Categorising cancers to enable tailored care planning through a secondary analysis of cancer registration data in the UK

Improving personalised care and support planning for people living with treatable-but-not-curable cancer

People living with treatable-but-not-curable (TbnC) cancer encounter cancer-related needs. While the NHS long-term plan commits to offering a Holistic Needs Assessment (HNA) and care plan to all people diagnosed with cancer, the content, delivery and timing of this intervention differs across practice. Understanding how people make sense of their cancer experience can support personalised care. A conceptual framework based on personal narratives of living with and beyond cancer (across different cancer types and all stages of the disease trajectory), identified three interlinked themes: Adversity, Restoration and Compatibility, resulting in the ARC framework.Our aim was to use the ARC framework to underpin the HNA to improve the experience of personalised care and support planning for people living with TbnC cancer. We used clinical work experience to operationalise the ARC framework and develop the intervention, called the ARC HNA, and service-level structure, called the ARC clinic. We sought expert input on the proposed content and structure from patients and clinicians through involvement and engagement activities. Delivered alongside standard care, the ARC HNA was piloted with patients on the TbnC cancer (myeloma and metastatic breast, prostate or lung) pathway, who were 6-24 months into their treatment. Iterations were made to the content, delivery and timing of the intervention based on user feedback.Fifty-one patients received the intervention. An average of 12 new concerns were identified per patient, and 96% of patients achieved at least one of their goals. Patients valued the space for reflection and follow-up, and clinicians valued the collaborative approach to meeting patients' supportive care needs. Compared with routine initial HNA and care plan completion rates of 13%, ARC clinic achieved 90% with all care plans shared with general practitioners. The ARC clinic adopts a novel and proactive approach to delivering HNAs and care plans in a meaningful and personalised way.

Clinicians' and Patients' Perceptions and Use of the Word "Cured" in Cancer Care: An Italian Survey

BACKGROUND

The words "hope" and "cure" were used in a greater number of articles and sentences in narrative and editorial papers than in primary research. Despite concomitant improvements in cancer outcomes, the related reluctance to use these terms in more scientifically oriented original reports may reflect a bias worthy of future exploration. This study aims to survey a group of physicians and cancer patients regarding their perception and use of the word cure.

MATERIALS AND METHOD

An anonymous online and print survey was conducted to explore Italian clinicians' (the sample includes medical oncologists, radiotherapists, and oncological surgeons) and cancer patients' approach to the perception and use of the word "cure" in cancer care. The participants received an email informing them of the study's purpose and were invited to participate in the survey via a linked form. A portion, two-thirds, of questionnaires were also administered to patients in the traditional paper form.

RESULTS

The survey was completed by 224 clinicians (54 oncologists, 78 radiotherapists, and 92 cancer surgeons) and 249 patients. The results indicate a favourable attitude for patients in favour of a new language ("cured" vs. "complete remission") of the disease experience.

CONCLUSIONS

The use of the word cured is substantially accepted and equally shared by doctors and patients. Its use can facilitate the elimination of metaphoric implications and toxic cancer-related connotations registered in all cultures that discourage patients from viewing cancer as a disease with varied outcomes, including cure.

'It feels it's wasting whatever time I've got left': A qualitative study of living with treatable but not curable cancer during the COVID-19 pandemic

BACKGROUND

People living with cancer that is treatable but not curable have complex needs, often managing health at home, supported by those close to them. Challenges are likely to be exacerbated during the COVID-19 pandemic and the risk-reducing measures introduced in response. The impact of COVID-19 on those living with incurable, life-threatening conditions is little understood.

AIM

To investigate the experiences and identify the impact of the COVID-19 pandemic for people living with treatable not curable cancer and their informal carers.

DESIGN

Qualitative semi-structured phone interviews were conducted with 21 patients living with cancer that is treatable but not curable and 14 carers.

SETTING/ PARTICIPANTS

Participants were part of a larger longitudinal qualitative study (ENABLE) on supported self-management for people living with cancer that is treatable but not curable.

RESULTS

The COVID-19 pandemic magnified uncertainty and anxiety and led to loss of opportunities to do things important to patients in the limited time they have left to live. Lack of face-to-face contact with loved ones had a significant impact on patients' and carers' emotional wellbeing. Carers experienced increased responsibilities but less access to formal and informal support and respite. While changes to treatment led to some concern about longer-term impact on health, most patients felt well-supported by healthcare teams.

CONCLUSION

The study provides rich insights into the nature of challenges, uncertainty and lost opportunities resulting from the COVID-19 pandemic for patients and carers living with cancer that is treatable but not curable, which has wider resonance for people living with other life-limiting conditions.

"This Graft-vs.-Host Disease Determines My Life. That's It."-A Qualitative Analysis of the Experiences and Needs of Allogenic Hematopoietic Stem Cells Transplantation Survivors in Germany

Background: Allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative treatment modality for many patients affected by hematologic malignancies. However, it can cause debilitating long-term effects. Understanding the impact of alloHSCT on all aspects of the patients' life is required for optimal survivorship management. Aim: To explore in-depth HSCT-survivors' experiences and needs post-transplant. Partners were included to provide further information on survivors' needs and how care could be improved in this area. Methods: We conducted semi-structured face-to-face and phone interviews with alloHSCT-survivors and their partners referred to a survivorship clinic in Germany. Theoretical sampling was used to recruit participants. Data were analyzed using framework analysis. Results: Thirty-two survivors (consent rate: 100%, response rate: 100%) and eighteen partners (consent rate: 84%, response rate: 72%) participated. Survivors were aged between 25 and 68 years (Median: 48, IQR: 25.3) and partners were aged between 26 and 64 years (Median: 54, IQR: 16, SD: 12.8). The themes emerging from the data involved survivors' needs included (i) the diversity of long-term treatment side-effects; and (ii) time post discharge as a dynamic process with individual peaks of burden. Survivors and their partners also suggested strategies for mitigating these unmet needs, i.e., (iii) transparent communication and patient empowerment; and (iv) improvement in continuity of care system and help with claiming social benefits as cornerstones of optimal survivorship care. Conclusion: To our knowledge, this is one of the first qualitative studies focused on the views of German alloHSCT-survivors on the long-term effects of alloHSCT and the first study integrating the view of their partners. Healthcare providers could better support survivors with managing their symptoms and adhering to their prescribed care by ensuring comprehensive, transparent communication that helps increase survivors' understanding and involvement in their care. Further efforts should be made to provide patient-centered, continuous survivorship care that involves additional support with navigating the healthcare and social service system. Intervention studies are required to test the effectiveness of the suggested strategies.

Accounting for Heterogeneity in Resource Allocation Decisions: Methods and Practice in UK Cancer Technology Appraisals

OBJECTIVES

The availability of novel, more efficacious and expensive cancer therapies is increasing, resulting in significant treatment effect heterogeneity and complicated treatment and disease pathways. The aim of this study is to review the extent to which UK cancer technology appraisals (TAs) consider the impact of patient and treatment effect heterogeneity.

METHODS

A systematic search of National Institute for Health and Care Excellence TAs of colorectal, lung and ovarian cancer was undertaken for the period up to April 2020. For each TA, the pivotal clinical studies and economic evaluations were reviewed for considerations of patient and treatment effect heterogeneity. The study critically reviews the use of subgroup analysis and real-world translation in economic evaluations, alongside specific attributes of the economic modeling framework.

RESULTS

The search identified 49 TAs including 49 economic models. In total, 804 subgroup analyses were reported across 69 clinical studies. The most common stratification factors were age, gender, and Eastern Cooperative Oncology Group performance score, with 15% (119 of 804) of analyses demonstrating significantly different clinical outcomes to the main population; economic subgroup analyses were undertaken in only 17 TAs. All economic models were cohort-level with the majority described as partitioned survival models (39) or Markov/semi-Markov models. The impact of real-world heterogeneity on disease progression estimates was only explored in 2 models.

CONCLUSION

The ability of current modeling approaches to capture patient and treatment effect heterogeneity is constrained by their limited flexibility and simplistic nature. This study highlights a need for the use of more sophisticated modeling methods that enable greater consideration of real-world heterogeneity.

Current developments in delivering customized care: a scoping review

BACKGROUND

In recent years, there has been a growing interest in health care personalization and customization (i.e. personalized medicine and patient-centered care). While some positive impacts of these approaches have been reported, there has been a dearth of research on how these approaches are implemented and combined for health care delivery systems. The present study undertakes a scoping review of articles on customized care to describe which patient characteristics are used for segmenting care, and to identify the challenges face to implement customized intervention in routine care.

METHODS

Article searches were initially conducted in November 2018, and updated in January 2019 and March 2019, according to Prisma guidelines. Two investigators independently searched MEDLINE, PubMed, PsycINFO, Web of Science, Science Direct and JSTOR, The search was focused on articles that included "care customization", "personalized service and health care", individualized care" and "targeting population" in the title or abstract. Inclusion and exclusion criteria were defined. Disagreements on study selection and data extraction were resolved by consensus and discussion between two reviewers.

RESULTS

We identified 70 articles published between 2008 and 2019. Most of the articles (n = 43) were published from 2016 to 2019. Four categories of patient characteristics used for segmentation analysis emerged: clinical, psychosocial, service and costs. We observed these characteristics often coexisted with the most commonly described combinations, namely clinical, psychosocial and service. A small number of articles (n = 18) reported assessments on quality of care, experiences and costs. Finally, few articles (n = 6) formally defined a conceptual basis related to mass customization, whereas only half of articles used existing theories to guide their analysis or interpretation.

CONCLUSIONS

There is no common theory based strategy for providing customized care. In response, we have highlighted three areas for researchers and managers to advance the customization in health care delivery systems: better define the content of the segmentation analysis and the intervention steps, demonstrate its added value, in particular its economic viability, and align the logics of action that underpin current efforts of customization. These steps would allow them to use customization to reduce costs and improve quality of care.

Personalized Cancer Follow-Up Care Pathways: A Delphi Consensus of Research Priorities

Development of personalized, stratified follow-up care pathways where care intensity and setting vary with needs could improve cancer survivor outcomes and efficiency of health-care delivery. Advancing such an approach in the United States requires identification and prioritization of the most pressing research and data needed to create and implement personalized care pathway models. Cancer survivorship research and care experts (n = 39) participated in an in-person workshop on this topic in 2018. Using a modified Delphi technique-a structured, validated system for identifying consensus-an expert panel identified critical research questions related to operationalizing personalized, stratified follow-up care pathways for individuals diagnosed with cancer. Consensus for the top priority research questions was achieved iteratively through 3 rounds: item generation, item consolidation, and selection of the final list of priority research questions. From the 28 research questions that were generated, 11 research priority questions were identified. The questions were categorized into 4 priority themes: determining outcome measures for new care pathways, developing and evaluating new care pathways, incentivizing new care pathway delivery, and providing technology and infrastructure to support self-management. Existing data sources to begin answering questions were also identified. Although existing data sources, including cancer registry, electronic medical record, and health insurance claims data, can be enhanced to begin addressing some questions, additional research resources are needed to address these priority questions.

Treatable but not curable cancer in England: a retrospective cohort study using cancer registry data and linked data sets

OBJECTIVES

This study estimates the prevalence of cancers that are categorised as treatable but not curable (TbnC) in England. It provides a quantification of the population and a framework to aid identification of this group to enable the design of tailored support services.

DESIGN

Through consultation with clinical and data experts an algorithmic definition of TbnC was developed. Using cancer registry data sets, with five other linked data sets held by the National Disease Registration Service, the algorithm was applied as part of this retrospective cohort study to estimate the size and characteristics of the TbnC population.

SETTING AND PARTICIPANTS

The health data records of 1.6 million people living with cancer in England in 2015, following a cancer diagnosis between 2001 and 2015, were retrospectively assessed for TbnC status.

RESULTS

An estimated 110 615 people in England were living with TbnC cancer at the end of 2015, following identification of TbnC cancer between 2012 and 2015. In addition, 51 946 people fit the initial search criteria but were found to have been in their last year of life at the end of 2015 and therefore considered separately here as end of life cases. A further 57 117 people in England were initially identified as being at high risk of recurrence or having their life being shortened by cancer but did not fit the TbnC conceptual framework and were excluded, but their results are also reported under 'group B'.

CONCLUSIONS

A population living with TbnC cancer can be identified using data currently collected on a national scale in England. This large population living with TbnC cancer requires personalised treatment and support.

What are the holistic experiences of adults living long-term with the consequences of cancer and its treatment? A qualitative evidence synthesis

PURPOSE

The number of people living with and beyond cancer is increasing; a significant number of these people will experience the long-term and late effects of cancer and its treatment. Research into this group has been identified as a priority to better understand healthcare needs. This review identified and synthesised qualitative research data relating to the lived experience of the consequences of cancer and its treatment.

METHODS

A systematic search via electronic databases was conducted in July 2019. Literature was identified that explored the experience of adults living beyond cancer from their own perspective. Thematic synthesis was used to extract and analyse data.

RESULTS

Six articles were reviewed. Three main themes were identified with four subthemes:1. Living with an altered sense of self; 2. Things are never going to be quite the same again (2.1. The unexpected. 2.2 The uncertain.); 3. Ways of coping with the unexpected and the uncertain. (3.1. Drawing on internal resilience. 3.2. The influence and impact of external relationships.). The findings showed that the participants' world-view changed after cancer and this affected everyday lives both positively and negatively.

CONCLUSIONS

The experience of having had cancer remains significant long after diagnosis and treatment, yet effective preparation and ongoing support for living beyond cancer is lacking. The experience of living long-term after cancer is characterised by an altered sense of self and has implications for long-term wellbeing. Further research should explore healthcare needs and services required to adequately meet the needs of this growing group of people.

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.

Implementing personalized pathways for cancer follow-up care in the United States: Proceedings from an American Cancer Society-American Society of Clinical Oncology summit

A new approach to cancer follow-up care is necessary to meet the needs of cancer survivors while dealing with increasing volume and provider shortages, knowledge gaps, and costs to both health care systems and patients. An approach that triages patients to personalized follow-up care pathways, depending on the type(s) and level(s) of resources needed for patients' long-term care, is in use in the United Kingdom and other countries and has been shown to meet patients' needs, more efficiently use the health care system, and reduce costs. Recognizing that testing and implementing a similar personalized approach to cancer follow-up care in the United States will require a multipronged strategy, the American Cancer Society and the American Society of Clinical Oncology convened a summit in January 2018 to identify the needed steps to move this work from concept to implementation. The summit identified 4 key strategies going forward: 1) developing a candidate model (or models) of care delivery; 2) building the case for implementation by conducting studies modeling the effects of personalized pathways of follow-up care on patient outcomes, workforce and health care resources, and utilization and costs; 3) creating consensus-based guidelines to guide the delivery of personalized care pathways; and 4) identifying and filling research gaps to develop and implement needed care changes. While these national strategies are pursued, oncology and primary care providers can lay the groundwork for implementation by assessing their patients' risk of recurrence and the chronic and late effects of cancer as well as other health care needs and resources available for care and by considering triaging patients accordingly, referring patients to appropriate specialized survivorship clinics as these are developed, helping to support patients who are capable of self-managing their health, setting expectations with patients from diagnosis onward for the need for follow-up in primary care and/or a survivorship clinic, and improving coordination of care between oncology and primary care.