Are survivorship care plans actually effective?

The “New” Prostate Cancer InfoLink has recently been arguing that prostate cancer patients who receive definitive treatment for their prostate cancer with curative intent need follow-up “survivorship care plans” or SCPs to be help them to optimize their recovery after treatment and their consequent quality of life. Of course this premise is based on the reasonable assumption that the development and implementation of such SCPs really does help patients to optimize their recovery post-treatment and their consequent quality of life!

Although it does not address the specific needs of prostate cancer patients, it is therefore somewhat disheartening to learn that a Canadian randomized trial testing the basic hypothesis that SCPs do improve the overall outcomes of patients who have them showed that, in fact, that was not the case!

Coyle et al. report their findings in an article just published in the Journal of Oncology Practice. It is likely to cause something of a furore in the breast cancer community.

The study looked at resource use and utility data for 408 patients with breast cancer who were randomly assigned to receive either an SCP or “standard care” without an SCP. The patients who were given an SCP received a 30-minute educational session with a nurse and their SCP; the patient’s primary care physician also received the SCP along with a full guideline on patient follow-up.

The basic result of the trial at 2 years of follow-up was that

  • The no-SCP group had slightly better outcomes than the SCP group.

Specifically, in this Canadian population

  • Total quality adjusted life years (QALYs) were closely comparable in the two trial arms
    • 1.41 for patients in the SCP arm
    • 1.42 for patients in the no-SCP arm
  • Total costs per patient were a little lower for patients in the no-SCP arm of the trial (Canadian $698 vs. $765).
  • The probability that the SCP was cost effective was 0.26 at a threshold value of a QALY of Canadian $50,000.

Clearly no rational healthcare system is going to implement programs on a national level if they don’t help the majority of the patients they are meant to help, especially if they are not cost-effective either. The data from this study are going to raise all sorts of questions about what might have led to such a result. At least some people will probably argue that this study shows that primary care physicians are not the appropriate primary care providers for women who have received first-line treatment for breast cancer in the 2 years immediately following their treatment. That may or may not actually be the case.

It is worth considering the possibility that the 408 women who were willing to be randomized to participation in this trial presumably had a higher than average level of motivation to take actions that would help themselves and their peers … simply because they were willing to participate in the trial at all. If these 408 “willing women” were actually all highly motivated — at a personal level — to ensure that they worked with their doctors to optimize their recovery after treatment and their consequent quality of life, then this might help to explain why the overall trial result was negative. It might be that SCPs may be of less value to the highly motivated, self-empowered types of women (or men) willing to participate in clinical trials. But of course we cannot really know if that was the case either.

5 Responses

  1. I once taught in a school where the students of one of the maths teachers complained regularly and loudly that he never taught them anything, and that they had to teach themselves and each other.

    I don’t know whether the teacher had this as a deliberate strategy or not, but his students produced excellent results.

    For similar reasons, I suspect it will be always difficult to have a control group in a trial where the participants know that others are getting information/training that is probably important to all in the trial.

  2. This might answer one matter I have been thinking about. The local Oncology division had a special unit for all sorts of psycho-social care of patients. I know nothing about it. About 6 months ago it was gone. I wondered why, as it seemed an important, often necessary facility. Perhaps it was either little used or was not cost-effective during its short existence. Too bad, since here in Uppsala there is no other specialised unit and little attention is given to psychological support.

  3. I am uncertain what comprises a PCa Survivorship Care Plan — and when I search on this site, I only find one other reference from 2010. Mike — you mention you have discussed this recently — please can you provide the link.

  4. Rick:

    If you enter just the word survivorship into the search engine at the top right of this page, you will get about 4 commentaries in the past 12 months. For more general information on cancer survivorship planning, see this article on the Memorial Sloan-Kettering web site and the Institute of Medicine report from 2006 that recommended that every cancer patient should be getting a survivorship plan.

  5. Many tx! Happy Holiday …

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