Results of a quantitative survey to explore both perceptions of the purposes of follow-up and preferences for methods of follow-up delivery among service users, primary care practitioners and specialist clinicians after cancer treatment

Systematic review of patients' and healthcare professionals' views on patient-initiated follow-up in treated cancer patients

BACKGROUND

Current follow-up models in cancer are seen to be unsustainable and inflexible, and there is growing interest in alternative models, such as patient-initiated follow-up (PIFU). It is therefore important to understand whether PIFU is acceptable to patients and healthcare professionals (HCPs).

METHODS

Standard systematic review methodology aimed at limiting bias was used for study identification (to January 2022), selection and data extraction. Thematic synthesis was undertaken for qualitative data, and survey findings were tabulated and described.

RESULTS

Nine qualitative studies and 22 surveys were included, mainly in breast and endometrial cancer. Women treated for breast or endometrial cancer and HCPs were mostly supportive of PIFU. Facilitators for PIFU included convenience, control over own health and avoidance of anxiety-inducing clinic appointments. Barriers included loss of reassurance from scheduled visits and lack of confidence in self-management. HCPs were supportive of PIFU but concerned about resistance to change, unsuitability of PIFU for some patients and costs.

CONCLUSION

PIFU is viewed mostly positively by women treated for breast or endometrial cancer, and by HCPs, but further evidence is needed from a wider range of cancers, men, and more representative samples. A protocol was registered with PROSPERO (CRD42020181412).

Exploring the views of patients' and their family about patient-initiated follow-up in head and neck cancer: A mixed methods study

OBJECTIVE

The objective of this work was to explore head and neck cancer (HNC) patients' and their family members' views on acceptability and feasibility of patient-initiated follow-up (PIFU), including concerns and anticipated benefits.

METHODS

Patients were recruited from UK HNC clinics, support groups and advocacy groups. They completed a survey (n = 144) and/or qualitative interview (n = 30), three with a family member. Qualitative data were analysed thematically, quantitative data using descriptive statistics.

RESULTS

Preference for follow-up care in HNC was complex and individual. Many patients thought PIFU could beneficially reallocate health care resources and encourage self-management. Patients' main concerns with PIFU were losing the reassurance of regular clinic appointments and addressing mental well-being needs within PIFU, possibly using peer support. Patients were concerned about their ability to detect recurrence due to lack of expertise and information. They emphasised the importance of a reliable, direct and easy urgent appointment service and of feeling supported and heard by clinicians. Patients believed family and friends need support.

CONCLUSION

PIFU may be feasible and acceptable for certain HNC patients, providing it addresses support for mental well-being, provides quick, reliable and direct clinician access and information on "red flag" symptoms, and ensures patients and their caregivers feel supported.

Late-effect awareness and follow-up of cancer in general practice

OBJECTIVE

With increasing cancer incidence and survival rates, follow-up care becomes a major healthcare concern, placing increased demands on general practitioners (GPs). We explored GPs' awareness of late effects (LEs) after cancer treatment. Their degree of involvement and attitudes towards follow-up care was studied separately for solid cancers and Hodgkin's lymphoma (HL).

DESIGN AND SETTING

Mailed questionnaire study in Norwegian general practice.

SUBJECTS

185 responding GPs with responsibility for HL survivors, more than 10 years since diagnosis.

MAIN OUTCOME MEASURES AND RESULTS

All GPs reported some awareness of LEs. Increasing awareness of LEs was associated with female sex, being a specialist, having experience from hospital-based cancer care and familiarity with official guidelines on LEs after treatment. The majority of GPs were involved in follow-up care, which increased with patients' time since treatment and was associated with higher awareness of LEs. GPs with work experience in hospital-based cancer care were more likely to be engaged in HL follow-up. Most GPs were willing to provide follow-up care at some point after treatment. Older and more experienced GPs, and those satisfied with the collaboration with hospital specialists, were more likely to provide follow-up earlier.

CONCLUSION

GPs' awareness of LEs and their willingness to provide follow-up care were related to familiarity with guidelines and experience. GPs more involved in follow-up care also had higher knowledge of LEs. Distribution of guidelines on LEs and follow-up care, and improving collaboration with hospital specialists, might increase GPs' knowledge and willingness to become involved in follow-up care, especially early in their careers. GPs' involvement and attitude towards follow-up of survivors of common solid cancers and HL, a rare malignant disease, were similar.KEY POINTSNorwegian general practitioners (GPs) are involved in survivorship care after cancer treatment. We investigated their awareness of late effects (LEs), their involvement and their attitude towards follow-up care of solid cancers and Hodgkin's lymphoma. • GPs registered as specialists, aware of guidelines and with experience from hospital-based cancer care reported higher awareness of LEs.  • GPs with higher awareness of LEs were more frequently involved in follow-up care.  • GPs with longer experience in general practice were comfortable with follow-up care at an earlier stage after treatment.  • Results were similar for follow-up care of survivors of solid cancers and Hodgkin's lymphoma.

Improved models of care for cancer survivors

The number of survivors of cancer is increasing substantially. Current models of care are unsustainable and fail to address the many unmet needs of survivors of cancer. Numerous trials have investigated alternate models of care, including models led by primary-care providers, care shared between oncology specialists and primary-care providers, and care led by oncology nurses. These alternate models appear to be at least as effective as specialist-led care and are applicable to many survivors of cancer. Choosing the most appropriate care model for each patient depends on patient-level factors (such as risk of longer-term effects, late effects, individual desire, and capacity to self-manage), local services, and health-care policy. Wider implementation of alternative models requires appropriate support for non-oncologist care providers and endorsement of these models by cancer teams with their patients. The COVID-19 pandemic has driven some changes in practice that are more patient-centred and should continue. Improved models should shift from a predominant focus on detection of cancer recurrence and seek to improve the quality of life, functional outcomes, experience, and survival of survivors of cancer, reduce the risk of recurrence and new cancers, improve the management of comorbidities, and reduce costs to patients and payers. This Series paper focuses primarily on high-income countries, where most data have been derived. However, future research should consider the applicability of these models in a wider range of health-care settings and for a wider range of cancers.

Clinicians' Views of Patient-initiated Follow-up in Head and Neck Cancer: a Qualitative Study to Inform the PETNECK2 Trial

AIMS

Current follow-up for head and neck cancer (HNC) is ineffective, expensive and fails to address patients' needs. The PETNECK2 trial will compare a new model of patient-initiated follow-up (PIFU) with routine scheduled follow-up. This article reports UK clinicians' views about HNC follow-up and PIFU, to inform the trial design.

MATERIALS AND METHODS

Online focus groups with surgeons (ear, nose and throat/maxillofacial), oncologists, clinical nurse specialists and allied health professionals. Clinicians were recruited from professional bodies, mailing lists and personal contacts. Focus groups explored views on current follow-up and acceptability of the proposed PIFU intervention and randomised controlled trial design (presented by the study co-chief investigator), preferences, margins of equipoise, potential organisational barriers and thoughts about the content and format of PIFU. Data were interpreted using inductive thematic analysis.

RESULTS

Eight focus groups with 34 clinicians were conducted. Clinicians highlighted already known limitations with HNC follow-up - lack of flexibility to address the wide-ranging needs of HNC patients, expense and lack of evidence - and agreed that follow-up needs to change. They were enthusiastic about the PETNECK2 trial to develop and evaluate PIFU but had concerns that PIFU may not suit disengaged patients and may aggravate patient anxiety/fear of recurrence and delay detection of recurrence. Anticipated issues with implementation included ensuring a reliable route back to clinic and workload burden on nurses and allied health professionals.

CONCLUSIONS

Clinicians supported the evaluation of PIFU but voiced concerns about barriers to help-seeking. An emphasis on patient engagement, psychosocial issues, symptom reporting and reliable, quick routes back to clinic will be important. Certain patient groups may be less suited to PIFU, which will be evaluated in the trial. Early, meaningful, ongoing engagement with clinical teams and managers around the trial rationale and recruitment process will be important to discourage selective recruitment and address risk-averse behaviour and potential workload burden.

The utility of surveillance CT scans in a cohort of survivors of colorectal cancer

PURPOSE

Colorectal cancer (CRC) is the third most common cancer worldwide. After curative intent treatment, international guidelines recommend surveillance protocols which include annual CT chest, abdomen and pelvis (CAP) and serum carcinoembryonic antigen (CEA) monitoring which aim to improve overall survival by early detection of recurrence. Despite the widespread recommendations, robust evidence of an overall survival benefit is lacking. Our study aimed to quantify the utility of annual CT CAP as a surveillance modality in comparison to the rate of potentially harmful false-positive and incidental findings.

METHODS

High-risk stage II and stage III CRC patients were retrospectively identified from the Sydney Cancer Survivorship Centre database. Findings on surveillance CT were classified into confirmed recurrence or the potentially harmful findings of (a) false-positive or (b) clinically significant incidental finding.

RESULTS

A total of 376 surveillance CT CAPs were performed in 174 survivors between 12 September 2013 and 30 June 2020. The recurrence rate during the study period was 23/174 (13.2%) with the majority of recurrences detected by abnormal CEA (14/23, 60.9%) versus surveillance CT (4/23, 17.4%), with the remainder identified on non-surveillance CT (5/23, 21.7%). Curative intent surgery was performed in 12/23 people with CRC recurrence. Surveillance CT was shown to result in high levels of false-positive (31/174, 17.8% of patients) or clinically significant incidental findings (30/174, 17.2% of patients). The risk of identifying these potentially harmful findings was ongoing with each year of surveillance CT.

CONCLUSION

Surveillance CT was associated with low detection rates and high rates of potentially harmful findings bringing this surveillance modality under further scrutiny.

IMPLICATIONS FOR CANCER SURVIVORS

An increased emphasis should be placed on educating survivors on the benefits of surveillance CT weighed against the risk of potentially harmful findings.

Sharing Cancer Survivorship Care between Oncology and Primary Care Providers: A Qualitative Study of Health Care Professionals' Experiences

Survivorship care that is shared between oncology and primary care providers may be a suitable model to effectively and efficiently care for the growing survivor population, however recommendations supporting implementation are lacking. This qualitative study aimed to explore health care professionals’ (HCPs) perceived facilitators and barriers to the implementation, delivery and sustainability of shared survivorship care. Data were collected via semi-structured focus groups and analysed by inductive thematic analysis. Results identified four overarching themes: (1) considerations for HCPs; (2) considerations regarding patients; (3) considerations for planning and process; and (4) policy implications. For HCPs, subthemes included general practitioner (GP, primary care physician) knowledge and need for further training, having clear protocols for follow-up, and direct communication channels between providers. Patient considerations included identifying patients suitable for shared care, discussing shared care with patients early in their cancer journey, and patients’ relationships with their GPs. Regarding process, subthemes included rapid referral pathways back to hospital, care coordination, and ongoing data collection to inform refinement of a dynamic model. Finally, policy implications included development of policy to support a consistent shared care model, and reliable and sustainable funding mechanisms. Based on study findings, a set of recommendations for practice and policy were developed.

Survivorship in Colorectal Cancer: A Cohort Study of the Patterns and Documented Content of Follow-Up Visits

Survivors of colorectal cancer (CRC) may experience a range of physical, psychosocial, and practical challenges as a consequence of their diagnosis. We assessed the patterns and documented content of follow-up visits within the first three years following treatment, in comparison to survivorship care guidelines. Survivors with stage I-III CRC who underwent curative resection at Peter MacCallum Cancer Centre from July 2015 to January 2018 were followed for up to 1080 days. Patterns of follow-up were calculated by recording the date and specialty of each visit; documented content was assessed using a study-specific audit tool for the first year (360 days) of follow-up. Forty-eight survivors comprised the study population, 34 of whom (71%) attended the recommended two to four follow-up visits in their first year. Visit notes documented new symptoms (96%), physical changes (85%), physical examination (63%), and investigations (56%–90%); none had documented discussions of screening for other primary cancers, or regular health checks and/or screening. Each survivor had at least one outpatient letter that was sent to their primary care physician, but responsibilities were not adequately defined (31%). Although survivors had regular follow-up in their first year, documentation did not consistently address aspects of wider survivorship care.

Facilitators and barriers to shared primary and specialist cancer care: a systematic review

PURPOSE

To care for the growing population of cancer survivors, health services worldwide must reconsider how to deliver care to people living with and beyond a cancer diagnosis. Shared care, defined as cancer care that is shared between specialist and primary care providers, is one model that has been investigated; however, practical guidance to support implementation is lacking. This systematic review aimed to explore facilitators and barriers to implementing shared cancer care and to develop practice and policy recommendations to support implementation.

METHODS

A systematic literature search was conducted in June 2019 across MEDLINE, Embase, Emcare, and PsycINFO databases. Quantitative and qualitative data relevant to the review question were extracted and synthesized following a mixed methods approach.

RESULTS

Thirteen papers were included in the review, 10 qualitative and three quantitative. Included articles were from Australia (n = 8), the USA (n = 3), and one each from the UK and the Netherlands. Sixteen themes were developed under four categories of patient, healthcare professional, process, and policy factors. Key themes included the perceived need for primary care provider training, having clearly defined roles for each healthcare provider, providing general practitioners with diagnostic and treatment summaries, as well as protocols or guidelines for follow-up care, ensuring rapid and accurate communication between providers, utilizing electronic medical records and survivorship care plans as communication tools, and developing consistent policy to reduce fragmentation across services.

CONCLUSION

Recommendations for practice and policy were generated based on review findings that may support broader implementation of shared cancer care.

Exploring health care professionals views on alternative approaches to cancer follow-up and barriers and facilitators to implementation of a recovery package

PURPOSE

To meet the long-term needs of cancer survivors the focus of recent cancer care reform in the United Kingdom (UK) has been the implementation of alternative follow-up strategies to relieve the growing pressures threatening to overwhelm cancer services. In 2013, the UK's National Cancer Survivorship Initiative recommended an integrated package of care called the Recovery Package to meet cancer survivors' psychosocial and information needs and supported self-management.

METHOD

We aimed to explore health care professionals' views of alternative strategies for follow-up care, and perceived barriers and facilitators to implementation of the Recovery Package for patients who had completed treatment for cancer. Semi-structured interviews with 19 participants sought views and experiences of key aspects of cancer care follow-up and aspects of the Recovery Package implementation.

RESULTS

Seven themes emerged from the data; sustainability and capacity, cost implications, primary care, self-management, recovery package, resistance to change, and visions for the future. Traditional hospital follow-up was considered suitable for patients with complex needs, rarer forms of cancer and/or a poorer prognosis. Risk stratification was considered a vital element of any future strategy as was interoperability of digital communication systems between health care providers. Charitable funding had enabled one site to introduce all elements of the recovery package for patients with common cancers.

CONCLUSION

Charitable funding had enabled implementation of elements of the Recovery Package. However, new approaches require services to be commissioned and funded appropriately with effective communication between patients and primary and secondary care facilitated by interoperability of health care records.

Endometrial cancer patients' preferences for follow-up after treatment: A cross-sectional survey

PURPOSE

Alternatives to hospital follow-up (HFU) following treatment for cancer have been advocated. Telephone follow-up (TFU) and patient-initiated follow-up are being implemented but it is unclear if these approaches will meet the preferences and needs of patients. This study aimed to explore the preferences of endometrial cancer patients and their levels of satisfaction with HFU and nurse-led TFU.

METHODS

A cross-sectional survey design was utilised and a questionnaire was administered to 236 patients who had participated in a randomised controlled trial comparing HFU with TFU for women diagnosed with Stage I endometrial cancer (ENDCAT trial).

RESULTS

211 (89.4%) patients returned the questionnaire; 105 in the TFU group and 106 in the HFU group. The TFU group were more likely to indicate that appointments were on time (p < 0.001) and were more likely to report that their appointments were thorough (p = 0.011). Participants tended to prefer what was familiar to them. Those in the HFU group tended to prefer hospital-based appointments while the TFU group tended to prefer appointments with a clinical nurse specialist, regardless of locality.

CONCLUSIONS

To provide patient centred follow-up services we need to ensure that patient preferences are taken into account and understand that patients may come to prefer what they have experienced. Patient initiated approaches may become standard and preferred practice but TFU remains a high-quality alternative to HFU and may provide an effective transition between HFU and patient-initiated approaches.

Building Personalized Cancer Follow-up Care Pathways in the United States: Lessons Learned From Implementation in England, Northern Ireland, and Australia

There is a global need to transform cancer follow-up care to address the needs of cancer survivors while efficiently using the health care system to limit the effects of provider shortages, gaps in provider knowledge, and already overburdened clinics; improve the mental health of clinicians; and limit costs to health care systems and patients. England, Northern Ireland, and Australia are implementing an approach that triages patients to personalized follow-up care pathways depending on the types and levels of resources needed for patients' long-term care that has been shown to meet patients' needs, more efficiently use the health care system, and reduce costs. This article discusses lessons learned from these implementation efforts, identifying the necessary components of these care models and barriers and facilitators to implementation of this care. Specifically, the United States and other countries looking to transform follow-up care should consider how to develop six key principles of this care: algorithms to triage patients to pathways; methods to assess patient issues to guide care; remote monitoring systems; methods to support patients in self-management; ways to coordinate care and information exchange between oncology, primary care, specialists, and patients; and methods to engage all stakeholders and secure their ongoing buy-in. Next steps to advance this work in the United States are discussed.

Gynecological cancer patients' attitudes toward follow-up care after cancer treatment: Do preferences reflect patients' experience? A cross-sectional questionnaire study

INTRODUCTION

Due to an increasing number of cancer patients, new follow-up models are being debated, among them follow-up by general practitioners. Before changing surveillance, it is important to explore patients' views. The purpose of this study was to compare attitudes toward follow-up care among patients treated for gynecological cancer who had not yet started a follow-up regimen, with those who had been attending a hospital-based follow-up regimen for more than one year.

MATERIAL AND METHODS

We conducted a cross-sectional survey among gynecological cancer patients recruited from three Norwegian hospitals in 2013-2015: Sørlandet Hospital Kristiansand, Sørlandet Hospital Arendal and St. Olavs Hospital, Trondheim.

RESULTS

In all, 239 patients agreed to participate, 100 who had not yet started follow-up and 139 who had been attending more than one year of follow-up. Patients reported that they preferred to be followed up by a gynecologist rather than by their GP, whom they viewed as less competent for this purpose. However, patients who had not yet started follow-up were more willing to be followed up by a GP. Overall, patients rated detection of recurrence as the most important aspect of follow-up visits.

CONCLUSIONS

The gynecological cancer patients in our study preferred a hospital-based follow-up model. However, patients who had not yet started follow-up were more willing to be followed up by a GP. If follow-up is to be provided by GPs for selected patients, it is important that these patients are informed early of the value and limitations of follow-up visits, to ensure that they feel safe.

Telephone follow-up after treatment for endometrial cancer: A qualitative study of patients' and clinical nurse specialists' experiences in the ENDCAT trial

PURPOSE

Endometrial cancer is the sixth most common female cancer worldwide. There is little evidence that routine hospital surveillance increases survival or decreases morbidity following treatment. Gynaecology Oncology clinical nurse specialists (CNSs) are ideally placed to provide the care, information and support to enable women with a gynaecological cancer to self-manage and live well. A multi-centre randomised controlled trial (RCT) compared hospital follow-up (HFU) with telephone follow-up (TFU) by CNSs. The structured telephone intervention focused on information provision to meet patients psychosocial and information needs. This study aimed to explore the views of women who had received TFU and the CNS's who had delivered the service.

METHOD

A qualitative study to complement the RCT using semi-structured interviews was conducted. Twenty-five patients were randomly selected from participants in the TFU arm stratified by study site. Seven CNSs were interviewed.

RESULTS

Patient and CNS regarded TFU positively; Three themes emerged from the patient interviews; Convenient Care, Discrete Personalised Care, Confidence and Reassurance. Themes arising from the CNS interviews were Patient Centred Care, Holistic Care and, Confidence and Skills. Patients found that TFU with CNS's was convenient and enabled discussion of issues and information provision at time-points relevant to them. The CNS's found the structured format of TFU enabled them to utilise their skills and knowledge to identify and meet patients holistic needs.

CONCLUSIONS

Alternative models of care such as TFU provided by CNSs provides the care, information and support to enable women treated for endometrial cancer to self-manage and live well.

Follow-up after curative treatment for colorectal cancer: longitudinal evaluation of patient initiated follow-up in the first 12 months

PURPOSE

To compare patient-triggered follow-up (PTFU) for curatively treated colorectal cancer against traditional outpatient follow-up (OPFU).

METHODS

Questionnaires were mailed at four time points over one-year post-treatment to two prospectively-recruited cohorts: A, patients entering follow-up and receiving OPFU pre-implementation of PTFU; B, patients entering follow-up (FU) and receiving either OPFU (B1) or PTFU (B2) post-implementation of PTFU. Bi-variate tests were used to compare patient characteristics and outcomes eight months after entering follow-up (generic and cancer-specific quality of life (QoL), satisfaction). Regression analysis explored associations between follow-up model and outcomes. Resource implications and costs of models were compared.

RESULTS

Patients in Cohort B1 were significantly more likely to have received chemotherapy (p < 0.001), radiotherapy (p < 0.05), and reported poorer QoL (p = 0.001). Having a longstanding co-morbid condition was the most important determinant of QoL (p < 0.001); model of care was not significant. Patients were satisfied with their follow-up care regardless of model. Health service costs were higher in PTFU over the first year CONCLUSIONS: PTFU is acceptable to patients with colorectal cancer and can be considered to be a realistic alternative to OPFU for clinically suitable patients. The initial costs are higher due to provision of a self-management (SM) programme and remote surveillance. Further research is needed to establish long-term outcomes and costs.

Eliciting Preferences for Clinical Follow-Up in Patients with Head and Neck Cancer Using Best-Worst Scaling

OBJECTIVES

There are no commonly accepted standards for monitoring patients treated for head and neck cancer. The aim of this study was to assess patients' preferences for different aspects of follow-up.

METHODS

A best-worst survey was conducted in a sample of head and neck cancer patients in clinical follow-up at the National Cancer Institute (Milan, Italy). Conditional logit regression with choice as the dependent variable was run to analyse the data. A covariate-adjusted analysis was performed in order to identify socio-demographic and clinical factors related to the selection of best-worst items. The participants were asked to report any difficulties encountered during the survey.

RESULTS

A total of 143 patients, predominantly male (74%) and with a mean age of 58 years were enrolled in the survey. The strongest positive preference was expressed for a hospital-based program of physical examinations with frequency decreasing over time. Conversely, the lowest valued item was not performing any positron emission tomography (PET) scan during follow-up. Patients with high educational levels were more likely to value attending a primary care-based program and undergoing intensive radiological investigations. Other patient-specific variables significantly associated with the choice of items were employment and living status, time already spent in follow-up and number of treatments received.

CONCLUSIONS

Overall, patients were more likely to choose an intensive follow-up scheme broadly consistent with the program currently administered by the hospital. There is little evidence of preference heterogeneity that might justify customized programs based on demographics. The best-worst scaling task appeared feasible for most participants.

Ovarian Cancer Follow-up: A Preliminary Comparison of 2 Approaches

OBJECTIVE

The aim of the study was to perform a preliminary comparison of quality of life (QoL) and patient satisfaction in individualized nurse-led follow-up versus conventional medical follow-up in ovarian cancer.

METHODS

One hundred twelve women who received a diagnosis of ovarian, fallopian tube, or peritoneal cancer, completed primary treatment by surgery alone or with chemotherapy, irrespective of outcome with regard to remission, and expected survival of more than 3 months. Fifty-seven participants were randomized to individualized follow-up and 55 patients to conventional follow-up. Well-being was measured at baseline and at 3, 6, 12, and 24 months after randomization for QoL (QLQ-C30 [European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire], QLQ-Ov28), the Hospital Anxiety and Depression Scale (HADS), and a Patient Satisfaction Questionnaire (PSQ-III). The primary endpoints were the effects of follow-up on each of the scores (via hierarchical mixed-effects model) and on relapse-free time (via Cox model). The total cost of follow-up was compared between each group.

RESULTS

There was evidence for a QoL and patient satisfaction benefit for individualized versus standard follow-up (QLQ-C30, P = 0.013; 95% confidence interval, -0.03 to -0.001; PSQ-III P = 0.002; 95% confidence interval, -0.003 to -0.015; QLQ-Ov28, P = 0.14). Hospital Anxiety and Depression Scale data provided no evidence in favor of either treatment (P = 0.42). Delivered to protocol individualized follow-up resulted in a delay in the presentation of symptomatic relapse (P = 0.04), although the effect on survival in this study is unknown. Cost was £700 lower on average for the individualized follow-up group, but the difference was not statistically significant at the 5% level (P = 0.07).

CONCLUSIONS

Individualized follow-up was superior to conventional follow-up in 3 of the 4 QoL and patient satisfaction surveys in this preliminary study. Further prospective studies are needed in a larger population.Trial registration number is ISRCTN59149551.

Determining cancer survivors' preferences to inform new models of follow-up care

BACKGROUND

Specialist-led cancer follow-up is becoming increasingly expensive and is failing to meet many survivors' needs. Alternative models informed by survivors' preferences are urgently needed. It is unknown if follow-up preferences differ by cancer type. We conducted the first study to assess British cancer survivors' follow-up preferences, and the first anywhere to compare the preferences of survivors from different cancers.

METHODS

A discrete choice experiment questionnaire was mailed to 1201 adults in Northeast Scotland surviving melanoma, breast, prostate or colorectal cancer. Preferences and trade-offs for attributes of cancer follow-up were explored, overall and by cancer site.

RESULTS

668 (56.6%) recipients (132 melanoma, 213 breast, 158 prostate, 165 colorectal) responded. Cancer survivors had a strong preference to see a consultant during a face-to-face appointment when receiving cancer follow-up. However, cancer survivors appeared willing to accept follow-up from specialist nurses, registrars or GPs provided that they are compensated by increased continuity of care, dietary advice and one-to-one counselling. Longer appointments were also valued. Telephone and web-based follow-up and group counselling, were not considered desirable. Survivors of colorectal cancer and melanoma would see any alternative provider for greater continuity, whereas breast cancer survivors wished to see a registrar or specialist nurse, and prostate cancer survivors, a general practitioner.

CONCLUSIONS

Cancer survivors may accept non-consultant follow-up if compensated with changes elsewhere. Care continuity was sufficient compensation for most cancers. Given practicalities, costs and the potential to develop continuous care, specialist nurse-led cancer follow-up may be attractive.

Models of survivorship care provision in adult patients with haematological cancer: an integrative literature review

PURPOSE

Increasing numbers of haematology cancer survivors warrants identification of the most effective model of survivorship care to survivors from a diverse range of haematological cancers with aggressive treatment regimens. This review aimed to identify models of survivorship care to support the needs of haematology cancer survivors.

METHOD

An integrative literature review method utilised a search of electronic databases (CINAHL, Medline, PsycInfo, PubMed, EMBASE, PsycArticles, and Cochrane Library) for eligible articles (up to July 2014). Articles were included if they proposed or reported the use of a model of care for haematology cancer survivors.

RESULTS

Fourteen articles were included in this review. Eight articles proposed and described models of care, and six reported the use of a range of survivorship models of care in haematology cancer survivors. No randomised controlled trials or literature reviews were found to have been undertaken specifically with this cohort of cancer survivors. There was variation in the models described and who provided the survivorship care.

CONCLUSION

Due to the lack of studies evaluating the effectiveness of models of care, it is difficult to determine the best model of care for haematology cancer survivors. Many different models of care are being put into practice before robust research is conducted. Therefore, well-designed high-quality pragmatic randomised controlled trials are required to inform clinical practice.

General practitioners' attitudes toward follow-up after cancer treatment: A cross-sectional questionnaire study

OBJECTIVE

An increasing number of cancer patients place a significant workload on hospital outpatient clinics, and health authorities are considering alternative follow-up regimens. It has been suggested that follow-up of cancer patients could be provided by GPs. This study aimed to explore GPs' experiences with the provision of follow-up care for cancer patients, and their views on assuming greater responsibility in the future.

DESIGN

Electronic questionnaire study.

SUBJECTS

GPs in seven regions in Norway.

RESULTS

A total of 317 GPs responded. Many GPs reported experience in providing follow-up care to cancer patients, during the years following initial diagnosis primarily in collaboration with hospital specialists. More than half of the GPs were satisfied with their collaboration. Most GPs preferred to be involved at an early stage in follow-up care and, generally, GPs felt confident in their skills to provide this type of service. Fewer than 10% were willing to assume responsibility for additional cancer patients, citing potentially increased workload as the main reason.

CONCLUSIONS

GPs acknowledged the importance of providing follow-up care to cancer patients, and the majority felt confident in their own ability to provide such care. However, they were hesitant to assume greater responsibility primarily due to fears of increased workload. Key Points It has been suggested that follow-up of cancer patients can be provided by general practitioners (GPs). The viewpoints and attitudes of GPs regarding such follow-up were investigated. GPs reported broad experience in providing follow-up care to patients after active cancer treatment. GPs acknowledged the importance of follow-up care, and they felt confident in their own ability to provide such care. Fewer than 10% of GPs were willing to assume responsibility for additional cancer patients, citing potentially increased workload as the main reason.

Increasing and worsening late effects in childhood cancer survivors during follow-up

Recent advances in childhood cancer treatment have increased survival rates to 80%. Two out of three survivors experience late effects (LEs). From a group of 241 survivors previously described, 193 were followed at the long-term follow-up clinic (LTFC) of Severance Hospital in Korea; the presence of LEs was confirmed by oncologists. We reported the change in LEs during 3 yr of follow-up. The median follow-up from diagnosis was 10.4 yr (5.1-26.2 yr). Among 193 survivors, the percentage of patients with at least one LE increased from 63.2% at the initial visit to 75.1% at the most recent visit (P = 0.011). The proportion of patients having multiple LEs and grade 2 or higher LEs increased from the initial visit (P = 0.001 respectively). Forty-eight non-responders to the LTFC were older and had less frequent and severe LEs than responders at initial visit (all P < 0.05). In multivariate analysis, younger age at diagnosis, older age at initial visit, a diagnosis of a brain tumor or lymphoma, and use of radiotherapy were significant risk factors for LEs (all P < 0.05). Adverse changes in LEs were seen among the survivors, regardless of most clinical risk factors. They need to receive comprehensive, long-term follow up.

Physician preferences and attitudes regarding different models of cancer survivorship care: a comparison of primary care providers and oncologists

PURPOSE

New strategies for delivering cancer follow-up care are needed. We surveyed primary care providers (PCPs) and oncologists to assess how physician attitudes toward and self-efficacy with cancer follow-up affect preferences for different cancer survivorship models.

METHODS

The survey of physician attitudes regarding the care of cancer survivors was mailed to a randomly selected national sample of PCPs and oncologists to evaluate their perspectives regarding physician roles, knowledge about survivorship care processes, and views on cancer surveillance. Multinomial logistic regression models were constructed to examine how physician attitudes towards, and self-efficacy with, their own skills affected preferences for different cancer survivorship care models.

RESULTS

Of 3,434 physicians identified, a total of 2,026 participants provided eligible responses: 938 PCPs and 1,088 oncologists. Most PCPs (51 %) supported a PCP/shared care model; whereas, the majority of specialists (59 %) strongly endorsed an oncologist-based model (p < 0.001). Less than a quarter of PCPs and oncologists preferred specialized survivor clinics. A significant proportion of oncologists (87 %) did not feel that PCPs should take on the primary role of cancer follow-up. Most PCPs believed that they were better able to perform breast and colorectal cancer follow-up (57 %), detect recurrent cancers (74 %), and offer psychosocial support (50 %), but only a minority (32 %) was willing to assume primary responsibility. PCPs already involved with cancer surveillance (43 %) were more likely to prefer a PCP/shared care than oncologist-based survivorship model (OR, 2.08; 95 % CI, 1.34-3.23).

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

PCPs and oncologists have different preferences for models of cancer survivorship care. Prior involvement with cancer surveillance was one of the strongest predictors of PCPs' willingness to assume this responsibility.

Managing the consequences of cancer treatment and the English National Cancer Survivorship Initiative

BACKGROUND

In 2007 the English National Cancer Survivorship initiative was launched as a partnership between a national charity, Macmillan Cancer Support, the English Department of Health (DH) and the quality improvement agency NHS Improvement. The initiative involved a number of work streams, one of which was to improve the detection and management of the Consequences of adult cancer Treatment (COT).

MATERIAL AND METHODS

The adult COT group took evidence from a range of stakeholders and published a vision and work programme focused on awareness raising, linking self- administered questionnaires to routine activity data collection and testing new models of care with a particular focus on pelvic cancers.

RESULTS

Key outputs include national media campaigns, publications demonstrating the value of linking cancer treatment episodes to routine recording of chronic illness, identification of sensitive Patient Reported Outcome Measures (PROMs) items for use in national surveys, evidence reviews and published national guidelines, together with the development of a three level risk stratified model of care. Pilot testing with survivors treated for pelvic cancers, and adult survivors with radiation-induced brachial plexopathy has been completed.

CONCLUSION

Early results suggest that a systematic approach to the prevention, detection and management of some treatment-related consequences can significantly improve the ability of patients to manage their conditions. As a result of these findings, new services have now been commissioned by the NHS, initially for those with complex problems.

Implementing improved post-treatment care for cancer survivors in England, with reflections from Australia, Canada and the USA

Increasing cancer incidence together with improved survival rates are contributing to the growing number of cancer survivors. Survivors may encounter a range of potential effects as a result of the cancer itself or cancer treatments. Traditionally, the major focus of follow-up care has been on detection of cancer recurrence; however, the efficacy of such strategies is questionable. Traditional follow-up frequently fails to identify or adequately address many survivors’ concerns. Aftercare needs to be planned to enable better outcomes for survivors, while using scarce health-care resources efficiently. This review focuses on provision of survivorship care, rather than on research. England’s National Cancer Survivorship Initiative has developed principles for improved care of those living with and beyond cancer. These include risk-stratified pathways of care, the use of treatment summaries and care plans, information and education to enable choice and the confidence to self manage, rapid re-access to specialist care, remote monitoring and well-coordinated care. Many of these principles are relevant internationally, though preferred models of care will depend on local circumstances.

Management of chronic venous disease by primary care

Objective:

To assess the patterns of referral for chronic venous disease (CVD).

Method:

General practitioners (GPs) were invited by an email to complete a validated online survey evaluating the referral and community management of CVD.

Results:

A total of 138 participants were recruited. Most GPs (85%) saw fewer than 50 patients with CVD a year. Thirty-one percent were aware of National Institute for Clinical Excellence referral guidelines for CVD and 36% were aware of and agreed with local referral guidelines. Eleven percent were aware of clinical venous scoring systems. Sixty-three percent believed mild CVD would progress and 84% believed treatment would improve the quality of life. Sixteen referred C3 disease, 43% C4, 37% C5 and 65% C6 disease. Forty-one percent would refer on request. Pain symptoms increased referral in C2 disease. Endothermal ablation was believed available to 33% and traditional stripping to 62% and 27% were unaware of the treatment options. Forty-five percent were happy to provide postoperative care.

Conclusions:

Despite national guidelines, the management of CVD in the UK is variable.