Evaluation of a cancer survivorship protocol: transitioning patients to survivors

What Nursing-Sensitive Outcomes Have Been Investigated to Date among Patients with Solid and Hematological Malignancies? A Scoping Review

Nursing-sensitive outcomes are those outcomes attributable to nursing care. To date three main reviews have summarized the evidence available regarding the nursing outcomes in onco-haematological care. Updating the existing reviews was the main intent of this study; specifically, the aim was to map the state of the art of the science in the field of oncology nursing-sensitive outcomes and to summarise outcomes and metrics documented as being influenced by nursing care. A scoping review was conducted in 2021. The MEDLINE, Cumulative Index to Nursing and Allied Health, Web of Science, and Scopus databases were examined. Qualitative and quantitative primary and secondary studies concerning patients with solid/haematological malignancies, cared for in any setting, published in English, and from any time were all included. Both inductive and deductive approaches were used to analyse the data extracted from the studies. Sixty studies have been included, mostly primary (n = 57, 95.0%) with a quasi- or experimental approach (n = 26, 55.3%), conducted among Europe (n = 27, 45.0%), in hospitals and clinical wards (n = 29, 48.3%), and including from 8 to 4615 patients. In the inductive analysis, there emerged 151 outcomes grouped into 38 categories, with the top category being 'Satisfaction and perception of nursing care received' (n = 32, 21.2%). Outcome measurement systems included mainly self-report questionnaires (n = 89, 66.9%). In the deductive analysis, according to the Oncology Nursing Society 2004 classification, the 'Symptom control and management' domain was the most investigated (n = 44, 29.1%); however, the majority (n = 50, 33.1%) of nursing-sensitive outcomes that emerged were not includible in the available framework. Continuing to map nursing outcomes may be useful for clinicians, managers, educators, and researchers in establishing the endpoints of their practice. The ample number of instruments and metrics that emerged suggests the need for more development of homogeneous assessment systems allowing comparison across health issues, settings, and countries.

Translation of Evidence-Based Interventions Into Oncology Care Settings: An Integrative Review

BACKGROUND

Adoption of evidence remains slow, leading to variations in practices and quality of care. Examining evidence-based interventions implemented within oncology settings can guide knowledge translation efforts.

OBJECTIVE

This integrative review aimed to (1) identify topics implemented for oncology-related evidence-based practice (EBP) change; (2) describe frameworks, guidelines, and implementation strategies used to guide change; and (3) evaluate project quality.

METHODS

PubMed and CINAHL were searched to identify published practice change projects. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Fifty articles met the inclusion criteria. Data were extracted; content analysis was conducted. The Quality Improvement Minimum Quality Criteria Set guided quality assessment.

RESULTS

Topics included infection control/prevention (n = 18), pain/palliative care (n = 13), psychosocial assessment (n = 11), and medication adherence (n = 8). Among the projects, Plan, Do, Study, Act (n = 8) and Lean Six Sigma (n = 6) frameworks were used most. Thirty-six projects identified guidelines that directed interventions. Multiple implementation strategies were reported in all articles with planning, education, and restructuring the most common. Reach, sustainability, and ability to be replicated were identified as quality gaps across projects.

CONCLUSION

The EBP topics that emerged are consistent with the oncology nursing priorities, including facilitating integration of EBP into practice. The studies identified used national guidelines and implementation strategies to move evidence into practice. Heterogeneity in measurement made synthesis of findings difficult across studies, although individual studies showed improvement in patient outcomes.

IMPLICATIONS FOR PRACTICE

Development of an interprofessional oncology consortium could facilitate a standardized approach to implementation of high-priority topics that target improved patient outcomes, harmonize measures, and accelerate translation of evidence into practice.

Understanding the Post-Treatment Concerns of Cancer Survivors with Five Common Cancers: Exploring the Alberta Results from the Pan-Canadian Transitions Study

As the rates of cancer incidence and survival increase in Canada, more patients are living in the post-treatment survivorship phase of their cancer journey. Identifying cancer survivors’ concerns and unmet needs is important so that health care teams can provide relevant information, supports, and resources. Secondary data analysis was carried out on the Alberta patient sample from the 2016 Pan-Canadian Transitions Study survey, designed by the Canadian Partnership Against Cancer. The top concerns for patients treated for five different cancers were examined descriptively and compared. A question about information that patients received post-treatment was also descriptively analyzed. Binary logistic regressions were conducted for each tumour group, using the top three concerns for each group as outcomes and a variety of demographic factors as independent variables. There were 1833 valid respondents in the Alberta sample. Fatigue and anxiety were top concerns for multiple tumour groups. Most patients received more information about treatment side effects than about signs of recurrence and community resources. Within certain tumour groups, younger patients had higher odds of having concerns, particularly anxiety. Awareness of the common and unique concerns experienced by cancer survivors post-treatment enables health care providers to tailor care and resources to help patients manage their symptoms and concerns. These findings address gaps in knowledge around the cancer survivorship phase and may be applicable to cancer programs and primary care providers in Alberta and beyond.

Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review protocol

INTRODUCTION

Transitions in Care (TiC) are vulnerable periods in care delivery associated with adverse events, increased cost and decreased patient satisfaction. Patients with cancer encounter many transitions during their care journey due to improved survival rates and the complexity of treatment. Collectively, improving TiC is particularly important among patients with cancer. The objective of this scoping review is to synthesise and map the existing literature regarding TiC among patients with cancer in order to explore opportunities to improve TiC among patients with cancer.

METHODS AND ANALYSIS

This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review Extension and the Joanna Briggs Institute methodology. The PubMed cancer filter and underlying search strategy will be tailored to each database (Embase, Cochrane, CINAHL and PsycINFO) and combined with search terms for TiC. Grey literature and references of included studies will be searched. The search will include studies published from database inception until 9 February 2020. Quantitative and qualitative studies will be included if they describe transitions between any type of healthcare provider or institution among patients with cancer. Descriptive statistics will summarise study characteristics and quantitative data of included studies. Qualitative data will be synthesised using thematic analysis.

ETHICS AND DISSEMINATION

Our objective is to synthesise and map the existing evidence; therefore, ethical approval is not required. Evidence gaps around TiC will inform a programme of research aimed to improve high-risk transitions among patients with cancer. The findings of this scoping review will be published in a peer-reviewed journal and widely presented at academic conferences. More importantly, decision makers and patients will be provided a summary of the findings, along with data from a companion study, to prioritise TiC in need of interventions to improve continuity of care for patients with cancer.

Existence of late-effects instruments for cancer survivors: A systematic review

Introduction

The number of cancer survivors is projected to increase to 22.1 million by 2030. Late effects incorporate the full domains of cancer survivorship (e.g., physiologic, psychosocial, economic). They are numerous, complex, and potentially alter the life trajectories of cancer survivors. Currently, research is missing on the impact of late effects (e.g., cardiomyopathy, fertility, lymphedema, anxiety) on cancer survivors.

Objective

The goal of this study is to present a systematic review of existing instruments for identifying, diagnosing, and managing late effects within cancer survivors.

Methods

Using PRISMA guidelines, a systematic search was conducted using the electronic databases of PubMed and Web of Science to identify relevant papers. Articles considered eligible for this review met the following criteria: 1) written in English, 2) published until September 30, 2019, and 3) containing instruments with questions on late effects. Hypothesis, study design, study sample, questionnaire domains, details of late effects, results, conclusions, and advantages/disadvantages of each article were assessed using a modified version of the NHLBI quality assessment tool.

Results

An exhaustive literature review revealed 576 publications in PubMed, 628 in Web of Science, and 260 from additional sources. After removing duplicates, articles without late-effects questionnaires, and publications using identical questionnaires, 11 studies fulfilled the eligibility criteria. Study quality assessment was measured on a scale of 0–6 (0 = poor quality; 6 = highest quality). Only one study was rated with a score of 5 (Rocque).

Conclusions

Taken in totality, none of the studies adequately addressed the prevalence, etiology, characteristics, management, and prevention of late effects. There is currently no comprehensive questionnaire that captures all of the relevant details of late effects across the cancer survivorship continuum nor that tracks the interrelatedness of multiple late effects. Hence, it is difficult to identify, diagnose, manage, and ultimately prevent late effects.

Implementation of Survivorship Care Plans in Patients With Glioblastoma

Background: The outcomes and survival of patients diagnosed with glioblastoma are improving due to advancements in therapy and better symptom management. Focusing on survivorship is an important initiative for these patients. A quality improvement project performed by an advanced practitioner in adults with glioblastoma evaluated the efficacy and utility of survivorship care plans (SCP). Providing patients and their families with SCPs gives them important information about their cancer, treatment, and follow-up management and care. Methods: Survivors of a glioblastoma who were receiving an oral alkylating agent and/or bevacizumab, as well as those who had completed these therapies within the past year were included. Patients had received surgery and radiation. The National Comprehensive Cancer Network (NCCN) Distress Thermometer and a pre- and postintervention survey evaluated knowledge, distress, and rate of follow-up care. Results: Over 2 months, 18 eligible participants received the SCP with a long-term care coaching appointment with an advanced practitioner. Knowledge pertaining to long-term effects of therapy and chemotherapy regimen improved. Ratings of overall distress and patient-reported primary care follow-up remained the same. Conclusion: Providing patients with glioblastoma with an SCP and an educational visit can improve knowledge pertaining to their chemotherapy regimens and long-term effects of therapy. This can result in more effective long-term management and care.

Implementation of a Survivorship Care Plan Program in a Community-Based Oncology Clinic

There is conflicting evidence from the small number of randomized controlled trials (RCTs) that have assessed the benefit of survivorship care plans (SCPs) on improving patient outcomes. Yet, published quasi-experimental and descriptive studies provide preliminary evidence suggesting that using survivorship care plans in practice may improve patient knowledge, decrease worry and anxiety, and lead to patient and primary care physician satisfaction. Given the conflicting evidence and the paucity of RCTs, further research is needed to more fully explore the effect of SCP on patient outcomes. To address this knowledge gap, an SCP program was implemented in a community-based oncology clinic and used quality improvement methodology to assess the effect on patient knowledge of diagnosis, treatment, and follow-up, and to understand patients’ satisfaction with the current SCP program. A total of 30 cancer patients were recruited in Southeast Michigan to participate in an SCP quality improvement project and completed surveys to evaluate the SCP program. Data were collected between December 2017 and March 2018. We observed a statistically significant (p = .028) difference between pre- and postintervention (survivorship care plan visit) knowledge scores about cancer diagnosis, treatment received, and follow-up recommendations. Moreover, participants were satisfied with the survivorship care plan and visit.

Assessment of the feasibility and acceptability, and pre-test of the utility of an individualized survivorship care plan (ISCP) for women with endometrial cancers during the transition of the end of active treatment to cancer survivorship

The transition from the end of active treatment to survivorship holds many challenges for women with endometrial cancer (WEC) and for the organization of health services. The feasibility and acceptability of implementing an individualized survivorship care plan (ISCP) at the end of treatment are documented as potential solutions. The utility of an ISCP on three indicators (SUNS, FCRI, and HeiQ) was pre-tested by comparing two groups of WEC (control and exposed to the ISCP). The WEC exposed to the ISCP had fewer needs, a lesser intensity of fear of cancer recurrence, and better health-related empowerment skills three months after the end of treatment, as compared to the control group. Obstacles of time, resources, and organization were raised.

BACKGROUND

The transition from the end of active treatment to cancer survivorship is a time of imbalance and turbulence for women with endometrial cancer (WEC). The transition to survivorship continues to be uncoordinated and the need for information about the side effects to watch for and the health risks is unmet. The implementation of an individualized survivorship care plan (ISCP) is suggested as an information and communication tool that could be a solution for facilitating the transition from the end of treatment to the beginning of survivorship.

RESEARCH OBJECTIVE AND METHOD

To assess and document the feasibility and acceptability of implementing an ISCP, qualitative data were gathered from WEC, oncology nurse navigators (ONN), and family doctors. A pre-experimental research design with a non-equivalent control group, an end of treatment (T0), and a three-month follow-up (T1) allowed us to pre-test its utility according to three indicators: (1) overall needs (SUNS); (2) fear of cancer recurrence (FCRI); and (3) empowerment (HeiQ) according to exposure to ISCP (control versus exposed) and to the time of measurement in the transition period (T0 versus T1).

RESULTS

The sample was made up of 18 WEC for the group exposed to the ISCP and 13 WEC for the control group, 12 general practitioners, and two ONN. After ONN training, the ISCP completion time varied between 60 and 75 minutes, and the meeting for providing the ISCP lasted 45-60 minutes. The WEC supported the idea that meetings with the ONN and the ISCP were useful in meeting their needs for information and support. The family doctors supported its relevancy in favouring follow-up and better subsequent healthcare management, as well as in reassuring patients and avoiding a sense of abandonment at the end of treatment. Comparing the group exposed to the ISCP versus the control group, fewer reported needs can be observed: information: 35% versus 74%, p = .030; professional and financial: 6% versus 19%, p = .057; access and continuity: 9% versus 25%, p = .078; support: 18% versus 50%, p = .007, emotional: 13% versus 28%, p = .044). Moreover, at T1, empowerment according to the skill and technique acquisition sub-scale shows a higher trend (M = 75.00 (10.21) versus M = 64.06 (10.67), p = .097). The level of fear of recurrence remains above the clinically significant score of 13 for both groups at the two times of measurement.

DISCUSSION

The ISCP is an informational tool that seeks to facilitate care-related communication and coordination between specialized and primary care. It is intended to facilitate the transition from the end of treatment to survivorship and survivors' commitment to health-related empowerment behaviours. The feasibility and utility of implementing an ISCP are supported if additional professional, organizational, and financial resources are specified and mobilized.

Development and validation of an individualized survivorship care plan (ISCP) for women with endometrial cancer during the transition of the end of active treatment to the cancer survivorship

Many cancer survivors finish their treatment without knowing the associated health risks and few are prepared to handle their health needs in the survivorship phase. Moreover, practical guides for follow- up care are not available and survivors' psychological and social needs often go unassessed. In this article, we propose the development and implementation of an individualized follow-up care plan (IFCP) after active treatment for women with endometrial cancers (WEC) to meet their needs for information and to facilitate the transition to the survivorship phase.

Background

The after-treatment phase is a distinct phase that is still neglected in the oncological continuum of care. It is the transition between two phases in the care trajectory-treatment and survivorship-that gives rise to many challenges for survivors, care providers and the healthcare system alike.

Research goal

Aiming to facilitate the transition between the end of active treatment and the cancer survivorship phases, we pursued two objectives: 1) Develop an individualized follow-up care plan (IFCP) based on both the literature and the perspective of WEC, healthcare professionals involved with the target clientele and oncology outreach managers, and 2) Have this IFCP validated by an interdisciplinary team.

Methodology

For the first objective, WEC-related needs at the end of active treatment (immediate end, three months and six months), as well as the perceptions of health professionals and oncology outreach managers were gathered by interview and group discussion on the benefit of an IFCP, its content and desired format. A content analysis of the interview data was performed using the Miles and Huberman approach (2003). For the second objective, an iterative consultation process with health professionals allowed for validation by consensus. These two objectives are the first qualitative phase of a mixed-methods sequential exploratory design that will make the development of an IFCP possible. In the second phase, we conducted a feasibility study of the implementation of the IFCP during the end of active treatment transition to cancer survivorship transition. This will be the subject of a second article.

Results

The interviews (n=47) revealed WECs' lack of preparation for the transition from the end of active treatment to the cancer survivorship. The following needs were specified: information (80%), emotional support, particularly to overcome their fear of recurrence (75%), the management of physical symptoms (45%), and support for adapting to change (45%). The data gathered from healthcare professionals and outreach managers support the utility of an IFCP in meeting these needs. The iterative validation process by the interdisciplinary team made consensus on the format and content possible. The final version of the IFCP is seen as a tool for information and communication in the survivorship phase. Some obstacles to its transfer to clinical practice are reported.

Conclusion

This study presents the entire process that led to the development of an IFCP that integrates both the needs of endometrial cancer survivors and the opinions of healthcare professionals and the oncology outreach managers organizing this care. Indications on how the IFCP could be implemented within this organization are also formulated.

A systematic review of barriers to optimal outpatient specialist services for individuals with prevalent chronic diseases: what are the unique and common barriers experienced by patients in high income countries?

Health utilization and need assessment data suggest there is considerable variation in access to outpatient specialist care. However, it is unclear if the types of barriers experienced are specific to chronic disease groups or experienced universally. This systematic review provides a detailed summary of common and unique barriers experienced by chronic disease groups when accessing and receiving care, and a synthesized list of possible health service initiatives to improve equitable delivery of optimal care in high-income countries. Quantitative articles describing barriers to specialist outpatient services were retrieved from CINAHL, MEDLINE, Embase, and PyscINFO. To be eligible for review, studies: were published from 2002 to May 2014; included samples with cancer, diabetes mellitus, osteoporosis, arthritis, ischaemic heart disease, stroke, asthma, chronic pulmonary disorder (COPD) or depression; and, were conducted in high-income countries. Using a previously validated model of access (Penchansky and Thomas' model of fit), barriers were grouped according to five overarching domains and defined in more detail using 33 medical subject headings. Results from reviewed articles, including the scope and frequency of reported barriers, are conceptualized using thematic analysis and framed as possible health service initiatives. A total of 3181 unique records were screened for eligibility, of which 74 studies were included in final analysis. The largest proportion of studies reported acceptability barriers (75.7 %), of which demographic disparities (44.6 %) were reported across all diseases. Other frequently reported barriers included inadequate need assessment (25.7 %), information provision (32.4 %), or health communication (20 %). Unique barriers were identified for oncology, mental health, and COPD samples. Based on the scope, frequency and measurement of reported barriers, eight key themes with associated implications for health services are presented. Examples include: common accommodation and accessibility barriers caused on service organization or physical structure, such as parking and appointment scheduling; common barriers created by poor coordination of care within the healthcare team; and unique barriers resulting from inadequate need assessment and referral practices. Consideration of barriers, across and within chronic diseases, suggests a number of specific initiatives are likely to improve the delivery of patient-centered care and increase equity in access to high-quality health services.

Models of Cancer Survivorship Care: Overview and Summary of Current Evidence

INTRODUCTION

This article, derived from a Technical Brief prepared for the Agency for Healthcare Research and Quality, presents an overview on current models of care for survivors of adult-onset cancer who have completed active treatment.

METHODS

This article integrates reviewed literature on background, context, research gaps, and future research directions for survivorship care models. We also conducted a systematic literature review of current evidence from studies of survivorship care models.

RESULTS

Our systematic review identified nine empirical studies of survivorship care models, covering multiple models types and illustrating the heterogeneity in this field. The literature review indicated considerable heterogeneity in models of survivorship care, components of models, survivor populations, and target outcomes. Models of survivorship care are highly individualized to the institution or setting where they are provided. "Usual care" is often uncoordinated and highly varied across cancer survivors and within cancer programs. Anticipated shortages in the oncology workforce may require the expanded use of nurse practitioners and physician assistants and shared care with primary care providers to deliver survivorship care to the growing number of survivors. Concerns associated with survivorship care models include payment considerations, adequacy of training, and the potential for lack of coordination and fragmented care.

CONCLUSION

There is substantial variation in survivorship care models. The optimal nature, timing, intensity, format, and outcomes of survivorship care models are uncertain and require further research. Specific research questions need to be addressed by the survivorship community to better understand the advantages and limitations of survivorship models.

Development and evaluation of a survey to assess survivor knowledge change after survivorship care plans: WiSDOM-B (Wisconsin Survey of cancer DiagnOsis and Management in Breast cancer)

The oncology community has increased efforts to inform survivors about long-term risks and planned follow-up after cancer treatment. Survivorship care plans (SCPs) have been recommended since 2005, yet the benefits of implementation are only now being emphasized. SCPs are hypothesized to enhance patient knowledge. The Wisconsin Survey of Diagnosis and Management in Breast Cancer (WiSDOM-B) was developed to measure changes in breast cancer survivor knowledge pre- and postdelivery of an SCP. The WiSDOM-B was developed with input from oncologists (medical, radiation, and surgical), patient advocates, cancer survivors, and survey design experts. Initially, nine patients evaluated survey content, and modifications were made to enhance clarity. Subsequently, 38 patients were enrolled in a randomized pilot trial assessing SCP impact on knowledge of diagnosis, treatment, late effects, and follow-up (WiSDOM-B) and satisfaction with knowledge (existing survey). The WiSDOM-B was developed using feedback from multiple stakeholders. Baseline knowledge was poor and remained stable in the control arm. There was a suggestion of increased survivor knowledge following receipt of SCPs in the intervention arm (68.4 vs. 74.4%). Change was not statistically significant compared with the control arm. Despite knowledge deficits, baseline satisfaction with knowledge was high for both groups, with 100% of patients being satisfied/very satisfied with information provided. Satisfaction did not change significantly following SCP receipt. The WiSDOM-B assesses survivor knowledge of cancer diagnosis, treatment, follow-up, and side effects. It will be a useful tool for future studies assessing the impact of care plans on survivor knowledge.

Transitional care of a childhood cancer survivor to adult services: facilitating the process of individual access to different models

PURPOSE OF REVIEW

In the past 20 years, several papers have been published concerning healthcare transition from pediatric after-care to long-term follow-up in adult health service for childhood cancer survivors. Initially, the papers were optimistic and included guidelines and models of care. However, after this optimistic beginning, more recent research has found that transitional care is not a successful process.

RECENT FINDINGS

Although the number of papers regarding transition in the past 2 years is few, they include revealing results about barriers and facilitators of the transition process.

SUMMARY

There is some evidence that joint pediatric/adult transition clinics are more successful in providing transitional care. The use of tools to assess individual psychological factors is important for the transition process and could lead to more individualized models of transition.