Follow-up care for childhood cancer survivors: A focus group analysis

A prospective cohort study on the trajectory of health-related quality of life in adult childhood cancer survivors attending a follow-up care program

Follow-up care in adult childhood cancer survivors (ACCS) aims to screen for, prevent, and treat potential late effects. The trajectory of ACCS' health-related quality of life (HRQoL) attending follow-up care is unclear. We investigated changes in HRQoL of ACCS attending a follow-up care program. The primary outcome was the minimal clinically important decrease (MCID) in HRQoL of ≥ 5 points in the mental (MCS) and/or physical component score (PCS) of the 36-item Short Form (SF-36) between baseline and follow-up (3-months after the first visit). We compared baseline characteristics, psychological factors, satisfaction, and distress (measured using the Brief Symptom Inventory). In 47 ACCS (100%), no significant change in the overall median MCS and PCS was observed. In 14 ACCS (29.8%) a MCID in HRQoL was observed. Compared to ACCS without a MCID, they reported lower PCS (median 45.2 [31.7; 51.4] vs. 55.6 [46.1; 57.6], p = 0.007), a higher proportion of low physical health (PCS < 48; 71.4% vs. 27.3%, p = 0.009) and distress (50% vs. 18.8%, p = 0.030) at baseline. Satisfaction was high (94.9%). One in three ACCS experienced a clinically important decrease in HRQoL after follow-up care, with higher rates in those with lower physical health and higher psychological distress at baseline.

Parent caregivers' preferences and satisfaction with currently provided childhood cancer survivorship care

PURPOSE

The aim of this study was to investigate the level of satisfaction of parent caregivers of childhood cancer survivors (CCSs) with currently provided survivorship care and their preferences for survivorship care provider.

METHODS

Study subjects were parent caregivers recruited at three hospitals in Korea. Study data were collected from self-administered questionnaires and medical records. We assessed parent caregivers' levels of satisfaction with specific survivorship care contents and preferred types of survivorship care provider among oncologists, primary care physicians (PCPs), and institutional general physicians (IGPs). Factors associated with parent caregivers' preferences for survivorship care provider were evaluated by multiple logistic regression analysis.

RESULTS

680 parent caregivers (mother 62.1% and father 37.9%) of 487 CCSs (mean age at diagnosis: 6.9 ± 5.1 years; mean time since treatment completion 5.4 ± 4.4 years) were included. Parent caregivers' dissatisfaction was the highest with screening for second primary cancer, followed by psychosocial problem management. Higher educational level of parent caregiver, parent caregiver's higher level of dissatisfaction with currently provided care, higher age of CCSs at cancer diagnosis, history of receiving hematopoietic stem cell transplant, and longer time lapse after cancer treatment were significantly associated with parent caregivers' higher preference for PCPs or IGPs than oncologists. Parent caregiver's multiple comorbidities and higher fear of cancer recurrence were associated with parent caregivers' higher preference for oncologists than PCPs or IGPs. Around 80% of parent caregivers recognized that a shared care system was helpful for promoting the health of CCSs.

CONCLUSION

Parent caregivers were substantially dissatisfied with currently provided care, especially regarding the health issues not directly associated with the primary cancer. Parent caregivers' preferences for survivorship care provider is influenced by multiple factors, including age and survival time of CCSs, characteristics of parent caregivers, satisfaction level with care, and specific survivorship care contents.

IMPLICATIONS FOR CANCER SURVIVORS

The findings of our study suggest that shared survivorship care for CCSs with consideration of specific care contents can complement the current oncologist-led survivorship care system.

Mixed methods assessment of impact on health awareness in adult childhood cancer survivors after viewing their personalized digital treatment summary and follow-up recommendations

Background

The survival rate after childhood cancer has improved to 80%. The majority of childhood cancer survivors (CCS) will experience late complications which require follow up care, including access to their individual cancer treatment summary. The need to understand CCS needs and preferences in terms of ways to receive information e.g. digitally, becomes important. This study aims to through a mixed methods approach a) examine how CCS’ health awareness was impacted by viewing their personalized digital treatment summary and follow-up recommendations, b) explore E health literacy, and c) determine self-reported survivorship experiences and health care usage.

Methods

Survivors with a recent visit to the Late effects clinic were eligible for the study (n = 70). A representative sample of primary diagnoses were invited (n = 28). 16 CCS were enrolled. Recent medical visits, e health literacy and impressions of the digital treatment summary were assessed by a survey in conjunction with viewing their digital treatment summary on a computer screen. Their experience of reading and understanding their digital treatment summary in the context of their health related survivorship experiences were assessed in focus groups. The transcribed data was analyzed with conventional qualitative content analysis.

Results

The self-reported medical problems largely reflected that, only 6,3% reported no cancer-related reasons for seeking medical attention. Of the medical specialists, the primary care physician was the most frequently visited specialist (68.8%). High E health literacy was not associated with treatment features but with educational level (p = 0.003, CI: 3.9–14.6) and sex (p = 0.022, CI: − 13.6- -1.3). All survivors graded the digital treatment summary above average in terms of being valuable, agreeable and comprehensive. The focus group interviews identified three themes: 1) The significance of information, 2) The impact of awareness; and 3) Empowerment.

Conclusions

Reading the treatment summaries furthered the survivors understanding of their health situation and consequently aided empowerment. A digital treatment summary, provided by knowledgeable health care professionals, may increase the self-managed care and adherence to follow-up recommendations. Further insights into e health literacy in larger samples of CCS may determine to what extent health-related information can be communicated via digital resources to this at risk population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08051-9.

Available, but not always accessible: A nationwide, qualitative study of multidisciplinary healthcare providers' experiences with follow-up care after paediatric brain tumour

OBJECTIVE

Paediatric brain tumour (PBT) survivors face high risks of disabling long-term and late effects. Whether survivors' needs are met in a system with publicly funded services, but in the absence of a formal long-term follow-up model, is uncertain. Empirically based recommendations for a national model are needed. We explored multidisciplinary healthcare providers' (HCP) experiences with providing such care.

METHODS

We conducted five focus-group interviews and five individual interviews with a nationally representative sample of 33 Norwegian HCPs. Focus-group interviews and individual interviews were analysed using systematic text condensation.

RESULTS

Three main themes were identified: (a) 'Providing care above and beyond system constraints', describing a perceived discrepancy between HCPs' knowledge of, and their ability to meet, the survivors' needs. (b) 'System barriers to providing optimal follow-up care', describing a perceived lack of routines for communication and coordination between the HCPs and existing care services. (c) 'Nurses and shared-care to improve care', including empowering nurses and establishing routines for collaborations and areas of responsibilities.

CONCLUSION

The current healthcare system was perceived not to fully meet the survivors' needs. Nurse-led care models, including standardised patient-care pathways, were suggested to increase the accessibility of already-existing services and thus to improve long-term follow-up care.

Distance and acceptance: Identity formation in young adults with chronic health conditions

Health has long been a chief concern of life course researchers, especially in examining early life. Research on chronic conditions and their impact on individual identity often center on biographical disruption or the idea of a bifurcation of "before and after" identities. This research examines identity formation in young adults with chronic health conditions that began in childhood, a population that continues to grow. This study focuses on young adults' narrative identities, both regarding how young adults describe the transition to adulthood and how cultural ideals of young adulthood and actors from institutions influence how they describe themselves. This study uses 22 in-depth qualitative interviews to reveal how young adults distance themselves from their conditions or move to acceptance through the narratives they tell about their health, feelings, and behaviors. This research suggests that identity confirmation by others forms an integral part of the nexus of health and the life course, shaping how adolescents make the transition into young adulthood. Social support from actors in institutions gives room to some young adults with chronic conditions to integrate their conditions into their narrative identities. This study reveals the social nature of young adult identities, and how cultural ideals guide them, precisely because it uses cases of young adults who must transition to adulthood in alternative ways.

Barriers and facilitators to incident reporting in mental healthcare settings: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: The barriers and facilitators to incident reporting are becoming well known in general healthcare settings due to a large body of research in this area. At present, it is unknown if these factors also affect incident reporting in mental healthcare settings as the same amount of research has not been conducted in these settings. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Some of the barriers and facilitators to incident reporting in mental healthcare settings are the same as general healthcare settings (i.e., learning and improvement, time and fear). Other factors appear to be specific to mental healthcare settings (i.e., the role of patient diagnosis and how incidents involving assault are dealt with). WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Interventions to improve incident reporting in mental healthcare settings may be adapted from general healthcare settings in some cases. Bespoke interventions for mental healthcare settings that focus specifically on violence and aggression should be co-designed with patients and staff. Thresholds for incident reporting (i.e., what types of incidents will not be tolerated) need to be set, communicated and adopted Trust wide to ensure parity across staff groups and services. ABSTRACT: Introduction Barriers and facilitators to incident reporting have been widely researched in general health care. However, it is unclear if the findings are applicable to mental health care where care is increasingly complex. Aim To investigate if barriers and facilitators affecting incident reporting in mental health care are consistent with factors identified in other healthcare settings. Method Data were collected from focus groups (n = 8) with 52 members of staff from across West London NHS Trust and analysed with thematic analysis. Results Five themes were identified during the analysis. Three themes (a) learning and improvement, (b) time and (c) fear were consistent with the existing wider literature on barriers and facilitators to incident reporting. Two further themes (d) interaction between patient diagnosis and incidents and (e) aftermath of an incident-prosecution specifically linked to the provision of mental health care. Conclusions Whilst some barriers and facilitators to incident reporting identified in other settings are also prevalent in the mental healthcare setting, the increased incidence of violent and aggressive behaviour within mental health care presents a unique challenge for incident reporting. Clinical implications Although interventions to improve incident reporting may be adapted/adopted from other settings, there is a need to develop specific interventions to improve reporting of violent and aggressive incidents.

A study of childhood cancer survivors' engagement with long-term follow-up care: 'To attend or not to attend, that is the question'

PURPOSE

In the UK, there are over 40,000 childhood cancer survivors (CCS); this figure grows approximately 1300 annually. Two-thirds are at risk of developing serious disabling or life-threatening conditions due to adverse late effects of the cancer or treatment received in childhood. Life-long, follow-up care for the surveillance and management of late effects is recommended. This study explored CCS' views and experiences of long-term follow-up (LTFU) care within a cancer centre.

METHODS

Paper questionnaires (n = 113) and qualitative interviews (n = 13).

RESULTS

The majority (n = 83, 80%) of CCS reported being satisfied with their LTFU care and felt that it was important to attend long-term survivorship follow-up (n = 97, 86%). However, some were not well informed about their cancer treatment history, purpose for attending the clinic or the potential for late effects. Barriers associated with LTFU included; provision of information, lack of interpersonal relationships, practical and logistic challenges.

CONCLUSIONS

Barriers identified can be addressed through strategies including provision of verbal and written information and care plans to increase CCS' knowledge of their cancer history, risk of late effects and the purpose of LTFU care, both at transition and throughout their survivorship journey; patient-centred services that enhance patient choice and flexibility of access to multiple specialities; and use of risk stratified pathways to encourage supported self-management based on cancer type, co-morbidity, and level of professional involvement required. Improving regular provision of information at critical time-points, and exploring a flexible, patient-centred delivery of LFTU care based on risk, could increase attendance and self-management in CCS.

Can the theory of planned behavior help explain attendance to follow-up care of childhood cancer survivors?

OBJECTIVE

Childhood cancer survivors are at high risk for late effects. Regular attendance to long-term follow-up care is recommended and helps monitoring survivors' health. Using the theory of planned behavior, we aimed to (1) investigate the predictors of the intention to attend follow-up care, and (2) examine the associations between perceived control and behavioral intention with actual follow-up care attendance in Swiss childhood cancer survivors.

METHODS

We conducted a questionnaire survey in Swiss childhood cancer survivors (diagnosed with cancer aged <16 years between 1990 and 2005; ≥5 years since diagnosis). We assessed theory of planned behavior-related predictors (attitude, subjective norm, perceived control), intention to attend follow-up care, and actual attendance. We applied structural equation modeling to investigate predictors of intention, and logistic regression models to study the association between intention and actual attendance.

RESULTS

Of 299 responders (166 [55.5%] females), 145 (48.5%) reported attending follow-up care. We found that subjective norm, ie, survivors' perceived social pressure and support (coef = 0.90, P < 0.001), predicted the intention to attend follow-up; attitude and perceived control did not. Perceived control (OR = 1.58, 95%CI:1.04-2.41) and intention to attend follow-up (OR = 6.43, 95%CI:4.21-9.81) were positively associated with attendance.

CONCLUSIONS

To increase attendance, an effort should be made to sensitize partners, friends, parents, and health care professionals on their important role in supporting survivors regarding follow-up care. Additionally, interventions promoting personal control over the follow-up attendance might further increase regular attendance.

Connecting with healthcare providers at diagnosis: adolescent/young adult cancer survivors' perspectives

Adolescents and young adults (AYAs) with cancer are a vulnerable and underserved population. AYAs' cancer survivorship is complicated by physical and psychosocial late effects which requires long-term follow-up. Connectedness with healthcare providers (HCPs) is a protective factor that may improve long-term follow-up behaviours of AYAs. However, little is known about AYAs' experiences connecting with HCPs. The purpose of this study was to describe AYA cancer survivors' experiences connecting with HCPs. This empirical phenomenological study interviewed nine AYA cancer survivors diagnosed during adolescence. Individual interviews were conducted and analysed using an adapted Colaizzi approach. The essential structure reveals that AYAs begin their experience of connectedness with a sense of disconnectedness prior to treatment. The diagnosis is a period of confusion and emotional turmoil that interfere with the AYAs' ability to connect. When AYAs come to accept their illness and gain familiarity with the environment, they then put forth an effort to connect with HCPs. Although it takes time for AYAs to reciprocate efforts to connect, HCPs should be aware that AYAs carefully assess and make judgments about whether or not HCPs can be trusted. Findings raise awareness of the actions and behaviours of HCPs that hinder connectedness, and targeted in future research.

Experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood lymphoma

PURPOSE

Given childhood cancer survivors' risk of treatment-induced late effects, long-term follow-up care is recommended. We explored experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood malignant lymphoma in Norway.

METHODS

We conducted five focus group interviews with 34 survivors (19 females; 21 Hodgkin/13 non-Hodgkin lymphoma survivors; mean age 39 years; mean time from diagnosis 26 years). Data was analyzed using principles of thematic analysis.

RESULTS

Two main themes were identified: (1) the survivors' experiences with late effects-related care and (2) their preferences for long-term follow-up care. Most of the survivors were dissatisfied with their late effects-related care due to perceptions of poor coordination of healthcare needs in a fragmented system, combined with a perceived lack of knowledge of late effects among themselves and general practitioners (GPs). All survivors valued long-term follow-up care. Oncologists were the preferred care providers, but GPs were considered acceptable providers if they had sufficient knowledge of late effects and routine examinations, short waiting times, and improved GP-oncologist collaboration.

CONCLUSIONS

Our results suggest that a shared care model of long-term follow-up care involving specialists, GPs, and the survivors themselves is likely to fulfill several of the currently unmet needs among adult survivors of childhood cancers. Improved patient education about late effects and follow-up care would aid self-management. The survivors' concerns regarding lack of sufficient knowledge of late effects among GPs suggest a need for improving access to, and dissemination of, information of late effects.

Childhood leukaemia survivors' experiences of long-term follow-ups in an endocrine clinic - A focus-group study

The survival rate after childhood cancer has improved markedly and today more than 80% of patients will survive. Many childhood cancer survivors suffer from late complications due to radiotherapy and chemotherapy. Survivors of Acute Lymphoblastic Leukaemia (ALL), treated with cranial radiotherapy, are at a particularly high risk of having endocrine complications.

PURPOSE

To illuminate childhood ALL survivors' experiences of a long-term follow-up in an endocrine clinic.

METHOD

Data collection carried out using semi-structured focus-group interviews. Fifteen ALL survivors were included in the study, divided into 4 groups. Data was analysed with conventional qualitative content analysis.

RESULTS

The survivors' experiences were captured in the theme: "The need for understanding and support in order to manage daily life". An understanding of their situation, as well as support for managing daily life was fundamental. Lack of understanding and support from the community was connected with a fear for the future. The follow-up at the endocrine clinic was shown to be crucial for increasing the survivors' understanding of late complications. The past feeling of being out of control was replaced with an increased self-confidence.

CONCLUSION

Many leukaemia survivors experienced their daily lives as a struggle and as a complicated issue to cope with. The theme "understanding and support to manage daily life" mirrors how the survivors are in need of knowledge and support in order to handle and understand their complex situation after surviving leukaemia. Offering understanding and support with a holistic approach, may be a way in which to strengthen the survivors' health.

Preferences for long-term follow-up care in childhood cancer survivors

Follow-up care is important for childhood cancer survivors to facilitate early detection and treatment of late effects. We aimed to describe preferences for different organisational aspects and models of follow-up care among Swiss childhood cancer survivors, and characteristics associated with preferences for different models. We contacted 720 survivors aged 18+ years, diagnosed with cancer after 1990 (age 0-16 years), registered in the Swiss Childhood Cancer Registry (SCCR), and Swiss resident, who previously participated in a baseline survey. They received questionnaires to assess attendance and preferences for follow-up (rated on 4-point scales, 0-3). Clinical information was available from the SCCR. Survivors (n = 314: response rate 43.6%; 47.8% still attended follow-up) rated clinical reasons for follow-up higher than supportive reasons (p < .001). They rated checking for cancer recurrence (mean = 2.78, SD = 0.53) and knowing about risks for my children most important (mean = 2.22, SD = 0.83). They preferred to attend a children's hospital (mean = 1.94, SD = 1.11), adult hospital (mean = 1.86, SD = 0.98) or general practitioner (mean = 1.86, SD = 1.01) rather than a central specialised late effects clinic (mean = 1.25, SD = 1.06, p < .001), and be seen by paediatric (mean = 2.24, SD = 0.72) or medical oncologist (mean = 2.17, SD = 0.69). Survivors preferred decentralised clinic-based follow-up, rather than one central specialised late effects clinic. Survivors' preferences should be considered to ensure future attendance.

Parental preferences for paediatric specialty follow-up care

Objective The aim of the present study was to examine factors associated with: (1) parental preference to receive follow-up care for their child from a general practitioner (GP); and (2) a decision to seek treatment when there is a slight worsening of their child's condition. Methods Parents presenting with their child at any one of five paediatric out-patient clinics at two public hospitals in Melbourne (Vic., Australia) were surveyed. We performed frequency distributions, bivariate analyses and multivariate logistic regression to evaluate associations with the preference for a GP for follow-up care and treatment in case of a slight worsening. Results In all, 606 parents were recruited to the study, 283 being new presentations and 323 presenting for review. GPs were selected as the preference for follow-up care by 23% (n=142) of respondents, and 26% (n=160) reported they would seek treatment from a GP if the condition of their child were to worsen slightly. There was an increased likelihood to prefer a GP for follow-up care for new patients (odds ratio (OR) 3.10; 95% confidence interval (CI) 1.99-4.83), those attending general paediatrics clinic (OR 1.73; 95% CI 1.11-2.70), and parents with a lower level of education (OR 1.74; 95% CI 1.09-2.78). For review patients, if during the previous visit a paediatrician suggested follow-up with a GP, parents were more likely to prefer a GP as a follow-up provider (OR 6.70; 95% CI 3.42-13.10) and to seek treatment from a GP in case of a slight worsening (OR 1.86; 95% CI 1.03-3.37). Conclusion Most parents attending paediatric out-patient appointments prefer to return for follow-up care; however, a paediatrician's advice may have an important role in return of paediatric patients to primary care. What is known about the topic? In Australia, there has been a growing concern regarding long waiting times for specialist consultations in out-patient clinics and difficulties with access for new patients. This has occurred when the ratio of review attendees to new patients has tipped towards the review attendees. What does this paper add? Most parents of children attending paediatric out-patient clinics value follow-up care with paediatric specialists, even if the referring GP requested a return to their surgery. The advice of the consulting paediatrician in support of follow-up care with a GP contributes significantly to the willingness of parents to return to primary care and to seek treatment from their GP for a slight worsening of their child's condition. What are the implications for practitioners? The findings of the present study have significant implications for the discharge of patients from speciality care: paediatricians can have an important role in the return of paediatric patients to primary care.

Follow-up care of young childhood cancer survivors: attendance and parental involvement

PURPOSE

Despite recommendations, only a proportion of long-term childhood cancer survivors attend follow-up care. We aimed to (1) describe the follow-up attendance of young survivors aged 11-17 years; (2) describe the parental involvement in follow-up, and (3) investigate predictors of follow-up attendance and parental involvement.

METHODS

As part of the Swiss Childhood Cancer Survivor Study, a follow-up questionnaire was sent to parents of childhood cancer survivors aged 11-17 years. We assessed follow-up attendance of the child, parents' involvement in follow-up, illness perception (Brief IPQ), and sociodemographic data. Clinical data was available from the Swiss Childhood Cancer Registry.

RESULTS

Of 309 eligible parents, 189 responded (67 %; mean time since diagnosis 11.3 years, range 6.8-17.2) and 75 % (n = 141) reported that their child still attended follow-up. Of these, 83 % (n = 117) reported ≥1 visit per year and 17 % (n = 23) reported <1 visit every year. Most survivors saw pediatric oncologists (n = 111; 79 % of 141), followed by endocrinologists (n = 24, 17 %) and general practitioners (n = 22, 16 %). Most parents (92 %) reported being involved in follow-up (n = 130). In multivariable and Cox regression analyses, longer time since diagnosis (p = 0.025) and lower perceived treatment control (assessed by IPQ4: how much parents thought follow-up can help with late effects; p = 0.009) were associated with non-attendance. Parents' overall information needs was significantly associated with parental involvement in the multivariable model (p = 0.041).

CONCLUSION

Educating survivors and their parents on the importance and effectiveness of follow-up care might increase attendance in the longer term.

Family Functioning as a Constituent Aspect of a Child's Chronic Illness

This study explored how family functioning may contribute to trace a child's illness trajectory. We conducted semi-structured interviews with 33 parents of children in care at a hospice in northern Italy. We also examined the medical records of the children, and interviewed the physician who cared for them. Data analysis was based on the grounded theory approach. Different illness progressions corresponded to the different ways with which families experienced the illness: possibility, focus on illness, denial, and anger. Clinical interventions should involve the whole family and take into account their role in the construction of illness trajectories.

Providing information about late effects after childhood cancer: lymphoma survivors' preferences for what, how and when

OBJECTIVE

Childhood cancer survivors need information about risks of late effects to manage their health. We studied how and when adult, long-term survivors prefer to receive information about late effects.

METHODS

Five focus-groups with adult survivors of childhood lymphomas who had completed routine follow-up care and participated in a preceding follow-up study (n = 34, 19 females, mean age = 39). We used thematic analysis to identify themes regarding providing late effects information.

RESULTS

The survivors wanted information about late effects (symptoms, prevention and treatment), lifestyle and social security rights. Information should be tailored, carefully timed, given "face-to-face" and in written format. Many expressed ambivalence regarding receiving information as adolescents, but it was seen as essential "to know" once a late effect occurred. A "re-information" consultation about late effects around age 25 was suggested as beneficial.

CONCLUSION

Although ambivalent, all survivors wanted information about late effects. They preferred individualized information, disclosed "step-by-step" and in a "re-information consultation" when reaching young adulthood.

PRACTICE IMPLICATIONS

Providing information about late effects should be an on-going process across the cancer care trajectory. (Re-)Informing survivors when older would enhance their understanding of their health risks and could aid better health self-management beyond completion of follow-up care.

Exploring the experience of an enhanced recovery programme for gynaecological cancer patients: a qualitative study

BACKGROUND

Perioperative enhanced recovery programmes (ERPs), identified as initiatives that improve care and save money, have been adopted by NHS Improvement and are currently being rolled out across many surgical departments within the NHS. To date, five papers have specifically explored patients' experiences of ERPs; none, however, has explored the gynaecological cancer patient experience.

METHODS

In total, 14 women (mean age, 66 years) participated in an audio-recorded face-to-face or telephone interview in which they discussed their experience of taking part in an ERP. The resulting data were transcribed verbatim and analysed using interpretative phenomenological analysis.

RESULTS

Two main themes emerged from the analysis. The first, 'Taking part in the programme', highlights two important aspects of the ERP: being given an opportunity to receive information and, following this, to build knowledge about the programme. The theme also explores the challenges associated with the programme, particularly around getting mobile and complying with its demands - the women report experiencing a constant battle between intuition and instruction. The second theme, 'Home', focuses on the role home plays in motivating the patients to aim for an early discharge from hospital. Patients describe their need to return to a suitable home and the need for support from others. They also discuss the importance of the follow-up phone call.

CONCLUSION

Overall, the patients in this study positively assessed the individual aspects of the ERP, in particular, information resources, the availability of the physiotherapist and the delivery of follow-up phone calls. These findings highlight the importance of developing and maintaining individual aspects of ERPs over time, to ensure their sensitivity and responsiveness to patient needs.

Living an Everyday Life Through a Child’s Cancer Trajectory

The aim of this study was to illuminate the lived experiences of families where a child had survived 7 years from a diagnosis of childhood cancer. This article describes one part of an inductive and longitudinal research project that included 17 families. Four families whose child was diagnosed with cancer 7 years previously were interviewed using a hermeneutical phenomenological approach. The families lived experience was described in one essential theme, “Living an everyday life through the child’s cancer trajectory,” further illuminated in 3 related themes: “Leaving the disease behind yet feeling its presence,” “Being the same yet always different,” and “Feeling stronger yet vulnerable.” The results suggest that family members feel vulnerable even if a long period of time has passed since completion of treatment. To varied degrees they still may need support. When moving forward in life, the family members are helped if they can reconcile their memories and experiences derived from the childhood cancer trajectory.

Impact of Social Support on Bereaved Siblings’ Anxiety

Purpose:To assess adolescent and young adult siblings’ perception of social support prior to and following the loss of their brother or sister to cancer, 2 to 9 years earlier, and their anxiety at follow-up. Method: In 2009, 174 (73%) bereaved siblings (12-25 years) participated in a nationwide, long-term follow-up study in Sweden using an anonymous study-specific questionnaire. The Hospital Anxiety and Depression Scale was used to measure self-assessed anxiety. Results: Siblings had a higher risk of anxiety if they perceived their need for social support was unsatisfied during their brother or sisters’ last month before death, relative risk (RR) = 3.6 (95% confidence interval [CI] = 1.8-7.3); time after death, RR = 2.9 (95% CI = 1.5-5.6); and at follow-up, RR = 3.8 (95% CI = 2.0-7.2). Furthermore, a higher risk for anxiety was shown for siblings if they did not perceive that their parents and neighbors cared for them after their brother or sisters’ death, RR = 2.7 (95% CI = 1.3-5.5), RR = 5.4 (95% CI = 1.3-21.9), respectively. Conclusion: Bereaved siblings had a greater probability to report self-assessed anxiety if they perceived that their need for social support was not satisfied prior to and following death. Information from both nurses and other health care professionals to families about the impact of social support may contribute to lessen the siblings’ risk of anxiety.

General practitioner involvement in follow-up of childhood cancer survivors: a systematic review

BACKGROUND

An increasing number of childhood cancer survivors need long-term follow-up care. Different models address this problem, including that of follow-up by general practitioners (GP). We describe models that involve GPs in follow-up for childhood cancer survivors, their advantages and disadvantages, clinics that employ these models, and the elements essential to high-quality, GP-led follow-up care.

PROCEDURE

We searched four databases (PubMed [including Medline], Embase, Cochrane, and CINAHL) without language restrictions.

RESULTS

We found 26 publications, which explicitly mentioned GP-led follow-up. Two models were commonly described: GP-only, and shared care between GP and pediatric oncology or late effects clinic. The shared care model appears to have advantages over GP-only follow-up. We found four clinics using models of GP-led follow-up, described in five papers. We identified well-organized transition, treatment summary, survivorship care plan, education of GPs and guidelines as necessary components of successful follow-up.

CONCLUSION

Scarcity of literature necessitated a review rather than a meta-analysis. More research on the outcomes of GP-led care is necessary to confirm the model for follow-up of childhood cancer survivors in the long term. However, with the necessary elements in place, the model of GP-led follow-up, and shared care in particular, holds promise.

Views of childhood cancer survivors and their families on the provision and format of a treatment summary

INTRODUCTION

Summaries of diagnosis, treatments, and their potential late adverse health effects (treatment summaries) are increasingly being provided routinely to survivors of childhood cancer. There is relatively little research into opinions of service users on the provision and format of treatment summaries.

METHODS

Semistructured interviews were conducted with 24 survivors of childhood cancer, and 25 parents of 20 of these survivors (n=49) were asked to explore these issues. Survivors were aged 4 to 22 years, with a range of previous oncological diagnoses. The mean (range) interval since treatment completion was 4.5 (0.5 to 13) years.

RESULTS

Twelve survivors (50%) and 16 parents (64%) fully supported the use of treatment summaries as: a memory aid, a reference tool for planned and emergency medical situations, life and financial planning, and to promote ownership of health. Four survivors felt they did not want, or did not need, a reminder of their medical past. Most participants (63% of survivors) desired a verbal explanation plus a written A4 paper treatment summary. However, other formats (wallet sized, audio guides) were suggested to address practical and individual needs raised by participants.

CONCLUSIONS

Most service users would benefit from treatment summaries, although notably not all. The format and timing of the provision need to be carefully considered.

Development of a comprehensive health-related needs assessment for adult survivors of childhood cancer

PURPOSE

Examine the construct validity, stability, internal consistency, and item-response performance of a self-report health needs assessment for adult survivors of childhood cancer.

METHODS

A 190-item mailed survey was completed by 1,178 randomly selected (stratified on age, diagnosis, time since diagnosis) Childhood Cancer Survivor Study participants (mean age, 39.66 [SD 7.71] years; time since diagnosis, 31.60 [SD 4.71] years). Minorities and rural residents were oversampled at a 2:1 ratio.

RESULTS

The final instrument included 135 items comprising nine unidimensional subscales (Psycho-emotional, Health System Concerns, Cancer-Related Health Information, General Health, Survivor Care and Support, Surveillance, Coping, Fiscal Concerns, and Relationships). Confirmatory factor analysis (n = 1,178; RMSEA = 0.020; 90 % CI = 0.019-0.020; CFI = 0.956; TLI = 0.955) and person-item fit variable maps established construct validity. Across subscales, Cronbach's alpha was 0.94-0.97, and the 4-week test-retest correlations were 0.52-0.91. In a Rasch analysis, item reliability was 0.97-0.99, person reliability was 0.80-0.90, and separation index scores were 2.00-3.01. Significant subscale covariates of higher need levels included demographics, diagnosis, and treatment exposures.

CONCLUSIONS

The Childhood Cancer Survivor Study Needs Assessment Questionnaire (CCSS-NAQ) is reliable and construct-valid, has strong item-response properties, and discriminates need levels.

IMPLICATIONS FOR CANCER SURVIVORS

The CCSS-NAQ potentially can be used to: (1) directly assess adult childhood cancer survivors' self-reported health-related needs, (2) identify individuals or subgroups with higher-level needs, (3) inform prevention and direct intervention strategies, and (4) facilitate prioritization of health-care resource allocation.

Using focus groups in radiation therapy research: Ethical and practical considerations

Focus groups are a means of gathering qualitative data from a group of participants who discuss a given topic. This method has been used in health care research for the past 30 years, but has seen limited use in radiation therapy research. Focus group discussions are a useful tool for investigating a variety of educational, training and clinical issues from the perspective of practitioners, students and patients. This paper reviews the issues associated with using focus groups as a means of data collection. In particular, it addresses some of the decisions which have to be made about group composition and conduct of the discussions. The literature review is contextualised using a recent example of how the authors used focus groups to investigate fitness to practise in radiation therapy. Other challenges such as familiarity between participants and researchers, power relationships and anonymity are addressed. The paper concludes with a consideration of data analysis.

The met and unmet health care needs of adult survivors of childhood central nervous system tumors: a double-informant, population-based study

BACKGROUND

The purpose of the current study was to examine the persistent health care needs (HCNs) of adult survivors of childhood central nervous system tumors.

METHODS

In this population-based study, 526 of 679 eligible survivors and 550 parents provided data. Survivors' HCNs were assessed using a questionnaire covering 4 domains: Medical Care, care coordination and communication (Care Coordination), Illness Education, and Psychosocial Services. Needs were categorized as no need, met need, and unmet need. Outcomes were analyzed specifically in relation to survivors' functional late effects as assessed using the Health Utilities Index Mark 2/3.

RESULTS

Approximately 40% of survivors experienced their HCNs as exceeding the supposed general population average, and 41% had a current HCN that was unmet. The most common unmet need concerned the Psychosocial Services domain (reported by 40%), followed by a lack of Illness Education (35%), Care Coordination (22%), and Medical Care (15%). Survivors experiencing functional late effects had greater HCNs, and a greater percentage of unmet needs. Agreement between survivor-reported and parent proxy-reported HCNs was satisfactory, whereas agreement for survivors' unmet HCNs ranged from poor to satisfactory.

CONCLUSIONS

Findings based on reliable double-informant data demonstrated that a considerable percentage of adult survivors report unmet HCNs, with female sex, younger age at diagnosis, and indications of disability and poor health status comprising significant risk factors. Issues critical for improved, comprehensive, long-term follow-up care were identified. Addressing these issues adequately in clinical follow-up extending into adulthood would likely improve the quality of comprehensive care for this patient group.

Comparison of self-reported late effects with medical records among survivors of childhood cancer

BACKGROUND

Survival rates following childhood cancer have increased, but survivors experience significant late effects. Long-term follow-up is recommended but imposes an increasing burden on health services. We report prevalence of morbidity in a cohort of survivors from South Yorkshire based on: (i) case-note analysis and (ii) self-reported late effects (parent-reported for under-16s).

METHODS

Treatment information was taken from case-notes. Comparisons were made between late effects described in notes and reported by 108 survivors aged >16 years, and 45 parents of survivors (12-15 years).

FINDINGS

Of 892 patients diagnosed with childhood cancer and some benign conditions registered on hospital databases from January 1990 to December 2005, 337 (37.8%) met eligibility criteria. Ninety-one survivors (16) (84.3%, confidence interval [CI]: 76.0-90.6) reported one or more late effects (mean=3.5; CI: 3.0-4.1), significantly higher than the number of late effects documented in medical notes (mean=0.7; CI: 0.5-0.9; t=-11.26, p<0.001). Thirty-five parents (77.8%, CI: 65.1-90.4) reported late effects for their children (mean=2.7; CI: 2.0-3.4), again higher than medical notes (mean=0.7; CI: 0.4-1.1; t=7.18, p<0.001). More than 30 specialties were involved in survivor care (mean=1.5; CI: 1.4-1.6; range 0-6). Those with more late effects saw more specialties (r=0.51, p<0.001).

INTERPRETATION

We confirm the wide range of late effects experienced by survivors of child cancer, significantly greater than those recorded in medical notes, and requiring care from a range of specialties. Decisions about follow-up need to take account of patient-reported morbidity and concerns.

Follow-up care for young adult survivors of cancer: lessons from pediatrics

INTRODUCTION

Recent advances in treatment of childhood cancer have resulted in overall survival rates approaching 75%, but approximately two-thirds experience late-effects related to the disease or treatment. Consequently, recommendations for comprehensive follow-up have been made. As the number of survivors of adult cancers increase, similar concerns about how to provide follow-up and achieve optimal quality of life are being raised. In this paper we propose that management of cancer survivors diagnosed in young adulthood (18-45 years) could benefit from experience gained treating survivors of childhood cancer.

MATERIALS AND METHODS

We reviewed research relating to differences in survival rates and late-effects; current arrangements for follow-up; effectiveness; and problems in organization of follow-up separately for survivors of child and adult cancers.

RESULTS

A number of models of follow-up were identified. Rationale for follow-up included early identification and treatment of second cancer and late-effects, health promotion and screening. Increasing numbers of survivors and range of late-effects were identified as problems in organizing services. A possible solution is risk-stratified follow-up, currently being developed in pediatrics.

CONCLUSIONS

New models of follow-up are needed that take account of financial costs for health services and survivors' concerns about their current and future health. Implications for continuing refinement of treatment protocols must be an integral part of the service.

IMPLICATIONS FOR CANCER SURVIVORS

International standards are needed to ensure all survivors have access to expert follow-up care and can benefit from new information that might lead to earlier treatment of late-effects.

Follow-up of children who survive cancer

Should be individually tailored but may not be necessary for all

Shared care by paediatric oncologists and family doctors for long-term follow-up of adult childhood cancer survivors: a pilot study

BACKGROUND

Since 75% of children with cancer will become long-term survivors, late effects of treatment are an ever increasing issue for patients. Paediatric oncologists generally agree that cancer survivors should be followed up for the remainder of their lives, but they might not be the most suitable health-care providers to follow up survivors into late adulthood. We designed a 3-year study to assess whether shared-care by paediatric oncologists and family doctors in the long-term follow-up of survivors of childhood cancers is feasible, whether a shared-care model is compatible with collection of data needed for registration of late effects, and how a shared-care model is assessed by survivors and family doctors.

METHODS

In 2004 and 2005, adult survivors of childhood cancers were randomly chosen from eligible patients diagnosed with childhood cancer (excluding CNS tumours) or Langerhans-cell histiocytosis between January, 1968, and December, 1997, and recalled to the long-term follow-up (LTFU) clinic at the University Medical Centre Groningen, Groningen, Netherlands, where they underwent physical and clinical assessments by an on-site family doctor (visit 1). At this visit, assessments were done according to guidelines of the UK Children's Cancer Study Group Late Effects Group, and late effects were graded by use of Common Terminology Criteria for Adverse Events (version 3). Follow-up assessments were done 1 year later in 2005 and 2006 by local family doctors (visit 2), who were asked to return data to the LTFU clinic. At this visit, the local family doctors were asked to complete a three-item questionnaire and patients were asked to complete a seven-item questionnaire about their satisfaction with the shared-care model. At the next consultation, which was planned for the end of the study (visit 3), the on-site family doctor advised patients about future follow-up on the basis of their individual risk of late effects. Main endpoints were numbers of participants, satisfaction ratings, and proportions of local family doctors who returned data that they obtained at visit 2 to the LTFU clinic.

FINDINGS

133 individuals were chosen at random from 210 enrolled adult survivors. 123 of 133 (92%) randomly selected survivors and 115 of 117 (98%) of their family doctors agreed to participate in the share-care programme. 103 of 115 (90%) family doctors returned data to the LTFU clinic at visit 2. 89 of 101 (88%) of survivors were satisfied with this shared-care model, as were 94 of 115 (82%) family doctors; 18 of 115 (16%) family doctors had no views either way; and three of 115 (3%) family doctors were dissatisfied.

INTERPRETATION

Shared-care by paediatric oncologists and family doctors is feasible for long-term follow-up of adult survivors of childhood cancers.

Is postal follow-up of childhood cancer survivors worthwhile?

BACKGROUND

Childhood cancer survival has increased over the last 30 years, but long-term effects necessitate continued monitoring of survivors. Since not all of them attend follow-up clinics, this study assesses the efficacy of obtaining information from general practitioners (GPs) through a 5-year rolling postal program.

PROCEDURE

Survivors were included who had been diagnosed with a malignancy in the West Midlands since 1957 and were not attending central long-term follow-up clinics.

RESULTS

One thousand twenty-seven patients were followed up between 1993 and 2004. Replies were received on 903 (88% response). There were 44 subsequent malignancies and 42 deaths. No medical problems were reported in 341/935 patients (36.5%); in the other 594 endocrine effects were the most common, with visual effects the biggest single problem. Brain tumor survivors had the largest proportion of problems.

CONCLUSIONS

The response rate and information quality achieved show that this method of follow-up is feasible, in cases of discharged or defaulting patients. These data will complement those derived from hospital-based follow-up studies, to give a broader understanding of the spectrum of late effects experienced by survivors and may inform the development of specific long-term follow-up protocols.

A review of long-term follow-up for survivors of childhood cancer

Though cure from cancer is not guaranteed, children's chances of survival have increased significantly. As a result the paediatric oncology community is focused on providing appropriate follow-up care to an increasing number of young cancer survivors. How this care should be designed and delivered however remains the centre of ongoing discussion and was the focus of this review. The aims of the review were to (1) gain an understanding of current follow-up practices from studies involving health care professionals, (2) identify and evaluate studies presenting views of survivors, (3) examine commentaries on both the current and future design of long-term follow-up services and (4) evaluate existing follow-up guidelines. Empirical research, commentary papers and published guidelines were reviewed. Twenty-eight papers and five guidelines were analysed. Empirical papers were examined in relation to sample, design, findings and limitations. Commentary papers were assessed in relation to key issues about follow-up care. Guidelines were assessed on how far they were evidence-based, peer-reviewed and involved users in their development. Varying models of care were illustrated, and were dependent upon personnel and centre orientation. Variability in the level and degree to which long-term survivors were followed up was also reported. Inconsistencies in practice were noted. Nonetheless requirements for an effective service were highlighted in the majority of publications, these included communication and information. Although young people and professionals had a shared view on many aspects of follow-up care, these preferences were not consistently mirrored in service provision.

Long-term follow-up of children treated for cancer: why is it necessary, by whom, where and how?

About 1 in 715 young adults is a survivor of childhood malignancy, but these individuals are at increased risk of considerable treatment-related morbidity or even mortality. A recent study suggests that at least 60% have one or more chronic health problems, whilst about 20% have three or more. The principle goal of long-term follow-up (LTFU) of survivors is to decrease the severity of late treatment complications by performing appropriate surveillance to detect incipient toxicity, and by facilitating timely diagnosis and management of emerging or established late adverse effects. The content of LTFU is dictated by the type and amount of treatment for the malignancy, and has been defined in recent clinical guidelines. Moreover, LTFU allows provision of survivor education, psychosocial support and health promotion advice. However, considerable variation exists in how LTFU is performed, with several alternative models involving a range of professionals in a variety of locations, depending on numerous clinical and organisational factors. There is increasing utilisation of multidisciplinary teams, and recognition of the importance of effective transition strategies whereby care is transferred to more age-appropriate providers, usually after a period of joint care in adolescence. It is of paramount importance to ascertain and meet the needs of survivors themselves.

Follow-up after childhood cancer: evaluation of a three-level model

INTRODUCTION

Follow-up for cancer survivors is recommended to detect recurrence; monitor late-effects; record toxicity and provide care and education. We describe our experience with a three-level model developed to guide decisions about intensity and frequency of follow-up [Wallace WHB, Blacklay A, Eiser C, et al. Developing strategies for the long term follow-up of survivors of childhood cancer. BMJ 2001;323:271-274].

PROCEDURE

One hundred and ninety eight survivors (52% male) recruited over 12-months: (mean age=23.8 years, range=16-39 years; mean time since diagnosis=16.2 years, range 2.4-32.7 years) reported their number of symptoms and late-effects. Information was taken from the medical records to assign each survivor to the appropriate levels by six clinic staff independently.

RESULTS

The survivors were assigned to level 1 (n=8), level 2 (n=97) and level 3 (n=93). There were seven cases of disagreement. Level 3 survivors self-reported more symptoms and late-effects than level 2 survivors.

CONCLUSIONS

Coding was relatively simple for experienced clinic staff, although there were some disagreements for the survivors of ALL. The relationship between assigned level and self-reported symptoms and late-effects provides some evidence for validity of the model. We conclude that it is important to maintain flexibility to allow movement between levels for individual patients and that the default should always be to the higher level.

Long-term follow-up of people who have survived cancer during childhood

Substantial improvements in survival after treatment for malignant disease in childhood are leading to a rapidly increasing number of long-term survivors, many of whom are now adults. However, late chronic adverse effects of treatment are common, and have potentially severe effects on survivors' future physical, cognitive, or psychosocial health. The aim of long-term follow-up is to facilitate timely diagnosis and appropriate management of late adverse effects, thereby reducing the frequency of severe complications. Although the delivery of long-term follow-up care varies substantially--particularly in terms of who provides it, where, and how--recognition of the importance of appropriate multidisciplinary care and cross-speciality care is increasing, especially for adolescent and adult survivors of cancer during childhood. Several models of long-term follow-up care have been developed to address this need. This review discusses the present provision of long-term follow-up, and summarises information that might facilitate design and implementation of future models of long-term follow-up care.