Simplifying Survivorship Care Planning

Study Overview
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Brief Summary
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OBJECTIVE: The purpose of this study is to identify an SCP process that is patient-centered, effective in promoting appropriate survivorship care and can be successfully implemented for patients with different types of cancer who are being treated in a broad range of clinical settings. There is a need for research related to SCP that prioritizes outcomes that are most highly valued by patients, caregivers and clinical stakeholders.

Detailed Description
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BACKGROUND: Each year, approximately 1.6 million people are diagnosed with cancer and the relative 5-year survival rate across all cancer types approaches 70%. As of 2014, there were almost 15 million Americans living with a history of cancer. Cancer survivors face a variety of health care needs, including surveillance for recurrence, treatment for long-term and late effects of cancer and its treatment, general primary and preventive care, management of any comorbidities, encouragement of healthy lifestyle behaviors, and attention to psychosocial issues. In 2005, the Institute of Medicine (IOM) report 'From Cancer Patient to Cancer Survivor: Lost in Transition' highlighted the challenges that cancer survivors face as they transition from acute treatment. The completion of acute cancer treatment is a critical juncture at which patients are in need of better support and communication to ensure optimal health and quality of life outcomes as they transition to long-term survivorship. Cancer survivors face substantial deficiencies in the quality of care that they receive, including both underuse of recommended care and overuse of services that are not recommended for routine follow-up. The 2005 IOM report called for all patients completing acute treatment to be provided with a survivorship care plan (SCP) that summarizes treatments received and outlines future healthcare priorities in order to facilitate effective management of health care between survivors and their oncology and primary care providers. STUDY PROCEDURES: The primary aim of this trial is to assess whether there is a difference among three SCP models of varying levels of resource intensity and patients' receipt of recommended health services in the months following completion of acute treatment. The investigators will conduct a randomized controlled trial (RCT) to measure whether the provision of the SCP to the survivor and primary care provider (PCP) is associated with survivors' receipt of cancer follow-up care as outlined on their SCP (primary outcome). Avoidance of non-recommended care, receipt of recommended primary and preventive care, and patient-reported outcome measures will serve as secondary endpoints. Participants in the RCT will have been treated for breast, prostate, or colorectal cancer. This RCT will be conducted in four oncology clinics in two medical systems. The investigators will enroll survivors of Stage I-III breast, prostate, or colorectal cancer who are completing treatment and transitioning to long-term survivorship, and use a stratified randomization to assign participants to one of three study conditions (Arms A, B or C). This study will focus specifically on the period following completion of acute treatment (e.g., surgery, radiation, and chemotherapy); patients receiving long-term adjuvant endocrine/antibody therapies will also be eligible. The proposed trial will be conducted at Johns Hopkins Medical Institution (JHMI) and Peninsula Regional Medical Center (PRMC). JHMI is a large, academic medical center in an urban setting with distinct treatment programs based on disease site. At JHMI, the investigators will recruit from the Breast Cancer Program, the Genitourinary Cancer Program (prostate cancer), and Gastrointestinal Cancer Program (colorectal cancer). These programs operate across disciplines (e.g., medical, radiation, and surgical oncology) but separately from each other, enabling evaluation of 3 separate clinical settings within JHMI. In addition, the trial will include the PRMC Richard A. Henson Cancer Institute, a community cancer program located in the rural area of Maryland's eastern shore. At PRMC there is a single general oncology practice. The four programs differ in the extent to which survivorship care planning is already a part of routine care. As yet, none of the clinics in this study has a consistent format for the delivery of SCP universally at the completion of acute treatment. The study design (cancer types, clinical systems and SCP models) is intended to enable the development of real-world best practices for the implementation of SCPs and assess whether these are consistent or vary across a wide range of clinical contexts and survivor characteristics. Each participant will be followed for 18 months, with the number of visits dependent on the randomization arm (described below). The investigators will abstract 18 months of follow-up data for enrolled patients from medical records, as well as from patient reports of health service use; data will be collected at months 6, 12, and 18. The investigators will obtain and abstract medical records guided by the information in the summary document (see Health Services Use Summary included as a supplemental study document) and from the patient using provided tracking tools of providers they have seen, tests they have undergone, etc. (see Tip Sheet in supplemental study documents). Patient-reported outcomes will be collected at baseline, 6, 12, and 18 months primarily via a REDCap form, with telephone or in-person data collection as a back-up when needed.

Official Title
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Simplifying Survivorship Care Planning; Comparing the Efficacy and Patient-Centeredness of Three Care Delivery Models

Conditions
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Cancer

Intervention / Treatment
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* Behavioral: Care Plan Only
* Behavioral: Care Plan During a Visit
* Behavioral: Care Plan During a Visit with an Additional Visit


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 21 years or older; Diagnosed with breast, colorectal, or prostate cancer (stages I-III); Treated with intent to cure People who are on long-term (>1 year) chronic treatment are eligible; No evidence of disease; Able to complete the study data collection in English; Had their cancer care primarily managed by either JHMI or PRMC, with JHMI or PRMC primarily responsible for the patients' survivorship care; and Has private insurance, or covered by Medicare or Medicaid. Exclusion Criteria: Younger than 21 years of age; Diagnosed with in situ or metastatic breast, prostate or colorectal cancer (i.e. Stage 0 or IV); Not treated with intent to cure; Did not have cancer care primarily managed within one of the 4 participating clinics, or JHMI or PRMC is not primarily responsible for the patients' survivorship care; and Does not have health insurance at screening.

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: ARM A<br>SCP document delivered to the patient & Primary Care Provider | Behavioral: Care Plan Only<br>* Patient participants randomized to Arm A will be sent a copy of the SCP within 3 months of completion of treatment and a copy will be added to their medical record. A copy of the SCP will also be sent to the PCP on record. The SCP will be completed by a nurse, nurse practitioner, or physician assistant. The SCP will be accompanied by a cover letter that will be signed by a member of the clinical team.<br>|
| Experimental: ARM B<br>SCP document provided to the patient in an in-person survivorship visit and copy sent to PCP | Behavioral: Care Plan During a Visit<br>* Patient participants randomized to Arm B will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider on record. The visit will be scheduled after consent is signed and will occur between 1 and 3 months after completion of treatment. The visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues.<br>|
| Experimental: ARM C<br>SCP document provided to the patient in an in-person survivorship visit with an additional follow-up visit and copy of the document sent to PCP | Behavioral: Care Plan During a Visit with an Additional Visit<br>* Participants randomized to Arm C will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider. The visit will be scheduled after consent is signed and will occur between 1-3 months after completion of treatment. The initial visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. Patients will also receive a follow up survivorship visit 7-10 months after the end of treatment that will focus on a review of the SCP and offer the opportunity to ask about any persistent or emerging issues.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Receipt of appropriate cancer-related follow-up care | The primary endpoint of this study will be the proportion of patients who receive appropriate cancer-related follow-up care (based on the individual's SCP). The outcome will be operationalized as a dichotomous variable (received recommended care: yes/no). This endpoint will be used to determine the preferable delivery modality (study arm). | 18 Months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Receipt of appropriate primary care | This outcome will be operationalized as a dichotomous variable (received recommended primary care: yes/no). | 18 Months | 
| Receipt of appropriate preventive care | This outcome will be operationalized as a dichotomous variable (received recommended preventive care: yes/no). | 18 Months | 
| Not receiving tests that are not recommended | This outcome will be operationalized as a dichotomous variable (did not receive inappropriate care: yes/no). | 18 Months | 
| Receipt of individual care services. | For example, the primary dichotomous outcome for colorectal cancer patients may include receipt of colonoscopy and CEA testing; we will examine receipt of each of those services separately. Each of these outcomes will be operationalized as a dichotomous variable (received colonoscopy: yes/no). | 18 Months | 
| Patient-reported Outcomes: Preparing for Life as a (New) Survivor (PLANS) | Scores will be compared at different timepoints for the assessment: Preparing for Life as a (New) Survivor (PLANS): 11 knowledge items rated on a 4-point Likert scale that was developed at the University of Michigan and was used by our team in a previous survivorship care planning evaluation (Dunn, R., Crowley, S., & Janz, N., 2011; Smith et al., 2016). | 18 Months | 
| Patient-reported Outcomes: Assessment of Survivor Concerns (ASC) | Scores will be compared at different timepoints for the assessment: Assessment of Survivor Concerns (ASC): a 5-item questionnaire that assesses two subscales: cancer worry and general health worry (Gotay, C. C., & Pagano, I. S., 2007; Hershman, D. L., et al., 2013). | 18 Months | 
| Patient-reported Outcomes: Follow-up Care Use among Survivors (FOCUS)-Information Needs Module | Scores will be compared at different timepoints for the assessment: Follow-up Care Use among Survivors (FOCUS)-Information Needs Module (Kent, E. E., et al., 2012): an information needs questionnaire that asks about the need for information regarding 12 topics; developed by the National Cancer Institute based on previously published information needs questionnaires (Beckjord, E. B., et al., 2008; Mallinger, et al., 2005; Nelson, et al., 2004). | 18 Months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Oncology, Survivorship