The efficacy, challenges, and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews

BACKGROUND

Telemedicine services have been increasingly used to facilitate post-treatment cancer survivorship care, including improving access; monitoring health status, health behaviors, and symptom management; enhancing information exchange; and mitigating the costs of care delivery, especially since the COVID-19 pandemic. To inform guidance for the use of telemedicine in the post-COVID era, the aim of this overview of systematic reviews (SRs) was to evaluate the efficacy of, and survivor engagement in, telemedicine interventions in the post-treatment survivorship phase, and to consider implementation barriers and facilitators.

METHODS

PubMed, Cochrane CENTRAL, CINAHL, Embase, and Web of Science databases were searched. SRs that examined the use of telemedicine in the post-treatment phase of cancer survivorship, published between January 2010 and April 2021, were included. Efficacy data were synthesized narratively. Implementation barriers and facilitators were synthesized using the Consolidated Framework for Implementation Research.

RESULTS

Twenty-nine SRs were included. A substantive body of evidence found telemedicine to benefit the management of psychosocial and physical effects, particularly for improving fatigue and cognitive function. There was a lack of evidence on the use of telemedicine in the prevention and surveillance for recurrences and new cancers as well as management of chronic medical conditions. This overview highlights a range of diverse barriers and facilitators at the patient, health service, and system levels.

CONCLUSIONS

This review highlights the benefits of telemedicine in addressing psychosocial and physical effects, but not in other areas of post-treatment cancer survivorship care. This large review provides practical guidance for use of telemedicine in post-treatment survivorship care.

Implementing a regional oncology information system: approach and lessons learned

RATIONALE

Paper-based medical record systems are known to have major problems of inaccuracy, incomplete data, poor accessibility, and challenges to patient confidentiality. They are also an inefficient mechanism of record-sharing for interdisciplinary patient assessment and management, and represent a major problem for keeping current and monitoring quality control to facilitate improvement. To address those concerns, national, regional, and local health care authorities have increased the pressure on oncology practices to upgrade from paper-based systems to electronic health records.

OBJECTIVES

Here, we describe and discuss the challenges to implementing a region-wide oncology information system across four independent health care organizations, and we describe the lessons learned from the initial phases that are now being applied in subsequent activities of this complex project.

RESULTS

The need for change must be shared across centres to increase buy-in, adoption, and implementation. It is essential to establish physician leadership, commitment, and engagement in the process. Work processes had to be revised to optimize use of the new system. Culture change must be included in the change management strategy. Furthermore, training and resource requirements must be thoroughly planned, implemented, monitored, and modified as required for effective adoption of new work processes and technology. Interfaces must be established with multiple existing electronic systems across the region to ensure appropriate patient flow. Periodic assessment of the existing project structure is necessary, and adjustments are often required to ensure that the project meets its objectives.

CONCLUSIONS

The implementation of region-wide oncology information systems across different health practice locations has many challenges. Leadership is essential. A strong, collaborative information-sharing strategy across the region and with the supplier is essential to identify, discuss, and resolve implementation problems. A structure that supports project management and accountability contributes to success.

The skin cancer prevention framework: a comprehensive tool for population-level efforts in skin cancer

The Skin Cancer Prevention Team (SCPT) required a comprehensive approach for guiding its efforts in population-level skin cancer prevention. After identifying and reviewing several models, it concluded that an appropriate population-level model applicable to the Alberta context did not exist. Thus, the SCPT, under the Alberta Health Services - Cancer Prevention Program, developed and evaluated a model for Alberta. Three inclusion criteria for a comprehensive framework were identified: 1) use an ecological approach to population health; 2) function as a dynamic tool for planning, implementing and evaluating population-level efforts; and 3) address weaknesses in existing theory in population health and health promotion. Theoretical constructs were layered together, on the basis of the criteria, to develop an omnibus framework. The resulting Framework represents a layering of several constructs used in popular health promotion and population health theories. It merges principles of the realist approach to scientific enquiry with principles of ecological theory. The Framework outlines a three-step, dynamic process for planning, implementing and evaluating population-level efforts. It also provides insight into the larger, unifying influences for changes in health outcomes and the complex mechanisms of behaviour change processes at the population level.

Assessing the evidence for organised cancer screening programmes

The aim of this study was to review the evidence in the literature for organised cancer screening programmes. A Medline search for publications related to organised cancer screening programmes and their components was done. While there is a broad descriptive literature on various cancer screening programmes, there are few published studies that evaluate the impact of organised cancer screening. Most of the evidence to date is from Scandinavian cervical and breast cancer screening programmes. There is a moderate amount of literature that evaluates specific components of cancer screening programmes (such as quality control and recruitment). There is a substantial body of literature on organised cancer screening programmes. However, the studies tend to describe organised screening programmes rather than evaluate their effectiveness relative to opportunistic screening. Furthermore, most studies focus on individual components of organised screening programmes, rather than on the programmes as a whole. More research is needed that directly compares organised with opportunistic cancer screening.

Workshop report: physical activity and cancer prevention

A workshop to evaluate the evidence for the role of physical activity in cancer prevention and to identify priorities for action, particularly in relation to the primary prevention of cancer, was held by Cancer Care Ontario in March 2000. A review of the scientific evidence was commissioned and an expert panel convened to consider the review report and to make recommendations for public health, research and intervention. The panel concluded that evidence was convincing for the role of physical activity in preventing colon cancer; probable for breast cancer; possible for prostate cancer and insufficient for other sites. It is recommended that physical activity messages promoting at least 30 45 minutes of moderate to vigorous activity on most days of the week be included in primary prevention interventions for cancer. The panel recommended that future research on physical activity incorporate comprehensive assessments, including measures of the multiple dimensions and types of physical activity; biological mechanisms; and behavioural and population factors. Cancer Care Ontario will incorporate physical activity messages in its primary prevention programming around nutrition and health body weight.

The Sociobehavioural Cancer Research Network: background and progress report

The Sociobehavioural Cancer Research Network (SCRN) was established in 1994 by the National Cancer Institute of Canada (NCIC) with funding from the Canadian Cancer Society (CCS). The network was created to facilitate the development of behavioural science studies that would contribute to a fuller understanding of the cancer experience, from prevention through detection, treatment and post treatment (including palliative care). This article describes the nature of network research, the development and organization of the Sociobehavioural Cancer Research Network and the challenges it faces.

Issues in the implementation of cancer staging in Canada

All sectors of the cancer control community in Canada agree that cancer staging is useful, and that stage should be assigned to every new case. At present, however, staging is not always recorded in the patient's records and treatment patterns and outcomes are rarely reported in terms of stage. This paper discusses what needs to be done to promote the use of staging in Canada. It is concluded that multifaceted programs of interventional continuing education (CE), tailored to meet the needs of the particular institution, offer the best prospect of success but the necessary organizational structure and information systems have to be put into place in advance. Implementation programs should be based on a thorough evaluation of the particular needs of the institution or community, and should be evaluated carefully in a few institutions before an attempt is made to disseminate them more widely. We recommend a phased approach to implementation which will first target institutions that already have the necessary infrastructure, i.e., provincial cancer centres. Demonstration of the feasibility and value of staging in that setting is seen as a means of promoting the adoption of staging in other institutions.

Survey of Canadian doctors' attitudes to cancer staging

OBJECTIVE

To collect opinions on the value of cancer staging, the impediments to realizing comprehensive staging and the support that may exist for providing stage information to cancer registries.

DESIGN

The National Cancer Institute of Canada and the Canadian Committee on Cancer Staging have conducted an opinion survey. Opinions were sought about who should be responsible for allocating the stage, what criteria should be used to alter staging classification and whether population-based registries should contain comprehensive staging data.

SETTING

The survey involved 1748 practising cancer specialists representing a cross section of Canadian physicians involved in the treatment and assessment of cancer patients.

RESULTS

The overall response rate was 44.4%. Respondents gave broad support to the universal recording of cancer stage in Canada with 75.2% to 78.6% stating that staging is extremely useful for research, cancer statistics and caring for patients. Most respondents (98%) considered that all new cancer patients should have a specific stage assigned at the time of their first definitive treatment, and 78% believed that the clinician responsible for treating patients should determine the stage of cancer. A high proportion (73% to 81%) of respondents considered staging to be extremely important to define disease extent, make treatment decisions, estimate prognosis, facilitate consistent management and to compare results of treatment. The respondents consider lack of adequate information from pathology and imaging reports as barriers to staging. Only a small proportion of respondents were familiar with the organizations responsible for promoting and developing staging classifications.

CONCLUSIONS

The Canadian survey showed strong support for universal staging and for the development of a central coordinated effort to promote cancer staging in Canada.

The consultation to develop a national strategy for cancer staging in Canada

The lack of uniform recording of stage is a continued barrier to the success of cancer control activities. To review the role of staging, in 1997 the Canadian Committee on Cancer Staging (CCCS) of the National Cancer Institute of Canada (NCIC) formalised a national Consultation initiative with the input of Canadian oncology leaders and international experts on staging. A document was created from prior background work by the Committee and pre-circulated for comment. The document described the importance of cancer staging to patient care, epidemiological and clinical research, and cancer control programs. The document was refined through an iterative process over much of a year which included a formal workshop of the participants and other meetings. The Consultation reaffirmed, with evidence, the central role of staging in all aspects of cancer management. The report of the Consultation, endorsed by the Board of Directors of NCIC, included the following recommendations: 1) the recording of TNM stage by the treating physician should be a standard of care for every cancer patient in Canada where TNM applies, 2) the Canadian Council on Health Services Accreditation should include the TNM stage for every cancer patient as a requirement for hospital accreditation. In conclusion, this process represents an effective method for raising awareness about important medical issues such as staging which are fundamental to the management and control of cancer.

A Canadian survey of cancer patients' experiences: are their needs being met?

Cancer patients (n = 913) who received treatment within the previous 2 years were interviewed to quantify reports of symptoms associated with cancer, measure the impact of symptoms on lifestyles, document experiences with accessing information and treatment for cancer and its symptoms, and record attitudes about the level of care received. Cancer patients were primarily recruited through newspaper ads placed throughout Canada and asked to complete a self-report questionnaire. Patients called a toll-free number and were interviewed to ensure eligibility. Most respondents were female (66%) with breast cancer (64%). Prostate cancer (40%) was the most common diagnosis among males. Almost all respondents (94%) reported experiencing one or more symptoms. Fatigue and anxiety were the most frequently reported symptoms (78% and 77%, respectively). Fatigue was most likely to be self-rated as moderate to severe and was most likely to interfere in normal daily activities. Respondents who experienced fatigue reported a more frequent use of healthcare services (including complementary therapies) than those who did not experience fatigue. Half of the respondents reported trying to find information on fatigue, but only half of these said they had obtained information. The most helpful sources of information were nurses, specialists, and other cancer patients. Respondents were more likely to be dissatisfied with their treatments for their symptoms than for their cancer. This survey indicates that most cancer patients experience symptoms related to the disease and its treatment. The most prevalent symptoms are fatigue and anxiety; fatigue is the most debilitating.

One-on-one peer support and quality of life for breast cancer patients

The Canadian Cancer Society's Reach to Recovery program provides one-on-one support for breast cancer patients that is delivered by breast cancer survivors. Professionally-led social support programs have generally been found to influence positively the quality of life of cancer patients. However, there is a lack of evidence on the benefits of one-on-one peer support programs. An evaluation of the Reach to Recovery program was completed in 1995 to determine if cancer patients who received the program were satisfied with the program and to determine if participation in Reach to Recovery affected the quality of life of program participants compared to patients who did not receive the program. We found that Reach to Recovery program participants were generally satisfied with the program they received and that the program has incremental benefits to the quality of life of patients with breast cancer. Peer-led, volunteer breast cancer support programs can be effective in enhancing the quality of life of breast cancer patients.

Knowledge, attitudes and behaviours concerning cancer screening in Canada

The Advisory Committee on Cancer Control funded a one-day workshop to discuss the surveillance of knowledge, attitudes/beliefs and behaviours concerning early cancer detection in Canada. Participants considered the need for such national surveillance and related methodological issues. Some exploratory work has been conducted in this regard. Results were presented from an inventory of existing survey questions and a summary of established cancer screening guidelines. There was overall agreement on the utility of collecting details of early cancer detection behaviours and their determinants. Explicitly, participants identified a need for site-specific information, highlighting cancers of the prostate and colon/rectum, as well as recognizing a need for qualitative information regarding the determinants that enable early cancer detection behaviours.

Development of an instrument to measure cancer screening knowledge, attitudes and behaviours

The development of a comprehensive survey instrument to measure the knowledge, attitudes and behaviours of the general public with regard to cancer screening was the goal of this project. A thorough review of the literature was undertaken, and existing survey instruments were identified and organized according to type of cancer screening behaviour being measured; question foci (predisposing, enabling and reinforcing factors); and survey implementation protocol. A comprehensive survey instrument was developed with the intention that, if feasible, the survey of cancer screening behaviours could be implemented nationally by telephone. Separate survey instruments were developed according to sex. Focus groups were held across Canada to determine the comprehensiveness of the survey items; ease of understanding and ability to respond; feasibility with respect to possible sensitivity of some of the question items; and general implementation issues (e.g. length, sex of interviewer). This paper reports on the qualitative portion of the project. Our study supports the use of qualitative methodology for instrument development and implementation.

Focus groups with cancer patients: toward a more comprehensive understanding of the cancer experience

Six focus groups of 58 individuals (30 women and 28 men) were held in 3 Canadian cities to help develop a survey instrument to be implemented nationally to identify cancer patients' experiences with cancer: treatment, symptoms and symptom management. Patient participants had different cancer diagnoses, but their experience with cancer had been within the year preceding the study. Our intent was to identify as many themes as possible to allow for comparison of different experiences in a national survey. This paper reports on what was learned substantively from these focus groups and discusses the methodological contribution of focus groups in developing survey tools.

Perspectives on Reach to Recovery and CanSurmount: informing the evaluation model

The Canadian Cancer Society requested that the Centre for Behavioural Research and Program Evaluation of the National Cancer Institute of Canada evaluate Reach to Recovery and CanSurmount, 1-on-1 peer-support programs that provide information and support to individuals with cancer and their families. Key informant interviews (with program participants and volunteer visitors) were conducted to gather qualitative data and to help us develop a framework and tools to evaluate these programs. We found that 1) there are program objectives from the perspective of volunteers and participants in addition to those outlined in the program materials; 2) there are variations in how the programs are delivered and how patients or family members are recruited into the program; and 3) there is evidence that Reach to Recovery and CanSurmount volunteers are in a unique position to deliver the programs, either because they have personally experienced cancer or have family members who have had cancer. We describe the key informant exercise developed for this evaluation project and present the results of preliminary data-gathering activities.

Focus group methodology in the development of a survey to measure physician use of cancer staging systems

Accurate classification and staging of cancers enables physicians to select appropriate treatments, to evaluate outcomes of health management more reliably, to compare and interpret statistics reported from various institutions on a local, regional, national and international basis more consistently and to assist exchanges of information between different centers of treatment. This paper examines group interview methodology to develop the first-ever survey of Canadian cancer care specialists pertaining to staging systems. It is shown how the responses provided by participants contributed to the formulation of testable hypotheses and shaped the development of survey questions. As well, experiences are shared regarding the technical issues that arose using the focus group technique with physicians. In conclusion, there is a brief discussion of how the use of staging classification systems might be understood from the perspective of diffusion theory and social marketing (i.e., how information about cancer staging has been communicated and disseminated.

Occupational repetitive strain injuries and gender in Ontario, 1986 to 1991

Repetitive strain injuries (RSIs) in Ontario were examined with respect to gender for the period 1986 to 1991, using data from Ontario Workers' Compensation Board systems. Technical issues surrounding analysis of workplace injuries and theoretical suggestions raised by the data are discussed. Analyses revealed that the risk of RSIs for women is greater than that for men. Furthermore, women receive compensation benefits because of RSIs for a longer period than do their male counterparts, which may indicate a longer-term effect of RSIs on women.

Charting the NCIC's future: stakeholder support for identified options

The National Cancer Institute of Canada (NCIC) conducted a survey of representatives of its stakeholder populations (members of the cancer research and control communities, past and present NCIC grantees, senior administrators in academic institutions, NCIC governing committee representatives and major partners) to get input on proposals to restructure the NCIC's research programs. The survey results demonstrate support for changes that are likely to significantly alter how the NCIC operates as well as the programs it sponsors. The results suggest support for increasing the percentage of NCIC funds allocated to the Individual Operating Grants area and for changing the NCIC's programs and operating procedures. While there was widespread support for an NCIC-sponsored regional development initiative, many issues remain unresolved, such as what type of cancer research to develop within the provinces.

Issues for interpreting external stakeholder feedback on restructuring NCIC's research programs

The National Cancer Institute of Canada surveyed members of its stakeholder groups on a number of issues pertaining to restructuring research programs. While it was hoped that the survey would ensure input from its primary stakeholder groups and thereby facilitate decision-making on critical issues like distribution of funds and research awards, there is reason to believe this may not have occurred. Some of the stakeholder groups seemed to be over-represented in the respondent population and the effect of this on the results was therefore examined. Analysis revealed several important issues: 1) a clear definition of who constitutes a "stakeholder" needs to be developed when stakeholder input-gathering is being contemplated; 2) multi-faceted strategies need to be developed to gain input from stakeholders; 3) potential sources of bias can emerge from the various techniques used to gather feedback from stakeholders; and 4) a clear outline of how the feedback is to be used in the decision-making process needs to be determined.