MODULE 3
TOOLBOX FOR PROVIDING CANCER SURVIVORSHIP CARE
Introduction
This module will provide an overview of the key elements and evidence based
tools and resource to support survivorship care. The specific elements
reviewed in this module do not provide an exhaustive list and they are not
mutually exclusive. They have been selected to provide exemplars of
strategies that you may find useful in providing survivorship care.
In this module
This module covers Therapeutic Communication- good communication skills
and goals they address; Framework for Supportive Care- the tiered
Supportive Care model; Multidisciplinary Care- skills required and who’s
involved; Survivorship Care Plans- what goes in them and who writes them;
Shared Care- how to effectively follow up with the GP Shared Care model;
and Promoting Quality in Survivorship Care- implementing and evaluating
quality programs.
Therapeutic communication
Good communication skills are criteria to all aspects of healthcare. Effective
communication can reduce stress, feelings of anxiety and uncertainty in
individuals. In the context of cancer survivorship, communication serves to
address particular goals that are essential to good outcomes. These goals
include: identification of individual needs; development of a therapeutic
relationship; meeting information needs in regarding diagnosis and treatment
plans; reducing distress; and development of the individual’s selfmanagement skills. There are a number of strategies integral to effective
communication.
Take some time to complete the following activities, to review these strategies
and reflect on your skills in these areas. While you’re watching, see how many
of the following exemplars of effective communication you can notice.
Communication training
Communicating with people affected by cancer has been identified as a
significant source of stress for cancer specialists. Breaking bad news and
feeling inadequately trained to communicate effectively contributes to
practitioner stress. There stressors can also extend to communication about
survivorship, especially when communicating about the challenges and
uncertainty that the cancer survivor may experience. Good communication
skills do not necessarily improve over time or with clinical experience, but they
can be learned. Approaches which improve communication skills include:
communication skills training, organisational changes to improve processes
and efficiency, and professional clinical supervision.
When you have time, watch the International Psycho-Oncology Society’s
Online Curriculum: Communication and Interpersonal Skills in Cancer Care
webinar. The webinar takes approximately 45 minutes. Upon completion of
the webinar, list 5 changes you could make to your practice to improve
communication with cancer survivors.
Framework for supportive care
Supportive Care interventions can prevent or minimise adverse effects in
survivors. Supportive Care embraces the full range of issues that emerge for
an individual as the impact of cancer and treatment is felt, and the person
tries to deal with the situation. In the context of cancer, Supportive Care
includes self-help and support, information, psychological support, symptom
control, social support, rehabilitation, spiritual support, palliative care and
bereavement care. Fitch defines 5 standards of Supportive Care that provide
a useful framework for Survivorship Care, which have been adapted for this
module as follows: all individuals receive ongoing Supportive Care needs
screening according to need; where necessary individuals receive ongoing
supportive care screening; all individuals have the opportunity to be referred
to an appropriate Supportive Care resource; all individuals have the
opportunity for self referral to Supportive Care resources, all individuals have
access to understandable relevant information regarding the medical,
practical and emotional aspects of their cancer and its treatment; and all
individuals receive Supportive Care that is relevant to their needs and
sensitive to their age, gender, language, culture, sexual preferences, religion
and economic status.
The tiered model of Supportive Care can be useful when developing a plan of
care. This model is consistent with the Risk Stratification Approach,
recommended for Survivorship Care. More information about the Risk
Stratification Approach can be found in Module 2.
Framework for supportive care activity
Describe specific examples of strategies to meet the following standards for
supportive care provision in Survivorship Care: All individuals receive ongoing
supportive care screening according to need; and all individuals have the
opportunity to be referred to an appropriate Supportive Care resource relevant
to their need or preference.
In your response, consider screening and assessment tools, clinical
resources, support services, multidisciplinary teams, referral pathways and
networks. The Supportive Cancer Care Victoria Project developed a suite of
resources to guide supportive needs screening and assessment. You can see
these 3 links on the screen. The National Cancer Survivorship Initiative in
England has a suite of resources including the 2 listed. The Supportive
Cancer Care Victoria Project developed a suite of resources to guide
supportive needs referral.
Multidisciplinary care
The importance of the multidisciplinary team during a person’s treatment
phase is well recognised. While there has been less attention given to the role
of multidisciplinary approaches in cancer survivorship, a multidisciplinary
approach is necessary to meet the Supportive Care needs of cancer
survivors, and to develop and implement a cancer Survivorship Care plan.
Skills that assist healthcare professionals to confidently introduce a
multidisciplinary team discussion and approach to Survivorship Care include
understanding the purpose and need for a multidisciplinary approach to
cancer Survivorship Care, and knowledge of the role of team members.
A Cochrane review of interventions to enhance return to work for cancer
patients, reported on the significant role of the multidisciplinary team. 3
multidisciplinary interventions involving physical training, in combination with
patient education, vocational counseling, training of coping skills regarding
return to work, or behavioural biofeedback, suggested that multidisciplinary
interventions lead to higher return to work rates than carers usual.
Rehabilitative approaches play a role in improving functional outcomes for
cancer survivors. Such approaches require a multidisciplinary team.
The following diagram illustrates the various contributions of members of the
multidisciplinary team to cancer rehabilitation.
Faces of cancer rehabilitation
Different patients will have different rehabilitation needs depending on the
type, location and stage of their cancer. Click on the boxes to see what
specialist interventions each team member might deliver.
Faces of cancer activity 1
Access the Supportive Cancer Care Victoria resource Scenario 4:
Multidisciplinary Team Communication.
Louise, a 55 year old, presents after finding a lump in her breast. She has a
past history of Hodgkin’s Lymphoma 20 years ago and breast cancer 12
months ago. She’s attending the late effects clinic and requires review by the
MDT. Review the interaction demonstrated in the video, and identify
strategies which facilitated effective interactions amongst the team. The video
goes for about 5 minutes. When you’re finished watching the video, click the
button to view a list of elements of effective communication that have been
identified.
Faces of cancer activity 2
Consider how you would support Louise to meet her Supportive Care needs
in your health service. Identify members of the multidisciplinary team in your
health service who would be involved in Louise’s care.
When you’re finished, click the MDT text to see a list of team members you
should consider involving.
Faces of cancer activity 3
Describe strategies used in your health service to ensure continuity of care
and effective communication between members of the MDT and the cancer
survivor.
In developing your response, consider the Livestrong Essential Elements
recommendations regarding the need for a Care Coordination Strategy. The
Care Coordination Strategy provides guidance for what services or activities
should be included as part of Survivorship Care and who is responsible for
overseeing this care.
When you’re finished click anywhere on the screen to see what elements
should be included in a Care Coordination Strategy.
At a basic level, a care coordination strategy should include: asking or
prompting a survivor during a clinic visit to identify other members of the team,
maintaining updated contact information for this team in the medical record,
providing specific guidance to the survivor on who they should include on their
healthcare team, and developing a treatment summary and survivorship care
plan which should be shared with all providers of their healthcare. At an
enriched level, this strategy is further integrated into an electronic health
records system with the ability to document and correspond with all members
of the survivor care team.
Survivorship care plans
Survivorship Care Plans are recommended to achieve an individualised and
coordinated approach to survivorship care. Survivorship Care Plans are
formal, written documents that provide details of a person’s cancer diagnosis
and treatment, potential late and long term effects arising from the cancer and
its treatment, recommended follow up and strategies to remain well.
Survivorship Care Plans are also a tool to delineate which provider is
responsible for which aspect of care.
The Institute of Medicine recommends that each person who completes
primary treatment for cancer, receive a comprehensive care summary and
follow up plan. This needs to be clearly and effectively explained to the
survivor.
Review the Survivorship Care Plan currently used in your healthcare service.
Does it meet the current recommendations identified on the rest of this slide?
If your health service does not have a Survivorship Care Plan, access the
example from the Australian Cancer Survivorship Centre at the Peter
MacCallum Cancer Centre. It is acknowledged that there is variation in
opinion regarding ideal content of the Survivorship Care Plan, who might
prepare it and how it might be discussed and utilised.
Development of the Survivorship Care Plan.
The Institute of Medicine recommends that the plan be written by the principle
specialists who provided the cancer treatment. The survivor needs to be
involved in the development of the Survivorship Care Plan, as care should be
responsive to the individual’s goals and needs.
The following is some recommendations for content included in Survivorship
Care Plans: the cancer for which the survivor receive treatment, short term
and long term effects of treatment, screening guidelines and symptoms of
cancer recurrence, how the survivor’s follow up care plan will be coordinated,
lifestyle changes needed to reduce the risk and severity of treatment side
effects, useful community resources should the survivor encounter
employment and insurance issues, information about fertility planning for
patients of reproductive age, and survivor’s values and preferences regarding
their care. Integration of Survivorship Care Plans into electronic health
records through automated, programmable applications is an important future
goal.
Associate Professor Michael Geofford, director of the ACFC cautions that
“While the use of care plans might make intuitive sense, or have good face
validity, their impact has not been formally evaluated. There are a number of
challenges to their routine use, most obviously who will produce the
document, how can it easily be tailored to an individual person, who will
discuss the document and how should it be used to enhance outcomes for
survivors.” We await further evaluation and publication.
Shared care
Ideally, a shared care model using a Risk Stratified approach can take
advantage of the expertise of the cancer team and the primary care provider
in coordinating survivor follow up. In a shared care model, cancer survivors
continue to have face-to-face, phone or email contact with professionals, as
part of continuing follow up. An increasing proportion of follow up care is likely
to be performed by primary care teams. Several studies of follow up in
primary care, versus secondary care settings, found no statistically significant
difference in patient wellbeing and satisfaction, and disease related outcomes,
including survival. Improved communication between primary and secondary
care has been identified as key to greater general practitioner involvement in
Survivorship Care.
Click on the link to see the Cancer Council Victoria’s resource- Cancer in
General Practice: A Practical Guide for Primary Healthcare Nurses.
Shared care activity
Watch the video mentioned on the previous slide “Cancer In General Practice:
A Practical Guide for Primary Healthcare Nurses- A Focus on Survivorship”,
and reflect upon the following issues when watching the experts speak: how
can survivors be assured a smooth transition between acute care and general
practice, what existing tools and practices can assist the patient’s transition to
the survivorship phase, how can primary healthcare nurses best assist
patients to ensure that their needs are met, and what are some of the
challenges for primary healthcare nurses in providing appropriate care for
cancer survivors.
You can click the buttons on the screen to see some examples of how these
issues may be resolved.
Promoting quality in survivorship care
Effective translation of guidelines and recommendations to implementation of
programs for Survivorship Care requires active planning, systematic
prioritisation and system changes to ensure sustainability. This figure outlines
one example of the process by which organisations can implement and
evaluate survivorship programs. The process is an ongoing and continuous
one of evaluation and input.
Click on each circle to find out more about each item.
Survivorship research
Further research is required to develop evidence to support the delivery of
effective Survivorship Care to meet survivor needs. In the latest National
Comprehensive Cancer Network Survivorship Guidelines, opportunities for
research have been identified and these are: linking specific cancer types or
treatments with specific late effects; developing increased understanding of
the prevalence of, mechanisms of, and risk factors for late and long term
effects of cancer and its treatment; defining interventions that relieve
symptoms, restore function and improve the quality of life of survivors; and
defining optimal follow up and surveillance schedules for cancer survivors
after treatment.
In Australia, it has also been recommended that progress is needed in the
areas of: survivorship issues in the specific populations, the influence of
lifestyle factors and behaviors on the health and wellbeing of survivors, and
flexible and cost effective models for providing Survivorship Care.
Survivorship research activity
Identify a program or intervention used to support cancer survivors in your
health service. Outline key outcomes which should be assessed in evaluating
its impact. In developing your response, you may consider the
recommendations outlined in the linked document “Moving Beyond Patient
Satisfaction: Tips to Measure Program Impact”. To ensure a comprehensive
evaluation of program impact, questions that explore the expected short,
intermediate and long term outcomes should be considered. You can click the
button to see some of these.
In assessing models of care, there are also a number of important elements
that have been identified. You can click the button to see these.
References 1
These 2 slides contain the list of references used to create this module.
Thanks for listening.