Introduction
The purpose of the present follow-up program, after treatment for early stage breast cancer, is to detect local and systemic recurrences, new primary tumors in the breasts, and secondary cancer. Furthermore, the clinicians aim to provide the patients with social and psychological support, if needed, and support them in managing side effects to their primary treatment and current endocrine therapy.
Patient reported outcomes (PRO)
It has been demonstrated that clinicians systematically underestimate patient symptoms, and that many symptoms go unrecognized. Patients frequently deal with symptoms of both physical and psychological origin between visits and may have been carrying them for an unacceptable period of time, because of the natural thresholds for calling the department. Also, they may forget to communicate the symptoms at their appointment in the clinic. If the symptoms persist and are revealed at the consultation, they are commonly more severe to the patient at this time than when they first appeared.
Information about the patient's individual symptoms and health status during cancer treatment and follow-up is currently obtained by the clinician as part of the communication with the patient. This approach is not systematic and cannot be used to monitor symptoms development over time. However, knowledge of health status is essential for assessing and improving well-being and rehabilitation in cancer care aiming the best possible outcome. Fewer symptoms may thus be an indication of whether supportive care has been effective, while the appearance of new symptoms may reflect recurrence in an early stage. Electronic registration of systemically obtained PRO data in clinical practice can be a method to improve the quality of the follow-up program .
PRO data is information about patient experienced symptoms, functional capacity, and quality of life and has not yet been implemented as a systemically obtained measurement in the follow-up program. According to the US Food and Drug Administration (FDA) PRO data is: "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else". PRO data are typically collected through a questionnaire in which measurements are repeated over time. This allows continuous monitoring of the patient health status. PRO data is a tool to improve healthcare quality and the key to organize and deliver healthcare in a way beneficial to the patients. Today, PRO data are not routinely obtained during follow-up, but the new guidelines from the Danish Health and Medicines Authority recommend the use of PRO data. The implementation faces several challenges due to the extra effort by the staff, the development of appropriate electronic equipment, and determination of the proper use in different parts of the healthcare system.
Providing information congruent with patient needs is important to denote patient involvement and satisfaction, and it may also affect the health-related quality of life. Shared decision making is one of the most recent models fostered by healthcare research and aims to establish a partnership between the healthcare professional and the patient. The model describes how decisions should be made. It is centered on the idea that the healthcare professional communicates medical knowledge to the patient, and that the patient's perspectives, preferences and rights are included in the clinical conversation. The exchange of knowledge and information is one of the most important preconditions to carry out shared decision making in clinical practice.
The study is a randomized trial in which patients are assigned to the department's standard follow-up program or to individualized follow-up in the context of shared decision making with PRO-data guiding the clinician as to the patient's need for consultations in the clinic by a nurse, doctor, physiotherapist, social workers and/or psychologist. The individual follow-up program also offers the possibility of consulting a sexologist and a coach, probably with an extent of self-payment. In both programs the patients can call the department and make arrangement for an urgent appointment. Only the individualized program offers email consultation and patient influence as to how much effort they want to spend on their follow-up.
Data collection:
PRO data will be handled electronically in the software program SurveyXact, where the patients obtain access to different questionnaires through secured links.
The clinicians and nurses who take care of the patients in either of the programs are requested to fill out a brief questionnaire after seeing each patient to register the complaints or concerns that led to the contact, and what was to solve the problem. In compliance with departmental guidelines, the patients will be recommended supportive medical care, referred to physiotherapy, plastic surgery, or extraordinary imaging.
The patients in both programs are also requested to fill out a patient satisfaction questionnaire after each consultation and a CollaboRATE questionnaire containing three brief questions to measure the level of shared decision making.
Perspectives:
The socioeconomic aspects related to the introduction of a patient centered, individualized follow-up program, where resources are spent on those in need of them, are of great importance in the Danish healthcare system. The results of this study can be used nationally in providing tailored follow-up to this group of patients.
