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Brauer ER, Ganz PA. History and current status of the survivorship care program at the University of California, Los Angeles Jonsson Comprehensive Cancer Center (UCLA JCCC). J Cancer Surviv 2024; 18:5-10. [PMID: 38183578 DOI: 10.1007/s11764-023-01522-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
As one of the first comprehensive cancer centers to receive a designation from the National Cancer Institute, the Jonsson Comprehensive Cancer Center at UCLA Health has served as a leader in survivorship research for three decades. A clinical survivorship program for childhood cancer survivors was established in the early 2000s as this became a standard of care in pediatric oncology. However, it was not until receipt of external funding and the establishment of a Survivorship Center of Excellence in 2006 that clinical services were expanded to include adult cancer survivors, as well as survivorship care delivery research in the community and at affiliated clinical sites. When this funding ended, there was limited institutional support for expansion of the program, and so the clinical programs did not develop further. Recently, there has been renewed interest in obtaining Commission on Cancer accreditation, and this has prompted an institutional assessment of survivorship care to inform future activities for system-wide program development. As oncology care expands throughout a large regional health system network, the future survivorship program will need to serve as a common resource for the entire health system by providing a repository of specialized services and resources as well as standard processes and pathways for a cohesive approach to care. IMPLICATIONS FOR CANCER SURVIVORS: There are many challenges to development and sustainment of cancer survivorship programs, even in NCI-designated comprehensive cancers. As the delivery of cancer care services expands and becomes more integrated in large health care systems, innovative strategies are needed to ensure delivery of tailored care to cancer survivors through acute treatment and beyond.
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Affiliation(s)
- Eden R Brauer
- School of Nursing, UCLA, 4-234 Factor Building, Box 956900, Los Angeles, CA, 90095-6900, USA.
- Center for Cancer Control and Prevention Research Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA.
| | - Patricia A Ganz
- Center for Cancer Control and Prevention Research Jonsson Comprehensive Cancer Center, UCLA, 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, UCLA, Los Angeles, CA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Van Dyk K, Wall L, Ellingson B, An N, Lai A, Cloughesy T, Brauer ER, Nghiemphu PL. QOL-12. “I’M JUST LIKE A BASKET FULL OF PROBLEMS”: QUALITATIVE STUDY OF COGNITIVE DYSFUNCTION AND QUALITY OF LIFE IN GLIOMA SURVIVORS. Neuro Oncol 2022. [PMCID: PMC9661032 DOI: 10.1093/neuonc/noac209.939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
For glioma survivors, cognitive impairment can be a central determinant of quality of life, but we need better understanding of their unique challenges and supportive care needs. In this qualitative study, we aimed to explore the post-treatment experiences of cognitive and functional challenges and their impact on quality of life from the perspectives of glioma survivors. Glioma survivors in an observational study were invited to participate in an in-depth qualitative interview. Using a semi-structured interview guide, interviews were audio-recorded and transcribed verbatim. Data were analyzed using a reflexive thematic analysis approach to develop key themes to inform clinical practice. Participants (n=9) ranged in age from 29 to 72 years, and were at least 4 years post-diagnosis. Under the overarching survivorship theme, three key themes were developed. The first theme, “Learning what my brain can and can’t handle,” centered on functional challenges related to cognitive impairments, including difficulties at work and managing home and family responsibilities. In response, participants described generating their own strategies to manage cognitive limitations in daily activities. The second theme, “Such an important crossroads”, reflected the significant emotional impact of persisting impairments (e.g., frustration, disappointment, reduced self-esteem, acceptance), increased anxiety around an uncertain future, and a shift in personal values towards an increased sense of gratitude, crystalizing of intentions, and focus on things of greatest importance. The final theme, “A solid foundation of people around me”, referred to the necessity of social support, in both emotional and instrumental terms. Many expressed a desire for and appreciation of coping tools and support for the support people in their lives. Nearly all participants expressed interest in cognitive rehabilitation – whether or not they were experiencing significant cognitive problems. These findings have implications for clinical practice and can inform the development of effective patient-centered supportive care interventions in this population.
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Affiliation(s)
| | - Lucy Wall
- UCLA - Semel Institute , Los Angeles , USA
| | | | | | - Albert Lai
- University of California Los Angeles , Los Angeles , USA
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Brauer ER, Lazaro S, Williams CL, Rapkin DA, Madnick AB, Dafter R, Cheng G, Porter A, Abemayor E, Chai-Ho W, Morasso E, Erman A, Chhetri D, John MS, Wong DJ. Implementing a Tailored Psychosocial Distress Screening Protocol in a Head and Neck Cancer Program. Laryngoscope 2022; 132:1600-1608. [PMID: 34953151 PMCID: PMC9875715 DOI: 10.1002/lary.30000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/03/2021] [Accepted: 12/14/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVES/HYPOTHESIS Psychosocial distress is common among patients with head and neck cancer (HNC) and is associated with poorer quality of life and clinical outcomes. Despite these risks, distress screening is not widely implemented in HNC care. In this study, we investigated the prevalence of psychosocial distress and its related factors in routine care of patients with HNC. METHODS Data from medical records between September 2017 and March 2020 were analyzed. Psychosocial distress was measured by the National Comprehensive Cancer Network's Distress Thermometer (DT), and a modified HNC-specific problem list; depression and anxiety were assessed using the Patient Health Questionnaire-4. Descriptive statistics and logistic regression were conducted to report prevalence of distress, depression and anxiety, and factors associated with clinical distress. Implementation outcomes, including rates of referrals and follow-up for distressed patients, are also reported. RESULTS Two hundred and eighty seven HNC patients completed the questionnaire (age 64.3 ± 14.9 years), with a mean distress score of 4.51 ± 3.35. Of those, 57% (n = 163) reported clinical distress (DT ≥ 4). Pain (odds ratio [OR] = 3.31, 95% CI = 1.75-6.26), fatigue (OR = 2.43, 95% CI = 1.1.7-5.05), anxiety (OR = 1.63, 95% CI = 1.30-2.05), and depression (OR = 1.51, 95% CI = 1.04-2.18) were significantly associated with clinical distress (P < .05). Of patients identified as distressed, 79% received same-day psychosocial evaluation. CONCLUSIONS Clinical distress was identified in 57% of patients who completed the questionnaire, suggesting that an ultra-brief psychosocial screening protocol can be implemented in routine ambulatory oncology care, and identifies patients whose distress might otherwise go unrecognized. LEVEL OF EVIDENCE 4 Laryngoscope, 132:1600-1608, 2022.
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Affiliation(s)
- Eden R Brauer
- Department of Nursing, UCLA School of Nursing, Los Angeles, CA
| | - Stephanie Lazaro
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Charlene L Williams
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David A Rapkin
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Amy B Madnick
- Department of Care Coordination & Clinical Social Work, Ronald Reagan-UCLA Medical Center
| | - Roger Dafter
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Guo Cheng
- Department of Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ashleigh Porter
- Department of Hematology Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Elliot Abemayor
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Wanxing Chai-Ho
- Department of Hematology Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Elizabeth Morasso
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Andrew Erman
- Department of Audiology and Speech Pathology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA
| | - Dinesh Chhetri
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Maie St. John
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Deborah J. Wong
- Department of Hematology Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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, Ganz PA. Moving the Translational Needle in Breast Cancer Survivorship: Connecting Intervention Research to Clinical Practice. J Clin Oncol 2022; 40:2069-2073. [PMID: 35439031 DOI: 10.1200/jco.22.00174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Eden R Brauer
- School of Nursing, University of California, Los Angeles, Los Angeles, CA
| | - Patricia A Ganz
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA.,Fielding School of Public Health and David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Eden R Brauer
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Patricia A Ganz
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA, USA.
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Brauer ER, Long EF, Melnikow J, Ravdin PM, Ganz PA. Communicating Risks of Adjuvant Chemotherapy for Breast Cancer: Getting Beyond the Laundry List. J Oncol Pract 2019; 15:e98-e109. [PMID: 30550372 PMCID: PMC6374637 DOI: 10.1200/jop.18.00162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 11/20/2022] Open
Abstract
PURPOSE According to the Institute of Medicine, high-quality cancer care should include effective communication between clinicians and patients about the risks and benefits, expected response, and impact on quality of life of a recommended therapy. In the delivery of oncology care, the barriers to and facilitators of communication about potential long-term and late effects, post-treatment expectations, and transition to survivorship care have not been fully defined. PATIENTS AND METHODS We collected qualitative data through semistructured interviews with medical oncologists and focus groups with breast cancer survivors and applied the Theoretical Domains Framework to systematically analyze and identify the factors that may influence oncologists' communication with patients with breast cancer about the long-term and late effects of adjuvant therapy. RESULTS Eight key informant interviews with medical oncologists and two focus groups with breast cancer survivors provided data. Both oncologists and patients perceived information on long-term effects as valuable in terms of improved clinical communication but had concerns about the feasibility of inclusion before treatment. They described the current approaches to communication of therapy risks as a brief laundry list that emphasized acute adverse effects and minimized more long-term issues. We describe the barriers to communication about potential long-term effects from the perspectives of both groups. CONCLUSION This study provides insight into oncologists' communication with patients with breast cancer regarding the potential long-term and late effects of adjuvant chemotherapy and about setting realistic expectations for life after treatment. Opportunities to improve oncologists' communication about the potential toxicities of therapy, particularly regarding long-term and late effects, should be examined further.
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Affiliation(s)
- Eden R. Brauer
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
| | | | - Joy Melnikow
- UC Davis Center for Healthcare Policy and Research, Davis, CA
| | | | - Patricia A. Ganz
- UCLA School of Medicine, Los Angeles, CA
- UCLA School of Public Health, Los Angeles, CA
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Kline RM, Arora NK, Bradley CJ, Brauer ER, Graves DL, Lunsford NB, McCabe MS, Nasso SF, Nekhlyudov L, Rowland JH, Schear RM, Ganz PA. Long-Term Survivorship Care After Cancer Treatment - Summary of a 2017 National Cancer Policy Forum Workshop. J Natl Cancer Inst 2018; 110:1300-1310. [PMID: 30496448 PMCID: PMC6658871 DOI: 10.1093/jnci/djy176] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/31/2018] [Accepted: 08/31/2018] [Indexed: 12/17/2022] Open
Abstract
The National Cancer Policy Forum of the National Academies of Sciences, Engineering and Medicine sponsored a workshop on July 24 and 25, 2017 on Long-Term Survivorship after Cancer Treatment. The workshop brought together diverse stakeholders (patients, advocates, academicians, clinicians, research funders, and policymakers) to review progress and ongoing challenges since the Institute of Medicine (IOM)'s seminal report on the subject of adult cancer survivors published in 2006. This commentary profiles the content of the meeting sessions and concludes with recommendations that stem from the workshop discussions. Although there has been progress over the past decade, many of the recommendations from the 2006 report have not been fully implemented. Obstacles related to the routine delivery of standardized physical and psychosocial care services to cancer survivors are substantial, with important gaps in care for patients and caregivers. Innovative care models for cancer survivors have emerged, and changes in accreditation requirements such as the Commission on Cancer's (CoC) requirement for survivorship care planning have put cancer survivorship on the radar. The Center for Medicare & Medicaid Innovation's Oncology Care Model (OCM), which requires psychosocial services and the creation of survivorship care plans for its beneficiary participants, has placed increased emphasis on this service. The OCM, in conjunction with the CoC requirement, is encouraging electronic health record vendors to incorporate survivorship care planning functionality into updated versions of their products. As new models of care emerge, coordination and communication among survivors and their clinicians will be required to implement patient- and community-centered strategies.
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Affiliation(s)
- Ronald M Kline
- Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Neeraj K Arora
- Healthcare Delivery and Disparities Research Program, Patient Centered Outcomes Research Institute, Washington, DC
| | - Cathy J Bradley
- Department of Health Systems, Management, and Policy, School of Public Health, University of Colorado, Denver, CO
| | - Eden R Brauer
- Jonsson Comprehensive Cancer Center, University of California – Los Angeles, Los Angeles, CA
| | - Darci L Graves
- Office of Minority Health, Centers for Medicare & Medicaid Services, Baltimore, MD
| | | | - Mary S McCabe
- Independent Consultant in Survivorship and Medical Ethics, Arlington, VA
| | | | - Larissa Nekhlyudov
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Julia H Rowland
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
- Smith Center for Healing and the Arts, Washington, DC
| | - Rebekkah M Schear
- LIVESTRONG Cancer Institutes at Dell Medical School, University of Texas at Austin, Austin, TX
- Department of Health Policy & Management and Medicine, Schools of Public Health and Medicine, Jonsson Comprehensive Cancer Center, University of California – Los Angeles, Los Angeles, CA
| | - Patricia A Ganz
- Jonsson Comprehensive Cancer Center, University of California – Los Angeles, Los Angeles, CA
- Department of Health Policy & Management and Medicine, Schools of Public Health and Medicine, Jonsson Comprehensive Cancer Center, University of California – Los Angeles, Los Angeles, CA
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Brauer ER, Pieters HC, Ganz PA, Landier W, Pavlish C, Heilemann MV. "Improving to where?": treatment-related health risks and perceptions of the future among adolescents and young adults after hematopoietic cell transplantation. Support Care Cancer 2018; 27:623-630. [PMID: 30043264 DOI: 10.1007/s00520-018-4350-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/09/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite the prevalence of hematological malignancies in early adulthood, very little is known about hematopoietic cell transplantation among adolescents and young adults, and even less is known about their transition from the completion of therapy to early survivorship. In this qualitative study, we investigated the impact of the cancer experience on sense of life potential and perception of the future from the perspectives of adolescents and young adults after hematopoietic cell transplantation. METHODS In-depth interviews were conducted with adolescents and young adults who underwent allogeneic or autologous hematopoietic cell transplantation between the ages of 15-29 years and were 6-60 months post-treatment. Interview transcripts were systematically coded based on constructivist grounded theory. RESULTS Eighteen adolescents and young adults participated and described how they came to understand the lifelong, chronic nature of cancer survivorship. "Improving to where?" was a question raised in the post-treatment period that reflected participants' confusion about the goals of treatment and expectations for survivorship. Participants reported bracing themselves for "something bad" to deal with the uncertainty of medical and psychosocial effects of treatment. They struggled to move forward with their lives given their substantial health risks and found it necessary to "roll with the punches" in order to adjust to this new reality. CONCLUSIONS Adolescents and young adults who undergo hematopoietic cell transplantation are at significant risk for long-term and late effects in survivorship. Age-appropriate interventions are needed to support these survivors as they manage their fears about the future while enhancing health and well-being.
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Affiliation(s)
- Eden R Brauer
- UCLA Jonsson Comprehensive Cancer Center, 650 Charles Young Drive South, Box 956900, Los Angeles, CA, 90095-6900, USA.
| | - Huibrie C Pieters
- UCLA School of Nursing, 4-956 Factor Bldg, Box 956918, Los Angeles, CA, 90095-6918, USA
| | - Patricia A Ganz
- UCLA Fielding School of Public Health, UCLA David Geffen School of Medicine, UCLA Jonsson Comprehensive Cancer Center, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Wendy Landier
- University of Alabama at Birmingham Schools of Medicine and Nursing, 1600 7th Avenue South, Lowder 500, Birmingham, AL, 35233, USA
| | - Carol Pavlish
- UCLA School of Nursing, 4-238 Factor Bldg, Box 956918, Los Angeles, CA, 90095-6918, USA
| | - MarySue V Heilemann
- UCLA School of Nursing, 5-252 Factor Bldg, Box 956919, Los Angeles, CA, 90095-6919, USA
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Brauer ER, Pieters HC, Ganz PA, Landier W, Pavlish C, Heilemann MV. Coming of Age With Cancer: Physical, Social, and Financial Barriers to Independence Among Emerging Adult Survivors. Oncol Nurs Forum 2018; 45:148-158. [PMID: 29466341 PMCID: PMC6162052 DOI: 10.1188/18.onf.148-158] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To explore the transition to self-care among a sample of emerging adult cancer survivors after hematopoietic cell transplantation (HCT).
. PARTICIPANTS & SETTING 18 HCT survivors who were aged 18-29 years at the time of HCT for a primary hematologic malignancy and were 8-60 months post-HCT participated in the study. The study took place in the hematology outpatient setting at City of Hope National Medical Center.
. METHODOLOGIC APPROACH The authors conducted in-depth semistructured interviews and analyzed interview transcripts using grounded theory methodology.
. FINDINGS Health-related setbacks following HCT disrupted not only participants' journey toward self-care, but also their overarching developmental trajectory toward adulthood. Physically, participants struggled with lack of personal space around caregivers, but felt unready to live on their own. Socially, they relied on multiple caregivers to avoid relying too much on any one person. Financially, participants worried about prolonged dependence and increased needs in the future.
. IMPLICATIONS FOR NURSING Nurses can support the transition to self-care among emerging adults after HCT by recognizing the broader developmental impact of their cancer experience.
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Affiliation(s)
- Eden R. Brauer
- UCLA Jonsson Comprehensive Cancer Center, Center for Cancer Prevention & Control Research, Box 956900, A2-125 CHS, Los Angeles, CA 90095-6900, , Telephone: (310) 724-7525, Fax: (310) 206-3566
| | | | - Patricia A. Ganz
- UCLA Schools of Medicine and Public Health, UCLA Jonsson Comprehensive Cancer Center,
| | - Wendy Landier
- University of Alabama at Birmingham, School of Medicine,
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Brauer ER, Pieters HC, Ganz PA, Landier W, Pavlish C, Heilemann MV. "From Snail Mode to Rocket Ship Mode": Adolescents and Young Adults' Experiences of Returning to Work and School After Hematopoietic Cell Transplantation. J Adolesc Young Adult Oncol 2017; 6:551-559. [PMID: 28594579 DOI: 10.1089/jayao.2017.0025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Resuming normal activities, such as work and school, is an important dimension of psychosocial recovery in cancer survivorship. Minimal data exist regarding adolescents or young adults' experiences of returning to school or work after cancer. The purpose of this study was to explore the processes of resuming work and school among adolescents and young adults after hematopoietic cell transplantation (HCT). METHODS In-depth interviews were conducted with 18 adolescents and young adults, who were 15-29 years when they underwent HCT and 6-60 months post-transplant at study enrollment. Interview transcripts were systematically analyzed using Grounded Theory methodology. RESULTS Participants described the context in which they attempted to return to work or school, specific challenges they faced, and strategies they developed in these environments. Feeling left behind from their peers and their pre-diagnosis selves, participants described "rushing" back to school and work impulsively, taking on too much too quickly while facing overwhelming physical and cognitive demands. Factors motivating this sense of urgency as well as barriers to successful and sustainable reentry in these settings are also addressed. CONCLUSION Findings are discussed in the context of important opportunities for clinical management, age-appropriate interventions, and implications for future research. A better understanding of psychosocial late effects, specifically related to school and work trajectories after cancer, is critical to survivorship care for adolescent and young adult cancer survivors.
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Affiliation(s)
- Eden R Brauer
- 1 Center for Cancer Prevention & Control Research, UCLA Jonsson Comprehensive Cancer Center , Los Angeles, California.,2 UCLA Fielding School of Public Health , Los Angeles, California
| | | | - Patricia A Ganz
- 1 Center for Cancer Prevention & Control Research, UCLA Jonsson Comprehensive Cancer Center , Los Angeles, California.,2 UCLA Fielding School of Public Health , Los Angeles, California
| | - Wendy Landier
- 4 University of Alabama at Birmingham Schools of Medicine and Nursing , Birmingham, Alabama
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Abstract
PURPOSE Aromatase inhibitors (AIs) are an important and effective hormonal adjuvant treatment for early-stage breast cancer. Up to 50% of women stop AIs prematurely, missing a valuable therapeutic intervention. PATIENTS AND METHODS We used grounded theory methodology to conduct in-depth, semistructured interviews and analyze data among patients with breast cancer diagnosed at age 65 years or older who were receiving an AI. The goal of the interviews was to understand decision making regarding persisting with AIs. Interview transcripts were systematically analyzed to identify emergent categories and relationships. RESULTS Interviews were conducted with 27 women. After completion of primary treatment, women in our sample found themselves "winging it" as they faced substantial struggles with infrequent support during this new phase of the cancer trajectory. Self-management of AI adverse effects occurred in the contexts of older age and early survivorship. "Bearing it" emerged as another important management process regarding the impact of AIs on quality of everyday life. The complex decision to persist with the AI involved weighing the possibility of a cancer-free future against the burden of adverse effects. Women relied on informal networks for support, rather than oncology providers, highlighting the need for practical self-management strategies. The notion of a tipping point in persistence revealed their susceptibility to early discontinuation. CONCLUSION This study provides insight into potential decisional pathways leading to early discontinuation of AIs among older women with breast cancer. Better support is needed for these women.
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Affiliation(s)
- Eden R Brauer
- University of California Los Angeles (UCLA) School of Nursing; UCLA Schools of Medicine and Public Health; and UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
| | - Patricia A Ganz
- University of California Los Angeles (UCLA) School of Nursing; UCLA Schools of Medicine and Public Health; and UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
| | - Huibrie C Pieters
- University of California Los Angeles (UCLA) School of Nursing; UCLA Schools of Medicine and Public Health; and UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
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