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Brauer ER, Petersen L, Ganz PA. Survivorship care in breast cancer: understanding implementation barriers through the lens of the Theoretical Domains Framework. JNCI Cancer Spectr 2024; 8:pkad108. [PMID: 38128018 PMCID: PMC10868380 DOI: 10.1093/jncics/pkad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Breast cancer survivorship guidelines with specific recommendations on managing long-term effects are available, but uptake in clinical practice remains low. Using the lens of the Theoretical Domains Framework, we aimed to understand key factors in guideline-concordant management of long-term effects to inform future implementation efforts in clinical practice contexts. METHODS As part of a broader survey of oncologists, a theory-guided questionnaire was developed. Oncologists were asked to report level of agreement with Theoretical Domains Framework-based statements, current usage and perceived value of survivorship resources, and frequency of managing long-term effects in routine care. Data analyses included psychometric assessment of the questionnaire, descriptive summaries of theoretical domains and survivorship resources, and multivariable logistic regression models. RESULTS In total, 217 oncologists completed the Theoretical Domains Framework-based questionnaire; 54% of oncologists reported "always or almost always" evaluating physical effects at routine survivorship appointments, while 34% did so for psychosocial effects. In regression models, Environmental Context and Resources was the only theoretical domain found to be statistically significantly associated with "always or almost always" evaluating both physical (odds ratio = 0.29, 95% confidence interval = 0.09 to 0.80) and psychosocial (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.35) effects. CONCLUSIONS Findings support application of the Theoretical Domains Framework in understanding oncologists' behaviors and perceived barriers in managing long-term effects in breast cancer survivors. In future implementation efforts, this theory-informed approach can be used to target relevant domains and strategies focused on embedding guideline recommendations in the clinical context through structured resources and environmental supports.
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Affiliation(s)
- Eden R Brauer
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
- Center for Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Laura Petersen
- Center for Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Patricia A Ganz
- Center for Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
- Division of Hematology-Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
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2
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Hertz DL, Tofthagen C, Rossi E, Bernasconi DP, Lim J, Carlson M, Sheffield KE, Nekhlyudov L, Grech L, Von Ah D, Mayo SJ, Ruddy KJ, Chan A, Alberti P, Lustberg MB, Tanay M. Patient perceptions of altering chemotherapy treatment due to peripheral neuropathy. Support Care Cancer 2023; 32:48. [PMID: 38129602 DOI: 10.1007/s00520-023-08209-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE Clinical practice guidelines recommend altering neurotoxic chemotherapy treatment in patients experiencing intolerable chemotherapy-induced peripheral neuropathy (CIPN). The primary objective of this survey was to understand patient's perspectives on altering neurotoxic chemotherapy treatment, including their perceptions of the benefits of preventing irreversible CIPN and the risks of reducing treatment efficacy. METHODS A cross-sectional online survey was distributed via social networks to patients who were currently receiving or had previously received neurotoxic chemotherapy for cancer. Survey results were analyzed using descriptive statistics and qualitative analysis. RESULTS Following data cleaning, 447 participants were included in the analysis. The median age was 57 years, 93% were white, and most were from the UK (53%) or USA (38%). Most participants who were currently or recently treated expected some CIPN symptom resolution (86%), but 45% of those who had completed treatment more than a year ago reported experiencing no symptom resolution. Participants reported that they would discontinue chemotherapy treatment for less severe CIPN if they knew their symptoms would be permanent than if symptoms would disappear after treatment. Most patients stated that the decision to alter chemotherapy or not was usually made collaboratively between the patient and their treating clinician (61%). The most common reason participants were reluctant to talk with their clinician about CIPN was fear that treatment would be altered. Participants noted a need for improved understanding of CIPN symptoms and their permanence, better patient education relating to CIPN prior to and after treatment, and greater clinician understanding and empathy around CIPN. CONCLUSIONS This survey highlights the importance of shared decision-making, including a consideration of both the long-term benefits and risks of altering neurotoxic chemotherapy treatment due to CIPN. Additional work is needed to develop decision aids and other communication tools that can be used to improve shared decision making and help patients with cancer achieve their treatment goals.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Room 2560C, Ann Arbor, MI, 48109-1065, USA.
| | | | - Emanuela Rossi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center - B4, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Davide Paolo Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center - B4, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Jiyoon Lim
- School of Medicine, Jeonbuk National University, Jeonju, Korea
| | - Martha Carlson
- No Affiliation, Independent Patient Advocate, Brookfield, IL, USA
| | | | - Larissa Nekhlyudov
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Grech
- Medicine Monash Health, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Diane Von Ah
- Center for Healthy Aging, Self-management and Complex Care, College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Samantha J Mayo
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Alexandre Chan
- Department of Clinical Pharmacy Practice, University of California Irvine School of Pharmacy & Pharmaceutical Sciences, Irvine, CA, USA
| | - Paola Alberti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Mary Tanay
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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3
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Cucciniello L, Garufi G, Di Rienzo R, Martinelli C, Pavone G, Giuliano M, Arpino G, Montemurro F, Del Mastro L, De Laurentiis M, Puglisi F. Estrogen deprivation effects of endocrine therapy in breast cancer patients: Incidence, management and outcome. Cancer Treat Rev 2023; 120:102624. [PMID: 37751658 DOI: 10.1016/j.ctrv.2023.102624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
Endocrine therapy is one of the standard adjuvant treatments to reduce the risk of recurrence and mortality in patients with hormone receptor positive early breast cancer. Despite its proven efficacy, ET side effects, which persist over time even if low grade, may deteriorate quality of life. During follow-up visits, emphasis is generally placed on the risk of disease recurrence, while the topic of ET side effects is commonly neglected and discussed only briefly. This could lead to poor adherence to therapy and early treatment discontinuation, resulting in worse survival outcomes. The aim of this review is to provide an overview of the available evidence on the incidence and reporting of ET-related side effects (including vasomotor symptoms, musculoskeletal disorders and genitourinary syndrome of menopause, as well as fatigue, psychological and ocular disorders, dysmetabolic effects and loss of bone density) and of the pharmacological and non-pharmacological strategies available to mitigate symptom burden.
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Affiliation(s)
- Linda Cucciniello
- Department of Medicine, University of Udine, Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.
| | - Giovanna Garufi
- Department of Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy; Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.
| | - Rossana Di Rienzo
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Claudia Martinelli
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Giuliana Pavone
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Center of Experimental Oncology and Hematology, A.O.U. Policlinico "G. Rodolico - San Marco", Catania, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy.
| | - Grazia Arpino
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | | | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy; Breast Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | | | - Fabio Puglisi
- Department of Medicine, University of Udine, Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.
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4
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Fauer AJ, Ganz PA, Brauer ER. A mixed method study of medical oncologists' perceived barriers and motivators to addressing long-term effects in breast cancer survivors. Breast Cancer Res Treat 2022; 194:699-707. [PMID: 35767127 PMCID: PMC9287210 DOI: 10.1007/s10549-022-06657-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this study was to identify oncologist-reported barriers and motivators in addressing long-term effects with breast cancer survivors.
Methods This study is a secondary analysis of data from a survey of U.S. medical oncologists (n = 217) about breast cancer survivorship care in clinical practice. Using both closed- and open-ended questions, we asked oncologists to report barriers and motivators they perceived in addressing long-term effects with breast cancer patients. Descriptive statistics were used to summarize and rank items endorsed by oncologists in analyses of quantitative data; content analysis was used to identify salient categories of barriers and motivators in qualitative data. Results Key barriers to managing physical long-term effects included lack of time during appointments (n = 128 oncologists, 59%) and perceived lack of evidence-based interventions (n = 89, 41%). With respect to psychosocial effects, oncologists reported lack of knowledge (n = 88, 40.6%) and challenges making referrals to mental health providers (n = 115, 53%). From the qualitative data, three distinct barrier categories emerged: “Competing priorities during brief appointments;” “Discussing long-term effects—Who? What? When?;” and “Beyond my expertise and comfort level.” Two motivator categories emerged: “I owe it to them;” and “Giving people a life worth living.” Conclusion Oncologists’ key motivators for addressing long-term effects were focused on professional values, relationships with survivors, and their commitment to prioritizing patients' quality of life. Future efforts should leverage oncologists' professional and interpersonal motivators to enhance the delivery of survivorship care for breast cancer. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06657-6.
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Affiliation(s)
- Alex J Fauer
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Patricia A Ganz
- Department of Health Policy & Management, Fielding School of Public Health, UCLA, Los Angeles, CA, USA.,Center for Cancer Control and Prevention Research, Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA
| | - Eden R Brauer
- Center for Cancer Control and Prevention Research, Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA. .,School of Nursing, UCLA, 4-234 Factor Building, Box 956900, Los Angeles, CA, 90095-6900, USA.
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Brauer ER, Long EF, Petersen L, Ganz PA. Current practice patterns and gaps in guideline-concordant breast cancer survivorship care. J Cancer Surviv 2021; 17:906-915. [PMID: 34970715 PMCID: PMC9243187 DOI: 10.1007/s11764-021-01152-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/30/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Breast cancer-specific survivorship care guidelines for the more than 3.8 million survivors in the U.S. are available, but implementation in clinical practice remains challenging. We examined current practice patterns and factors associated with guideline-concordant survivorship care among oncologists. METHODS A national sample of medical oncologists, recruited using two databases, participated in a survey focused on practice patterns for breast cancer survivorship care. A "survivorship care composite score" was calculated for each respondent based on provision of services recommended in the survivorship guidelines. Descriptive statistics and multivariable linear regression analyses examined associations between physician and practice characteristics and composite scores. RESULTS The survey was completed by 217 medical oncologists, with an overall response rate of 17.9% and eligibility rate of 56.9% for those who responded. Oncologists reported high engagement in evaluation of disease recurrence (78%). Performed less frequently were the provision of survivorship care plans (46%), assessment of psychosocial long-term and late effects (34%), and screening for subsequent cancers (34%). Lack of survivorship care training (p = 0.038) and not routinely informing patients about potential late effects (p = 0.003) were significantly associated with poorer survivorship care composite scores. CONCLUSIONS Despite the availability of disease-specific survivorship care guidelines, adherence to their recommendations in clinical practice is suboptimal. Survey results identified key gaps in survivorship care for breast cancer survivors, particularly related to subsequent primary cancers and psychosocial long-term and late effects. IMPLICATIONS FOR CANCER SURVIVORS Improving the delivery of comprehensive survivorship care for the growing population of breast cancer survivors is a high priority. Disease-specific clinical guidelines for cancer survivorship provide valuable recommendations, but innovative strategies are needed to integrate them into the care of long-term breast cancer survivors.
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Affiliation(s)
- Eden R. Brauer
- School of Nursing, University of California, Los Angeles (UCLA)
| | - Elisa F. Long
- Anderson School of Management, University of California, Los Angeles (UCLA)
| | - Laura Petersen
- Cancer Prevention and Control Research, University of California, Los Angeles (UCLA)
| | - Patricia A. Ganz
- David Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles (UCLA)
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Reporting of paclitaxel-induced peripheral neuropathy symptoms to clinicians among women with breast cancer: a qualitative study. Support Care Cancer 2020; 28:4163-4172. [PMID: 31897779 DOI: 10.1007/s00520-019-05254-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Cases of chemotherapy-induced peripheral neuropathy (CIPN) under-reporting have been sporadically described in the literature, but no studies have focused on actively examining this behavior. Our primary aim was to identify women who purposefully under-reported CIPN, along with reasons for doing so. A secondary aim was to explore factors enabling or hindering communication of CIPN to clinicians. METHODS Semi-structured interviews were conducted with women with breast cancer who had received paclitaxel in a prospective observational study. The interview guide was developed based on factors hypothesized to influence side effect disclosure to clinicians. Interviews were recorded, transcribed verbatim, and thematically content analyzed. RESULTS Thirty-four women were interviewed. Three main themes emerged from the analysis: (1) enablers of CIPN reporting (e.g., positive relationship with the oncology team, sufficient appointment time, existence of alternative communication channels to office visits, expectation of CIPN as a side effect); (2) deterrents to CIPN reporting (e.g., perception of need to complete the full course of therapy, fear of treatment discontinuation, lack of knowledge of long-term consequences of CIPN); and (3) balancing survival versus functional impairment due to CIPN. Women prioritized efficacy over CIPN until physical functioning was meaningfully affected. No patients reported purposeful CIPN under-reporting, but three women admitted having considered doing so. CONCLUSIONS Despite the lack of evidence of CIPN withholding, women considered both the effectiveness and the toxicity of paclitaxel treatment, as well as beliefs about treatment and long-term consequences of CIPN and relationship with the oncology team, when deciding whether to report CIPN symptoms.
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Mandelblatt JS, Zhai W, Ahn J, Small BJ, Ahles TA, Carroll JE, Denduluri N, Dilawari A, Extermann M, Graham D, Hurria A, Isaacs C, Jacobsen PB, Jim HSL, Luta G, McDonald BC, Patel SK, Root JC, Saykin AJ, Tometich DB, Zhou X, Cohen HJ. Symptom burden among older breast cancer survivors: The Thinking and Living With Cancer (TLC) study. Cancer 2019; 126:1183-1192. [PMID: 31860135 DOI: 10.1002/cncr.32663] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/27/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known about longitudinal symptom burden, its consequences for well-being, and whether lifestyle moderates the burden in older survivors. METHODS The authors report on 36-month data from survivors aged ≥60 years with newly diagnosed, nonmetastatic breast cancer and noncancer controls recruited from August 2010 through June 2016. Symptom burden was measured as the sum of self-reported symptoms/diseases as follows: pain (yes or no), fatigue (on the Functional Assessment of Cancer Therapy [FACT]-Fatigue scale), cognitive (on the FACT-Cognitive scale), sleep problems (yes or no), depression (on the Center for Epidemiologic Studies Depression scale), anxiety (on the State-Trait Anxiety Inventory), and cardiac problems and neuropathy (yes or no). Well-being was measured using the FACT-General scale, with scores from 0 to 100. Lifestyle included smoking, alcohol use, body mass index, physical activity, and leisure activities. Mixed models assessed relations between treatment group (chemotherapy with or without hormone therapy, hormone therapy only, and controls) and symptom burden, lifestyle, and covariates. Separate models tested the effects of fluctuations in symptom burden and lifestyle on function. RESULTS All groups reported high baseline symptoms, and levels remained high over time; differences between survivors and controls were most notable for cognitive and sleep problems, anxiety, and neuropathy. The adjusted burden score was highest among chemotherapy-exposed survivors, followed by hormone therapy-exposed survivors versus controls (P < .001). The burden score was related to physical, emotional, and functional well-being (eg, survivors with lower vs higher burden scores had 12.4-point higher physical well-being scores). The composite lifestyle score was not related to symptom burden or well-being, but physical activity was significantly associated with each outcome (P < .005). CONCLUSIONS Cancer and its treatments are associated with a higher level of actionable symptoms and greater loss of well-being over time in older breast cancer survivors than in comparable noncancer populations, suggesting the need for surveillance and opportunities for intervention.
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Affiliation(s)
| | - Wanting Zhai
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC
| | - Jaeil Ahn
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC
| | - Brent J Small
- School of Aging Studies, University of South Florida, and Senior Member, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Tim A Ahles
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Judith E Carroll
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, California
| | | | - Asma Dilawari
- Department of Medicine, Georgetown University, Washington, DC
| | - Martine Extermann
- Department of Medicine, H. Lee Moffitt Cancer Center, Tampa, Florida.,Department and Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Deena Graham
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Arti Hurria
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Claudine Isaacs
- Department of Oncology, Georgetown University, Washington, DC.,Department of Medicine, Georgetown University, Washington, DC
| | - Paul B Jacobsen
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland
| | - Heather S L Jim
- Health Outcomes and Behavior Department, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Brenna C McDonald
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sunita K Patel
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California.,Department of Supportive Care Medicine, City of Hope Comprehensive Cancer Center, Duarte, California
| | - James C Root
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, California
| | - Andrew J Saykin
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
| | - Danielle B Tometich
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indiana
| | - Xingtao Zhou
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC
| | - Harvey J Cohen
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
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