The effectiveness of personalised surveillance and aftercare in breast cancer follow-up: a systematic review

PURPOSE

Breast cancer follow-up (surveillance and aftercare) varies from one-size-fits-all to more personalised approaches. A systematic review was performed to get insight in existing evidence on (cost-)effectiveness of personalised follow-up.

METHODS

PubMed, Scopus and Cochrane were searched between 01-01-2010 and 10-10-2022 (review registered in PROSPERO:CRD42022375770). The inclusion population comprised nonmetastatic breast cancer patients ≥ 18 years, after completing curative treatment. All intervention-control studies studying personalised surveillance and/or aftercare designed for use during the entire follow-up period were included. All review processes including risk of bias assessment were performed by two reviewers. Characteristics of included studies were described.

RESULTS

Overall, 3708 publications were identified, 64 full-text publications were read and 16 were included for data extraction. One study evaluated personalised surveillance. Various personalised aftercare interventions and outcomes were studied. Most common elements included in personalised aftercare plans were treatment summaries (75%), follow-up guidelines (56%), lists of available supportive care resources (38%) and PROs (25%). Control conditions mostly comprised usual care. Four out of seven (57%) studies reported improvements in quality of life following personalisation. Six studies (38%) found no personalisation effect, for multiple outcomes assessed (e.g. distress, satisfaction). One (6.3%) study was judged as low, four (25%) as high risk of bias and 11 (68.8%) as with concerns.

CONCLUSION

The included studies varied in interventions, measurement instruments and outcomes, making it impossible to draw conclusions on the effectiveness of personalised follow-up. There is a need for a definition of both personalised surveillance and aftercare, whereafter outcomes can be measured according to uniform standards.

Feasibility of delivering survivorship care via lay health educators: A pilot randomized controlled trial among rural cancer survivors

PURPOSE

We tested the feasibility of survivorship care plan (SCP) delivery with/without a lay health educator (LHE) telephone-delivered information session among rural cancer survivors, and their effects on health-related self-efficacy and knowledge of cancer history.

METHODS

Randomized trial of cancer survivors from 3 rural oncology clinics featuring either SCP alone (control) or SCP plus LHE-delivered information session (intervention). Participants completed a questionnaire on health-related self-efficacy and knowledge of cancer-specific medical history. Responses were compared to medical records for accuracy. SCPs were then mailed to participants. Approximately 5 months later, participants completed a follow-up questionnaire. A subset of participants took part in subsequent qualitative interviews about their study experience.

FINDINGS

Of 301 survivors approached, 72 (23.9%) were randomized (mean age 66.4 years; 3.1 years from diagnosis; 62.5% female), and 65 (90.3%) completed the study. Global mental and physical health or self-efficacy scores did not change significantly from baseline to follow-up for either group. In exploratory analyses, self-efficacy increased in participants with inadequate/marginal health literacy in the intervention arm (+0.7, 95% CI = 0.1-1.2; P = .01). Accuracy of knowledge did not improve but was high at baseline (mean 76.0±14.5%). 60.1% and 48.4% of control and intervention participants, respectively, found SCPs definitely/somewhat useful. Qualitative data (n = 20) suggested that SCPs were helpful to patients when primary and oncology care were less integrated.

CONCLUSIONS

An LHE-delivered informational session was feasible but had limited benefit to rural cancer survivors versus delivery of SCP alone but may be of benefit to patients with low health literacy or with less integrated care.

Late effects in a high-risk population of breast cancer survivors

PURPOSE

To better understand the impact of cancer and treatment on outcomes and guide program development, we evaluated breast cancer survivors at risk for long-term medical and psychosocial issues who participated in survivorship care visits (SVs) at Johns Hopkins Hospital.

METHODS

We conducted a prospective survey study of women with stage I-III breast cancer who participated in SVs from 2010-2016. The same 56-item questionnaire administered at SV and follow-up included an assessment of symptoms, social factors, demographics, anxiety, depression, and comorbidities. We added the Godin Exercise questionnaire to the follow-up.

RESULTS

In 2018, 74 participants were identified as disease-free and mailed a follow-up survey; 52 (70.3%) completed the survey. At a median follow-up time of 3.1 years after diagnosis, participants were less likely to be employed (54% vs. 67%) than at the SV. About two-thirds were sedentary, and this was associated with high body mass index (p = 0.02). Sufficiently active participants (≥ 150 min per week of moderate-intensity activity) were less likely to report pain (p = 0.02) or fatigue (p = 0.001). Although 19% had moderate/severe anxiety or depression at follow-up, participants who reported employment satisfaction were less likely to be depressed (p = 0.02).

CONCLUSIONS

Awareness of issues faced by survivors is critical for enhancing care and developing models to identify patients who might benefit most from targeted long-term interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Interventions to address physical activity, persistent symptoms, and mental health are critical for breast cancer survivors.

Primary Care Physicians' Perspectives in Leading Breast Cancer Follow-Up Care

INTRODUCTION

Limited data exist on the barriers associated with transitioning breast cancer follow-up care to primary care physicians (PCPs). This study aimed to describe the current perspectives of PCPs in managing breast cancer follow-up.

METHOD

An online survey was distributed to PCPs in Toronto, ON, Canada. Questions examined PCPs' view of transitioning breast cancer follow-up care to their practices.

RESULTS

Of 800 PCPs invited, 126 responded (response rate: 15.7%). The types of practice models amongst respondents included blended capitation (42.9%), blended salary (27%), and fee-for-service (17.5%). Seventy-seven percent of respondents stated they provided follow-up care. Approximately half of the respondents stated they were somewhat comfortable providing follow-up care. PCP-led follow-up care was considered either very (49.2%) or somewhat appropriate (30.2%). When asked about financial remuneration, 43.7% of respondents stated it was somewhat important. The factors that influenced the feasibility of PCP-led follow-up care included receipt of a detailed follow-up care plan provided by the specialist after discharge (81%), the ability to re-refer to specialists rapidly (56.3%), and the ability to obtain regular updates of best practice changes (59.5%). The preferred means of educational updates included E-mail (40.5%), continuing medical education events (30.2%), and electronic medical records (19.8%). When the fee model was taken into consideration there was no significant difference in opinions regarding follow-up care.

CONCLUSIONS

Transitioning to a PCP-led model was supported by most of the PCPs who participated in this study. Their perspective on PCP-led follow up care and barriers associated with implementation of this model of care needs to be further explored with future studies that include larger sample size and a more diverse PCP population.

Economic Evaluation of Long-Term Survivorship Care for Cancer Patients in OECD Countries: A Systematic Review for Decision-Makers

Long-term cancer survivorship care is a crucial component of an efficient healthcare system. For numerous reasons, there has been an increase in the number of cancer survivors; therefore, healthcare decision-makers are tasked with balancing a finite budget with a strong demand for services. Decision-makers require clear and pragmatic interpretation of results to inform resource allocation decisions. For these reasons, the impact and importance of economic evidence are increasing. The aim of the current study was to conduct a systematic review of economic evaluations of long-term cancer survivorship care in Organization for Economic Co-operation and Development (OECD) member countries and to assess the usefulness of economic evidence for decision-makers. A systematic review of electronic databases, including MEDLINE, PubMed, PsycINFO and others, was conducted. The reporting quality of the included studies was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Each included study’s usefulness for decision-makers was assessed using an adapted version of a previously published approach. Overall, 3597 studies were screened, and of the 235 studies assessed for eligibility, 34 satisfied the pre-determined inclusion criteria. We found that the majority of the included studies had limited value for informing healthcare decision-making and conclude that this represents an ongoing issue in the field. We recommend that authors explicitly include a policy statement as part of their presentation of results.

Simplifying Survivorship Care Planning: A Randomized Controlled Trial Comparing 3 Care Plan Delivery Approaches

BACKGROUND

Survivorship care plans seek to improve the transition to survivorship, but the required resources present implementation barriers. This randomized controlled trial aimed to identify the simplest, most effective approach for survivorship care planning.

METHODS

Stage 1-3 breast, colorectal, and prostate cancer patients aged 21+ completing treatment were recruited from an urban-academic and rural-community cancer center. Participants were randomized, stratified by recruitment site and cancer type, 1:1:1 to (a)mailed plan, (b)plan delivered during one-time transition visit, or (c)plan delivered during transition visit plus 6-month follow-up visit. Health service use data were collected from participants and medical records for 18 months. The primary outcome, receipt of all plan-recommended care, was compared across intervention arms using logistic regression adjusting for cancer type and recruitment site with p < 0.05 considered statistically significant.

RESULTS

Of 378 participants randomized, 159 (42.1%) were breast, 142 (37.6%) prostate, 77 (20.4%) colorectal cancer survivors; 207 (54.8%) from the academic site, 171 (45.2%) from the community site; 316 analyzable for the primary outcome. There was no difference across arms in the proportion of participants receiving all plan-recommended care: 45.2% mail, 50.5% one-visit, 42.7% two-visit (2-sided P = 0.60). Adherence by cancer type for mail, one-visit, and two-visit, respectively, was 52.2%, 53.3%, 40.0% for breast cancer; 48.6%, 64.1%, 57.1% for prostate cancer; and 23.8%, 19.0%, 26.1% for colorectal cancer. There were no statistically significant interactions by recruitment site or cancer type.

CONCLUSIONS

This study did not find differences in receipt of recommended follow-up care by plan delivery approach. Feasibility and other factors may determine the best approach for survivorship care planning.

Role of the nurse in the design, delivery, monitoring and coordination of cancer survivorship care plans: An integrative review

AIM

Survivorship care plans (SCPs) are recommended as a tool for the care of cancer survivors. SCPs have been implemented with a multidisciplinary approach; however, the specific role of nurses in the SCP is unknown. Our aim is to determine the role of nurses and their degree of participation in cancer SCPs.

DESIGN

Integrative review of the literature with systematic methodology.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science, Cochrane and Cancerlit databases were reviewed. Articles published up to March 2021 were included.

REVIEW METHOD

Of the 2,638 publications identified, 22 studies met our inclusion criteria. Quality of included studies was assessed using Joanna Briggs Institute quality assessment tools.

RESULTS

The studies showed that nurses play a key role and participate in different phases of the SCP, including design, delivery, monitoring and coordination among different levels of care, with varying degrees of involvement and responsibility; design and delivery of the SCP are the phases with the highest nurse participation (18 out of 22 studies). The majority of SCPs are implemented in specialized, hospital-based care and focus on short-term cancer survivors, who are actively undergoing oncological treatments.

CONCLUSION

This review shows that nurses actively participate in the design, implementation and coordination of SCPs. However, SCPs focus on the acute survival and treatment phases, and there is a gap in their use in long-term cancer survivorship. This gap may be one reason the needs of long-term cancer survivors are not covered.

IMPACT

This review contributes to the current body of knowledge by addressing the role of nurses in cancer SCPs. We recommend the involvement of an advanced practice nurse as SCP coordinator to improve communication between cancer specialists and primary care providers and to promote continued care throughout the different phases of cancer survivorship, including long-term survival.

Use and impact of breast cancer survivorship care plans: a systematic review

BACKGROUND

Survivorship care plan (SCP) comprising a treatment summary and plan for follow-up care is recommended by various organizations to address long-term needs of an increasing number of breast cancer survivors. Although there have been previous systematic reviews of SCPs in cancer, none has focused on breast cancer exclusively. This systematic review evaluates the use and impact of SCP in breast cancer survivors.

METHODS

Randomized (RCTs) and non-randomized (non-RCT) studies evaluating health care and patient-related outcomes after implementation of SCPs for survivors were identified by searching databases (MEDLINE, EMBASE, CINHAL, and Scopus). Data were extracted, quality assessed, and summarized on the basis of qualitative synthesis.

RESULTS

Ten non-RCTs and 14 RCTs met the inclusion criteria. Although the overall quality of RCTs was superior to non-RCTs with mean quality score of 81.5% vs 64.3%, two mixed-methods non-RCTs which were individualized and included both provider and patient perspectives had comparable scores like RCTs. Several models of SCP were evaluated (paper based/online, oncologist/nurse/primary-care physician-delivered, and different templates). Descriptive information from non-RCTs suggests improvement in survivorship knowledge, satisfaction with care, and improved communication with providers. Findings from RCTs were variable. Potential gaps existed in content of SCP including unclear recommendation on frequency and ownership of follow-up. Levels of survivor satisfaction with, and self-reported understanding of, their SCP were high. Distal outcomes like health care delivery measures including costs and efficiency were mostly mixed, but heterogeneous study designs make interpretation difficult.

CONCLUSIONS

Existing research provides positive impact of SCPs on more proximal outcomes of patient experience and care delivery but mixed results for health outcomes in breast cancer survivors. Future research should focus on better defining SCP content and ensuring follow-up recommendations are acted upon, and provider feedback is included and use of novel tools to empower stakeholders.

Follow-up strategies following completion of primary cancer treatment in adult cancer survivors

BACKGROUND

Most cancer survivors receive follow-up care after completion of treatment with the primary aim of detecting recurrence. Traditional follow-up consisting of fixed visits to a cancer specialist for examinations and tests are expensive and may be burdensome for the patient. Follow-up strategies involving non-specialist care providers, different intensity of procedures, or addition of survivorship care packages have been developed and tested, however their effectiveness remains unclear.

OBJECTIVES

The objective of this review is to compare the effect of different follow-up strategies in adult cancer survivors, following completion of primary cancer treatment, on the primary outcomes of overall survival and time to detection of recurrence. Secondary outcomes are health-related quality of life, anxiety (including fear of recurrence), depression and cost.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases and two trials registries on 11 December 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised trials comparing different follow-up strategies for adult cancer survivors following completion of curatively-intended primary cancer treatment, which included at least one of the outcomes listed above. We compared the effectiveness of: 1) non-specialist-led follow-up (i.e. general practitioner (GP)-led, nurse-led, patient-initiated or shared care) versus specialist-led follow-up; 2) less intensive versus more intensive follow-up (based on clinical visits, examinations and diagnostic procedures) and 3) follow-up integrating additional care components relevant for detection of recurrence (e.g. patient symptom education or monitoring, or survivorship care plans) versus usual care.

DATA COLLECTION AND ANALYSIS

We used the standard methodological guidelines by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC). We assessed the certainty of the evidence using the GRADE approach. For each comparison, we present synthesised findings for overall survival and time to detection of recurrence as hazard ratios (HR) and for health-related quality of life, anxiety and depression as mean differences (MD), with 95% confidence intervals (CI). When meta-analysis was not possible, we reported the results from individual studies. For survival and recurrence, we used meta-regression analysis where possible to investigate whether the effects varied with regards to cancer site, publication year and study quality.

MAIN RESULTS

We included 53 trials involving 20,832 participants across 12 cancer sites and 15 countries, mainly in Europe, North America and Australia. All the studies were carried out in either a hospital or general practice setting. Seventeen studies compared non-specialist-led follow-up with specialist-led follow-up, 24 studies compared intensity of follow-up and 12 studies compared patient symptom education or monitoring, or survivorship care plans with usual care. Risk of bias was generally low or unclear in most of the studies, with a higher risk of bias in the smaller trials. Non-specialist-led follow-up compared with specialist-led follow-up It is uncertain how this strategy affects overall survival (HR 1.21, 95% CI 0.68 to 2.15; 2 studies; 603 participants), time to detection of recurrence (4 studies, 1691 participants) or cost (8 studies, 1756 participants) because the certainty of the evidence is very low. Non-specialist- versus specialist-led follow up may make little or no difference to health-related quality of life at 12 months (MD 1.06, 95% CI -1.83 to 3.95; 4 studies; 605 participants; low-certainty evidence); and probably makes little or no difference to anxiety at 12 months (MD -0.03, 95% CI -0.73 to 0.67; 5 studies; 1266 participants; moderate-certainty evidence). We are more certain that it has little or no effect on depression at 12 months (MD 0.03, 95% CI -0.35 to 0.42; 5 studies; 1266 participants; high-certainty evidence). Less intensive follow-up compared with more intensive follow-up Less intensive versus more intensive follow-up may make little or no difference to overall survival (HR 1.05, 95% CI 0.96 to 1.14; 13 studies; 10,726 participants; low-certainty evidence) and probably increases time to detection of recurrence (HR 0.85, 95% CI 0.79 to 0.92; 12 studies; 11,276 participants; moderate-certainty evidence). Meta-regression analysis showed little or no difference in the intervention effects by cancer site, publication year or study quality. It is uncertain whether this strategy has an effect on health-related quality of life (3 studies, 2742 participants), anxiety (1 study, 180 participants) or cost (6 studies, 1412 participants) because the certainty of evidence is very low. None of the studies reported on depression. Follow-up strategies integrating additional patient symptom education or monitoring, or survivorship care plans compared with usual care: None of the studies reported on overall survival or time to detection of recurrence. It is uncertain whether this strategy makes a difference to health-related quality of life (12 studies, 2846 participants), anxiety (1 study, 470 participants), depression (8 studies, 2351 participants) or cost (1 studies, 408 participants), as the certainty of evidence is very low.

AUTHORS' CONCLUSIONS

Evidence regarding the effectiveness of the different follow-up strategies varies substantially. Less intensive follow-up may make little or no difference to overall survival but probably delays detection of recurrence. However, as we did not analyse the two outcomes together, we cannot make direct conclusions about the effect of interventions on survival after detection of recurrence. The effects of non-specialist-led follow-up on survival and detection of recurrence, and how intensity of follow-up affects health-related quality of life, anxiety and depression, are uncertain. There was little evidence for the effects of follow-up integrating additional patient symptom education/monitoring and survivorship care plans.

Survivorship Care Plans in Cancer: A Meta-Analysis and Systematic Review of Care Plan Outcomes

BACKGROUND

The Institute of Medicine recommends that survivorship care plans (SCPs) be included in cancer survivorship care. Our meta-analysis compares patient-reported outcomes between SCP and no SCP (control) conditions for cancer survivors. Our systematic review examines the feasibility of implementing SCPs from survivors' and health care professionals' perspectives and the impact of SCPs on health care professionals' knowledge and survivorship care provision.

METHODS

We searched seven online databases (inception to April 22, 2018) for articles assessing SCP feasibility and health care professional outcomes. Randomized controlled trials comparing patient-reported outcomes for SCP recipients versus controls were eligible for the meta-analysis. We performed random-effects meta-analyses using pooled standardized mean differences for each patient-reported outcome.

RESULTS

Eight articles were eligible for the meta-analysis (n = 1,286 survivors) and 50 for the systematic review (n = 18,949 survivors; n = 3,739 health care professionals). There were no significant differences between SCP recipients and controls at 6 months postintervention on self-reported cancer and survivorship knowledge, physical functioning, satisfaction with information provision, or self-efficacy or at 12 months on anxiety, cancer-specific distress, depression, or satisfaction with follow-up care. SCPs appear to be acceptable and potentially improve survivors' adherence to medical recommendations and health care professionals' knowledge of survivorship care and late effects.

CONCLUSION

SCPs appear feasible but do not improve survivors' patient-reported outcomes. Research should ascertain whether this is due to SCP ineffectiveness, implementation issues, or inappropriate research design of comparative effectiveness studies.

IMPLICATIONS FOR PRACTICE

Several organizations recommend that cancer survivors receive a survivorship care plan (SCP) after their cancer treatment; however, the impact of SCPs on cancer survivors and health care professionals is unclear. This systematic review suggests that although SCPs appear to be feasible and may improve health care professionals' knowledge of late effects and survivorship care, there is no evidence that SCPs affect cancer survivors' patient-reported outcomes. In order to justify the ongoing implementation of SCPs, additional research should evaluate SCP implementation and the research design of comparative effectiveness studies. Discussion may also be needed regarding the possibility that SCPs are fundamentally ineffective.

Survivorship Care Plan Implementation in US Cancer Programs: a National Survey of Cancer Care Providers

Survivorship care plans (SCPs)-documents intended to improve care for cancer survivors who have completed active treatment-are required, yet implementation is poor. We sought to understand SCP implementation in cancer programs in the USA with the objective of identifying opportunities for improvement. We recruited cancer care providers in the USA via several cancer care networks to participate in a survey regarding SCP implementation. We used descriptive statistics to analyze the data. Three hundred ninety-five providers from diverse cancer programs in 47 states and Washington, DC responded to the survey. The timing of SCP implementation varied across and within cancer programs, with approximately 40% of respondents reporting developing SCPs more than 3 months after primary treatment or adjuvant therapy completion. Nurse navigators were responsible for 48-58% of each stage of SCP implementation. Processes that could have been automated often occurred in-person or via phone and vice versa. Respondents reported spending more than 2 h per SCP to complete all stages of implementation, of which less than a third was reimbursed by third-party payers. We identified several opportunities for improving SCP implementation, including broadening the base of responsibility, optimizing modes of communication, decreasing the time required and increasing the funding available, and limiting variation in SCP implementation across and within cancer programs. Future work should assess the influence of approaches to SCP implementation on desired outcomes.

Adopting patient-centred tools in cancer care: role of evidence and other factors

Background

Randomized controlled trials (rcts) provide limited evidence to support the use of survivorship care plans (scps), but they provide strong evidence for patient decision aids (ptdas). Despite that evidence, the uptake of ptdas has been limited, but scps are being endorsed and implemented in many cancer programs across Canada. The objective of the present study was to illuminate the decision-making processes involved in the adoption of scps and ptdas.

Methods

Informed by the principles of grounded theory, in-depth semi-structured interviews were conducted with clinicians, managers, and administrators who work in cancer care programs across Canada (n = 21). Data were collected and analyzed concurrently, using a constant comparative analysis approach. Data collection ended when theoretical saturation was reached.

Results

For these types of patient-centred tools, participants noted that high-quality research evidence is often unnecessary for adoption decisions. Six key factors contribute to adoption or non-adoption decisions for scps and ptdas:■ Alignment of research evidence with other evidence■ Perceived clinician benefit■ Endorsement by organizations and professional bodies■ Existence of local champions■ Adaptability to local contexts■ Ability to routinize and reach a large patient population.

Conclusions

High-level evidence is not always the main consideration when adopting new tools into practice. And yet, understanding how clinicians and health system decision-makers decide whether and how to adopt new tools is important to optimizing the use of new tools and practices that are supported by research evidence.

Financial Hardship and the Economic Effect of Childhood Cancer Survivorship

In addition to the long-term physical and psychological sequelae of cancer therapy, adult survivors of childhood cancer are at an elevated risk for financial hardship. Financial hardship can have material, psychological, and behavioral effects, including high out-of-pocket medical costs, asset depletion and debt, limitations in or inability to work, job lock, elevated stress and worry, and a delaying or forgoing of medical care because of cost. Most financial hardship research has been conducted in survivors of adult cancers. The few studies focused on childhood cancer survivors have shown that these individuals are at elevated risk for having difficulties with affording needed health care and report high out-of-pocket medical expenses, difficulty with paying medical bills, or consideration of filing for bankruptcy. Childhood cancer survivors are more likely to be unable to work or to have missed work because of poor health. They are more likely to report difficulties with obtaining insurance coverage and rely more frequently on government-sponsored insurance. Globally, countries able to provide curative cancer therapies have witnessed a growing population of survivors, which places a burden on their health care systems because survivors are more likely to require hospitalization and experience a higher burden of chronic illness than the general population. Guidelines for surveillance for late effects are intended to reduce the burden of morbidity, but research is needed to determine whether such surveillance is cost effective. Of note, risk-based survivor care should include routine surveillance for financial hardship. Improved measures of financial hardship, enhanced data infrastructure, and research studies to identify survivors and families most vulnerable to financial hardship and adverse health outcomes will inform the development of targeted programs to serve as a safety net for those at greatest risk.

Strategies for Successful Survivorship Care Plan Implementation: Results From a Qualitative Study

INTRODUCTION

Care for US cancer survivors is often fragmented, contributing to poor health outcomes. Care and outcomes may improve when survivors and follow-up care providers receive survivorship care plans (SCPs), written documents containing information regarding cancer diagnosis, treatment, surveillance plans, and health promotion. However, implementing SCPs is challenging. As such, we sought to identify strategies for successfully implementing SCPs.

METHODS

We measured SCP implementation using performance data from cancer programs participating in the American Society of Clinical Oncology Quality Oncology Practice Initiative, an oncologist-led quality assessment and improvement program. We used semistructured interviews with cancer program employees (eg, physicians) to identify strategies for successfully implementing SCPs by comparing approaches in cancer programs that, according to Quality Oncology Practice Initiative performance indicators, developed and delivered SCPs to a relatively small proportion of eligible survivors and their follow-up care providers (ie, low performers; n = 6 participants in five programs) with approaches among programs with better performance (ie, moderate performers; n = 15 participants in nine programs).

RESULTS

Ten of 14 cancer programs developed SCPs for ≥ 50% of eligible survivors; two of 14 delivered SCPs to any survivors; and eight of 14 delivered SCPs to ≥ 25% of follow-up care providers. We found that moderate performers proactively addressed SCP requirements, leveraged requirements to improve survivorship care, set internal targets, automated implementation, had active leaders and champions, and tasked appropriate employees with SCP implementation.

CONCLUSION

SCP implementation remains challenging. We identified strategies for successfully implementing SCPs. Future research should examine how cancer programs have achieved these strategies; findings could contribute to an understanding of the changes needed to implement comprehensive survivorship care.

Systematic Review of the Impact of Cancer Survivorship Care Plans on Health Outcomes and Health Care Delivery

Purpose Numerous organizations recommend that patients with cancer receive a survivorship care plan (SCP) comprising a treatment summary and follow-up care plans. Among current barriers to implementation are providers' concerns about the strength of evidence that SCPs improve outcomes. This systematic review evaluates whether delivery of SCPs has a positive impact on health outcomes and health care delivery for cancer survivors. Methods Randomized and nonrandomized studies evaluating patient-reported outcomes, health care use, and disease outcomes after delivery of SCPs were identified by searching MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Data extracted by independent raters were summarized on the basis of qualitative synthesis. Results Eleven nonrandomized and 13 randomized studies met inclusion criteria. Variability was evident across studies in cancer types, SCP delivery timing and method, SCP recipients and content, SCP-related counseling, and outcomes assessed. Nonrandomized study findings yielded descriptive information on satisfaction with care and reactions to SCPs. Randomized study findings were generally negative for the most commonly assessed outcomes (ie, physical, functional, and psychological well-being); findings were positive in single studies for other outcomes, including amount of information received, satisfaction with care, and physician implementation of recommended care. Conclusion Existing research provides little evidence that SCPs improve health outcomes and health care delivery. Possible explanations include heterogeneity in study designs and the low likelihood that SCP delivery alone would influence distal outcomes. Findings are limited but more positive for proximal outcomes (eg, information received) and for care delivery, particularly when SCPs are accompanied by counseling to prepare survivors for future clinical encounters. Recommendations for future research include focusing to a greater extent on evaluating ways to ensure SCP recommendations are subsequently acted on as part of ongoing care.

The cost-effectiveness of follow-up strategies after cancer treatment: a systematic literature review

INTRODUCTION

The cost of treatment and follow-up of cancer patients in the UK is substantial. In a budget-constrained system such as the NHS, it is necessary to consider the cost-effectiveness of the range of management strategies at different points on cancer patients' care pathways to ensure that they provide adequate value for money.

SOURCES OF DATA

We conducted a systematic literature review to explore the cost-effectiveness of follow-up strategies of patients previously treated for cancer with the aim of informing UK policy. All papers that were considered to be economic evaluations in the subject areas described above were extracted.

AREAS OF AGREEMENT

The existing literature suggests that intensive follow-up of patients with colorectal disease is likely to be cost-effective, but the opposite holds for breast cancer.

AREAS OF CONTROVERSY

Interventions and strategies for follow-up in cancer patients were variable across type of cancer and setting. Drawing general conclusions about the cost-effectiveness of these interventions/strategies is difficult.

GROWING POINTS

The search identified 2036 references but applying inclusion/exclusion criteria a total of 44 articles were included in the analysis. Breast cancer was the most common (n = 11) cancer type followed by colorectal (n = 10) cancer. In general, there were relatively few studies of cost-effectiveness of follow-up that could influence UK guidance. Where there was evidence, in the most part, NICE guidance broadly reflected this evidence.

AREAS TIMELY TO DEVELOP RESEARCH

In terms of future research around the timing, frequency and composition of follow-ups, this is dependent on the type of cancer being considered. Nevertheless, across most cancers, the possibility of remote follow-up (or testing) by health professionals other than hospital consultants in other settings appears to warrant further work.

Survivorship care plans: are randomized controlled trials assessing outcomes that are relevant to stakeholders?

PURPOSE

The purpose of this study was to compare outcomes assessed in extant randomized controlled trials (RCTs) to outcomes that stakeholders expect from survivorship care plans (SCPs). To facilitate the transition from active treatment to follow-up care for the 15.5 million US cancer survivors, many organizations require SCP use. However, results of several RCTs of SCPs' effectiveness have been null, possibly because they have evaluated outcomes on which SCPs should be expected to have limited influence. Stakeholders (e.g., survivors, oncologists) may expect outcomes that differ from RCTs' outcomes.

METHODS

We identified RCTs' outcomes using a PubMed literature review. We identified outcomes that stakeholders expect from SCPs using semistructured interviews with stakeholders in three healthcare systems in the USA and Canada. Finally, we mapped RCTs' outcomes onto stakeholder-identified outcomes.

RESULTS

RCT outcomes did not fully address outcomes that stakeholders expected from SCPs, and RCTs assessed outcomes that stakeholders did not expect from SCPs. RCTs often assessed outcomes only from survivors' perspectives.

CONCLUSIONS

RCTs of SCPs' effectiveness have not assessed outcomes that stakeholders expect. To better understand SCPs' effectiveness, future RCTs should assess outcomes of SCP use that are relevant from the perspective of multiple stakeholders.

IMPLICATIONS FOR CANCER SURVIVORS

SCPs' effectiveness may be optimized when used with an eye toward outcomes that stakeholders expect from SCPs. For survivors, this means using SCPs as a map to guide them with respect to what kind of follow-up care they should seek, when they should seek it, and from whom they should seek it.

Survivorship care plan outcomes for primary care physicians, cancer survivors, and systems: a scoping review

PURPOSE

With the focus on survivorship care-coordination between oncology and primary care providers (PCPs), there is a need to assess the research regarding the use of survivorship care plans (SCPs) and determine emerging research areas. We sought to find out how primary care physicians have been involved in the use of SCPs and determine SCP's effectiveness in improving care for cancer survivors. In this scoping review, we aimed to identify gaps in the current research and reveal opportunities for further research.

METHODS

We followed the methodology for scoping studies which consists of identifying the research question, locating relevant studies, selecting studies, charting the data, and collating, summarizing, and reporting the results.

RESULTS

Out of 5375 original articles identified in the literature search, 25 met the inclusion/exclusion criteria. Eight articles examined PCP-only related outcomes, eight examined survivor-only related outcomes, eight examined mixed outcomes between both groups, and one examined system-based outcomes. Findings highlighted several areas where SCPs may provide benefits, including increased confidence among PCPs in managing the care of survivors and increased quality of life and well-being for survivors. This research also highlighted the need for careful consideration of SCP mode of delivery and content in order to maximize their utility to patients and providers.

CONCLUSIONS

Based on the findings of this review, SCPs may benefit providers and health care systems, but the benefits to patients remain unclear. Further research on the potential benefits of SCPs to particular patient populations is warranted.

IMPLICATIONS FOR CANCER SURVIVORS

SCPs appear to be beneficial to PCPs in improving overall quality of care. However, more work needs to be done to understand the direct impact on cancer survivors.

Integrated Care Planning for Cancer Patients: A Scoping Review

Introduction

There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact.

Methods

Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake.

Results

Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators.

Conclusions

Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.

The impact of cancer survivorship care plans on patient and health care provider outcomes: a current perspective

BACKGROUND

To help the growing number of cancer survivors deal with the challenges of cancer survivorship, survivorship care plans (SCPs) were recommended by the Institute of Medicine (IOM) in 2006. The SCP is a formal document that contains both a tailored treatment summary and a follow-up care plan. Since the IOM recommendation 10 years ago, the implementation in daily clinical practice is minimal. Several studies have investigated the effects of SCPs on patient-reported outcomes and oncology and primary care providers (PCPs), but the quantity and quality of these studies are limited.

RESULTS

The first four randomized trials comparing SCP delivery with usual care failed to show a positive effect on satisfaction with information provision, satisfaction with care, distress or quality of life. SCPs did improve the amount of information provided and communication of PCPs with medical specialists and patients. A recent small trial that changed the focus from SCP as primarily an information delivery intervention to a behavioral intervention did observe positive effects on self-reported health, lower social role limitations and a trend towards greater self-efficacy. Gaps in knowledge about SCPs include uncertainty about content and length of the SCP; whether it should be delivered online or on paper; the timing and frequency of delivery; which health care provide should deliver SCP care. Finally, cost-effectiveness of SCP interventions has received limited attention.

CONCLUSION

Currently, there is not enough evidence to warrant large-scale implementation of SCPs, or to abandon SCPs altogether. Emphasis on the SCP process and survivor engagement, supporting self-management may be an important way forward in SCP delivery. Whether this is beneficial and cost-effective on the long term and among different groups of cancer survivors needs further investigation.

Cancer survivorship care-planning: Practice, research, and policy implications for social work

Increasing numbers of cancer survivors are living longer than 5 years from their diagnosis date. This has resulted in a growing population of cancer survivors, expected to reach 19 million by 2024. Survivors frequently experience late effects caused by cancer and its treatment, reducing survivors' quality of life in multiple domains. Survivorship care-plans may aid the many physical, psychosocial, and financial needs that emerge posttreatment. However, the lack of reimbursement mechanisms, the limited amount of effectiveness research, and minimal guidelines for content and delivery are barriers to the widespread provision of survivorship care-plans. Challenges and opportunities for social work practice, research, and policy are identified and discussed.

Cost implications of unwarranted imaging for distant metastasis in women with early-stage breast cancer in Ontario

INTRODUCTION

Despite the publication of multiple evidence-based guidelines recommending against routine imaging for distant metastasis in patients with early-stage (i/ii) breast cancer, such imaging is frequently performed. The present retrospective cohort study was conducted to estimate the cost of unnecessary imaging tests in women with stage i and ii breast cancer diagnosed between 1 January 2007 and 31 December 2012 in Ontario.

METHODS

We obtained patient-level demographic and tumour data from a large provincial dataset. The total cost of unwarranted imaging tests (in 2015 Canadian dollars) was considered to be equal to the sum of imaging costs incurred between 2007 and 2012 and was stratified by disease stage, imaging modality, and body site.

RESULTS

Of the 26,547 identified patients with early-stage breast cancer, 22,811 (85.9%) underwent at least 1 imaging test, with an average of 3.7 tests per patient (3.2 for stage i patients and 4.0 for stage ii patients) over 5 years. At least 1 imaging test was performed in 79.6% of stage i and 92.7% of stage ii patients. During a 5-year period, the cost of unwarranted imaging in patients with early-stage breast cancer ranged from CA$4,418,139 to CA$6,865,856, depending on guideline recommendations.

CONCLUSIONS

Our study highlights the substantial cost of excess imaging that could be saved and re-allocated to patient care if evidence-based guidelines are followed. Future studies should assess strategies to ensure that evidence-based guidelines are followed and to increase awareness of the cost implications of nonadherence to guidelines.

Economic evaluations of follow-up strategies for cancer survivors: a systematic review and quality appraisal of the literature

The aim of this study was to review and critically assess the health economics literature on post-treatment follow-up for adult cancer survivors. A systematic search was performed using PubMed, EMBASE and the Cochrane Library. The Consolidated Health Economic Evaluation Reporting Standards checklist was adopted to assess the quality of the included studies. Thirty-nine articles met the eligibility criteria. Around two thirds of the studies addressed the most common cancers (i.e., breast, colorectal, cervical and lung); 21 were based on a single clinical study, while the rest were modeling papers. All types of economic evaluations were represented other than cost-benefit analysis. The overall quality was generally high with an average proportion of 74% of checklist criteria fulfilled. The cost-effectiveness results supported the current trend towards less intensive, primary care-based and risk-adapted follow-up schemes.

Criteria for evaluation of breast cancer survivorship care plans

Survivorship care plans are comprehensive, individualized documents that are recommended for all cancer survivors by the Institute of Medicine, and soon to be required by the Commission on Cancer. Breast cancer survivors are in many ways an ideal population for provision of survivorship care plans due to prominence within the survivorship population, relatively well-understood risk for late effects, data supporting improved outcomes with aggressive survivorship management and general interest within the population. Care plans that are provided must be of excellent quality in order to provide benefit, and quality should be measured with regard to content accuracy and language, customized information, completeness, applicability to diverse user groups and feasibility.

A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial

PURPOSE

Prevailing wisdom suggests that implementation of a survivorship care plan (SCP) will address deficits in survivorship care planning and delivery for cancer patients. Here, we present 24-month results of a randomized clinical trial on health service and patient-reported outcomes among breast cancer patients transferred to their primary care physician for follow-up care. The 24-month assessments represent the long-term benefit and sustainability of the implantation of a SCP.

METHODS

In all, 408 patients with early-stage breast cancer were randomized to the SCP or control group. Patient self-completed questionnaires, supplemented with telephone interviews, during the 24-month study period assessed health service and patient-reported outcomes. The primary outcome was cancer-specific distress. Secondary outcomes included health-related quality of life, patient satisfaction, continuity and coordination of care, and health service outcomes such as adherence to guidelines.

RESULTS

Over the course of 24 months, there were no differences between both groups in health service and patient-reported outcomes. Women from Quebec compared to those from Western Canada (p < 0.001), women within 2 years of completion of primary treatment compared to a longer period (p = 0.013), and those with a higher SF-36 mental component score compared to a lower score (p = 0.044) were positively associated with adherence to guidelines.

CONCLUSION

The implementation of a SCP in the transition of survivorship care from cancer center to primary care did not contribute to improved health service or patient-reported outcomes in this study population. Therefore, additional research is needed before widespread implementation of a SCP in clinical practice.

IMPLICATIONS OF CANCER SURVIVORS

The transition of survivorship care from cancer center to the primary care setting showed no negative effect on health service and patient-reported outcomes.

Challenges to Standardizing the Care for Adult Cancer Survivors: Highlighting ASCO's Fatigue and Anxiety and Depression Guidelines

There are over 14 million survivors of cancer living in the United States alone and tens of millions more worldwide, with this population expected to nearly double in the next decade. The successes of prevention, early detection, and better therapies have lead to an emerging understanding of the substantial medical and psychosocial issues for this growing population that must be tackled for individuals and from the health care system and societal perspectives.

Associations among survivorship care plans, experiences of survivorship care, and functioning in older breast cancer survivors: CALGB/Alliance 369901

PURPOSE

Survivorship care plans (SCP) are recommended for all cancer patients and could be especially useful to survivors 65 years and over ("older"). This study examined receipt of SCPs among older breast cancer survivors and whether SCPs were associated with improved patient-reported outcomes.

METHODS

Three hundred and twenty-eight older women diagnosed with invasive, nonmetastatic breast cancer between 2007-2011 were recruited from 78 cooperative-group sites. Participants completed telephone interviews at baseline and 1-year posttreatment. Regression analyses examined SCP receipt (yes/no) and functioning (EORTC-QLQ-C30), cancer worry, and experiences of survivorship care (care coordination, knowledge).

RESULTS

Only 35% of women received SCPs. For each 1-year increase in age, there was a 5% lower odds of receiving an SCP (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.91-0.98, p = 0.007). Besides age, no other factor predicted SCPs. SCP receipt was associated with greater knowledge and understanding of requisite follow-up care (p < 0.05); however, functioning was not significantly different among those with vs. without SCPs.

CONCLUSIONS

Receipt of care plans was limited. SCPs improved understanding of breast cancer follow-up care among older survivors, but did not impact functioning one year post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

To impact functioning and salient needs of the growing cohort of older survivors, survivorship care plans likely should be tailored to geriatric-specific issues. To improve functioning, SCP content should expand to include exercise, nutrition, polypharmacy, social support and management of symptom burden from cancer, and other comorbid conditions. To improve follow-up care for cancer survivors, SCPs should delineate shared care roles between oncology and primary care in managing recurrence surveillance, screening, and cancer sequelae.