Optimizing veteran-centered prostate cancer survivorship care: study protocol for a randomized controlled trial

Military service and health-related quality of life among gay and bisexual prostate cancer survivors: Results from the -2 study

INTRODUCTION

There are notable disparities in health-related quality of life (HRQOL) between gay and bisexual men (GBM) and heterosexual patients with prostate cancer (PCa); however, the role of past military service is unclear. This study examines HRQOL differences in GBM PCa survivors based on reported military service history.

METHODS

We used data from the 24-month follow-up survey of the Restore-2 study, a clinical trial which evaluated a rehabilitation programme for GBM PCa survivors. PCa HRQOL was assessed using the Expanded Prostate Cancer Index Composite (EPIC-50) and the Functional Assessment of Cancer Treatment-Prostate (FACT-P). Mental health quality of life was assessed using the Brief Symptom Inventory-18 (BSI-18) scale, while sexual functioning was measured using the Sexual Minorities and Prostate Cancer Scale (SMACS). Multivariable linear regression was used to estimate unadjusted and adjusted mean differences in HRQOL between GBM with and without a reported history of military service.

RESULTS

In this cross-sectional study of 351 GBM PCa survivors, 47 (13.4%) reported a history of US military service. After adjusting for covariates, participants who reported a history of military service (compared with those with no military service) had clinically better scores on the FACT-P physical, social and emotional well-being domains, as well as higher total FACT-General, EPIC urinary bother and hormonal function scores. Additionally, men with a history of military service reported significantly fewer sexual problems, more sexual confidence and less urinary incontinence in sex.

CONCLUSION

This exploratory study provides the first evidence that GBM PCa survivors with a military background may have clinically better outcomes than those without military service. Potential reasons may include the structured support and healthcare access associated with military service, fostering resilience and well-being. These findings underscore the need for further research to elucidate how military service influences PCa HRQOL.

Improved cancer coping from a web-based intervention for prostate cancer survivors: A randomized controlled trial

OBJECTIVES

Prostate cancer (PCa) survivors report poor physical functioning alongside negative psychological outcomes as they cope with treatment side effects and practical concerns after treatment completion. This study evaluated PROGRESS, a web-based intervention designed to improve adaptive coping among PCa survivors.

METHODS

Localized PCa patients (N = 431) within one year of treatment completion were randomized to receive educational booklets or PROGRESS + educational booklets. Surveys completed at baseline, 1-, 3-, and 6-months assessed patient characteristics; functional quality of life and coping (primary outcomes); and psychosocial outcomes (e.g., self-efficacy, marital communication; secondary outcomes). Intent-to-treat and as-treated analyses were completed to assess change in outcomes from baseline to 6 months using linear mixed effects regression models.

RESULTS

In the intent-to-treat analyses, participants randomized to the intervention group had improved diversion coping (i.e., healthy redirection of worrying thoughts about their cancer), but more difficulties in marital communication (ps < 0.05). However, PROGRESS usage was low among those randomized to the intervention group (38.7%). The as-treated analyses found PROGRESS users reported fewer practical concerns but had worse positive coping compared to PROGRESS non-users (ps < 0.05).

CONCLUSIONS

The findings suggest PROGRESS may improve certain aspects of adaptive coping among PCa survivors that use the website, but does not adequately address the remaining coping and psychosocial domains. Additional research is needed to better understand the gaps in intervention delivery contributing to low engagement and poor improvement across all domains of functional quality of life and adaptive coping.

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.

Self-Management in Long-Term Prostate Cancer Survivors: A Randomized, Controlled Trial

PURPOSE

This randomized clinical trial compared a personally tailored, automated telephone symptom management intervention to improve self-management among long-term survivors of prostate cancer with usual care enhanced with a nontailored newsletter about symptom management. We hypothesized that intervention-group participants would have more confident symptom self-management and reduced symptom burden.

METHODS

A total of 556 prostate cancer survivors who, more than 1 year after treatment, were experiencing symptom burden were recruited from April 2015 to February 2017 across four Veterans Affairs sites. Participants were randomly assigned to intervention (n = 278) or usual care (n = 278) groups. We compared differences in the primary (symptom burden according to Expanded Prostate Cancer Index Composite-26 [EPIC], confidence in self-management) and secondary outcomes between groups using intent-to-treat analyses. We compared domain-specific changes in symptom burden from baseline to 5 and 12 months among the intervention group according to the primary symptom focus area (urinary, bowel, sexual, general) of participants.

RESULTS

Most of the prostate cancer survivors in this study were married (54.3%), were white (69.2%), were retired (62.4%), and underwent radiation therapy (56.7% v 46.2% who underwent surgery), and the mean age was 67 years. There were no baseline differences in urinary, bowel, sexual, or hormonal domain EPIC scores across groups. We observed higher EPIC scores in the intervention arm in all domain areas at 5 months, though differences were not statistically significant. No differences were found in secondary outcomes; however, coping appraisal was higher (2.8 v 2.6; P = .02) in intervention-arm patients at 5 months. In subgroup analyses, intervention participants reported improvement from baseline at 5 and 12 months in their symptom focus area domains.

CONCLUSION

This intervention was well received among veterans who were long-term survivors of prostate cancer. Although overall outcome differences were not observed across groups, the intervention tailored to symptom area of choice may hold promise to improve associated burden.

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

Background

Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial.

Methods/design

This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies.

Discussion

Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring.

Trial registration

ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.

Telemedicine and prostate cancer survivorship: a narrative review

Prostate cancer survivors have unique needs that encompass diagnosis and treatment-related side effects. The provision of services for prostate cancer survivors is often limited by resources, time constraints in traditional clinic visits, payment, and patient and provider comfort with discussion of sensitive topics including sexual and urinary health, both of which are largely impacted by treatment. Telemedicine, the remote delivery of health care services using telephone, mobile, web, and video platforms, allows for potential cost savings, in addition to ease and comfort as patients can engage in telemedicine-based resources in the comfort of their homes. Furthermore, survivors prefer to seek information online making telemedicine approaches for prostate cancer survivorship care an ideal combination. A majority of the telemedicine-based interventions used the web, followed by telephone, mobile, and video platforms. In limited studies, telemedicine delivery of survivorship care has equal efficacy to traditional care delivery. In addition, although older patients did not use the Internet regularly, they were willing to adapt to Internet usage if it had the potential to increase their quality of life. Telemedicine delivery of prostate cancer survivorship care is acceptable, feasible, cost-effective, and potentially preferred by prostate cancer survivors. Additionally, it emphasizes knowledge, self-management and self-monitoring serving to increase self-efficacy. This specialized care allows for greater access and reaches a wider catchment area compared to traditional clinic visits. This is especially important as the number of prostate cancer survivors increases and healthcare systems incorporate alternatives to traditional in-person care.

Enhancing prostate cancer survivorship care through self-management

The lack of clear roles for prostate cancer survivorship care providers places prostate cancer survivors at significant risk of inappropriate use of services delivered piecemeal by different providers, persistent bothersome symptoms, and silent suffering. Optimizing quality of care for prostate cancer survivors hinges on decreasing fragmentation of care, and providing quality symptom management. This is achieved through comprehensive, appropriate medical, surgical, pharmacological and psychosocial care, coupled with self-management, as highlighted in several recent resources addressing long-term and late effects of treatment. Although further study is warranted, prostate cancer survivors engaging in self-management may reduce the negative impact of prostate cancer in their lives through better quality of care (better symptom management and efficient use of services) and quality of life.