The effec tiven e s s of s h a r e d c a r e in c a n c e r s u rvivor s - a sys t e m a tic

r eviewZh ao, Y, Bre t tl e, AJ a n d Qiu, L

h t t p://dx.doi.o rg/1 0.53 3 4/ijic.39 5 4

Tit l e The effec tiven e ss of s h a r e d c a r e in c a n c e r s u rvivors - a sys t e m a tic r evie w

Aut h or s Zh ao, Y, Bre t tl e, AJ a n d Qiu, L

Typ e Article

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IntroductionWith the improvements in medical treatment and ageing populations, the number of cancer survivors is increasing worldwide [1, 2]. Cancer survivors are vulnerable to suffer-ing from second cancer and comorbid chronic conditions with advanced age [3, 4]. Historically, most cancer patients were followed up by hospital specialists [5, 6]. However, Nielsen et al. [7] believes that most cancer patient might feel left alone after they are discharged from the hospi-tal. Besides, Yang et al. [8] argues that cancer specialists might not be able to provide necessary care unless there is enhanced oncological productivity. Due to the increased need, stabilised health care costs, and the sustainable burden of hospitals, the involvement of primary care has been increasingly recognized as a vital component in the management of cancer survivors [9, 10].

To date, much of the studies mainly assessing the capa-bility of primary care providers (PDPs) in survivorship care and indicate that the PDP’s skills and confidence may be lacking, but their skills could be enhanced by collaboration with hospital specialists [11, 12]. In addition, a landmark report from the US Institute of Medicine lists coordinative care between primary care and secondary care as an essen-tial component for cancer survivorship care [13]. Shared care that integrate primary care and hospital care was originally created for patients with chronic disease [14], and it has been endorsed as an important component of high-quality of survivorship care [15]. Johnson et al. [16, p. 350] defines shared care as:

“an organizational model involving both primary care physicians (PCPs) and specialists in a formal, explicit manner.”

Shared care does not only mean that both hospital and primary care join in the follow-up, but also means there is interaction between them. It is argues that the key points of this model are the communication between the care providers by exchange of information and arranging responsibility to improve the follow-up management [17].

The published reviews have focused on comparing the primary care provider and cancer specialist in the

RESEARCH AND THEORY

The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewYan Zhao*, Alison Brettle† and Ling Qiu‡

Objectives: To determine whether the shared care model during the follow-up of cancer survivors is effective in terms of patient-reported outcomes, clinical outcomes, and continuity of care.Methods: Using systematic review methods, studies were searched from six electronic databases— MEDLINE (n = 474), British Nursing Index (n = 320), CINAHL (n = 437), Cochrane Library (n = 370), HMIC (n = 77), and Social Care Online (n = 210). The review considered all health-related outcomes that evaluated the effectiveness of shared care for cancer survivors.Results: Eight randomised controlled trials and three descriptive papers were identified. The results showed the likelihood of similar effectiveness between shared care and usual care in terms of quality of life, mental health outcomes, unmet needs, and clinical outcomes in cancer survivorship. The reviewed studies indicated that shared care overall is highly acceptable to cancer survivors and primary care practitioners, and shared care might be cheaper than usual care.Conclusions: The results from this review suggest that the patient satisfaction of shared care is higher than usual care, and the effectiveness of shared care is similar to usual care in cancer survivorship. Interventions that formally involve primary care and improve the communication between primary care and hospital care could support the PCPs in the follow-up.

Keywords: shared care; survivors; follow-up; cancer

* Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, CN

† School of Nursing and Midwifery, University of Salford, Salford, Greater Manchester, M5 4WT, UK

‡ Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, CN

Corresponding authors: Ling Qiu, RN (295936293@qq.com), Lihuan Liu, RN (2503183899@qq.com)

Zhao, Y, et al. The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review. International Journal of Integrated Care, 2018; 18(4): 2, 1–17. DOI: https://doi.org/10.5334/ijic.3954

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 2 of 17

management of cancer follow-up. Lewis et al. [5] released a systematic review that aimed to evaluate the effectiveness and cost-effectiveness of cancer follow-up by primary care. The author could not make a conclusion since the quality of data was generally poor and no statistically significant difference was found in the effectiveness of primary care follow-up. A second review [18] argued that local health care practitioners could benefit patients with physical and psychosocial problem in survivorship care, but proactive initiatives should be conducted to involve PDPs in the fol-low-up. However, although integrating PCPs into the survi-vorship care is needed, recent reviews found little evidence regarding the effectiveness of shared care, and there is a lack of standard models of shared care [6, 10, 14, 19].

Review questions and objectivesIn this study, we systematically review the literature that focuses on the effectiveness and feasibility of shared care in the management of follow-up for cancer patients in different settings, and critically appraise the quality of evidence. The key objectives are: 1) to evaluate whether shared care is feasible or effective in the management of physical or psychological problems in cancer survivors; 2) to provide a comprehensive review of the studies for achieving best practice in the management of follow-up for cancer survivors. The primary outcome will be whether shared care could solve the survivors’ physical or psycho-logical problems, and patients’ attitudes toward shared care will be summarised. The physical problem could include the quality of life, the side effect, the recurrence

rate, or any other symptoms. The psychological problems would include the anxiety, the distress level or other men-tal health disorders. The secondary outcomes include the patient reported and practitioner reported satisfaction towards shared care, and the cost of shared care. Studies that assessed shared care in short- and long-term cancer survivors were both included and reported, but those assessed patients at the end of life were not included because they usually need more complicated care and a lot of them might stay in the intensive care unit or hos-pice care unit [20].

MethodsSearch strategyThe PRISMA systematic review and meta-analysis pro-tocols (PRISMA-P) [21] was used as the guideline in this study, although minor changes were made to adapt to unanticipated circumstances. Six databases were searched based on the research question and objectives of this study—MEDLINE (Ovid), British Nursing Index, CINAHL (EBSCO), Cochrane Library, Health Management Informa-tion Consortium (HMIC), and Social Care Online. Besides, two journals—Journal of Clinical Oncology and Journal of Adolescent and Young Adult Oncology were identified for hand searching, and all reference lists of the selected papers and relevant reviews were looked through. The search terms were identified based on the planned pop-ulation, intervention, comparison, and outcome (PICO) [22], and they were adjusted slightly according to the dif-ferent databases (see Appendix 1). Table 1 shows the core

Table 1: Core components of the search strategy.

Population Intervention Context Outcome

cancer (MeSH) shared care (MeSH) follow-up (MeSH) All outcomes are included.

neoplasms (MeSH) co-management After care (MeSH)

cancer* “sharing of care” aftercare

neoplas* “collaborative care” follow up

malignan* “care coordination” followup*

carcinoma* “coordinated care” postsurgery

sarcoma “referral and consultation” post-surgery

oncolog* “cooperative behavio?r” postsurgical*

tumo?r* “shared service*” post-surgical*

adenocarcinoma* “delivery of health care” postoperat*

infiltrat* “integrated care” post-operat*

medullary “shared model” “continuity of patient care”

intraductal “inter-organizational coordination” “disease management”

surveillance

“disease progression”

survivorship

rehabilitation

post treatment

post-treatment

posttreatment

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 3 of 17

components of the search strategy, and the last search was conducted on 17th May 2017.

Eligibility criteriaInclusion criteria: 1) all types of primary research studies which assesses the shared care model in the management of follow-up for cancer patients, the formal interaction between primary care and secondary care; AND 2) include studies that examine any outcome in all types and any stage of cancer; AND 3) the population of interest included cancer survivors in any age; AND 4) published in English.

Exclusion criteria: 1) there was no formal interaction between primary care and secondary care as it is not shared care; OR 2) articles without outcomes such as com-mentary, protocol, or meeting abstract; OR 3) the research did not report any outcome about shared care; OR 4) the healthcare service were provided by other practitioners rather than hospital specialists and primary care team, or a multidisciplinary team include other practitioners; OR 5) the patients did not finish all the curative intent or adju-vant treatment; OR 6) the study only focus on the transi-tion manner rather than the whole follow-up process.

Selection process and method of appraisalThe author screened the title and abstract first, and any study that seemed to meet the selection criteria was full-text screened. Besides, two other reviewers randomly selected and reviewed 20% of the search records indepen-dently. Subsequently, studies were picked out according to the inclusion criteria. Any discrepancies were discussed and where there was any uncertainty, the professor with experi-ence in systematic reviews was consulted. In addition, the study author was contacted by email when more informa-tion was needed. The reasons for excluding the studies were recorded to enable transparency of the selection process.

The Critical Appraisal Skills Programme (CASP) is a widely available appraisal tool developed by Oxford University, which includes eight checklists for the different types of studies [23]. The RCTs were appraised by the CASP Randomised Controlled Trial Checklist (see Appendix 2). The CASP comprises of 11 questions that assist a systematic thinking about the paper. The Health Care Practice R&D Unit (HCPRDU) has developed three checklists, with 6, 6, 7 sections respectively, to appraise quantitative, qualitative and mixed-method studies [24]. Thus, other studies were appraised with one of the HCPRDU checklists according to the research methodology (see Appendix 3, 4). Häggman-Laitila et al. [25] evaluated the studies by selecting a score from 0 to 2 points in a systematic review, and this method was utilised and adapted for this review. For all studies, each question on the appraisal tools was scored from “0” to “2” separately and then the total scores were calculated. Among them, “0” means many limitations, “1” means some limitation, and “2” means excellent.

Data collection and synthesis of the findingsGough et al. [26] argue that the content of both quantita-tive and qualitative studies should be described and coded first, then the data extracted from these descriptions can be synthesised into the findings. Therefore, the the-matic analysis, which is a widespread analytical method

to accommodate a diversity of studies including both experimental and observational studies [27], was used in this review. Besides, since the data in the selected stud-ies are not sufficiently similar to allow for meta-analysis, the narrative approach was utilised in this review [28]. First, one author extracted the information and the other author verified all the information, the disagreements were solved by discussion; second, after a comprehensive understanding of all the results and a critical scrutiny of the themes was achieved, the final theme was summa-rised from all the papers in order to answer the research question; finally, the sample size, the study design, the limitation, and the quality of evidence were considered when there were conflicting themes, and the study with larger sample size or better quality might contribute more to the conclusion. The main review focus on the objectives of the systematic review, and the subgroup analysis were also included when they important to answer the ques-tions of the review questions.

ResultsA total of 1,888 records were identified through six data-bases, with 521 records identified through hand searching two oncology journals and citation tracking. All records were imported into Endnote, and 1,698 records were adopted after removing the duplicates by Endnote and scanning the title and authors. Then, the remaining 1,698 records were reviewed according to the eligibility criteria by two steps. First, the title and abstract of the records were reviewed in Endnote. Next, the potential studies were downloaded, and the full-text reviewed. Finally, twelve studies met the inclusion criteria, eight of which were RCTs, three of which were observational quantitative studies, and one was a mixed-method study. The selection process is illustrated in Figure 1. The study description based on the PICO framework is illustrated in Tables 2 and 3. Besides, the essence of shared care that includes the methods of communication, the major care provider, and the length of follow-up is described in Table 4.

Data extraction and quality appraisalAll studies except the mixed-method study [29] were con-sidered as excellent or good quality, and were included. To keep a balance between having confidence about the findings by only including good quality evidence and com-prising enough evidence in order to answer the research question, only those studies which were considered as bad quality were excluded [30]. As a result, this review finally includes seven RCTs reported in eight papers and three descriptive quantitative studies. One RCT was reported in two papers which assessed different types of outcomes [31, 32]. The results of the quality appraisal of the studies can be found in Tables 5 and 6 (included studies), and Appendix 7 (excluded study), and the examples of the appraisal process with the checklist can be found in Appendix 5, 6, and 7.

Effectiveness of shared carePhysical and psychological health statusA total of seven papers assessed whether shared care could improve the survivors’ health status, including both physical and psychological improvements. Among

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 4 of 17

those six papers that detected the quality of life, five papers detected the differences between the two arms at the end of the intervention, and one paper compared the outcomes between the beginning and the end of the shared care, but none of these papers detected any sig-nificant difference [31, 33–37]. As for the survivors’ psy-chological status, the two papers evaluated the survivors’ psychological distress level, finding no significant differ-ence between the intervention group and control group [31, 37]. Besides, the paper that assessed the survivorship worries found no difference before and after the shared care, but there was a borderline difference between the two groups after the shared care [38]. Turning to the sur-vivors’ physical conditions, the paper that evaluated the survivors’ performance status found no significant differ-ences between the two arms [33]. Further, the study used a non-inferiority design to evaluate the number of recur-rences, death, and the serious clinical event could not

demonstrate whether the intervention group was worse than the control group [35].

Satisfaction, attitudes and needs towards health careSeven out of eleven papers evaluated the survivors’ attitudes and needs toward the shared care. The results include the satisfaction with the follow-up [34, 37, 38], the satisfaction towards the PCPs [36], the attitudes toward the cooperation between health providers [33], the attitudes toward the information they received [39], survivorship unmet needs [37], and the preference for the care provider [37, 38]. From the survivor report results, the cooperation between health care practitioners improved (p = 0.025 and p = 0.004 in two out of four items) in the intermediate outcomes [33], and Emery et al. found the survivors in the shared care group would prefer shared care in the follow-up after the study (p = 0.07) [37]. Apart from these, the studies found no other significant differences between the two arms.

Figure 1: PRISMA flow diagram.

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 5 of 17

Tabl

e 2

: Ove

rvie

w o

f the

incl

uded

rand

omis

ed c

ontr

olle

d st

udie

s.

Aut

hor,

yea

r,

coun

try

Sam

ple

and

sett

ing

Inte

rven

tion

gro

upCo

ntro

l gr

oup

Leng

th o

f fol

low

-up

, inc

lusi

on t

ime

Canc

er t

ype

Out

com

esCo

nclu

sion

Berg

hold

t, et

al.

[31,

32]

, 20

12, 2

013,

D

enm

ark

955

new

ly d

iagn

osed

ca

ncer

pat

ient

s (≧

18 y

ears

) tre

ated

in

a p

ublic

regi

onal

ho

spit

al fr

om M

ay

2008

to F

ebru

ary

2009

and

323

Dan

ish

gene

ral p

ract

ices

(GP)

w

ere

enro

lled

to th

e tr

ial.

n =

486,

two

nurs

es w

ith

onco

logi

cal e

xper

ienc

e in

vite

d th

e pa

tien

ts to

join

an

inte

rvie

w

abou

t reh

abili

tati

on n

eeds

, an

d pa

tien

ts w

ere

sugg

este

d to

co

nsul

t the

ir G

P w

hen

nece

ssar

y.

n =

469,

us

ual c

are

mon

ths,

all

pati

ents

w

ere

diag

nose

d as

ca

ncer

wit

hin

the

prev

ious

3 m

onth

s

All

canc

ers

exce

pt

carc

inom

a in

si

tu a

nd n

on-

mel

anom

a sk

in c

ance

rs

No

sign

ifica

nt d

iffer

ence

s be

twee

n tw

o gr

oups

wit

h EO

RTC

QLQ

-C30

su

rvey

at 6

mon

ths

or 1

4 m

onth

s,

and

POM

S at

14

mon

ths.

No

sign

ifica

nt d

iffer

ence

s be

twee

n tw

o gr

oups

wit

h th

e nu

mbe

r of

G

P pr

oact

ive

cont

act n

or p

atie

nts’

pa

rtic

ipat

ion

in r

ehab

ilita

tion

ac

tivi

ties

.

The

mul

tim

odal

in

terv

enti

on c

ould

not

be

nefit

pat

ient

s w

ith

heal

th-r

elat

ed q

ualit

y of

life

or

psyc

holo

gica

l di

stre

ss. I

t cou

ld n

ot

impr

ove

GP

proa

ctiv

e co

ntac

t nor

pat

ient

s’

part

icip

atio

n in

reh

abili

-ta

tion

act

ivit

ies,

nei

ther

.

Nie

lsen

, et a

l. [3

3], 2

003,

D

enm

ark

248

canc

er p

atie

nts

(≧18

yea

rs) f

rom

the

onco

logy

dep

artm

ent

of a

uni

vers

ity

hosp

ital

be

twee

n A

ugus

t 199

8 an

d D

ecem

ber 1

998.

n =

127,

the

inte

rven

tion

in

clud

es th

ree

elem

ents

: pro

vide

G

P an

d pa

tien

ts w

ith

stan

dard

-is

ed k

now

ledg

e pa

ckag

e, b

uild

th

e co

mm

unic

atio

n ch

anne

ls

betw

een

hosp

ital

and

GP,

and

en

cour

age

pati

ents

to c

onta

ct

thei

r GPs

whe

n th

ey h

ad h

ealt

h-ca

re p

robl

ems.

n =

121,

no

rmal

pr

oced

ure

6 m

onth

s, b

oth

prim

ary

canc

er a

nd

recu

rren

t can

cer

pati

ents

wer

e in

clud

ed

All

type

s of

ca

ncer

exc

ept

lym

phom

a

Pati

ents

’ att

itud

es to

war

d th

e sh

ared

car

e an

d th

eir

GPs

is

mor

e po

siti

ve in

the

inte

rven

-ti

on g

roup

at 3

mon

ths

in 2

of

4 it

ems

(p <

0.0

5), a

nd p

atie

nts

cont

acte

d w

ith

thei

r G

Ps m

ore

than

the

cont

rol g

roup

(p <

0.0

5).

How

ever

, no

sign

ifica

nt d

iffer

ence

s w

ere

dete

cted

in q

ualit

y of

life

or

perf

orm

ance

sta

tus

betw

een

two

grou

ps. T

he s

ubgr

oup

anal

yses

in

dica

ted

that

men

and

you

ng

pati

ents

(18–

49 y

ears

) ten

t to

rate

th

e sh

ared

car

e m

ore

posi

tive

ly.

Shar

ed c

are

coul

d en

hanc

e th

e in

volv

e-m

ent o

f pri

mar

y ca

re

and

pati

ents

, whi

ch

influ

ence

d th

e pa

tien

ts’

atti

tude

tow

ard

heal

th-

care

ser

vice

s po

siti

vely

, es

peci

ally

for

men

and

yo

ung

pati

ents

.

Hol

teda

hl,

et a

l. [3

4],

2005

, Nor

way

91 a

dult

can

cer

pati

ents

(≧18

yea

rs) i

n a

univ

ersi

ty h

ospi

tal

wer

e en

rolle

d fr

om

Oct

ober

199

9 to

Sep

-te

mbe

r 200

0.

n =

41, t

wo

30 m

inut

es v

isit

s w

ere

cond

ucte

d by

GP

and

phys

icia

n se

para

tely

. The

topi

c is

abo

ut p

atie

nts’

exp

erie

nces

re

late

d to

can

cer.

Besi

des,

pa

tien

ts w

ere

enco

urag

ed to

co

ntac

t the

ir G

Ps if

they

had

any

he

alth

-rel

ated

pro

blem

.

n =

50, n

ot

men

tion

ed

abou

t the

ca

re c

on-

tent

.

6 m

onth

s, b

oth

prim

ary

canc

er

and

recu

rren

t ca

ncer

pat

ient

s w

ho h

ad fi

nish

ed

canc

er th

erap

y w

ere

incl

uded

All

type

s of

ca

ncer

exc

ept

pre-

can

cero

us

cond

itio

ns

such

as

in s

itu

cerv

ical

can

cer

Ther

e w

as n

o si

gnifi

cant

diff

eren

ce

betw

een

two

arm

s in

qua

lity

of

life,

pat

ient

s’ s

atis

fact

ion,

or

the

cons

ulta

tion

tim

es w

ith

GP

at s

ix

mon

ths.

The

rel

ativ

es’ s

atis

fact

ion

impr

oved

in th

e in

terv

enti

on g

roup

at

six

mon

ths

(P =

0.0

18).

Som

e pa

tien

ts m

ight

be

nefit

from

the

GP

follo

w-u

p, b

ut th

e im

prov

emen

ts w

ere

not

iden

tifie

d th

is s

tudy

. Be

side

s, th

e in

terv

en-

tion

did

not

gen

erat

e cl

oser

con

tact

bet

wee

n pa

tien

ts a

nd th

eir

GPs

.

(con

td.)

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 6 of 17

Aut

hor,

yea

r,

coun

try

Sam

ple

and

sett

ing

Inte

rven

tion

gro

upCo

ntro

l gr

oup

Leng

th o

f fol

low

-up

, inc

lusi

on t

ime

Canc

er t

ype

Out

com

esCo

nclu

sion

Gru

nfel

d,

et a

l. [3

5],

2006

, Can

ada

968

earl

y-st

age

brea

st

canc

er p

atie

nts

from

si

x ca

ncer

cen

tres

w

ere

enro

lled

from

Ja

nuar

y 19

97 to

June

20

01.

n =

483,

the

fam

ily p

hysi

cian

re

ceiv

ed a

one

-pag

e gu

idel

ine

from

the

canc

er c

entr

e. T

he

guid

elin

e in

clud

ed fo

llow

-up

arra

ngem

ent,

refe

rral

inst

ruc-

tion

, and

dis

ease

rele

vant

in

form

atio

n. T

he p

atie

nts

rece

ived

follo

w-u

p ca

re fr

om

thei

r fam

ily p

hysi

cian

.

n =

485,

th

e pa

tien

ts

rece

ived

fo

llow

-up

care

from

ca

ncer

ce

ntre

From

less

than

2

year

s to

5 y

ears

, pa

tien

ts w

ho h

ad

been

dia

gnos

ed

wit

h ca

ncer

from

9

to 1

5 m

onth

s ag

o an

d ha

d co

m-

plet

ed tr

eatm

ent 3

m

onth

s ag

o

earl

y st

age

brea

st c

ance

rTh

e pe

rcen

tage

of r

ecur

renc

e,

deat

h, a

nd s

erio

us c

linic

al e

vent

in

sha

red

care

gro

up w

ere

11.2

%,

6.0%

, and

3.5

%, r

espe

ctiv

ely,

co

mpa

red

to 1

3.2%

, 6.2

%, a

nd

3.7%

, res

pect

ivel

y, in

con

trol

gro

up.

The

heal

th-r

elat

ed q

ualit

y of

life

th

at a

sses

sed

by S

F-36

and

HA

DS

betw

een

two

arm

s di

d no

t sho

w

sign

ifica

nt d

iffer

ence

s.

The

shar

ed c

are

follo

w-

up d

id n

ot in

crea

se

the

risk

of i

mpo

rtan

t re

curr

ence

-rel

ated

se

riou

s cl

inic

al e

vent

or

heal

th-r

elat

ed q

ualit

y of

life

for

brea

st c

ance

r pa

tien

ts.

Blaa

uwbr

oek,

et

al.

[36]

, 20

08,

Net

herl

ands

( his

tori

cal

cont

rol

desi

gn)

121

adul

t sur

vivo

rs

(≧18

yea

rs) w

ho u

sed

to b

e di

agno

sed

as

child

hood

can

cer i

n a

paed

iatr

ic o

ncol

ogy

depa

rtm

ent a

nd d

id

not j

oin

any

follo

w-u

p st

udy

agre

ed to

ent

er

the

stud

y in

200

4 an

d 20

05.

n =

121,

thre

e vi

sits

wer

e ca

r-ri

ed o

ut d

urin

g th

ree

year

s pe

riod

. Vis

it 1

and

vis

it 3

wer

e co

nduc

ted

by a

n on

-sit

e fa

mily

do

ctor

at t

he m

edic

al c

entr

e,

visi

t 2 w

as c

ondu

cted

by

the

loca

l fam

ily d

octo

r. A

sses

s-m

ents

, sur

vey,

and

indi

vidu

al-

ised

follo

w-u

p su

gges

tion

wer

e pr

ovid

ed in

thes

e vi

sits

.

The

data

fr

om

anot

her

mat

ched

st

udy

in th

e N

ethe

rlan

ds

was

use

d as

con

trol

gr

oup

data

.

year

s, a

ll pa

tien

ts

had

been

trea

ted

in

the

hosp

ital

at l

east

5

year

s ag

o

All

child

hood

ca

ncer

s an

d La

nger

hans

-ce

ll hi

stio

cy-

tosi

s, e

xcep

t ce

ntra

l ner

v-ou

s sy

stem

tu

mou

rs

At v

isit

1, p

atie

nts

in in

terv

enti

on

arm

sho

wed

low

er le

vel o

f hea

lth-

rela

ted

qual

ity

of li

fe w

ith

RAN

D-3

6 su

rvey

com

pare

d to

con

trol

gro

up

data

, but

no

sign

ifica

nt d

iffer

ence

s w

ere

dete

cted

at v

isit

3. P

atie

nt s

at-

isfa

ctio

n w

as a

sses

sed

at v

isit

2, a

nd

89 (8

8%) o

f the

101

pat

ient

s w

ere

sati

sfie

d w

ith

shar

ed c

are

mod

el.

Shar

ed c

are

invo

lved

pa

edia

tric

onc

olog

ists

an

d fa

mily

doc

tors

can

be

use

d in

the

long

-ter

m

follo

w-u

p in

chi

ldho

od

canc

er p

atie

nts.

Emer

y, e

t al.

[37]

, 201

7,

Aus

tral

ia

pros

tate

can

cer

pati

ents

wit

h lo

w

risk

or m

oder

ate

risk

feat

ures

wer

e re

crui

ted

from

two

rura

l and

four

urb

an

med

ical

cen

tres

from

N

ovem

ber 2

011

to

July

201

3.

n =

45, a

GP

visi

t was

con

duct

ed

to re

-eng

age

thei

r rel

atio

n-sh

ip w

ith

pati

ents

. Bes

ides

, the

tr

eatm

ent c

entr

e pr

ovid

ed a

SCP

to

the

pati

ents

and

thei

r GPs

, an

d a

regi

ster

and

reca

ll sy

stem

w

as b

uilt

to e

nhan

ce G

Ps’ a

nd

pati

ents

’ com

plia

nce.

Aft

er th

at,

GP

repl

aced

two

hosp

ital

rout

ine

follo

w-u

p vi

sits

at 6

mon

ths

and

9 m

onth

s.

n =

43,

usua

l ca

re (t

he

pati

ents

vi

site

d th

e ho

spit

al

spec

ialis

ts

ever

y th

ree

mon

ths)

mon

ths,

all

pati

ents

ha

d co

mpl

eted

cu

rati

ve in

tent

tr

eatm

ents

wit

hin

the

prev

ious

8

wee

ks

Pros

tate

ca

ncer

wit

h lo

w ri

sk o

r m

oder

ate

risk

feat

ures

, ex

pect

the

met

asta

tic

dise

ase

No

sign

ifica

nt d

iffer

ence

s be

twee

n tw

o gr

oups

wit

h th

e H

AD

S, th

e Ca

SUN

, the

EPI

C, a

nd th

e PS

Q-1

8 re

sult

s. B

ut th

e in

terv

enti

on g

roup

ha

d a

pref

eren

ce o

f sha

red

care

th

an c

ontr

ol g

roup

(P <

0.0

01),

and

shar

ed c

are

cost

s le

ss th

an u

sual

ca

re.

Shar

ed c

are

mod

el c

ould

no

t ben

efit

pro

stat

e ca

ncer

pat

ient

s w

ith

dist

ress

, unm

et n

eeds

, ca

ncer

-spe

cific

qua

lity

of

life,

or

sati

sfac

tion

, but

it

is fe

asib

le a

s to

pro

vide

a

sim

ilar

outc

ome

wit

h le

ss m

oney

.

(con

td.)

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 7 of 17

Aut

hor,

yea

r,

coun

try

Sam

ple

and

sett

ing

Inte

rven

tion

gro

upCo

ntro

l gr

oup

Leng

th o

f fol

low

-up

, inc

lusi

on t

ime

Canc

er t

ype

Out

com

esCo

nclu

sion

May

er, e

t al.,

[3

8], 2

016,

U

nite

d St

ates

37 c

ance

r pat

ient

s (≧

21 y

ears

) who

had

co

mpl

eted

cur

ativ

e in

tent

trea

tmen

t in

a ca

ncer

hos

pita

l wer

e re

crui

ted.

n =

20, t

he re

sear

ch n

urse

in th

e ho

spit

al m

ade

a dr

aft S

CP, t

hen

the

onco

logy

nur

se p

ract

itio

ner

mad

e a

40 m

inut

es tr

ansi

tion

vi

sit w

ith

the

pati

ent a

nd re

vise

d th

e SC

P. T

he fi

nal S

CP w

as s

ent

to b

oth

pati

ents

and

thei

r PCP

s.

Besi

des,

the

PCPs

rece

ived

rele

-va

nt k

now

ledg

e ab

out f

ollo

w-u

p.

Aft

erw

ards

, the

PCP

s ca

rrie

d ou

t a

sem

i-str

uctu

red

follo

w-u

p vi

sit

wit

h pa

tien

ts w

ithi

n fo

ur w

eeks

.

n =

17, t

he

sam

e w

ith

inte

rven

tion

gr

oup

but

wit

hout

GP

visi

t

6 w

eeks

, all

pati

ents

ha

d co

mpl

eted

cu

rati

ve in

tent

tr

eatm

ents

wit

hin

the

prev

ious

4 to

6

wee

ks

All

type

s of

ca

ncer

exc

ept

met

asta

tic

canc

er

All

pati

ents

rep

orte

d ha

ving

less

co

ntra

dict

ory

info

rmat

ion

abou

t ca

re (P

< 0

.000

1) a

nd e

xpec

ted

less

follo

w-u

p fr

om o

ncol

ogis

ts

(P =

0.0

3) a

t 6 w

eeks

. All

PCPs

felt

m

ore

conf

iden

t (P

= 0.

01) a

bout

su

rviv

orsh

ip c

are.

How

ever

, the

PCP

vi

sit h

as li

ttle

eff

ect o

n th

e re

sult

s,

exce

pt m

akin

g a

bord

erlin

e di

ffer

-en

ce w

ith

wor

ry le

vel (

P =

0.05

).

The

SCP

coul

d im

prov

e pa

tien

ts’ a

nd P

CP’s

co

nfid

ence

in s

urvi

vor-

ship

info

rmat

ion,

but

no

sig

nific

ant b

enef

it

was

iden

tifie

d ab

out G

P vi

sit.

This

is a

pilo

t stu

dy,

a la

rger

stu

dy s

houl

d ex

plor

e th

e ch

ange

s in

th

e fu

ture

.

GP

= ge

nera

l pra

ctit

ione

r. EO

RTC

QLQ

-C30

= th

e Eu

rope

an O

rgan

isat

ion

for

Rese

arch

and

Tre

atm

ent o

f Can

cer

Qua

lity

of L

ife Q

uest

ionn

aire

Cor

e 30

. PO

MS

= Pr

ofile

of M

ood

Stat

es S

cale

. RA

ND

-36

= RA

ND

36-

Item

Hea

lth

Surv

ey. S

CP: s

urvi

vors

hip

care

pla

n. H

AD

S =

14-it

em H

ospi

tal A

nxie

ty a

nd D

epre

ssio

n Sc

ale.

CaS

UN

= U

nmet

nee

ds w

ere

asse

ssed

wit

h th

e Ca

ncer

Sur

vivo

rs’ U

nmet

Nee

ds

mea

sure

. EPI

C =

Expa

nded

Pro

stat

e Ca

ncer

Inde

x Co

mpo

site

. PSQ

-18

= 18

-item

Sho

rt-fo

rm P

atie

nt S

atis

fact

ion

Que

stio

nnai

re. S

F-36

= M

edic

al O

utco

mes

Stu

dy S

hort

For

m 3

6-It

em G

ener

al H

ealt

h Su

rvey

.

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 8 of 17

Tabl

e 3

: Ove

rvie

w o

f the

oth

er s

tudi

es.

Aut

hor,

yea

r,

coun

try

Rese

arch

de

sign

Sam

ple

and

sett

ing

Proc

edur

es (I

nter

vent

ion

and

com

pari

son)

Leng

th o

f fol

low

-up

, ons

et t

ime

Canc

er t

ype

Out

com

esCo

nclu

sion

Han

an, e

t al.,

[29]

, 20

14, I

rela

nd

Des

crip

tive

, si

ngle

-cen

tre,

m

ixed

m

etho

ds

The

com

mun

ity

nurs

e to

ok th

e re

spon

sibi

lity

of m

anag

emen

t of

canc

er p

atie

nts

inst

ead

of h

ospi

tal n

urse

s,

and

the

visi

t was

co

nduc

ted

at p

atie

nts’

ho

me.

The

rese

arch

incl

uded

a

six

mon

ths

skill

s tr

aini

ng

(fro

m s

peci

alis

t can

cer

staf

f) fo

r com

mun

ity

nurs

es, s

peci

fic re

ferr

al

form

, and

pro

vide

d ho

spi-

tal s

uppo

rt fo

r com

mun

ity

nurs

es in

urg

ent s

itua

tion

by

pho

ne. T

he p

atie

nts

wer

e to

ld th

at th

e m

edic

al

onco

logi

sts

still

took

the

resp

onsi

bilit

y of

them

. Th

e pa

tien

ts w

ere

maj

orly

m

anag

ed b

y co

mm

unit

y nu

rses

.

5 ye

ars,

not

m

enti

oned

Not

men

tion

ed

Qua

ntit

ativ

e ou

tcom

es:

Com

mun

ity

nurs

e-le

d ca

ncer

car

e w

as

com

pare

d w

ith

hosp

ital

act

ivit

y da

ta

befo

re th

e pr

ogra

mm

e (b

asel

ine)

, in

the

mid

dle

of th

e pr

ogra

mm

e (a

fter

th

e si

x m

onth

s tr

aini

ng),

and

five

year

s af

ter

the

base

line.

The

com

mun

ity

nurs

es d

eliv

ered

saf

e ca

ncer

car

e, a

nd

the

hosp

ital

att

enda

nces

was

dec

reas

ed.

The

com

mun

ity

nurs

es h

ad m

ore

conf

iden

ce in

can

cer

man

agem

ent.

Qua

litat

ive

outc

omes

: Th

e pa

tien

ts r

epor

ted

a sh

orte

r tr

avel

to

hea

lth

care

, and

impr

oved

qua

lity

of

life.

The

y ha

d co

nfid

ence

in c

omm

unit

y nu

rses

, and

they

indi

cate

d th

eir

sens

e of

aut

onom

y in

crea

sed.

Shar

ed c

are

appr

oach

wit

h tr

aini

ng c

omm

unit

y nu

rses

cou

ld b

enef

it

both

pat

ient

s an

d he

alth

car

e pr

ovid

ers.

Blaa

uwbr

oek,

et a

l. [3

9], 2

012,

N

ethe

rlan

ds

Des

crip

tive

, si

ngle

-cen

tre,

qu

anti

tati

ve

80 c

hild

hood

can

cer

surv

ivor

s (≧

18 y

ears

) w

ho u

sed

to b

e di

ag-

nose

d in

a lo

ng-t

erm

fo

llow

-up

clin

ic a

nd

did

not j

oin

any

follo

w-

up s

tudy

and

thei

r fa

mily

doc

tors

(n =

79)

jo

ined

this

stu

dy fr

om

Sept

embe

r 200

8.

The

rese

arch

team

( h

ospi

tal s

peci

alis

ts)

cons

truc

ted

a pe

rson

alis

ed

SCP

and

sent

the

prin

ted

book

let t

o th

e pa

tien

ts.

The

plan

was

als

o ac

ces-

sibl

e th

roug

h a

secu

re

web

site

to th

e su

rviv

ors

and

thei

r fam

ily d

octo

rs.

Besi

des,

the

rese

arch

team

as

ked

the

surv

ivor

s to

m

ake

a ha

lf-ho

ur m

eeti

ng

wit

h th

eir f

amily

doc

tors

, th

ey w

ould

rem

ind

the

sur-

vivo

rs a

gain

if th

ey d

id n

ot

mee

t the

ir fa

mily

doc

tors

si

x m

onth

s la

ter.

Follo

w-u

p w

as d

one

prim

arily

by

the

fam

ily d

octo

r.

one

year

, at

leas

t 5 y

ears

of

f-tre

atm

ent

All

type

s of

ca

ncer

exp

ect

cent

ral n

ervo

us

syst

em tu

mou

rs,

surv

ivor

s of

all

thre

e le

vels

of r

isk

wer

e in

clud

ed

( low

-ris

k,

med

ium

-ris

k,

and

high

risk

)

The

fam

ily d

octo

rs w

ere

aske

d to

fini

sh

an in

form

atio

n fo

rm a

bout

the

scre

en-

ing

and

the

addi

tion

al te

st r

esul

ts.

Besi

des,

an

18-it

em q

uest

ionn

aire

and

a

14-it

em q

uest

ionn

aire

wer

e us

ed to

as

sess

sur

vivo

rs’ a

nd fa

mily

doc

tors

’ vi

ews,

res

pect

ivel

y, a

bout

the

web

site

an

d th

e pr

ovid

ed in

form

atio

n, th

e la

te

effe

cts

wer

e al

so c

olle

cted

by

the

fam

ily

doct

ors.

Out

com

es:

73 s

urvi

vors

and

72

fam

ily d

octo

rs

com

plet

ed th

e st

udy.

97%

of t

he

surv

ivor

s th

ough

t the

follo

w-u

p w

as

bene

ficia

l, bu

t 11%

of t

he s

urvi

vors

felt

th

at th

e in

form

atio

n w

as in

adeq

uate

. 82

% o

f the

sur

vivo

rs b

elie

ved

in th

eir

fam

ily d

octo

rs’ a

bilit

y in

the

follo

w-u

p.

How

ever

, 77%

of s

urvi

vors

felt

wor

ried

ab

out t

he r

eaw

aken

ed m

emor

ies

abou

t th

e di

seas

e.

The

shar

ed c

are

wit

h w

eb-b

ased

SCP

is

avai

labl

e in

the

long

-te

rm c

ance

r fo

llow

-up

of a

dult

s w

ith

child

hood

can

cer,

and

mos

t sur

vivo

rs

and

fam

ily d

octo

rs

wer

e sa

tisf

ied

wit

h th

is m

odel

. Bes

ides

, bo

th s

urvi

vors

and

th

e fa

mily

doc

tors

th

ough

t the

ir

rele

vant

kno

wle

dge

impr

oved

thou

gh

this

pro

cess

. The

ne

gati

ve e

ffec

t was

th

e fo

llow

-up

mig

ht

reaw

aken

sur

vivo

rs

of b

ad m

emor

ies

abou

t dis

ease

.

(con

td.)

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 9 of 17

Aut

hor,

yea

r,

coun

try

Rese

arch

de

sign

Sam

ple

and

sett

ing

Proc

edur

es (I

nter

vent

ion

and

com

pari

son)

Leng

th o

f fol

low

-up

, ons

et t

ime

Canc

er t

ype

Out

com

esCo

nclu

sion

60 fa

mily

doc

tors

(83%

) fin

ishe

d al

l the

re

com

men

ded

test

s. 9

5% o

f the

fam

ily

doct

ors

felt

the

follo

w-u

p w

as m

ore

bene

ficia

l and

83%

felt

thei

r kn

owl-

edge

of l

ate

effe

cts

incr

ease

d. B

esid

es,

93%

of t

he fa

mily

doc

tors

felt

con

fi-de

nt a

bout

man

agem

ent o

f fol

low

-up

if th

ey r

ecei

ved

the

SCP.

Berg

er, e

t al.,

[40]

, 20

17, F

ranc

e D

escr

ipti

ve,

sing

le-c

entr

e,

quan

tita

tive

150

child

hood

can

cer

surv

ivor

s (≧

18 y

ears

) an

d th

eir G

Ps (n

= 1

06)

invo

lved

in th

is s

tudy

fr

om D

ecem

ber 2

010

to Ju

ne 2

013.

The

se

surv

ivor

s w

ere

from

a

regi

on c

ance

r reg

istr

y an

d di

agno

sed

of

canc

er b

efor

e 15

yea

rs

old.

The

paed

iatr

ic o

ncol

ogis

t an

d th

e in

tern

ist i

nvit

ed

the

surv

ivor

s to

join

a

cons

ulta

tion

, in

whi

ch th

e pr

acti

tion

ers

expl

aine

d th

e m

edic

al h

isto

ry a

nd

pote

ntia

l lat

e ef

fect

s to

th

e su

rviv

ors.

Add

itio

nal

test

s w

ere

cond

ucte

d ba

sed

on th

e co

nsul

tati

on.

Besi

des,

the

med

ical

doc

tor

prov

ided

the

cons

ulta

tion

su

mm

arie

s an

d re

com

men

-da

tion

s ab

out f

ollo

w-u

p (r

ecom

men

dati

on c

ard)

for

the

surv

ivor

s an

d th

eir G

Ps.

The

med

ical

doc

tor w

ould

ca

ll th

e G

Ps if

they

did

not

re

spon

d to

the

stud

y at

fir

st.

One

yea

r, di

ag-

nose

d as

pri

mar

y ca

ncer

from

Ja

nuar

y 19

87 to

D

ecem

ber 1

992.

All

type

s of

ca

ncer

exp

ect

leuk

aem

ia

120

surv

ivor

s fin

ishe

d th

e ni

ne-

ques

tion

sat

isfa

ctio

n fo

rm, 1

07 o

f the

m

(89%

) wer

e sa

tisf

ied

wit

h th

e co

nsul

ta-

tion

. 86%

of t

he s

urvi

vors

foun

d th

e re

com

men

dati

on c

ard

was

use

ful.

Mor

e th

an 7

5% fe

lt th

eir

lifes

tyle

cha

nged

su

ch a

s ph

ysic

al a

ctiv

ity

and

diet

s. T

ype

of c

ance

r an

d tr

eatm

ent w

ould

influ

-en

ce th

e sa

tisf

acti

on w

ith

the

follo

w-u

p (p

< 0

.05)

. The

sur

vivo

rs w

ho r

ecei

ved

chem

othe

rapy

felt

mor

e sa

tisf

acti

on

wit

h th

e sh

ared

car

e (p

= 0

.03)

.10

6 G

Ps fi

nish

ed th

e fiv

e ar

eas

sati

sfac

-ti

on s

urve

y, 6

3 of

them

(59%

) rep

orte

d th

ey w

ere

not p

rovi

ded

enou

gh in

for-

mat

ion

abou

t the

pat

ient

’s tr

eatm

ent,

82 o

f the

m (7

7%) r

epor

ted

lack

of l

ate

effe

ct o

f che

mot

hera

py. B

ut m

ost o

f th

em fe

lt th

e re

com

men

dati

on c

ard

was

use

ful (

61%

), ov

er 8

0% o

f the

m

appr

ecia

te th

e co

llabo

rati

on a

nd a

vail-

abili

ty o

f con

tact

wit

h ho

spit

al.

The

long

-ter

m

follo

w-u

p by

co

llabo

rati

on o

f GP

and

hosp

ital

spe

cial

-is

t was

feas

ible

an

d co

uld

bene

fit

child

hood

can

cer

surv

ivor

s an

d fa

mily

ph

ysic

ians

.

Lund

, et a

l. [4

1],

2016

, Den

mar

kD

escr

ipti

ve,

mul

ti-c

entr

e,

quan

tita

tive

530

canc

er p

atie

nts

from

thre

e ho

spita

ls

wer

e tr

ansf

erre

d to

th

eir G

Ps a

nd in

vite

d to

join

the

shar

ed c

are

follo

w u

p be

twee

n Se

ptem

ber 2

011

and

Mar

ch 2

012,

the

follo

w-

up la

sts

for t

hree

yea

rs.

The

urol

ogic

al s

peci

al-

ists

dev

elop

ed fo

llow

-up

reco

mm

enda

tion

s fo

r ev

alua

ting

pat

ient

and

GP

com

plia

nce,

incl

udin

g th

e sc

hedu

le o

f fol

low

-up

and

the

inst

ruct

ions

of r

efer

ral.

The

pati

ents

wer

e tr

ans-

ferr

ed to

thei

r GPs

.

3 ye

ars,

wit

h or

w

itho

ut re

laps

ePr

osta

te c

ance

r42

6 (8

0.8%

) pat

ient

s w

ere

anal

ysed

, 39

0 pa

tien

ts (9

1.5%

) wer

e ra

ted

as

“acc

epta

ble”

or

“goo

d” c

ompl

ianc

e (t

he

com

plia

nce

was

rat

ed a

s fo

ur c

olum

ns:

unkn

own,

poo

r, ac

cept

able

, and

goo

d);

a to

tal o

f 393

GP

(92.

3%) w

ere

rate

d as

“g

ood”

or

“acc

epta

ble”

com

plia

nce

(the

co

mpl

ianc

e w

as r

ated

as

four

col

umns

: un

know

n, p

oor,

acce

ptab

le, a

nd g

ood)

.

Shar

ed c

are

mod

el is

a

safe

app

roac

h w

ith

high

rat

e of

pat

ient

an

d G

P co

mpl

ianc

e

GP

= ge

nera

l pra

ctit

ione

r. SC

P: s

urvi

vors

hip

care

pla

n.

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 10 of 17

Tabl

e 4

: Ess

ence

of s

hare

d ca

re.

Aut

hor,

yea

r,

coun

try

Maj

or

follo

w-u

p ca

re

prov

ider

in

shar

ed c

are

Oth

er

follo

w-u

p ca

re p

rovi

der

in s

hare

d ca

re

Met

hod

of s

hare

d ca

re in

volv

emen

tN

umbe

r of

form

al

inte

ract

ion

betw

een

diff

eren

t ca

re

prov

ider

s, c

omm

uni-

cati

on t

ool b

etw

een

care

pro

vide

rs

Num

ber/

freq

uenc

y of

inte

ract

ion

betw

een

pati

ents

an

d pr

imar

y ca

re

in in

terv

enti

on

grou

p

Num

ber/

freq

uenc

y of

inte

ract

ion

betw

een

pati

ents

an

d pr

imar

y ca

re

in c

ontr

ol g

roup

Dif

fere

nce

betw

een

two

grou

ps

Han

an, e

t al.

[29]

, 201

4,

Irel

and

Com

mun

ity

nurs

esO

ncol

ogy

day-

war

d nu

rses

, sp

ecia

list

canc

er s

taff

The

shar

ed c

are

incl

uded

a s

ix m

onth

s sk

ills

trai

ning

(fro

m s

peci

alis

t can

cer s

taff

) for

com

-m

unit

y nu

rses

, spe

cific

refe

rral

form

, and

pro

-vi

ded

hosp

ital

sup

port

for c

omm

unit

y nu

rses

in

urg

ent s

itua

tion

by

phon

e. T

he p

atie

nts

wer

e to

ld th

at th

e m

edic

al o

ncol

ogis

ts s

till

took

the

resp

onsi

bilit

y of

them

.

Mor

e th

an o

nce,

skill

trai

ning

, pho

ne,

and

reso

urce

boo

k

Not

men

tion

edN

ot m

enti

oned

Not

men

tion

ed

Berg

hold

t, et

al.

[31,

32]

, 20

12, 2

013,

D

enm

ark

Gen

eral

pra

cti-

tion

erTw

o ho

spit

al

nurs

es w

ith

onco

logi

cal

expe

rien

ce

The

hosp

ital

nur

ses

sugg

este

d pa

tien

ts to

con

-su

lt th

eir G

Ps w

hen

nece

ssar

y. E

qual

ly, t

hey

also

en

cour

aged

the

GPs

to b

e pr

oact

ive

to o

ffer

sup

-po

rt to

thei

r pat

ient

s, a

nd s

end

the

GP

an e

mai

l, w

hich

incl

ude

the

pati

ents

’ inf

orm

atio

n.

Onc

e,Em

ail a

nd p

hone

Pati

ents

rep

orte

d:

168

cont

acts

(101

GP

proa

ctiv

e co

ntac

t, 61

.1%

) G

P re

port

ed:

379

cont

acts

(232

G

P pr

oact

ive

cont

act,

61.2

%)

Pati

ents

rep

orte

d:

156

cont

acts

(81

GP

proa

ctiv

e co

ntac

t, 51

.9%

) GP

repo

rted

: 37

3 co

ntac

ts (2

06

GP

proa

ctiv

e co

ntac

t, 55

.2%

)

No

sign

ifica

nt

diff

eren

ces

in b

oth

pati

ents

rep

orte

d an

d G

P re

port

ed

cont

acts

.

Nie

lsen

, et a

l. [3

3], 2

003,

D

enm

ark

Both

hos

pita

l sp

ecia

lists

and

G

Ps

/Tr

ansf

erri

ng k

now

ledg

e an

d in

form

atio

n fr

om

hosp

ital

to G

P, b

uild

ing

com

mun

icat

ion

chan

-ne

ls, e

ncou

ragi

ng p

atie

nts

to c

onta

ct th

eir G

Ps

Onc

e,or

dina

ry m

ail

Not

men

tion

edN

ot m

enti

oned

Mor

e pa

tien

ts h

ad

cont

act w

ith

thei

r G

P in

inte

rven

tion

gr

oup

(p =

0.0

49

at 3

mon

ths,

p =

0.

046

at 6

mon

ths)

Hol

teda

hl,

et a

l. [3

4],

2005

, Nor

way

Both

GP

and

hosp

ital

ph

ysic

ian

/Th

e G

P w

as a

sked

to in

itiat

e a

cons

ulta

tion

with

pa

tient

s. Th

e pa

tient

s w

ere

enco

urag

ed to

con

-ta

ct th

eir G

Ps if

they

hav

e he

alth

rela

ted

prob

lem

.

Onc

e,un

clea

rTh

e av

erag

e co

nsul

-ta

tion

tim

e w

as 1

.26

per

pati

ents

The

aver

age

cons

ul-

tati

on ti

me

was

1.0

4 pe

r pa

tien

ts

No

sign

ifica

nt

diff

eren

ce b

etw

een

two

arm

s

Gru

nfel

d,

et a

l. [3

5],

2006

, Can

ada

Fam

ily

phys

icia

nPr

acti

tion

er in

ca

ncer

cen

tre

The

fam

ily p

hysi

cian

rece

ived

a o

ne-p

age

guid

elin

e fr

om th

e ca

ncer

cen

tre.

The

gui

de-

line

incl

uded

follo

w-u

p ar

rang

emen

t, re

ferr

al

inst

ruct

ion,

and

dis

ease

rele

vant

info

rmat

ion.

Onc

e,un

clea

rN

ot m

enti

oned

Not

men

tion

edN

ot m

enti

oned

Blaa

uwbr

oek,

et

al.

[36]

, 20

08,

Net

herl

ands

Both

pae

diat

ric

onco

logi

sts

and

fam

ily d

octo

rs

/Th

e m

edic

al c

entr

e ad

vise

d th

e pa

tien

ts to

mee

t th

eir f

amily

doc

tors

. The

pat

ient

info

rmat

ion

and

the

test

resu

lts

wer

e sh

ared

by

med

ical

ce

ntre

and

pri

mar

y ca

re.

Mor

e th

an o

nce,

em

ail o

r tel

epho

neN

ot m

enti

oned

N

ot m

enti

oned

Not

men

tion

ed (con

td.)

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 11 of 17

Aut

hor,

yea

r,

coun

try

Maj

or

follo

w-u

p ca

re

prov

ider

in

shar

ed c

are

Oth

er

follo

w-u

p ca

re p

rovi

der

in s

hare

d ca

re

Met

hod

of s

hare

d ca

re in

volv

emen

tN

umbe

r of

form

al

inte

ract

ion

betw

een

diff

eren

t ca

re

prov

ider

s, c

omm

uni-

cati

on t

ool b

etw

een

care

pro

vide

rs

Num

ber/

freq

uenc

y of

inte

ract

ion

betw

een

pati

ents

an

d pr

imar

y ca

re

in in

terv

enti

on

grou

p

Num

ber/

freq

uenc

y of

inte

ract

ion

betw

een

pati

ents

an

d pr

imar

y ca

re

in c

ontr

ol g

roup

Dif

fere

nce

betw

een

two

grou

ps

Emer

y, e

t al.

[37]

, 201

7,

Aus

tral

ia

Both

hos

pita

l sp

ecia

lists

and

G

Ps

/Th

e tr

eatm

ent c

entr

e fa

xed

a SC

P to

the

GP.

The

re

gist

er a

nd re

call

syst

em s

ent G

P fo

llow

-up

rem

inde

r let

ters

.

Mor

e th

an o

nce,

fa

x, le

tter

Not

men

tion

edN

ot m

enti

oned

Not

men

tion

ed

May

er, e

t al.

[38]

, 201

6,

Uni

ted

stat

es

Both

hos

pita

l nu

rses

and

GPs

/H

ospi

tal n

urse

s pr

ovid

ed S

CP to

bot

h pa

tien

ts

and

PCPs

, the

y al

so c

ondu

cted

a tr

ansi

tion

vis

it

wit

h th

e su

rviv

ors.

The

PCP

car

ried

out

a s

emi-

stru

ctur

ed fo

llow

-up

visi

t wit

h su

rviv

ors

(tal

king

po

ints

wer

e de

velo

ped

by th

e ho

spit

al).

Mor

e th

an o

nce,

Elec

tron

ic h

ealt

h sy

stem

, mai

l, or

em

ail,

web

site

s

Not

men

tion

edN

ot m

enti

oned

Not

men

tion

ed

Blaa

uwbr

oek,

et

al.

[39]

, 20

12,

Net

herl

ands

Fam

ily d

octo

rsLo

ng-t

erm

fo

llow

-up

clin

ic

The

rese

arch

team

(hos

pita

l spe

cial

ists

) con

-st

ruct

ed a

per

sona

lised

SCP

web

site

whi

ch w

as

acce

ssib

le to

the

fam

ily d

octo

rs. B

esid

es, t

he

rese

arch

team

ask

ed th

e su

rviv

ors

to m

ake

a ha

lf-ho

ur m

eeti

ng w

ith

thei

r fam

ily d

octo

rs,

they

rem

inde

d th

e su

rviv

or a

gain

if th

ey d

id n

ot

mee

t the

ir fa

mily

doc

tors

six

mon

ths

late

r.

Mor

e th

an o

nce,

secu

re w

ebsi

te o

r let

ter

Not

men

tion

edN

ot m

enti

oned

Not

men

tion

ed

Berg

er, e

t al.

[40]

, 201

7,

Fran

ce

GP

A p

aedi

atri

c on

colo

gist

and

an

inte

rnis

t

The

med

ical

doc

tor p

rovi

ded

the

cons

ulta

tion

su

mm

arie

s an

d re

com

men

dati

ons

abou

t fol

low

-up

for t

he s

urvi

vors

and

thei

r GPs

. The

med

i-ca

l doc

tor w

ould

cal

l the

GPs

if th

ey d

id n

ot

resp

ond

to th

e st

udy

at fi

rst.

Onc

e,

uncl

ear

Not

men

tion

edN

ot m

enti

oned

Not

men

tion

ed

Lund

, et a

l. [4

1], 2

016,

D

enm

ark

GP

Hos

pita

l ou

tpat

ient

ur

olog

ical

sp

ecia

lists

The

urol

ogic

al s

peci

alis

ts d

evel

oped

follo

w-u

p re

com

men

dati

ons

for e

valu

atin

g pa

tien

t and

GP

com

plia

nce,

incl

udin

g th

e sc

hedu

le o

f fol

low

-up

and

the

inst

ruct

ions

of r

efer

ral.

Onc

e,un

clea

rN

ot m

enti

oned

Not

men

tion

edN

ot m

enti

oned

GP

= ge

nera

l pra

ctit

ione

r. SC

P: s

urvi

vors

hip

care

pla

n.

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 12 of 17

Tabl

e 5

: Cri

tica

l rev

iew

of t

he R

CTs

wit

h Cr

itic

al A

ppra

isal

Ski

lls P

rogr

amm

e (C

ASP

).

Sect

ion/

Que

stio

nSc

ore

Berg

hold

t,

et a

l., 2

012

[3

1]

Berg

hold

t,

et a

l., 2

013

[3

2]

Nie

lsen

, et

al.,

20

03

[3

3]

Hol

teda

hl,

et a

l., 2

00

5

[34

]

Gru

nfel

d,

et a

l., 2

00

6

[35

]

Blaa

uwbr

oek,

et

al.,

20

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Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 13 of 17

Some studies used a descriptive way to assess the satisfac-tion of survivors and got similar results. First, Blaauwbroek et al. found that 88% of the survivors who completed the questionnaire were satisfied with the follow-up [36], while Berger et al. found a similar result in that 89% of the survivors who finished the questionnaire were satisfied with the health care [40]. Second, more than 80% of the survivors were generally satisfied with the information they received in the follow-up in two studies, and 71% of the survivors followed the instructions [39, 40]. Third, Blaauwbroek et al. reported that survivors were more aware of the benefits of follow-up (90.2%), and 73.6% of the survivors were more confident with the GPs’ capac-ity [39]. The only disadvantage of shard care reported in all eleven studies was that 15.3% of the childhood cancer survivors mentioned that the information they received reminded them of the negative memories from the past [39]. Finally, the subgroup analysis found that the men and younger age group (18–49 years) were significantly more satisfied with the shared care and found it easier to accept the GPs as their care provider [33], and the diagno-sis and the treatment could affect the satisfaction with the follow-up (p < 0.05) [40].

Care referral and continuity of careThe studies evaluated the continuity of care in different aspects, such as the primary care practitioner’s confidence in survivorship knowledge, their attitudes toward the follow-up and the information they received during the follow-up, and the frequency that survivors participated in the follow-up, but no significant differences were found between the intervention group and control group [32, 38]. Besides, most studies used descriptive data to report the outcomes. Blaauwbroek et al. found that 71.7%–77.4% of family doctors reported that their knowledge and abil-ity of providing follow-up care were improved [39], and Lund et al. reported that 91.5%–92.3% could follow the follow-up recommendations [41]. Besides, Blaauwbroek

et al. found that 82% of the family doctors were satisfied with the cooperation and the information they received [36]. Another study reported that 61% of GPs consid-ered the information they received and 82% ranked the collaboration with hospital as helpful, 59%–77% of the general practitioners stated that they received insufficient information in different aspects. Furthermore, GPs recom-mended that specific cancers needed particular follow-up more than other cancers such as more GPs considering that renal tumour survivors needed more specific care than lymphomas survivors (p = 0.013) [40].

The cost of shared careOnly one paper compared the cost of shared care with usual care and found that shared care was cheaper than usual care [37]. In the Emery et al. study, a multisite ran-domised controlled trial which included patients of two rural and four urban treatment centres was conducted. Five routine follow-up visits were carried out in both two groups, and two hospital visits were replaced by GP in the experimental group. At the end of the research, the shared care spent $323 less than usual care for each patient in the one-year follow-up.

The care in the shared care group and control groupThe interventions were complex. Three trials implemented the shared care with a clear division of tasks by hospital specialists and primary care physicians [34, 36, 37], while the other seven trials implemented the shared care by intending to transfer the follow-up care to primary care providers smoothly with specified information exchange [31–33, 35, 38–41]. The hospital centre and primary care formally communicated with each other more than once in four out of eleven trials [36–39], but the others only involved one formal communication [31–35, 40–41]. The cancer survivors in the control group were followed up by usual care [31–33, 37] or in the hospital [35] in most of the trials. However, one study [38] did not include

Table 6: Critical review of the quantitative studies with Health Care Practice R&D Unit (HCPRDU).

Question Score

Blaauwbroek, et al., 2012

[39]

Berger, et al., 2017

[40]

Lund, et al., 2016

[41]

(1) Study overview 2 2 1

(2) Study, setting, sample and ethics

2 2 1

(3) Ethics 2 0 1

(4) Group comparability and outcome measurement

1 1 1

(5) Policy and practice implica-tions

1 1 2

(6) Other comments 2 1 2

Total score (maximum 12)

10 7 8

“0” represents many limitations, “1” represents some limitation, “2” represents excellent.

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 14 of 17

survivors in the control group but applied the data from another matched study in the same country as the control group. Besides, two studies did not clearly describe the content of the control group [34, 38].

DiscussionThis review included 11 papers that evaluated shared care in the continuity of care for cancer survivors. These studies conducted shared care with various and complex multifac-eted interventions for improving the follow-up of cancer survivors, especially their quality of life and depression. An overview of the results in the selected studies suggests that survivors and general practitioners reported favour-ing shared care, and the survivors who had experienced shared care had a stronger preference for shared care in the future. However, there were no significant differences in terms of quality of life, mental health outcomes, unmet needs, and serious clinical events between shared care and usual care. One important confounding factor might be that the patient-reported results could have been affected by the lack of confidence in primary care [42] since it is impossible to blind the survivors.

Although only 11 papers were included in the present review, the overall sample size and the quality of studies constitutes an overview with a preliminary picture of the possible way to conduct shared care and the effectiveness of shared care. Two models of shared care were identified as offering potential to improve the monitoring of cancer survivors: the transference of survivors, which lies within the information exchange; and the coordination of assess-ments and treatments, which allows distant health pro-fessionals to conduct the monitoring alternately. Several interventional strategies that were utilised played a role in enhancing the efforts in terms of care cooperation: (1) sur-vivorship care plan; (2) referral and consultation visit; (3) improving the knowledge of PCPs; (4) enhancing patient’s confidence in health care practitioners, especially in PCPs; (5) building the communication channel between health care professionals; and (6) the register and recall system.

The studies that assessed the continuity of care found that shared care could meet the requirements of follow-up, and the PCPs felt their knowledge was improved and that they had the capability of providing healthcare with the support of hospital specialists. Blaauwbroek et al. found that 77.4% of the PCPs considered that they had the capacity of providing follow-up if the SCP was avail-able [39], while another survey found that only 40% of the PCPs felt confident of their knowledge in the follow-up of cancer survivors in the usual care [43]. Besides, the only study that compared the cost of shared care to usual care found that the shared care on average reduced costs by $323 per patient at one-year follow-up [37].

Although only those studies that were rated as “good” or “excellent” were included in this review, several stud-ies had major limitations, such as the sample size being insufficient [34, 38], the significant differences at the baseline [33], and the outcome assessor not being blinded in most of the trials. Besides, there were only six RCTs that compared shared care with usual care, and many of the results were illustrated within a descriptive method. Thus,

the small number of available studies could not provide a solid foundation for this review. Furthermore, there were various types of outcomes that were detected in the stud-ies, so many of the results could not be regrouped based on the considerable heterogeneity. Besides, all the stud-ies were conducted in developed countries, and most of the studies were performed in city settings, so the results might not apply to other undeveloped countries or rural regions. Further limitations include that only papers writ-ten in English were included and the author appraised the papers without blinding to the published journal or the writers.

ConclusionsImplications for practiceThe present review shines a light on improving the follow-up, with current evidence indicating that shared care is an affordable model as well as being feasible and accept-able for cancer survivors. It enables GP’s involvement in survivorship care and help the cooperation between hos-pital and primary care. Although the evidence showed that the effectiveness of shared care is similar to hospital follow-up, the strategies we identified from the included studies could be useful to all stakeholders of health care and provide a preference for implementing new strategies in cancer follow-up to address the sustainable burden of hospitals. Due to limited evidence of financial analysis, we could not make conclusion that shared care is cheaper than usual care, but it is potentially contributing to help resolve the stabilised health care costs. However, more solid evidence about the effectiveness of shared care is needed before it can be routinely implemented.

Implications for researchAlthough the results of this review do not confirm that shared care is more effective than usual care in the management of follow-up in cancer survivors, several key elements have been identified in shared care: the consultation meeting, the formal transferring of docu-ments, encouraging communication between the survi-vors and the practitioners, and the length of follow-up. Besides, the communication channel and register and recall system are also considered as important elements in shared care. The research gaps of the included stud-ies also indicate the directions that future studies need to address. First, further RCTs with sufficient sample size are needed to explore the health-related cost of shared care and the clinical outcomes. Second, the differences in the subgroup indicate that individual follow-up should be conducted based on the diagnosis, treatment, age, and gender. Third, the follow up should be modified accord-ing to the specific health care needs in different time frames since diagnosis [44].

Additional FilesThe additional files for this article can be found as follows:

• Appendix 1. MEDLINE (Ovid) and HMIC search strategy. DOI: https://doi.org/10.5334/ijic.3954.s1

Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 15 of 17

• Appendix 2. Critical Appraisal Skills Programme (CASP) Randomised Controlled Trials Checklist. DOI: https://doi.org/10.5334/ijic.3954.s1

• Appendix 3. Health Care Practice R&D Unit ( HCPRDU) quantitative research checklists. DOI: https://doi.org/10.5334/ijic.3954.s1

• Appendix 4. Health Care Practice R&D Unit (HCPRDU) mixed methods research checklists. DOI: https://doi.org/10.5334/ijic.3954.s1

• Appendix 5. Example of using CASP RCT checklist to appraise a selected RCT. DOI: https://doi.org/10.5334/ijic.3954.s1

• Appendix 6. Example of using HCPRDU quantitative research checklists to appraise a selected quantitative study. DOI: https://doi.org/10.5334/ijic.3954.s1

• Appendix 7. Example of using HCPRDU mixed methods research checklists to appraise a selected mixed methods’ study. DOI: https://doi.org/10.5334/ijic.3954.s1

AcknowledgementsI would like to acknowledge the help of my supervisor, Ms. Alison Brettle, for her professional instructions and for walking me through all the stages during the writing-up process. She has spent a lot of time reading through the drafts and providing insightful criticism. Without her continuous encouragement and expert guidance, I would not have completed this research. I also want to express my great gratitude to my friend, Ms. Yanni Wu, who has provided great support during my study.

ReviewersDr Irene Ngune, School of Pharmacy, Faculty of Health Sciences, School of Nursing, Midwifery and Paramedicine.

Ana Rodríguez Cala, Director of Strategy and Corporate Social Responsibility at the Catalan Institute of Oncology (Institut Català d’Oncologia), Spain.

Competing InterestsThe authors have no competing interests to declare.

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How to cite this article: Zhao, Y, Brettle, A and Qiu, L. The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review. International Journal of Integrated Care, 2018; 18(4): 2, 1–17. DOI: https://doi.org/10.5334/ijic.3954

Submitted: 14 December 2017 Accepted: 25 September 2018 Published: 12 October 2018

Copyright: © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

OPEN ACCESS International Journal of Integrated Care is a peer-reviewed open access journal published by Ubiquity Press.