J Cancer Surviv (2014) 8:167–172 DOI 10.1007/s11764-013-0328-0
The integration of cancer survivorship training in the curriculum of hematology/oncology fellows and radiation oncology residents Michelle Shayne & Eva Culakova & Michael T. Milano & Sughosh Dhakal & Louis S. Constine
Received: 24 September 2013 / Accepted: 11 November 2013 / Published online: 5 December 2013 # Springer Science+Business Media New York 2013
Abstract Background Cancer specialists require an understanding of survivors' needs to insure optimal delivery of care. Training programs currently focus on treatment, while survivorship care focuses on time after treatment. Cancer survivorship training represents an education paradigm shift. Methods The Cancer Survivorship Workshop was held at the James P. Wilmot Cancer Center of the University of Rochester in academic year 2011–2012, with six sessions held. Objectives included the following: learning about survivorship from patient, primary care physician, and oncologist perspectives using a curriculum based on survivorship literature; designing treatment summaries (TSs) and survivorship care plans (SCPs) for five malignancies (lung, breast, prostate, colon, and lymphoma); and establishing collaboration between hematology/oncology (HO) and radiation oncology (RO) trainees by working together in teams. Course impact was assessed pre- and post-training using a 13-question survey. Questions were answered using a 10-point scale, with predefined rating for each question. Results Statistically significant differences in responses to several survey questions were observed comparing pre- and post-course experience. Improvement was noted in comfort discussing survivorship issues with patients (p =0.001), reported knowledge of survivorship care for five types of cancer (p =0.002), confidence in ability to explain a SCP (p =0.001), and comfort discussing late effects of cancer treatment (p = 0.001). Five unique sets of TS and SCPs were completed.
M. Shayne (*) : M. T. Milano : S. Dhakal : L. S. Constine University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA e-mail: [email protected] E. Culakova Duke University, 2424 Erwin Road, Suite 205, Durham, NC 27705, USA
Conclusions This study demonstrates the feasibility of implementing cancer survivorship education into the curriculum of HO and RO training. Implications for Cancer Survivors The project was designed with intension to optimize survivor care through enhanced provider training. Keywords Education . Curriculum . Care plans . Treatment summaries . Surveys
Introduction Significant recent advances in the diagnosis and treatment of cancer, as well as heightened recognition and optimized management of treatment-related late effects, have contributed to a steady increase in the population of cancer survivors. As of 2012, there were estimated 13.7 million cancer survivors living in the USA, and it is expected that by 2022, there will be 18 million cancer survivors [1]. Recognizing that the needs of this growing population of patients might not be adequately or consistently addressed, the Institute of Medicine (IOM) issued a comprehensive report on cancer survivorship in 2006 [2]. According to this report, the recommendation to provide cancer patients with documentation of their treatment as well as longitudinal plans of care was deemed fundamental to the provision of optimized survivorship care. Accordingly, the American Society of Clinical Oncology (ASCO), LIVESTRONG, Journey Forward, and several independent cancer centers have developed templates for treatment summaries and survivorship care plans (SCPs). Furthermore, accreditation standards stipulate the necessity to establish survivorship programs for cancer patients [3]. A cadre of cancer care specialists with a refined understanding of cancer survivors' unique needs is essential to insure the optimal delivery of cancer care going forward.
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Yet, there is a fundamental disconnect between the traditional approach to cancer care training, which focuses on treatment and end of life, and survivorship care which focuses on care delivered between these time points. Trainees educated in a traditional system may, therefore, be ill prepared to provide optimal cancer survivorship care as they enter the workforce. To our knowledge, there is no specific survivorship curriculum designed to bridge this gap in adult hematology/ oncology and radiation oncology training, although a welldesigned survivorship training program may indeed address all five of the Accreditation Counsel of Graduate Medical Education core competencies [4]. We describe the development and implementation of a multidisciplinary (medical and radiation oncology) pilot course in cancer survivorship training, review qualitative course assessments, and suggest an approach to the incorporation of similar training in other programs.
Methods Survivorship workshop course The survivorship workshop course was held at the James P. Wilmot Cancer Center of the University of Rochester, a comprehensive cancer center with an accredited fellowship program in hematology oncology and residency program in radiation oncology. The pilot course was initiated in the second semester of the academic year 2011–2012, and sessions were conducted monthly for a total of six sessions. The objectives for the pilot course included the following: (1) to learn about survivorship from a variety of perspectives including the patient, primary care physician, and oncologist, via a curriculum based upon selected published peer-reviewed articles derived from the survivorship literature; (2) to design templates for cancer treatment summaries and SCPs for five malignancies (lung cancer, breast cancer, prostate cancer, colon cancer, and lymphoma) that would ultimately be integrated into the electronic medical record and disseminated to patients treated at our cancer center; (3) to establish a collaborative effort between the disciplines of hematology/oncology and radiation oncology by having trainees from both disciplines work together on these treatment summaries and SCPs in assigned teams. A fourth objective that was suggested but not deemed mandatory as part of the exercise was the development of evidence tables. In this way, our trainees could understand the varying levels of evidence that support the recommendations contained within their SCPs. Course attendance was deemed mandatory for all fellows in hematology/oncology and residents in radiation oncology. Five teams consisting of two hematology/oncology fellows and one radiation oncology resident were assigned to work on one cancer type each. Due to schedule constraints, surgical oncology trainees were not included in the pilot study. Also present at each
J Cancer Surviv (2014) 8:167–172
meeting along with the trainees was the course designer and hematology/oncology fellowship program director (MS), radiation oncology residency program director (MTM), and our institutional survivorship program director (LSC). In addition, one faculty member or nurse practitioner was invited from each of the cancer subspecialties for the specific session during which treatment summaries and care plans for their particular area of expertise were to be discussed. At each session, there was an average of 14 trainees present (range 13–15). Survivorship literature discussions The first half hour of five sessions was devoted to a discussion of a peer-reviewed article or report about cancer survivorship. Prior to each workshop session, the trainees were assigned to read an article and come to the workshop prepared for discussion. To establish a core understanding of survivorship care, the 2006 Institute of Medicine report was also assigned [2]. Due to the length of the report, there was an expectation that, at minimum, the executive summary be read prior to the fist working session and that trainees at least familiarize themselves with the remainder of the document. The second session involved a discussion of the paper “Survivorship care plans in research and practice” by Salz et al. [5]. Review of this paper allowed for an in-depth analysis of proposed care plan content, and its strengths and limitations, in order to prepare the trainees for the process of assembling their own SCPs. This article distills essential elements of the SCP from the IOM recommendations. In addition, the article provides a table of studies from the varying stakeholder perspectives including oncologist, primary care physician, and survivors. In order to provide a balanced discussion regarding potential limitations of SCPs, the results of the only rigorous multicenter, randomized trial assessing the benefits of SCPs on patientreported outcomes was discussed in our review of “Evaluating survivorship care plans: results of a randomized clinical trial of patients with breast cancer” by Grunfeld et al. [6]. For a discussion involving the primary care physician perspective, the article “Caring for cancer survivors” [7] was selected. We also addressed the perspective of survivors themselves (and their partners) using the article “Sources of uncertainty in cancer survivorship” [8]. Design of treatment summary templates and SCPs Each of the five groups of trainees was assigned one of five cancer subtypes on which to focus: breast, colon, lung, prostate cancer and lymphoma (diffuse large B cell and follicular types). Trainees were invited to access existing versions of treatment summaries and SCPs compiled by the ASCO, LIVESTRONG, and others. The assignment was to modify and develop these documents to uniquely reflect the needs of the cancer survivors whom they have treated, while, at the
J Cancer Surviv (2014) 8:167–172
same time, to remain cognizant of the essential components of these documents as delineated by the 2006 IOM report [2]. The trainees were asked to meet as a group to develop the documents. They were encouraged, though not required, to present their documents to attending physicians with expertise in the area of their work assignments. The second half hour of five of the workshop sessions was dedicated to discussing the documents and refining them with all members of the workshop present. Five unique sets of treatment summary templates and SCPs were completed by the end of the academic year 2011–2012. As part of further refinement and harmonization, the documents were reviewed by the survivorship advisory committee at the James P. Wilmot Cancer Center of the University of Rochester Medical Center. The documents were then integrated into the electronic medical record after receiving cancer center committee approval.
Results Prior to beginning the pilot study in cancer survivorship training, the trainees were asked, by means of a 13-question survey, to provide anonymous quantitative feedback. The questions were to be answered using a 10-point scale, with the rating system predefined for each question. The pre- and post-course surveys were not identical; however, the scoring of responses to pre- and post-course survey questions that were identical between the two surveys was evaluated utilizing descriptive statistics such as mean, median, range, and standard error. The difference between pre- and posttest scores was compared via paired Student's t test. p values of
The integration of cancer survivorship training in the curriculum of hematology/oncology fellows and radiation oncology residents Michelle Shayne & Eva Culakova & Michael T. Milano & Sughosh Dhakal & Louis S. Constine
Received: 24 September 2013 / Accepted: 11 November 2013 / Published online: 5 December 2013 # Springer Science+Business Media New York 2013
Abstract Background Cancer specialists require an understanding of survivors' needs to insure optimal delivery of care. Training programs currently focus on treatment, while survivorship care focuses on time after treatment. Cancer survivorship training represents an education paradigm shift. Methods The Cancer Survivorship Workshop was held at the James P. Wilmot Cancer Center of the University of Rochester in academic year 2011–2012, with six sessions held. Objectives included the following: learning about survivorship from patient, primary care physician, and oncologist perspectives using a curriculum based on survivorship literature; designing treatment summaries (TSs) and survivorship care plans (SCPs) for five malignancies (lung, breast, prostate, colon, and lymphoma); and establishing collaboration between hematology/oncology (HO) and radiation oncology (RO) trainees by working together in teams. Course impact was assessed pre- and post-training using a 13-question survey. Questions were answered using a 10-point scale, with predefined rating for each question. Results Statistically significant differences in responses to several survey questions were observed comparing pre- and post-course experience. Improvement was noted in comfort discussing survivorship issues with patients (p =0.001), reported knowledge of survivorship care for five types of cancer (p =0.002), confidence in ability to explain a SCP (p =0.001), and comfort discussing late effects of cancer treatment (p = 0.001). Five unique sets of TS and SCPs were completed.
M. Shayne (*) : M. T. Milano : S. Dhakal : L. S. Constine University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA e-mail: [email protected] E. Culakova Duke University, 2424 Erwin Road, Suite 205, Durham, NC 27705, USA
Conclusions This study demonstrates the feasibility of implementing cancer survivorship education into the curriculum of HO and RO training. Implications for Cancer Survivors The project was designed with intension to optimize survivor care through enhanced provider training. Keywords Education . Curriculum . Care plans . Treatment summaries . Surveys
Introduction Significant recent advances in the diagnosis and treatment of cancer, as well as heightened recognition and optimized management of treatment-related late effects, have contributed to a steady increase in the population of cancer survivors. As of 2012, there were estimated 13.7 million cancer survivors living in the USA, and it is expected that by 2022, there will be 18 million cancer survivors [1]. Recognizing that the needs of this growing population of patients might not be adequately or consistently addressed, the Institute of Medicine (IOM) issued a comprehensive report on cancer survivorship in 2006 [2]. According to this report, the recommendation to provide cancer patients with documentation of their treatment as well as longitudinal plans of care was deemed fundamental to the provision of optimized survivorship care. Accordingly, the American Society of Clinical Oncology (ASCO), LIVESTRONG, Journey Forward, and several independent cancer centers have developed templates for treatment summaries and survivorship care plans (SCPs). Furthermore, accreditation standards stipulate the necessity to establish survivorship programs for cancer patients [3]. A cadre of cancer care specialists with a refined understanding of cancer survivors' unique needs is essential to insure the optimal delivery of cancer care going forward.
168
Yet, there is a fundamental disconnect between the traditional approach to cancer care training, which focuses on treatment and end of life, and survivorship care which focuses on care delivered between these time points. Trainees educated in a traditional system may, therefore, be ill prepared to provide optimal cancer survivorship care as they enter the workforce. To our knowledge, there is no specific survivorship curriculum designed to bridge this gap in adult hematology/ oncology and radiation oncology training, although a welldesigned survivorship training program may indeed address all five of the Accreditation Counsel of Graduate Medical Education core competencies [4]. We describe the development and implementation of a multidisciplinary (medical and radiation oncology) pilot course in cancer survivorship training, review qualitative course assessments, and suggest an approach to the incorporation of similar training in other programs.
Methods Survivorship workshop course The survivorship workshop course was held at the James P. Wilmot Cancer Center of the University of Rochester, a comprehensive cancer center with an accredited fellowship program in hematology oncology and residency program in radiation oncology. The pilot course was initiated in the second semester of the academic year 2011–2012, and sessions were conducted monthly for a total of six sessions. The objectives for the pilot course included the following: (1) to learn about survivorship from a variety of perspectives including the patient, primary care physician, and oncologist, via a curriculum based upon selected published peer-reviewed articles derived from the survivorship literature; (2) to design templates for cancer treatment summaries and SCPs for five malignancies (lung cancer, breast cancer, prostate cancer, colon cancer, and lymphoma) that would ultimately be integrated into the electronic medical record and disseminated to patients treated at our cancer center; (3) to establish a collaborative effort between the disciplines of hematology/oncology and radiation oncology by having trainees from both disciplines work together on these treatment summaries and SCPs in assigned teams. A fourth objective that was suggested but not deemed mandatory as part of the exercise was the development of evidence tables. In this way, our trainees could understand the varying levels of evidence that support the recommendations contained within their SCPs. Course attendance was deemed mandatory for all fellows in hematology/oncology and residents in radiation oncology. Five teams consisting of two hematology/oncology fellows and one radiation oncology resident were assigned to work on one cancer type each. Due to schedule constraints, surgical oncology trainees were not included in the pilot study. Also present at each
J Cancer Surviv (2014) 8:167–172
meeting along with the trainees was the course designer and hematology/oncology fellowship program director (MS), radiation oncology residency program director (MTM), and our institutional survivorship program director (LSC). In addition, one faculty member or nurse practitioner was invited from each of the cancer subspecialties for the specific session during which treatment summaries and care plans for their particular area of expertise were to be discussed. At each session, there was an average of 14 trainees present (range 13–15). Survivorship literature discussions The first half hour of five sessions was devoted to a discussion of a peer-reviewed article or report about cancer survivorship. Prior to each workshop session, the trainees were assigned to read an article and come to the workshop prepared for discussion. To establish a core understanding of survivorship care, the 2006 Institute of Medicine report was also assigned [2]. Due to the length of the report, there was an expectation that, at minimum, the executive summary be read prior to the fist working session and that trainees at least familiarize themselves with the remainder of the document. The second session involved a discussion of the paper “Survivorship care plans in research and practice” by Salz et al. [5]. Review of this paper allowed for an in-depth analysis of proposed care plan content, and its strengths and limitations, in order to prepare the trainees for the process of assembling their own SCPs. This article distills essential elements of the SCP from the IOM recommendations. In addition, the article provides a table of studies from the varying stakeholder perspectives including oncologist, primary care physician, and survivors. In order to provide a balanced discussion regarding potential limitations of SCPs, the results of the only rigorous multicenter, randomized trial assessing the benefits of SCPs on patientreported outcomes was discussed in our review of “Evaluating survivorship care plans: results of a randomized clinical trial of patients with breast cancer” by Grunfeld et al. [6]. For a discussion involving the primary care physician perspective, the article “Caring for cancer survivors” [7] was selected. We also addressed the perspective of survivors themselves (and their partners) using the article “Sources of uncertainty in cancer survivorship” [8]. Design of treatment summary templates and SCPs Each of the five groups of trainees was assigned one of five cancer subtypes on which to focus: breast, colon, lung, prostate cancer and lymphoma (diffuse large B cell and follicular types). Trainees were invited to access existing versions of treatment summaries and SCPs compiled by the ASCO, LIVESTRONG, and others. The assignment was to modify and develop these documents to uniquely reflect the needs of the cancer survivors whom they have treated, while, at the
J Cancer Surviv (2014) 8:167–172
same time, to remain cognizant of the essential components of these documents as delineated by the 2006 IOM report [2]. The trainees were asked to meet as a group to develop the documents. They were encouraged, though not required, to present their documents to attending physicians with expertise in the area of their work assignments. The second half hour of five of the workshop sessions was dedicated to discussing the documents and refining them with all members of the workshop present. Five unique sets of treatment summary templates and SCPs were completed by the end of the academic year 2011–2012. As part of further refinement and harmonization, the documents were reviewed by the survivorship advisory committee at the James P. Wilmot Cancer Center of the University of Rochester Medical Center. The documents were then integrated into the electronic medical record after receiving cancer center committee approval.
Results Prior to beginning the pilot study in cancer survivorship training, the trainees were asked, by means of a 13-question survey, to provide anonymous quantitative feedback. The questions were to be answered using a 10-point scale, with the rating system predefined for each question. The pre- and post-course surveys were not identical; however, the scoring of responses to pre- and post-course survey questions that were identical between the two surveys was evaluated utilizing descriptive statistics such as mean, median, range, and standard error. The difference between pre- and posttest scores was compared via paired Student's t test. p values of
