Health care for childhood cancer survivors: insights and perspectives from a Delphi panel of young adult survivors of childhood cancer.

BACKGROUND: Most children diagnosed with cancer are surviving into adulthood but are not receiving adequate or appropriate follow-up health care. However, to the authors' knowledge, there is little literature published to date exploring potential barriers to long-term risk-based follow-up care for young adult survivors of childhood cancer. METHODS: In the current study, using a modified Delphi technique, young adult cancer survivors identified barriers to utilizing appropriate follow-up care and offered suggestions for ways to enhance health care in this young adult population. RESULTS: Major barriers to health care were found to be a lack of knowledge on the part of both physicians and survivors regarding long-term health issues related to cancer. Suggestions to enhance care included self-advocacy training for survivors and advanced training for primary care physicians who may treat childhood cancer survivors as they transition into adulthood. CONCLUSIONS: The results of the current study are consistent with reports that young adult survivors of childhood cancer need or desire information regarding their medical histories, psychosocial support, and social advocacy.     

Colorectal Cancer Screening Practices of Primary Care Providers: Results of a National Survey in Malaysia

The incidence of colorectal cancer has been increasing in many Asian countries including Malaysia duringthe past few decades. A physician recommendation has been shown to be a major factor that motivates patientsto undergo screening. The present study objectives were to describe the practice of colorectal cancer screeningby primary care providers in Malaysia and to determine the barriers for not following recommendations. Inthis cross sectional study involving 132 primary care providers from 44 Primary Care clinics in West Malaysia,self-administered questionnaires which consisted of demographic data, qualification, background on the primarycare clinic, practices on colorectal cancer screening and barriers to colorectal cancer screening were distributed.A total of 116 primary care providers responded making a response rate of 87.9%. About 21% recommendedfaecal occult blood test (FOBT) in more than 50% of their patients who were eligible. The most common barrierwas “unavailability of the test”. The two most common patient factors are “patient in a hurry” and “poor patientawareness”. This study indicates that colorectal cancer preventive activities among primary care providers arestill poor in Malaysia. This may be related to the low availability of the test in the primary care setting and poorawareness and understanding of the importance of colorectal cancer screening among patients. More awarenessprogrammes are required for the public. In addition, primary care providers should be kept abreast with thelatest recommendations and policy makers need to improve colorectal cancer screening services in health clinics.     

Equitable access to cancer services: A review of barriers to quality care

BACKGROUND: Barriers to cancer care have been documented in nearly all settings and populations; such barriers represent potentially avoidable morbidity or mortality. A conceptual framework was used to describe patient, provider, and system barriers to cancer services. METHODS: A review of the English language literature on cancer care from 1980-1998 was conducted; key research was summarized for each domain in the conceptual model. RESULTS: Key patient barriers are related to old age, minority race, and low socioeconomic class; the common pathways by which these sociodemographic factors appear to mediate cancer outcomes include social class and race-related or class-related attitudes. Providers are often ill-prepared to communicate the complexities of cancer care to their diverse patient populations; constraints of the medical care system also can impede the delivery of care. To the authors' knowledge the impact of the rapid growth in managed care organizations (MCOs) on access to care has yet to be evaluated fully. Although MCOs historically have provided high levels of cancer screening in healthy populations, to the authors' knowledge there are fewer data regarding outcomes for elderly and poor populations and for treatment services. CONCLUSIONS: Additional research is needed to develop and test interventions to overcome barriers to care and evaluate the impact of the growth of managed care on access to cancer care for diverse populations.     

The current status of early detection and screening for colorectal cancer

There are several approaches to the early detection of colorectal cancer that currently are in use in various segments of the health care system. Herein, the status of cancer control research regarding symptom and risk factor assessment, sigmoidoscopy and colonoscopy, double contrast barium enema, and fecal occult blood testing is reviewed. In addition to the different technologies of early cancer detection, there are different models of disease control intervention. These include the routine clinical activities of primary care providers as well as programmatic screening of mass populations. The currently available techniques for early colorectal cancer detection appear better suited for existing patient care settings than for programs outside the direct supervision and follow-up of the health professional.     

Using navigators to improve care of underserved patients: current practices and approaches

BACKGROUND: Logistic, cultural, educational, and other barriers can impede the delivery of high-quality cancer care to underserved patients. Patient navigation services represent one innovation for addressing perceived barriers to care encountered by disadvantaged patients. In this report, the authors have 1) defined patient navigation, distinguishing it from other cancer support services; 2) described how programs are organized; and 3) discussed the need for research on program effectiveness. METHODS: Information was examined on navigation programs published in the scientific literature and on line. Qualitative research also was conducted, consisting of direct observation of patient care in cancer clinics with and without navigators in northern California, in-person interviews with personnel and patients in the clinics observed, and telephone interviews with navigators at four sites across the United States. RESULTS: The authors found that navigation services have been implemented at all stages of cancer care: prevention, screening, treatment, and survival. Navigators differ from other cancer support personnel in their orientation toward flexible problem solving to overcome perceived barriers to care rather than the provision of a predefined set of services. There are no rigorous demonstrations of the effects and effectiveness of navigation, although such studies are underway. CONCLUSIONS: Currently, patient navigation is understudied, and literature documenting its effects and effectiveness is scant. Rigorous studies are needed of the navigator role and program costs and benefits. Such studies will facilitate an assessment of program effectiveness, feasibility across a range of health care settings, and performance relative to alternative approaches for addressing barriers to care among the underserved.     

Basic geriatric principles for colorectal surgeons: How to optimize assessment and care of older patients in the perioperative period

BackgroundThe majority of patients with colorectal cancer are older. For surgeons dealing with older patients, it is important to recognize patients that are frail and have an increased risk of complications and mortality. In this review, we will go through pre-treatment assessment, peri-operative management, as well as discharge planning and rehabilitation.MethodsThis review is based on searching the literature for studies regarding colorectal cancer, frailty, cognition, patient preferences and geriatric assessment as well as the academic and clinical experience of the authors.ResultsIn the pre-treatment assessment, surgeons need to consider capacity to consent, patient preferences, frailty and life-expectancy, risk of complications, and whether the patient can be optimized before surgery. Then, the patient and treatment options should be discussed at a multidisciplinary team meeting. When the patient is admitted for surgery, discharge planning should start immediately, and if complications such as delirium or falls occur, the patient should be co-managed with geriatric services.ConclusionFrail older adults with colorectal cancer need a tailored approach from pre-treatment assessment until discharge after surgery, and co-management with a geriatrician is recommended. If this is not possible, surgeons treating frail older patients may improve care by adapting some geriatric principles.     

The effect of medicare health care delivery systems on survival for patients with breast and colorectal cancer.

BACKGROUND: Two of the most common types of health care delivery systems in the U.S. are fee-for-service (FFS) and managed care systems such as health maintenance organizations (HMO). Differences may exist in patient outcomes depending on the health care delivery system in which they are enrolled. We evaluated differences in the survival of patients with breast and colorectal cancer at diagnosis between the two Medicare health care delivery systems (FFS and HMO). METHODS: We used a linkage of two national databases, the Medicare database from the Centers for Medicare and Medicaid Services, and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database, to evaluate differences in demographic data, stage at diagnosis, and survival between breast and colorectal cancer over the period 1985 to 2001. RESULTS: Medicare patients enrolled in HMOs were diagnosed at an earlier stage of diagnosis than FFS patients. HMO patients diagnosed with breast and colorectal cancer had improved survival, and these differences remained even after controlling for potential confounders (such as stage at diagnosis, age, race, socioeconomic status, and marital status). Specifically, patients enrolled in HMOs had 9% greater survival in hazards ratio if they had breast cancer, and 6% if they had colorectal cancer. CONCLUSIONS: Differences exist in survival among patients in HMOs compared with FFS. This is likely due to a combination of factors, including but not limited to, earlier stage at the time of diagnoses.     

Does access to a colorectal cancer screening website and/or a nurse-managed telephone help line provided to patients by their family physician increase fecal occult blood test uptake?: A pragmatic cluster randomized controlled trial study protocol

ABSTRACT: BACKGROUND: Fecal occult blood test screening in Canada is sub-optimal. Family physicians play a central role in screening are limited by the time constraints of clinical practice. Patients face multiple barriers that further reduce completion rates. Tools that support family physicians in providing their patients with colorectal cancer information and that support uptake may prove useful. The primary objective of the study is to evaluate the efficacy of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website) distributed by community-based family physicians, in improving colorectal cancer screening rates. Secondary objectives include evaluation of (dis)incentives to patient FOBT uptake and internet use among for health-related questions. Challenges faced by family physicians in engaging in collaborative partnerships with primary healthcare researchers will be documented. METHODS: A pragmatic, two-arm, randomized cluster controlled trial conducted in 22 community-based family practice clinics (36 clusters) with 76 fee-for-service family physicians in Winnipeg, Manitoba, Canada. Each physician will enroll 30 patients attending their periodic health examination and at average risk for colorectal cancer. All physicians will follow their standard clinical practice for screening. Intervention group physicians will provide a fridge magnet to each patient that contains information facilitating access to the study-specific colorectal cancer screening decision aids (telephone help-line and website). The primary endpoint is patient Fecal occult blood test completion rate after four months (intention to treat model). Multi-level analysis will include clinic, physician and patient level variables. Patient Personal Health Identification Numbers will be collected from those providing consent to facilitate analysis of repeat screening behavior. Secondary outcome data will be obtained through the Clinic Characterization Form, Patient Tracking Form, In-Clinic Patient Survey, Post-Study Follow-Up Patient Survey, and Family Physician Survey. Study protocol approved by The University of Manitoba Health Research Ethics Board. DISCUSSION: The study intervention has the potential to increase patient fecal occult blood test uptake, decrease colorectal cancer mortality and morbidity, and improve the health of Manitobans. If utilization of the website and/or telephone support line result in clinically significant increases in colorectal cancer screening uptake, changes in screening at the policy- and system-level may be warranted. Trial Registration: clinicaltrials.gov identifier NCT01026753.     

Patterns and predictors of colorectal cancer test use in the adult U.S. population

BACKGROUND: Screening is effective in reducing the incidence and mortality of colorectal cancer. Rates of colorectal cancer test use continue to be low. METHODS: The authors analyzed data from the National Health Interview Survey concerning the use of the home-administered fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy/proctoscopy to estimate current rates of colorectal cancer test use and to identify factors associated with the use or nonuse of tests. RESULTS: In 2000, 17.1% of respondents reported undergoing a home FOBT within the past year, 33.9% reported undergoing an endoscopy within the previous 10 years, and 42.5% reported undergoing either test within the recommended time intervals. The use of colorectal cancer tests varied by gender, race, ethnicity, age, education, income, health care coverage, and having a usual source of care. Having seen a physician within the past year had the strongest association with test use. Lack of awareness and lack of physician recommendation were the most commonly reported barriers to undergoing such tests. CONCLUSIONS: Less than half of the U.S. population age >/= 50 years underwent colorectal cancer tests within the recommended time intervals. Educational initiatives for patients and providers regarding the importance of colorectal cancer screening, efforts to reduce disparities in test use, and ensuring that all persons have access to routine primary care may help increase screening rates.     

Treatment choices in advanced cancer: issues and perspectives

Treatment choices are difficult in advanced cancer, a disease in which there is little chance of a cure and in which the aim of treatment is usually to achieve palliation. With the clinical evidence and quality-of-life instruments currently available, it may be difficult to decide whether the burdens of cytotoxic chemotherapy are outweighed by its benefits. However, in some cancers, such as advanced colorectal cancer, there is evidence to demonstrate that chemotherapy is justified, with overall benefit to the patient. There are, nevertheless, many factors to be considered in the selection of the best possible care for each patient. These include the availability of new treatments with improved tolerability profiles, resource implications, quality of life and survival benefits (and how to assess them), the willingness or otherwise of patients to undergo chemotherapy, and information and participation preferences among patients. The differing attitudes of health care professionals and groups of patients add to the complexity of this issue. Guidelines offer one way of promoting the consistent and optimal management of patients with advanced cancer; however, individual patient choice will always take precedence over guidelines which, by definition, are devised with common needs in mind.     

Barriers and Challenges of Cancer Patients and Their Experience with Patient Navigators in the Rural US/Mexico Border Region

Patient navigation is a widely used approach to minimize health disparities among socioeconomically marginalized cancer patients. Although patient navigation is widely used, there is a dearth of studies exploring patient experience with navigators among rural cancer patients. This qualitative study explores the challenges and barriers to cancer care faced by cancer patients living in a US/Mexico border region in Southern California. We individually interviewed 22 cancer patients, most of whom were Latino. Data were analyzed using constant comparison with a reiterative analysis method. The main themes relating to barriers to care and experiences with patient navigators include the following: (1) removing financial barriers, (2) coordinating services, and (3) providing therapeutic interventions. The cancer patients highly valued the navigators for their knowledge about community resources, support, and advocacy. This study suggests that it is imperative that navigators know the regional and binational health care utilization issues that impact patients’ access to cancer care.     

Synchronous resection of colorectal primary and hepatic metastasis

Up to 50% of the over 140,000 new colorectal cancer patients will present with synchronous colorectal cancer and liver metastasis. Surgical management of patients with resectable synchronous colorectal hepatic metastasis is complex and must consider multiple factors, including the presence of symptoms, location of primary tumor and liver metastases, extent of tumor (both primary and metastatic), patient performance status, and underlying comorbidities. Possible approaches to this select group of patients have included a synchronous resection of the colorectal primary and the hepatic metastases or a staged resection approach. The available literature regarding the safety of synchronous versus staged approaches confirms that a simultaneous resection may be performed in selected patients with acceptable morbidity and mortality. Perioperative mortality when minor hepatectomies are combined with colorectal resection is consistently ≤5%. Perioperative morbidity varies considerably following both synchronous and staged resections. However, the bulk of the existing literature confirms that simultaneous resections are both feasible and safe when hepatic resections are limited to <3 segments. Data regarding the oncologic outcomes following synchronous versus staged resections for Stage IV colorectal cancer are more limited than those available regarding postoperative morbidity and mortality. The available data suggest equivalent overall and disease-free survival regardless of timing of resection. Experience with minimally invasive combined colorectal and hepatic resections is extremely limited to date and consists exclusively of small single center series. The potential benefits of a minimally invasive approach will await the results of larger studies.Key Words: Colorectal cancer, colorectal liver metastases, synchronous resection     

Metastases of colorectal cancer to the liver and peritoneum: comparison of surgical paradigms

The treatment of metastatic colorectal cancer is evolving. Although the advent of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients, surgical resection in certain subsets of patients with advanced colorectal cancer is the only chance for long-term survival. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. Since hepatic metastases are the most common, there is a tremendous amount of data on the efficacy of this approach and the clinical outcomes. However, more recently, another metastatic site in colorectal cancer has received attention as a potential organ system that can be completely extirpated with improved clinical outcomes. This is the peritoneum, and tumor lesions at this site are referred to as peritoneal surface disease. Macroscopically complete cytoreductive surgery in combination with intraperitoneal hyperthermic chemotherapy for peritoneal surface disease has been demonstrated to produce survival outcomes equal to liver resection for hepatic metastases. This review will examine recent evidence regarding these two surgical oncology paradigms and compare patient populations, clinical outcomes and future challenges.     

Metastases of colorectal cancer to the liver and peritoneum: comparison of surgical paradigms

The treatment of metastatic colorectal cancer is evolving. Although the advent of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients, surgical resection in certain subsets of patients with advanced colorectal cancer is the only chance for long-term survival. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. Since hepatic metastases are the most common, there is a tremendous amount of data on the efficacy of this approach and the clinical outcomes. However, more recently, another metastatic site in colorectal cancer has received attention as a potential organ system that can be completely extirpated with improved clinical outcomes. This is the peritoneum, and tumor lesions at this site are referred to as peritoneal surface disease. Macroscopically complete cytoreductive surgery in combination with intraperitoneal hyperthermic chemotherapy for peritoneal surface disease has been demonstrated to produce survival outcomes equal to liver resection for hepatic metastases. This review will examine recent evidence regarding these two surgical oncology paradigms and compare patient populations, clinical outcomes and future challenges.     

Colorectal cancer screening and treatment: review of outcomes research

BACKGROUND: Colorectal cancer is the second leading cause of cancer deaths in the United States each year. Screening is effective in reducing colorectal cancer mortality; however, compliance with screening is poor, and factors associated with its compliance are poorly understood. The outcomes of treatment of colorectal cancer (surgery, radiation therapy, and chemotherapy) may have profound effects on quality of life (QOL). Furthermore, colorectal cancer screening and treatment may be expensive, and the costs are important from a policy perspective. This review examines patient-centered outcomes research related to colorectal cancer screening and treatment and outlines the work that has been done in several areas, including patient preferences, QOL, and economic analysis. METHODS: The literature on the health outcomes associated with colorectal cancer screening and treatment was reviewed. A MEDLINE search of English language articles published from January 1, 1990 through February 2001, was conducted and was supplemented by a review of references of obtained articles. Criteria for study inclusion were identified a priori. A standardized data abstraction form was developed. Summary statistical analyses were performed on the results. RESULTS: Six hundred eighty-six articles were selected for review. In total, 530 articles were excluded because they either did not include patient-centered outcomes, were duplicate articles, or could not be obtained. There were 156 articles included in the analysis; 67 addressed screening, 18 examined surveillance of high-risk groups, 22 concerned treatment of local disease, 10 examined treatment of local and metastatic disease, and 19 considered treatment of metastatic disease only. One study examined end-of-life care. In 19 studies, the phase of care was unspecified. CONCLUSIONS: Standardized, disease-specific QOL instruments should be applied in clinical trials so that the results may be compared across different types of interventions. Valid and reliable methods that accurately capture patient preferences regarding screening and treatment should be developed.     

Prognostic and Predictive Markers in Colorectal Cancer

Prognostic and predictive biomarkers have revolutionized medicine by allowing individualized treatment decisions. Most notably in oncology, where treatment can be associated with significant toxicities and often unpredictable outcomes, there is a need to isolate patients that are likely to benefit from an intervention. In colorectal cancer, there are many markers being investigated but only a few that have sufficient evidence to warrant use in clinical practice. This paper will review these prominent biomarkers in both adjuvant and metastatic colorectal cancer and summarize the data regarding their utility. The markers reviewed include microsatellite instability, 18qLOH, gene profile assays such as ColoPrint and Oncotype DX, Kras, Braf, thymidylate synthase, and circulating tumor cells. The paper will also discuss optimal clinical trial design, with a focus on different validation strategies for emerging biomarkers. By highlighting the pertinent literature, the hope is to facilitate a personalized approach to colorectal cancer care.     

A case of fatal cetuximab-induced interstitial lung disease during the first weeks of treatment

Cetuximab is a monoclonal antibody targeting the epidermal growth factor receptor. It has demonstrated activity against a number of cancers including lung, head and neck, and colorectal. The most common side effects associated with this agent are dermatological; however, other types of toxicities have been reported with varying frequencies. Here, we report a case of interstitial lung disease that developed within the first 4 weeks of cetuximab treatment initiation in a patient with metastatic colorectal cancer and led to patient death. Early fatal pulmonary events secondary to cetuximab is rarely reported in the literature; this case report highlights the importance of awareness among treating health care professionals of this potentially fatal toxicity.     

Examining stools for colon cancer prevention: what are we really looking for?

Fecal immunochemical testing (FIT) is superior to guiac-based testing if we are looking for blood in stools, as it has better one-time colorectal cancer sensitivity and specificity and better patient acceptance. In this issue of the journal, Cai and colleagues (beginning on page 1572) and Khalid-de Bakker and colleagues (beginning on page 1563) present new information about the one-time test performance of FIT. FIT will have a growing appeal to providers and health care systems as resources for clinical preventive services shrink and as incentives to expand colorectal screening rates increase, but there are good reasons to be cautious about the temptation to organize new FIT screening programs. Colorectal screening has two potential objectives: To find cancers in an earlier, more-treatable stage and to find and remove adenomas to prevent cancers from forming in the first place. Because most adenomas, even advanced adenomas, do not bleed, tests designed to identify occult blood in the stool are better for detecting colorectal cancer, whereas direct endoscopic visualization of the colorectum is better for prevention. Even if advanced adenomas did commonly bleed, low compliance with repeat annual testing will seriously erode the benefit of FIT.     

Patient navigation: State of the art or is it science?

First implemented in 1990, patient navigation interventions are emerging today as an approach to reduce cancer disparities. However, there is lack of consensus about how patient navigation is defined, what patient navigators do, and what their qualifications should be. Little is known about the efficacy and cost-effectiveness of patient navigation. For this review, the authors conducted a qualitative synthesis of published literature on cancer patient navigation. By using the keywords 'navigator' or 'navigation' and 'cancer,' 45 articles were identified in the PubMed database and from reference searches that were published or in press through October 2007. Sixteen studies provided data on the efficacy of navigation in improving timeliness and receipt of cancer screening, diagnostic follow-up care, and treatment. Patient navigation services were defined and differentiated from other outreach services. Overall, there was evidence of some degree of efficacy for patient navigation in increasing participation in cancer screening and adherence to diagnostic follow-up care after the detection of an abnormality. The reported increases in screening ranged from 10.8% to 17.1%, and increases in adherence to diagnostic follow-up care ranged from 21% to 29.2% compared with control patients. There was less evidence regarding the efficacy of patient navigation in reducing either late-stage cancer diagnosis or delays in the initiation of cancer treatment or improving outcomes during cancer survivorship. There were methodological limitations in most studies, such as a lack of control groups, small sample sizes, and contamination with other interventions. Although cancer-related patient navigation interventions are being adopted increasingly across the United States and Canada, further research will be necessary to evaluate their efficacy and cost-effectiveness in improving cancer care.