Follow-up care of breast cancer survivors

Care of the breast cancer survivor

Earlier detection of invasive and noninvasive breast cancer and more effective treatments have led to both an improved prognosis for women with breast cancer and an increasing number of long-term survivors. However, such advances present various physical and emotional health challenges to patients facing breast cancer and its aftermath. Thus, understanding of the specific medical and psychosocial problems associated with survivorship is paramount in primary care.

Perceptions of Primary Care Among Breast Cancer Survivors: The Effects of Weight Status

Background:

Obese breast cancer survivors (BCSs) are impacted by diminished quality of life (QOL), multiple comorbid conditions, and poor disease outcomes. Despite national guidelines recommending a healthy weight to improve QOL and outcomes posttreatment, support and education are not routinely provided to BCSs in primary care. To fill this gap, we assessed perceptions of primary care received among BCSs by weight status.

Methods:

Cross-sectional surveys were administered to early-stage BCSs (N = 188) from 2 New Jersey cancer centers between May 2012 and July 2013. Sociodemographics, medical history, functional health status, perceived satisfaction with one’s primary care provider (PCP), and PCP involvement in follow-up care were assessed.

Results:

In total, 82% of overweight BCSs and 30% of obese BCSs reported not being told by their doctor that they were overweight or obese, despite these conditions being highly prevalent (35% and 35%, respectively). Obese BCSs were more likely than healthy weight BCSs to be African American, have a higher comorbidity score, poorer functional health, and greater satisfaction with their PCPs.

Conclusion:

The PCP–patient encounter may represent an opportunity for PCPs to correct misperceptions and promote weight reduction efforts among BCSs, thus improving QOL and disease outcomes.

A comprehensive framework and key guideline recommendations for the provision of evidence-based breast cancer survivorship care within the primary care setting

BACKGROUND

Breast cancer survivors continue to experience physical and psychosocial health care needs post-treatment. Primary care involvement is increasing as cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up. Research suggests primary care providers (PCPs) are willing to provide survivorship care but many lack knowledge and confidence to provide evidence-based care. Although clinical practice guidelines (CPGs) exist for follow-up surveillance and certain aspects of survivorship care, no single comprehensive guideline addresses all significant breast cancer survivorship issues encountered in primary care.

PURPOSE

The purpose of this research was to create a comprehensive clinical practice framework to guide the provision of breast cancer survivorship care in primary care settings.

METHODS

This study consisted of an extensive search, appraisal and synthesis of CPGs for post-treatment breast cancer care using a modified Delphi method. Breast cancer survivorship issues and relevant CPGs were mapped to four essential components of survivorship care to create a comprehensive clinical practice framework to guide provision of breast cancer survivorship care.

RESULTS

The completed framework consists of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations and a one-page list of guideline sources. The framework and key guideline recommendations were verified by a panel of experts for comprehensiveness, importance and relevance to primary care.

CONCLUSIONS

This framework may serve as a tool to remind PCPs about issues impacting breast cancer survivors, as well as the evidence-based recommendations and resources to provide the associated care.

Adherence to surveillance care guidelines after breast and colorectal cancer treatment with curative intent

BACKGROUND

Evidence-based guidelines recommend routine surveillance, including office visits and testing, to detect new and recurrent disease among survivors of breast and colorectal cancer. The extent to which surveillance practice is consistent with guideline recommendations or may vary by age is not known.

METHODS

Cohorts of adult patients diagnosed with breast (n = 6205) and colorectal (n = 2297) cancer between 2000 and 2008 and treated with curative intent in 4 geographically diverse managed care environments were identified via tumor registries. Kaplan-Meier estimates were used to describe time to initial and subsequent receipt of surveillance services. Cox proportional hazards models evaluated the relation between patient characteristics and receipt of metastatic screening.

RESULTS

Within 18 months of treatment, 87.2% of breast cancer survivors received recommended mammograms, with significantly higher rates noted for patients aged 50 years to 65 years. Among survivors of colorectal cancer, only 55.0% received recommended colon examinations, with significantly lower rates for those aged ≥ 75 years. The majority of breast (64.7%) and colorectal (73.3%) cancer survivors received nonrecommended metastatic disease testing. In patients with breast cancer, factors associated with metastatic disease testing include white race (hazards ratio [HR], 1.13), comorbidities (HR, 1.17), and younger age (HR, 1.13; 1.15; 1.13 for age groups: <50, 50-64, and 65-74 respectively). In those with colorectal cancer, these factors included younger age (HR, 1.31; 1.25 for age groups: <50 and 50-64 respectively) and comorbidities (HR, 1.10).

CONCLUSIONS

Among an insured population, wide variation regarding the use of surveillance care was found by age and relative to guideline recommendations. Breast cancer survivors were found to have high rates of both guideline-recommended recurrence testing and non-guideline-recommended metastatic testing. Only approximately 50% of colorectal cancer survivors received recommended tests but greater than 67% received metastatic testing.

Problems in transition and quality of care: perspectives of breast cancer survivors

PURPOSE

We conducted a qualitative study to explore breast cancer survivors' perceptions and attitudes about their current healthcare utilization, screening, and information needs.

METHODS

We completed eight focus groups of breast cancer survivors. We included women, adult survivors, with an initial diagnosis of breast cancer in the year 2000, treated, and without a recurrence as per medical record. To analyze transcripts, we used grounded theory methods, wherein unexpected themes and direct answers emerged from consensus between co-coders.

RESULTS

Focus groups included 33 participants, the majority of whom were white (84.8%), college-educated (66.7%), and covered by private medical insurance (75.7%) or Medicare (27.3%). Participants' perceptions and attitudes about care were framed in terms of personal experiences (including facing barriers to screening, feeling in limbo in the healthcare system, having problems with communication with and between physicians, confusion about symptoms, and using self-prescribe remedies), personal attitudes (including strong opinions about what survivorship means, concerns about recurrence, and changes in self-perception and agency), and social influences (including modeling others' behaviors, changes in social life, and listening to family).

CONCLUSION

Survivorship attitudes, recurrence fears, memories, and self-perceptions were influential personal factors in addition to self-efficacy. Solutions such as providing a cancer treatment summary might resolve many of the problems by consolidating and making readily available the numerous medical history and recommendations that survivors accrue over time, switching from provider to provider. Clinicians must also implement communication changes in their interactions with patients to enhance positive attitudes and behaviors, and leverage social influences.

Longitudinal patterns in survival, comorbidity, healthcare utilization and quality of care among older women following breast cancer diagnosis

OBJECTIVES

To compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer.

DESIGN

Prospective five-year longitudinal comparison of cases and matched controls.

SUBJECTS

Newly identified breast cancer patients recruited during 1997-1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656).

OUTCOMES

Survival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening.

RESULTS

Five-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p < 0.01), with most differences diminishing over time. However, the number of physician visits was higher for cases (p < 0.01) in every year, driven partly by more cancer and surgical specialist visits. Cases and controls adhered similarly to recommended bone density testing, and monitoring of cardiovascular disease and diabetes; adherence to recommended colorectal cancer screening was better among cases.

CONCLUSION

Breast cancer survivors' health care utilization and disease burden return to pre-diagnosis levels after one year, yet their greater use of outpatient care persists at least five years. Quality of care for other chronic health problems is similar for cases and controls.

Evidence-based care for breast cancer survivors: communicating the Institute of Medicine Guidelines in medical practice

OBJECTIVE

To investigate patient reports of physician communication about the 2006 Institute of Medicine (IOM) Guidelines for Survivorship Care, and patient follow-up care behaviors in a sample of African American and Caucasian breast cancer survivors.

METHODS

Fifteen-minute telephone interviews were conducted in a cross-sectional study with a sample of African American (n=30) and Caucasian (n=69) breast cancer patients, who were within 5 years of their diagnosis and primary treatment for breast cancer at two Baltimore, Maryland medical centers, during the summer of 2006. Multiple items assessed patient reports of physician discussions about IOM Guidelines, their recurrence concerns, and their follow-up treatment, screening, diet and exercise practices.

RESULTS

Patients with higher incomes, more education, female physicians, and of younger ages reported more complete physician discussions of the IOM Guidelines. No significant differences were noted between African American and Caucasian patients.

CONCLUSION

Patients at greatest risk for breast cancer recurrence - those with less education, income, and resources - report limited guidance from their physicians about evidence-based, follow-up care guidelines, designed to minimize their risk.

PRACTICE IMPLICATIONS

Physicians need strategies for effectively delivering the IOM Guidelines for Survivorship Care to disadvantaged breast cancer patients, to promote enhanced quality of life and reduced risk of recurrence.

Transitioning to breast cancer survivorship: perspectives of patients, cancer specialists, and primary care providers

BACKGROUND

Limited research exists regarding views of patients, oncology specialists, and primary care providers (PCPs) concerning breast cancer survivorship care.

OBJECTIVE

To qualitatively explore the needs and priorities of breast cancer survivors, oncology specialists, and PCPs.

METHODS

Focus groups were conducted of survivors (21 in 5 groups), PCPs (15 in 2 groups), and oncology specialists (16 in 2 groups). One survivor group consisted of four African-Americans. Discussions used a semi-structured guide, were transcribed verbatim, and were analyzed qualitatively. Groups explored transitions to follow-up, communication, patient needs, and provider roles.

RESULTS

Survivors form intense relationships with specialists for reassurance and expertise. Many believed PCPs lacked necessary oncology expertise. Survivors reported psychosocial and communication issues. African-Americans cited concerns about access to care and clinical trials, as well as taboos to discussing cancer. Specialists reported that they struggle with discharging survivors due to protective relationships. PCPs were concerned about time and training to provide survivorship care and communication problems with oncologists. Written survivorship care plans were regarded by all groups as possibly helpful, but insufficient to ease the transition.

CONCLUSIONS

Breast cancer patients may experience difficulties transitioning to survivorship, including ongoing psychosocial issues. African-American patients may face additional and unique barriers to successful survivorship. Oncology specialists may have concerns about discharging cherished patients. These findings suggest a psychological component that may influence the use of written survivorship care plans. PCPs may need additional training and greater access to specialists in order to care for survivors.

Applying a conceptual model for examining health-related quality of life in long-term breast cancer survivors: CALGB study 79804

OBJECTIVES

The Survivor's Health and Reaction study used a quality-of-life model adapted for cancer survivors by Dow and colleagues to identify factors related to global health-related quality of life (HRQL) and to document the prevalence of problems and health-oriented behaviors in a follow-up study of breast cancer patients who participated in CALGB 8541.

METHODS

A total of 245 survivors (78% of those invited) who were 9.4-16.5 years post-diagnosis completed surveys that inquired about current HRQL, economic, spiritual, physical and psychosocial concerns, and health-oriented behaviors (e.g. smoking, exercise, and supplement use). A regression model was developed to examine factors related to global HRQL across all domains.

RESULTS

The regression model revealed that decreased energy levels (odds ratio (OR)=1.05, 95% confidence interval (CI): 1.03, 1.07), having heart disease (OR=5.01, 95% CI: 1.39, 18.1), having two or more co-morbidities (OR=2.39, 95% CI: 1.10, 5.19), and lower social support (OR=1.03, 95% CI: 1.02, 1.05) were associated with lower global HRQL. Factors related to psychological, spiritual, and economic domains were not predictive of global HRQL. Regarding lifestyle changes, some women reported engaging in health-oriented behaviors since their cancer diagnosis, such as improving eating habits (54%), increasing exercise (32%), and reducing/quitting smoking (20%). The most prevalent problems reported by women at follow-up were menopausal symptoms (64%), such as hot flashes and vaginal dryness, osteoporosis (25%), and lymphedema (23%).

CONCLUSION

Suggestions are provided to target interventions, such as provider-based strategies, in order to improve HRQL in long-term breast cancer survivors.

Use of Guideline Recommended Follow-Up Care in Cancer Survivors

BACKGROUND

After potentially curative cancer treatment, patients may receive procedures for routine monitoring for recurrence or for evaluation of symptoms or signs.

OBJECTIVE

We sought to characterize surveillance care guideline-recommended and other procedures performed in cancer survivors according to routine versus diagnostic indications.

METHODS

This was a retrospective cohort study of paper and electronic medical records between 1990 and 2000 from a large midwestern U.S. integrated health care delivery system of 500 patients who received curative treatment of breast, colorectal, endometrial, lung, or prostate cancer. Our measures were the indications for potential surveillance procedures as recommended by clinical practice guidelines or otherwise.

RESULTS

Among 14,670 procedures of interest received, 82.0% were performed for routine surveillance, whereas 10.6% were performed for diagnostic indications and 7.3% had indeterminate indications. Office visits most were often delivered for routine indications (91.6%), followed by guideline recommended tests for local recurrence (range 74.1-98.4%, depending on the specific test and cancer). In general, tests that were not recommended in established guidelines were for the purposes of detection of metastatic recurrence and were less often delivered for routine indications (overall frequency 59.2%, P<0.0001 compared with recommended testing).

CONCLUSION

Office visits and testing for local recurrence of cancer generally are performed for routine surveillance, regardless of recommendation by practice guidelines. Because procedures not recommended by practice guidelines were more often for diagnostic purposes, classification of patients as undergoing intensive surveillance may be misleading and may require record review to confirm.

Health maintenance and screening in breast cancer survivors in the United States

BACKGROUND

The general health maintenance and follow-up of breast cancer survivors has not been well-studied. In a population-based sample we sought to investigate the health practices of breast cancer survivors and to compare rates of screening to women with no history of breast cancer.

METHODS

Subjects were participants of the medical expenditure survey in the years 1996 and 1998, years for which information on screening were available. We used a matched cohort design. Breast cancer survivors aged 40 and older were matched (on age and race/ethnicity) to women with no breast cancer history. We performed logistic regression to estimate the odds of receiving appropriate health care services in breast cancer survivors versus women with no breast cancer history. In addition, we examined demographic and socioeconomic differences between breast cancer survivors who reported appropriate screening and survivors who had inadequate screening.

RESULTS

A small minority of breast cancer survivors report inadequate mammography (18%) and clinical breast exam (12%) follow-up. A significant portion of breast cancer survivors report inadequate screening for Pap smear (40%), general physical exam (GPE) (30%) and flu shot (33%). The odds of receiving appropriate screening were higher in survivors versus matched women for mammography, clinical breast and cholesterol screening. There were no differences for other screening. Across all health maintenance and screening practices, breast cancer survivors who did not receive appropriate screening were less likely to have private insurance, to be married and to be above the mean income level, though these differences were non-significant.

CONCLUSIONS

Although survivors report high levels of screening, a small minority of women report inadequate mammography and clinical breast exam follow-up which is concerning given their risk of recurrence and second primary breast cancer. Additionally, a significant portion of survivors report inadequate screening for general health maintenance issues. Demographic and socioeconomic factors were associated with lower screening rates. However, the deficits in screening among breast cancer survivors appears to be smaller compared to women in the general population.

Informational and emotional needs of long-term survivors of breast cancer

AIMS

This paper presents a review of the informational and emotional needs of long-term breast cancer survivors, with particular attention to the different needs of women according to their age and to critiquing healthcare provision to these women.

BACKGROUND

Women with a history of breast cancer are the largest group of cancer survivors. While they may be disease-free, their cancer diagnosis has ongoing physical and psychosocial implications for their lives and well-being.

METHODS

A literature search for the period 1985 to March 2004 was undertaken using the CINAHL, MEDLINE, CANCERLIT, PubMed and CUIDEN databases and the keywords long-term, breast cancer survivors, needs and social support. Hand-searching was also done, and reference lists of papers were examined for relevant studies.

RESULTS

Survivors of breast cancer continue to experience informational and emotional needs during their long-term survivorship, and variation in the amount and type of support required is age-related. However, women's needs are often unmet by oncology teams and they have to find other sources of support, such as self-help groups. Thus, ongoing care is required after completion of medical treatment, and nurses have a significant contribution to make here.

CONCLUSIONS

Nursing research on long-term breast cancer survivorship is limited. Future studies need to investigate the unmet needs of long-term survivors of breast cancer and, specifically, explore the kind of support women would like to receive from oncology teams, and particularly from breast cancer nurses.