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PRIFYSGOL BANGOR / BANGOR UNIVERSITY. Developing and testing new models of follow-up care in cancer Dr Richard Neal Clinical Senior Lecturer in General Practice North Wales Centre for Primary Care Research [email protected]. CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL - PowerPoint PPT Presentation
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CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL NORTH WALES CENTRE FOR PRIMARY CARE RESEARCH
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Developing and testing new models of follow-up care in cancer
Dr Richard NealClinical Senior Lecturer in General Practice
North Wales Centre for Primary Care [email protected]
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• Why follow-up in cancer?
• Differing models for follow-up and the evidence for them
• Some theory about contemporary follow-up
• Using two examples to consider the development and evaluation of the design of future trials
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• Detect recurrence (patients’ main concern)• Assess response and side-effects of treatment• Assess disease progression and further treatment planning• Preparing for palliative and terminal care• Assessment and treatment of psychosocial issues• Information provision• Ongoing management of co-morbidity• Co-ordination of care• Patient preference and reassurance• Continuity of care from treating doctor• Carer support• Clinical trials
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‘Traditional’ hospital follow-up
• Conventional hospital based follow-up places a considerable burden on hospital outpatient clinics
• Is of debatable value for many cancers in terms of prompt diagnosis of recurrence and improved survival
• Patients may find it reassuring
• Patients may find it anxiety raising
• Patients may find it a waste of time
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• Specialists – Medical / clinical oncologists– Surgeons– Physicians
• GPs• Specialist nurses (nurse-led models)
• Models– Traditional– Phone– Patient initiated– ….or a combination of these
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Huge variation in follow-up needs
Patient:– By cancer– By stage– By treatment modality– By prognosis– By co-morbidity– By needs– By preference
.....not a one size fits all
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assessment of risks and needs
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SITY Designing trials
• Which patients? • Which interventions?
– Biomarkers– Imaging– Clinical examination– Psycho-educational– Setting / clinician / mode
• Which outcomes?– Patient safety– Detection of recurrence– Quality of Life– Satisfaction
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SITY Developing interventions
For lung and prostate cancers we have undertaken:
• Guideline review
• Systematic review
• Case-note analysis
• Database analysis
• Qualitative study
…….and developed / developing trial interventions
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For lung cancer:
Primary care • Continues to see patients frequently after diagnosis• Knows these patients well• Is good at managing co-morbidity• Is good at smoking cessation• Is good at co-ordination and liaison
Primary care is less good at• Specialist lung cancer knowledge• Understanding what is happening in secondary care
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For prostate cancer:
• Need for robust primary research to inform future evidence-based models of follow-up care
• Deficiencies in the system between primary and secondary care
• Some patients falling between primary and secondary care and getting lost to follow-up
• • Identified steps needed to breakdown the barriers to make primary care
follow-up happen• • High levels of unmet needs (especially psychosocial, sexual,
incontinence)
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A randomized controlled trial of a nurse-led psycho-educational intervention delivered in primary care to prostate
cancer survivors (PROSPECTIV)• Funding: Prostate Cancer Charity, PI: Eila Watson, Oxford Brookes (with
Bangor, Edinburgh, Oxford, Cambridge)
• Cluster randomization (150 practices)
• Identification of men suitable for discharge to primary care from participating practices
• Screen to identify patients with problems (urinary, sexual, bowel, hormonal, anxiety / depression) (n=350)
• Allocation to nurse led psycho-educational intervention or usual care
• Follow up: 1, 6, 12 months
• Main outcome: prostate cancer related quality of life
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Interventions:
• An ‘end of active treatment MDT’ held for prostate cancer patients held, for care planning, with levels of intervention stratified with risk of adverse events
• An automated IT system linking primary and secondary for routine aspects (PSA)
• Clinical Nurse Specialists as change agents to train primary care practitioners in the delivery of high quality patient-centred follow-up care
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SITY Discussion / questions
Dr Richard NealNorth Wales Centre for Primary Care Research
