recommended by 15 and 11 guidelines, respectively, most commonly in stage IIC or higher, with a variable frequency and total duration. Five out of 9 guidelines indicated a preference for skin surveillance to be completed with a dermatologist.

CONCLUSION

Guidelines were highly variable for many aspects of melanoma surveillance, which may be partly attributed to regional differences in healthcare workforce distribution and availability of imaging technologies. Further high-level studies are recommended to provide more evidence on the most effective clinical and imaging follow-up surveillance protocols.

Stage IA melanoma follow‐up: Exploring the level of confidence of South Australian general practitioners in undertaking surveillance skin checks including considerations for shared care

BACKGROUND

The literature highlights the role of Australian general practitioners (GP) in the management of skin cancers. With melanoma incidences on the rise, there have been discussions into whether lower-risk stage IA patients could safely be followed up by their GPs for annual surveillance full skin examinations (FSE). This study explores the level of confidence of South Australian (SA) GPs in undertaking FSEs including factors that could support discussions around shared care between GPs and dermatology units for lower-risk patients.

METHODS

An online survey was designed and distributed to SA GPs via email, newsletters and social media between 5 December 2021 and 30 January 2022. Descriptive statistics were used to describe survey responses. Pearson's Chi-squared analysis was used to investigate associations between key variables of interest and explanatory variables. Logistic regression analysis was used to model odds ratios for associations between the dependent variable and independent variables.

RESULTS

A total of 135 responses were obtained. Forty-four per cent of GPs were comfortable undertaking annual FSEs, 41% were uncomfortable and 15% were unsure. Scope of work, >20 years experience and additional training had statistically significant relationships (p < 0.05). Dermoscopy and detecting melanoma recurrences were reported to be skills with lower levels of confidence. With regards to shared care, 77% indicated that they would feel supported undertaking FSEs if rapid access referral pathways were allocated for patients who developed suspicious lesions. Preferred upskilling modalities included, face-to-face sessions in a dermatology unit (39%), dermatologist run webinars (25%) and certificate courses (20%).

CONCLUSIONS

At present, there is a subset of SA GPs who are comfortable undertaking FSEs and therefore could be engaged in shared care with specialists. Further considerations have to be made in the areas of upskilling and supporting the workforce to enhance engagement in shared care.

Fear of Cancer Recurrence in Sarcoma Survivors: Results from the SURVSARC Study

Fear of cancer recurrence (FCR) is often reported as an unmet concern by cancer patients. The aim of our study was to investigate (1) the prevalence of FCR in sarcoma survivors; (2) the factors associated with a higher level of FCR; the relationship between (3) FCR and global health status and (4) FCR and use of follow-up care.

METHODS

A cross-sectional study was conducted among sarcoma survivors 2 to 10 years after diagnosis. Patients completed the Cancer Worry Scale (CWS), the global health status subscale of the EORTC QLQ-C30 and a custom-made questionnaire on follow-up care.

RESULTS

In total, 1047 patients were included (response rate 55%). The prevalence of high FCR was 45%. Factors associated with high FCR were female sex with 1.6 higher odds (95% CI 1.22-2.25; p = 0.001); having ≥1 comorbidities and receiving any treatment other than surgery alone with 1.5 (95% CI 1.07-2.05; p = 0.017) and 1.4 (95% CI 1.06-1.98; p = 0.020) higher odds, respectively. Patients on active follow-up had 1.7 higher odds (95% CI 1.20-2.61; p = 0.004) and patients with higher levels of FCR scored lower on the global health status scale (72 vs. 83 p ≤ 0.001).

CONCLUSIONS

Severe FCR is common in sarcoma survivors and high levels are related to a decreased global health status. FCR deserves more attention in sarcoma survivorship, and structured support programs should be developed to deliver interventions in a correct and time adequate environment.

Patient initiated follow-up in cancer patients: A systematic review

Background

Patient-initiated follow-up (PIFU) is increasingly being implemented for oncology patients, particularly during the COVID-19 pandemic, given the necessary reduction in face-to-face hospital outpatient appointments. We do not know if PIFU has a positive (or negative) impact on overall, or progression free, survival.

Objectives

To investigate the impact of PIFU on overall survival, progression free survival, patient satisfaction, psychological morbidity, specifically quality of life (QoL) and economic costs compared to hospital follow up (HFU), for any type of cancer.

Methods

We carried out a systematic review using five electronic databases: MEDLINE, CINAHL, EMBASE, PsycInfo and Cochrane Central Register of Controlled Trials. Studies were eligible if they were controlled clinical trials comparing PIFU with another form of active follow-up. Effectiveness was assessed using the primary outcome of overall survival and secondary outcomes of progression free survival, patient satisfaction, psychological morbidity, QoL and cost effectiveness.

Results

Eight studies met the inclusion criteria and were included. Only one study included survival as a primary outcome and indicated no significant differences between hospital-based follow-up and PIFU, although not adequately powered to detect a difference in survival. For secondary outcomes, few differences were found between PIFU and other forms of active follow-up. One study reported significant differences in fear of cancer recurrence between PIFU and HFU although did not reach the limit of clinical significance; in the short term, fear decreased significantly more in hospital based follow-up.

Conclusion

We do not have evidence to support the impact of PIFU on survival or progression free survival. Fully powered randomized controlled trials are required to determine the full impact of PIFU in the longer term.

Factors influencing the translation of shared cancer follow-up care into clinical practice: a systematic review

BACKGROUND

The increasing incidence of cancer, coupled with improved survivorship, has increased demand for cancer follow-up care and the need to find alternative models of care. Shared cancer follow-up care in general practice is a safe option in terms of quality of life and cancer recurrence; however, there are barriers to translating this into practice. This review aimed to identify factors that influence the translation of shared cancer follow-up care into clinical practice.

METHODS

Systematic review. Seven electronic databases: MEDLINE, Science Citation Index, Academic Search Complete, CINAHL, APA Psychinfo, Health Source: Nursing/Academic Edition and Psychology and Behavioural Sciences Collection, were searched for published papers between January 1999 and December 2021. The narrative review included papers if they were available in full-text, English, peer-reviewed and focused on shared cancer follow-up care.

RESULTS

Thirty-eight papers were included in the final review. Five main themes emerged: (1) reciprocal clinical information sharing is needed between oncologists and general practitioners, and needs to be timely and relevant; (2) responsibility of care should be shared with the oncologist overseeing care; (3) general practitioners skills and knowledge to provide cancer follow-up care; (4) need for clinical management guidelines and rapid referral to support general practitioners to provide shared follow-up care and (5) continuity of care and satisfaction of care is vital for shared care.

CONCLUSION

The acceptability of shared cancer follow-up care is increasing. Several barriers still exist to translating this into practice. Work is required to develop a shared-care model that can support general practitioners, while the oncologist can oversee the care and implement two-way communication between general and oncologists' clinics. The move towards integrating electronic healthcare records and web-based platforms for information exchange provides a promise to the timely exchange of information.

PROSPERO REGISTRATION NUMBER

CRD42020191538.

Risk Stratification and Cancer Follow-Up: Towards More Personalized Post-Treatment Care in Canada

After treatment, cancer survivors require ongoing, comprehensive care to improve quality of life, reduce disability, limit complications, and restore function. In Canada and internationally, follow-up care continues to be delivered most often by oncologists in institution-based settings. There is extensive evidence to demonstrate that this model of care does not work well for many survivors or our cancer systems. Randomized controlled trials have clearly demonstrated that alternate approaches to follow-up care are equivalent to oncologist-led follow-up in terms of patient outcomes, such as recurrence, survival, and quality of life in a number of common cancers. In this paper, we discuss the state of follow-up care for survivors of prevalent cancers and the need for more personalized models of follow-up. Indeed, there is no one-size-fits-all solution to post-treatment follow-up care, and more personalized approaches to follow-up that are based on individual risks and needs after cancer treatment are warranted. Canada lags behind when it comes to personalizing follow-up care for cancer survivors. There are many reasons for this, including difficulty in determining who is best served by different follow-up pathways, a paucity of evidence-informed self-management education and supports for most survivors, poorly developed IT solutions and systems, and uneven coordination of care. Using implementation science theories, approaches, and methods may help in addressing these challenges and delineating what might work best in particular settings and circumstances.

Primary Care Physicians' Perspectives in Leading Breast Cancer Follow-Up Care

INTRODUCTION

Limited data exist on the barriers associated with transitioning breast cancer follow-up care to primary care physicians (PCPs). This study aimed to describe the current perspectives of PCPs in managing breast cancer follow-up.

METHOD

An online survey was distributed to PCPs in Toronto, ON, Canada. Questions examined PCPs' view of transitioning breast cancer follow-up care to their practices.

RESULTS

Of 800 PCPs invited, 126 responded (response rate: 15.7%). The types of practice models amongst respondents included blended capitation (42.9%), blended salary (27%), and fee-for-service (17.5%). Seventy-seven percent of respondents stated they provided follow-up care. Approximately half of the respondents stated they were somewhat comfortable providing follow-up care. PCP-led follow-up care was considered either very (49.2%) or somewhat appropriate (30.2%). When asked about financial remuneration, 43.7% of respondents stated it was somewhat important. The factors that influenced the feasibility of PCP-led follow-up care included receipt of a detailed follow-up care plan provided by the specialist after discharge (81%), the ability to re-refer to specialists rapidly (56.3%), and the ability to obtain regular updates of best practice changes (59.5%). The preferred means of educational updates included E-mail (40.5%), continuing medical education events (30.2%), and electronic medical records (19.8%). When the fee model was taken into consideration there was no significant difference in opinions regarding follow-up care.

CONCLUSIONS

Transitioning to a PCP-led model was supported by most of the PCPs who participated in this study. Their perspective on PCP-led follow up care and barriers associated with implementation of this model of care needs to be further explored with future studies that include larger sample size and a more diverse PCP population.

What do patients and dermatologists prefer regarding low-risk basal cell carcinoma follow-up care? A discrete choice experiment

BACKGROUND

Follow-up after low-risk basal cell carcinoma (BCC) is being provided more frequently than recommended by guidelines. To design an acceptable strategy to successfully reduce this 'low-value' care, it is important to obtain insights into the preferences of patients and dermatologists.

OBJECTIVE

To determine the preferences and needs of patients and dermatologists to reduce low-risk BCC follow-up care, and the trade-offs they are willing to make.

METHODS

A questionnaire including a discrete choice experiment was created, containing attributes regarding amount of follow-up, continuity of care, method of providing addition information, type of healthcare provider, duration of follow-up visits and skin examination. In total, 371 BCC patients and all Dutch dermatologists and dermatology residents (n = 620) were invited to complete the questionnaire. A panel latent class model was used for analysis.

RESULTS

Eighty-four dermatologists and 266 BCC patients (21% and 72% response rates respectively) completed the discrete choice experiment. If the post-treatment visit was performed by the same person as treatment provider and a hand-out was provided to patients containing personalised information, the acceptance of having no additional follow-up visits (i.e. following the guidelines) would increase from 55% to 77% by patients. Female patients and older dermatologists, however, are less willing to accept the guidelines and prefer additional follow-up visits.

LIMITATIONS

The low response rate of dermatologists.

CONCLUSION

This discrete choice experiment revealed a feasible strategy to substantially reduce costs, while maintaining quality of care, based on the preferences and needs of BCC patients, which is supported by dermatologists.

Psychosocial care for cancer survivors: A systematic literature review on the role of general practitioners

OBJECTIVE

To explore the general practitioners (GP's) role in providing psychosocial care for cancer survivors through a systematic literature review.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL and included the studies that complied with the predefined inclusion and exclusion criteria. At least two independent reviewers performed the quality appraisal and data extraction.

RESULTS

We included 33 (five qualitative, 19 observational, and nine intervention) studies; the majority of these studies focused on care for depression and anxiety (21/33). Cancer survivors were more likely to contact their GP for psychosocial problems compared with noncancer controls. Survivors were more likely to use antidepressants compared with controls, although 71% of survivors preferred depression treatment to be "talking therapy only." Overall, GPs and patients mostly agreed that GPs are the preferred healthcare provider to manage psychosocial problems. The major exception is a survivor's fear of recurrence-here, the oncologist was the preferred healthcare provider. Only two interventions effectively decreased depression or anxiety; these studies included patients who had a clinical indication for psychosocial care, were specifically designed for decreasing depression/anxiety, and consisted of a multidisciplinary team approach. The other interventions evaluated GP-led follow-up for cancer survivors and found that this did not impact the patients' levels of anxiety, depression, or distress neither negatively nor positively.

CONCLUSIONS

Cancer survivors often prefer psychosocial care by their GP, and GPs generally consider they are well placed to provide this care. Although evidence on the effectiveness of psychosocial care by GPs is limited, an active multidisciplinary team approach seems key.

Analyzing Controversies in Management and Surveillance of Early-Stage Melanoma

The incidence of cutaneous melanoma continues to rise dramatically worldwide, presenting a significant burden to the healthcare system. Despite this, there is still controversy in the guidelines regarding follow-up surveillance for patients with thin melanoma. Since there are no randomized clinical trials to support evidence-based guidelines for follow-up surveillance, dermatologic and oncologic organizations have developed their own recommendations based on expert opinion. However, these recommendations differ widely and are often vague, resulting in considerable variability in the management of early-stage melanoma among clinicians. The benefits of frequent follow-up visits are early detection of recurrent lesions, lower cost of early-stage melanoma compared to that of late-stage melanoma, decreased need for sentinel lymph node biopsy and adjuvant therapies, and the opportunity to educate patients on self-examination and sun protection. However, the high cost of screening and potential increased rates of biopsy, as well as over-imaging and overtreating, pose serious concerns about this approach. While more rigorous research is needed to resolve this controversy, currently clinicians should follow a relatively universal recommendation to tailor the follow-up regimen based on the patient's relative risk of recurrence and comfort.

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.

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.

Building Personalized Cancer Follow-up Care Pathways in the United States: Lessons Learned From Implementation in England, Northern Ireland, and Australia

There is a global need to transform cancer follow-up care to address the needs of cancer survivors while efficiently using the health care system to limit the effects of provider shortages, gaps in provider knowledge, and already overburdened clinics; improve the mental health of clinicians; and limit costs to health care systems and patients. England, Northern Ireland, and Australia are implementing an approach that triages patients to personalized follow-up care pathways depending on the types and levels of resources needed for patients' long-term care that has been shown to meet patients' needs, more efficiently use the health care system, and reduce costs. This article discusses lessons learned from these implementation efforts, identifying the necessary components of these care models and barriers and facilitators to implementation of this care. Specifically, the United States and other countries looking to transform follow-up care should consider how to develop six key principles of this care: algorithms to triage patients to pathways; methods to assess patient issues to guide care; remote monitoring systems; methods to support patients in self-management; ways to coordinate care and information exchange between oncology, primary care, specialists, and patients; and methods to engage all stakeholders and secure their ongoing buy-in. Next steps to advance this work in the United States are discussed.

Choosing Wisely India: ten low-value or harmful practices that should be avoided in cancer care

The Choosing Wisely India campaign was an initiative that was established to identify low-value or potentially harmful practices that are relevant to the Indian cancer health-care system. We undertook a multidisciplinary framework-driven consensus process to identify a list of low-value or harmful cancer practices that are frequently undertaken in India. A task force convened by the National Cancer Grid of India included Indian representatives from surgical, medical, and radiation oncology. Each specialty had representation from the private and public sectors. The task force included two representatives from national patient and patient advocacy groups. Of the ten practices that were identified, four are completely new recommendations, and six are revisions or adaptations from previous Choosing Wisely USA and Canada lists. Recommendations in the final list pertain to diagnosis and treatment (five practices), palliative care (two practices), imaging (two practices), and system-level delivery of care (two practices). Implementation of this list and reporting of concordance with its recommendations will facilitate the delivery of high-quality, value-based cancer care in India.

Use of shared care and routine tests in follow-up after treatment for localised cutaneous melanoma

BACKGROUND

Patients may decide to undertake shared care with a general practitioner (GP) during follow-up after treatment for localised melanoma. Routine imaging tests for surveillance may be commonly used despite no evidence of clinical utility. This study describes the frequency of shared care and routine tests during follow-up after treatment for localised melanoma.

METHODS

We randomly sampled 351 people with localised melanoma [American Joint Cancer Committee (AJCC) substages 0 - II] who had not had recurrent or new primary melanoma diagnosed from a total of 902 people diagnosed and treated for localised melanoma at a specialist centre in 2014. We interviewed participants by telephone about their experience of follow-up in the past year, and documented the proportion of patients who were undertaking shared care follow-up with a GP. We also recorded the frequency and type of investigations during follow-up. We calculated weighted estimates that are representative of the full inception cohort.

RESULTS

Of the 351 people who were invited to participate, 230 (66%) people consented to the telephone interview. The majority undertook shared care follow-up with a GP (61%). People who choose to have shared care follow-up with a GP are more likely to be male (p = 0.006), have lower AJCC stage (p for trend = 0.02), reside in more remote areas (p for trend< 0.001), and are less likely to have completed secondary school (p < 0.001). Few people saw a non-doctor health practitioner as part of their follow-up (9%). Many people report undergoing tests for melanoma, much of which may be routine tests for surveillance (37%).

CONCLUSIONS

The majority of people treated for a first primary localised melanoma at a specialist centre, without recurrent or new melanoma, choose to undertake shared care follow-up with a GP. Many appear to have routine diagnostic imaging as part of their melanoma surveillance.

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.

Total skin self-examination at home for people treated for cutaneous melanoma: development and pilot of a digital intervention

OBJECTIVES

To develop a digital intervention to prompt, support, and respond to the outcomes of total skin self-examinations (TSSEs) at home by people treated for cutaneous melanoma.

DESIGN

A complex intervention development study.

SETTING

Northeast Scotland.

PARTICIPANTS

Semistructured scoping interviews; people previously treated for cutaneous melanoma (n=21). Pilot testing: people treated for melanoma stages 0-2C (n=20); general practitioners (n=6); and a nurse specialist in dermatology (n=1).

INTERVENTION

A tablet-based digital intervention designed to prompt and support TSSEs comprising instructional videos and electronic reporting (including photographs) to a clinical nurse specialist in dermatology, with subsequent clinical triage.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative assessment of intervention feasibility and acceptability, and quantitative assessment of intentions and confidence to perform TSSEs in pilot participants.

RESULTS

The majority of pilot participants were strongly positive and adhered well to the intervention (n=15), with 7 of these reporting symptoms of concern at some point during the 6-month pilot. 4 patients complied intermittently, 3 reporting skin problems at least once during the pilot, and 1 withdrew. 2 patients underwent skin surgery as a result of participating in the pilot, with 1 diagnosed as having a recurrent melanoma and the other, a benign lesion. A number of practical issues to improve the usability of the intervention were identified. The proportion of participants reporting intention to check their skin at least monthly increased during the intervention as did confidence to conduct a skin check.

CONCLUSIONS

People previously treated for cutaneous melanoma are prepared to use digital technology to support them in conducting TSSE. An intervention has been developed which is practical, effective and safe, and after addressing minor practical issues, could now be evaluated for clinical outcomes in a randomised clinical trial.

Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care

Using knowledge translation and exchange efforts, this list should empower patients with cancer and physicians to participate in a targeted conversation about the appropriateness and quality of individual patient care.

Long-term follow-up for melanoma patients: is there any evidence of a benefit?

As the incidence of melanoma and the number of melanoma survivors continues to rise, optimal surveillance strategies are needed that balance the risks and benefits of screening in the context of contemporary resource use. Detection of recurrences has important implications for clinical management. Most current surveillance recommendations for melanoma survivors are based on low-level evidence with wide variations in practice patterns and an unknown clinical impact for the melanoma survivor.

The impact of Sun Solutions educational interventions on select health belief model constructs

The purpose of this study was to offer the Sun Solutions intervention to operating engineers (N = 232) to decrease sun exposure and skin cancer. The majority (82%) of the engineers worked outside between 10 a.m. and 3 p.m., 4 to 5 hours a day; 81.4% reported more than one sunburn during the past year and 70% sometimes or never used sunscreen compared to 30% who wore sunscreen approximately 50% or more of the time. Most reported that the intervention was helpful (97%), most were satisfied (96%) with the intervention, and 84% expressed a future intention to use sunscreen. Regarding sun protective behaviors, the intervention significantly improved perceived self-efficacy (p < .05) and increased perceived barriers (p < .05). Regarding sunburn and skin cancer, the intervention increased perceived benefits (p < .05), susceptibility (p < .05), and severity (p < .05) for sunburning, but not skin cancer (p > .10). The Sun Solutions intervention showed the potential to increase sunscreen use and decrease the risk of sunburn and skin cancer among operating engineers.

Using technology to deliver cancer follow-up: a systematic review

BACKGROUND

People with cancer receive regular structured follow up after initial treatment, usually by a specialist in a cancer centre. Increasing numbers of cancer survivors prompts interest in alternative structured follow-up models. There is worldwide evidence of increasing interest in delivering cancer follow-up using technology. This review sough evidence supporting the use of technology in cancer follow-up from good quality randomised controlled trials.

METHOD

A search strategy was developed to identify randomised controlled trials and reviews of randomised trials of interventions delivering some aspect of structured cancer follow-up using new technologies. Databases searched were: All EBM Reviews; Embase; Medline (No Revisions); Medline (Non-Indexed Citations), and CAB Abstracts. Included articles were published in English between 2000 and 2014. Key words were generated by the research question. Papers were read independently and appraised using a standardised checklist by two researchers, with differences being resolved by consensus [J Epidemiol Community Health, 52:377-384, 1998]. Information was collected on the purpose, process, results and limitations of each study. All outcomes were considered, but particular attention paid to areas under consideration in the review question.

RESULTS

The search strategy generated 22879 titles. Following removal of duplicates and abstract review 17 full papers pertaining to 13 randomised controlled studies were reviewed. Studies varied in technologies used and the elements of follow-up delivered, length of follow-up, tumour type and numbers participating. Most studies employed only standard telephone follow-up. Most studies involved women with breast cancer and included telephone follow-up. Together the results suggest that interventions comprising technology had not compromised patient satisfaction or safety, as measured by symptoms, health related quality of life or psychological distress. There was insufficient evidence to comment on the cost effectiveness of technological cancer follow-up interventions.

CONCLUSIONS

Modern technology could deliver cancer follow-up that is acceptable and safe. More research is required to develop cancer follow-up systems which exploit modern technology, which should be assessed using randomised trials, with consistent outcomes, so that evidence on the acceptability, safety, cost effectiveness and impact in quality of life of technological follow-up can accumulate and be made available to patients, professionals and policy makers.

Protocol for the ProCare Trial: a phase II randomised controlled trial of shared care for follow-up of men with prostate cancer

INTRODUCTION

Men with prostate cancer require long-term follow-up to monitor disease progression and manage common adverse physical and psychosocial consequences of treatment. There is growing recognition of the potential role of primary care in cancer follow-up. This paper describes the protocol for a phase II multisite randomised controlled trial of a novel model of shared care for the follow-up of men after completing treatment for low-moderate risk prostate cancer.

METHODS AND ANALYSIS

The intervention is a shared care model of follow-up visits in the first 12 months after completing treatment for prostate cancer with the following specific components: a survivorship care plan, general practitioner (GP) management guidelines, register and recall systems, screening for distress and unmet needs and patient information resources. Eligible men will have completed surgery and/or radiotherapy for low-moderate risk prostate cancer within the previous 8 weeks and have a GP who consents to participate. Ninety men will be randomised to the intervention or current hospital follow-up care. Study outcome measures will be collected at baseline, 3, 6 and 12 months and include anxiety, depression, unmet needs, prostate cancer-specific quality of life and satisfaction with care. Clinical processes and healthcare resource usage will also be measured. The principal emphasis of the analysis will be on obtaining estimates of the treatment effect size and assessing feasibility in order to inform the design of a subsequent phase III trial.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the University of Western Australia and from all hospital recruitment sites in Western Australia and Victoria.

RESULTS

of this phase II trial will be reported in peer-reviewed publications and in conference presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12610000938000.

Risk-based health care, the cancer survivor, the oncologist, and the primary care physician

Cancer survivors face substantial risks for morbidity, reduced quality of life, and premature mortality related to the cancer itself and/or the interventions undertaken to control cancer. Risk-based care that involves a personalized systematic plan of periodic screening, surveillance, and prevention relevant to the cancer experience is recommended to address the comprehensive health needs of the growing population of cancer survivors. Risk-based care and coordination between oncology and primary care providers have been identified as important metrics of quality cancer survivorship care. Various models of survivorship care, treatment summaries, and survivorship care plans have been promoted as methods to facilitate communication among providers across care transitions and improve survivor access to quality survivorship care. However, research supporting the feasibility of implementing these practices and their effectiveness in enhancing health outcomes is limited. This article reviews key concepts underpinning clinical and research initiatives endeavoring to improve access to quality care among long-term survivors and summarizes results of intervention studies implementing these elements in transitioning survivors from oncology to primary care providers for long-term follow-up care.

Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review

There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. There are significant intercountry and interspecialty variations in the surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.

Shared care in the follow-up of early-stage melanoma: a qualitative study of Australian melanoma clinicians' perspectives and models of care

BACKGROUND

Patients with early stage melanoma have high survival rates but require long-term follow-up to detect recurrences and/or new primary tumours. Shared care between melanoma specialists and general practitioners is an increasingly important approach to meeting the needs of a growing population of melanoma survivors.

METHODS

In-depth qualitative study based on semi-structured interviews with 16 clinicians (surgical oncologists, dermatologists and melanoma unit GPs) who conduct post-treatment follow-up at two of Australia's largest specialist referral melanoma treatment and diagnosis units. Interviews were recorded, transcribed and analysed to identify approaches to shared care in follow-up, variations in practice, and explanations of these.

RESULTS

Melanoma unit clinicians utilised shared care in the follow-up of patients with early stage melanoma. Schedules were determined by patients' clinical risk profiles. Final arrangements for delivery of those schedules (by whom and where) were influenced by additional psychosocial, professional and organizational considerations. Four models of shared care were described: (a) surgical oncologist alternating with dermatologist (in-house or local to patient); (b) melanoma unit dermatologist and other local doctor (e.g. family physician); (c) surgical oncologist and local doctor; or (d) melanoma physician and local doctor.

CONCLUSIONS

These models of shared care offer alternative solutions to managing the requirements for long-term follow-up of a growing number of patients with stage I/II melanoma, and warrant further comparative evaluation of outcomes in clinical trials, with detailed cost/benefit analyses.

Follow-up of early stage melanoma: specialist clinician perspectives on the functions of follow-up and implications for extending follow-up intervals

BACKGROUND

There is limited evidence on the relative effectiveness of different follow-up schedules for patients with AJCC stage I or II melanoma, but less frequent follow-up than is currently recommended has been proposed.

OBJECTIVES

To describe melanoma clinicians' perspectives on the functions of follow-up, factors that influence follow-up intervals, and important considerations for extending intervals.

METHODS

Qualitative interviews with 16 clinicians (surgical oncologists, dermatologists, melanoma unit physicians) who conduct follow-up at two of Australia's largest specialist centers.

RESULTS

Follow-up is conducted for early detection of recurrences or new primary melanomas, to manage patient anxiety, support patient self-care, and as part of shared care. Recommended intervals are based on guidelines but account for each patient's clinical risk profile, level of anxiety, patient education requirements, capacity to engage in skin self-examination, and how the clinician prefers to manage any suspicious lesions.

CONCLUSIONS

To revise guidelines and implement change it is important to understand the rationale underpinning existing practice. Extended follow-up intervals for early stage melanoma are more likely to be adopted after the first year when patients are less anxious and sufficiently prepared to conduct self-examination. Clinicians may retain existing schedules for highly anxious patients or those unable to examine themselves.

Psychosocial aspects of post-treatment follow-up for stage I/II melanoma: a systematic review of the literature

BACKGROUND

Patients treated for melanoma are advised to have lifelong full body skin examinations. Extended intervals between examinations have been proposed, but although this may be clinically effective, psychosocial aspects of follow-up are not well understood. This systematic review summarised patient and clinician preferences, experiences and adherence with recommended follow-up of stage I/II melanoma.

METHODS

Medline, PsycINFO, CINAHL, Embase, Cochrane Library, ACP Journal Club and NHS Economic Evaluation Database were searched from database inception to week 3 April 2010, to identify original studies of psychosocial outcomes of follow-up after treatment of stage I/II primary cutaneous melanoma, as reported by patients or clinicians. The results were synthesised, and characteristics likely to maximise patients' well-being and adherence to follow-up schedules were proposed.

RESULTS

We found 15 studies that met the inclusion criteria. Anxiety with melanoma follow-up was common; patients valued reassurance, information and psychosocial support, but long-term adherence to schedules was variable. Some wanted more emotional support from their clinician than was provided. Clinicians sometimes ordered additional blood and imaging tests to reassure patients. GPs were hesitant to conduct melanoma follow-up, but a trial providing technical training and protocols reported positive outcomes. Both patients and GPs wanted prompt access to melanoma specialists when suspicious lesions were found.

CONCLUSION

Psychosocial aspects of follow-up impact on patient well-being and potential adherence to schedules, and may influence clinician practice. If follow-up schedules or personnel are to be revised, psychosocial impacts on patients must be explicitly addressed, as well as guidance and specialist support for clinicians.

Toward shared care for people with cancer: developing the model with patients and GPs

BACKGROUND

The number of people surviving cancer for extended periods is increasing. Consequently, due to workload and quality issues, there is considerable interest in alternatives to traditional secondary care-led cancer follow-up.

OBJECTIVE

To explore the views of potential recipients of shared follow-up of cancer. To conduct a modelling exercise for shared follow-up and to explore the opinions and experiences of both the patients and GPs involved.

METHODS

Semi-structured audio-taped telephone or face-to-face interviews were conducted with 18 patients with a range of cancers currently attending for structured follow-up in secondary care. Six GPs and five patients (four with melanoma and one with stable metastatic colorectal cancer) took part in a shared follow-up modelling exercise. During the modelling exercise, the GPs attended 4 review meetings, which included brief training seminars, and at the conclusion 10 individuals took part in semi-structured audio-taped telephone or face-to-face interviews.

RESULTS

Many rural patients, and some urban patients, would appreciate follow-up being available nearer to home with the associated benefits of time saved and easier parking and continuity of care. Patients have concerns related to the level of extra training received by the GP and loss of contact with their consultant. GPs have concerns about gaining and maintaining the clinical skills needed to conduct follow-up, especially if the numbers of patients seen are small. They also have concerns about lack of support from other GPs, and some administrative and organizational issues.

CONCLUSIONS

Many patients would be willing to have GPs share their cancer follow-up with the caveat that they had received extra training and were appropriately supported by secondary care specialists. Patients attending shared care clinics appreciated a local service and longer appointment times. GPs stress the importance of maintaining their own clinical skills and reliable clinical and administrative support from secondary care.