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Tailored breast cancer survivorship plans improve implementation, adherence

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May 5, 2017

Physicians implementation of recommended survivorship care improved after low-income breast cancer survivors received counseling and a tailored survivorship plan, according to a randomized controlled trial.

Women who received this intervention also reported greater adherence to the tailored treatment plan.

Rose C. Maly

The Institute of Medicine has recommended the use of treatment summaries and survivorship plans to improve coordination of post-treatment care in cancer survivors and to address any immediate and long-term effects from breast cancer.

However, research on the implementation of treatment summaries and survivorship care plans have demonstrated little to no impact on patient outcomes, such as cancer-related distress, quality of life and patient satisfaction.

Low-income women, in particular, may benefit from treatment summaries and survivorship care plans because they have less access to high-quality health care, study researcher Rose C. Maly, MD, MSPH, family physician and geriatrician at UCLA Health and a member of UCLA Jonsson Cancer Center, said in a press release.

“Despite this, there has been little data collected from clinical trials to support the widespread adoption of treatment summaries and survivorship care plans and no standard protocol for their implementation,” she added.

Therefore, Maly and colleagues designed and evaluated an intervention specifically tailored to this patient population. The intervention included usual care coupled with a survivorship care nurse counseling session, a baseline interview at 1 month with practiced role play, and individualized treatment summaries and survivorship care plans from the patients’ health care providers.

“The intervention group may have been more likely to benefit from an improved understanding of the treatment summaries and survivorship care plans and better informed interaction with their physician,” Maly said.

The researchers recruited 212 low-income survivors (mean age, 53 years; 72.6% Latina) of stage 0 to III breast cancer.

In total, 107 survivors received the experimental intervention and 105 survivors received usual care.

Intervention effects on physician implementation and patient adherence to recommended survivorship care served as the primary endpoints.

Researchers reported higher mean physician implementation scores for the intervention group (60.8 ± 32.6; median, 66.7; interquartile range [IQR], 50-85.7) than the control group (48.6 ± 29.1; median, 50; IQR, 26.8-66.7; unadjusted P = .005). Further, mean patient adherence score also appeared greater for the intervention group (55.7 ± 29.2) compared with the control group (48.7 ± 26.8); however, this did not reach statistical significance.

Multiple linear regression demonstrated survivors in the intervention group reported greater physician implementation of recommended breast cancer survivorship care, for example, treatment of depression or hot flashes (adjusted difference, 16 ± 5.3; P = .003).

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Physicians implementation of recommended survivorship care improved when participants were more satisfied with care and information at baseline (coefficient, 5.22 ± 2.22; P = .02).

Patient adherence to recommended survivorship care was negatively associated with being married or partnered (-11.8 ± 4.04; P = .004) and older age (-0.52 ± 0.24; P = .028).

“The results are very exciting as they clearly demonstrate that the combination of a survivorship care plan with counseling can empower low-income women as they transition from breast cancer patient to breast cancer survivor,” study researcher Patricia Ganz, MD, director of prevention and control research at the UCLA Jonsson Comprehensive Cancer Center, said in a press release.

A subset analysis of the intervention group demonstrated a greater proportion of Latinas than non-Latinas followed recommended care (80.6% vs. 45.8%; P = .001). Further, a greater proportion of Latina patients agreed their care plan provided more information than their provider (96.0% vs. 72.0%; P = .002), provided new information they had not previously found on their own (97.3% vs. 68.0%; P = .001), and improved communication with their doctors (97.1% vs. 73.7%; P = .005).

“One of the most important findings of this study is that women should not be afraid to ask their doctor to pay attention to their chief concerns,” Maly said. “When women are empowered to better understand and talk about their survivorship needs, it is directly and positively related to physician implementation of their recommended care.”

The researchers noted future intervention designs should also focus more intently on quality of life.

“The UCLA researchers hope the study will lead to further investigation of whether these findings are unique to this vulnerable low-income population and their physicians, and if this type of intervention may have wider applicability to other cancer survivor types and settings,” Ganz said. “Future research may also examine the impact of interventions on the symptoms experienced by breast cancer survivors, as well as if the timing of interventions closer to the end of active treatment could result in greater benefit to patients.” – by Kristie L. Kahl

Disclosure: The researchers report no relevant financial disclosures.

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PERSPECTIVE
Magdolna Solti

Magdolna Solti

After a few negative results from previous studies, this is the first randomized controlled trial to show that survivorship counseling coupled with a tailored care plan improved adherence of treating oncologists to recommended survivorship care. The study population included medically high-need Latina breast cancer survivors. Instead of providing just a treatment summary, oncologists need to encourage patients to take ownership of caring for themselves and how to ask for help.

The new feature of this study compared with previous studies is that a trained research nurse provided the counseling. It also was conducted outside of the clinical setting, in a research clinic. Lastly, it included patient empowerment with the role-playing system.

This was the first study — but hopefully not the last where — we see survivorship care is addressed and followed through so we can encourage survivors to ask about these recommendations from their primary oncologists.


Magdolna Solti, MD
Compass Oncology, The US Oncology Network

 

Disclosure: Solti reports no relevant financial disclosures.