Providers’ Perspectives of Survivorship Care for Young Adult Survivors of Childhood Cancer

We examined healthcare providers’ perceptions of the goals of survivorship care and survivor programs, systems-level barriers and individual patient-level barriers to engaging patients in survivorship care, and potential resources for increasing engagement. In 2012, we recruited 21 healthcare providers of young adult survivors of childhood cancers from a children’s hospital and a cancer center in the Southeastern USA to complete telephone-based semi-structured interviews. The sample was 45.95 years old (SD?=?7.57) on average, 52.4 % female, and 81.0 % MDs. The major goals of survivorship programs identified were medical care management (e.g., addressing late and long-term effects, providing survivorship care plans (SCPs), assisting in transition of care) and holistic care including addressing psychosocial issues and promoting healthy lifestyles. Systems-level barriers to engagement in survivorship care included limited resources (e.g., time), role confusion (e.g., within cancer centers, from treatment team to survivorship care, role of primary care providers), communication challenges within the medical system (e.g., limited tracking of patients, lack of understanding of the role of survivorship clinic), communication challenges with patients (e.g., setting expectations regarding transition to survivorship care), and lack of insurance coverage. Perceived patient-level factors included psychological barriers (e.g., fear, avoidance), resistance to survivorship care, and physical barriers (e.g., distance from survivorship clinics). Resources to address these barriers included increased access to information, technology-based resources, and ensuring valuable services. There are several systems-level and patient-level barriers to survivorship care, thus requiring multilevel interventions to promote engagement in care among young adult survivors of childhood cancer.     

Cancer Survivors’ Reported Discussions with Health Care Providers About Follow-Up Care and Receipt of Written Care Plans

Prior studies reveal gaps in cancer survivors’ discussions with health care providers about follow-up care and receipt of care plans; however, whether survivorship care planning may vary by cancer type is not known. We surveyed 615 survivors of breast, colorectal, prostate, lung cancer, and melanoma enrolled in three health plans to examine cancer survivors’ self-reported discussions of follow-up care, including the need for surveillance, late and long-term effects, emotional needs, and health behaviors. We assessed whether cancer survivors received a written treatment summary and post-treatment care instructions. Most (92%) survivors reported having a discussion about the need for surveillance; 75%, late and long-term effects; 69%, lifestyle and health behaviors; and 53%, emotional and social needs. Most (88%) reported receiving post-treatment care instructions and 47%, a treatment summary. While there was little difference among survivors’ receipt of surveillance or health behavior recommendations by cancer type (p = 0.85 and p = 0.66, respectively), discussions of late and long-term effects occurred among 82% of prostate, 78% of breast, 73% of melanoma, 72% of colorectal, and 67% of lung survivors (p = 0.06). Approximately half of survivors reported discussions of emotional needs, with modest differences by cancer type (p = 0.08). Our findings indicate that most patient-provider discussions cover information on surveillance, with less emphasis on late and long-term effects, lifestyle and health behaviors, and substantially less focusing on emotional and social needs. No or modest differences in discussions occurred by cancer type. Whether tailoring information to individual cancer survivor needs is beneficial should be examined.     

Primary Care Physicians’ Perspectives in Leading Breast Cancer Follow-Up Care

IntroductionLimited data exist on the barriers associated with transitioning breast cancer follow-up care to primary care physicians (PCPs). This study aimed to describe the current perspectives of PCPs in managing breast cancer follow-up.MethodAn online survey was distributed to PCPs in Toronto, ON, Canada. Questions examined PCPs’ view of transitioning breast cancer follow-up care to their practices.ResultsOf 800 PCPs invited, 126 responded (response rate: 15.7%). The types of practice models amongst respondents included blended capitation (42.9%), blended salary (27%), and fee-for-service (17.5%). Seventy-seven percent of respondents stated they provided follow-up care. Approximately half of the respondents stated they were somewhat comfortable providing follow-up care. PCP-led follow-up care was considered either very (49.2%) or somewhat appropriate (30.2%). When asked about financial remuneration, 43.7% of respondents stated it was somewhat important. The factors that influenced the feasibility of PCP-led follow-up care included receipt of a detailed follow-up care plan provided by the specialist after discharge (81%), the ability to re-refer to specialists rapidly (56.3%), and the ability to obtain regular updates of best practice changes (59.5%). The preferred means of educational updates included E-mail (40.5%), continuing medical education events (30.2%), and electronic medical records (19.8%). When the fee model was taken into consideration there was no significant difference in opinions regarding follow-up care.ConclusionsTransitioning to a PCP-led model was supported by most of the PCPs who participated in this study. Their perspective on PCP-led follow up care and barriers associated with implementation of this model of care needs to be further explored with future studies that include larger sample size and a more diverse PCP population.     

The Relationship Between Cancer Survivors’ Socioeconomic Status and Reports of Follow-up Care Discussions with Providers

Socioeconomically disadvantaged cancer survivors are less likely to have adequate follow-up care. In this study, we examined whether socioeconomically disadvantaged survivors are at risk for not having follow-up care discussions with providers, a critical determinant of access to follow-up care and desirable health outcomes. Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, we used a binary logit model with sample weights to examine associations between 1320 cancer survivors’ socioeconomic status (SES) and reports of follow-up care discussions with providers, controlling for clinical and demographic characteristics. The multivariable model indicated survivors with incomes ≤200 % Federal Poverty Level (FPL) had a lower probability of reporting a follow-up care discussion than survivors with incomes >400 % FPL (p?<?0.05). Survivors with less than high school education had a lower probability of reporting a discussion than survivors who had a college education or greater (p?<?0.05). However, even after controlling for income, survivors with financial hardship had a greater probability of reporting a discussion than survivors with no financial hardship (p?<?0.05). Insurance status was not a significant predictor of reporting a discussion (p?>?0.05). Socioeconomically disadvantaged cancer survivors are at risk for not having follow-up care discussions with providers, particularly those who report lower income and education. The development of educational interventions targeting provider communication with socioeconomically disadvantaged cancer survivors, and survivors’ understanding of the benefits of follow-up care discussions, may promote access to these services. Future research assessing mechanisms underlying relationships between survivors’ SES indicators and reports of follow-up care discussions with providers is also warranted.     

Primary Care Physicians’ Cancer Screening RecommendationPractices and Perceptions of Cancer Risk of Asian Americans

Asian Americans experience disproportionate incidence and mortality rates of certain cancers, compared toother racial/ethnic groups. Primary care physicians are a critical source for cancer screening recommendationsand play a significant role in increasing cancer screening of their patients. This study assessed primary carephysicians’ perceptions of cancer risk in Asians and screening recommendation practices. Primary care physicianspracticing in New Jersey and New York City (n=100) completed a 30-question survey on medical practicecharacteristics, Asian patient communication, cancer screening guidelines, and Asian cancer risk. Liver cancerand stomach cancer were perceived as higher cancer risks among Asian Americans than among the generalpopulation, and breast and prostate cancer were perceived as lower risks. Physicians are integral public healthliaisons who can be both influential and resourceful toward educating Asian Americans about specific cancerawareness and screening information.     

Breast Cancer Survivors’ Efforts to Renew and Preserve Their Health in Taiwan

Aims: This study was designed to describe the personal life experiences of breast cancer survivors regardingtheir efforts to recover and preserve their health in Taiwan. Method: The study utilized a qualitative researchmethod, wherein purposive sampling, one-on-one, face-to-face, in-depth semi-structured interviews wereconducted. The data were then analyzed using content analysis. Data were saturated after interviewing 15cancer survivors. Results: Three common themes emerged: introspection on the cause of the cancer, realizationof a harmonized lifestyle, and reflecting on the strong will to survive. Conclusions: These findings are helpfulin understanding the relationship between breast cancer survival and individual efforts to restore and preservehealth.     

Care of Seniors with Breast Cancer – Treatment Received and Refining Decision Making

AimsTreatment decisions for older patients with breast cancer are complex and evidence is largely extrapolated from younger populations. Frailty and comorbidity need to be considered. We studied the baseline characteristics and treatment decisions in older patients in Christchurch with breast cancer and assessed survival outcomes and prognostic/discriminatory performance of several tools.Materials and methodsWe searched the Canterbury Breast Cancer Registry and identified patients aged 70 years or older at diagnosis with invasive, non-metastatic breast cancer between 1 June 2009 and 30 June 2015. We retrieved demographics, treatment and outcome information. Overall survival and breast cancer-specific survival were estimated. Tools analysing performance status and comorbidity were assessed for their prognostic and discriminatory power.ResultsIn total, 440 patients were identified. Primary surgery was carried out for 362 patients (82.3%): breast-conserving surgery in 114 (of whom 88.6% received radiation therapy); mastectomy in 248 (of whom 24.6% received radiation). Hormone therapy was given for 265 (71.1%) patients with oestrogen receptor-positive cancers. Two hundred and seventy-four (62.3%) patients received full standard treatment, which was associated with significantly improved 5-year survival and 5-year breast cancer-specific survival. The median estimated overall survival was 8.2 years (95% confidence interval 7.3–9.1 years). Of those who died, 71.3% of deaths were due to causes other than breast cancer or unknown causes. The comorbidity-adjusted life expectancy (CALE) showed partial prognostic accuracy. CALE, Charlson and Eastern Cooperative Oncology Group tools all showed discriminatory value.ConclusionIn this population-based series of older patients with breast cancer, showing high levels of primary and adjuvant treatment, patients were more likely to die of causes other than breast cancer. Performance status and comorbidity tools showed prognostic and discriminatory potential in this population supporting their use in treatment decision making. CALE showed the most potential to improve treatment decisions but requires validation in this population to improve prognostic accuracy.     

Diagnosis and Treatment Experience of 14 Cases of Breast Cancer Associated with Pregnancy or Lactation

Objective： To explore the diagnosis and treatment experience of breast cancer associated with pregnancy or lactation. Methods： From January 1990 to December 2005, 14 cases with breast cancer associated with pregnancy or lactation were analyzed retrospectively （TNM stage Ⅱ, 2 cases; stage Ⅲ, 11 cases; stage Ⅳ, 1 case）. Diagnosis was established by fine needle aspiration biopsy primarily or routine pathological method if necessary. Abortion was used for discontinuation of pregnancy in 1 case with early pregnancy and 1 case with meddle pregnancy. 2 patients with late pregnancy received cesarean section, 10patients of breast cancer associated with lactation received multidisciplinary and-tumor treatment after discontinuation of lactation. Results： Diagnosis was confirmed by fine noodle aspiration biopsy in 9 cases and by secondary routine pathological method in the other 5 cases, 12 cases were followed up, 1 case of stage Ⅳ died of metastasis 5 months after diagnosis. 3-, 5-year survival rates in 10 cases of stage Ⅲ were 66% and 30% respectively. One case remained alive without recurrence for 8 years up to now. Conclusion： A thorough breast examination is necessary at the first antenatal visit physicians should aggressively pursue work-up in women with a palpable breast tass. In the patients during the second and third trimness, the various modalities available for treatment inholding abortion and their risks and beneath modalities available for treatment including abortion and their risks and benefits must be discussed openly with patients and their families.     

Beyond Teenage and Young Adult Cancer Care: Care Experiences of Patients Aged 25–39 Years Old in the UK National Health Service

AimsAdolescents and young adults aged 15–39 years with cancer face unique medical, practical and psychosocial issues. In the UK, principal treatment centres and programmes have been designed to care for teenage and young adult patients aged 13–24 years in an age-appropriate manner. However, for young adults (YAs) aged 25–39 years with cancer, little access to age-specific support is available. The aim of this study was to examine this possible gap by qualitatively exploring YA care experiences, involving patients as research partners in the analysis to ensure robust results.Materials and methodsWe conducted a phenomenological qualitative study with YAs diagnosed with any cancer type between ages 25 and 39 years old in the last 5 years. Participants took part in interviews or focus groups and data were analysed using inductive thematic analysis. Results were shaped in an iterative process with the initial coders and four YA patients who did not participate in the study to improve the rigor of the results.ResultsSixty-five YAs with a range of tumour types participated. We identified seven themes and 13 subthemes. YAs found navigating the healthcare system difficult and commonly experienced prolonged diagnostic pathways. Participants felt under-informed about clinical details and the long-term implications of side-effects on daily life. YAs found online resources overwhelming but also a source of information and treatment support. Some patients regretted not discussing fertility before cancer treatment or felt uninformed or rushed when making fertility preservation decisions. A lack of age-tailored content or age-specific groups deterred YAs from accessing psychological support and rehabilitation services.ConclusionsYAs with cancer may miss some benefits provided to teenagers and young adults in age-tailored cancer services. Improving services for YAs in adult settings should focus on provision of age-specific information and access to existing relevant support.     

Adult Non Hodgkin’s Lymphoma Patients: Experience from a Tertiary Care Cancer Centre in North East India

There is paucity of data on non Hodgkin’s lymphoma (NHL) from our population in North-East India. Inthis retrospective study, patients were consecutively followed-up to see the clinic-pathological pattern of NHL,various responses, and pattern of relapses to first line treatment with chemotherapy. All patients in the presentstudy received standard regimen of cyclophosphamde, doxorubicin, vincristine, prednisolone (CHOP) with orwithout rituximab (R-CHOP) as per our institutional protocol as first line therapy. Our study has shown that,in our adult population, the majority of NHL cases present with stage II and stage III disease and extra nodalinvolvement, B-cell lymphomas and diffuse large cell lymphomas being the most common subtypes. Internationalprognostic index was a significant factor for varied responses to treatment. The majority of relapses after completeremission occurred in the first year.     

Influence of Patient’s Perceptions,Beliefs and Knowledge about Cancer on Treatment Decision Making in Pakistan

Introduction: Cancer is a cause of major disease burden across the world and Pakistani data suggest that itsincidence is increasing. Pakistan’s socio-cultural history, social practices, religious beliefs and family systemsdiffer in many ways from rest of the world. These factors make the practice of oncology a challenge. Materialsand Methods: A comprehensive questionnaire focusing on socio-cultural and religious aspects was administeredto patients with a diagnosis of cancer and receiving chemotherapy at the Aga Khan University Hospital, Karachi,Pakistan. Results: A total of 230 patients agreed to answer the questionnaire, with a mean age of 46 years and63% were females. Obtaining some formal education was claimed by 87%, 75.2% had received some treatmentbefore seeing an oncologist, including homeopathic physicians and faith healers. Of all 27 % thought that canceris contagious, a fact observed more so in those who were illiterate, 27 % believed in some myth such as past sins,evil eye or God’s curse as to be cause of their cancer, while 39.6% thought that cancer can be prevented by aregular religious activity. Some 30% thought that a meaningful life after diagnosis of cancer was not possibleand 28%considered that they did not have proper information about chemotherapy. About 73% wanted to havetheir treatment related decision made by the treating physician. Conclusions: Patient related beliefs in mythsand concerns are unique in the socio-cultural set up of Pakistan. If physicians are better aware of these factors,they may be able to handle patient related issues in a more effective way.     

Oncologists’ Confidence in Knowledge of Fertility Issues for Young Women with Cancer

We sought to identify factors associated with greater cancer-related fertility knowledge in a national survey of oncologists. We surveyed 344 oncologists from a sampling pool drawn randomly from the AMA Masterfile. We conducted multiple linear regression to determine the relationship between confidence in knowledge and oncologists' characteristics. Respondents' average age was 48.5, and 75.3% were male. The average confidence in knowledge summary score was 23.8 (SD 6.4, range 8-40). In multivariable regression, confidence was higher among oncologists with more information resources, a sense of responsibility to discuss fertility issues and among gynecologic oncologists vs. other oncology specialties. Physician age, gender, and practice setting were not associated with fertility-related knowledge. Oncologists lack confidence in their knowledge of fertility issues in young women with breast cancer. Increasing professional responsibility to discuss fertility and greater information access could improve the depth and breadth of education regarding fertility issues among oncologists and their young patients.     

Stacked Stigma: Oncology Social Workers’ Perceptions of the Lung Cancer Experience

This study explores stigma in the lung cancer experience by interviewing 18 oncology social workers employed at cancer centers across the United States who provide care to people diagnosed with lung cancer and their family members. A content analysis of the interviews suggests stacked stigma exists with respect to cigarette smoking. Poor prognosis and disparity in advocacy efforts emerged as stigmatizing events that are linked with smoking stigma, particularly in the arenas of support groups, patient-matching programs, availability of resources, and the lung cancer population itself. Emotional phenomenon resulting from this stigma experience may increase the illness burden for people with lung cancer and explain the variance in distress levels among people with different cancer diagnoses.     

Population-Level Trends in Posttreatment Cancer Survivors’ Concerns and Associated Receipt of Care: Results from the 2006 and 2010 LIVESTRONG Surveys

There is a need to better understand the posttreatment concerns of the nearly 14 million survivors of cancer alive in the United States today and their receipt of care. Using data from 2,910 posttreatment survivors of cancer from the 2006 or 2010 LIVESTRONG Surveys, the authors examined physical, emotional, and practical concerns, receipt of care, and trends in these outcomes at the population level. Results: 89% of respondents reported at least one physical concern (67% received associated posttreatment care), 90% reported at least one emotional concern (47% received care), and 45% reported at least one practical concern (36% received care). Female survivors, younger survivors, those who received more intensive treatment, and survivors without health insurance often reported a higher burden of posttreatment concerns though were less likely to have received posttreatment care. These results reinforce the importance of posttreatment survivorship and underscore the need for continued progress in meeting the needs of this population. Efforts to increase the availability of survivorship care are extremely important to improve the chances of people affected by cancer living as well as possible in the posttreatment period.     

Health Services Research and Regionalization of Care—From Policy to Practice: the Ontario Experience in Head and Neck Cancer

Patients being treated at higher case volume hospitals or by higher case volume physicians appear to have better outcomes. This volume–outcome relationship is reviewed for oncologic and non-oncologic surgery with a focus on head and neck oncology. The impact of these research findings on health policy and health-care organization in Ontario, Canada, is then outlined. Lastly, future directions for quality improvement in surgical oncology are reviewed in the context of a universal health-care system. These include surgeon report cards, pre-operative checklists, linking funding and remuneration to the quality of delivered care, and the use of process improvement techniques.     

Prediction of Response to Multimodality Treatment in Esophageal Cancer

Patients with locally advanced esophageal cancer have a dismal prognosis when treated exclu-sively by surgery.This fact prompted many investigators to apply neoadjuvant treatment strategies in aneffort to improve survival.Results from phase Ⅲ randomized trials are encouraging however,they revealedthat only patients with major histopathological response will benefit from treatment.Therefore,predic-tive molecular markers indicating response or non-response to neoadjuvant treatment would be extremelyhelpful in selecting patients for current and future treatment protocols.In this paper we review the roleof the molecular markers ERCC1 (excision repair cross-complementing 1 gene) and c-erbB-2 (synonym:HER2/neu) in predicting response to radiochemotherapy and outcome for patients with locally advancedresectable esophageal cancers (cT2-4,Nx,M0).The results are promising and it appears that we mightexpect to unequivocally identify with ERCC1 and c-erbB-2 respectively,approximately up to one third ofpatients who fulfil the criteria for neoadjuvant treatment for locally advanced esophageal cancer but willnot benefit from our treatment protocol.Integration of such markers in the clinical setting might prevent asubstantial number of patients from expensive,non-effective and potentially harmful therapies,and couldlead to a more individualized type of combined multimodality treatment in the near future.