CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL NORTH WALES CENTRE FOR PRIMARY CARE...
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Transcript of CANOLFAN GOGLEDD CYMRU AR GYFER YMCHWIL GOFAL CYCHWYNNOL NORTH WALES CENTRE FOR PRIMARY CARE...
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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TY Overview
• 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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TY Why follow-up in cancer?
• 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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TY Who provides follow-up, and how?
• 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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A framework for holistic assessment of risks and needs
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TY 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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TY 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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TY Developing interventionsFor 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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TY Potential Macmillan funding for BCUHB / north Wales
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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TY Discussion / questions
Dr Richard NealNorth Wales Centre for Primary Care Research