Advertisement

Journal of Cancer Survivorship

, Volume 6, Issue 4, pp 359–371 | Cite as

Models of care for post-treatment follow-up of adult cancer survivors: a systematic review and quality appraisal of the evidence

  • D. HowellEmail author
  • T. F. Hack
  • T. K. Oliver
  • T. Chulak
  • S. Mayo
  • M. Aubin
  • M. Chasen
  • C. C. Earle
  • A. J. Friedman
  • E. Green
  • G. W. Jones
  • J. M. Jones
  • M. Parkinson
  • N. Payeur
  • C. M. Sabiston
  • S. Sinclair
Reviews

Abstract

Purpose

The impact of cancer and cancer treatment on the long-term health and quality of life of survivors is substantial, leading to questions about the most appropriate configuration of services and models of care for follow-up of post-primary treatment survivors.

Methods

A systematic review and quality appraisal of the health literature for structure of services and models of follow-up care for post-treatment survivors was identified through a search of guideline sources and empirical databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Library, CINAHL, and EBSCO from 1999 through December 2009.

Results

Ten practice guidelines and nine randomized controlled trials comprised the evidence base for models of care for adult cancer survivors. Although the evidence base was rated as low quality, nurse-led and primary care physician models of follow-up care were equivalent for detecting recurrence. Consensus also suggests that cancer survivors may benefit from coordinated transition planning that includes the provision of survivorship care plans as part of standard care.

Conclusions

Realignment of models of care is identified as a health system priority to meet the supportive care and surveillance needs of a burgeoning survivor population. Further research is needed to evaluate the efficacy of models of care in a broader population of cancer survivors with differing needs and risks. While the evidence is limited, there is research that may be used to guide the configuration of health care services and planning.

Keywords

Psychosocial and supportive care Cancer survivorship Organization of care Delivery structure Care plan Systematic review 

Notes

Acknowledgments

The survivorship expert panel would like to thank Ms. Sandra Costa for her assistance in the preparation of the manuscript. We thank Fay Bennie for her administrative support and Margaret Thompson who provided her insights as a cancer survivor and advocate, and expert in adult education. The systematic review evidence informed development of a guideline made possible through a grant from Health Canada, through the Canadian Partnership Against Cancer.

Conflict of interest

Each author completed conflict of interest forms, and forms were centrally collected and filed. None of the authors declared any real or perceived potential conflicts of interest associated with this systematic review of the evidence.

Editorial independence

The authors are editorially independent of any funding sources. The views and interests of the funding sources have not influenced the conclusions derived in this document.

References

  1. 1.
    Hewitt M, Greenfield S, Stovall E, editors. From cancer patient to cancer survivor: lost in transition. Washington: National Academies Press; 2006.Google Scholar
  2. 2.
    Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol. 2006;24(32):5117–24.PubMedCrossRefGoogle Scholar
  3. 3.
    Burton AW, Fanciullo GJ, Beasley RD, Fisch MJ. Chronic pain in the cancer survivor: a new frontier. Pain Med. 2007;8(2):189–98. See comment.PubMedCrossRefGoogle Scholar
  4. 4.
    Correa DD, Ahles TA. Neurocognitive changes in cancer survivors. Cancer J. 2008;14(6):396–400.PubMedCrossRefGoogle Scholar
  5. 5.
    Fossa SD, Vassilopoulou-Sellin R, Dahl AA. Long term physical sequelae after adult-onset cancer. J Cancer Surviv. 2008;2(1):3–11.PubMedCrossRefGoogle Scholar
  6. 6.
    Mancini J, Rey D, Preau M, Malavolti L, Moatti JP. Infertility induced by cancer treatment: inappropriate or no information provided to majority of French survivors of cancer. Fertil Steril. 2008;90(5):1616–25.PubMedCrossRefGoogle Scholar
  7. 7.
    Matei D, Miller AM, Monahan P, Gershenson D, Zhao Q, Cella D, et al. Chronic physical effects and health care utilization in long-term ovarian germ cell tumor survivors: a gynaecologic oncology group study. J Clin Oncol. 2009;27(25):4143–9.CrossRefGoogle Scholar
  8. 8.
    Minton O, Stone P. How common is fatigue in disease-free breast cancer survivors? A systematic review of the literature. Breast Cancer ResTreat. 2008;112(1):5–13.CrossRefGoogle Scholar
  9. 9.
    Mao JJ, Armstrong K, Bowman MA, Xie SX, Kadakia R, Farrar JT. Symptom burden among cancer survivors: impact of age and co-morbidity. JABFM. 2007;20(5):434–43.PubMedCrossRefGoogle Scholar
  10. 10.
    Peuckmann V, Ekholm O, Sjogren P, Rasmussen NK, Christiansen P, Moller S, et al. Health care utilisation and characteristics of long-term breast cancer survivors: nationwide survey in Denmark. Eur J Cancer. 2009;45(4):625–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Polomano RC, Farrar JT. Pain and neuropathy in cancer survivors. Cancer Nurs. 2006;29(2 Suppl):39–47.PubMedCrossRefGoogle Scholar
  12. 12.
    Richardson LC, Wingo PA, Zack MM, Zahran HS, King JB. Health-related quality of life in cancer survivors between ages 20 and 64 years: population-based estimates from the behavioural risk factor surveillance system. Cancer. 2008;112(6):1380–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Rao AV, Demark-Wahnefried W. The older cancer survivor. Crit Rev Oncol-Haemat. 2006;60(2):131–43.CrossRefGoogle Scholar
  14. 14.
    Roscoe JA, Kaufman ME, Matteson-Rusby SE, Palesh OG, Ryan JL, Kohli S, et al. Cancer-related fatigue and sleep disorders. Oncologist. 2007;12 Suppl 1:35–43.PubMedCrossRefGoogle Scholar
  15. 15.
    Stein KD, Syrjala KL, Andrykowski MA. Physical and psychological long-term and late effects of cancer. Cancer. 2008;112(11 Suppl):2577–92.PubMedCrossRefGoogle Scholar
  16. 16.
    Stewart A, Bielajew C, Collins B, Parkinson M, Tomiak E. A meta-analysis of the neuropsychological effects of adjuvant chemotherapy treatment in women treated for breast cancer. Clin Neuropsychol. 2006;20(1):76–89.PubMedCrossRefGoogle Scholar
  17. 17.
    Meneses KD, McNees MP. Upper extremity lymphedema after treatment for breast cancer: a review of the literature. Ostomy Wound Manag. 2007;53(5):16–29.Google Scholar
  18. 18.
    Stanton AL. Psychosocial concerns and interventions for cancer survivors. J Clin Oncol. 2006;24(32):5132–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Alfano CM, Rowland JH. Recovery issues in cancer survivorship: a new challenge for supportive care. Cancer J. 2006;12(5):432–43.PubMedCrossRefGoogle Scholar
  20. 20.
    Andrykowski MA, Lykins E, Floyd A. Psychological health in cancer survivors. Semin Oncol Nurs. 2008;24(3):193–201.PubMedCrossRefGoogle Scholar
  21. 21.
    Costanzo ES, Ryff CD, Singer BH. Psychosocial adjustment among cancer survivors: findings from a national survey of health and well-being. Heal Psychol. 2009;28(2):147–56.CrossRefGoogle Scholar
  22. 22.
    Mehnert A, Koch U. Psychological comorbidity and health-related quality of life and its association with awareness, utilization, and need for psychosocial support in a cancer register-based sample of long-term breast cancer survivors. J Psychosom Res. 2008;64(4):383–91.PubMedCrossRefGoogle Scholar
  23. 23.
    Pelusi J. Sexuality and body image. Research on breast cancer survivors documents altered body image and sexuality. Am J Nurs. 2006;106(3 Suppl):32–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Meyerowitz BE, Kurita K, D'Orazio LM. The psychological and emotional fallout of cancer and its treatment. Cancer J. 2008;14(6):410–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Tschudin S, Bitzer J. Psychological aspects of fertility preservation in men and women affected by cancer and other life-threatening diseases. Hum Reprod Updat. 2009;15(5):587–97.CrossRefGoogle Scholar
  26. 26.
    Camp-Sorrell D. Cardiorespiratory effects in cancer survivors. Cancer Nurs. 2006;29(2 Suppl):55–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Carver JR, Shapiro CL, Ng A, Jacobs L, Schwartz C, Virgo KS, et al. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. J Clin Oncol. 2007;25(25):3991–4008. See comment.PubMedCrossRefGoogle Scholar
  28. 28.
    Ell K, Xie B, Wells A, Nedjat-Haiem F, Lee PJ, Vourlekis B. Economic stress among low-income women with cancer: effects on quality of life. Cancer. 2008;112(3):616–25.PubMedCrossRefGoogle Scholar
  29. 29.
    de Boer AG, Taskila T, Ojajarvi A, van Dijk FJ, Verbeek JH. Cancer survivors and unemployment: a meta-analysis and meta-regression. JAMA. 2009;301(7):753–62.PubMedCrossRefGoogle Scholar
  30. 30.
    Hoving JL, Broekhuizen ML, Frings-Dresen MH. Return to work of breast cancer survivors: a systematic review of intervention studies. BMC Cancer. 2009;9:117.PubMedCrossRefGoogle Scholar
  31. 31.
    Lee MK, Lee KM, Bae JM, Kim S, Kim YW, Ryu KW, et al. Employment status and work-related difficulties in stomach cancer survivors compared with the general population. Br J Cancer. 2008;98(4):708–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Ganz P. The ‘three Ps’ of cancer survivorship care. BMC Med. 2011;9(14):1–2.Google Scholar
  33. 33.
    Landler W. Survivorship care: essential components and models of delivery. Oncology (Williston Park). 2009;23(4 Suppl Nurse Ed):46–53.Google Scholar
  34. 34.
    Australian Institute of Health and Welfare and Australasian Association of Cancer Registries. Cancer in Australia 2001. Canberra: AIHW; 2004.Google Scholar
  35. 35.
    Davies NJ, Batehup L. Cancer follow-up: towards a personalized approach to aftercare services. A review of current practice and selected initiatives. National Cancer Survivorship Initiative Supported Self-Management Workstream. Macmillan Cancer Support, November 2009, National Health Service, Department of Health.Google Scholar
  36. 36.
    Brown L, Payne S, Royle G. Patient initiated follow up of breast cancer. Psychooncology. 2002;11:346–55.PubMedCrossRefGoogle Scholar
  37. 37.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42. Epub 2010 Jul 5.PubMedCrossRefGoogle Scholar
  38. 38.
    Scottish Intercollegiate Guideline Network. Sign 50: a guideline's developer's handbook. Elliot House: Edinburgh; 2008. At: www.sign.ac.uk. Accessed December 2009.Google Scholar
  39. 39.
    National Comprehensive Cancer Network. Clinical practice guidelines in oncology: colon cancer. Philadelphia: National Comprehensive Cancer Network; 2010. At: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed December 2009.Google Scholar
  40. 40.
    National Comprehensive Cancer Network. Clinical practice guidelines in oncology: rectal cancer. Philadelphia: National Comprehensive Cancer Network; 2010. At: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed December 2009.Google Scholar
  41. 41.
    Hudson SV, Chubak J, Coups EJ, Blake-Gumbs L, Jacobsen PB, Neugut AI, et al. Identifying key questions to advance research and practice in cancer survivorship follow-up care: a report from the ASPO Survivorship Interest Group. Cancer Epidemiol Biomark Prev. 2009;18(7):2152–4.CrossRefGoogle Scholar
  42. 42.
    Association of Community Cancer Centers. Cancer program guidelines. Rockville: Association of Community Cancer Centers; 2009. At: http://www.accc-cancer.org/publications/publications-cpguidelines.asp. Accessed December 2009.Google Scholar
  43. 43.
    Institute of Medicine. Cancer care for the whole patient: meeting psychosocial health needs. Washington: National Academies Press; 2008.Google Scholar
  44. 44.
    Oncoline. Prostate cancer: nationwide guideline, version 1. Netherlands: Dutch Association of Comprehensive Cancer Centres; 2007. At: http://www.oncoline.nl/index.php?pagina=/richtlijn/item/pagina.php&richtlijn_id=575. Accessed May 2010.Google Scholar
  45. 45.
    Katcheressian JL, Wolff AC, Smith TJ, Grunfeld E, Muss HB, Vogel VG, et al. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol. 2006;24:1–7.CrossRefGoogle Scholar
  46. 46.
    Urological Tumours National Working Group. Renal cell carcinoma: nationwide guideline, version 1.1. Netherlands: Dutch Association of Comprehensive Cancer Centres; 2006.Google Scholar
  47. 47.
    Grunfeld E, Dhesy-Thind S, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 9. follow-up after treatment for breast cancer (2005 update). CMAJ. 2005;172(10):1319.PubMedCrossRefGoogle Scholar
  48. 48.
    Grunfeld E, Levine MN, Julian JA, Coyle D, Szechtman B, Mirsky D, et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006;24(6):848–55.PubMedCrossRefGoogle Scholar
  49. 49.
    Wattchow DA, Weller DP, Esterman A, Pilotto LS, McGorm K, Hammett Z, et al. General practice vs surgical-based follow-up for survivors with colon cancer: randomised controlled trial. Br J Cancer. 2006;94(8):1116–21.PubMedCrossRefGoogle Scholar
  50. 50.
    Koinberg IL, Fridlund B, Engholm GB, Holmberg L. Nurse-led follow-up on demand or by a physician after breast cancer surgery: a randomised study. Eur J Oncol Nurs. 2004;8(2):109–17.PubMedCrossRefGoogle Scholar
  51. 51.
    Moore S, Corner J, Haviland J, Wells M, Salmon E, Normand C, et al. Nurse led follow up and conventional medical follow up in management of survivors with lung cancer: randomised trial. BMJ. 2002;325(7373):1145.PubMedCrossRefGoogle Scholar
  52. 52.
    Baildam A, Keeling F, Noblet M, Thomson L, Bundred N, Hopwood P. Nurse led follow up clinics for women treated for primary breast cancer: a randomised controlled trial. Eur J Cancer. 2002;38:363.CrossRefGoogle Scholar
  53. 53.
    Helgesen F, Andersson SO, Gustafsson O, Varenhorst E, Goben B, Carnock S, et al. Follow-up of prostate cancer survivors by on-demand contacts with a specialist nurse: a randomized study. Scand J Urol Nephrol. 2000;34(1):55–61.PubMedCrossRefGoogle Scholar
  54. 54.
    Gulliford T, Opomu E, Hanham I, Epstein R. Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study. Br Med J. 1997;314(7075):174.CrossRefGoogle Scholar
  55. 55.
    Grunfeld E, Mant D, Yudkin P, Adewuyi-Dalton R, Cole D, Stewart J, et al. Routine follow up of breast cancer in primary care: randomised trial. Br Med J. 1996;313(7058):665–9.CrossRefGoogle Scholar
  56. 56.
    Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):669–77.PubMedCrossRefGoogle Scholar
  57. 57.
    Gates P, Krishnasamy M. Nurse-led survivorship care. Cancer Forum. 2009;33(3):1–4.Google Scholar
  58. 58.
    Chomik Consulting and Research Ltd. Supporting the role of primary care in cancer follow-up. Prepared for the Canadian Association of Provincial Cancer Agencies; 2010.Google Scholar
  59. 59.
    Howell D, Marshall D, Brazil K, Taniguchi A, Howard M, Foster G, et al. A shared care model pilot for palliative home care in a rural area: impact on symptoms, distress, and place of death. J Pain Symptom Manag. 2011;42(1):60–75.CrossRefGoogle Scholar
  60. 60.
    Watson EK, Rose PW, Neal RD, et al. Personalized cancer follow-up: risk stratification, needs assessment or both? Br J Cancer. 2012;106:1–5.PubMedCrossRefGoogle Scholar
  61. 61.
    Hudson MM, Landler W, Ganz PA. Impact of survivorship-based research on defining clinical care guidelines. Cancer Epidemiol Biomark Prev. 2011;20:2085–92.CrossRefGoogle Scholar
  62. 62.
    Grunfeld E. Cancer survivorship: a challenge for primary care physicians. Br J Gen Pract. 2005;55(519):741–2.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • D. Howell
    • 20
    • 21
    • 22
    Email author
  • T. F. Hack
    • 2
    • 3
  • T. K. Oliver
    • 4
  • T. Chulak
    • 5
  • S. Mayo
    • 1
  • M. Aubin
    • 6
  • M. Chasen
    • 7
    • 8
  • C. C. Earle
    • 9
  • A. J. Friedman
    • 10
    • 11
  • E. Green
    • 11
  • G. W. Jones
    • 12
    • 13
  • J. M. Jones
    • 14
  • M. Parkinson
    • 15
  • N. Payeur
    • 16
  • C. M. Sabiston
    • 17
  • S. Sinclair
    • 18
    • 19
  1. 1.Faculty of NursingUniversity Health NetworkTorontoCanada
  2. 2.Faculty of NursingUniversity of ManitobaWinnipegCanada
  3. 3.Patient and Family Support ServicesCancer Care ManitobaWinnipegCanada
  4. 4.Department of OncologyMcMaster UniversityHamiltonCanada
  5. 5.Nutrition Sciences, ParticipACTIONTorontoCanada
  6. 6.Department of Family Medicine and Emergency MedicineUniversité LavalQuebecCanada
  7. 7.Palliative Care ProgramUniversity of OttawaOttawaCanada
  8. 8.Palliative Rehabilitation and SurvivorshipElisabeth Bruyere Research Institute and Ottawa Regional Cancer FoundationOttawaCanada
  9. 9.Health Services Research ProgramCancer Care Ontario and the Ontario Institute for Cancer ResearchTorontoCanada
  10. 10.Cancer Patient Education and SurvivorshipUniversity Health NetworkTorontoCanada
  11. 11.Cancer Care OntarioTorontoCanada
  12. 12.Peel Regional Oncology ProgrammeCredit Valley HospitalMississaugaCanada
  13. 13.Department of Radiation OncologyUniversity of TorontoTorontoCanada
  14. 14.Department of Psychiatry, Cancer Survivorship Program, University Health NetworkUniversity of TorontoTorontoCanada
  15. 15.Patient and Family Counselling ServicesBC Cancer AgencyVancouverCanada
  16. 16.Patient and Family Counselling ServicesBC Cancer AgencyVictoriaCanada
  17. 17.Department of Kinesiology and Physical EducationMcGill UniversityMontrealCanada
  18. 18.Manitoba Palliative Care Research UnitUniversity of ManitobaWinnipegCanada
  19. 19.Faculty of Medicine, Calgary, Alberta, and Spiritual Care Services, Alberta Health Services, Tom Baker Cancer CentreUniversity of CalgaryCalgaryCanada
  20. 20.Faculty of NursingUniversity Health Network (Princess Margaret Hospital)TorontoCanada
  21. 21.Psychosocial Oncology and Palliative CareOntario Cancer InstituteTorontoCanada
  22. 22.Lawrence Bloomberg Faculty of NursingUniversity of TorontoTorontoCanada

Personalised recommendations