Enhancing Early-Stage Breast Cancer Survivorship: Evidence-Based Strategies, Surveillance Testing, and Imaging Guidelines

Addressing the challenges of survivorship necessitates a comprehensive, patient-centered approach, focusing on mitigating risk through lifestyle modification, identifying distant recurrence, and optimization of breast imaging. This article will discuss the current and emerging clinical strategies for the survivorship period, advocating a multidisciplinary and comprehensive approach. In this manner, early-stage breast cancer survivors are empowered to navigate their journey with enhanced knowledge, facilitating a transition to life beyond cancer.

Understanding advanced practice registered nurse perspectives on providing care to people with a history of breast cancer

BACKGROUND

People with a history of breast cancer (PHBC) face a lifelong risk of treatment-related sequelae affecting their quality of life. Stakeholders advocate for improving breast cancer survivorship outcomes by increasing clinicians' knowledge of cancer survivorship issues. In Missouri, advanced practice registered nurses (APRNs) in nononcology settings provide routine survivorship care to PHBC; however, little is known about how they approach survivorship care planning for PHBC.

PURPOSE

Examine perspectives of Missouri APRNs practicing in nononcology settings about providing survivorship care to PHBC.

METHODS

A combination of grounded theory and thematic analysis techniques was used for focus groups and semistructured interviews. The interviews were audio-recorded, transcribed, and analyzed using grounded theory coding methods.

RESULTS

Nineteen nononcology Missouri-based APRNs (18 NPs, 1 CNS/DNP) shared their perspectives about managing care for PHBC. We identified four major themes. Our participants (1) attuned their baseline assessment techniques to a history of breast cancer; (2) were prepared to order additional evaluations; (3) were willing to proactively figure out next best steps for PHBC beyond theneed for breast cancer recurrence surveillance; and (4) suggest that streamlining cancer survivorship care resources would benefit both clinicians and PHBC.

CONCLUSIONS

Our findings shed light on how APRNs approach care planning for PHBC and the needs of nononcology APRNs for managing PHBC.

IMPLICATIONS FOR PRACTICE

Advanced practice registered nurses are well-positioned to improve cancer survivorship care. Increasing knowledge of cancer survivorship care guidelines could improve long-term health outcomes of PHBC. Access to cancer survivorship resources or experts via telehealth/technology for both APRNs and patients could improve survivorship care and overall health of PHBC.

Patient preferences and comfort for cancer survivorship models of care: results of an online survey

PURPOSE

Workforce shortages will impact oncologists' ability to provide both active and survivorship care. While primary care provider (PCP) or survivorship clinic transition has been emphasized, there is little evidence regarding patient comfort.

METHODS

We developed an online survey in partnership with patient advocates to assess survivors' comfort with PCP or survivorship clinic care and distributed the survey to online, cancer-specific patient communities from June to August 2020. Descriptive and logistic regression analyses were conducted.

RESULTS

A total of 975 surveys were complete. Most respondents were women (91%) and had private insurance (65%). Thirty-six cancer types were reported. Ninety-three percent had a PCP. Twenty-four percent were comfortable seeing a PCP for survivorship care. Higher odds of comfort were seen among respondents who were Black or had stage 0 cancer; female sex was associated with lower odds. Fifty-five percent were comfortable with a survivorship clinic. Higher odds of comfort were seen with lymphoma or ovarian cancer, > 15 years from diagnosis, and non-US government insurance. Lower odds were seen with melanoma, advanced stage, Medicaid insurance, and one late effect. Preference for PCP care was 87% for general health, 32% for recurrence monitoring, and 37% for late effect management.

CONCLUSIONS

One quarter of cancer survivors were comfortable with PCP-led survivorship care and about half with a survivorship clinic. Most preferred oncologist care for recurrence monitoring and late-effect management.

IMPLICATIONS FOR CANCER SURVIVORS

Patient preference and comfort should be considered when developing survivorship care models. Future efforts should focus on facilitating patient-centered transitions to non-oncologist care.

Cancer Cure and Consequences on Survivorship Care: Position Paper from the Italian Alliance Against Cancer (ACC) Survivorship Care Working Group

A multidisciplinary panel of experts and cancer patients developed a position paper to highlight recent evidence on "cancer cure" (ie, the possibility of achieving the same life expectancy as the general population) and discuss the consequences of this concept on follow-up and rehabilitation strategies. The aim is to inform clinicians, patients, and health-care policy makers about strategies of survivorship care for cured cancer patients and consequences impacting patient lives, spurring public health authorities and research organizations to implement resources to the purpose. Two identifiable, measurable, and reproducible indicators of cancer cure are presented. Cure fraction (CF) is >60% for breast and prostate cancer patients, >50% for colorectal cancer patients, and >70% for patients with melanoma, Hodgkin lymphoma, and cancers of corpus uteri, testis (>90%), and thyroid. CF was >65% for patients diagnosed at ages 15-44 years and 30% for those aged 65-74 years. Time-to-cure was consistently <1 year for thyroid and testicular cancer patients and <10 years for patients with colorectal and cervical cancers, melanoma, and Hodgkin lymphoma. The working group agrees that the evidence allows risk stratification of cancer patients and implementation of personalized care models for timely diagnosis, as well as treatment of possible cancer relapses or related long-term complications, and preventive measures aimed at maintaining health status of cured patients. These aspects should be integrated to produce an appropriate follow-up program and survivorship care plan(s), avoiding stigma and supporting return to work, to a reproductive life, and full rehabilitation. The "right to be forgotten" law, adopted to date only in a few European countries, may contribute to these efforts for cured patients.

Life-Saving Cancer Care

What, precisely, are we seeking to achieve in offering 'life-saving' treatment to patients with cancer? Research funding agencies and pharmaceutical industry media releases, and government cancer screening programs all promise that their cancer programs save lives. But everybody dies. The nature of life and death from cancer is explored philosophically in this essay, with particular reference to the quality of life, and its meaning, during the period of prolongation of survival by 'life-saving' cancer care.

Health After Cancer: An Innovative Continuing Medical Education Course Integrating Cancer Survivorship Into Primary Care

PROBLEM

The transition from oncology care back to primary care after cancer therapy is challenging for cancer survivors who seek services that address the effect of their cancer history on their present health. Lack of knowledge about the health needs of cancer survivors is a barrier to incorporating survivorship care into primary care practice. Formal training in cancer survivorship is rarely included in medical education and presents an opportunity for intervention.

APPROACH

The authors developed (January 2019-March 2020) an online continuing medical education (CME) course for primary care physicians (PCPs) that launched in April 2020. Course design and content were informed by critically reviewing cancer survivorship CME courses and understanding cancer survivors' clinical experiences in a primary care setting. The course aims to pique learners' interest through a concise, practical educational experience using peer-to-peer primary care-focused instruction in a case-based, multimedia-enriched format. In the course, 4 patient cases illustrate the physical and psychological effects of cancer treatment, and a primary care narrator demonstrates ways to approach these concerns during a clinic visit, providing tips for empathic communication with cancer survivors. The course development team-including a PCP, medical and pediatric oncologists, and medical educators with expertise in instructional design-used an iterative process to review and revise the content. PCPs and specialists reviewed the script and provided constructive feedback that was incorporated into revisions.

OUTCOMES

The authors will evaluate course effectiveness based upon user experience and perceived effect on clinical practice and professional growth. A follow-up survey will assess barriers to course completion and durability of effect.

NEXT STEPS

Future directions include dissemination of the course to a broader audience including medical trainees, evaluation of higher-level learning outcomes (e.g., effect on PCPs' clinical practice), and adaptation of the course for patients with a focus on self-management.

Impact of provider type and number of providers on surveillance testing among survivors of head and neck cancers

BACKGROUND

Guidelines for follow-up after head and neck cancer (HNC) treatment recommend frequent clinical examinations and surveillance testing. Here, the authors describe real-world follow-up care for HNC survivors and variations in surveillance testing.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study examined a population-based cohort of HNC survivors between 2001 and 2011 Usage of cross-sectional head and neck imaging (CHNI), chest imaging (CI), positron emission tomography (PET), fiberoptic nasopharyngolaryngoscopy (FNPL), and, in irradiated patients, thyroid function testing (TFT) was captured over 2 consecutive surveillance years. Multivariate modeling with logistic regression analyses was used to assess variations by clinical factors, nonclinical factors, number and types of providers seen and their evolution over time.

RESULTS

Among 13,836 HNC survivors, the majority saw a medical, radiation, or surgical oncologist and a primary care provider (PCP; 81.7%) in their first year of surveillance. However, only 58.1% underwent either PET or CHNI, 47.8% underwent CHNI, 64.1% underwent CI, 32.5% underwent PET scans, 55.0% underwent FNPL, and 55.9% underwent TFT. In multivariate analyses, patients who followed up with more providers and those who followed up with both a PCP and an oncologist were more likely to undergo surveillance testing (P < .007). However, adjusting for providers seen did not explain the variations in surveillance testing rates based on age, race, education, income level, and place of residence. Over time, there was a gradual increase in the use of PET scans and TFT during surveillance years.

CONCLUSIONS

In this large SEER-Medicare data study, only half of HNC survivors received the recommended testing, and greater compliance was seen in those who followed up with both an oncologist and a PCP. More attention is needed to minimize variations in surveillance testing across sociodemographic groups.

A 4-Month Whole-Systems Ayurvedic Medicine Nutrition and Lifestyle Intervention Is Feasible and Acceptable for Breast Cancer Survivors: Results of a Single-Arm Pilot Clinical Trial

PURPOSE

Ongoing symptoms and impairments in quality of life (QOL) among breast cancer survivors remain a significant problem. We tested the feasibility and acceptability of a manualized Ayurvedic nutrition and lifestyle intervention for breast cancer survivors.

METHODS

Eligible participants had Stage I-III breast cancer, underwent treatment within the past year that included chemotherapy, and were without active disease. The 4-month individualized Ayurvedic intervention included counseling on nutrition, lifestyle, yoga, and marma (like acupressure) during 8 one-on-one visits with an Ayurvedic practitioner. Feasibility and acceptability were the primary outcomes. QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ C30]) and symptoms-sleep disturbance (General Sleep Disturbance Scale [GSDS]), fatigue (Lee Fatigue Scale [LFS]), depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D]), anxiety (Spielberger State-Trait Anxiety Inventory [STAI-S, STAI-T]), and stress (Perceived Stress Scale [PSS])-were measured prior to, at midpoint, and at the end of the 4-month intervention. Effect sizes (Cohen's d) were calculated along with paired t tests comparing baseline to end of month 4 time points. Mixed effects models were used for repeated measures analyses.

RESULTS

Participants (n = 32) had a mean age of 48 years (SD = 10). Retention at the end of the intervention was 84%. Among those who completed the intervention (n = 27), adherence was high (99.5% of visits with practitioners attended). Large improvements were seen in QLQ-C30 emotional functioning (d = 0.84, P < 0.001), QLQ-C30 cognitive functioning (d = 0.86, P < 0.001), GSDS (d = -1.23, P < 0.001), and CES-D (d = -1.21, P < 0.001). Moderate improvements were seen in QLQ-C30 global health (d = 0.65, p = 0.003), LFS (d = -0.68, P = 0.002), and PSS (d = -0.75, P < 0.001). No adverse events were observed due to the intervention.

CONCLUSION

This 4-month Ayurvedic whole-systems multimodal nutrition and lifestyle intervention was feasible and acceptable for breast cancer survivors. Promise of clinical benefit was seen in terms of improvements in symptoms and QOL that warrants further investigation.

The Creation of a Comprehensive Adolescent and Young Adult Cancer Survivorship Program: "Lost in Transition" No More

Purpose: The Reid R. Sacco AYA Cancer Program set out to improve survivorship care for AYA-aged patients (15-39 years) of pediatric or AYA cancer. This article discusses the steps in establishing the clinic, including the creation of a database on cancer history, exposures, and attendant risks of late effects. Results from the database tell the broader story of AYAs who seek care within a dedicated survivorship clinic. Methods: The database was created with REDCap^® (Research Electronic Data Capture), a secure web-based, HIPAA compliant application for research and clinical study data. Data were abstracted and analyzed by trained members of the program team. Results: A total of 144 patients were seen for their initial survivorship visit between January 2013 and September 2019. Regarding physical health, two-thirds of the patients presented with an established late effect, one third with an established medical comorbidity, and 11% (n = 16) with secondary cancer related to their oncologic treatment. In assessing mental health, a significant cohort reported a known affective disorder (32%, n = 46) with one quarter already taking a psychotropic medication. Despite the transient nature of AYAs, 85% of patients remained in care within the long-term follow-up clinical model. Conclusions: Data presented illustrate how multilayered and complex survivorship care needs can be, as patients enter the clinic with complicated pre-existing psychosocial issues, significant late effects, and comorbidities. This study reinforces the value of a clinical database to better understand AYA survivors with the ultimate goal of optimizing and coordinating care.