A quality improvement project to optimize access to psychosocial care for cancer survivors who experience fear of recurrence

BACKGROUND

The prevalence of moderate to high levels of fear of cancer recurrence (FCR) in cancer survivors may vary from 22% to 87%, although most are not usually referred to psychosocial support. The After Cancer Treatment Transition (ACTT) clinic in Women's College Hospital (Toronto) provides follow-up care to cancer survivors but in a sample of 2893 patients seen April 2019 to March 2022, only 1.5% were referred to a social worker for psychosocial needs. A single-question screening tool is currently available to screen for FCR.

OBJECTIVE

To evaluate the use of the single-question screening tool for FCR among cancer survivors and its impact on social work referrals.

RESULTS

Between July and October 2022, 788 patients were seen in the ACTT clinic. Generally, most patients in ACTT are breast cancer survivors (75%), and the remaining survivors are a mix of other cancer types (colorectal cancer, ovarian cancer, thyroid cancer, melanoma). Three hundred thirty (41.9%) ACTT patients completed the single-question screening tool for FCR. Most screened patients were female (96%), the average age was 60 years, and most were diagnosed with breast cancer (90%). Among screened patients, 37 (11%) indicated a moderately severe to high level of FCR and efforts were made to refer these 37 patients to a social worker. In the end, 22 (59.5%) patients with moderately severe/high levels of FCR were offered and accepted referral to a social worker. In comparison to the 1.5% referred to social work (among 2893 patients) prior to FCR screening, referrals increased to 6.7% (among 330 screened).

CONCLUSION

Use of a single-question FCR screening tool improved identifying cancer survivors in need of psychosocial support and improved access to a social worker.

Developing an Education Pathway for Breast Cancer Patients Receiving Rapid Diagnostic Testing: Investigating Informational and Supportive Care Needs

Several studies have examined the informational needs of patients undergoing the breast diagnostic process where needs are highest during testing and prior to receiving a diagnosis. To aid in the development of an education pathway, we identified patient information needs. A multi-method approach to identify areas of need and to understand when and how information should be provided to patients was undertaken. The methods included an environmental scan of consumer health information, ethnographic observation of the patient clinical experience, key informant interviews, and a needs assessment survey. The data collected from the environmental scan, ethnography, and interviews were used to develop the items in the survey. The survey was developed around four domains: (1) Medical Procedures and Tests, (2) Understanding the Rapid Diagnostic Process, (3) Breast Cancer and Other Breast Conditions, and (4) Support and Coping. A total of 101 patients completed the survey. Mean importance scores were significantly different between domains of information need (p < .0001) and significantly higher for the 'Medical Procedures and Tests' domain compared with all others. Multivariate analysis suggested that participants with higher levels of education (p = .02) and a preference to speak English at home (p = .009) tended to rate the importance of 'Support and Coping' information lower than other participants. Information about medical procedures and tests are most important for the patients undergoing rapid diagnostic testing in our sample. Education materials that are tailored to patient needs should be provided to patients during this stage of the cancer journey to help meet informational needs.

The development and implementation of the After Cancer Treatment Transition (ACTT) Program for survivors of cancer

Background: The After Cancer Treatment Transition (ACTT) program at Women’s College Hospital (Toronto) is a transitional follow-up program for patients, their families, and healthcare providers to address the broad range of post-cancer treatment and survivorship needs. This publication describes the systematic development and implementation of the ACTT program, with a focus on the advanced practice nursing (APN) role. Program Development: ACTT development required the collaboration of an APN, a general practitioner in oncology (GPO), and an inter-professional team. ACTT developers proposed a clinic structure in an ambulatory setting, linking healthcare professionals to provide post-treatment follow-up and ongoing survivorship care. Post-treatment guidelines were developed based on expert oncologist consensus, cancer site group input, and evidence-informed guidelines or best practice recommendations. Program Implementation: Initial challenges and concerns were rooted in the requirements that post-cancer treatment care was maintained and survivor needs were addressed. Cancer site groups and the inter-professional teams provided continuous feedback on processes and protocols. ACTT established a standard approach to transition patients safely and effectively out of tertiary care and, ultimately, to primary care. Current ACTT Program: ACTT delivers comprehensive post- treatment and survivorship care through close collaboration between the GPO and APN. Both roles specialize in managing late or persistent effects, cancer surveillance and prevention, and addressing psychosocial needs prior to discharge to primary care. The survivorship care plan provided by ACTT is an informative tool for both patient and primary care provider to continue post-treatment follow-ups. Future Directions: Next steps for ACTT include expanding to other cancer specialties, exploring new ways to deliver care, optimizing the transition of care, and conducting comprehensive evaluations of patient reported outcomes.

Conception et mise en œuvre d’un programme de transition post-traitement pour les survivants du cancer

Contexte : Le programme « After Cancer Treatment Transition » ou ACTT du Women’s College Hospital, à Toronto, est un programme de transition à l’intention des patients, des familles et des professionnels de la santé dont le but est de répondre aux nombreux besoins survenant après le traitement et en phase de survivance. Le présent article décrit l’élaboration et la mise en œuvre systématiques du programme ACTT, plus précisément, le rôle des infirmières en pratique avancée (IPA). Conception du programme : La mise en œuvre de l’ACTT requérait la collaboration d’une IPA, d’un omnipraticien en oncologie (OO) et d’une équipe interprofessionnelle. Les concepteurs de l’ACTT ont proposé d’instaurer une structure clinique dans un milieu de soins externes afin de mettre en lien les professionnels de la santé et d’arriver à fournir un suivi post-traitement et des soins continus aux survivants. L’élaboration des lignes directrices post-traitement s’est appuyée sur un consensus d’experts en oncologie, l’avis d’un groupe spécialiste de certains types de cancer, d’autres lignes directrices fondées sur la recherche ou des recommandations sur les pratiques exemplaires. Mise en œuvre du programme : Au départ, on s’inquiétait surtout de l’importance de maintenir les soins post-traitement et de répondre aux besoins des survivants. On a donc demandé aux groupes spécialistes et aux équipes interprofessionnelles de fournir leurs commentaires en continu. L’ACTT a établi une approche normalisée pour assurer aux patients une transition sûre et efficace à la fin des soins tertiaires et, en bout de ligne, les aider à obtenir des soins primaires. Programme ACTT actuel : L’ACTT fournit des soins post-traitement et des soins aux survivants complets grâce à l’étroite collaboration entre l’OO et l’IPA. Tous deux sont des spécialistes de la prise en charge des effets tardifs ou persistants, de la surveillance et de la prévention du cancer, ainsi que de la satisfaction des besoins psychosociaux avant la transition vers les soins primaires. Le plan de soins aux survivants de l’ACTT est un outil informatif pour les patients et les fournisseurs de soins primaires en vue de continuer les suivis post-traitement. Orientations futures : Il est prévu d’étendre le programme ACTT à d’autres types de cancer, d’explorer de nouvelles modalités de soins, d’optimiser le processus de transition et d’analyser en profondeur les résultats rapportés par les patients.

Protocol of a randomized controlled trial of the fear of recurrence therapy (FORT) intervention for women with breast or gynecological cancer

Background

Clinically significant levels of fear of cancer recurrence (FCR) affect up to 49 % of cancer survivors and are more prevalent among women. FCR is associated with psychological distress, lower quality of life, and increased use of medical resources. Despite its prevalence, FCR is poorly addressed in clinical care. To address this problem, we first developed, and pilot tested a 6-week, 2 h, Cognitive-existential group intervention therapy that targeted FCR in survivors of breast or gynecological cancer. Following the positive outcome of the pilot, we are now testing this approach in a randomized clinical trial (RCT).

Goal and hypotheses: This multicenter, prospective RCT aims to test the efficacy of the intervention. The study hypotheses are that, compared to a control group, cancer survivors participating in the intervention (1) will have less FCR, (2) will show more favorable outcomes on the following measures: cancer-specific distress, quality of life, illness uncertainty, intolerance of uncertainty, perceived risk of cancer recurrence, and coping skills. We further postulate that the between-group differences will persist three and 6 months post-intervention.

Methods

Sixteen groups of seven to nine women are being allocated to the intervention or the control group. The control group receives a 6-week, 2 h, structurally equivalent support group. We are recruiting 144 cancer survivors from four hospital sites in three Canadian cities. The sample size was based on the moderate pre/post-test changes found in our pilot study and adjusted to the drop-out rates. Measurements: The primary outcome, FCR, is measured by the Fear of Cancer Recurrence Inventory. Secondary outcomes measured include cancer-specific distress, perceived risk of cancer recurrence, illness uncertainty, intolerance of uncertainty, coping, and quality of life. We use reliable and recognized valid scales. Participants are to complete the questionnaire package at four times: before the first group session (baseline), immediately after the sixth session, and 3 and 6 months post-intervention. Analysis: In the descriptive analysis, comparison of group equivalent baseline variables, identification of confounding/intermediate variables and univariate analysis are planned. Each participant’s trajectory is calculated using Generalized Estimating Equation models to determine the time and group effects, after considering the correlation structures of the groups. An intent-to-treat analysis approach may be adopted.

Discussion

Our Fear of Recurrence Therapy (FORT) intervention has direct implications for clinical service development to improve the quality of life for patients with breast (BC) and gynecological cancer (GC). Based on our pilot data, we are confident that the FORT intervention can guide the development of effective psychosocial cancer survivorship interventions to reduce FCR and improve psychological functioning among women with BC or GC.

Trial registration

Dr. Christine Maheu registered the trial with ISRCTN registry (Registration number: ISRCTN83539618, date assigned 03/09/2014).

Pilot Testing of a Psycho-educational Telephone Intervention for Women Receiving Uninformative BRCA1/2 Genetic Test Results

Evidence suggests that women who receive uninformative results for breast and ovarian cancer (BRCA1/2) gene mutations may experience as much distress as women whose results indicate the presence of a gene mutation. No intervention to reduce distress after receipt of uninformative results has yet been tested. The purpose of this study was to test the feasibility and preliminary effects of a psycho-educational telephone (PET) intervention to reduce distress in women who receive uninformative BRCA1/2 results. A single group with repeated measures was used to assess the impact of the intervention on 72 such women. After receiving the results, most of the women continued to feel uncertain about their carrier genetic status. However, their distress significantly decreased between receipt of uninformative results and 3 months post-intervention (p = 0.01). The preliminary findings suggest that a PET uncertainty intervention is clinically feasible and may reduce the distress of receiving uninformative results.

Addressing fear of cancer recurrence among women with cancer: a feasibility and preliminary outcome study

BACKGROUND

Evidence suggests that fear of cancer recurrence (FCR) is one of the most frequently cited unmet needs among cancer survivors and is associated with psychological distress, stress-response symptoms, and lower quality of life, as well as increased use of health care resources. Despite these factors, few manualized interventions exist to address FCR among cancer survivors.

PURPOSE

To develop, manualize, and pilot test the feasibility and preliminary efficacy of a 6-week cognitive-existential (CE) group intervention designed to address FCR in women with breast or ovarian cancer.

METHODS

This study was a single-arm multi-site study with pre-, post-, and 3-month follow-up measurement occasions.

RESULTS

A total of 56 breast or ovarian cancer survivors enrolled in the study; 44 completed the CE group intervention. Following the intervention, women experienced a reduction in the primary study outcome measure of FCR and secondary study outcome measures of cancer-specific distress and uncertainty. They also reported improvements in secondary study outcome measures of quality of life and coping. The effect sizes of the observed changes were for the most part in the medium to large effect range; furthermore, almost all changes were sustained at 3-month follow-up.

CONCLUSION

This brief intervention appears feasible and has shown promising results in addressing FCR and related secondary outcomes of cancer-specific distress, uncertainty, quality of life, and coping; however, it should be further tested using a randomized controlled study design to more definitively assess its efficacy.

IMPLICATIONS FOR CANCER SURVIVORS

FCR is a near-universal worry for cancer survivors that, when left unaddressed, tends to remain stable over time. This study has important implications for all cancer survivors as it is the first published intervention that provides preliminary evidence of its efficacy in decreasing fear of cancer recurrence.

Multi-drug resistant non-typhi salmonellae in Kenya

Two methods of plasmid characterization, restriction digest patterns and incompatibility grouping, were used to study self-transmissible multi-drug resistance among non-typhi salmonellae (NTS). Resistance to ampicillin and other commonly applied beta-lactams was evaluated by iso-electric focusing and disc inactivation. Of the NTS isolated from blood, 75% were Salmonella typhimurium but those included several different phage types. Over 47% of isolates were resistant to three or more of the readily available drugs including ampicillin, cefuroxime, chloramphenicol, co-trimoxazole, streptomycin and tetracycline. Self-transferable resistance plasmids (c. 100 kb) were essentially of incompatibility group incFIIA, but their restriction fragment patterns revealed a diversity in relatedness. More than half of parent strains and their transconjugants produced beta-lactamases which co-electrophoresed with TEM-1 and OXA-1. This study has observed a disturbingly high prevalence of transmissible multi-drug resistance among NTS which are an important cause of morbidity in HIV-1 seropositive individuals.