Implementing Cancer Survivorship Care Planning Workshop Summary (2007) / Chapter Skim
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4 Resources for Completing the Care Plan
4 Resources for Completing the Care Plan
Pages 64-106
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From page 64... ...
Lawrence Shulman will then reflect on the state of information technology as it pertains to survivorship care planning. Finally, Tim Byers will discuss regional approaches to cancer survivorship planning.
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From page 65... ...
There are very few studies that examine how surveillance affects outcomes, in part because of the relatively small numbers of pediatric cancer survivors. Consequently, expert clinical experience and principles of screening in the general population and other high-risk groups was relied on for the aspects of care considered as part of the guideline development process.
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From page 66... ...
detailed and in-depth systematic reviews on focused topics such as chest radiation and its relationship with breast cancer development; and (2) general reviews that are geared more toward the practicing primary physician and the community-based pediatric oncologist.
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From page 67... ...
67 effects. late chemotherapy to related guidelines COG of 2006.
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From page 68... ...
The proportion of survivors of childhood cancer with a cancer center visit within the past 2 years is about 35 percent at 7 years after cancer therapy or from the cancer diagnosis, according to results from the Childhood Cancer Survivor Study published a few years ago.2 As the bottom line on Figure 4-2 illustrates, the further survivors are from their cancer diagnosis, the less likely they are to have been seen at a cancer center. These results are based on patients who were treated from 1970 to 1986.
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From page 69... ...
Some barriers to comprehensive survivorship care extend beyond the reach of long-term follow-up programs. Primary care physicians are not familiar with pediatric cancer survivors, which is not unexpected because, on average, a general internist or a family physician has three to five pediatric cancer survivors in their practice.
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From page 70... ...
. In terms of models of care, Eva Grunfeld's series of randomized clinical trials illustrates how follow-up care for breast cancer survivors can be accomplished in the primary care community.4 The shared care model can be stratified by risk.
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From page 71... ...
Cancer survivors are being characterized as having a chronic condition, but cancer is quite distinct from cardiovascular disease and diabetes. Cancer survivors may have a late effect that becomes a chronic health problem, but often it is their risk for developing new problems that presents a different paradigm.
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From page 72... ...
For many aspects of survivorship care there is limited clinical trialbased evidence, and generalizations about care from cancer registries are difficult because registries do not capture complete information on treatment and late effects. Furthermore, adult cancer survivors often have comorbid conditions that can confound interpretation of outcomes by researchers as they attempt to establish relationships among treatments, late effects, and health outcomes.
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From page 73... ...
is markedly beneficial in the early stage of breast cancer according to clinical trials, but the median follow-up period in these trials is 2 to 3 years. It has become the standard of care for women with breast cancer who overexpress the growth factor protein HER2.
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From page 74... ...
ASCO's consensus guideline states that it is reasonable to screen for cardiac dysfunction in women who have had greater than 300 mg/m2 doxorubicin or who had breast radiation that involved the chest wall. Such screening is not now part of standard breast cancer follow-up.
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From page 75... ...
Survivorship care planning, including the development of guidelines, provides such an opportunity. Discussion Dr.
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From page 76... ...
PSYCHOSOCIAL SUPPORT RESOURCES Presenter: Ms. Diane Blum The IOM recommended that the Survivorship Care Plan include information on the availability of community-based psychosocial services.
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CancerCare, the National Coalition for Cancer Survivorship (NCCS) , the Lance Armstrong Foundation (LAF)
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From page 78... ...
. The 2004 IOM report, Meeting Psychosocial Needs of Women with Breast Cancer, found psychosocial interventions to be effective but underused for many reasons, including stigma, inadequate insurance coverage, and, very importantly, lack of knowledge on the part of health care professionals.10 How can problems related to lack of knowledge and underutilization be addressed?
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From page 79... ...
The ACS has very high name recognition with the public and, given the volume of calls and visits to their survivorship-related web content, provides an important dissemination mechanism for information on survivorship. The ultimate goal in terms of psychosocial services for cancer survivors is for each person at the completion of treatment to have a psychosocial assessment.
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From page 80... ...
Although admonitions to increase awareness have become a cliché, some awareness campaigns have been very successful, for example, those launched in mid-1980s to raise awareness of breast cancer. An organization like the LAF could probably facilitate this kind of awareness program.
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From page 81... ...
Wendy Demark-Wahnefried Lifestyle factors, such as diet, exercise, and smoking cessation, should be considered in the care plans that are given to cancer patients as they finish their primary treatment. Cancer survivors are at greater risk for cardiovascular disease, osteoporosis, and diabetes, and changes in health behaviors may reduce these treatment-related conditions, cancer-related symptoms, comorbidity, and functional declines.
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From page 82... ...
Shown in Figure 4-4 are data on breast cancer survivors enrolled in the Nurses Health Study. Women who increased their body mass index from 0.5 to 2 units were at significantly higher risk for breast cancer recurrence, breast cancer mortality, and overall mortality when compared with women who maintained their weight (represented by the second set of bars from the left)
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From page 83... ...
Even if cancer survivors are able to maintain their prediagnostic body weight, their body composition often changes, especially during treatment with adjuvant chemotherapy. Figure 4-5 shows changes observed among breast cancer patients who received adjuvant chemotherapy (solid lines)
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. Research is needed to identify weight loss interventions that are effective among cancer survivors.
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From page 85... ...
& diet focused on nutrient-rich, lower energy density foods & portion control · If overweight or obese, encourage weight loss Practical Guide established by NHLBI & NAASO (NIH Pub 00-4084) · More research needed to develop optimal programs of weight loss for cancer survivors FIGURE 4-6 ACS recommendation for weight management.
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From page 86... ...
than the general population, most survivors still fail to achieve recommended levels of exercise. Shown in Figure 4-8 are data on cancer recurrence, breast cancer mortality, and all-cause mortality among a cohort of breast cancer survivors enrolled in the Nurses Health Study according to their levels of physical activity.
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From page 87... ...
These promising results are from only one study in breast cancer; however, the Journal of Clinical Oncology has recently published two similar studies regarding the association of physical activity and colon cancer outcomes.13 13Meyerhardt JA.
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From page 88... ...
among most cancer survivors is really no different than that seen in the general population. Higher rates of risky drinking have been noted among survivors of prostate cancer, head and neck cancers, and lung cancer.
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From page 89... ...
Cancer survivors are very interested in such lifestyle factors as diet, exercise, and smoking. When asked "How do you like to receive assistance?
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From page 90... ...
It is clear, however, that sustained lifestyle modification is crucial to achieving optimal health among cancer survivors. Related assessments, education and counseling, and appropriate referrals need to be incorporated into survivorship care planning.
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From page 91... ...
The Passport for Care is being developed to provide this care plan information to childhood cancer survivors. It is an Internet-based resource that provides survivors and their physicians or caregivers immediate access to a portable care summary of the survivor's treatment history, individualized guidelines for care, information and links on prevention and healthy lifestyles, alerts to guideline changes and new information on late effects of therapies that the survivor may have received, general news on survivor 14 For additional information on the Passport For Care, see the background paper prepared by Drs.
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From page 92... ...
COG members have enthusiastically endorsed broader dissemination and use of the guidelines in helping childhood cancer survivors and other health professionals who provide care to survivors to recognize and manage health risks related to late effects of treatment. However, because of the length of the guidelines and the detail contained in them, clinical utility of the paper-based version of the guidelines on a dayto-day basis in a busy clinical practice is limited.
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From page 93... ...
Adult oncology care differs markedly from pediatric oncology care. Nevertheless, it is likely that the Passport for Care could eventually be adapted for survivors of adult cancers.
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From page 94... ...
Dr. Poplack is optimistic that the passport can be adapted for survivors of adult cancer, but he cautioned that "the devil is in the details." In the context of adult cancer, he advised starting with a discrete population of patients, for example, breast cancer survivors.
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From page 95... ...
· Decision support should be a component to improve the output and benefit of the tool. In relation to completion of forms: knowing the last bit of data should lead to entry of the next, for example, choosing breast cancer should lead to breast cancer chemotherapy and hormonal regimens and breast radiation options.
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From page 96... ...
. The information provided on chemotherapy and radiation therapy is summarized on a treatment summary page (Figure 4-12)
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· Could the use of this tool be tied to pay for performance and reimbursement to improve the quality and rationality of follow-up care? Payers and insurers want well-codified care plans.
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From page 98... ...
national effort, similar to the COG guideline development project, is needed in adult oncology. Teams will need to be assembled by cancer type to achieve consensus on the content of the care plan -- for example, the chemotherapy and radiation therapy regimens that need to be included, the risks for late effects, and recommended follow-up.
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From page 99... ...
RESOURCES FOR COMPLETING THE CARE PLAN 99 FIGURE 4-13 Assessment/problem list. SOURCE: Shulman, 2006.
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Funding will have to support this effort -- including the development, implementation, maintenance, and evaluation costs. REGIONAL APPROACHES TO CANCER SURVIVORSHIP PLANNING Presenter: Dr.
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From page 101... ...
There are going to be national efforts, but also some state, regional, and local ideas and demonstration projects that will emerge. 15For additional information on regional approaches to cancer survivorship planning, see the background paper prepared by Dr.
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From page 102... ...
States have received assistance for planning, but they now face the challenge of implementing their plans with limited support. Most have specified that they want to cut cancer death rates, decrease smoking, address the problems of obesity and physical inactivity, and increase screening for cervical and breast cancer.
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From page 103... ...
There is an enormous opportunity to use the state cancer planning groups and the state cancer coalitions to move survivorship care planning forward into demonstration projects. Every one of the 44 state cancer plans mentions cancer survivorship as an important issue.
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From page 104... ...
Inclusion in the plan does not ensure its implementation. However, if there are actionable items in the plans, and if there is interest in the community, then putting some specific goals and objectives into plans for cancer survivorship care planning could be very helpful.
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From page 105... ...
As demonstrations are proceeding, business models must be developed to sustain survivorship care planning.
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From page 106... ...
This planning effort should be moved out of public health agencies, so that public health is a partner but not a convener of these plans. Extending the public health function of surveillance to include cancer outcomes that are common and important to cancer survivors should be considered and tested.
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