Feasibility study into the establishment of Gippsland best

practice shared care model (telehealth) for post treatment

follow up of cancer patients

Catherine Beaufort and Leigh Smith Alfred Health Radiation Oncology

Cancer - the current picture

• Cancer is now considered a chronic condition

• The prognosis of many cancers has dramatically improved over the past few decades (Cuzick, 2015)

• We now talk increasingly about “living with cancer” and “survivorship”

• The follow-up cohort grows ever larger

Alfred Health Radiation Oncology and radiation therapy

Two sites, The Alfred in Melbourne and Latrobe Regional Hospital, Traralgon

This financial year (2015/16) we expect:

- about 1,800 new patients

- 2,100 courses of radiation therapy (mostly megavoltage treatment)

- 7,560 follow up hospital clinic consultations, 2,500 of which will be at LRH

Routine follow up

* Management of early (acute) and late effects of treatment (surgery, chemotherapy, radiation)

* Evaluating treatment efficacy, quality of life and survival

* Surveillance, detection of recurrence

* Psycho-social support of the patient

* Enables feedback to treating staff

Why the study? * Many patients live long distances from Latrobe Regional Hospital (LRH), time, distance, and cost for the patient * A round trip from Orbost region to LRH is about 6-7 hours for a relatively short follow up visit, 207km one way * Could routine long term follow up of radiation therapy patients be organised differently around the patient rather than the hospital clinic?

Orbost Regional Health, courtesy of Orbost Regional Health website

What does the literature tell us about the benefits to the patient of

long term follow up?

* No literature or evidence that proves or even

suggests benefit of a routine follow up schedule in laryngeal cancer patients (or other H&N sites) * Surgeons and radiation oncologists should withdraw (from follow-up)

Marres, H, World Congress on Larynx Cancer, Cairns, 2015

General practitioner-based models of post-treatment follow-up

* In Australia, most survivorship care is currently provided by specialist oncologists * The increasing numbers of cancer survivors, together with workforce issues in oncology, make the development of alternative ,models of care essential Brennan M and Jefford M, Clinical Oncology, 2015/06/CF09Nov, 179-182

A retrospective study of H&N cancer patients, Stanford University School of Medicine * Recurrences detected by long term (12 and 24 month) PET/CT or clinical examination * In 13 patients no clinically detected distant metastasis recurrences were identified

Ho et al, 2013 cited by Wratten C, World Congress of Larynx Cancer, Cairns, 2015

What are the benefits of routine breast cancer follow-up? * Routine follow-up after potentially curative treatment of breast cancer is inefficient in the detection of recurrence * ……but is highly rated for providing reassurance and reducing anxiety and may be the most important function of follow-up

Morris et al, University Surgical Unit, Southampton University Hospitals, UK, Post Graduate Medical Journal, BMJ, 1992

Benefits to nurse-led telephone follow-up for prostate cancer

* telephone consultations shown to provide significant improvements in service delivery * 90% overall satisfaction with telephone follow-up

Anderson B, British Journal of Nursing, September 2010

Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial Telephone versus hospital clinic follow up: * higher satisfaction levels with telephone follow up (mean hospital consultation time = 6 minutes) * no physical or psychological disadvantage * suitable for women at low to moderate risk of recurrence * suitable for women with long travelling distances or mobility problems

Beaver K et al, BMJ, 2009;338:a3147

Results of our study – where do our long distance patients come from?

Town No. patients

Warragul 274

Sale 267

Bairnsdale 179

Leongatha 196

Wonthaggi 160

Lakes Entrance 86

Orbost 31

Omeo 9

Results cont. Location of patients surveyed and distance from home to Traralgon Place of residence no. of patients Distance to LRH (km) Bairnsdale 2 119 Bemm River 1 263 Corinella 1 131 Dalyston 1 117 Foster 2 101 Inverloch 4 98 Lakes Entrance 3 155 Leongatha 1 71 Orbost 2 207 Paynesville 2 134 Sale 2 50 Swifts Creek 1 148 Walkerville 1 125 Woodside 1 73 Wy yung 1 132 average 128

Results cont. * 27 patients surveyed and all would accept telehealth follow up, one would still prefer to visit LRH for social reasons

* Distance, time and cost common issues for those surveyed

* Pilot consultation with two patients from far east Gippsland conducted between LRH and Orbost Regional Health

* Pilot demonstrated excellent audio and visual quality during consultation and satisfied participants

* Sites such as Bairnsdale and Wonthaggi keen to participate

Conclusion

* Telehealth follow up of cancer patients feasible in Gippsland

* Acceptable to patients and staff and psycho-social support may be most important function

* Other Gippsland sites willing to participate

* Various follow up models could be further explored, shared GP,/nurse practitioners, maybe other community based allied health practitioners

Sunset over Sydenham Inlet, Bemm River, Gippsland, courtesy Wikipedia

References Anderson B, The benefits to nurse-led telephone follow-up for prostate cancer, British Journal of Nursing (Mark Allen Publishing), 19(17):1085-90, September 2010

Beaver K et al, Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial, BMJ, 2009;338:a3147 Brennan M and Jefford M, General practitioner-based models of post-treatment follow up, Cancer Forum, Clinical Oncology Society of Australia, 2015/06/CF09Nov 179-182 Cuzick J, Statistical controversies in clinical research: long-term follow up of clinical trials in cancer, Annals of Oncology (2015) 26 (12) 2363 2366. Ho et al, 2013 cited by Wratten C, World Congress of Larynx Cancer, Cairns, 2015 Marres H, World Congress on Larynx Cancer, Cairns, 2015 Morris S et al, What are the benefits of routine breast cancer follow-up, University Surgical Unit, Southampton University Hospitals, UK, Post Graduate Medical Journal, BMJ, 1992