Prostate Cancer Survivorship Care

Understanding symptom management (eg, incontinence, impotence) across this interface is also critical to the design and implementation of survivorship quality improvement interventions. Promoting clear responsibilities for prostate-specific antigen surveillance, symptom management, and bone density testing for men treated with androgen deprivation therapy across the primary-specialty care interface is a potential starting point.

Transformative Tools

Whether targeting cancer care or not, quality improvement interventions often lack insight into the causal mechanisms by which they effect change.^60-62 This is particularly true for interventions targeting clinician behavior change, such as improving uptake of evidence-based practice.^63,64 For example, the effectiveness of audit with feedback interventions to improve guideline adherence ranges from 1% to 16%.^65-69 The same intervention can vary in its effectiveness, depending on context.^70-72 Barriers and enablers that vary by provider, facility, and other contextual factors (eg, workforce, location) contribute to this variable effectiveness.^73-79 For this reason, a guiding theoretical framework is useful to understand an intervention’s transferability among different settings, as well as to ensure comprehensive assessment of the factors that can prevent uptake of evidence-based practice.^80-83 For example, a theoretical framework might provide insight into how causal mechanisms of an intervention to improve cancer survivorship care might vary in a community-based outpatient clinic vs a tertiary center.^84-86

A guiding theoretical framework is even more useful when used to design quality improvement interventions.^82,83,87,88 Mapping barriers to theoretical constructs, and theoretical constructs to interventions to facilitate clinician behavior change can assist in planning strategies for effective implementation across a range of settings.⁸⁸ While psychological theories like the Theoretical Domains Framework and Theory of Planned Behavior are pertinent for individual behavior change, understanding how best to implement interventions targeted at the facility level requires a broader perspective focused on context.^83,88-92

The Consolidated Framework for Implementation Research (CFIR) provides a comprehensive, practical taxonomy for understanding important organizational, individual, and intervention characteristics to consider during an implementation process.^75,76 The CFIR framework provides the broader contextual milieu contributing to the quality of survivorship care at the facility level across 5 domains: (1) intervention characteristics—evidence, complexity, relative advantage; (2) outer setting—peer pressure, external policies; (3) inner setting­­—structural characteristics, readiness for implementation, culture; (4) individual characteristics—knowledge about intervention, self-efficacy; and (5) process—planning, engaging stakeholders, champions, execution.

Using both individual and organizational constructs to effectively characterize the relationships, needs, intentions, and organizational characteristics of primary and cancer care providers throughout VHA will be key to designing successful interventions to broadly ensure quality survivorship care. The best interventions to improve survivorship care will likely vary across facilities based on contextual factors such as cancer specialist availability, facility characteristics, and the current delivery system for survivorship care.

Intervention modalities currently being used by the VHA Office of Specialty Care Transformation to improve access to specialty care are indeed transformative tools to optimize the quality of survivorship care. The latter builds on a successful approach developed and widely used in New Mexico, which makes the expertise of academic specialists at the University of New Mexico available throughout the state, using video teleconferencing.^93,94 The opportunities for video-enabled interaction between specialists and PCPs in VHA, both in consultation about specific patients and in educational sessions to enhance PCP knowledge and self-efficacy in managing patients requiring specialty knowledge, are revolutionary for cancer care.^93,95

Conclusions

Due to the expanding population of veteran prostate cancer survivors, improving their QOL by ensuring proper cancer surveillance, effectively managing their treatment complications and transitions of cancer care will reduce risk and provide timely management of symptoms and disease recurrence.

Understanding how variation in the VHA cancer specialist workforce impacts the quality of cancer survivorship care is a critical step towards optimizing veteran cancer care. Through this understanding, communication between PCPs, PACT, and cancer specialists can be improved via theory-based quality improvement tools to address gaps in the quality of prostate and other VHA cancer survivorship care. Interventions designed to enhance PCP self-efficacy in delivering high-quality prostate cancer survivor care may improve job satisfaction among PCPs and specialists.

Clarifying issues in the delivery of optimal prostate cancer survivorship care may inform models for other cancer survivorship care in the VHA. The contextual factors contributing to a VHA facility’s performance for prostate cancer survivorship care may be very relevant to the facility’s performance for other types of cancer survivorship care. A facility’s primary care organizational structure, cancer specialist workforce, and oncology-specific facility characteristics vary little across cancer types, suggesting that a better understanding of how to improve PSA surveillance for prostate cancer, the most common cancer treated in the VHA, should apply to carcinoembryonic antigen surveillance for colon cancer, hematology studies for lymphoma, and the surveillance of other malignancies in the VHA.^96,97