Applying Implementation Science to Identify Primary Care Providers' Enablers and Barriers to Using Survivorship Care Plans.

Primary care providers (PCPs) have been given the responsibility of managing the follow-up care of low-risk cancer survivors after they are discharged from the oncology center. Survivorship Care Plans (SCPs) were developed to facilitate this transition, but research indicates inconsistencies in how they are implemented. A detailed examination of enablers and barriers that influence their use by PCPs is needed to understand how to improve SCPs and ultimately facilitate cancer survivors' transition to primary care. An interview guide was developed based on the second version of the Theoretical Domains Framework (TDF-2). PCPs participated in semi-structured interviews. Qualitative content analysis was used to develop a codebook to code text into each of the 14 TDF-2 domains. Thematic analysis was also used to generate themes and subthemes. Thirteen PCPs completed the interview and identified the following barriers to SCP use: unfamiliarity with the side effects of cancer treatment (Knowledge), lack of clarity on the roles of different healthcare professionals (Social Professional Role and Identity), follow-up tasks being outside of scope of practice (Social Professional Role and Identity), increased workload, lack of options for psychosocial support for survivors, managing different electronic medical records systems, logistical issues with liaising with oncology (Environmental Context and Resources), and patient factors (Social Influences). PCPs value the information provided in SCPs and found the follow-up guidance provided to be most helpful. However, SCP use could be improved through streamlining methods of communication and collaboration between oncology centres and community-based primary care settings.

Standardized versus personalized survivorship care plans for breast cancer survivors: A program evaluation.

The Wellness Beyond Cancer Program provides survivorship care plans (SCPs) to cancer survivors, as they transition from cancer centres back to their primary care provider (PCP) upon treatment completion. A program evaluation examined whether standardized SCPs resulted in comparable outcomes on perceived knowledge and patient activation as personalized SCPs. Breast cancer survivors who received either standardized or personalized SCPs completed pre- and post-surveys during their discharge appointment, which included an in-house measure on perceived knowledge, The Perceived Efficacy in Patient-Physician Interactions, and The Patient Activation Measure. Eighty-seven breast cancer survivors completed the surveys (personalized SCP n = 43; standardized SCP n = 44). Standardized SCPs resulted in comparable knowledge and activation outcomes as personalized SCPs. Cost-efficient standardized SCPs may help alleviate human resource constraints and may be considered for further evaluation and implementation in cancer centres.

An evaluation of a cancer survivorship education class for follow-up care.

The Wellness Beyond Cancer Program is part of a tertiary care hospital in Ontario, Canada. It provides cancer survivors with information and resources needed to self-manage their follow-up care (i.e., learn relevant information and skills to adapt to life with a chronic illness) after active cancer treatment (i.e., chemotherapy, radiation). A program evaluation was conducted on the two-hour survivorship education class (one component of the overall Wellness Beyond Cancer Program) with the purpose of evaluating whether attendance increased survivors' perceived knowledge and intent to self-manage follow-up care. Breast (n = 107) and colorectal (n = 38) cancer survivors who attended classes completed questionnaires on information needs and intent to self-manage pre- and postclass. Perceived increase in knowledge and intent to self-manage follow-up care were unrelated to age, gender, or time since diagnosis. After attending the class, survivors reported increased knowledge (F(1,11) = 144.6, p < .001) and intent to participate in self-management of their follow-up care (F(1,103) = 57.3, p < .001). Improvements in knowledge predicted increased intent to self-manage (R2 = .64; F(4,86) = 38.5, p < .001). Colorectal cancer survivors showed greater improvement in intent to self-manage than breast cancer survivors (ß = .14, t = 2.2, p < .05). These results can inform the development and implementation of future education classes for survivors.

Empowering cancer survivors to meet their physical and psychosocial needs: An implementation evaluation.

Our Wellness Beyond Cancer Survivorship Program was established and evaluated as a quality improvement project. Individualized survivorship care plans for survivors and primary care providers included cancer surveillance recommendations and survivors' self-reported physical and psychosocial needs. At the discharge visit, an oncology nurse reviewed the care plan and symptom management strategies with survivors. We assessed the physical and psychosocial needs and feelings of empowerment of 70 breast and 53 colorectal cancer survivors on entry into the program and one year after discharge to primary care. Survivors were months to 10 or more years since the end of active treatment, with colorectal cancer survivors referred sooner (average 1.2 years). At baseline, colorectal cancer survivors reported little concern about their needs (scores <1.0 out of 5.0) and breast cancer survivors reported some concern about sleep disturbances, weight changes, memory/concentration changes, and fear of recurrence (scores 1.0 to 1.5 out of 5.0). All survivors reported feeling empowered (>3.0 out of 4.0). Needs and empowerment levels were mostly unchanged one year later. Colorectal cancer survivors showed a statistically significantly increased fear of recurrence at one year. In summary, cancer survivors with a survivorship care plan continued to feel empowered one year following discharge.

An implementation evaluation of a wellness beyond cancer program survivorship class: Who is attending?

Breast and endometrial cancer survivors referred to the Wellness Beyond Cancer Program were invited to a survivorship education class. As not all survivors attended the class, this study aimed to identify socio-demographic and medical characteristics, and survivorship needs that predict attendance. A chart review was conducted on survivors who completed a needs assessment survey between 2012 and 2014 (n=144 endometrial; n=170 breast). Class attendees' characteristics were compared to those of non-attendees using t-tests, chi-square analyses, and regression analysis. Univariate analyses showed that age, distance from hospital, emotional and physical needs, and receiving chemotherapy and/or radiation therapy were associated with class attendance. Distance from hospital and physical needs were identified as multivariate predictors. The results of this study will help inform class content, improve class attendance, and identify attendees' characteristics.

Decision Support for a Woman Considering Continuing Extended Endocrine Therapy for Breast Cancer: A Case Study.

This case study evaluated decision coaching with a breast cancer survivor considering continuing extended endocrine therapy from eight years to 10 years. The survivor, aged 58 years and who completed surgery and chemotherapy eight years ago, was concerned about side effects of endocrine therapy. Decision coaching based on the Ottawa Decision Support Framework involved an oncology nurse using the Ottawa Personal Decision Guide. Compared to baseline (2 out of 4), decisional comfort improved (3 out of 4) post decision coaching. The survivor felt more certain, but wanted further advice from her oncologist. She was leaning toward discontinuing endocrine therapy given she valued quality of life over a small risk of recurrence. Audio-recording analysis using the Decision Support Analysis Tool revealed high decision coaching quality (10/10). Breast cancer survivors facing preference-sensitive decisions about extended endocrine therapy could be supported with decision coaching by oncology nurses to ensure informed values-based decisions.