Adrian Gerstel

Patient and Provider Preferences for Survivorship Care Plans

PURPOSE Survivorship care plans (SCPs) are tools used to assist in the transition from treatment to surveillance cancer care. However, few studies have investigated survivor and provider preferences regarding SCPs. Our purpose was to explore survivor and primary care provider preferences regarding content, format, and delivery of SCPs. METHODS Focus groups and provider interviews were performed in 2010. Five different templates were presented to study participants for their feedback. Each SCP included a treatment summary, surveillance schedule, and care plan for the same fictitious patient. Sessions were transcribed, and field notes taken. RESULTS Four focus groups (n = 29 survivors) and five primary care providers participated. No cancer survivors had ever received a written SCP. We found clear preferences for the Journey Forward format (with some modifications) and face-to-face delivery (print or electronic) to the survivor by his or her oncologist just before or soon after completion of treatment. Primary care providers preferred an abbreviated version. CONCLUSION Written SCPs were endorsed by all patients and primary care providers as helpful communication tools. However, if used alone, the SCP would be insufficient to ease the transition to follow-up care. Improved communication and care coordination were identified as important for survivorship care that went beyond what this document might provide.

Implementing survivorship care plans for colon cancer survivors

PURPOSE/OBJECTIVES To evaluate the feasibility, usability, and satisfaction of a survivorship care plan (SCP) and identify the optimum time for its delivery during the first 12 months after diagnosis. DESIGN Prospective, descriptive, single-arm study. SETTING A National Cancer Institute-designated cancer center in the southeastern United States. SAMPLE 28 nonmetastatic colon cancer survivors within the first year of diagnosis and their primary care physicians (PCPs). METHODS Regular screening identified potential participants who were followed until treatment ended. An oncology certified nurse developed the JourneyForward™ SCP, which then was delivered to the patient by the oncology nurse practitioner (NP) during a routine follow-up visit and mailed to the PCP. MAIN RESEARCH VARIABLES Time to complete, time to deliver, usability, and satisfaction with the SCP. FINDINGS During one year, 75 patients were screened for eligibility, 34 SCPs were delivered, and 28 survivors and 15 PCPs participated in the study. It took an average of 49 minutes to complete a surgery SCP and 90 minutes to complete a surgery plus chemotherapy SCP. Most survivors identified that before treatment ended or within the first three months was the preferred time to receive an SCP. CONCLUSIONS The SCPs were well received by the survivors and their PCPs, but were too time and labor intensive to track and complete. IMPLICATIONS FOR NURSING More work needs to be done to streamline processes that identify eligible patients and to develop and implement SCPs. Measuring outcomes will be needed to demonstrate whether SCPs are useful or not.

Guidelines for the use of survivorship care plans: a systematic quality appraisal using the AGREE II instrument

BackgroundSurvivorship care plans (SCPs) are written treatment summaries and follow-up care plans that are intended to facilitate communication and coordination of care among survivors, cancer care providers, and primary care providers. A growing number of guidelines for the use of SCPs exist, yet SCP use in the United States remains limited. Limited use of SCPs may be due to poor quality of these guidelines. The purpose of the study was to evaluate the quality of guidelines for SCP use, tools that are intended to promote evidence-based medicine.MethodsWe conducted a comprehensive search of the literature using MEDLINE/PubMed, EMBASE (Excerpta Medica Database), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) published through April 2014, in addition to grey literature sources and bibliographic and expert reviews. Guideline quality was assessed using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation, 2nd edition), a tool developed by an international group of scientists to advance the quality of clinical practice guidelines. To promote consistency with extant studies using the AGREE II instrument and to clearly and unambiguously identify potentially useful guidelines for SCP use, we also summarized AGREE II scores by strongly recommending, recommending, or not recommending the guidelines that we evaluated.ResultsOf 128 documents screened, we included 16 guidelines for evaluation. We did not strongly recommend any of the 16 guidelines that we evaluated; we recommended 5 and we did not recommend 11. Overall, guidelines scored highest on clarity of presentation (i.e., guideline language, structure, and format): Guidelines were generally unambiguous in their recommendations that SCPs should be used. Guidelines scored lowest on applicability (i.e., barriers and facilitators to implementation, implementation strategies, and resource implications of applying the guideline): Few guidelines discussed facilitators and barriers to guideline application; advice and tools for implementing guidelines were vague; and none explicitly discussed resource implications of implementing the guidelines.ConclusionsGuidelines often advocated survivorship care plan use without justification or suggestions for implementation. Improved guideline quality may promote survivorship care plan use.

Using survivorship care plans to enhance communication and cancer care coordination: Results of a pilot study

PURPOSE/OBJECTIVES To compare a structured cancer survivorship care plan (SCP) transition visit versus an SCP transition visit coupled with a coordinated follow-up visit from the primary care provider (PCP).
. DESIGN Pilot randomized, controlled study.
. SETTING REX Cancer Hospital, a community cancer center in Raleigh, North Carolina.
. SAMPLE 34 adults completing treatment with curative intent. 
. METHODS Patients and PCPs completed measures at baseline and at six weeks. Wilcoxon signed rank and rank sum tests were used for comparisons of SCP only versus SCP with PCP follow-up visit, as well as between high- and low-activated patients.
. MAIN RESEARCH VARIABLES Confidence in survivorship information and survivor concerns.
. FINDINGS The intervention was feasible and acceptable to patients and their PCPs. All patients (N = 34) had less contradictory information about care after SCP receipt. PCPs reported improved confidence in patients, regardless of intervention arm. Highly activated or empowered patients benefited more and had increased confidence and fewer concerns about cancer care. 
. CONCLUSIONS The SCP interventions led to increased confidence in survivorship information, but some benefits were greater for highly activated patients. PCPs also had improved confidence in survivorship care after SCP receipt, whether or not they saw the patient in follow-up. A larger study is needed to further explore these findings and the changes over time.
. IMPLICATIONS FOR NURSING Nurses can be instrumental in facilitating the development and delivery of SCP to survivors and PCPs.

Potential determinants of health-care professionals' use of survivorship care plans: a qualitative study using the theoretical domains framework.

BackgroundSurvivorship care plans are intended to improve coordination of care for the nearly 14 million cancer survivors in the United States. Evidence suggests that survivorship care plans (SCPs) have positive outcomes for survivors, health-care professionals, and cancer programs, and several high-profile organizations now recommend SCP use. Nevertheless, SCP use remains limited among health-care professionals in United States cancer programs. Knowledge of barriers to SCP use is limited in part because extant studies have used anecdotal evidence to identify determinants. This study uses the theoretical domains framework to identify relevant constructs that are potential determinants of SCP use among United States health-care professionals.MethodsWe conducted semi-structured interviews to assess the relevance of 12 theoretical domains in predicting SCP use among 13 health-care professionals in 7 cancer programs throughout the United States with diverse characteristics. Relevant theoretical domains were identified through thematic coding of interview transcripts, identification of specific beliefs within coded text units, and mapping of specific beliefs onto theoretical constructs.ResultsWe found the following theoretical domains (based on specific beliefs) to be potential determinants of SCP use: health-care professionals’ beliefs about the consequences of SCP use (benefit to survivors, health-care professionals, and the system as a whole); motivation and goals regarding SCP use (advocating SCP use; extent to which using SCPs competed for health-care professionals’ time); environmental context and resources (whether SCPs were delivered at a dedicated visit and whether a system, information technology, and funding facilitated SCP use); and social influences (whether using SCPs is an organizational priority, influential people support SCP use, and people who could assist with SCP use buy into using SCPs). Specific beliefs mapped onto the following psychological constructs: outcome expectancies, intrinsic motivation, goal priority, resources, leadership, and team working.ConclusionsPrevious studies have explored a limited range of determinants of SCP use. Our findings suggest a more comprehensive list of potential determinants that could be leveraged to promote SCP use. These results are particularly timely as cancer programs face impending SCP use requirements. Future work should develop instruments to measure the potential determinants and assess their relative influence on SCP use.

Social Relationships, Inflammation, and Cancer Survival

Background: Social stressors, such as social relationship deficits, have been increasingly linked to chronic disease outcomes, including cancer. However, critical gaps exist in our understanding of the nature and strength of such links, as well as the underlying biological mechanisms relating social relationships to cancer progression and survival. Methods: Utilizing novel questionnaire and biomarker data from the UNC Health Registry/Cancer Survivorship Cohort, this study examines the associations between diverse measures of social support and mortality risk among individuals with cancer (N = 1,004). We further assess the role of multiple serum markers of inflammation, including high-sensitivity C-reactive protein (CRP), IL6, TNFα, and VEGF, as potential mediators in the social relationship–cancer link. Results: The findings revealed that ones appraisal of their social support was associated with cancer mortality, such that individuals reporting higher levels of social support satisfaction had lower mortality risk than individuals reporting lower levels of satisfaction. The amount of support received, on the other hand, was not predictive of cancer survival. We further found evidence that inflammatory processes may undergird the link between social support satisfaction and mortality among individuals with cancer, with individuals reporting higher levels of social support satisfaction having lower levels of CRP, IL6, and TNFα. Conclusions: These results provide new knowledge of the biosocial processes producing population disparities in cancer outcomes. Impact: Our study offers new insights for intervention efforts aimed at promoting social connectedness as a means for improving cancer survival. Cancer Epidemiol Biomarkers Prev; 27(5); 541–9. ©2018 AACR.

Primary care providers’ evaluation of survivorship care plans.

188 Background: Survivorship care represents a distinct phase of the cancer care and addresses surveillance, the physical and psychosocial sequelae of the cancer and treatment, and health promotion. Survivorship care plans (SCP) were recommended in the 2005 IOM From Cancer Patient to Cancer Survivor as a tool to address these issues and will be required by the Commission on Cancer in 2015. As part of two studies implementing SCP using the JourneyForward (JF-SCP) template, we evaluated primary care providers (PCP) perspective on their use. METHODS JF-SCP were developed and delivered to patients and PCP at the end of treatment. We collected information about usability, comprehension, barriers to use, and respondent demographics. RESULTS Of the 61 PCP who responded: 86% were physicians, 60% were women, had an average of 20 years in practice. PCP strongly agreed/agreed that SCP were easy to understand (95.7%), the right length (73.9%), addressed the right topics (95.7%), would be useful in talking with patients about survivorship plans (91.3%), would improve communication with oncologists (74.4%) and with patients (74.4%). Significant barriers interfering with the PCP providing follow-up care included: limited access to survivors as they stay with oncologists (59.5%), insufficient knowledge of issues (53.4%), inadequate recommendations from the oncologist (43.9%), lack of survivor care guidelines (42%), lack of time (38%), and poor reimbursement (16.6%). Specific suggestions about the JF-SCP included making it shorter and being clear about which provider was responsible for obtaining recommended testing. PCP commented on the importance of ongoing primary care provided throughout the cancer continuum. CONCLUSIONS PCP reported ease of SCP use but did identify areas for improvement. Many PCP were frequently not included or did not stay involved with the cancer patient when being seen by oncologists. The SCP was viewed as a tool to facilitate communication with oncologists and patients.