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Comparing hospital and telephone follow- up after treatment for breast cancer: a randomised controlled trial Kinta Beaver Professor of Nursing University.

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Presentation on theme: "Comparing hospital and telephone follow- up after treatment for breast cancer: a randomised controlled trial Kinta Beaver Professor of Nursing University."— Presentation transcript:

1 Comparing hospital and telephone follow- up after treatment for breast cancer: a randomised controlled trial Kinta Beaver Professor of Nursing University of Manchester, UK NCRN Trial ID 1477

2 Why bother? The way in which hospital follow-up is conducted at present in the UK has little benefit for patients and health professionals Aim to detect recurrence but routine clinical examination rarely detects recurrence in asymptomatic patients Recurrence detected – patient report, mammography Increasing number of routine follow-up patients – screening extended

3 Standard practice (hospital follow-up) with New intervention (telephone follow-up by specialist breast care nurses) Patients randomised to Hospital or Telephone Two centre study (Northwest England) Comparison

4 Standard Practice (control group) Routine hospital visits Regular but decreasing intervals Duration 3-10 years (current guidelines 3yrs) Patients often seen by junior doctor In UK increase in nurse led clinics

5 Telephone follow-up (new Intervention) Shift in focus from searching for recurrence to providing information and support Structured (specific questions); allows for repetition of information Uses and develops the skills of BCNs (7 nurses trained to deliver intervention) Developed from previous work on information needs of women with breast cancer (patient led)

6 Why telephone follow-up? Convenient for patients No long waiting times in clinic No parking problems No travelling, own home (saves money)

7 Why specialist nurses? Specialist knowledge and expertise Meeting physical & psycho-social needs histology, genetic risk, side effects, breast reconstruction, breast prosthesis, body image issues Appropriate referrals lymphoedema, GP, surgeon, oncologist, psychologist Written information Continuity of care

8 Telephone Intervention Previous issues Any changes? Information about spread of disease Information about treatments and side effects Information about genetic risk Information about sexual attractiveness Information about caring for self Concerns about how family are coping Anything else? Mammograms (request if necessary) Next Appointment

9 Practicalities Telephone clinics Telephone appointments (appointment cards) Appointments entered on Hospital Information System Giving the telephone appointments credibility

10 Inclusion criteria Known diagnosis of breast cancer Completed treatment (surgery, radiotherapy, chemotherapy) No evidence of local/regional recurrence or metastatic disease Attending outpatient clinics for the purposes of surveillance Defined as low/moderate risk of recurrence Not taking part in any other clinical trial Access to a telephone Hearing acceptable

11 Outcomes Psychological morbidity STAI - 20 items, 4 point scale, range GHQ items, 4 point scale, range 0-12 Patient satisfaction with information Rating scale - very satisfied to very unsatisfied Patient satisfaction with service Rating scale (higher scores = higher levels of satisfaction) Cost effectiveness Time to detection of recurrence (days)

12 Sample Size Study powered on psychological morbidity for equivalence Aimed to demonstrate that telephone group no more anxious as a result of foregoing clinical examination and face to face contact Target sample size – 324 (162 in each group)

13 Flow of participants through trial Medical notes assessed for eligibility at 968 clinic sessions n=24,362 Patients identified as routine breast cancer follow-up n= 2,542 Excluded n=2169 Did not meet inclusion criteria (n= 1646) Refused consent (n=255) Missed by researchers (n=172) Patient did not attend (n=95) Randomised n=374 Telephone follow-up (n= 191)Hospital follow-up (n= 183) Lost to follow-up: n=22 Lost to follow-up: n=11 Returned baseline measures 91.6% Returned end trial measures 80.6% Returned baseline measures 93.4% Returned end trial measures 79.2%

14 Psychological Morbidity Differences between groups were not statistically significant at baseline, mid or end-trial Equivalence demonstrated Telephone group were not more anxious

15 Patient satisfaction with information given Telephone group significantly more satisfied at mid and end-trial (p < 0.001)

16 Patient satisfaction with follow-up service Score n

17 Cost effectiveness Data on 561 telephone appointments and 555 hospital appointments No significant differences in number of tests/investigations ordered between groups No differences in contacts with other health professionals e.g. GP Telephone FU was not a cheaper option in terms of NHS savings. Telephone FU was not a cheaper option in terms of NHS savings.

18 HospitalTelephonep Type of recurrence Local44p=0.34 Distant metastases27 Pt died (breast cancer related) Yes26p=0.62 No45 Presentation: Pt contacted GP36p=0.89 Pt phoned BCN with problem11 Pt presented symptoms to BCN during routine appt 02 Routine mammogram22 Routine/interval visit Routine, symptomatic02p=0.79 Interval, symptomatic47 Interval, routine mammogram22 Totals611 Recurrence

19 Time to detection of recurrence Median time to confirmation: Hospital: 60 days (range 37 to 131) Telephone: 39 days (range 10 to 152) This apparently large difference between groups, at least in terms of the medians, was not statistically significant (Mann-Whitney U = 21.0, p = 0.228).

20 Conclusions Specialist nurses can deliver a high quality follow-up service over the telephone Shifts focus away from clinical examinations with limited value to meeting the information needs of patients. High levels of patient satisfaction in T group Reduced burden on hospital outpatient clinics Savings for patients (money, time) Suitable for patients with long travelling distances Beaver et al (2009). Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial. British Medical Journal. 338; a3147

21 Colleagues Clinical: Nursing Sr L Bracegirdle (BCN) Sr J Faraut (OPD Manager) S/N S Foster (Nurse Researcher) Sr S Greer (Oncology Unit Manager) Sr M Noblet (BCN Practitioner) Sr F ORegan (BCN) Sr L Thomson (BCN Practitioner) Mrs C Turner (Lead Cancer Nurse) Sr D Tysver-Robinson (Nurse Consultant) Academic Dr M Campbell (Lecturer in Statistics) Professor G Dunn (Professor of Biomedical Statistics) Dr W Hollingworth (Health Economist) Professor K Luker (Professor of Nursing) Dr R McDonald (Senior Research Fellow/) Ms M Twomey (Research Associate) Dr S Williamson (Research Fellow) Clinical: Surgery Mr A Baildam (Consultant Surgeon) Mr L Barr (Consultant Surgeon) Professor N Bundred (Consultant Surgeon) Mr G Byrne (Consultant Surgeon) Mr P Kiriparan (Consultant Surgeon) Mr ME Lambert (Consultant Surgeon) Mr S Rajan (Consultant Surgeon) Clinical: Oncology Dr F Danwata (Specialist Registrar) Dr A Hindley (Consultant Clinical Oncologist) Dr S Susnerwala (Consultant Clinical Oncologist) Admin: Medical Records Ms N Billington (Medical Records Clerk) Ms A Bowes (Medical Records Clerk) Admin: Secretarial Mrs J Linihan (Secretary) Mrs S Tizini (Secretary)

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