Improving Transition to Cancer Survivorship Care Through Engagement and Collaboration

Project Leader Marg Hammersla, Ph.D., RN
MSU Mark & Robyn Jones College of Nursing
margaret.hammersla@montana.edu 

To facilitate quality care during transition from anti-cancer treatment to cancer survivorship care, clear communication and collaboration among the healthcare team, including oncology and primary care providers, are necessary. The five domains of the National Cancer Institute’s quality cancer survivorship care include prevention and surveillance for recurrences and new cancers; surveillance and management of physical effects; surveillance and management of psychosocial effects; surveillance and management of chronic medical conditions; and health promotion and disease prevention. To provide actionable strategies for oncologic practice, the American College of Surgeons’ Commission on Cancer (CoC) recommends and encourages that cancer survivors (CS) receive a written summary of the treatment and plan for addressing need for ongoing care coordination beyond initial treatment. Despite this recommendation, there are well-documented gaps in care during transitions to cancer survivorship care.

To address these significant gaps in the operationalization of best practice recommendations compared to current practice, this study used a community-engaged research (CEeR) approach coupled with intervention mapping (IM) by engaging survivors, oncology providers, and primary care providers. Utilizing this CEeR IM process, this study 1) identified individual- and provider-level facilitators and barriers of cancer survivorship care transitions; and 2) identified and prioritized opportunities to improve collaborative cancer survivorship care transition.

The overarching aim of this research (continued in a second-year pilot project) is to develop systems-level strategies to improve cancer survivorship care transitions in Montana. This is being accomplished via focus group interviews with 3 key stakeholders: 1) cancer survivors, 2) oncology providers, and 3) primary care providers. The data collected from these 3 groups of stakeholders continues to inform the work of a previously assembled Community Advisory Board (CAB), consisting of individuals from each of the 3 stakeholder groups, who participate in discussions to identify and prioritize potential interventions to address the unique challenges of delivering and accessing cancer survivorship transition care in Montana. The CAB also participates in project interpretation and will be involved in future projects.