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CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL

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 r.neal@bangor.ac.uk. CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL

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CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL

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  1. PRIFYSGOL BANGOR / BANGOR UNIVERSITY Developing and testing new models of follow-up care in cancerDr Richard NealClinical Senior Lecturer in General PracticeNorth Wales Centre for Primary Care Researchr.neal@bangor.ac.uk CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL NORTH WALES CENTRE FOR PRIMARY CARE RESEARCH

  2. Overview PRIFYSGOL BANGOR / BANGOR UNIVERSITY • 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

  3. Why follow-up in cancer? PRIFYSGOL BANGOR / BANGOR UNIVERSITY • 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

  4. ‘Traditional’ hospital follow-up PRIFYSGOL BANGOR / BANGOR UNIVERSITY • 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

  5. Who provides follow-up, and how? PRIFYSGOL BANGOR / BANGOR UNIVERSITY • Specialists • Medical / clinical oncologists • Surgeons • Physicians • GPs • Specialist nurses (nurse-led models) • Models • Traditional • Phone • Patient initiated • ….or a combination of these

  6. Huge variation in follow-up needs PRIFYSGOL BANGOR / BANGOR UNIVERSITY Patient: • By cancer • By stage • By treatment modality • By prognosis • By co-morbidity • By needs • By preference .....not a one size fits all

  7. PRIFYSGOL BANGOR / BANGOR UNIVERSITY

  8. PRIFYSGOL BANGOR / BANGOR UNIVERSITY A framework for holistic assessment of risks and needs

  9. Designing trials PRIFYSGOL BANGOR / BANGOR UNIVERSITY • Which patients? • Which interventions? • Biomarkers • Imaging • Clinical examination • Psycho-educational • Setting / clinician / mode • Which outcomes? • Patient safety • Detection of recurrence • Quality of Life • Satisfaction

  10. Developing interventions PRIFYSGOL BANGOR / BANGOR UNIVERSITY For lung and prostate cancers we have undertaken: • Guideline review • Systematic review • Case-note analysis • Database analysis • Qualitative study …….and developed / developing trial interventions

  11. Developing interventions PRIFYSGOL BANGOR / BANGOR UNIVERSITY 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

  12. Developing interventions PRIFYSGOL BANGOR / BANGOR UNIVERSITY 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)

  13. A randomized controlled trial of a nurse-led psycho-educational intervention delivered in primary care to prostate cancer survivors (PROSPECTIV) PRIFYSGOL BANGOR / BANGOR UNIVERSITY • 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

  14. Potential Macmillan funding for BCUHB / north Wales PRIFYSGOL BANGOR / BANGOR UNIVERSITY 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

  15. Discussion / questions PRIFYSGOL BANGOR / BANGOR UNIVERSITY Dr Richard Neal North Wales Centre for Primary Care Research r.neal@bangor.ac.uk

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