Care of Cancer Survivors: What works? Plenary session by Kim Hobbs, Clinical Specialist Social Worker, Department of Gynaecological Cancer, Westmead Hospital.
COSA ASM 2014, Melbourne, Australia
This was a well attended plenary session chaired by Michael Jefford.
The first speaker was Mary McCabe from Memorial Sloan Kettering (MSK) with a paper entitled “Cancer Survivorship: The future is now“. Both the medical community and consumers place greater emphasis on patient-centred issues, as increasing numbers of cancer survivors shift the focus towards incorporating quality (not quantity alone) of life.
Cancer survivors are at increased risk of negative health outcomes. A combination of genetic factors, co-morbidities, lifestyle factors and the consequences of exposures to treatment result in long-term side-effects and late effects. Cancer survivors are more likely to die from non-cancer causes, such as cardiovascular disease, than their peers who have not had cancer.
The MSK Model
There are many models of survivorship care, but all of them incorporate the same basic elements: surveillance for cancer recurrence, monitoring of medical and psychosocial late effects, and screening for secondary cancers. There is a growing number of published survivorship care guidelines, both for specific cancer sites and for suites of survivorship issues, such as fatigue, neuropathy and lymphoedema.
The MSK model is that of shared care, largely managed and coordinated by nurse practitioners. This model encourages communication between oncology specialists and primary care physicians.
The challenge for any model of survivorship care is determining risk-based care for survivors: who needs what sort of follow up, and for how long? The development and evaluation of survivorship models is still in process.
GP led survivorship care encourages empowerment
David Weller, an Australian trained, now Edinburgh-based academic General Practitioner, presented the second paper of the session about new directions for the role of general practitioners in survivorship care. David reiterated Mary’s points about the need to monitor for detecting recurrence and monitoring treatment side-effects; but emphasised the focus of primary care in managing co-morbid conditions, incorporating ongoing therapies (such as endocrine therapy), addressing quality of life and psychosocial concerns. Survivorship care by the GP encourages empowerment and self-management.
David described a Cancer Australia initiative of a shared care demonstration project. The aim of the project was to look at acceptability and cost of survivorship care in primary care. It’s not yet formally reported but there was a high rate of uptake for referral back to primary care.
In the UK the NHS has produced a stratified care plan for people with cancer. Called “Innovation to Implementation”, it’s a “how to” guide for health professionals. Survivors and health care professionals both agree on the acceptability and utility of survivorship care plans, but there has been limited uptake.
The case is strong for primary care led follow up and survivorship care. Outcomes are equivalent or better, and with an ageing population (with more co-morbid initials) and improved cancer survival, there is a need to reduce demand on tertiary cancer centre.
So, why are things slow to change? David identified as the major barriers: task shifting, role re-definition, professional boundaries, territorial issues and patient preference for ongoing care in cancer centres. David concluded by suggesting that perhaps it’s time to shift from an “either-or” approach to an integrated approach of shared care.
Is exercise safe?
Kerry Courneya from University of Alberta in Canada addressed the question of the role of physical activity in both symptom control and survival. From a position of “exercise is medicine”, Courneya asks the question “is exercise safe?”
Specifically, will exercise interfere with treatment or response to treatment? Can exercise help to mange treatment side-effects? Can exercise lower the risk of cancer recurrence and improve survival? Can exercise improve recovery from treatment and enhance quality of life after treatment? What is the optimal exercise program? Who responds best to a given exercise program?
Kerry reported on the Supervised Trial of Aerobic versus Resistance Training (START) study. This is a Canadian study in which breast cancer patients in treatment were given one of two structured exercise programs. Both the aerobic and resistance exercise groups maintained fitness throughout treatment; whilst a usual care group demonstrated a decline in fitness levels. The usual care group gained fat and lost lean body mass (both of which are commonly reported concerns in breast cancer patients); but the exercise groups did not gain weight or lose lean body mass. Most strikingly, the resistance exercise group had improved chemotherapy completion rates, with fewer delays and dose reductions.
The START trial involved 242 women, and median follow up is now 89 months. Both exercise groups have been found to have better disease free survival and overall survival up to eight years.
The Combined Aerobic and Resistance Exercise (CARE) trial has recruited a stratified cohort randomised into three exercise programs: standard (30 minutes of exercise three times per week), combined (standard plus resistance exercise training) and high (standard plus double the exercise resistance training of the combined group). There was no difference in chemotherapy completion across the groups; which means that even women assigned to high levels of exercise are able to complete treatment. Those on either combined or high exercise groups reported better management of side-effects of endocrine symptoms and improved sleep quality.
Kerry conclude that exercise IS safe during chemotherapy and radiotherapy and that it doesn’t interfere with treatment completion. In fact, exercise regimens may improve treatment completion, assist in management of symptoms, and improvements in recovery and quality of life. In very early findings, there MAY be survival advantages in some cancer groups (breast, colo-rectal and prostate).
Exercise should be promoted!
Outcome measures in survivorship
The final paper in this session was by Irene Higginson, Professor of Palliative Care and Policy from King’s College London and Director of the Cicely Saunders Institute, who presented on outcome measures in survivorship. Irene described the tools developed by her group: the Palliative Care Outcome Scale (the POS). Additional versions of the tool have been developed: such as the POS-S (symptoms), I-POS (integrated POS).Ten questions are asked, with answers recorded on a five point likert scale.
The domains recorded are:
- Other symptoms
- Family/friends anxiety
- Information received
- Support from family and friends
- Life worthwhile (assesses depression)
- Wasted time
- Practical matters
- Free text report of main problems
The various POS tools have been validated for use in diseases other than cancer. They are freely available and downloadable at http://pos-pal.org/. The tools are available in eleven languages, and now include specific measures for diseases (eg, myeloma), for CALD populations and for decision support. The website also includes information about training days, details about the Outcomes, Assessment and Complex Collaborative (OACC) and a downloadable reference book, “Outcome Measurement in Palliative Care: The Essentials”. Future directions include ongoing training and support, more courses and e-learning and further development of the POS measure.
However the use of outcome measures can be controversial but cultural changes and staff training can support outcome measurement, without confrontation.
Kim has previously contributed expert commentary for OncologyNews: