endometrial cancer survivorship: improving long-term …...endometrial cancer survivorship:...
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Endometrial Cancer Survivorship:Improving long-term outcomes
Conclusion
Background Results
The audit highlighted that women with endometrical cancer residing in the Waitemata DHB catchment, possess risk factors that echo those of cardiovascular disease. A link was also demonstrated between ethnicity and increased number of these risk factors. This potentially impacts overall survival. As a result of this research, a revised model of follow-up care is proposed that will be patient-focused and nurse-led, focusing on self-care strategies and survivorship to manage these risk factors, and utilise primary care and community services with the goal of improving outcomes.
Endometrial cancer (EC) is the commonest gynaecological
cancer in the developed world and increasing at a significant
rate. In New Zealand (NZ) there has been a 39% rise in the
incidence of endometrial cancer over the past four decades.
This increase has been largely driven by risk factors linked to
lifestyle behaviours that are considered modifiable.1 These risk
factors echo those of cardiovascular disease (CVD), and indeed
CVD is the leading cause of death in women successfully treated
for early stage endometrial cancer.2
Previous research has identified marked disparities in the
incidence and outcomes of endometrial cancer in Māori and
Pacific women.3 Between 23-27% of deaths from endometrial
cancer in NZ are considered avoidable.4
262 Patients were included in the audit
Objective and Study MethodThe author elected to undertake Masters research to
understand the incidence of EC and patient profile of women
residing in Waitemata District Health Board (DHB) catchment.
A retrospective audit was undertaken utilising the clinical
records of all women with a confirmed diagnosis of endometrial
cancer in a community-based hospital between 2002 and 2014.
OutcomeThe findings highlighted a large number of women possessed
modifiable risk factors. A new model of care is proposed for a
nurse-led, patient-focused follow-up process that addresses
these risk factors in collaboration with primary care and
community services.
DiscussionNew Model of Care (MOC):
International research demonstrates a lack of information and
advice given to patients regarding lifestyle behaviours.
A small in-house survey with a representative sample of 17
gynaecology physicians and 7 Pacific patients identified a
discrepancy between provider and recipient perception of
information given about risk factors. Whilst doctors stated they
“occasionally/frequently” discuss modifiable risk factors and
“frequently” discuss adopting healthy lifestyle behaviours,
patients stated they could not remember such a conversation.
An audit of 61 clinical records revealed no documentation of
lifestyle conversations.
The new proposed MOC moves away from a traditional
physician-led approach that focuses on recurrence to one that is
facilitated by the nurse specialist and primary care team ,
capitalising on the “teachable moment” and works with the
patient and their whānau, empowering women to take
responsibility for their own health.
Strengths :
• The audit identified women residing in the Waitemata DHB
catchment possessed risk factors that not only increased
their risk of endometrial cancer but may also increase their
risk of cardiovascular disease in line with international
research.
• NZ has a unique population and this study demonstrated that
particular ethnicities possess more risk factors than others.
Weaknesses:
• The number of patients included in the audit are very small
and so may not be representative of the whole of New
Zealand.
• The limitations of the model are not yet fully known and it
awaits full development.
Context
Next Steps
Proposed Survivorship ModelIntegrating Primary, Secondary and Complimentary Health
NZ Gynaecological Cancer Group Follow-up Guidelines forLow-risk EC that have informed the proposed new model of care
Process Map for New Model of Care
• Māori and Pacific women had a younger mean age at diagnosis compared with NZ European women (57yrs & 54yrs vs. 65yrs)
• Youngest patient was 23yrs and of Pacific ethnicity
Development of the model using a co-design approach.
Patient overview
• The majority of women were post-menopausal (75%) • 66% of the women were considered obese with 27%
categorised as Obesity Class III (BMI ≥40) • 13% were considered pre-menopausal
with 7% being under 40yrs
Menopausal status & Body Mass Index (BMI)
Thank you to Sue French for assistance with the diagrams and Cassie Khoo for the poster design.
Acknowledgements
• 40% had a NZ deprivation index score of 7–10 (scale: 1 “least socio-economically deprived” to 10 “most socio-economically deprived”)
Social Factors
• 85% Endometrioid adenocarcinoma • Of these 45% were Stage 1A, G1 or 2
Histology
• 90% underwent surgery as first treatment • 72% disease-free (at end of data collection)
• Consider virtual clinic for well motivated / very rural patients • Discharge at 2 years if no symptoms / ongoing concerns • *3 month and 2 year nurse-led survivosrhip clinic is recommended
Treatment & Outcome
Low Risk — Stage IA, G1, 2
3 MONTH 6 MONTH 1 YEAR 18 MONTH 2 YEAR 5 YEAR
GynaecologicalSurgeon
Specialist Nurse*SP
Exit SP
Collect5 yeardata
outcomes
GP
References1. Soliman, P. T., Bassett, R. L. J., Wilson, E. B., Boyd-Rogers, S., Schmeler, K. M., Milam, M. R., . . . Lu, K. H. (2008). Limited public
knowledge of obesity and endometrial cancer risk: what women know. Obstetrics and Gynecology, 112(4), 835-842. doi:10.1097/AOG.0b013e318187d022
2. Felix, A. S., Bower, J. K., Pfeiffer, R. M., Raman, S. V., Cohn, D. E., & Sherman, M. E. (2017). High cardiovascular disease mortality after endometrial cancer diagnosis: Results from the Surveillance, Epidemiology, and End Results (SEER) Database. International Journal of Cancer, 140(3), 555-564. doi:10.1002/ijc.30470
3. Firestone, R. T., Ellison-Loschmann, L., Shelling, A. N., Ekeroma, A., Ikenasio-Thorpe, B. A., Pearce, N., & and Jeffreys, M. (2012). Ethnic differences in disease presentation of uterine cancer in New Zealand women. The Journal of Family Planning and Reproductive Health Care, 38(4), 239-245. doi:10.1136/jfprhc-2011-100113
4. Sandiford, P., Abdel-Rahman, M. E., Allemani, C., Coleman, M. P., & Gala, G. (2015). How many cancer deaths could New Zealand avoid if five-year relative survival ratios were the same as in Australia? Australian and New Zealand Journal of Public Health, 39(2), 157-161. doi:10.1111/1753-6405.12344
CONTACT: Gwyneth [email protected] • 021 919 762
Gwyneth CapesClinical Nurse Specialist–Cancer Nurse Coordinator, Waitemata District Health Board and Institute of Innovation and Improvement, Auckland, NZ
Risk factors associated with endometrial cancer(2002–2014)
% o
f pat
ient
s (n
=26
2)
BMI0
10
20
30
40
50
6058
53
33
25
19
5 4
70
Hypertension
Hyperlipidaem
ia
Diabetes m
ellitus
type II
Endometri
osis/
mennorh
a...
Infertil
ity
PCOS
Total of Patients with ≥3 Risk Factors Per Ethnicity
European (23%)
Māori (53%)
Pasifika (52%)
Asian (39%)
GP Care: ReferralP1 & HSCN
0 1 2 3 4 5
Cancer Nurse CoordinatorInte
nsity
of s
ervi
ce e
ngag
emen
t
Time since diagnosis – in years
Propose Human Centered Design Model: Nurse-Led
Service addressing lifestyle risk factors, improving QoL,
transitioning to primary care.Creating better outcomes
(See Process Map)
Current gap between Primary and Secondary care, and curative and
preventative medical models
Primary care & Support services:GP, psychology, social services, NGO’s
Secondary medical services: gynecologists, general
surgeons, gynae-oncologist, radiation oncologists
Dia
gnos
is a
nd T
reat
men
t
Post-op medicalfollow-up
Phas
e 1:
0–6
2 da
ys (F
aste
r Can
cer T
reat
men
t Tar
get)
Phas
e 2:
2–3
0 m
onth
s po
st-o
p
Phas
e 3:
3-5
yea
rs p
ost d
iagn
osis
Migrating from current medical model to new Integrated Care Model
Post diagnosis & Pre 1st Treatment
Patient & Nurse 1:1 Preventative Health Assessment
Current framework includes: Physical and psychosocial health needs and planning
Outcome Measures: > Pre-op universal Quality of Life Measure (EQ 5D) & Gynaecology
specific Patient Reported Outcome Measure (PROM) – (to be determined to working group)
Outcome Measures: > EQ 5D, Gynaecology specific PROM and Patient Experience Measure (TBC), Health Outcome Prediction Engineering (HOPE) analysis > Quality-adjusted Life Years (QALYs), Disability-adjusted Life Years (DALYs), CVD risk score, secondary cancer prevalence
To be determined by primary sector stakeholders
Post Treatment delivery GP Practice and NGO’s
Proposed Integrated Care Model Primary Care
New Framework expands to include:
• CNS
• GP
• Endocrine Management Therapies
• Dietician
Collaborative Secondary and Primary sector programme delivered in a community setting with the following providers:
• Green Script
• Psychology
• Social worker
• Sexual health
• Pharmacist
• Physiotherapist
• Life-style coach
• Complimentary therapies
• Ethnically specific community support
Nurse Led Service
Assessment of following needs:
Psychosocial Support/counselling
Information sharing
Education
Whānau engagement
Symptom severity post surgery
Financial
Integrated Care plan – developed with the patient and whānau
Patient led risk factor management with community support
• Age • Socioeconomic status • Risk factors • Obesity
• Increased Blood Pressure • Increased Cholesterol • Diabetes
Risk Factors Summary • 34% of all women had 3 or more risk factors • Of the 27% who were deceased (at end of data
collection) — 56% had ≥2 risk factors and 23% had 4–5 risk factors