- Email: [email protected]
Improving Quality of Care for Breast Cancer Survivors
20. Lawenda BD, Taghian AG, Kachnic LA, et al: Dose-volume analysis of radiotherapy for T1N0 invasive breast cancer treated by local excision and partial breast irradiation by low-doserate interstitial implant. Int J Radiat Oncol Biol Phys 56:671680, 2003. 21. Chen PY, Vicini FA, Benitez P, et al: Long-term cosmetic results and toxicity after accelerated partial-breast irradiation: A method of radiation delivery by interstitial brachytherapy for the treatment of early-stage breast carcinoma. Cancer 106:991999, 2006. 22. Woodworth PA, McBoyle MF, Helmer SD, et al: Seroma formation after breast cancer surgery: incidence and predicting factors. Am Surg 66:444-450, 2000. 23. Kestin LL, Goldstein NS, Martinez AA, et al: Mammographically detected ductal carcinoma in situ treated with conservative surgery with or without radiation therapy: Patterns of failure and 10-year results. Ann Surg 231:235-245, 2000.
Improving Quality of Care for Breast Cancer Survivors Karen Lane, MD Currently, there are more than 2 million breast cancer survivors in the United States. A recent and provocative report from the Institute of Medicine Committee on Cancer Survivorship discussed significant problems with coordinating care among breast cancer survivors. A variety of complications can develop after primary treatment of breast cancer, and patients are often unclear where to turn for help. Breast surgeons are most familiar with concerns regarding lymphedema and postmastectomy pain, whereas medical oncologists specialize in chemotherapy sequelae. The treatment of menopausal symptoms and reproductive concerns are often left to primary care physicians who may not have experience with these issues. The President’s Cancer Commission1 and the Institute of Medicine committee have proposed an end-of-treatment summary coupled with a treatment plan (“prescription”) to ensure high-quality care and better coordination of care. In addition, the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) recently published a consensus statement on quality cancer care. One of the 10 stated goals in-
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24. Wong JS, Kaelin CM, Troyan SL, et al: Prospective study of wide excision alone for ductal carcinoma in situ of the breast. J Clin Oncol 24:1031-1036, 2006. 25. Bijker N, Meijnen P, Peterse JL, et al: Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: Ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853—A study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 24:3381-3387, 2006. 26. Vicini FA, Beitsch PD, Quiet CA, et al: First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity: Results of the American Society of Breast Surgeons MammoSite breast brachytherapy trial. Cancer 104:1138-1148, 2005.
volved the provision of a comprehensive care summary for all cancer survivors.2 It seems premature, however, to create and implement this “prescription” before accurately detailing the concerns with follow-up care as seen by the patient. Data on this important topic are currently limited. The most relevant studies are reviewed below, including findings on patient preferences, type of follow-up, demographic discrepancies, use of health care resources, and psychological well-being. In one study, de Bock and colleagues3 analyzed the needs of women who participated in a routine follow-up program after treatment for primary breast cancer. A survey of patients 2 to 4 years after primary treatment indicated that they were most interested in information regarding the long-term effects of treatment and prognosis, discussion of prevention of breast cancer and hereditary factors, and changes in the untreated breast. Patients also preferred that additional x-rays and blood tests be part of the follow-up. Of note, not all patients needed the same information. These findings led the authors to conclude that each individual patient’s information needs and preferences should be identified early and incorporated into the follow-up routine care to target resources and maximize positive outcomes.3 Individualizing follow-up care is clearly important, but a minimum standard of care is a necessity. One concern is that
patients during the survivorship phase will receive a different level of noncancer preventive care than will women without cancer. Earle and colleagues assessed the quality of care among almost 6,000 elderly breast cancer survivors and found that, overall, breast cancer survivors received more preventive services than did matched controls. However, increasing age, African-American race, lower socioeconomic status, living in a rural area, and receiving care at a nonteaching center were all associated with receipt of fewer preventive services. In this study, patients who were followed by both primary care physicians and oncologists were more likely to receive both appropriate follow-up mammography and noncancer–related preventive services.4 These results point out discrepancies in care based on patient characteristics and type of follow-up (ie, that by a primary care physician, an oncologist, or both). However, that study did not assess the patients’ satisfaction with their follow-up care or their perception of the coordination of care among each patient’s physicians. The use of and access to follow-up care has been addressed by Mandelblatt and colleagues, who described health service use in a cohort of breast cancer survivors. After primary treatment of breast cancer, 558 patients completed health diaries for 12 months to assess health care use. The authors concluded that although use of health services is frequent and intensive during the first year after treatment, there is room for improving the receipt of guidelinesuggested surveillance mammography.5 In addition to the need for appropriate surveillance and screening during the survivorship period, patients’ psychological states are critical for their overall well-being. Ganz and colleagues previously reported that long-term survivors of breast cancer show increased emotional disruption, particularly among the youngest patients. Factors that contribute to this reduced quality of life included experiencing a menopausal transition and feeling more vulnerable after cancer.6 Therefore, it seems that improving patients’ follow-up care, including the treatment of menopausal symptoms and symptoms of depression or anxiety, could potentially have long-term effects in improving breast cancer survivors’ quality of life. Another study by Schover and colleagues used a peer counseling program to improve sexual function, increase knowledge about reproductive health, and decrease menopausal symptoms and infertility-related distress for African-American breast cancer survivors. The authors found that knowledge of reproductive issues improved significantly from baseline to 3month follow-up, as did emotional distress and menopausal symptoms.7 These findings support the idea that improving follow-up care will also improve patients’ emotional health.
These preliminary studies all indicate that significant problems remain with respect to follow-up care for breast cancer survivors. To date, however, we have not captured the breadth or substance of these problems. Quantitative (eg, survey) and qualitative (eg, focus group) data are therefore needed to identify urgent follow-up care concerns. Obtaining this information can be best achieved by comprehensively describing the symptoms and care needs of women who have recently completed primary treatment for breast cancer and are now presumably receiving follow-up care. This effort should include both quantitative and qualitative reports of comprehensive needs identification as well as the necessary compatible care resources. Lastly, patients should be given a health diary to record their complications and concerns and their doctor visits to assess how and why survivors are accessing the health care system. Only after this information is obtained would it be feasible to convene a multidisciplinary panel to develop a “prescription” to help guide patients through the survivorship phase of breast cancer. The ultimate goal is to empower patients to act as their own advocates. Such an approach would facilitate the doctorpatient relationship, thereby ensuring the highest quality of care for all patients and allowing patients and their doctors to function as a team to achieve a state of wellness for the lifelong phase of cancer survivorship.
References 1. US Department of Health and Human Services. Living beyond cancer: A European dialogue. Bethesda, MD, 2004, pp 1-47. 2. ASCO-ESMO consensus statement on quality cancer care. J Clin Oncol 24:3498-3499, 2006. 3. de Bock GH, Bonnema J, Zwaan RE, et al: Patient’s needs and preferences in routine follow-up after treatment for breast cancer. Br J Cancer 90:1144-1150, 2004. 4. Earle CC, Burstein HJ, Winer EP, et al: Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol 21:1447-1451, 2003. 5. Mandelblatt JS, Lawrence WF, Cullen J, et al: Patterns of care in early-stage breast cancer survivors in the first year after cessation of active treatment. J Clin Oncol 24:77-84, 2006. 6. Ganz PA, Greendale GA, Petersen L, et al: Breast cancer in younger women: Reproductive and late health effects of treatment. J Clin Oncol 21:4184-4193, 2003. 7. Schover LR, Jenkins R, Sui D, et al: Randomized trial of peer counseling on reproductive health in African American breast cancer survivors. J Clin Oncol 24:1620-1626, 2006.
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Improving Quality of Care for Breast Cancer Survivors Karen Lane, MD Currently, there are more than 2 million breast cancer survivors in the United States. A recent and provocative report from the Institute of Medicine Committee on Cancer Survivorship discussed significant problems with coordinating care among breast cancer survivors. A variety of complications can develop after primary treatment of breast cancer, and patients are often unclear where to turn for help. Breast surgeons are most familiar with concerns regarding lymphedema and postmastectomy pain, whereas medical oncologists specialize in chemotherapy sequelae. The treatment of menopausal symptoms and reproductive concerns are often left to primary care physicians who may not have experience with these issues. The President’s Cancer Commission1 and the Institute of Medicine committee have proposed an end-of-treatment summary coupled with a treatment plan (“prescription”) to ensure high-quality care and better coordination of care. In addition, the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) recently published a consensus statement on quality cancer care. One of the 10 stated goals in-
328 328
®
Breast Diseases: A Year Book Quarterly Vol 17 No 4 2007
24. Wong JS, Kaelin CM, Troyan SL, et al: Prospective study of wide excision alone for ductal carcinoma in situ of the breast. J Clin Oncol 24:1031-1036, 2006. 25. Bijker N, Meijnen P, Peterse JL, et al: Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: Ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853—A study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 24:3381-3387, 2006. 26. Vicini FA, Beitsch PD, Quiet CA, et al: First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity: Results of the American Society of Breast Surgeons MammoSite breast brachytherapy trial. Cancer 104:1138-1148, 2005.
volved the provision of a comprehensive care summary for all cancer survivors.2 It seems premature, however, to create and implement this “prescription” before accurately detailing the concerns with follow-up care as seen by the patient. Data on this important topic are currently limited. The most relevant studies are reviewed below, including findings on patient preferences, type of follow-up, demographic discrepancies, use of health care resources, and psychological well-being. In one study, de Bock and colleagues3 analyzed the needs of women who participated in a routine follow-up program after treatment for primary breast cancer. A survey of patients 2 to 4 years after primary treatment indicated that they were most interested in information regarding the long-term effects of treatment and prognosis, discussion of prevention of breast cancer and hereditary factors, and changes in the untreated breast. Patients also preferred that additional x-rays and blood tests be part of the follow-up. Of note, not all patients needed the same information. These findings led the authors to conclude that each individual patient’s information needs and preferences should be identified early and incorporated into the follow-up routine care to target resources and maximize positive outcomes.3 Individualizing follow-up care is clearly important, but a minimum standard of care is a necessity. One concern is that
patients during the survivorship phase will receive a different level of noncancer preventive care than will women without cancer. Earle and colleagues assessed the quality of care among almost 6,000 elderly breast cancer survivors and found that, overall, breast cancer survivors received more preventive services than did matched controls. However, increasing age, African-American race, lower socioeconomic status, living in a rural area, and receiving care at a nonteaching center were all associated with receipt of fewer preventive services. In this study, patients who were followed by both primary care physicians and oncologists were more likely to receive both appropriate follow-up mammography and noncancer–related preventive services.4 These results point out discrepancies in care based on patient characteristics and type of follow-up (ie, that by a primary care physician, an oncologist, or both). However, that study did not assess the patients’ satisfaction with their follow-up care or their perception of the coordination of care among each patient’s physicians. The use of and access to follow-up care has been addressed by Mandelblatt and colleagues, who described health service use in a cohort of breast cancer survivors. After primary treatment of breast cancer, 558 patients completed health diaries for 12 months to assess health care use. The authors concluded that although use of health services is frequent and intensive during the first year after treatment, there is room for improving the receipt of guidelinesuggested surveillance mammography.5 In addition to the need for appropriate surveillance and screening during the survivorship period, patients’ psychological states are critical for their overall well-being. Ganz and colleagues previously reported that long-term survivors of breast cancer show increased emotional disruption, particularly among the youngest patients. Factors that contribute to this reduced quality of life included experiencing a menopausal transition and feeling more vulnerable after cancer.6 Therefore, it seems that improving patients’ follow-up care, including the treatment of menopausal symptoms and symptoms of depression or anxiety, could potentially have long-term effects in improving breast cancer survivors’ quality of life. Another study by Schover and colleagues used a peer counseling program to improve sexual function, increase knowledge about reproductive health, and decrease menopausal symptoms and infertility-related distress for African-American breast cancer survivors. The authors found that knowledge of reproductive issues improved significantly from baseline to 3month follow-up, as did emotional distress and menopausal symptoms.7 These findings support the idea that improving follow-up care will also improve patients’ emotional health.
These preliminary studies all indicate that significant problems remain with respect to follow-up care for breast cancer survivors. To date, however, we have not captured the breadth or substance of these problems. Quantitative (eg, survey) and qualitative (eg, focus group) data are therefore needed to identify urgent follow-up care concerns. Obtaining this information can be best achieved by comprehensively describing the symptoms and care needs of women who have recently completed primary treatment for breast cancer and are now presumably receiving follow-up care. This effort should include both quantitative and qualitative reports of comprehensive needs identification as well as the necessary compatible care resources. Lastly, patients should be given a health diary to record their complications and concerns and their doctor visits to assess how and why survivors are accessing the health care system. Only after this information is obtained would it be feasible to convene a multidisciplinary panel to develop a “prescription” to help guide patients through the survivorship phase of breast cancer. The ultimate goal is to empower patients to act as their own advocates. Such an approach would facilitate the doctorpatient relationship, thereby ensuring the highest quality of care for all patients and allowing patients and their doctors to function as a team to achieve a state of wellness for the lifelong phase of cancer survivorship.
References 1. US Department of Health and Human Services. Living beyond cancer: A European dialogue. Bethesda, MD, 2004, pp 1-47. 2. ASCO-ESMO consensus statement on quality cancer care. J Clin Oncol 24:3498-3499, 2006. 3. de Bock GH, Bonnema J, Zwaan RE, et al: Patient’s needs and preferences in routine follow-up after treatment for breast cancer. Br J Cancer 90:1144-1150, 2004. 4. Earle CC, Burstein HJ, Winer EP, et al: Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol 21:1447-1451, 2003. 5. Mandelblatt JS, Lawrence WF, Cullen J, et al: Patterns of care in early-stage breast cancer survivors in the first year after cessation of active treatment. J Clin Oncol 24:77-84, 2006. 6. Ganz PA, Greendale GA, Petersen L, et al: Breast cancer in younger women: Reproductive and late health effects of treatment. J Clin Oncol 21:4184-4193, 2003. 7. Schover LR, Jenkins R, Sui D, et al: Randomized trial of peer counseling on reproductive health in African American breast cancer survivors. J Clin Oncol 24:1620-1626, 2006.
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