Title: Improving support for older patients undergoing treatment for advanced colorectal cancer: A qualitative approach and feasibility study
Funder: Health Education England

Abstract: Aims This programme of work aims to improve how the NHS offers support to older people undergoing treatment for advanced colorectal cancer (aCRC). It aims to identify evidence for best practice in the care of older people undergoing treatment for aCRC; identify the experiences of older people undergoing treatment for aCRC and their priorities for care and support; identify which aspects of patient experience or healthcare processes are amenable to modification and improvement; and conduct preliminary testing of a preparation for treatment' consultation with older people having treatment for advanced cancer. Background Over a third of cancers are diagnosed in patients over 75. There is increasing recognition that this patient group has specific needs that need to be addressed, in part because they may also be dealing with other factors affecting the elderly, including comorbidities, general frailty and social isolation. Thus far, the focus in the literature in terms of older people receiving cancer treatment has largely been on the relationship between age and clinical decision-making, rather than on what support patients and their families might need while treatment is underway, and how the NHS can effect this. Research Questions 1)What is the evidence for best practice in the care of older people undergoing treatment for advanced cancer? 2)What are the experiences and priorities for care and support of older people undergoing treatment for aCRC? 3)Which aspects of patient experience or healthcare processes are amenable to modification and improvement? 4)How might future interventions, resources, and research be targeted to improve experience and health outcomes for patients undergoing treatment for aCRC? 5)What is the role and contribution of a preparation for treatment' consultation with older people having treatment for aCRC with respect to experience and outcomes? Plan of investigation The programme of work will contain 4 linked workstreams (WS1-WS4), based on the MRC Guidance on the Development and Evaluation of Complex Interventions.WS1: Systematic review of best practice in the care of older people (75 years of age) undergoing treatment for advanced colorectal cancer. WS2: Formulation of a series of case studies using qualitative methodologies (interviews and observation) to understand the experiences of older people undergoing treatment for advanced colorectal cancer, and their priorities and expectations for care. These data, combined with data from interviews with family members and healthcare professionals nominated by the patient, will be used to create visual models in the form of cognitive maps which can help identify where interventions can be targeted most effectively.WS3: After consultation with expert panels, a series of recommendations for service development will be generated. WS4: A preparation for treatment' interview will be tested in up to 30 patients and evaluated in order to assess which aspects might contribute to improved outcomes and experience. The exact composition of this intervention will be determined using the results from WS1-3. Summary of the potential benefits to patients and the NHS The major benefits of this programme of work are: a) the development of a series of recommendations for service improvement and b) a preliminary evaluation of a preparation for treatment' consultation and identification of elements for further testing. If the feasibility outcomes are appropriate, a Randomised Controlled Trial can be planned. If patients are better prepared for, and supported through, their cancer treatment, they will experience fewer complications, fewer emergency admissions, and potentially better health outcomes as a result. Ultimately, this programme of work could make a significant contribution to improving outcomes and experiences for this complex, growing patient group, and will suggest the modifications the NHS will need to make in order to meet demand.

Lay abstract: Aim of the research This research aims to improve how the NHS manages the care and support of older people who are having treatment for advanced bowel cancer. Background to the research Over a third of cancers are found in patients over 75 years old. Many have treatment, including drugs (chemotherapy) and radiation (radiotherapy). As well as cancer, older people have other health problems, and might be frail. This can make having treatment for cancer more difficult. At the moment, it is not known what kind of support older people having treatment for cancer want, or the point of view of their family and friends. Knowing this would help the NHS develop ways to offer older patients the support that they need, and help improve their experience. It is hoped that as well as giving patients a better experience, improving cancer services offered to older people will improve their health outcomes in the long term. Design and methods used The research team will: Review previously published studies for evidence of how older patients having treatment for advanced cancer can best be supported. This will help us see what best practice' should look like.Interview 15-20 patients to find out their experiences of having treatment for advanced bowel cancer: what was useful or helpful, and what was difficult and how it might be made easier. Patients will also be asked to name a family member or friend, as well as a health care professional involved in their care (such as their hospital doctor, nurse or GP) they are happy for us to interview. These interviews will reveal how patients are managed by the healthcare system, and what could be done to improve management in the future.Observe patients' clinic appointments with their hospital doctor. This will help us see how decisions are made about patient care. This information will be used to develop a model to show what patients, family members and healthcare professionals think. The model will show where changes could be made to improve support from the healthcare system. This model will be shown to people who are experts in looking after older people and people with cancer. With their help we will put together a list of suggestions on how to improve the service offered to older people with advanced cancer. This will show people who organise the health service what support older people having treatment for cancer want, and what the healthcare system might be able to do for them. Using the results from the above, we will develop and test a preparation for treatment' consultation with older people who are about to start treatment for advanced bowel cancer. The consultation will identify areas where patients might need more support, or help from other services. We will offer the consultation to up to 30 patients, and follow their treatment for 6 months to explore whether it could potentially make a difference to their experience or outcome of treatment. Patients, family members, as well as the patient's cancer doctor, will be asked to evaluate which parts of the consultation were most useful. It is likely further testing will be needed after this small scale testing, and the next step will be for the research team to apply for more money to do this. Patient and public involvement Patients and members of the public will be involved in the research from start to finish. Patients with cancer have already helped to set the research topic and research questions through a group meeting. They will also be involved in making sure the design of the research project is sensible. Two patients will be on the project steering group, and bring their direct experience to make sure the project is useful to patients.Benefits to patients The findings from this research project will be published in journals and taken to conferences and meetings. They will also be taken to patient groups so patients themselves can have input into the changes that could be made. This will make sure that the knowledge is spread throughout the NHS and lead to better care for more patients. The research findings will help the NHS better support older patients who are having cancer treatment. This might mean that they have fewer problems with their treatment, and do not have to be admitted to hospital. Patients, as well as their friends and family, will have a better experience of cancer treatment, and be healthier as a result.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: CANCER AND NEOPLASMS