Transcript PATIENT SATISFACTION WITH THE HNC SURVIVORSHIP CLINIC

THE LONG-TERM QUALITY OF LIFE
OF HEAD AND NECK CANCER PATIENTS
FINDING OUR WAY TO SURVIVORSHIP MANAGEMENT
Gerry F. Funk, MD
Department of OtolaryngologyHead and Neck Surgery
University of Iowa College of Medicine
Iowa City, Iowa
October 11, 2013
CAN WE SIGNIFICANTLY IMPROVE THE SURVIVAL
OF HNC PATIENTS THROUGH POST-TREATMENT
SURVIVIRSHIP CARE?
Co-morbidities
General health maintenance
Health behaviors
Oropharyngeal functioning
Pain
HRQOL
UNIVERSITY OF IOWA HNC
OUTCOMES PROGRAM
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1995 Outcomes Assessment Program started
– Head and Neck Cancer Specific Function and
QOL
– Medical Outcomes Study SF-36
– Psychosocial evaluation
– Case-mix data: demographics, stage, survival,
co-morbidity, tobacco & alcohol use, pain,
employment,…
Patients
– Over 2500 enrolled
– Information gathered pre-Rx, 3mo, 6mo, 1yr,
yearly.
Funding
– ACS Seed Grants
– ACS Career Development Award, 95-33
– NIH, NCI, Office of Cancer Survivorship, R01
CA106908
– NIH, NCI Office of Cancer Survivorship, ARRA
Admin Supplement R01 CA106908-04S1
– Iowa Cancer Consortium
THE HNC OUTCOMES PROGRAM
25 Studies published with data from the
Outcomes Program
- Comparative, Psychosocial, Functional
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Smoking behavior
General health outcomes
Depression, Social Support
Alcohol use
Post-treatment employment
Surgery vs Chemoradiation
Long-term outcomes of Chemoradiation, XRT, IMRT
Long-term HRQOL
Relationship of PET (SUV) and XRT dose with HRQOL
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HRQOL profiles
Self-reported general health
Pain
Gastrostomy tube use and dysphagia
2-yr conditional survival
- Predictors of survival and long-term outcomes
- Health Service Utilization and Survivorship
- Health care utilization by HNC patients
- HNC Survivorship Clinic
FIRST-YEAR HRQOL PROFILES ARE ASSOCIATED
WITH SURVIVAL
HRQOL stratified short and long-term survivors.
SELF-REPORTED GENERAL HEALTH
Co-morbidity predicted overall survival.
Self-reported physical health predicted both
overall and disease-specific survival.
THE ROLE OF PAIN
Post-treatment pain is an
independent predictor of
recurrence and is significantly
associated with decreased
disease-specific survival.
DYSPHAGIA AND SURVIVAL
RISK FACTORS FOR DEATH ON MVA
Patients >70 yrs
Hypopharyngeal primary
Treatment included XRT
SPS = 7
SPS 7 group (severe dysphagia) had
significantly lower overall survival than
the other groups.
2-YEAR CONDITIONAL SURVIVAL
Variables present at 2 years that are
predictive of 5-year survival in 2-year
survivors of HNC.
Obs Survival
Factor
DS Survival
P
value
HR
P
value
HR
Age
0.01
1.07
0.03
1.07
Stage
0.03
2.49
0.008
4.84
Tobac use
---
---
0.003
4.22
Pain @ 2yr
0.03
2.09
---
---
QOL @ 2yr
0.02
4.62
HOW ARE WE DOING WITH SURVIVAL OF HNC PATIENTS?
SUCCESS AT THE FRONT END OF TREATMENT
Surg Tech
Anesth
Rad Tech
Chemo
Molec Targ Rx
The 5-yr disease-specific survival for
head and neck cancer is ~ 65%
THE QUESTION
Can the survival of HNC patients be improved
through focused survivorship care?
SUCCESS AT THE BACK END OF TREATMENT
Co-morbidities
General health maintenance
Health behaviors
Oropharyngeal functioning
Pain
HRQOL
SURVIVORSHIP
In 1971 there were 3 M cancer survivors in the US. Currently there
are 13.7 M, and in 2022 there will be an estimated 18 M
• Survivorship Initiatives
– Office of Cancer Survivorship: Established in 1996 is
dedicated to enhancing the length and QOL of cancer
survivors (NCI)
– IOM, NRC: From Cancer Patient to Cancer Survivor: Lost in
Transition
– CDC/LAF: National Action Plan for Cancer Survivorship:
Advancing Public Health Strategies
– NCCS, IOM, LAF, NCI : Implementing Cancer Survivorship
Care Planning – Commission on Cancer Standards
Over half of our patients will become cancer survivors, and we
need to engage them as cancer survivors.
COMMISSION ON CANCER STANDARDS REGARDING
SURVIVORSHIP JANUARY 1, 2015
HNC SURVIVORSHIP CLINIC GOALS
• Facilitate focused attention to identified long-term
survivorship issues
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Co-morbidities
General health maintenance
Health behaviors
Oropharyngeal functioning
Pain
HRQOL
• Provide guideline-concordant, high-quality, HNC
surveillance.
• Institute the use of Survivorship Care Plans
• Evaluate the use of a Survivorship Clinic on
patient outcomes (survival, HRQOL, general
health benchmarks)
• Improve resource use of HNC clinicians
Arch Otolaryngol Head Neck Surg. 2012;138(2):123-133
JUSTIFICATION FOR INSTITUTING A HNC
SURVIVORSHIP CLINIC
• Over half of patients treated for HNC will become
long-term survivors.
• Co-morbid illnesses are not being optimally
managed.
• Unhealthy lifestyles persist after treatment.
• HNC patients have unmet health care needs.
• HNC patients seen for follow-up make up 72% of
patients seen in HNC clinics. The HNC clinics are
poorly resourced to meet the global survivorship
needs of these patients.
• The model selected for the survivorship clinic is
financially sound.
UNIVERSITY OF IOWA HNC SURVIVORSHIP CLINIC
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Hybrid - transitional and shared
model
HNC Survivorship Clinic is co-located
with the HNC clinic
PA-C directed care
HNC survivorship PA spent 1 year
– Working in HNC clinics with HNC
surgeons, radiation oncologists,
medical oncologists – learning
about HNC post-treatment care
and cancer surveillance
– Developing HNC Survivorship
Care Plans with the HNC team
– Organizing adjuvant care
collaborators
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Speech and swallowing
Pain and symptom management
Tobacco cessation intervention
Social Services
EMR Template for Survivorship
Care Plan & Survivorship Clinic
Visit
Support Services available
through the Survivorship
Clinic
HNC SURVIVORSHIP CLINIC
ELIGIBILITY
• Initial visit (SCP, Psychosoc screen) at
completion of treatment.
• Formal HNCSC referral.
– HNC Patients >/= 2 year out from last cancer
directed therapy.
– Referral from the primary Head and Neck
Surgeon/Oncologist.
– Clinical assessment consistent with low risk of
recurrence.
– Immediate return to HNC clinic if any concern for
recurrence is identified.
HNC SURVIVORSHIP CARE PLAN
HNC SURVIVORSHIP
CLINIC
Characteristic
Age
Table 1: Patient, disease, and
treatment characteristics of
patients enrolled in the
Survivorship Clinic who have
filled out the patient satisfaction
survey to date (N=65)
<55
55-64
65-74
75+
Number
Percent
19
30
13
3
29.2
46.2
20.0
4.6
40
25
61.5
38.5
26
27
2
5
5
40.0
41.5
3.1
7.7
7.7
19
44
2
29.2
67.8
3.0
20
5
15
20
1
4
30.8
7.7
23.1
30.8
1.5
6.2
Gender
Male
Female
Site
Oral cavity
Oropharynx
Hypopharynx
Larynx
Other
Stage
Early (1-2)
Advanced (3-4)
Unstageable/unknown
Treatment
Surgery only
RT only
Surgery + RT
RT + Chemo
All 3
Unknown**
PATIENT SATISFACTION WITH THE
HNC SURVIVORSHIP CLINIC
Item
Strongly
agree
Agree
Disagree
Strongly
disagree
Overall satisfaction
with medical care
87
13
--
--
Competent/complete
HNC care
89
11
--
--
Communicate well
with P.A.
89.2
10.8
--
--
Receive
courtesy/respect
92.3
7.7
--
--
91
9
--
--
87.5
12.5
--
--
Would recommend
Survivorship Clinic
All med issues
addressed
Survey of the first 100 HNC Survivorship Clinic patients to evaluate their perceptions
about the care in the Clinic.
HNC SURVIVORSHIP PATIENT POPULATION
AND OUTCOMES
EVALUATING UTILITY
• Recurrence
• Overall and DS
survival
• Tobacco and alcohol use
• Preventable hospitalizations
• General health maintenance benchmarks
• Age and gender appropriate
cancer screening – benchmarks
• Resource utilization
• Health-related quality of life
HNC SURVIVORSHIP CLINIC
Aggressive Survivorship
Management as a Focused
Intervention
There are no associated toxicities
It is not rocket science
May improve resource utilization
Begins implementation of Surv Care Plans
May improve HRQOL
May improve survival
THANK YOU