Abstract
Purpose
We performed this study to characterize the population at the Lifespan Cancer Institute (LCI) who received a survivorship care plan (SCP) with or without a survivorship care visit (SCV) to determine both the impact on specialty referrals and the demographic and clinical predictors of SCPs and SCVs.
Methods
We retrospectively reviewed EMR records on 1960 patients at LCI between 2014 and 2017 for SCPs and SCVs and extracted demographics, distress thermometer (DT) scores collected at the time of initial presentation, and subsequent referrals. We evaluated the bivariate associations of SCP and SCV with continuous and categorical factors and assessed the adjusted effect of these factors on receipt of SCP and SCV independently. All analyses were performed in R v4.0.2.
Results
SCPs were completed in 740 (37.8%) patients, and of those, 65.9% had a SCV. The mean age was 63.9, 67% were female, and 51.2% were married or partnered. Patients treated for breast, lung, and prostate cancers most received an SCP. Compared to SCP alone, the SCV was associated with more specialty referrals. Those who were younger and had breast cancer were more likely to receive a SCP, and those who were younger and female and had breast cancer were more likely to receive a SCV.
Conclusions
Gender, age, and type of cancer are significant predictors of receipt of SCP and SCV. Patients who received either SCP, SCV, or both were more likely to receive specialty referrals than those who received neither.
Implications for Cancer Survivors.
Identifying predictive factors of SCP and SCV can help facilitate earlier receipt of specialty services and specialty referrals as needed.
Keywords: Survivorship care plan, Visit, Distress thermometer
Introduction
For patients who had completed initial treatment of cancer, the survivorship care plan (SCP) was established to both address both knowledge of post-treatment side effects and coordination of care1. SCPs include guidelines for monitoring and improving a survivor’s health against late effects of cancer treatment and/or recurrence, information about diagnosis, treatment summary, lifestyle recommendations, and establishing follow-up care with various providers [1]. The Commission on Cancer accreditation guidelines in 2019 had mandated 50% of cancer survivors receive SCPs with care planning visits; however, strict quotas for accreditation have been eliminated due to barriers in widespread implementation, such as lack of resources, inadequate reimbursement, and limited evidence on effectiveness [1]. A systematic review of prospective studies and randomized trials involving SCPs noted high levels of patient satisfaction and self-reported understanding with SCPs, but there was no significant effect on subsequent distress, coordination of care, or cancer outcomes [2]. In addition, data on whether a survivorship care visit (SCV) impacts care or affects patients’ distress have yet to be established [2].
At the LCI, we aimed to meet the 2019 COC guidelines by providing patients completing curative cancer treatment with an SCP. This was delivered according to their preference, either through an SCV conducted by an advanced practice provider or by sending it to them through mail or electronically without an SCV. Our study sought to examine the survivorship care program at the Lifespan Cancer Institute (LCI) to determine the demographic and clinical predictors of SCPs and SCVs and to see if having an SCV impacted subsequent specialty referrals, compared to having the SCP sent to the patient.
Methods
We retrospectively reviewed records on 1960 patients at LCI between the years 2014 and 2017 utilizing our EMR. Demographics, treatment variables, and whether or not patients received SCPs and/or SCVs were documented. Also obtained were whether patients were referred to any services after their treatment course. Included in the study were patients with the following cancer types: breast, lung, gastrointestinal, gynecological, and prostate as these were the most common solid tumors seen at LCI. Excluded from the study were patients who were deceased at the time of record review as most of these patients were diagnosed with an advanced stage of cancer at diagnosis that precluded discussion of survivorship care. T-test or Wilcoxon rank test was used to evaluate the bivariate associations of continuous factors with SCPs and SCVs, and the chi-square test was used for categorical factors. Logistic regression models were used to assess adjusted effects of factors associated with receipt of SCPs and SCVs independently. All analyses were performed in R v4.0.2 [3].
Results
Of the 1960 patients evaluated in this study, 1315 (67%) were male and 645 (32.9%) were female. The mean age was 63.9 years old, and 1004 (51.2%) were married or partnered. The most common cancer was breast cancer (38.8%), followed by lung (17.6%), prostate (13.7%), colon (8.8%), endometrial (4.4%), and rectal cancer (3.8%). At the time of diagnosis, 897 (45.7%) had stage I cancer, 515 (26.2%) had stage II cancer, and 347 (17.7%) had stage III cancer (Table 1).
Table 1.
Demographics (n = 1960)
| N (%) | |
|---|---|
| Gender | |
| Female | 1315 (67.0%) |
| Male | 645 (32.9%) |
| Missing | 2 (0.1%) |
| Age | |
| Mean (SD) | 63.9 (11.8) |
| Missing | 1 (0.1%) |
| Married or partnered | |
| Yes | 1004 (51.2%) |
| No | 717 (36.5%) |
| Missing | 241 (12.3%) |
| Primary cancer | |
| Breast | 761 (38.8%) |
| Lung | 345 (17.6%) |
| Prostate | 268 (13.7%) |
| Colon cancer | 173 (8.8%) |
| Upper GI | |
| Esophageal | 38 (1.9%) |
| Gastric | 35 (1.8%) |
| Pancreatic | 30 (1.5%) |
| Cholangiocarcinoma | 8 (0.4%) |
| Hepatocellular | 17 (0.9%) |
| Gynecologic | |
| Ovarian | 19 (1.0%) |
| Endometrial | 86 (4.4%) |
| Uterine sarcoma | 2 (0.1%) |
| Cervical | 21 (1.1%) |
| GYN-other | 5 (0.3%) |
| Non-colorectal | |
| CA of small intestine | 27 (1.4%) |
| Anal cancer | 29 (1.5%) |
| GI-other | 24 (1.2%) |
| Rectal cancer | 74 (3.8%) |
| Stage | |
| I | 897 (45.7%) |
| II | 515 (26.2%) |
| III | 347 (17.7%) |
| IV | 17 (0.9%) |
| Unavailable | 42 (2.1%) |
| Missing | 144 (7.3%) |
Factors associated with receipt of SCP and SCV
We found an SCP in the charts of 37.7% of patients, with the median age of those receiving one of 61 years. Of these, 65.9% received it in the context of an SCV. Women were significantly more likely to have an SCP compared to men (p < 0.001). Other significant associations were a diagnosis of breast cancer (p < 0.001), younger age (p < 0.001), and a stage I cancer at diagnosis (p < 0.001). Women were also most likely to obtain an SCP in the context of an SCV (p < 0.001), as were those of younger age (p = 0.003) and those treated for breast cancer (p < 0.001) (Table 2).
Table 2.
Factors associated with provision of a SCP and having a SCV
| Survivorship care plan | Survivorship care visit | |||||
|---|---|---|---|---|---|---|
| Yes (%) (N = 740) | No (%) (N = 1220) | p value | Yes (%) (N = 488) | No (%) (N = 252) | p value | |
| Gender | ||||||
| Female | 590 (79.7%) | 723 (59.3%) | < 0.001 | 414 (84.8%) | 176 (69.8%) | < 0.001 |
| Male | 148 (20.0%) | 497 (40.7%) | 73 (15.0%) | 75 (29.8%) | ||
| Missing | 2 (0.3%) | 1 (0.2%) | 1 (0.4%) | |||
| Age | ||||||
| Mean (SD) | 61.6 (11.2) | 65.3 (12.0) | < 0.001 | 60.7 (11.1) | 63.3 (11.3) | 0.003 |
| Missing | 1 (0.1%) | |||||
| Married or partnered | ||||||
| Yes | 340 (45.9%) | 664 (54.4%) | 0.067 | 245 (50.2%) | 95 (37.7%) | 0.638 |
| No | 212 (28.6%) | 505 (41.4%) | 148 (30.3%) | 64 (25.4%) | ||
| Missing | 188 (25.4%) | 51 (4.2%) | 95 (19.5%) | 93 (36.9%) | ||
| Primary cancer | ||||||
| Breast | 427 (57.7%) | 334 (27.4%) | < 0.001 | 320 (65.6%) | 107 (42.5%) | < 0.001 |
| Lung | 101 (13.6%) | 242 (19.8%) | 28 (5.7%) | 73 (29.0%) | ||
| Prostate | 30 (4.1%) | 238 (19.5%) | 13 (2.7%) | 17 (6.7%) | ||
| Colon cancer | 58 (7.8%) | 115 (9.4%) | 47 (9.6%) | 11 (4.4%) | ||
| Upper GI | ||||||
| Esophageal | 12 (1.6%) | 26 (2.1%) | 5 (1.0%) | 7 (2.8%) | ||
| Gastric | 11 (1.5%) | 24 (2.0%) | 7 (1.4%) | 4 (1.6%) | ||
| Pancreatic | 8 (1.1%) | 22 (1.8%) | 6 (1.2%) | 2 (0.8%) | ||
| Cholangiocarcinoma | 3 (0.4%) | 5 (0.4%) | 1 (0.2%) | 2 (0.8%) | ||
| Hepatocellular | 2 (0.3%) | 15 (1.2%) | 1 (0.2%) | 1 (0.4%) | ||
| Gynecologic | ||||||
| Ovarian | 3 (0.4%) | 16 (1.3%) | 3 (0.6%) | 0 (0%) | ||
| Endometrial | 20 (2.7%) | 66 (5.4%) | 11 (2.3%) | 9 (3.6%) | ||
| Uterine sarcoma | 0 (0%) | 2 (0.2%) | 0 (0%) | 0 (0%) | ||
| Cervical | 6 (0.8%) | 15 (1.2%) | 3 (0.6%) | 3 (1.2%) | ||
| GYN-other | 1 (0.1%) | 4 (0.3%) | 0 (0%) | 1 (0.4%) | ||
| Non-colorectal | ||||||
| CA of small intestine | 4 (0.5%) | 23 (1.9%) | 3 (0.6%) | 1 (0.4%) | ||
| Anal cancer | 14 (1.9%) | 15 (1.2%) | 11 (2.3%) | 3 (1.2%) | ||
| GI-other | 10 (1.4%) | 14 (1.1%) | 8 (1.6%) | 2 (0.8%) | ||
| Rectal cancer | 30 (4.1%) | 44 (3.6%) | 21 (4.3%) | 9 (3.6%) | ||
| Stage | ||||||
| I | 348 (47.0%) | 548 (44.9%) | < 0.001 | 221 (45.3%) | 127 (50.4%) | 0.571 |
| II | 203 (27.4%) | 311 (25.5%) | 133 (27.3%) | 70 (27.8%) | ||
| III | 141 (19.1%) | 206 (16.9%) | 94 (19.3%) | 47 (18.7%) | ||
| IV | 2 (0.3%) | 15 (1.2%) | 2 (0.4%) | 0 (0%) | ||
| Unavailable | 4 (0.5%) | 38 (3.1%) | 4 (0.8%) | 0 (0%) | ||
| Missing | 42 (5.7%) | 102 (8.4%) | 34 (7.0%) | 8 (3.2%) | ||
| Distress thermometer score (at presentation) | ||||||
| Mean (SD) | 4.07 (2.99) | 3.69 (3.10) | 0.014 | 4.16 (2.98) | 3.88 (3.02) | 0.258 |
p - value < 0.05 denotes significance
We also looked to see if the SCV was associated with differences in referrals after cancer treatment among those with an SCP. Compared to receipt of an SCP without a visit, the SCV was associated with higher referrals to psychological evaluation (11.9 vs 6%, p < 0.015), physical therapy or lymphedema evaluation (58.4 vs 22.2%, p < 0.001), nutrition (26.2 vs 10.3%, p < 0.001), and sexual health counseling (7.4 vs 2%, p < 0.004). In addition, provision of an SCP through an SCV was associated with significantly more referrals to all other services (11.3 vs 5.2%, p = 0.01) (Table 3).
Table 3.
Frequency of referrals based on provision of an SCP with or without an SCV
| Survivorship care visit | |||
|---|---|---|---|
| Referral placed in survivorship care plan | Yes (%) (N = 488) | No (%) (N = 252) | p value |
| Psych | 58 (11.9%) | 15 (6.0%) | 0.015 |
| PT/lymphedema | 285 (58.4%) | 56 (22.2%) | < 0.001 |
| Nutrition | 128 (26.2%) | 26 (10.3%) | < 0.001 |
| Smoking cessation | 34 (7.0%) | 10 (4.0%) | 0.141 |
| Fiscal services | 9 (1.8%) | 1 (0.4%) | 0.2 |
| Sexual health | 36 (7.4%) | 5 (2.0%) | 0.004 |
| Other | 55 (11.3%) | 13 (5.2%) | 0.01 |
p - value < 0.05 denotes significance
Distress thermometer scores
The average patient self-reported DT score, taken at the time of multidisciplinary cancer treatment meeting, was significantly higher in women and in breast cancer patients. Interestingly, people presenting with stage I disease had a higher average DT (4.12) than those with stage II or III/IV cancer (3.36 and 3.99, respectively) (Table 4).
Table 4.
Distress scores at presentation for this cohort
| N (%) | Mean distress score (SD) | p value | |
|---|---|---|---|
| Overall | 1960 (100%) | 3.882 (3.051) | |
| Gender | < 0.001 | ||
| Male | 643 (32.826%) | 2.91 (2.91) | |
| Female | 1317 (67.174%) | 4.36 (3.01) | |
| Married or partnered | 0.398 | ||
| Yes | 1009 (51.481%) | 3.93 (2.96) | |
| No | 636 (32.426%) | 4.12 (3.09) | |
| Missing | 315 (16.093%) | 3.24 | |
| Primary cancer | < 0.001 | ||
| Breast | 885 (45.156%) | 4.53 (2.94) | |
| Lung | 278 (14.171%) | 3.71 (3.15) | |
| Prostate | 326 (16.653%) | 2.80 (2.71) | |
| GI (colorectal) | 141 (7.206%) | 3.37 (3.07) | |
| GI (non-colorectal) | 267 (13.612%) | 3.41 (3.21) | |
| Gynecologic | 63 (3.202%) | 4.22 (3.07) | |
| Stage | < 0.001 | ||
| I | 897 (45.7%) | 4.12 (2.95) | |
| II | 515 (26.2%) | 3.36 (3.01) | |
| III or IV | 364 (18.6%) | 3.99 (3.25) | |
| Unavailable | 42 (2.1%) | 3.23 (3.11) | |
| Missing | 144 (7.3%) | 4.39 |
p - value < 0.05 denotes significance
We found that those referred for psychological care in their SCP had a higher initial DT score than those who were not (mean, 5.25 vs 3.8, p < 0.001). There was no association between other referrals and initial DT otherwise (Table 5).
Table 5.
Associations between DT score at initial presentation and subsequent referrals
| Distress score | |||
|---|---|---|---|
| Type of referral | Checked mean (sd) | Unchecked mean (sd) | p value |
| Psych | 5.25 (2.64) | 3.8 (3.06) | < 0.001 |
| PT/lymphedema | 4.13 (2.95) | 3.79 (3.08) | 0.052 |
| Nutrition | 3.85 (3.13) | 3.88 (3.04) | 0.842 |
| Smoking cessation | 4.78 (3.58) | 3.85 (3.03) | 0.121 |
| Sexual health | 4.26 (2.9) | 3.86 (3.06) | 0.353 |
| Fiscal services | 4.3 (3.23) | 3.88 (3.05) | 0.658 |
| Other | 3.31 (2.93) | 3.9 (3.06) | 0.125 |
| No referral | 3.69 (3.1) | 4.07 (2.99) | 0.14 |
Factors predicting receipt of SCP and SCV
In the unadjusted models, gender, age, initial DT score, and cancer type were significantly associated with receipt of SCP (Table 6). In the model adjusted for age, sex, partner status, cancer stage, and cancer type, age and cancer type were the only significant factors (Table 7). In contrast, being seen in an SCV was significantly associated with gender, age, and cancer type in both the unadjusted and adjusted models (Tables 8 and 9).
Table 6.
Predictors of having a SCP completed (unadjusted estimates)
| Variable | Unadjusted estimates |
|---|---|
| OR (95% CI) | |
| Sex (ref female) | |
| Male | 0.37 (0.29, 0.45)** |
| Age | 0.97 (0.967, 0.982)** |
| Married or partnered (ref no) | |
| Yes | 1.22 (0.99, 1.50) |
| Cancer stage (ref I or II) | |
| III or IV | 1.01 (0.80, 1.28) |
| Distress thermometer score | 1.04 (1.004, 1.081)* |
| Cancer type (ref breast) | |
| Lung | 0.326 (0.25, 0.43)** |
| Prostate | 0.099 (0.06, 0.15)** |
| Colon cancer | 0.395 (0.28, 0.56)** |
| Non-colorectal | 0.391 (0.29, 0.52)** |
| Gynecologic | 0.228 (0.15, 0.35)** |
**p value < 0.001
*p value < 0.05
Table 7.
Predictors of having a SCP completed (adjusted estimates, full model)
| Variable | Adjusted estimates |
|---|---|
| OR (95% CI) | |
| Age | 0.98 (0.97, 0.99)** |
| Sex (ref female) | |
| Male | 0.85 (0.55, 1.30) |
| Married or partnered (ref no) | |
| Yes | 1.25 (0.97, 1.61) |
| Cancer stage (ref I or II) | |
| III or IV | 1.33 (0.94, 1.86) |
| Cancer type (ref breast) | |
| Lung | 0.135 (0.08, 0.19)** |
| Prostate | 0.044 (0.02, 0.09)** |
| Colon cancer | 0.157 (0.07, 0.22)** |
| Non-colorectal | 0.146 (0.10, 0.25)** |
| Gynecologic | 0.153 (0.10, 0.25)** |
**p value < 0.001
*p value < 0.05
Table 8.
Predictors of having a SCV completed (unadjusted estimates)
| Variable | Unadjusted estimates |
|---|---|
| OR (95% CI) | |
| Sex (ref female) | |
| Male | 0.41 (0.29, 0.60)** |
| Age | 0.98 (0.97, 0.99)** |
| Married or partnered (ref no) | |
| Y es | 1.12 (0.76, 1.62) |
| Cancer stage (ref I or II) | |
| III or IV | 1.14 (0.77, 1.69) |
| Cancer type (ref breast) | |
| Lung | 0.13 (0.08, 0.21)** |
| Prostate | 0.26 (0.12, 0.54)** |
| Colon cancer | 1.43 (0.74, 2.99) ** |
| Non-colorectal | 0.68 (0.42, 1.11) * |
| Gynecologic | 0.44 (0.21, 0.95)** |
**p value < 0.001
*p value < 0.05
Table 9.
Predictors of having a SCV completed (adjusted estimates, full model)
| Variable | Adjusted estimates |
|---|---|
| OR (95% CI) | |
| Age | 0.97 (0.96, 0.99)** |
| Sex (ref female) | |
| Male | 0.52 (0.30, 0.91)* |
| Married or partnered (ref no) | |
| Yes | 1.23 (0.93, 1.62) |
| Cancer stage (ref I or II) | |
| III or IV | 1.39 (0.93, 2.06) |
| Cancer type (ref breast) | |
| Lung | 0.08 (0.04, 0.14)** |
| Prostate | 0.08 (0.03, 0.18)** |
| Colon cancer | 0.26 (0.14, 0.46)*** |
| Non-colorectal | 0.19 (0.11, 0.33)*** |
| Gynecologic | 0.14 (0.08, 0.25)** |
**p value < 0.001
*p value < 0.05
Discussion
For people treated for cancer, the provision of care at the end of curative cancer therapy has been a focus for quality improvement since the 2006 publication of the seminal report, From Cancer Patient to Cancer Survivor: Lost in Transition, from the National Academies of Science, Engineering and Medicine [4]. It served as a wake-up call to the oncology and primary care communities and was the impetus for the survivorship care plan: a document that provided cancer survivors with a treatment summary, delineation of cancer-related follow-up, and information on late and long-term effects of cancer treatment. In 2015, the Commission on Cancer made provision of an SCP a quality benchmark, despite the lack of evidence of its impact on the quality of care post-treatment [5, 6]. A 2020 systematic review and meta-analysis reported no significant differences between SCP recipients and controls on cancer-related knowledge, physical function, satisfaction, or self-efficacy at 6 months, with no differences in anxiety, cancer-specific distress, and depression of satisfaction with how they were being followed at 12 months [7]. Interestingly, most of the data evaluates the implementation of SCPs and outcomes but less so on the impact of the SCV among those who receive an SCP.
At LCI, we aimed to provide all people completing cancer treatment with an SCP and provided them with the option to review it at a formal SCV or to have it mailed to them directly. Our overall rate of SCP completion is 37.7%, which reflects the barriers to implementation we have experienced, particularly time and reimbursement. A national survey of cancer care providers noted that clinicians were only willing to dedicate about 20 min of their time toward developing a SCP, which can take up to 1.5 h for development [8]. Although Medicare funding is available for documenting SCP development, no funding is available for reimbursing providers for this service [8].
Among those receiving an SCP, we found significant differences among those who were seen in an SCV around gender, age, and cancer type. In the provision of SCPs and SCVs, women, age under 60 years, and diagnosis of breast cancer were significantly associated with both. While these factors reflect the general demographics of the population studied, it may also reflect differences in disease-specific specialists as it relates to their uptake and hence referral for survivorship care services. In one study that applied machine learning using the Oncolink database, breast cancer survivors were reported as much more likely to receive an SCP with melanoma survivors far less likely to report getting an SCP [9].
Of perhaps greater interest is our finding that having an SCV was associated with higher rates of subsequent referrals among those receiving an SCP. Compared to patients who only received an SCP, those who received a SCV had a significantly increased referral rate to psychological support, PT/lymphedema, nutrition, and sexual health services. This correlates with a prior survivorship study involving patients with ovarian cancer who favored an in-person visit over a mailed document alone after completion of treatment to discuss the need for further referrals [10]. This finding suggests that the SCP may provide value by pointing survivors towards specialty services and that an SCV can increase the identification of issues which would necessitate more referrals.
In our health system, predictive factors of receipt of both SCP and SCV include age, gender, and cancer type. This correlates with a prior study involving breast cancer survivors which reported that the top five variables associated with obtaining an SCP were cancer type, the setting in which care was rendered (e.g., university versus community-based), the type of clinician managing their cancer care, the receipt of a treatment summary, and geographic location [9]. The reason for cancer type being predictive of SCP and SCV referrals is likely in part provider dependent. During our data collection, we noted our oncologists managing patients with breast and colorectal cancers, for example, were found to initiate more survivorship care planning than those managing lung and prostate cancers. One reason could be that oncologists in the former category likely had more frequent follow-up visits scheduled with their patients and thus more opportunity to initiate survivorship care discussion.
Patients with particular cancers may desire different mechanism and timing of delivery of survivorship information. One study that looked at unmet needs and barriers to use SCP breast cancer survivors reported that patients found it difficult to keep up with several follow-up preventative care appointments occurring at varying intervals as well as lack of understanding and need to self-manage treatment-related symptoms without discussing with a provider [11]. On the other hand, one study reported that GI cancer survivors tend to seek out nutritional and activity recommendations from their oncologists sooner than other cancer survivors as they present with more nutritional complications and more gastrointestinal symptoms following completion of their treatment modalities [12].
There are ongoing studies assessing how risk-stratified survivorship care can be delivered to cancer patients. Patients with low risk of recurrence or low likelihood of treatment side effects may benefit from self-management, whereas those with medium risk of recurrence could benefit from a SCP alone with regular follow-up primarily with their primary care team [13]. For those patients with a high risk of recurrence, significant medical or psychosocial co-morbidities, or late or significant treatment adverse effects, a SCV including follow-up with specialized clinical nurses, scheduled screening for recurrence, and referrals to rehabilitation, psychological, or nutritional support services as needed would be more beneficial than a SCP alone [13]. However, barriers such as limited upfront risk-stratifying methods and limited coordination among care providers have prevented risk-stratified survivorship care from being widely adopted to standard practice [14].
Patient preferences likely also play a role in whether or not a SCV occurs. Some patients in our institution were given preferences for their SCP to be delivered over the phone or mailed, but reasons for those preferences had not been recorded. Some reasons could likely be time or financial constraints (including copays for visits) or restrictions with travel.
Despite the Commission on Cancer removing the SCP mandates, our data show that patients who received either SCP, SCV, or both were more likely to receive specialty referrals than those who received neither and that patients with higher mean distress scores at presentation had a higher referral to psychiatric/psychological services following completion of cancer care. Thus, there continues to be a demonstrable benefit to both SCP and SCV despite institutional barriers such as lack of time and resources. One strategy for successful implementation of SCPs can be assigning the duty to other employees such as NPs or nurse navigators, which has been occurring at our institution [8, 15]. Other strategies can be updating EMR documentation to include accurate cancer diagnostic and treatment history and follow-up as well as possibly automating SCPs to the EMR [13, 16].
One future area of research would be to determine why oncologists may or may not choose to offer SCPs and why patients prefer to receive a SCP alone versus a SCV. Especially considering the current COVID-19 pandemic, it would also be interesting to examine if a plan delivered via video conferencing has similar efficacy to one delivered via an in-person visit. Barriers such as limited access to technology, lack of policies for reimbursement of telehealth, and safety/privacy concerns have limited adoption of telehealth for survivorship care across institutions in addition to patient perceptions that only an in-person visit would be effective to discuss symptoms and questions with care [17]. In the context of social distancing, cancer survivors may not be adherent to cancer surveillance and may not fully report any symptoms or concerns with their care due to the fear that an in-person visit would expose them to infection [18].
Finally, we note that there is a reconsideration afoot on how we should deliver and how patients should access these care plans. Given the increasing survival rates across multiple cancers with advances in immunotherapies and precision therapies, it is paramount that services extend to all these long-term survivors, defined from the point of their initial diagnosis through the balance of their treatment. Patients who live long term with distant disease or other immune and precision therapies should be included in survivorship services. As such, we have re-envisioned our survivorship program to encompass all patients following from the time of their diagnosis in our cancer center. Our Oncology Wellness, Lifestyles, and Survivorship (OWLS) program ensures that all our patients have access to quality care following a cancer diagnosis.
One strength of our institutional study included our large sample size of patients with several different malignancies. Another is the fact that it is one of the first to distinguish patterns of specialty referrals between SCPs and SCVs. Limitations of this study include that this data is from a single institution. We do not have more information on why patients did not opt for a SCP or SCV and whether patients completed their referrals to specialists; we only know whether referrals were made or not. We did not specifically assess satisfaction among patients who did or did not receive a SCP or SCV. We also do not know why there is a difference in referral patterns among oncologists in different subspecialties.
Conclusions
Those who received SCV were more likely to receive specialty referrals than those who received SCP alone. Gender, age, being married/partnered, and patients with breast cancer predict receipt of referrals. Distress thermometer score was only associated with referrals to psychiatry. Gender, age, and cancer type predict receipt of both SCP and SCV. While cancer stage predicts receipt of SCP alone, female gender predicts receipt of SCV alone. Our studies also suggest that oncologist and patient preference may impact receipt of SCP ± SCV. Future studies should investigate this further to determine specific patient and oncologist characteristics that predict referral and receipt of SCP and SCV.
Author contributions
H.S. performed all data collection. C.S. performed all statistical analyses of the data and prepared all tables. H.S. and C.D. wrote the abstract and main manuscript text. All authors edited and reviewed the manuscript prior to submission.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Hua A, Sesto ME, Zhang X, Wassenaar TR, Tevaarwerk AJ. Impact of survivorship care plans and planning on breast, colon, and prostate cancer survivors in a community oncology practice. J Cancer Educ. 2020;35(2):249–255. doi: 10.1007/s13187-018-1457-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Skuli SJ, Sheng JY, Bantug ET, Zafman N, Riley C, Ruck JM, …& Wolff AC. Survivorship care visits in a high-risk population of breast cancer survivors. Breast Cancer Res Treat. 2019;173(3):701–708. doi: 10.1007/s10549-018-5028-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. References-Scientific Research Publishing. 2022. https://www.R-project.org/.
- 4.Institute of Medicine and National Research Council . From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006. [Google Scholar]
- 5.Jacobsen PB, DeRosa AP, Henderson TO, Mayer DK, Moskowitz CS, Paskett ED, Rowland JH. Systematic review of the impact of cancer survivorship care plans on health outcomes and health care delivery. J Clin Oncol. 2018;36(20):2088–2100. doi: 10.1200/JCO.2018.77.7482. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Blaes AH, Adamson PC, Foxhall L, Bhatia S. Survivorship care plans and the commission on cancer standards: the increasing need for better strategies to improve the outcome for survivors of cancer. JCO Oncol Pract. 2020;16(8):447–450. doi: 10.1200/JOP.19.00801. [DOI] [PubMed] [Google Scholar]
- 7.Hill RE, Wakefield CE, Cohn RJ, Fardell JE, Brierley ME, Kothe E, Jacobsen PB, Hetherington K, Mercieca-Bebber R. Survivorship care plans in cancer: a meta-analysis and systematic review of care plan outcomes. Oncologist. 2020;25(2):351–372. doi: 10.1634/theoncologist.2019-0184. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Birken SA, Raskin S, Zhan Y, Lane G, Zizzi A, Pratt-Chapman M. Survivorship care plan implementation in US cancer programs: a national survey of cancer care Providers. J of Cancer Ed. 2019;34(3):614–622. [DOI] [PMC free article] [PubMed]
- 9.Benci JL, Vachani CC, Hampshire MK, Bach C, Arnold-Korzeniowski K, Metz JM, Hill-Kayser CE. Factors influencing delivery of cancer survivorship care plans: a national patterns of care study. Front Oncol. 2020;9:1577. doi: 10.3389/fonc.2019.01577. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.De Rooij BH, Thomas TH, Post KE, Flanagan J, Ezendam NPM, Peppercorn J, Dizon DS. Survivorship care planning in gynecologic oncology – perspectives from patients, caregivers, and health care providers. J of Canc Survivorship. 2018;12(6):762–774. doi: 10.1007/s11764-018-0713-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kapoor A, Nambisan P. Personal decision support for survivor engagement: formulation and feasibility evaluation of a conceptual framework for implementing online cancer survivorship care plans. BMC Med Inform Decis Mak. 2020;20(1):1–12. doi: 10.1186/s12911-020-1073-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Hutchinson T, Hoffe S, Saeed S, Pflanzer SA, Fleming JB, Pabbathi S. Gastrointestinal disease–specific survivorship care: a new personalized model integrating onco-wellness. Cancer Control. 2021;28:10732748211006081. doi: 10.1177/10732748211006081. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Tremblay D, Touati N, Bilodeau K, Prady C, Usher S, Leblanc Y. Risk-stratified pathways for cancer survivorship care: insights from a deliberative multi-stakeholder consultation. Current oncology (Toronto Ont) 2021;28(5):3408–3419. doi: 10.3390/curroncol28050295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Walter F, Usher-Smith J, Yadlapalli S, Watson E. Caring for people living with, and beyond, cancer: an online survey of GPs in England. Br J Gen Pract. 2015;65:761–768. doi: 10.3399/bjgp15X687409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Nekhlyudov L. Survivorship care plan: we’ve got the tool – it’s time to fix the process. JNCI. 2018;110(12):1285–1286. doi: 10.1093/jnci/djy077. [DOI] [PubMed] [Google Scholar]
- 16.Birken SA, Clary AS, Bernstein S, Bolton J, Tardif-Douglin M, Mayer DK, Deal AM, Jacobs SR. Strategies for successful survivorship care plan implementation: results from a qualitative study. J of Onc Practice. 2018;14(8):462–483. doi: 10.1200/JOP.17.00054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Chan A, Ashbury F, Fitch MI, Koczwara B, Chan RJ, & MASCC Survivorship Study Group Cancer survivorship care during COVID-19—perspectives and recommendations from the MASCC survivorship study group. Supp Care Cancer. 2020;28(8):3485–3488. doi: 10.1007/s00520-020-05544-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Koczwara B. Cancer survivorship care at the time of the COVID‐19 pandemic. The Med J Aust. 2020;213(3):107–108. [DOI] [PMC free article] [PubMed]