Oncologists' and primary care physicians' awareness of late and long-term effects of chemotherapy: implications for care of the growing population of survivors

Primary care physicians' knowledge and confidence in providing cancer survivorship care: a systematic review

PURPOSE

To systematically review existing literature on knowledge and confidence of primary care physicians (PCPs) in cancer survivorship care.

METHODS

PubMed, Ovid MEDLINE, CINAHL, Embase, and PsycINFO were searched from inception to July 2022 for quantitative and qualitative studies. Two reviewers independently assessed studies for eligibility and quality. Outcomes were characterized by domains of quality cancer survivorship care.

RESULTS

Thirty-three papers were included, representing 28 unique studies; 22 cross-sectional surveys, 8 qualitative, and 3 mixed-methods studies. Most studies were conducted in North America (n = 23) and Europe (n = 8). For surveys, sample sizes ranged between 29 and 1124 PCPs. Knowledge and confidence in management of physical (n = 19) and psychosocial effects (n = 12), and surveillance for recurrences (n = 14) were described most often. Generally, a greater proportion of PCPs reported confidence in managing psychosocial effects (24-47% of PCPs, n= 5 studies) than physical effects (10-37%, n = 8). PCPs generally thought they had the necessary knowledge to detect recurrences (62-78%, n = 5), but reported limited confidence to do so (6-40%, n = 5). There was a commonly perceived need for education on long-term and late physical effects (n = 6), and cancer surveillance guidelines (n = 9).

CONCLUSIONS

PCPs' knowledge and confidence in cancer survivorship care varies across care domains. Suboptimal outcomes were identified in managing physical effects and recurrences after cancer.

IMPLICATIONS FOR CANCER SURVIVORS

These results provide insights into the potential role of PCPs in cancer survivorship care, medical education, and development of targeted interventions.

Myths and Presumptions About Cancer Survivorship

Identifying cancer survivorship myths and presumptions perpetuated in survivorship circles.

Bridging the gap: Palliative care integration into survivorship care

As the number of cancer survivors grows, there is an increasing need for comprehensive care to address the unique physical, psychological, and social needs of this population. Palliative care (PC) integration within survivorship care offers a promising model of care, however, there is no comprehensive review of literature to guide clinical practice. This manuscript presents a scoping review of the research literature on models of care that integrate PC with survivorship care, as well as a detailed description of an exemplar clinical model. We identified 20 articles that described various models of survivorship care with integrated PC, highlighting the diversity of approaches and the multidisciplinary nature of interventions. Few studies reported outcomes but those that did demonstrated improvements in pain, self-efficacy, depression, function, and documentation of advance care planning. The evidence base remains limited, indicating the need for further research in this area with a focus on exploring outcomes using prospective experimental designs. Future clinical practice and research should explore sustainable payment models and the implementation of integrated survivorship care in value-based payment systems.

Oncofertility awareness among primary care physicians in India

BACKGROUND

Primary care physicians not only coordinate referrals to oncology services but can play a crucial role in successful fertility preservation referrals in cancer-diagnosed patients. Hence, it is important to assess their knowledge and attitudes towards fertility preservation.

METHODS

An eighteen-item oncofertility survey was administered to primary care physicians between May 2019 to September 2020.  Results: A total of forty-six responses were received and analysed. About 60% of primary care physicians did not have adequate knowledge about available fertility preservation options and only 26-32% were aware of international guidelines recommending fertility preservation in cancer patients.  Conclusions: Imparting awareness and knowledge of fertility preservation and its options to primary care physicians could enable an integrated cancer care model while also facilitating successful oncofertility referrals in countries like India.

Fertility Preservation in Children and Adolescents during Oncological Treatment-A Review of Healthcare System Factors and Attitudes of Patients and Their Caregivers

Oncofertility is any therapeutic intervention to safeguard the fertility of cancer patients. Anti-cancer therapies (chemotherapy, radiation therapy, etc.) entail the risk of reproductive disorders through cytotoxic effects on gamete-building cells, especially those not yet fully developed. This literature review analyzes the available data on securing fertility in pediatric and adolescent populations to identify the methods used and describe aspects related to financing, ethics, and the perspective of patients and their parents. Topics related to oncofertility in this age group are relatively niche, with few peer-reviewed articles available and published studies mostly on adults. Compared to pubertal individuals, a limited number of fertility preservation methods are used for prepubertal patients. Funding for the procedures described varies from country to country, but only a few governments choose to reimburse them. Oncofertility of pediatric and adolescent patients raises many controversies related to the decision, parents' beliefs, having a partner, ethics, as well as the knowledge and experience of healthcare professionals. As the fertility of young cancer patients is at risk, healthcare professionals should make every effort to provide them with an opportunity to fulfill their future reproductive plans and to have a family and offspring. Systemic solutions should form the basis for the development of oncofertility in pediatric and adolescent populations.

Neurological Complications of Conventional and Novel Anticancer Treatments

Various neurological complications, affecting both the central and peripheral nervous system, can frequently be experienced by cancer survivors after exposure to conventional chemotherapy, but also to modern immunotherapy. In this review, we provide an overview of the most well-known adverse events related to chemotherapy, with a focus on chemotherapy induced peripheral neurotoxicity, but we also address some emerging novel clinical entities related to cancer treatment, including chemotherapy-related cognitive impairment and immune-mediated adverse events. Unfortunately, efficacious curative or preventive treatment for all these neurological complications is still lacking. We provide a description of the possible mechanisms involved to drive future drug discovery in this field, both for symptomatic treatment and neuroprotection.

Baseline cardiac function checkup in patients with gastric or breast cancer receiving trastuzumab or anthracyclines

BACKGROUND

Although trastuzumab and anthracyclines are frequently used to treat breast cancer (BC) and gastric cancer (GC), cardiotoxicity is a serious concern. The cardiac function assessment is recommended at baseline before initiating treatment. However, the prevalence rates of baseline cardiac checkups are unknown.

METHODS

The national database of hospital-based cancer registries linked to the health services-utilization data was used to study patients with newly diagnosed stage IV BC and GC (n = 6271) who received trastuzumab (n = 4324, 69.0%) or anthracyclines between January 2012 and December 2015. The baseline ultrasound echocardiogram (UCG) performance rate and factors related to adequate UCG performance for all patients and those receiving trastuzumab were analyzed.

RESULTS

The adequate baseline UCG checkup rate was higher in patients treated with trastuzumab than in those treated with anthracyclines (71.8% vs 44.1%, respectively). Additionally, patients with GC were less likely to receive an adequate baseline UCG performance than those with BC (70.4% vs 75.0%, respectively). After adjusting for potential confounders, patients with anthracycline-treated BC and GC were less likely to receive adequate baseline UCG performance than those with trastuzumab-treated BC (odds ratio [OR]: 0.24, 95% confidence interval [CI]: 0.20-0.28, and OR: 0.07, 95% CI: 0.03-0.16, respectively). Furthermore, patients with trastuzumab-treated GC were less likely to receive adequate baseline UCG performance than those with BC (OR: 0.65, 95% CI: 0.50-0.84).

CONCLUSIONS

The baseline UCG was less likely to be performed in patients receiving anthracyclines than in those receiving trastuzumab, as well as in patients with GC than in those with BC.

Long-term assessment of efficacy with a novel thoracic survivorship program for patients with lung cancer

OBJECTIVE

We developed a novel, nurse practitioner-run Thoracic Survivorship Program to aid in long-term follow-up. Patients with non-small cell lung cancer who were disease-free at least 1 year after resection could be referred to the Thoracic Survivorship Program by their surgeon. Our objectives were to summarize follow-up compliance and assess long-term outcomes between Thoracic Survivorship Program enrollment and non-Thoracic Survivorship Program.

METHODS

Patients who underwent R0 resection for stages I to IIIA between 2006 and 2016 were stratified by enrollment in Thoracic Survivorship Program versus surgeon only follow-up (non-Thoracic Survivorship Program). Follow-up included 6-month chest computed tomography scans for 2 years and then annually. Lack of follow-up compliance was defined by 2 or more consecutive delayed annual computed tomography scans/visits ± 90 days. Relationships between Thoracic Survivorship Program and second primary non--small cell lung cancers, extrathoracic cancers, and survival were quantified using multivariable Cox proportional hazards regression with time-varying covariate reflecting timing of enrollment.

RESULTS

A total of 1162 of 3940 patients (29.5%) were enrolled in the Thoracic Survivorship Program. The median time to enrollment was 2.3 years; 3279 of 3940 (83%) had complete computed tomography scan data, and 60 of 3279 (1.8%) had 2 or more delayed scans; 323 of 9082 (3.6%) non-Thoracic Survivorship Program visits were noncompliant versus 132 of 4823 (2.7%) of Thoracic Survivorship Program visits (P = .009); 136 of 1146 Thoracic Survivorship Program patients developed second primary non-small cell lung cancer, and 69 of 1123 developed extrathoracic cancer, whereas 322 of 2794 of non-Thoracic Survivorship Program patients developed second primary non-small cell lung cancer and 225 of 2817 patients developed extrathoracic cancer. In multivariable analyses, Thoracic Survivorship Program enrollment was associated with improved disease-free survival (hazard ratio, 0.57; 95% confidence interval, 0.48-0.67; P < .001).

CONCLUSIONS

Our novel nurse practitioner-run Thoracic Survivorship Program is associated with high patient compliance and outcomes not different from those seen with physician-based follow-up. These results have important implications for health care resource allocation and costs.

Co-designing an Early Menopause Digital Resource: Model for Interdisciplinary Knowledge Translation

Early menopause/premature ovarian insufficiency is associated with negative health impacts, unmet information needs, delayed diagnosis, and variation in management. Co-designed digital resources for women with early menopause/premature ovarian insufficiency and health practitioners were developed to address information needs and support management. A five-phase mixed methods multidisciplinary research, co-design and translation process comprised: (1) survey/interviews with women and health practitioners to explore early menopause/premature ovarian insufficiency needs, experiences, and management; (2) appraisal of clinical guidelines to develop management algorithms; (3) digital resource development (https://healthtalkaustralia.org/early-menopause-experiences-and-perspectives-of-women-and-health-professionals/; (4) evaluation; and (5) dissemination/implementation. The digital resources included audio/video clips of women with early menopause/premature ovarian insufficiency and health practitioners providing early menopause/premature ovarian insufficiency care, a question prompt list, health practitioner algorithms, information links, and a list of services for women, achieving high satisfaction ratings from women and health practitioners. Engaging our stakeholder partners, multimodal dissemination has included community and conference presentations, social media, lay and professional publications, and webinars. This project provides a model for successful interdisciplinary co-design research translation to improve women's health.

Lifestyle among long-term survivors of cancers in young adulthood

PURPOSE

To investigate lifestyle in a population-based sample of long-term (≥ 5 years since diagnosis) young adult cancer survivors (YACSs), and explore factors associated with not meeting the lifestyle guidelines for physical activity (PA), body mass index (BMI), and smoking.

METHODS

YACSs (n = 3558) diagnosed with breast cancer (BC), colorectal cancer (CRC), non-Hodgkin lymphoma (NHL), acute lymphoblastic leukemia (ALL), or localized malignant melanoma (MM) between the ages of 19 and 39 years and treated between 1985 and 2009 were invited to complete a mailed questionnaire. Survivors of localized MM treated with limited skin surgery served as a reference group for treatment burden.

RESULTS

In total, 1488 YACSs responded (42%), and 1056 YACSs were evaluable and included in the present study (74% females, average age at survey 49 years, average 15 years since diagnosis). Forty-four percent did not meet PA guidelines, 50% reported BMI ≥ 25 and 20% smoked, with no statistically significant differences across diagnostic groups. Male gender, education ≤ 13 years, comorbidity, lymphedema, pain, chronic fatigue, and depressive symptoms were associated with not meeting single and/or an increasing number of lifestyle guidelines.

CONCLUSION

A large proportion of long-term YACSs do not meet the lifestyle guidelines for PA, BMI, and/or smoking. Non-adherence to guidelines is associated with several late effects and/or comorbidities that should be considered when designing lifestyle interventions for YACSs.

Knowledge of iatrogenic premature ovarian insufficiency among Chinese obstetricians and gynaecologists: a national questionnaire survey

Background

With increasing cases of iatrogenic premature ovarian insufficiency (POI), more clinicians are required to counsel patients regarding the gonadotoxic effects of iatrogenic treatments. This survey aimed to explore obstetricians and gynaecologists’ knowledge regarding iatrogenic POI. A national online questionnaire survey was conducted across China. Respondents were asked to select the iatrogenic condition(s) that can cause POI based on their experience and knowledge.

Results

Of the 5523 returned questionnaires, 4995 were analysed. Among tumour therapies causing POI, most respondents agreed that radiotherapy (73.5% of respondents) and chemotherapy (64.1%) are risk factors for POI. While only 6.5 and 7.8% of the gynaecological oncologists believed that tumour immunotherapy and tumour-targeting therapy, respectively, may cause ovarian impairment, 31.8 and 22.2% of the non-gynaecologic oncologists believed that these therapies could affect ovarian health. Most respondents believed that ovarian cystectomy (54.4%) was a risk factor for POI. In contrast, only a few respondents believed that hysterectomy with bilateral salpingectomy (39.6%) and uterine artery embolisation (33.5%) could cause ovarian impairment. Only 30.5% of respondents believed that immunosuppressants (ISs) increased the risk of POI. Views differed with experience and hospital setting.

Conclusions

The knowledge of gonadal toxicity due to traditional tumour treatments is generally high among Chinese obstetricians and gynaecologists. A misunderstanding may exist in primary care hospitals and general gynaecologists regarding a link between novel tumour treatments and POI, owing to the lack of convincing evidence. Knowledge of POI caused by hysterectomy and ISs should be improved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-020-00739-z.

Knowledge and self-efficacy for caring for breast and colon cancer survivors among safety net primary care providers

BACKGROUND

Primary care providers (PCPs) are critical to the provision of comprehensive care for cancer survivors, yet there is very little data on the practices and quality of survivorship care occurring in safety net primary care settings. This study aimed to assess the knowledge and attitudes of PCPs and preferences for care models for breast and colon cancer survivors in a safety net health network.

METHODS

A modified National Cancer Institute Survey of Physician Attitudes Regarding the Care of Cancer Survivors was sent electronically to 220 PCPs in 12 primary care clinics in the San Francisco Health Network affiliated with Zuckerberg San Francisco General Hospital and Trauma Center.

RESULTS

The response rate was 50% (110/220). About half of PCPs strongly/somewhat agreed (vs. strongly/somewhat disagreed) that PCPs have the knowledge needed to provide follow-up care related to breast (50%) and colon cancer (54%). Most providers (93%) correctly reported recommended frequency of mammography, however, frequency of blood tests and other imaging surveillance were not as well recognized for breast or colon cancer. Recognition of long-term side effects of chemotherapy drugs ranged from 12% for oxaliplatin to 44% for doxorubicin. Only 33% of providers reported receiving any survivorship training. The most preferred model for survivorship care was shared care model (40%).

CONCLUSIONS

Safety net PCPs prefer a shared care model for care of cancer survivors but are limited by lack of training, poor communication, and poor delineation of roles. Patient-centered survivorship care can be improved through effective oncologist-PCP-patient partnerships and coordination.

Overview of Cancer Survivorship Care for Primary Care Providers

Survivorship care for a patient with cancer is often complex and requires a multidisciplinary approach. Cancer and its treatment can have late and long-term physical and psychosocial effects. After the acute and intense period of treatment and surveillance administered by oncology teams, cancer survivors slowly transition care to primary providers. Cancer survivors then enter into an extended phase of survivorship whether they are cancer-free, in remission, or living with cancer. In this phase, symptoms related to cancer and its treatment may vary over time. Developing a care plan can facilitate the transition of care between all providers taking care of cancer patients.

Healthcare provider perspectives on pediatric cancer survivorship care plans: a single institution pilot study

PURPOSE

Survivorship care plans (SCPs) are used to facilitate communication between oncology and primary care providers (PCPs) after cancer treatment and to assist cancer survivors with healthcare decisions. We evaluated pediatric oncology providers' experiences creating and delivering SCPs. We also evaluated PCPs' opinions of SCPs.

METHODS

Together, oncology nurses and oncologists created individualized SCPs for leukemia patients treated at a children's hospital in Utah, with nurses in charge of inputting the majority of SCP content. We surveyed providers after each SCP was completed. We also mailed SCPs to PCPs with a survey on SCP content and their knowledge and comfort level caring for cancer survivors. Descriptive statistics were used to summarize survey content.

RESULTS

A total of 6 nurses and 8 oncologists created 21 SCPs. On average, nurses assisted with 3.5 SCPs and spent 209 min (range 100-600 min) on completing their sections of each SCP, whereas oncologists assisted with 2.6 SCPs and spent 47.4 min (range 15-120). For most SCPs, there was agreement that they should be shared with PCPs (nurse surveys 71.4%, oncologist surveys 100%). Of the 15 participating PCPs, only 28% felt prepared to manage long-term effects in pediatric cancer survivors. They agreed that the SCP would improve communication with their patient's oncologist (80%) and their knowledge for future care (100%).

CONCLUSIONS

SCPs require substantial clinician time to create, but are seen as useful by PCPs. PCPs require specific guidelines and resources concerning ongoing care for pediatric cancer survivors.

Expectations of and recommendations for a cancer survivorship guideline in Japan: a literature review of guidelines for cancer survivorship

BACKGROUND

Optimal cancer survivorship care needs its comprehensive guidelines. We aimed to identify English and Japanese guidelines that include cancer survivorship in their title, the issues highlighted in such guidelines, and any existing oncology practice guidelines in Japan that address these issues.

METHODS

This literature review was performed in three stages. First, guidelines published in English or Japanese that included cancer survivorship in the title were identified. Then, the issues that each cancer survivorship guideline addressed were defined. Lastly, Japanese guidelines that include survivorship issues were sought.

RESULTS

Six guidelines published in English addressed 31 cancer survivorship issues. No specific cancer survivorship guideline was available in Japanese. Thirty-four Japanese guidelines mentioned cancer survivorship issues. These guidelines addressed screening/surveillance for detecting recurrence or secondary cancer but did not address coordination of care, implications for practice, or inclusion of family. At present, Japanese guidelines poorly address the issue of promotion of a healthy lifestyle in cancer survivors. Also, poorly addressed were long-term and late effects such as pain, psychological distress, fatigue, cognitive dysfunction, cardiovascular effects (including anthracycline-induced cardiac toxicity), sleep disorders, and sexual dysfunction in cancer survivors.

CONCLUSION

There is a need for guidelines on optimal coordination of care between oncologists and other health care providers to support patients along the cancer care continuum and specifically to encourage a healthy lifestyle as part of cancer survivorship. The development of a comprehensive Japanese guideline that addresses these issues would help to improve the clinical outcome for cancer survivors in Japan.

Healthcare professionals' perspectives of barriers and facilitators in implementing physical activity programmes delivered to cancer survivors in a shared-care model: a qualitative study

BACKGROUND

The positive impact of physical activity programmes has been recognised, but the current uptake is low. Authorities believe delivering these programmes in a shared-care model is a future perspective. The present study aimed to identify the barriers and facilitators affecting physical activity programme implementation in a shared-care model delivered with the cooperation of all the types of healthcare professionals involved.

METHODS

Thirty-one individual interviews with primary healthcare professionals (PHPs) and four focus group interviews with 39 secondary healthcare professionals (SHPs) were undertaken. We used Grol and Flottorp's theoretical models to identify barriers and facilitators in six domains: (1) physical activity programmes, (2) patients, (3) healthcare professionals, (4) social setting, (5) organisation and (6) law and governance.

RESULTS

In the domain of physical activity programmes, those physical activity programmes that were non-tailored to the patients' needs impeded successful implementation. In the domain of healthcare professionals, the knowledge and skills pertaining to physical activity programmes and non-commitment of healthcare professionals impeded implementation. HCPs expressed their concerns about the negative influence of the patient's social network. Most barriers occurred in the domain of organisation. The PHPs and SHPs raised concerns about ineffective collaboration and networks between hospitals. Only the PHPs raised concerns about poor communication, indeterminate roles, and lack of collaboration with SHPs. Insufficient and unclear insurance coverage of physical activity programmes was a barrier in the domain of law and governance.

CONCLUSIONS

Improving the domain of organisation seems the most challenging because the collaboration, communication, networks, and interactive roles between the PHPs and SHPs are all inadequate. Survivor care plans, more use of health information technology, improved rehabilitation guidelines, and better networks might benefit implementing physical activity programmes.

General practitioners' involvement during survivorship care of colon cancer in the Netherlands: primary health care utilization during survivorship care of colon cancer, a prospective multicentre cohort study

BACKGROUND

Primary health care use increases when cancer is diagnosed. This increase continues after cancer treatment. More generalist care is suggested to improve survivorship care. It is unknown to what extent cancer-related symptoms are currently presented in primary care in this survivorship phase.

OBJECTIVE

To analyse primary health care utilization of colon cancer patients during and after treatment with curative intent.

METHODS

In a prospective multicentre cohort study among patients with curatively treated colon cancer, we describe the primary health care utilization during the first 5 years of follow-up. Data were collected at general practitioner (GP) practices during 6 months.

RESULTS

Of 183 included participants, 153 (84%) consulted their GP resulting in 606 contacts (mean 3.3, standard deviation 3.01) with on average 0.9 contact for colon-cancer-related (CCR) problems in the 6-month study period. Median time after surgery at inclusion was 7.6 months (range 0-58). Abdominal pain and chemotherapy-related problems were the most frequently reported CCR reasons. Of the CCR contacts, 83% was managed in primary care. As time after surgery passed, the number of CCR contacts declined in patients without chemotherapy and remained constant in patients who received chemotherapy.

CONCLUSION

Colon cancer survivors contact their GP frequently also for reasons related to cancer. Currently, a formal role for GPs in survivorship care is lacking, but nevertheless GPs provide a substantial amount of care. Working agreements between primary and secondary care are necessary to formalize the GP's role in order to improve the quality of survivorship care.

Management of Primary Ovarian Insufficiency Symptoms in Survivors of Childhood and Adolescent Cancer

Cancer treatments can damage the ovaries, causing primary ovarian insufficiency (POI), a condition associated with numerous sequelae that impact long-term quality of life. This article systematically reviews the literature on the prevalence, surveillance, and treatment of POI in survivors of pediatric and adolescent and young adult (AYA) cancers. A systematic review of the literature was conducted in January 2018 through a search of Medline, Embase, Web of Science, and SCOPUS, alongside the screening of relevant reference lists. An initial search identified 746 potentially relevant studies. A total of 36 studies were included in the final review. Studies were categorized into one of the following categories: incidence/prevalence of POI, measurement of ovarian reserve, and other. Depending on patient characteristics, cancer diagnosis, and treatment, the prevalence of POI ranged from 2.1% to 82.2%. Risk factors for POI included exposure to alkylating agents and abdominal/pelvic radiation. POI may be associated with a number of complications, including low bone mineral density and poor cardiovascular health. Radiotherapy and chemotherapy are known to cause gonadal damage in female survivors of pediatric and AYA cancers. Acute or chronic effects depend on the dose of treatment, age of the individual, radiotherapy field, and ovarian reserve of the individual. Some women experience short-term loss of reproductive function and then may resume menstrual cycles, months or even years later. Although protecting fertility through banking of mature eggs, embryos, and tissue samples has become standard of care, additional steps need to be taken to ensure that patients have adequate hormone levels to maintain whole-body health, including life expectancy, bone health, cardiovascular health, quality of life, sexual and genitourinary function, and neurologic function. Surveillance and management of each of these comorbidities is critically important to survivor health.

Definition and Coordination of Roles and Responsibilities Among Cancer Center Clinic and Research Personnel

PURPOSE

Effective enrollment and treatment of patients in cancer clinical trials require definition and coordination of roles and responsibilities among clinic and research personnel.

MATERIALS AND METHODS

We developed a survey that incorporated modified components of the Survey of Physician Attitudes Regarding the Care of Cancer Survivors. Surveys were administered to clinic nursing staff and research personnel at a National Cancer Institute-designated comprehensive cancer center. Results were analyzed using χ²-tests, t tests, and analyses of variance.

RESULTS

Surveys were completed by 105 staff members (n = 50 research staff, n = 55 clinic staff; 61% response rate). Research staff were more likely to feel that they had the skills to answer questions, convey information, and provide education for patients on trials (all P < .05). Both clinic and research staff reported receipt of communication about responsibilities in fewer than 30% of cases, although research staff reported provision of such information in more than 60% of cases. Among 20 tasks related to care of patients in trials, no single preferred model of responsibility assignment was selected by the majority of clinic staff for nine tasks (45%) or by research staff for three tasks (15%). Uncertainty about which team coordinates care was reported by three times as many clinic staff as research staff (P = .01). There was also substantial variation in the preferred model for delivery of care to patients in trials (P < .05).

CONCLUSION

Knowledge, attitudes, and perception of care and responsibilities for patients on clinical trials differ between and among clinic and research personnel. Additional research about how these findings affect efficiency and quality of care on clinical trials is needed.

Understanding Long-Term Cancer Survivors' Preferences for Ongoing Medical Care

BACKGROUND

Due to risk for treatment-related late effects and concerns about cancer recurrence, long-term cancer survivors have unique medical needs. Survivors' preferences for care may influence adherence and care utilization.

OBJECTIVE

To describe survivors' preferences for care and factors associated with preferred and actual care.

DESIGN

Cross-sectional analysis of participants in a longitudinal study using mailed questionnaires.

PARTICIPANTS

Survivors of ten common cancers (n = 2,107, mean years from diagnosis 8.9).

MAIN MEASURES

(1) Survivors' preferences for primary care physician (PCP) and oncologist responsibilities across four types of care: cancer follow-up, cancer screening, preventive health, and comorbid conditions. (2) Survivor-reported visits to PCPs and oncologists.

KEY RESULTS

The response rate was 42.1%. Most long-term survivors preferred PCPs and oncologists share care for cancer follow-up (63%) and subsequent screening (65%), while preferring PCP-led preventive health (77%) and comorbid condition (83%) care. Most survivors (88%) preferred oncologists involved in cancer follow-up care, but only 60% reported an oncologist visit in the previous 4 years, and 96% reported a PCP visit in the previous 4 years. In multivariable regressions, those with higher fear of cancer recurrence were less likely to prefer PCP-led cancer follow-up care (OR = 0.96, CI = 0.93-0.98), as did survivors with advanced cancer stage (OR = 0.56, CI = 0.39-0.79). Those with higher fear of recurrence (OR = 1.03, CI = 1.01-1.04) or who preferred oncologist-led cancer follow-up care (OR = 2.08, CI = 1.63-2.65) had greater odds of seeing an oncologist in the last 4 years.

CONCLUSIONS

Most cancer survivors preferred PCPs and oncologists share care for cancer follow-up and screening, yet many had not seen an oncologist recently. Survivors preferred PCP-led care for other preventive services and management of comorbid conditions. These findings highlight the important role PCPs could play in survivor care, suggesting the need for PCP-oriented education and health system policies that support high-quality PCP-led survivor care.

NCCN Guidelines Insights: Survivorship, Version 2.2019

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for consequences of cancer and cancer treatment to aid healthcare professionals who work with survivors of adult-onset cancer. Guidance is also provided to help promote physical activity, weight management, and proper immunizations in survivors and to facilitate care coordination to ensure that all needs are addressed. These NCCN Insights summarize some of the topics discussed by the NCCN Survivorship Panel during the 2019 update of the guidelines, including the survivorship population addressed, ways to improve care coordination, and pain management.

Physical fitness in survivors of childhood Hodgkin lymphoma: A report from the St. Jude Lifetime Cohort

BACKGROUND

There are limited data describing fitness and associated health-related quality of life (HRQoL) in survivors of childhood Hodgkin lymphoma (HL).

PROCEDURE

Fitness was evaluated among 336 adult survivors of childhood-onset HL treated at St. Jude Children's Research Hospital and 327 controls who never had childhood cancer. The controls were frequency matched on age, sex, and race. Associations were examined between chronic disease and fitness and between fitness and HRQoL using a multivariable linear and logistic regression.

RESULTS

Male survivors had lower endurance (6-min walk [6MW] distance 604.4 ± 7.9 m vs 637.0 ± 7.5 m, P < 0.01), and worse neuropathy (modified Total Neuropathy Score [mTNS] 2.7 ± 0.2 vs 1.4 ± 0.2, P < 0.01) compared to controls. Female survivors had lower endurance (6MW distance 564.5 ± 6.9 m vs 590.6 ± 7.0 m, P < 0.01), quadriceps strength (145.7 ± 4.0 vs 163.4 ± 4.0 N·m per kilogram, P < 0.01), and worse neuropathy (mTNS 3.2 ± 0.2 vs 1.4 ± 0.3, P < 0.01) compared to controls. Moderate, severe/disabling, or life-threatening (grades 2-4) neurological conditions were associated with impaired quadriceps strength (odds ratio [OR] 2.94, 99% confidence interval [CI] 1.24-6.96) and impaired endurance (OR 2.96, 99% CI 1.28-6.69). Cardiovascular (OR 2.36, 99% CI 1.00-5.61) and pulmonary (OR 2.78, 99% CI 1.30-5.94) conditions were associated with impaired endurance. Quadriceps strength (β -6.44 ± 2.01, P < 0.01), endurance (β -4.63 ± 1.54, P < 0.01), and neuropathy (β -4.98 ± 1.14, P < 0.01) were associated with a lower physical component summary on the HRQoL.

CONCLUSION

Survivors of childhood HL, particularly those with neurological, cardiac, and pulmonary chronic conditions, are at risk for impaired fitness and HRQoL.

Knowledge and Preferences of Primary Care Providers in Delivering Head and Neck Cancer Survivorship Care

Long-term care for head and neck cancer (HNC) survivors is complex and requires coordination among multiple providers. Clinical practice guidelines highlight the role of primary care providers (PCPs) in screening for secondary cancer/recurrence, assessment of late/long-term side effects, and referrals for appropriate specialty management of toxicity. However, these responsibilities may be difficult to meet within the scope of primary care practice. We conducted this study to explore preferences, comfort, and knowledge of PCPs in the care of HNC survivors. We piloted a 40-item web-based survey developed with oncologist and PCP input targeted for family medicine and internal medicine providers. Responses were collected within a single university health system over 2 months. PCPs (n = 28; RR = 11.3%) were interested in learning about health promotion after cancer treatment (89%) and generally agree that their current practice patterns address healthy lifestyle behaviors (82%). However, only 32% of PCPs felt confident they could manage late/long-term side effects of chemotherapy, radiation, or surgery. Only 29% felt confident they could provide appropriate cancer screening. Looking at shared care responsibilities with oncology providers, PCPs perceived being responsible for 30% of care in the first year after treatment and 81% of care after 5 years. Seventy-one percent of PCPs agreed that oncologists provided them necessary information, yet 32% of PCPs found it difficult to coordinate with cancer providers. While these PCPs perceive increased care responsibility for long-term survivors, most are uncomfortable screening for recurrence and managing late/long-term side effects. Education and mutual coordination between PCPs and oncology providers may improve survivor care.

Anticipating the "Silver Tsunami": Prevalence Trajectories and Comorbidity Burden among Older Cancer Survivors in the United States

BACKGROUND

Cancer survivors are a growing population, due in large part to the aging of the baby boomer generation and the related "silver tsunami" facing the U.S. health care system. Understanding the impact of a graying nation on cancer prevalence and comorbidity burden is critical in informing efforts to design and implement quality cancer care for this population.

METHODS

Incidence and survival data from 1975 to 2011 were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program to estimate current cancer prevalence. SEER-Medicare claims data were used to estimate comorbidity burden. Prevalence projections were made using U.S. Census Bureau data and the Prevalence Incidence Approach Model, assuming constant future incidence and survival trends but dynamic projections of the U.S.

RESULTS

In 2016, there were an estimated 15.5 million cancer survivors living in the United States, 62% of whom were 65 years or older. The prevalent population is projected to grow to 26.1 million by 2040, and include 73% of survivors who are 65 years and older. Comorbidity burden was highest in the oldest survivors (those ≥85 years) and worst among lung cancer survivors.

CONCLUSIONS

Older adults, who often present with complex health needs, now constitute the majority of cancer survivors and will continue to dominate the survivor population over the next 24 years.

IMPACT

The oldest adults (i.e., those >75 years) should be priority populations in a pressing cancer control and prevention research agenda that includes expanding criteria for clinical trials to recruit more elderly participants and developing relevant supportive care interventions. Cancer Epidemiol Biomarkers Prev; 25(7); 1029-36. ©2016 AACR.

Chemotherapy-induced peripheral neurotoxicity in cancer survivors: an underdiagnosed clinical entity?

Systemic chemotherapy is a cornerstone of the modern medical management of cancer, although its use is limited by toxicity on normal tissues and organs, including the nervous system. Long-surviving or cured people strongly require a high level of wellness in addition to prolongation of life (the concept of the quality of survival), but neurologic dysfunction can severely affect daily life activities. Chemotherapy-related peripheral neurotoxicity is becoming one of the most worrisome long-term side effects in patients affected by a neoplasm. The central nervous system has a limited capacity to recover from injuries, and it is not surprising that severe damage can determine long-term or permanent neurologic dysfunction. However, the peripheral nervous system also can be permanently damaged by anticancer treatments despite its better regeneration capacities, and the effect on patients' daily life activities might be extremely severe. However, only recently, the paradigms of peripheral neurotoxicity reversibility have been scientifically challenged, and studies have been performed to capture the patients' perspectives on this issue and to measure the effect of peripheral neurotoxicity on their daily life activities. Despite these efforts, knowledge about this problem is still largely incomplete, and further studies are necessary to clarify the several still-unsettled aspects of long-term peripheral neurotoxicity of conventional and targeted anticancer chemotherapy.

Identification of health care needs of long-term breast cancer survivors among Israeli women

PURPOSE

Improvement in treatment has extended survival of breast cancer patients. Our study aimed to characterize health service use among long-term breast cancer survivors in Israel in order to identify and address specific needs of this subpopulation.

METHODS

The study population included 250 women diagnosed with breast cancer, 8-12 years prior to study initiation (cases), and 250 individually matched cancer-free controls. Participants were recruited from the second largest Israeli HMO, and data were collected through personal interviews. ORs and 95 % CIs were estimated using conditional logistic regression and generalized estimating equations.

RESULTS

Greater use of health services was observed among cases, compared to an age-matched comparison group, expressed by more visits to family physicians and specialists, longer duration of visits, more requests for referrals, more frequent contact with emergency services, and hospitalizations. The study groups were similar regarding socioeconomic variables, current smoking and physical activity, BMI, and prevalence of reported morbidity. Although 80 % of cases defined the family physician as their main treating physician, half still considered their oncologist responsible for cancer follow-up. Only 14.4 and 10.4 % of cases and controls, respectively, reported receiving psychological support during the year preceding the interview.

CONCLUSIONS

Further studies should assess the contribution of apprehension concerning health-related issues that still accompany breast cancer survivors, to the excess use of health services. Concern among family practitioners may contribute as well. In addition, our results emphasize the need to improve coordination between the disciplines of oncology and community medicine for the medical care of this group.

Understanding Fertility in Young Female Cancer Patients

Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Studies demonstrate that future fertility is a concern for many women diagnosed with cancer, but physician knowledge and attitudinal barriers can still prevent females from receiving care. Today, fertility preservation is an option for girls and women facing a cancer diagnosis, and emerging research is providing clinicians with an increasing number of reproductive and hormonal management tools. Physicians can play an important role in fertility by working closely with oncologists, providing patients with information about fertility preservation options prior to the start of cancer treatment, monitoring reproductive capacity after treatment, and working with cancer survivors to explore potential avenues to parenthood.

Institute of medicine recommendations for improving the quality of cancer care: what do they mean for the general internist?

In order to evaluate and address the deficiencies in the U.S. cancer care system, particularly affecting the growing elderly population, the Institute of Medicine (IOM) convened a panel representing oncology providers, surgeons, primary care providers, researchers, policy makers and patients. The Committee concluded that cancer care is on the brink of crisis and issued recommendations targeting all stakeholders involved in cancer care. General internists play a critical role in the care of cancer patients, from the time of diagnosis, through treatment, survivorship and end of life care. We review the IOM recommendations, highlight those that are particularly relevant to the general internist, and outline clinical, research and educational opportunities where general internists should take an expanded role.

The state of cancer survivorship programming in Commission on Cancer-accredited hospitals in Georgia

PURPOSE

In Georgia, there are more than 356,000 cancer survivors. Although many encounter challenges as a result of treatment, there is limited data on the availability of survivorship programming. This paper highlights findings from two surveys assessing survivorship care in Commission on Cancer (CoC)-accredited hospitals in Georgia.

METHODS

In 2010, 38 CoC-accredited hospitals were approached to complete a 36-item survey exploring knowledge of national standards and use of survivorship care plans (SCPs), treatment summaries (TSs), and psychosocial assessment tools. In 2012, 37 CoC-accredited hospitals were asked to complete a similar 21-item survey.

RESULTS

Seventy-nine percent (n = 30) of cancer centers completed the 2010 survey. Sixty percent (n = 18) reported having a cancer survivorship program in place or in development. Forty-three percent (n = 13) provided survivors with a SCP and 40% (n = 12) a TS. Sixty percent (n = 18) reported either never or rarely using a psychosocial assessment tool. Sixty-two percent (n = 23) completed the 2012 survey. Ninety-six percent (n = 22) were aware of the new CoC guideline 3.3. Thirty-nine percent (n = 9) provided a SCP and/or TS. Eighty-seven percent (n = 20) stated they were very confident or somewhat confident their organization could implement a SCP and/or TS by 2015.

CONCLUSIONS

The data indicated the importance of collaboration and shared responsibility for survivorship care. Broad implementation of SCPs and TSs can help address the late and long-term effects of treatment.

IMPLICATIONS FOR CANCER SURVIVORS

Increasing knowledge on survivorship care is imperative as the Georgia oncology community engages oncologists and primary care providers to achieve higher quality of life for all survivors.

Cancer survivorship training: a pilot study examining the educational gap in primary care medicine residency programs

BACKGROUND

Cancer survivors need high-quality follow-up care that addresses long-term problems related to cancer and their treatment. With growing numbers of cancer patients transitioning from oncological treatment to survivorship care, primary care physicians (PCPs) will play a major role in the delivery of survivorship care.

OBJECTIVE

This pilot study was undertaken to provide initial insights into internal medicine (IM) and family medicine (FM) residents' educational experience, training, and preparedness for practice as healthcare providers of adult cancer survivors (ACS).

DESIGN

This study utilizes an anonymous cross-sectional, electronic survey of a sample of US IM and FM residents.

PARTICIPANTS

A total of 77 residents in their PGY-3 year of training responded to the survey, including 53 IM (69%) and 24 FM (31%) residents.

RESULTS

The majority (97%) of respondents performed as PCPs for ACS during their training, and 81% expected to take care of such patients in the future. However, only a minority reported feeling very comfortable in this role or very confident of identifying cancer recurrence and potential long-term effects of cancer treatment (13%, 21%, and 15%, respectively). Formal education in survivorship care was reported by 27% of residents and was modestly associated with knowledge responses. High clinical exposure (defined as having ≥10 opportunities to perform as the PCP for ACS) was significantly associated with self-reported knowledge, comfort level, and self-confidence in being able to evaluate and manage potential long-term effects of cancer treatment and their symptoms.

CONCLUSIONS

Our results suggest there is a substantial disconnect between resident's educational experience, training, and self-reported preparedness for practice in cancer survivorship in both IM and FM training specialties.

IMPLICATIONS FOR CANCER SURVIVORS

Inadequate training in cancer survivorship represents a barrier to providing adequate cancer follow-up. Inexperience or unawareness of essential survivorship issues could lead to mistakes which affect survivors' health and timely assessment of long-term cancer-associated morbidity. As PCPs will play a key role in the delivery of survivorship care, effective educational opportunities and achievement of competencies in adult cancer survivorship care by primary care trainees are needed.

Patient perceptions of a comprehensive cancer navigation service

OBJECTIVE

Our aim was to determine the extent to which comprehensive navigation augments the provincial health system for meeting the needs of newly-diagnosed cancer patients (clients). We also assessed reactions of attending physicians to comprehensive navigation.

METHODS

Clients who completed navigation as an employee benefit or through membership in an insurance organization were polled to determine whether they needed help beyond that provided by the provincial health system and the extent to which that help was provided by navigation. Exit interviews were analyzed for perceptions of the clients about reactions by their attending physicians to navigation.

RESULTS

Of eligible clients, 72% responded. They reported needing help beyond that which the provincial system could provide in 64%-98% of specified areas. Navigation provided help in more than 90% of those cases. Almost all respondents (98%) appreciated having a designated oncology nurse navigator. Family doctors were perceived to be positive or neutral about navigation in 100% of exit interviews. Oncologists were positive or neutral in 92% (p < 0.001 for difference from family doctors).

CONCLUSIONS

In many areas, cancer patients need additional help beyond that which the provincial health system can provide. Comprehensive cancer navigation provides that help to a considerable extent. Clients perceived the reactions of attending physicians to comprehensive navigation to be generally supportive or neutral.