Integrating survivorship care planning in radiation oncology workflow

UW radiation oncology survivorship transition visit

The overall workflow of our Transition Visit is depicted in the Figure. Toward the end of the breast cancer survivor’s radiation treatments, the radiation oncologist instructs the schedulers to arrange the 1-month, post-radiation Transition Visit with the APP and informs the survivor about the nature of the appointment. The Transition Visit is scheduled as a 60-minute appointment. Before the survivor’s arrival, an APP generates the written SCP. The activity includes completing the Treatment Summary, or verifying the accuracy of a prepopulated Treatment Summary, and individualizing the SCP section for the patient based on treatment received and follow-up recommendations using drop-down functionality. As the SCP is printed for review with the survivor, it is simultaneously sent to the survivor’s primary care provider. This is accomplished by using EHR functionality to route the document internally to UW primary care providers or automatically faxing the document to external primary care providers. Each SCP is also marked as complete within the EHR for the purposes of documenting compliance with this activity for later data analysis.

On arrival for the appointment, each breast cancer survivor completes the survivorship questionnaire. During the Transition Visit, the questionnaire is reviewed with the survivor and additional information is provided. Referral options are discussed if indicated with desired referrals made by the APP. The survivor is interviewed and examined for any persistent side effects of treatment. Next, the Treatment Summary and SCP are reviewed with the survivor, emphasizing the follow-up plan, signs or symptoms of breast cancer recurrence, and chronic or late treatment-related toxicities. Ample opportunity is provided for the survivor to ask questions and voice concerns.

Follow-up appointments with members of the patient’s care team (ie, medical, surgical, or radiation oncology) as well as necessary breast imaging (ie, mammogram, MRI) are coordinated and scheduled before the survivor leaves the department. A survey of oncologists (medical, surgical, radiation) identified specific cancer-related components of survivorship care that oncologists felt most responsible for as well as opportunities to improve the quality and efficiency of care provided by oncologists.¹⁸ At our institution, the breast surgical, medical, and radiation oncologists all generally participate in follow-up care through at least 1 year following completion of active, primary treatment.

Outcomes, quality improvement opportunities, and continued challenges with the process

There is presently a lack of long-term outcome data about the impact of SCPs. As mandates for the provision of SCPs are made, research focusing on whether SCPs result in improved health behaviors and outcomes, reduced burden in care transitions from the oncology setting, and increased cost-effectiveness will be needed.¹⁹ The long-term effects of SCPs on psychological, oncologic, and resource outcomes should be evaluated,²⁰ as well as the impact on health behaviors, such as smoking cessation or participation in rehabilitation programs.²¹

Following the implementation of our Transition Visits in 2015, we conducted a quality improvement review. This review included summation of 69 recent breast cancer questionnaires from Transition Visits with our APPs (Table 2 and Table 3). The most common concerns raised by our breast cancer survivors include desire for weight loss, improving diet, and increasing physical activity. Of note, concerns did not often translate into a desire for more information or referrals.²² Survivors were generally satisfied with the timing of the Transition Visits and generally indicated that the visits were helpful, with self-reported improvements in their understanding of planned follow-up. A Canadian group evaluating breast and head and neck cancer survivors has suggested that SCPs could produce long-term improvements in healthy lifestyle behaviors; however, further research is needed to determine the extent to which SCPs might improve follow-up care over the long term.²³

Finally, although efforts to date have been focused on the breast cancer survivor at the completion of treatment, long-term survivors may also benefit from receiving the SCP. A study by the American Cancer Society found that long-term cancer survivors had unmet informational needs, particularly with regard to screening, long-term cancer and treatment effects, and healthy lifestyle behaviors.²⁴ Identifying and subsequently delivering an SCP to eligible long-term survivors is a challenging prospect, which depends on further refinement of EHR-based tracking of the date of diagnosis, cancer stage, and end-of-treatment date.
 

Summary and recommendations

Survivorship care has been efficiently integrated into our 1-month post-radiation follow-up appointment for breast cancer survivors. By using current resources in the radiation oncology department, the process has provided an effective way to deliver the SCP to breast cancer survivors. Future plans include implementing the process for all patients receiving curative-intent radiation for additional solid tumor survivors. Quality improvement projects will be developed to assess survivor satisfaction and the impact on health behaviors.