Integrating survivorship care planning in radiation oncology workflow

Survivorship care plan

This same EHR functionality is leveraged to generate, populate, and maintain the individualized SCP for each breast cancer survivor. The Treatment Summary section of the SCP can be quickly prepared within the EHR by autopopulating data previously entered by treating providers. Content and language for SCP templates in breast, colorectal, prostate, and gynecologic cancers are in use at the time of publication. The templates are developed as a collaborative effort between oncology subspecialists, with input from the UW Health survivor and family advocacy councils.

Each template contains a Treatment Summary section and an SCP section. The Treatment Summary section includes survivor general information, diagnosis and treatment information, and the clinical and supportive/survivor care team names and contact information. The SCP section includes follow-up recommendations, signs of recurrence and/or symptoms to report, healthy lifestyle and maintenance, chronic or late effects of specific treatment if applicable (eg, surgery, chemotherapy by drug, radiation therapy, and endocrine therapy), and general resources for common psychosocial concerns (Table 1).^12,13

Each SCP is visible to the entire health care team, including other specialists and primary care, as long as they have access to UW Health’s EHR.¹⁴ The result is a readily accessible, comprehensive document that is individualized for each survivor, residing in a standard location with standardized format and content to facilitate review and use.¹⁵

General survivorship patient education booklet

Many cancer survivors request additional information about their posttreatment concerns. The “UW Health Facts for You: Cancer Survivorship, Carbone Cancer Center” booklet was developed by a multidisciplinary team including oncologists, advanced practice providers (APPs), navigators, social workers, program leadership, cancer survivors, and caregivers. The guide includes detailed information for the cancer survivor on topics including nutrition, exercise, sleep, tobacco cessation, sexual health, and spirituality. Common concerns and symptom management are addressed as well as a comprehensive list of community resources. The booklet can be found at https://www.uwhealth.org/healthfacts/cancer/7834.
 

Survivorship questionnaire

Breast cancer survivors often have multiple concerns as they transition from active treatment to the survivorship phase of their cancer journey. Specific concerns may vary slightly form one survivor to another. Guided by recommendations for the American Society of Clinical Oncology and the National Comprehensive Cancer Network, we developed a 10-question, 2-page questionnaire to identify those concerns with input from members of the Breast Cancer Steering Committee. Members of the committee include surgical, medical, and radiation oncologists, AAPs, radiologists, pathologists, program leadership, and nurses, along with breast cancer survivors. Elements in the questionnaire include nutrition, activity, mood, sleep, sexual health, employment/insurance, pain/swelling, desires regarding pregnancy or prevention, memory/concentration, smoking, alcohol, genetic testing/counseling, and assistance with establishing care with a primary care provider. By completing the questionnaire, breast cancer survivors identify specific concerns within each category and are able to request additional information about those concerns and/or a referral to appropriate resources. They may also select the I need nothing further option if the concern is present but already being addressed.
 

SCP delivery and the transition visit

The next task in implementation of the care process for survivors encompassed the development of clinical workflows and processes to provide the document to the breast cancer survivor at the completion of treatment. In a study of breast cancer survivors, it was found that the preferred format for survivorship care planning is generally an in-person consultation at completion of treatment with an oncology professional.¹⁶ The best time for distribution of the written SCP is, however, unclear. Intuitively, it seems optimal to distribute SCPs around the time of completion of active treatment. However, for SCP delivery to be feasible and sustainable, delivery must be integrated into existing clinical care-delivery processes, and content must be streamlined and focused to meet the needs of their intended recipients without becoming overly burdensome to prepare and deliver.¹⁷

Ultimately, and after significant multidisciplinary discussion, it was determined that Stage 0-III breast cancer patients would have a visit focusing on symptoms and transitioning to surveillance follow-up (Transition Visit) as they completed active curative-intent cancer treatment. During this Transition Visit, the SCP document would be provided and reviewed with survivors. The Transition Visit for breast cancer survivors would be conducted by an APP following the completion of their final stage of active, primary treatment (surgery, chemotherapy, and/or radiation therapy). Additional long-term adjuvant therapy for breast cancer survivors (ie, trastuzumab, endocrine therapy) would continue as indicated during and after delivery of the SCP.

The radiation oncology clinic was chosen as a venue for these Transition Visits for breast cancer survivors whose treatment included radiotherapy. Despite little historical experience with delivery of SCPs in radiation oncology clinics, this was a logical choice given that radiotherapy is usually the final phase of active treatment for these breast cancer survivors, and a follow-up visit about a month after completing radiotherapy is already part of standard practice. Collaborating with the multidisciplinary UW Health Breast Center, we therefore integrated the formal breast survivorship care planning process and provision of the SCP into the current radiation oncology workflow. About 40% of the roughly 600 breast cancer patients treated by surgical and/or medical oncology at our institution annually also receive radiation therapy at our site. For the remaining 60% of breast cancer survivors who do not receive radiation therapy or who completed radiotherapy at an outside facility, the SCP is provided by an APP within the UW Health Breast Center.