San Diego, CA—Surviving cancer is the start of a new journey for many individuals. Cancer survivors face a multitude of challenges, including prevention of new and recurrent cancers; interventions for illnesses secondary to cancer and its treatment; concerns related to employment, insurance, and disability; and coordination between specialists and primary care providers. These challenges are compounded when trying to ensure the appropriate, culturally sensitive delivery of care to vulnerable populations, said Margaret Q. Rosenzweig, PhD, FNP-BC, AOCN, FAAN.
At the 2017 Cancer Survivorship Symposium, Dr Rosenzweig, Professor of Acute & Tertiary Care, University of Pittsburgh School of Nursing, and a nurse practitioner for women with breast cancer, University of Pittsburgh Cancer Institute, Pittsburgh, PA, outlined research regarding disparities in cancer survivorship treatment and discussed what is needed to deliver equitable care.
“Structurally, we know that vulnerable populations are made vulnerable by race, geography, ethnicity, income, or education, and they have less access to quality cancer care overall. This is particularly true if survivorship care cannot go back to the community, or if the primary care setting is not structured to deal with that. Reaccessing cancer care centers is particularly challenging for poor and rural patients,” she said.
As Dr Rosenzweig reported, there are clinical and physician factors to contend with as well. Vulnerable populations have higher cancer-risk presentations, making cancer recurrence more likely. They also have more comorbid illness at presentation, and African-American patients, in particular, report more pain overall. These problems are magnified by poor patient–provider communication.
“Across the board, when nonwhite patients have white providers, they report less satisfaction with patient–provider communication, which can contribute to poor outcomes in survivorship care,” said Dr Rosenzweig.
Multiple patient factors also contribute to disparities in care. Poor nonwhite patients report more barriers to receiving optimal survivorship care; specific barriers include transportation and personal financial issues. Dr Rosenzweig also noted that personal choices regarding nutrition, physical activity, and tobacco are important considerations. In addition, researchers are increasingly recognizing the role of chronic stress and poverty as contributing factors to inequitable care.
Personalizing Survivorship Care Plans
However, there are promising strategies that can limit barriers and provide novel methods of equitable care delivery, such as efforts to extend survivorship care into the primary care setting (eg, reduce structural barriers such as transportation, distance, and finances). At the center of these efforts, said Dr Rosenzweig, is the development and use of the survivorship care plan (SCP) and care summary, although she cited numerous challenges to the implementation of SCPs. Specifically, for vulnerable populations, individualization of the SCP, consideration of culture as the care plan is developed, and integration of the navigator are complex, but vital, components.
“For vulnerable populations, the survivorship care plan must include a more holistic assessment of their particular culture. In addition, care planning should be based on exposure and risk, highly specific to the individual patient, rather than just a generic plan. The patient should be involved in the formulation of the plan, and a realistic assessment of what’s possible in terms of travel, finance, and time needs to be incorporated,” she said.
Patient navigation is another important component of survivorship care planning. As Dr Rosenzweig explained, several published studies have demonstrated that navigation succeeds in bringing an individual from the community into the patient setting. Less understood, however, is what happens once the patient is in the cancer care setting and then transitions from treatment into survivorship. These are areas that still need to be studied and developed, along with appropriate training on cultural sensitivity.
“In the ideal survivorship care model, the navigator should continue throughout active treatment to maintain that relationship and to help when problems arise. It is critically important that we know how navigators are trained, what the interpersonal processes of care are, and how that is measured, and that this information gets into the literature,” said Dr Rosenzweig.
“Navigation has been embraced, but without this type of transparency, it is prone to budget cuts, particularly in the community,” she added.
Symptom Distress an Important Consideration
For patients receiving treatment in the survivorship setting, symptom distress is an understudied, but important, consideration.
“In our own work among women who have initiated chemotherapy, we found that nearly half of patients were unable to receive full-dose chemotherapy because of treatment delays, early cessation or hold, and that was correlated to symptom distress,” said Dr Rosenzweig.
Improvement in patient–provider communication could play a part in reducing this distress.
“As patients relay their symptoms, it’s very important how those symptoms are received and managed. If that is not done in a quality manner, we believe that can influence treatment adherence and ultimately outcomes,” she said.
To ensure that cancer survivorship care is equitable, she explained, lifetime stress exposure is a patient factor that clinicians should take into considereration.
“We know that telomere length shortening leads to premature aging through oxidative processes, and we know that that can be exacerbated through exposure to stress. This stress can be linked to zip code and ultimately cancer occurrence, cancer recurrence, and cancer survival. It’s important that we measure lifetime stress exposure for patients, particularly as they return to the community as cancer survivors,” said Dr Rosenzweig, adding that stress exposure should also be incorporated into the SCP.
Future Interventions to Improve Patient Outcomes
As Dr Rosenzweig reported, nutrition, obesity, and physical activity are the most common concerns prompting interventions among diverse populations in cancer care, particularly in breast cancer survivorship care. Short- and long-term studies are needed to evaluate current intervention methodologies.
“These are very exciting and innovative strategies not only to improve overall health but also to reduce the possibility of cancer recurrence,” she said.
Tobacco cessation is another important area of intervention.
“Standard tools do work in survivors to decrease tobacco usage, but the important caveat is that cancer survivors without access to healthcare do not quit smoking. It is the addition of access to healthcare and a plan that is worked on that allows smoking cessation to be successful,” said Dr Rosenzweig.
Finally, Dr Rosenzweig urged her colleagues to continue to advocate for access to care. Survivorship in the community is not possible without affordable and accessible care, she said.
“We know a lot about what works, and we know a lot about the gaps in our knowledge. Through continued efforts, we can help to ensure equitable survivorship care for all patients with cancer. If Netflix knows what movie I want to watch next, we certainly can figure out how to personalize care to get the optimal care to the right patient,” Dr Rosenzweig concluded.