Outcomes of Cancer Survivorship Care Provided by Advanced Practice RNs Compared to Other Models of Care: A Systematic Review

Feasibility, acceptability, and utility of a nurse-led survivorship program for people with metastatic melanoma (MELCARE)

PURPOSE

Immune checkpoint inhibitors (ICIs) and targeted therapy (TT) have improved the survival of people with metastatic melanoma. We assessed the feasibility, acceptability, and utility of a novel model of nurse-led, telehealth-delivered survivorship care (MELCARE) for this survivor group.

METHODS

People ≥ 18 years diagnosed with unresectable stage III or stage IV melanoma who were ≥ 6 months post initiation of ICI/TT with a radiological response suggestive of a long-term response to ICI/TT were recruited from a specialist melanoma centre in Australia. All participants received MELCARE, a nurse-led survivorship program involving two telehealth consultations 3 months apart, needs assessment using the Distress Thermometer (DT) and Problem List, and creation of a survivorship care plan. Feasibility, acceptability, and utility were assessed using rates of consent and study completion, time taken to complete each component of MELCARE, the Acceptability of Intervention Measure (AIM), and a customised utility survey.

RESULTS

31/54 (57%) people consented. Participants were male (21, 68%), with a median age of 67 (range: 46-82). Eleven (35%) were receiving/had received ipilimumab and nivolumab and 27 (87%) had ceased treatment. Feasibility was demonstrated with 97% completing MELCARE. Utility was demonstrated on a customised survey and supported by a reduction in the mean DT score (initial: 5.6, SD: 2.9; follow-up: 1.5, SD: 1.2). Acceptability was demonstrated on 3/4 AIM items.

CONCLUSION

MELCARE was feasible and acceptable with high levels of utility. However, the consent rate was 57% indicating some people do not require support. Future studies should consider MELCARE's optimal timing, resourcing, and cost-effectiveness.

Defining a patient-centered approach to cancer survivorship care: development of the patient centered survivorship care index (PC-SCI)

Purpose

This study presents the validation of an index that defines and measures a patient-centered approach to quality survivorship care.

Methods

We conducted a national survey of 1,278 survivors of breast, prostate, and colorectal cancers to identify their priorities for cancer survivorship care. We identified 42 items that were “very important or absolutely essential” to study participants. We then conducted exploratory and confirmatory factor analyses (EFA/CFA) to develop and validate the Patient-Centered Survivorship Care Index (PC-SCI).

Results

A seven-factor structure was identified based on EFA on a randomly split half sample and then validated by CFA based on the other half sample. The seven factors include: (1) information and support in survivorship (7 items), (2) having a medical home (10 items) (3) patient engagement in care (3 items), (4) care coordination (5 items), (5) insurance navigation (3 items), (6) care transitions from oncologist to primary care (3 items), and (7) prevention and wellness services (5 items). All factors have excellent composite reliabilities (Cronbach’s alpha 0.84-0.94, Coefficient of Omega: 0.81-0.94).

Conclusions

Providing quality post-treatment care is critical for the long-term health and well-being of survivors. The PC-SCI defines a patient-centered approach to survivorship care to complement clinical practice guidelines. The PC-SCI has acceptable composite reliability, providing the field with a valid instrument of patient-centered survivorship care. The PC-SCI provides cancer centers with a means to guide, measure and monitor the development of their survivorship care to align with patient priorities of care.

Trial registration

ClinicalTrials.gov ID: NCT02362750, 13 February 2015

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07356-6.

Oncology Medical Home: ASCO and COA Standards

PURPOSE

To provide Standards on the basis of evidence and expert consensus for a pilot of the Oncology Medical Home (OMH) certification program. The OMH model is a system of care delivery that features coordinated, efficient, accessible, and evidence-based care and includes a process for measurement of outcomes to facilitate continuous quality improvement. The OMH pilot is intended to inform further refinement of Standards for OMH model implementation.

METHODS

An Expert Panel was formed, and a systematic review of the literature on the topics of OMH, clinical pathways, and survivorship care plans was performed using PubMed and Google Scholar. Using this evidence base and an informal consensus process, the Expert Panel developed a set of OMH Standards. Public comments were solicited and considered in preparation of the final manuscript.

RESULTS

Three comparative peer-reviewed studies of OMH met the inclusion criteria. In addition, the results from 16 studies of clinical pathways and one systematic review of survivorship care plans informed the evidence review. Limitations of the evidence base included the small number of studies of OMH and lack of longer-term outcomes data. More data were available to inform the specific Standards for pathways and survivorship care; however, outcomes were mixed for the latter intervention. The Expert Panel concluded that in the future, practices should be encouraged to publish the results of OMH interventions in peer-reviewed journals to improve the evidence base.

STANDARDS

Standards are provided for OMH in the areas of patient engagement, availability and access to care, evidence-based medicine, equitable and comprehensive team-based care, quality improvement, goals of care, palliative and end-of-life care discussions, and chemotherapy safety. Additional information, including a Standards implementation manual, is available at www.asco.org/standards.

Are Nursing Interventions Effective in Improving Quality of Life in Cancer Survivors? A Systematic Review

BACKGROUND

Cancer survivors (CSs) have needs that can negatively impact their quality of life (QoL). Oncology nurses play a key role in providing comprehensive care in cancer survivorship, although little is known about their impact on health outcomes.

OBJECTIVE

The aim of this study was to determine the effectiveness of nursing interventions to improve QoL and satisfaction with care of CSs.

METHODS

A systematic review was conducted. PubMed, CINAHL, PsycINFO, and Cochrane databases were searched for experimental studies. The Joanna Briggs Institute Checklist for Randomized Controlled Trials was used to verify the quality of the studies (Prospero reference: CRD42020148294).

RESULTS

Of the 8 clinical trials eligible for inclusion, 5 demonstrated that interventions conducted by nurses improved the overall QoL or some of its domains in CSs. The included studies focused on short-term survival; no studies in long-term CSs were identified. Two studies assessed satisfaction with care of survivors, obtaining positive results.

CONCLUSIONS

Nursing interventions seem to improve the QoL of short-term CSs. However, because of the low number of studies identified, the findings of this systematic review should be interpreted with caution.

IMPLICATIONS FOR PRACTICE

Further studies are necessary to strengthen the implementation of effective nursing intervention in cancer practice. Research should particularly be conducted with long-term CSs as there is lack of data on this specific stage of cancer.

Cancer survivor's perspectives on the major challenge in the transition to survivorship

OBJECTIVES

To understand cancer survivors' perspectives regarding the major challenge in transitioning from cancer treatment to follow-up care. Identification of major issues should inform survivorship care and help reduce suffering.

METHODS

A national survey was conducted to identify experiences with follow-up for cancer survivors one to three years post-treatment. The survey included open-ended questions for respondents to add topics of importance and details that offer deeper insight into their experiences. This publication presents analysis of the open-ended question about the major challenge faced by adult cancer population.

RESULTS

Of 13,534 unique adult survey respondents, 8706 respondents identified major challenges. Of those reporting challenges, 4727 (54.3 %) named a single challenge but 3979 (45.7 %) identified more than one. In total, 15,351 challenges were identified. Responses to open-ended questions are summarized under significant themes: major concerns are often more than singular issues; recovery and fear of recurrence; and information needs.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Results indicate significant numbers of adult survivors have multiple concerns about physical, emotional, and practical issues but are not receiving assistance and/or appropriate information to help manage these concerns. It is important to determine how health care can be proactive in identifying and addressing needs of survivors.

Breast Cancer Survivor Symptoms: A Comparison of Physicians' Consultation Records and Nurse-Led Survivorship Care Plans

BACKGROUND

Survivorship care plans (SCPs) have been used to address ongoing health problems associated with the diagnosis and treatment of early-stage breast cancer.

OBJECTIVES

The aim of this article was to determine whether nurse-led consultations using SCPs, as compared with a standard medical consultation, identify more side effects and supportive care needs and lead to appropriate referral patterns.

METHODS

The study audited 160 retrospective medical clinic and nursing SCP records in a sample of patients receiving treatment for early-stage breast cancer at a tertiary-level breast service in Australia.

FINDINGS

Breast care nurses (BCNs) undertaking SCPs at a nurse-led consultation were significantly more likely than physicians to record symptoms related to menopausal/hormonal therapy, psychosocial/mental health, lifestyle, bone health, and sexuality. BCNs were also significantly more likely to refer patients for concerns related to psychosocial/mental health, lifestyle, and sexuality.

Evaluating an Online Training Course to Develop and Sustain Cancer Navigation and Survivorship Programs

OBJECTIVES

To evaluate the impact of the Executive Training on Navigation and Survivorship (Executive Training) online training course, designed by the George Washington University Cancer Center, on nurses and other healthcare professionals.

SAMPLE & SETTING

A volunteer sample of 499 healthcare professionals, including nurses and patient navigators, were recruited through multiple Internet-based channels.

METHODS & VARIABLES

Participants completed questionnaires before and after each module and at the end of the training. Descriptive statistics were calculated, and paired t tests were used to assess pre- and post-test learning confidence gains for each module. Qualitative feedback from participants was also summarized.

RESULTS

From pre- to post-test, each group demonstrated statistically significant improvements in confidence (p < 0.05) for all seven training modules. Confidence gains were statistically significant for 19 of 20 learning objectives (p < 0.05). Overall rating scores and qualitative feedback were positive.

IMPLICATIONS FOR NURSING

The Executive Training course prepares healthcare professionals from diverse backgrounds to establish navigation and survivorship programs. In addition, the training content addresses gaps in nursing education on planning and budgeting that can improve success.

The Integration of Survivorship Care Planning at a Comprehensive Cancer Center

Research has demonstrated that cancer survivors who receive a survivorship care plan (SCP) have better coordinated follow-up care, higher overall satisfaction, and report significantly fewer posttreatment emotional concerns. The Commission on Cancer, a program of the American College of Surgeons, has developed a standard of care in which 100% of eligible patients are to receive an SCP by the end of 2019. Nurse practitioners at a National Cancer Institute (NCI)-designated academic medical center worked to develop a standardized process to deliver SCPs to all eligible patients. The primary objective of the project was to standardize how SCPs were completed and embed them into the electronic medical record (EMR) using a templated note created for the EMR. Through an interdisciplinary steering committee, survivorship priorities were established and aligned with LIVESTRONG and American Society of Clinical Oncology guidelines. In addition, survivorship care planning was identified as an essential service to be provided by all cancer disease management groups (DMG) at the cancer center. A cancer SCP subcommittee was formed to explore methods to expand the delivery of SCPs and standardize the SCP process. Prior to this project, SCPs were being done by less than 10% of the providers and only for a few diagnoses, and no standardized method of documentation existed prior to this quality improvement initiative. The standardization of the SCP has increased both participation of other DMGs as well as increased the rate of completion to 34%. We believe that continuous reassessment and process improvement will help us reach the Commission on Cancer goal of providing SCPs to all eligible patients.

Transition to survivorship: can there be improvement?

PURPOSE OF REVIEW

The transition from primary cancer treatment to posttreatment follow-up care is seen as critical to the long-term health of survivors. However, relatively little attention has been paid to understanding this pivotal period. This review will offer a brief outline of the significant work surrounding this pivotal time published in the past year.

RECENT FINDINGS

The growing number of cancer survivors has stimulated an emphasis on finding new models of care, whereby responsibility for survivorship follow-up is transitioned to primary care providers. A variety of models and tools have emerged for follow-up care. Survivorship care plans are heralded as a key component of survivorship care and a vehicle for supporting transition. Uptake of survivorship care plans and implementation of evidence-based models of survivorship care has been slow, hindered by a range of barriers.

SUMMARY

Evaluation is needed regarding survivorship models in terms of feasibility, survivor friendliness, cost effectiveness, and achievement of sustainable outcomes. How, and when, to introduce plans for transition to the patient and determine transition readiness are important considerations but need to be informed by evidence. Additional study is needed to identify best practice for the introduction and application of survivorship care plans.

Advanced Practice Providers and Survivorship Care: They Can Deliver

INTRODUCTION

As the number of cancer survivors grows, new models of survivorship care are being implemented, but there is limited evaluation to date. This retrospective review assesses the concordance of care provided to adult-onset cancer survivors by advanced practice providers (nurse practitioners and physician assistants) with Institute of Medicine guidelines for survivorship care.

METHODS

Records from three survivorship clinics at a single institution were reviewed for frequency of recurrence surveillance, screening for second cancers, symptom management (physical, psychological), health promotion education (alcohol, tobacco, cholesterol, and bone density screenings; diet/exercise discussion), care coordination, and provision of care plan. Data were characterized using descriptive statistics.

RESULTS

Over 2 years, 9,052 unique survivorship visits occurred; 210 breast, 208 prostate, and 204 colorectal visits were randomly selected for review. All patients with breast cancer underwent surveillance for recurrence; 99% were screened for new cancers. Discussion of health promotion activities ranged from 83% to 100%; 91% of patients were reviewed for physical symptoms, and 93% were reviewed for psychological symptoms. All patients with prostate cancer underwent recurrence surveillance; 97% were screened for new primaries. Health promotion activities ranged from 70% to 97%, and symptoms were discussed in 89% of visits. All patients with colorectal cancer underwent a surveillance colonoscopy for recurrence; 97% had a carcinoembryonic antigen test. Among women, 97% had mammograms, and 96% had a Papanicolaou test; 83% of men had a prostate-specific antigen test. Health promotion activities ranged from 69% to 100%, and symptoms were discussed in 93% to 97% of visits.

CONCLUSIONS

Findings suggest that advanced practice providers can provide survivorship care in accordance with Institute of Medicine standards, which provide a normative standard. This assessment is an important step in evaluating survivorship outcomes.