Assessing Impact of CCO's PSO & PC Pathway in Ambulatory HNC Clinics
Condition: Head and Neck Cancer; Supportive Care
MeSH terms: Head and Neck Neoplasms
Study type: Interventional

Summary: 
      Rates of depression and anxiety in cancer patients are much higher compared to the general
      population. 40% of head and neck cancer patients will develop significant distress along the
      cancer journey. Less than half of these patients are able to access support, with factors
      such as age, social difficulty, cancer stage and site affecting referral. In 2016, 78,000
      Canadians died of cancer, yet there is limited implementation of routine and integrated
      advanced care planning in cancer care.

      An upcoming deliverable of all cancer centres in Ontario is the integration of Cancer Care
      Ontario's Psychosocial and Palliative Care (PSOPC) pathway into all disease pathways.
      Successful widespread implementation of this pathway at Odette Cancer Centre (OCC) will
      impact >16,000 patients/year. If effective, it will reduce suffering, unnecessary healthcare
      utilization, improve treatment decisions and compliance, enable a better quality of life in
      survivorship and improve quality at end of life. There is a need for better developed,
      standardized response pathways to address PSO and PC needs throughout the patient's journey.
    

Detailed description: 
      Head and neck cancer (HNC) is the sixth most commonly diagnosed cancer worldwide. Individuals
      with HNC experience a high burden of symptom-related distress (e.g. emotional, physical,
      psychological, spiritual etc.). Additionally, HNC patients may experience facial
      disfigurement, communication barriers, social stigma, lack of social support, and/or
      self-imposed or experienced disease stigma. The presence of depression, anxiety or social
      difficulty is relatively common in HNC patients yet less than half of those with significant
      distress access psychosocial (PSO) and palliative care (PC). Few studies have examined a
      systematic response to reducing distress, integrating a routine psychosocial and palliative
      care approach to oncology, with planning for future care for this population.

      Most cancer centres do not have a systematic model of practice geared towards distress
      screening, PC and PSO approach to care. Therefore, determining how to best incorporate PSO
      and PC (PSOPC) into the interprofessional oncology clinic management of patients with HNC
      remains an important and unanswered question. The question remains of how to proactively
      identify those at higher risk for distress and greater need for specialized psychosocial or
      palliative care. Some oncologists consider the provision of PSOPC as an integral part of
      their professional role. Yet increasing the delivery of quality primary PSOPC by busy
      oncologists may require targeted training, the use of algorithms to prompt PC and PSO
      assessment, incorporating response to distress screening / advanced care planning tools into
      routine clinical processes, prompts to document conversations about illness understanding and
      consideration of individual factors influencing treatment decisions.

      The primary goal of this study is to integrate quality primary level PSO and PC into clinic
      care by developing and evaluating a routine response to screening in hopes of increasing
      documentation of the following: discussion of response to ESAS, illness understanding,
      advanced care planning or goals of care conversations.

      Specifically, this study will examine the impact of Cancer Care Ontario's (CCO) PSOPC
      Pathway, an expert panel recommended algorithm for assessing and managing symptoms and
      initiating a PSOPC approach and timely specialized referral, when necessary.

      Phase Two: Randomized Controlled Trial

      After completing the needs assessment and interprofessional team training in PSO and PC, an
      RCT will be used to examine the impact of using a standardized PSOPC pathway approach,
      prompted follow up with patients and documentation. Participants will be recruited and
      randomized into care as usual group and "intervention" PSOPC pathway group.

      Main Hypothesis:

      It is hypothesized that compared to treatment as usual, the PSOPC pathway intervention group
      will result in an increase in (larger proportion of):

      Rationale and Objective:

      Innovation: Model of clinical service delivery Currently, there is no standardized process
      for meeting the psychosocial and palliative care needs of HNC. This project promotes
      learner,needs-driven professional development, and knowledge translation. It will foster a
      person-focused, results-driven, integrated and sustainable model of clinical service
      delivery.

      Individual clinics and cancer centres have developed their own responses to Edmonton Symptom
      Assessment System (ESAS) distress screening. However, we believe this project is a unique
      Oncology Team/PC/PSO/Patient Advisor collaboration, where all members will work together to
      improve symptom assessment and management, improve discussions and documentation involving
      illness understanding and advanced care planning to better meet PSO and PC needs, whilst
      assessing the role for the PSOPC Pathway.

      An additional innovation for this project is to develop and evaluate a customizable approach
      to assessing the needs of an oncology team, thereby shaping both professional development
      experiences and determining a model of care delivery that should be acceptable within the
      clinic frame.

      Improving Healthcare and Patient Experience:

      The CCO PSOPC pathway was designed to guide improvements in the provision of primary PSOPC
      Care, including symptom response, communication, illness understanding, advanced care
      planning, as well as increased identification of those who require access to specialized PSO
      and PC beyond the skill set of the oncology team. An inaccurate illness understanding
      (whether the cancer is curable or not and whether it is progressing) hinders informed
      discussions and decisions and supportive end of life planning. And, while some patients with
      moderate to severe ESAS ratings have their symptoms assessed and managed, this is not the
      case for all patients. Earlier advanced care planning discussions help patients and their
      families have a better understanding of the disease to make more personalized, informed
      decisions about care.
    

Intervention name(s): PSOPC pathway approach
Intervention type(s): Other
Intervention description(s): The intervention will use a standardized PSOPC pathway approach, prompted follow up with patients and documentation.
Additionally, clinicians will be prompted to document conversations about response to emotional or physical ESAS symptom scores, symptom management plan (self/education/monitoring/medication), illness understanding; and, if necessary, an offer of PSO/PC referral.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized Controlled Trial
After completing HNC staff interprofessional team training in PSO and PC, an RCT will be used to examine the impact of using a standardized PSOPC pathway approach, prompted follow up with patients and documentation. Participants will be recruited and randomized into (1) care as usual group and (2) "intervention" PSOPC pathway group.
Masking: None (Open Label)
Primary purpose: Supportive Care