Evaluating Survivorship Care Plans: Results of a Randomized, Clinical Trial of Patients With Breast Cancer

Ontario Institute for Cancer Research, Ontario, Canada.
Journal of Clinical Oncology (Impact Factor: 18.43). 12/2011; 29(36):4755-62. DOI: 10.1200/JCO.2011.36.8373
Source: PubMed

ABSTRACT An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes.
Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures.
Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005).
The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.

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Available from: Susan Dent, Dec 21, 2013
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    • "Based on the pre-implementation findings, we conceptualized a SCP that included multiple components: web-based and paper-based, and tailored to the specific needs of both patients and providers. This is a more holistic approach than is usually cited in the literature; most SCPs consist of providing written treatment summaries and instructions for follow-up monitoring [8,9,11]. Fortunately this is beginning to change and more tools are available than when we began our study [27,28]. "
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    ABSTRACT: Following the completion of treatment and as they enter the follow-up phase, breast cancer patients (BCPs) often recount feeling 'lost in transition', and are left with many questions concerning how their ongoing care and monitoring for recurrence will be managed. Family physicians (FPs) also frequently report feeling ill-equipped to provide follow-up care to BCPs. In this three-phase qualitative pilot study we designed, implemented and evaluated a multi-faceted survivorship care plan (SCP) to address the information needs of BCPs at our facility and of their FPs. In Phase 1 focus groups and individual interviews were conducted with 35 participants from three stakeholder groups (BCPs, FPs and oncology specialist health care providers (OHCPs)), to identify specific information needs. An SCP was then designed based on these findings, consisting of both web-based and paper-based tools (Phase 2). For Phase 3, both sets of tools were subsequently evaluated via focus groups and interviews with 26 participants. Interviews and focus groups were audio taped, transcribed and content analysed for emergent themes and patterns. In Phase 1 patients commented that web-based, paper-based and human resources components were desirable in any SCP. Patients did not focus exclusively on the post-treatment period, but instead spoke of evolving needs throughout their cancer journey. FPs indicated that any tools to support them must distill important information in a user-friendly format. In Phase 2, a pilot SCP was subsequently designed, consisting of both web-based and paper-based materials tailored specifically to the needs of BCPs as well as FPs. During Phase 3 (evaluation) BCPs indicated that the SCP was effective at addressing many of their needs, and offered suggestions for future improvements. Both patients and FPs found the pilot SCP to be an improvement from the previous standard of care. Patients perceived the quality of the BCP-FP relationship as integral to their comfort with FPs assuming follow-up responsibilities. This pilot multi-component SCP shows promise in addressing the information needs of BCPs and the FPs who care for them. Next steps include refinement of the different SCP components, further evaluation (including usability testing), and planning for more extensive implementation.
    BMC Medical Informatics and Decision Making 07/2013; 13(1):76. DOI:10.1186/1472-6947-13-76 · 1.83 Impact Factor
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    • "Interventions for early-stage breast cancer patients have frequently combined elements of psychoeducational and other psychosocial support, stress management techniques, and cognitive behavioral therapy [36, 37]. In a study by Grunfeld et al. [38], compilation of survivorship care plans and a psychoeducational session were undertaken in a pragmatic trial that was consistent with usual practices and feasible to implement within time and human resource constraints. It is important to examine whether interventions need to combine psychoeducational, emotional, and physical support while considering timing of such interventions. "
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    ABSTRACT: Most breast cancer patients receive psychosocial support interventions. However, the effectiveness of these interventions has not yet been clarified. Quality of life (QOL) was an important construct that should be considered when assessing these interventions. The purpose was to evaluate the effectiveness of psychosocial and especially psychoeducational support interventions for early-stage breast cancer patients since the follow-up was bound up to 6 months after finishing the intervention. We conducted a systematic review and meta-analysis to identify randomized controlled trials with early-stage breast cancer patients receiving psychosocial (psychoeducational and other) support in which QOL was measured as a treatment outcome. We compared mean differences at less than 6 months post-intervention with a control group. The primary outcome was Global Health Status/QOL scale (Global QOL), and secondary outcomes were the subscales of QOL. No significant effect was observed for Global QOL; however, individuals receiving psychosocial support scored higher on the Breast Cancer Symptoms subscale. For psychoeducational support in the psychosocial support, significant effect was observed on the Emotional subscale. Our analysis strengthens the evidence of the effectiveness of psychosocial support in improving breast cancer symptoms and psychoeducational support in improving emotional well-being within 6 months post-intervention.
    Quality of Life Research 07/2013; 23(1). DOI:10.1007/s11136-013-0460-3 · 2.49 Impact Factor
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    • "And third, this US study was done at a time and in a climate of increasing attention to cancer survivorship in general and SCPs in particular in this country. Studies such as ours and that of Grunfeld et al. [11] may be producing true null effects for reasons other than those noted above. One possibility might be that patients do not know what they do not know. "
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    ABSTRACT: Objective: Despite recommendations from the Institute of Medicine regarding survivorship care plan (SCP) delivery to cancer patients, there have been few health service outcome evaluations thus far. Methods: Gynecologic cancer survivors who were up to one-year post-treatment could participate in an evaluation assessing the health services provided and their perceptions of quality of care. A randomized, nested, cross-sectional design was used in a large group gynecologic oncology practice. Half (n=3) of the physicians were randomized to provide and discuss a SCP to patients during a follow-up visit, and the other half did not. Following their visits, all patients were informed that a health service evaluation of the practice was being conducted. Interested patients completed an anonymous 26-item survey assessing administrative, clinical, and educational health services, helpfulness of written materials, and perceptions of quality of care. Results: Of the 121 survivors surveyed, 64 received SCPs and 57 were in the no-SCP condition. As a validity check, one question asked about educational materials received during the visit with an expected significant difference noted between conditions (X(2)=5.513, p=.019; more SCP patients reported receiving materials). However, there were no differences between conditions when patients rated health services (Fs>.37) or helpfulness of materials and perceptions of care (Fs>.19). Conclusions: Gynecologic oncology patients providing ratings of health services and satisfaction with care provided equivalent evaluations, regardless if they had/had not received a SCP from the physician. Thus, the need remains for further evaluations of SCPs if they are to be vehicles for improving health service outcomes.
    Gynecologic Oncology 03/2013; 129(3). DOI:10.1016/j.ygyno.2013.02.037 · 3.77 Impact Factor
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