Abstract P3-08-15: Improving survivors’ quality of care through use of self-reported satisfaction data

Background: Despite numerous initiatives to improve the quality and safety of care for the growing number of cancer survivors, little empirical evidence is available about survivor satisfaction with post-treatment care or whether their information needs are met. Our specific aim was to conduct a comparative evaluation of 2 cohorts of survivors to determine their satisfaction with services provided in a breast survivorship clinic.

Methods: We compared satisfaction in 2 separate cohorts of women who completed their curative treatment. Eligibility criteria for both groups included being a woman diagnosed with breast cancer and transitioned to “long-term survivor” status by their primary oncologist. Women were then grouped into no-visit, those who had never been to a breast survivorship clinic or completed-visit, survivors who had completed a visit to the survivorship clinic. Data was collected for the no-visit group in 2009, when the breast survivorship clinic was initially launched. Data collection for the comparative or completed-visit cohort is ongoing.

The instrument consisted of 6 items reflecting 2 subscales: satisfaction and information needs. The first subscale focused on satisfaction with their visit, time spent with provider, and management of emotional distress. The second sub-scale focused on information received related to disease surveillance, late effects, health promotion, and social services. Survivors in both groups received the questionnaire upon their clinic arrival and completed it during their visit. Descriptive statistics were used to summarize all responses. All data were de-identified.

Results: The no-visit cohort consisted of 81 breast cancer survivors who had never been seen in any type of survivorship clinic. Responses indicating that the survivors strongly agreed with an item were reported as follows: 79.5% satisfied with their visit, 77.3% information received, and 77.8% adequate time with provider. Of survivors who reported they were experiencing emotional distress, 50% strongly agreed that the clinicians in the clinic did all possible to address their distress, such as making referrals to the clinic social worker or to community-based mental health services. Bone health, cancer education, recurrence, and screening were the educational topics most requested. Final data collection and analysis for the comparative cohort, completed-visit, will be concluded by August 2013.

Discussion: The no-visit cohort reported high satisfaction with survivorship care and information before they were seen in any type of institutional survivorship clinic. This finding could be a bias resulting from satisfaction with care received as a patient in active treatment. Results however, also suggest survivors of breast cancer who had not been seen in a survivorship clinic were aware of the type of specialized care or education needed to maintain their health after curative treatment. Further evaluation and research is needed to determine how satisfaction and unmet educational needs can be used to optimize outcomes for our growing population of cancer survivors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-15.

Cervical and colorectal cancer screening among breast cancer (BrCa) survivors followed in either a breast center (BC) or a breast survivorship clinic (SvC) at The University of Texas M.D. Anderson Cancer Center

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Background: An essential component of cancer survivorship care includes the prevention and early detection of new cancers. We sought to determine if documentation of appropriate cervical and/or colon cancer screening differed between BrCa survivors followed in our BC (patients < 5 yrs from diagnosis of invasive BrCa or with active BrCa issues) and those seen in our SvC (patients with history of DCIS or ≥ 5 yrs from invasive BrCa diagnosis). Methods: IRB approval was obtained for this retrospective study. 5,982 BrCa survivors were seen for follow-up in our BC or SvC between 7/1/05 and 12/31/06. 2,811 BC patients and 1191 SvC patients (total = 4,002) met inclusion criteria: 1) not receiving chemotherapy, radiation, or undergoing surgical evaluation; 2) no evidence of recurrent BrCa; 3) ≥ 12 months from BrCa diagnosis, 4) no active GYN or GI complaints. Results: BrCa survivors followed our SvC were significantly more likely to have provider documentation of both cervical and colon cancer screening than those followed in our BC (72% versus 22.7%, and 68.4% versus 14.5%, respectively; both p values <0.001). Although nursing documentation of cervical cancer screening is required in both centers, SvC patients were more likely to have this documented than those in the BC (95.3% versus 56.5%, respectively; p <0.001). Nursing documentation of colon cancer screening is required in SvC (84.2% documented) but not in the BC (3.5% documented). Conclusions: BrCa survivors receiving care in our survivorship clinic were more likely to have nursing or provider documentation of cervical and/or colon cancer screening. Strategies that trigger documentation of non-BrCa screening take advantage of the “teachable moment” during a routine visit- thereby promoting the long-term health of cancer survivors.

No significant financial relationships to disclose.

The study of tamoxifen and raloxifene (STAR): Initial findings from the NSABP P-2 breast cancer prevention study

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Background: The STAR trial was designed to compare raloxifene to tamoxifen in terms of relative effect on invasive breast cancer risk and on other beneficial and detrimental outcomes associated with the use of tamoxifen. Methods: The trial opened on 7-1-1999, and accrual was completed November 4, 2004, with 19,747 women enrolled. To be eligible, a woman had to be postmenopausal with a 5-year predicted breast cancer risk of 1.66% as determined by the modified Gail model. Women were randomized and treated in a double-blinded fashion to receive 5 yr of therapy with either 20 mg per day of tamoxifen or 60 mg per day of raloxifene. The protocol-defined monitoring plan called for a final analysis and release of findings when 327 invasive breast cancer cases had been diagnosed in the total population. The mean age of the population at the time of entry into this trial was 58 yr, and the mean 5-yr risk of breast cancer was 4.04%. 93.5% of the women were white; 51.5% had a hysterectomy before entry into the study; 9.2% had a history of LCIS; 71.1% had at least one first-degree relative with a history of breast cancer. The average time on the study is 47 months. Results: There was no difference between the treatment groups in terms of effect on invasive breast cancer: 163 cases in women assigned to tamoxifen and 167 in women assigned to raloxifene (RR = 1.02, 95% CI = 0.82–1.27). The risk of invasive uterine malignancies was 40% less in the raloxifene group (36 in women assigned tamoxifen and 23 in women assigned raloxifene [RR = 0.62, 95% CI = 0.35–1.08]). The risk of non invasive breast cancer was less in the tamoxifen group (57 cases in those assigned to tamoxifen and 81 in those assigned to raloxifene [RR = 1.41, 95% CI = 1.00–2.02]). There were no significant differences between the treatment groups for any of the other invasive cancer sites or for cardiac events, osteoporotic fractures, or deaths. There were fewer thromboembolic events in women taking raloxifene than in those taking tamoxifen. Conclusions: Raloxifene is an effective alternative to tamoxifen for reducing the incidence of invasive breast cancer in postmenopausal women at increased risk of developing the disease and is associated with fewer endometrial cancers, deep vein thromboses, and pulmonary emboli.

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Novel translational model for breast cancer chemoprevention study: accrual to a presurgical intervention with tamoxifen and N-[4-hydroxyphenyl] retinamide

Surrogate end point biomarkers for risk assessment and efficacy of potential chemopreventive agents are needed to improve the efficiency and reduce the cost of chemoprevention trials. It is imperative to develop the best clinical breast model for translational surrogate end point biomarker studies, especially with respect to accrual feasibility. We have initiated a prospective study to develop biomarkers for tamoxifen and N-[4-hydroxyphenyl] retinamide by administering either a placebo or both drugs for 2-4 weeks to women with ductal carcinoma in situ or early invasive cancers in the interval between the initial diagnostic core biopsy and definitive surgery. The principle end point is pretreatment versus posttreatment tumor levels of Ki-67; a number of other exploratory markers will also be examined. The planned target sample size is 100 patients. Between February 1997 and February 2000, 4514 women who had either an abnormal mammogram or a diagnosed breast cancer were screened for the study. Of these 4514 screened patients, 52 (1%) were registered on the study. Major factors of nonparticipation in the remaining 4462 women were as follows: (a) no evidence of malignancy (2081 patients; 46%); (b) ineligible per protocol criteria (575 patients; 13%); (c) preoperative chemotherapy/tamoxifen (520 patients; 11%); (d) surgery scheduling conflict (360 patients; 8%); (e) outside needle biopsy (221 patients; 5%); (f) no residual disease after excisional biopsy (345 patients; 8%); and (g) second opinion only (123 patients; 3%). Other nonparticipation factors included fine needle aspiration only, refusal, tumor size > 2 cm, and estrogen replacement therapy (35 patients each; 2% each). The protocol was amended in midstudy to allow outside needle biopsy, tumor > 2 cm, and estrogen replacement therapy. Accrual to biomarker (nontherapeutic) protocols with delay in definitive cancer surgery is challenging but feasible. Although some accrual problems remain, we have nonetheless succeeded in recruiting 50% of our target sample size in a 3-year period.