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 Method The 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. Outcome The 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. Discussion New 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 Model Integrating Primary, Secondary and Complimentary Health NZ Gynaecological Cancer Group Follow-up Guidelines for Low-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 Gynaecological Surgeon Specialist Nurse* SP Exit SP Collect 5 year data outcomes GP References 1. 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 Capes [email protected] • 021 919 762 Gwyneth Capes Clinical 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) % of patients (n=262) BMI 0 10 20 30 40 50 60 58 53 33 25 19 5 4 70 Hypertension Hyperlipidaemia Diabetes mellitus type II Endometriosis/ mennorha... Infertility PCOS Total of Patients with ≥3 Risk Factors Per Ethnicity European (23%) Māori (53%) Pasifika (52%) Asian (39%) GP Care: Referral P1 & HSCN 0 1 2 3 4 5 Cancer Nurse Coordinator Intensity of service engagement 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 Diagnosis and Treatment Post-op medical follow-up Phase 1: 0–62 days (Faster Cancer Treatment Target) Phase 2: 2–30 months post-op Phase 3: 3-5 years post diagnosis 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

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Page 1: Endometrial Cancer Survivorship: Improving long-term …...Endometrial Cancer Survivorship: Improving long-term outcomes Conclusion Background Results The audit highlighted that women

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