Survivorship Care Plans.ppt

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					Follow up and survivorship issues
after treatment for breast cancer
Michael Jefford

Clinical Consultant, Cancer Council Victoria
Consultant Medical Oncologist, Peter MacCallum Cancer Centre
Associate Professor of Medicine, University of Melbourne
Key points

   There are a large number of breast
    cancer survivors – high incidence x high
    survival rates
   Current focus of follow up / surveillance
    is (largely) on detection of cancer
   Women with a prior experience of breast
    cancer have much broader survivorship
Key points

   Women should be informed of ways to
    maintain their health and wellness
    – Survivorship care plan
    – Advice and coaching regarding healthy
   Alternative models of care (rather than
    led by medical specialists) should be
Useful resources
Cancer Council resources

 Cancer Council Helpline
  13 11 20, and database
 DVD and booklet
 Regional seminars
 Survivors Cancer
 Support groups – face to
  face, telephone, internet
Breast cancer
is the third
most common
cancer in
(excluding non
melanoma skin cancers)
1, 5 and 10
year survival
from breast
cancer is high
5 year survival
Survival rates are improving
3rd highest
cause of
cancer death
(after lung,
number of
survivors are
breast cancer
Available as a PDF from the Cancer Council website –
Breast cancer – incidence and
mortality trends (Victoria)

    Canstat: Cancer in Victoria 2006. The Cancer Council Victoria Epidemiology Centre 2009
Potential issues after completing
treatments for (breast) cancer
 Varied reactions to    Late and long-term
  finishing treatment     effects of treatment
                           – menopausal
 Fear of recurrence         symptoms, loss of
                             fertility, osteoporosis,
 Ongoing treatment          cognitive disturbance,
  side effects               weight changes,
                             altered body image,
 Relationship issues        sexual problems,
                             fatigue, heart
 Work / financial           problems, risk of
  issues                     second cancers

 Impact on family       Distress, anxiety,
The US Institute of Medicine (IOM)
   From Cancer Patient
    to Cancer Survivor:
    Lost in Transition
   Landmark report
   Argued that the post
    treatment phase is a
    distinct phase that
    requires increased
    attention by              17 minute video on YouTube
    clinicians                 at
The US Institute of Medicine report

    Recommends four components of
     quality survivorship care
    1. prevention of recurrent and new cancers
    2. surveillance for cancer recurrence as well
       as for medical and psychosocial late effects
    3. strategies to deal with the broad
       consequences of cancer and its treatment
    4. coordination between specialists and
       primary care providers
Strategies to improve outcomes for
cancer survivors
 Information
  – Survivorship care plans
 Strategies to remain well
 Regular surveillance
  – Hospital, GP, nurses?
 Supports
Survivorship care plans

   A key component of optimal survivorship care
    is the use of a survivorship care plan (SCP)
   The SCP is a summary of:
    –   Cancer diagnosis and treatments
    –   Plans for follow up
    –   Current medical, psychosocial, practical issues,
        and a plan for management
    –   Potential future issues and a plan for
   Ideally discussed with someone toward the
    end of potentially-curative treatment(s)
Why do we need them?

 Because patients are ‘lost in transition’
  (from cancer patient to cancer survivor)
 Fragmented, poorly coordinated
  healthcare system
 Patients need a coordinated plan for
  follow up and a plan to protect their health
 Patients (and GPs) want to be informed
  and help ensure good survivorship
The SCP in more detail

 Essential elements include details about:
  (i) the cancer (diagnosis and stage), all
     treatments (with dates, doses, complications),
     and potential short and long-term
  (ii) the content and timing of recommended
     follow up (monitoring for treatment toxicity,
     cancer recurrence, and psychosocial /
     supportive care issues)
The SCP in more detail

 Essential elements include details about:
  (iii) who will take responsibility for survivorship
      care (oncologist, primary care doctor (GP),
      survivor, carers)
  (iv) health promotional strategies (e.g. weight,
      exercise, diet, smoking cessation)
  (v) practical information and advice (e.g.
      regarding employment, insurance), and
  (vi) the availability of psychosocial/supportive
      care services
There are a range of
resources available
from the
Patient guides
available at the ASCO
website and at

 For whom?
  – Person affected by cancer, GP, other treating
 In what format?
  – Paper and electronic
  – Tailored to the person’s (a) diagnosis,
    treatment, (b) own identified needs, and (c) to
    their preference for information (brief 

 Completing the SCP
  – ? Nurse or oncologist
  – Many components are ‘generic’
  – Resources available: (a) ‘implementing SCP’
    workshop reports are available free (next
    slide); (b) ASCO guidelines for follow up; (c)
    community-based supports
 Limited implementation to date
Useful (free) resources
     Health behaviours of cancer survivors

      An Australian study (2007) compared
       health behaviours of cancer survivors to a
       cohort of people without cancer
      968 survivors, 5808 controls
      Asked about smoking, physical activity,
       servings of fruit and vegetables, alcohol
       use, skin checks

Eakin EG et al. Cancer Causes Control 2007; 18(8): 881-894.
     Health behaviours of cancer survivors

      More likely to have comorbidities (and more of
      More likely to be current smokers
      More likely to have regular skin checks
      (not stat sig) More likely to be overweight / obese
      (not stat sig) Had higher alcohol consumption
      No differences regarding physical activity, fruit
       and vegetable consumption

Eakin EG et al. Cancer Causes Control 2007; 18(8): 881-894.
Information about staying well

 Maintain a healthy
 More fruit and
 Less fat
 Exercise
 Limit or avoid alcohol
 Stop smoking

      In women who had never smoked, those
       who gained between 0.5-2.0 kg/m2 had a
       relative risk of 1.35 of death from breast
       cancer, compared to those who
       maintained their weight
      In women who had never smoked, those
       who gained > 2.0 kg/m2 had a relative risk
       of 1.64

Kroenke CH et al. J Clin Oncol 2005; 23(7): 1370-8. Epub Jan 31
     Dietary change

      WHEL study
          – Women’s Healthy Eating and Living
            randomised controlled trial
          – Diet very high in vegetables, fruit, fibre and
            low in fat
          – People were able to adopt / maintain the diet
          – Did not reduce breast cancer recurrence /

Pierce JP et al. JAMA 2007; 298(3): 289-98
     Dietary change

      WINS study
          – Women’s Intervention Nutrition Study
            randomised controlled trial
          – % of calories from fat to 15% (realistic aim of
            20% of calories from fat)
          – 2437 women enrolled, median follow up 60
          – Significant reduction in cancer recurrence –
            9.8% vs 12.4% (HR 0.76, 24% reduction in
            risk of cancer recurrence)

Chlebowski RT et al. J Natl Cancer Inst 2006; 98: 1767-76
Information about staying well

 Stop smoking
 Maintain a healthy
 More fruit and
 Less fat
 Exercise
 Limit or avoid alcohol
Views of survivors and health
professionals regarding follow up and
the SCP (Peter Mac)
 General support for the notion of a SCP
 Support for core content areas
 Support for information for, and
  involvement of GPs
 Uncertainties regarding: (a) who
  coordinates follow up; (b) who might
  complete / discuss the SCP; (c) content of
  the SCP
Survivorship care

 The SCP needs to be integrated into a
  more complete approach / strategy

 Alternate models of follow up may include
  nurse-led follow up (face to face,
  telephone), GP follow up, survivorship
Beaver K et al. BMJ 2009; Jan 14;338:a3147
GP follow up of women with early
stage breast cancer
 Work of Dr Eva Grunfeld (series of RCTs
  of GP vs specialist follow up) shows that
  GP follow up is associated with
  – Similar disease outcomes (recurrence)
  – Similar quality of life
  – Greater satisfaction
  – Lower costs (patient, health service)
   An example from our current work
  We are developing a ‘comprehensive survivorship
   package’ including
     – DVD, booklet and a question prompt list
     – SCP – for patient and for GP
     – Nurse-led ‘end of treatment’ session
     – Telephone-based follow up                        Review needs
                                                        Discuss QPL
   Given DVD, booklet, QPL   End of treatment session
                                                        Discuss SCP


                                       Telephone-based follow up
GP involvement

   There are a large number of breast
    cancer survivors
   The current focus of follow up is (likely)
    inadequate and probably inefficient
   There are different models of providing
    survivorship care – these need to be
    piloted and evaluated
   The most appropriate model will depend
    on local factors

   Tailored, survivorship care plans are
    part of good survivorship care
   We need to determine the ideal way to
    develop and discuss the SCP and how
    this is best integrated into survivorship
    care (models of care)
   Ideally ongoing survivorship care should
    screen for, and respond to unmet needs

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