Understanding primary care-oncology relationships within a changing healthcare environment

A systematic review of risk factors associated with depression and anxiety in cancer patients

Depression and anxiety are common comorbid conditions associated with cancer, however the risk factors responsible for the onset of depression and anxiety in cancer patients are not fully understood. Also, there is little clarity on how these factors may vary across the cancer phases: diagnosis, treatment and depression. We aimed to systematically understand and synthesise the risk factors associated with depression and anxiety during cancer diagnosis, treatment and survivorship. We focused our review on primary and community settings as these are likely settings where longer term cancer care is provided. We conducted a systematic search on PubMed, PsychInfo, Scopus, and EThOS following the PRISMA guidelines. We included cross-sectional and longitudinal studies which assessed the risk factors for depression and anxiety in adult cancer patients. Quality assessment was undertaken using the Newcastle-Ottawa assessment checklists. The quality of each study was further rated using the Agency for Healthcare Research and Quality Standards. Our search yielded 2645 papers, 21 of these were eligible for inclusion. Studies were heterogenous in terms of their characteristics, risk factors and outcomes measured. A total of 32 risk factors were associated with depression and anxiety. We clustered these risk factors into four domains using an expanded biopsychosocial model of health: cancer-specific, biological, psychological and social risk factors. The cancer-specific risk factors domain was associated with the diagnosis, treatment and survivorship phases. Multifactorial risk factors are associated with the onset of depression and anxiety in cancer patients. These risk factors vary across cancer journey and depend on factors such as type of cancer and individual profile of the patients. Our findings have potential applications for risk stratification in primary care and highlight the need for a personalised approach to psychological care provision, as part of cancer care.

Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study

BACKGROUND

Advances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery.

METHODS

This protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation.

DISCUSSION

Study findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov on June 2, 2022: NCT05400941.

Identification of an oncological clinical pathway through questionnaires to health professionals

BACKGROUND

Clinical Pathways in Oncology can benefit patients using organized interventions to standardize and increase care efficiency. Healthcare systems should have tools to identify their oncological clinical pathways for a better institutional organization to reduce mortality rates and contain costs without compromising quality. Our objective is to determine the regional Oncology Clinical Pathway from a first basic hypothesis using questionnaires directed to healthcare professionals considered key deciders within the Pathway.

METHODS

Study design consisted of data analysis of two structured region-wide questionnaires; built using available literature on Oncology Clinical Pathways, in a Portuguese Healthcare context and pre-tested in a focus group of key deciders (Physicians and nurses with management functions) from which a design was created. Queries analyzed the patients: tumor staging at service arrival; time intervals on tumor suspicion/diagnosis confirmation and diagnosis/first treatment; referral pathway; diagnostic networks and patient Follow-up. One questionnaire was sent to key deciders directly involved with Oncology patients at a Regional Hospital. 15 physicians and 18 nurses of this sample answered the questionnaire (approx. response rate = 67%). Another questionnaire sent to healthcare professionals in Primary Healthcare Centers yielded response rate 19.2%, N = 29 physicians and 46 nurses. Finally, we performed a descriptive analysis and a Cronbach Alpha reliability analysis.

RESULTS

Our findings reveal: different appreciations of tumor staging at arrival in Primary Healthcare Centers and Regional Hospitals (the latter receiving more metastatic cases); approximately 4 weeks between tumor suspicion-diagnostic and divided opinions regarding diagnostic-treatment time intervals. Primary Healthcare Centers depend on private laboratories for diagnostics confirmation, while the Hospitals resolve this locally. Referral pathways indicate almost half of the patients being sent from primary healthcare centers to National Reference Hospitals instead of a Regional Hospital. Patient follow-up is developed throughout the institutions, however, is more established at Regional Hospitals. As patients advance through the Oncology Clinical Pathway and toward treatment stages the number of healthcare professionals involved reduce.

CONCLUSION

Our questionnaires enable us to understand the real pathway between the different institutions involved and the main entry points of the patients into the Oncology Clinical Pathway.

Quantifying the Impact of Family Doctors on the Care Experiences of Patients with Cancer: Exploring Evidence from the 2021 Ambulatory Oncology Patient Satisfaction Survey in Alberta, Canada

Oncology programs across Canada are reaching capacity as more Canadians are diagnosed with and treated for cancer each year. There is an increasing need to share care with family doctors, however it is unclear how this type of care impacts patient experiences, particularly while receiving active treatment. Retrospective data from the 2021 Ambulatory Oncology Patient Satisfaction Survey (AOPSS) in Alberta, Canada was used in this study. A unique question on the Alberta survey asks patients about their family doctor's involvement during their cancer care. Patient satisfaction across the six domains of person-centred care on the AOPSS was analyzed based on how involved a patient's family doctor was. Compared to patients who indicated their family doctor was "Not involved", patients with "Very involved" family doctors had significantly higher satisfaction scores in all six domains of care. The three domains which showed the largest positive impact of family doctor involvement were: Coordination & Integration of Care, Emotional Concerns, and Information, Communication & Education. The results demonstrate that involving family doctors in cancer care can be beneficial for patients. Based on the observed satisfaction increases in this study, shared care models may be preferred by many patients. These models of care can also help alleviate strain and capacity issues within cancer programs. The results could be used to support recommendations for cancer care teams to regularly involve and communicate with family doctors, to ensure that patients receive comprehensive and tailored care from all their health care providers.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Barriers and facilitators to the use of survivorship care plans by hematopoietic stem cell transplant survivors and clinicians

PURPOSE

Survivors of hematopoietic stem cell transplants (HSCT) have complex care needs for the remainder of their lives, known as the survivorship period. Survivorship care plans (SCPs) have been proposed to improve care coordination and ultimately survivorship outcomes. We explored the barriers and facilitators of SCP use among HSCT survivors and their clinicians in order to develop more useful SCPs for the HSCT context.

METHODS

Analogous surveys regarding perceived barriers to and facilitators of SCP use based on a sample SCP for a female allogenic HSCT survivor were administered to HSCT survivors and non-transplant oncology and primary care clinicians.

RESULTS

Twenty-seven HSCT survivors and 18 clinicians completed the survey. The main barriers to SCP use were lack of awareness of SCP existence, uncertainty regarding where to find SCP, unclear roles and responsibilities among healthcare teams, length of SCP, and difficultly understanding SCPs. The facilitators of SCP use were increased understanding of survivorship care needs, clarified roles and responsibilities of survivors and clinicians, SCPs that are readily available and searchable in electronic health record, increased awareness of SCP existence and provision to all survivors, and if the SCP is survivor-specific and up-to-date.

CONCLUSIONS

Much of the work regarding SCPs has looked at barriers to creation and provision; however, our study examines factors influencing use of SCPs. By determining the barriers and facilitators surrounding SCP use for HSCT survivors and their clinicians, we can create SCP templates and clinical workflows to optimize SCP use, ideally leading to better outcomes for HSCT survivors.

Health care costs for adolescents and young adults with cancer: a Wisconsin community-based hospital study between 2005 and 2020

INTRODUCTION

Adolescents and young adults (AYA) with cancer are at risk of high cumulative healthcare system costs potentially associated with poor health and financial outcomes. Although this has been studied at academic centers, little data on AYA costs at community-based practices exist. The goals of this study were to understand direct health care costs for AYA patients, identify factors for high costs, and assess how total health care costs may relate to survival.

METHODS

AYA patients (15-39 years) treated at a community hospital in Wisconsin (USA) between 2005 and 2020 were identified. Patient demographics, cancer characteristics, therapies, support services, and all direct health care charges (including up to 1 year prior to diagnosis to capture any diagnostic workup) were collected. Logistic and Cox proportional hazard regression models identified factors associated with high costs and survival, respectively.

RESULTS

The 388 AYA patients had a median follow-up of 9 years (97% survival). Most were 30-39 years (62%), female (61%), white (95%), diagnosed early-stage (85%), and underwent surgery (83%). Complete health care costs were available for 233 patients (60%). Median total costs per patient were $123 K (range, $73-$215 K). On adjusted analysis, higher direct health care costs (> $125 K) were associated with greater odds of hospital admissions (odds ratio [OR] = 1.7, 95% CI = 1.35-2.27), chemotherapy (OR = 4.1, 95% CI = 1.44-12.70), and breast cancer diagnosis (OR = 3.8, 95% CI = 1.07-14.70). Living farther from the hospital (OR = 0.1, 95% CI = 0.02-0.50), later year of diagnosis (OR = 0.7, 95% CI = 0.55-0.77), and uninsured/unknown insurance status (OR = 0.1, 95% CI = 0.01-0.57) were associated with decreased odds of having higher health care costs. On adjusted analysis, death was associated with greater odds of higher direct health care costs per $125 K (hazards ratio [HR] = 7.9, 95% CI = 2.22-27.80) and radiation (HR = 31.8, 95% CI = 3.15-321) but lower odds of hormone therapy (HR = 0.1, 95% CI = 0.01-0.72) and later year of diagnosis (HR = 0.3, 95% CI = 0.12-0.60).

CONCLUSION

High direct health care costs among AYA patients are associated with hospital admissions, chemotherapy, breast cancer diagnosis, hospital proximity, and earlier year of diagnosis. Death was associated with high direct health care costs, earlier years of diagnosis, and radiation therapy. Total health care costs in community-based hospitals should be considered in the context of AYA patients with cancer.

Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems

PURPOSE

Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation.

MATERIALS AND METHODS

We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation.

RESULTS

Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05).

CONCLUSION

The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

Assessing Cancer History Accuracy in Primary Care Electronic Health Records Through Cancer Registry Linkage

BACKGROUND

Many cancer survivors receive primary care in community health centers (CHCs). Cancer history is an important factor to consider in the provision of primary care, yet little is known about the completeness or accuracy of cancer history data contained in CHC electronic health records (EHRs).

METHODS

We probabilistically linked EHR data from more than1.5 million adult CHC patients to state cancer registries in California, Oregon, and Washington and estimated measures of agreement (eg, kappa, sensitivity, specificity). We compared demographic and clinical characteristics of cancer patients as estimated by each data source, evaluating distributional differences with absolute standardized mean differences.

RESULTS

A total 74 707 cancer patients were identified between the 2 sources (EHR only, n = 22 730; registry only, n = 23 616; both, n = 28 361). Nearly one-half of cancer patients identified in registries were missing cancer documentation in the EHR. Overall agreement of cancer ascertainment in the EHR vs cancer registries (gold standard) was moderate (kappa = 0.535). Cancer site-specific agreement ranged from substantial (eg, prostate and female breast; kappa > 0.60) to fair (melanoma and cervix; kappa < 0.40). Comparing population characteristics of cancer patients as ascertained from each data source, groups were similar for sex, age, and federal poverty level, but EHR-recorded cases showed greater medical complexity than those ascertained from cancer registries.

CONCLUSIONS

Agreement between EHR and cancer registry data was moderate and varied by cancer site. These findings suggest the need for strategies to improve capture of cancer history information in CHC EHRs to ensure adequate delivery of care and optimal health outcomes for cancer survivors.