Cluster Analysis Demonstrates the Need to Individualize Care for Cancer Survivors

Demographic and Clinical Factors Associated With Health-Related Quality-of-Life Profiles Among Prostate Cancer Survivors

PURPOSE

Our purpose was to describe the prevalence and predictors of symptom and function clusters related to physical, emotional, and social components of general health-related quality of life (HRQOL) in a population-based sample of prostate cancer (PCa) survivors.

METHODS

Participants (N = 1,162) completed a baseline survey at a median of 9 months after diagnosis to ascertain the co-occurrence of eight symptom and functional domains that are common across all cancers and not treatment-specific. We used latent profile analysis (LPA) to identify subgroup profiles of survivors with low, moderate, or high HRQOL levels. Multinomial logistic regression models were used to identify clinical and sociodemographic factors associated with survivors' membership in the low versus moderate or high HRQOL profile.

RESULTS

The LPA identified 16% of survivors who were categorized in the low HRQOL profile at baseline, indicative of the highest symptom burden and lowest functioning. Factors related to survivors' membership in the low versus higher HRQOL profile groups included less than age 65 years at diagnosis, identifying as non-Hispanic Black race, not working, being a former versus never smoker, systemic therapy, less companionship, more comorbidities, lower health care financial well-being, or less spirituality. Several factors remained associated with remaining in the low versus higher HRQOL profiles on the follow-up survey (n = 699), including younger age, Black race, comorbidity, and lower financial and spiritual well-being.

CONCLUSION

About one of six PCa survivors experienced elevated physical and psychosocial symptoms that were independent of local curative therapy, but with younger age, race, comorbidity, and lower financial and spiritual well-being as stable risk factors for poor HRQOL over time.

Cancer survivor late-effects, chronic health problems after cancer treatment: what's the evidence from population and registry data and where are the gaps?

PURPOSE OF REVIEW

Improvements in cancer treatment have led to more people living with and beyond a cancer diagnosis but survivors may have increased health problems as they age. The purpose of this review is to critically evaluate population data exploring incidence of late effects for cancer survivors.

RECENT FINDINGS

18 studies were identified between 2013 and 2023 that explored the impact on survivors' physical and emotional health. Patients who had been treated at least 2 years previously for cancer had significant cardiovascular risk factors compared with age-matched controls. Women with breast cancer were more likely to have cardiovascular disease, including hypertension, arrythmias and congestive heart failure. This was associated with anthracyclines and/or trastuzumab as part of systemic anti-cancer therapy. Survivors of colorectal cancer were three times more likely to have acute kidney injury than age-matched controls. Stress and mood disorders were higher in survivors of testicular cancer and prostate cancer.

SUMMARY

Population studies are important to identify the 'real world' consequences of cancer and its treatment beyond clinical trials. Knowledge is critical for managing an ageing cancer population. Data to personalise cancer survivorship care, not only helps determine potential health risks, but can improve secondary prevention, emotional health, recovery, and long-term outcomes.

How to create value with constrained budgets in oncological care? A narrative review

INTRODUCTION

As a result of an increasing focus on patient-centered care within oncology and more pressure on the sustainability of health-care systems, the discussion on what exactly constitutes value re-appears. Policymakers seek to improve patient values; however, funding all values is not sustainable.

AREAS COVERED

We collect available evidence from scientific literature and reflect on the concept of value, the possible incorporation of a wide spectrum of values in reimbursement decisions, and alternative strategies to increase value in oncological care.

EXPERT OPINION

We state that value holds many different aspects. For reimbursement decisions, we argue that it is simply not feasible to incorporate all patient values because of the need for efficient resource allocation. We argue that we should shift the value debate from the individual perspective of patients to creating value for the cancer population at large. The different strategies we address are as follows: (1) shared decision-making; (2) biomarkers and molecular diagnostics; (3) appropriate evaluation, payment and use of drugs; (4) supportive care; (5) cancer prevention and screening; (6) monitoring late effect; (7) concentration of care and oncological networking; and (8) management of comorbidities. Important preconditions to support these strategies are strategic planning, consistent cancer policies and data availability.

Feasibility of introducing a smartphone navigation application into the care of breast cancer patients (The FIONA Study)

PURPOSE

Patients with breast cancer (BC) face complex medical information and decisions. The Outcomes4Me mobile app provides evidence-based BC education, symptom management tracking and clinical trial matching. This study sought to evaluate the feasibility of introducing this app into routine BC care.

METHODS

In this pilot study among BC patients undergoing therapy at an academic cancer center, patients were followed for 12 weeks with survey administration and electronic health record (EHR) abstraction at baseline and completion. Feasibility was defined as 40% of patients engaging with the app 3 or more times during the study. Additional endpoints included app usability (system usability scale), patient care experience, symptom evaluation, and clinical trial matching.

RESULTS

The study enrolled 107 patients from 6/01/2020 to 3/31/2021. Utilization of the app was deemed feasible with 60% of patients engaging with the app at least 3 times. SUS score of 70 indicated above average usability. New diagnosis and higher education level was associated with greater app engagement, with usability similar across all age groups. 41% of patients found the app helped track symptoms. Cognitive and sexual symptoms were infrequently reported, but were more frequently captured in the app than in the EHR. After using the app, 33% of patients reported increased interest in clinical trial enrollment.

CONCLUSION

Introducing the Outcomes4Me patient navigation app into routine BC care is feasible and may improve the patient experience. These results support further evaluation of this mobile technology platform to improve BC education, symptom management, and decision making.

CLINICAL TRIAL REGISTRY

Clinicaltrials.gov registration #: NCT04262518.

OUP accepted manuscript

Appropriate models of survivorship care for the growing number of adult survivors of childhood cancer are unclear. We conducted a realist review to describe how models of care that include primary care and relevant resources (eg, tools, training) could be effective for adult survivors of childhood cancer. We first developed an initial program theory based on qualitative literature (studies, commentaries, opinion pieces) and stakeholder consultations. We then reviewed quantitative evidence and consulted stakeholders to refine the program theory and develop and refine context-mechanism-outcome hypotheses regarding how models of care that include primary care could be effective for adult survivors of childhood cancer. Effectiveness for both resources and models is defined by survivors living longer and feeling better through high-value care. Intermediate measures of effectiveness evaluate the extent to which survivors and providers understand the survivor’s history, risks, symptoms and problems, health-care needs, and available resources. Thus, the models of care and resources are intended to provide information to survivors and/or primary care providers to enable them to obtain/deliver appropriate care. The variables from our program theory found most consistently in the literature include oncology vs primary care specialty, survivor and provider knowledge, provider comfort treating childhood cancer survivors, communication and coordination between and among providers and survivors, and delivery/receipt of prevention and surveillance of late effects. In turn, these variables were prominent in our context-mechanism-outcome hypotheses. The findings from this realist review can inform future research to improve childhood cancer survivorship care and outcomes.

Conceptualizing problems with symptoms, function, health behavior, health-seeking skills, and financial strain in breast cancer survivors using hierarchical clustering

Purpose

Determine whether a diverse set of problems experienced by breast cancer survivors (BCS) following curative treatment can be formulated into a reduced number of clusters, potentially simplifying the conceptualization of these problems.

Method

Female BCS were recruited from four cancer hospitals in China. The Chinese translation of the Cancer Survivor Profile (CSPro) was used to measure 18 common problem areas, as supported by epidemiological and phenomenological research. The Functional Assessment of Cancer Therapy–Breast (FACT-B) was used to measure quality of life, as a validation of any observed groupings. Hierarchical clustering using multiple distance criteria and aggregation methods to detect patterns of problems was used.

Results

A total of 1008 BCS (mean 46.51 years old) living in both urban and rural areas were investigated. Hierarchical cluster analysis identified two major clusters of problems. One set was classified as “functional limitations,” while the other cluster was labeled “multi-problems.” Those who fell into the multi-problem cluster experienced poorer quality of life.

Conclusion

Eighteen non-medical problems were broken down into two major clusters: (1) limitations in higher level functions required of daily life and (2) limitations in health care–seeking skills, problems with certain symptoms, unhealthy behaviors, and financial problems related to cancer. The breakdown of problem areas into these two clusters may help identify common mechanisms.

Implications for Cancer Survivors

In the future, the search for common clusters and the mechanisms for the many problems that breast cancer survivors and other cancer survivors can experience following primary treatment may improve how we help manage these problems in the future.

Understanding Posttreatment Patient-Provider Communication and Follow-Up Care Among Self-Identified Rural Cancer Survivors in Illinois

PURPOSE

As disparities in rural-urban cancer survivorship rates continue to widen, optimizing patient-provider communication regarding timely follow-up care is a potential mechanism to improving survivorship-related outcomes. The current study examines sociodemographic and health predictors of posttreatment patient-provider communication and follow-up care and associations between written communication and timely follow-up care for cancer survivors who identify as rural.

METHODS

Data were analyzed from posttreatment cancer survivor respondents of the Illinois Rural Cancer Assessment Study. The current study tested associations between sociodemographic variables and health factors on the quality of patient-provider communication and timely posttreatment follow-up care, defined as visits ≤ 3 months posttreatment, and associations between the receipt of written patient-provider communication on timely posttreatment follow-up care.

RESULTS

Among 90 self-identified rural cancer survivors, respondents with annual incomes < $50,000 and ≤ High School diploma were more likely to report a high quality of posttreatment patient-provider communication. Posttreatment written communication was reported by 62% of the respondents and 52% reported timely follow-up visits during the first 3 years of posttreatment care. Patients who reported receiving written patient-provider communication were more likely to have timely posttreatment follow-up care after completing active treatment than patients who had not received written patient-provider communication.

CONCLUSIONS

Our findings suggest that written patient-provider communication improved timely follow-up care for self-identified rural cancer survivors. This research supports policy and practice that recommend the receipt of written survivorship care plans. Implementation of written survivorship care recommendations has the potential to improve survivorship care for rural cancer survivors.

Implementation of a Brief Screening Tool to Identify Needs of Breast Cancer Survivors

BACKGROUND

Innovation in health care delivery is needed to improve care for cancer survivors. We report our experience with adapting screening questions from the National Comprehensive Cancer Network (NCCN) guideline to evaluate the needs of breast cancer survivors.

MATERIALS AND METHODS

We adapted the NCCN-recommended screening questions into a plain language, self-administered 1-page intake questionnaire. The tool was administered to a convenience sample of female breast cancer survivors at follow-up oncology and primary care visits. Domains included symptoms, lifestyle concerns, and financial issues. Frequency of concerns was assessed as "never," "rarely," "sometimes," "very frequently," and "always." We evaluated feasibility and utility of administration and the prevalence and frequency of patient-reported concerns.

RESULTS

The questionnaire was highly acceptable to patients and enhanced visits for clinicians. Clinicians reported that it led to discussion of issues that may not otherwise be addressed in the visit and did not find it burdensome. The most commonly endorsed patient concerns were desire to improve fitness or nutrition, worry about cancer recurrence, and insomnia. A majority also reported feeling anxiety and aches or pains in joints or extremities. Several issues known to be underreported in clinic visits were frequently endorsed, included sexual dissatisfaction and memory impairments. Clinicians suggested incorporating the tool into the electronic health record to increase utility and awareness.

CONCLUSION

Screening for individual needs among breast cancer survivors is feasible, efficient, and may identify prevalent issues that otherwise can be missed in routine survivorship care.

The use of survivorship care plans by female racial and ethnic minority breast cancer survivors: a systematic review

PURPOSE

Racial/ethnic breast cancer survivorship disparities persist as minority breast cancer survivors (MBCSs) report fragmentation in survivorship care, namely in the access and delivery of survivorship care plans (SCPs). To better understand care coordination of MCBS, this review elucidated concerns of female MBCS about their preparation for post-treatment survivorship care, the preferred practices for the delivery of a SCP, and the associated content to improve post-treatment survivorship care understanding.

METHODS

A systematic search of articles from PubMed, Ovid-Medline, CINAHL databases, and bibliographic reviews included manuscripts using keywords for racial/ethnic minority groups and breast cancer survivorship care coordination terms. Salient themes and article quality were analyzed from the extracted data.

RESULTS

Fourteen included studies represented 5,854 participants and over 12 racial/ethnic groups. The following themes of post-treatment MBCS were identified from the review: (1) uncertainty about post-treatment survivorship care management is a consequence of sub-optimal patient-provider communication; (2) access to SCPs and related materials are desired, but sporadic; and (3) advancements to the delivery and presentation of SCPs and related materials are desired.

CONCLUSIONS

Representation of only 14 studies indicates that the MBCSs' perspective post-treatment survivorship care is underrepresented in the literature. Themes from this review support access to, and implementation of, culturally tailored SCP for MBCS. There was multi-ethnic acceptance of SCPs as a tool to help improve care coordination.

IMPLICATIONS FOR CANCER SURVIVORS

These findings highlight the importance of general education about post-treatment survivorship, post-treatment survivorship needs identification, and the elucidation of gaps in effective SCP delivery among MBCS.

Patients' information coping styles influence the benefit of a survivorship care plan in the ROGY Care Trial: New insights for tailored delivery

BACKGROUND

In efforts to improve the implementation of survivorship care plans (SCPs), the authors assessed whether the impact of SCPs on patient-reported outcomes differed between patients with an information-seeking coping style (monitoring) versus those with an information-avoiding coping style (blunting).

METHODS

In the Registration System Oncological Gynecology (ROGY) Care Trial, 12 hospitals in the Netherlands were randomized to deliver SCP care or usual care. All patients with newly diagnosed endometrial and ovarian cancer in the SCP care arm received an SCP that was generated automatically by their oncology provider through the web-based ROGY registration system. Outcomes (satisfaction with information provision and care, illness perceptions, and health care use) were measured directly after initial treatment and after 6, 12, and 24 months. Information coping style was measured at 12 months after initial treatment.

RESULTS

Among patients who had a monitoring coping style (N = 123), those in the SCP care arm reported higher satisfaction with information provision (mean score: 73.9 vs 63.9, respectively; P = .04) and care (mean score: 74.5 vs 69.2, respectively; P = .03) compared with those in the usual care arm. Among patients who had a blunting coping style (N = 102), those in the SCP care arm reported a higher impact of the disease on life (mean score: 5.0 vs 4.5, respectively; P = .02) and a higher emotional impact of the disease (mean score: 5.4 vs 4.2, respectively; P = .01) compared with those in the usual care arm.

CONCLUSIONS

SCPs may be beneficial for patients who desire information about their disease, whereas SCPs may be less beneficial for patients who avoid medical information, suggesting a need for tailored SCP delivery to improve survivorship care.