Reducing Disparities in Survivorship Care
Surviving cancer is the start of a new journey for many individuals. Cancer survivors face a multitude of challenges, including the prevention of new and recurrent cancers; interventions for illnesses secondary to cancer and its treatment; concerns about employment, insurance, and disability; and coordination between specialists and primary care providers. These challenges are compounded by the need to ensure appropriate, culturally sensitive delivery of care to vulnerable patient populations, said Margaret Q. Rosenzweig, PhD, FNP-BC, AOCNP, FAAN, Professor of Acute and Tertiary Care, University of Pittsburgh School of Nursing, PA, at the 2017 Cancer Survivorship Symposium.
“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,” said Dr Rosenzweig.
Clinical and physician factors are contending issues as well, reported Dr Rosenzweig. Vulnerable patients present with high-risk features, making cancer recurrence more likely in these patients than in nonvulnerable patients. Vulnerable patient populations also have more comorbid illnesses at presentation, and African-American patients report more pain overall than nonvulnerable patients. 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.
In addition, multiple patient factors contribute to disparities in survivorship care. Poor nonwhite patients report increased barriers—including transportation and personal financial issues—to receiving optimal survivorship care.
Personal choices regarding nutrition, physical activity, and tobacco are also important considerations when assessing disparities in survivorship care. Researchers are increasingly also recognizing the role of chronic stress and poverty as contributing factors to inequitable survivorship care.
Personalizing Survivorship Care Plans
Promising strategies can limit these barriers and provide novel methods of equitable survivorship care delivery, including extending survivorship care into the primary care setting (eg, reduce structural barriers, such as transportation, distance, and finances).
At the center of these efforts is the use of survivorship care plans and care summaries. Dr Rosenzweig cited challenges to the implementation of survivorship care plans, specifically for vulnerable patient populations, including individualization of the plan, consideration of culture in the plan, and integration of the navigator.
“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,” Dr Rosenzweig said. “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 added.
For patients receiving treatment in the survivorship care 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.
Improving patient–provider communication could help to reduce 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, lifetime stress exposure is a patient factor that clinicians should take into consideration.
“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,” she said, adding that stress exposure should also be incorporated into the survivorship care plan.
Nutrition, obesity, and physical activity are the most common concerns prompting interventions among diverse patient populations in cancer care, particularly in breast cancer survivorship care, reported Dr Rosenzweig. 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, she urged her colleagues to continue advocating for access to survivorship 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,” concluded Dr Rosenzweig.