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The effec tiven e s s of s h a r e d c a r e in c a n c e r s u rvivor s - a sys t e m a tic
r eviewZh ao, Y, Bre t tl e, AJ a n d Qiu, L
h t t p://dx.doi.o rg/1 0.53 3 4/ijic.39 5 4
Tit l e The effec tiven e ss of s h a r e d c a r e in c a n c e r s u rvivors - a sys t e m a tic r evie w
Aut h or s Zh ao, Y, Bre t tl e, AJ a n d Qiu, L
Typ e Article
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IntroductionWith the improvements in medical treatment and ageing populations, the number of cancer survivors is increasing worldwide [1, 2]. Cancer survivors are vulnerable to suffer-ing from second cancer and comorbid chronic conditions with advanced age [3, 4]. Historically, most cancer patients were followed up by hospital specialists [5, 6]. However, Nielsen et al. [7] believes that most cancer patient might feel left alone after they are discharged from the hospi-tal. Besides, Yang et al. [8] argues that cancer specialists might not be able to provide necessary care unless there is enhanced oncological productivity. Due to the increased need, stabilised health care costs, and the sustainable burden of hospitals, the involvement of primary care has been increasingly recognized as a vital component in the management of cancer survivors [9, 10].
To date, much of the studies mainly assessing the capa-bility of primary care providers (PDPs) in survivorship care and indicate that the PDP’s skills and confidence may be lacking, but their skills could be enhanced by collaboration with hospital specialists [11, 12]. In addition, a landmark report from the US Institute of Medicine lists coordinative care between primary care and secondary care as an essen-tial component for cancer survivorship care [13]. Shared care that integrate primary care and hospital care was originally created for patients with chronic disease [14], and it has been endorsed as an important component of high-quality of survivorship care [15]. Johnson et al. [16, p. 350] defines shared care as:
“an organizational model involving both primary care physicians (PCPs) and specialists in a formal, explicit manner.”
Shared care does not only mean that both hospital and primary care join in the follow-up, but also means there is interaction between them. It is argues that the key points of this model are the communication between the care providers by exchange of information and arranging responsibility to improve the follow-up management [17].
The published reviews have focused on comparing the primary care provider and cancer specialist in the
RESEARCH AND THEORY
The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewYan Zhao*, Alison Brettle† and Ling Qiu‡
Objectives: To determine whether the shared care model during the follow-up of cancer survivors is effective in terms of patient-reported outcomes, clinical outcomes, and continuity of care.Methods: Using systematic review methods, studies were searched from six electronic databases— MEDLINE (n = 474), British Nursing Index (n = 320), CINAHL (n = 437), Cochrane Library (n = 370), HMIC (n = 77), and Social Care Online (n = 210). The review considered all health-related outcomes that evaluated the effectiveness of shared care for cancer survivors.Results: Eight randomised controlled trials and three descriptive papers were identified. The results showed the likelihood of similar effectiveness between shared care and usual care in terms of quality of life, mental health outcomes, unmet needs, and clinical outcomes in cancer survivorship. The reviewed studies indicated that shared care overall is highly acceptable to cancer survivors and primary care practitioners, and shared care might be cheaper than usual care.Conclusions: The results from this review suggest that the patient satisfaction of shared care is higher than usual care, and the effectiveness of shared care is similar to usual care in cancer survivorship. Interventions that formally involve primary care and improve the communication between primary care and hospital care could support the PCPs in the follow-up.
Keywords: shared care; survivors; follow-up; cancer
* Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, CN
† School of Nursing and Midwifery, University of Salford, Salford, Greater Manchester, M5 4WT, UK
‡ Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, CN
Corresponding authors: Ling Qiu, RN (295936293@qq.com), Lihuan Liu, RN (2503183899@qq.com)
Zhao, Y, et al. The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review. International Journal of Integrated Care, 2018; 18(4): 2, 1–17. DOI: https://doi.org/10.5334/ijic.3954
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 2 of 17
management of cancer follow-up. Lewis et al. [5] released a systematic review that aimed to evaluate the effectiveness and cost-effectiveness of cancer follow-up by primary care. The author could not make a conclusion since the quality of data was generally poor and no statistically significant difference was found in the effectiveness of primary care follow-up. A second review [18] argued that local health care practitioners could benefit patients with physical and psychosocial problem in survivorship care, but proactive initiatives should be conducted to involve PDPs in the fol-low-up. However, although integrating PCPs into the survi-vorship care is needed, recent reviews found little evidence regarding the effectiveness of shared care, and there is a lack of standard models of shared care [6, 10, 14, 19].
Review questions and objectivesIn this study, we systematically review the literature that focuses on the effectiveness and feasibility of shared care in the management of follow-up for cancer patients in different settings, and critically appraise the quality of evidence. The key objectives are: 1) to evaluate whether shared care is feasible or effective in the management of physical or psychological problems in cancer survivors; 2) to provide a comprehensive review of the studies for achieving best practice in the management of follow-up for cancer survivors. The primary outcome will be whether shared care could solve the survivors’ physical or psycho-logical problems, and patients’ attitudes toward shared care will be summarised. The physical problem could include the quality of life, the side effect, the recurrence
rate, or any other symptoms. The psychological problems would include the anxiety, the distress level or other men-tal health disorders. The secondary outcomes include the patient reported and practitioner reported satisfaction towards shared care, and the cost of shared care. Studies that assessed shared care in short- and long-term cancer survivors were both included and reported, but those assessed patients at the end of life were not included because they usually need more complicated care and a lot of them might stay in the intensive care unit or hos-pice care unit [20].
MethodsSearch strategyThe PRISMA systematic review and meta-analysis pro-tocols (PRISMA-P) [21] was used as the guideline in this study, although minor changes were made to adapt to unanticipated circumstances. Six databases were searched based on the research question and objectives of this study—MEDLINE (Ovid), British Nursing Index, CINAHL (EBSCO), Cochrane Library, Health Management Informa-tion Consortium (HMIC), and Social Care Online. Besides, two journals—Journal of Clinical Oncology and Journal of Adolescent and Young Adult Oncology were identified for hand searching, and all reference lists of the selected papers and relevant reviews were looked through. The search terms were identified based on the planned pop-ulation, intervention, comparison, and outcome (PICO) [22], and they were adjusted slightly according to the dif-ferent databases (see Appendix 1). Table 1 shows the core
Table 1: Core components of the search strategy.
Population Intervention Context Outcome
cancer (MeSH) shared care (MeSH) follow-up (MeSH) All outcomes are included.
neoplasms (MeSH) co-management After care (MeSH)
cancer* “sharing of care” aftercare
neoplas* “collaborative care” follow up
malignan* “care coordination” followup*
carcinoma* “coordinated care” postsurgery
sarcoma “referral and consultation” post-surgery
oncolog* “cooperative behavio?r” postsurgical*
tumo?r* “shared service*” post-surgical*
adenocarcinoma* “delivery of health care” postoperat*
infiltrat* “integrated care” post-operat*
medullary “shared model” “continuity of patient care”
intraductal “inter-organizational coordination” “disease management”
surveillance
“disease progression”
survivorship
rehabilitation
post treatment
post-treatment
posttreatment
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 3 of 17
components of the search strategy, and the last search was conducted on 17th May 2017.
Eligibility criteriaInclusion criteria: 1) all types of primary research studies which assesses the shared care model in the management of follow-up for cancer patients, the formal interaction between primary care and secondary care; AND 2) include studies that examine any outcome in all types and any stage of cancer; AND 3) the population of interest included cancer survivors in any age; AND 4) published in English.
Exclusion criteria: 1) there was no formal interaction between primary care and secondary care as it is not shared care; OR 2) articles without outcomes such as com-mentary, protocol, or meeting abstract; OR 3) the research did not report any outcome about shared care; OR 4) the healthcare service were provided by other practitioners rather than hospital specialists and primary care team, or a multidisciplinary team include other practitioners; OR 5) the patients did not finish all the curative intent or adju-vant treatment; OR 6) the study only focus on the transi-tion manner rather than the whole follow-up process.
Selection process and method of appraisalThe author screened the title and abstract first, and any study that seemed to meet the selection criteria was full-text screened. Besides, two other reviewers randomly selected and reviewed 20% of the search records indepen-dently. Subsequently, studies were picked out according to the inclusion criteria. Any discrepancies were discussed and where there was any uncertainty, the professor with experi-ence in systematic reviews was consulted. In addition, the study author was contacted by email when more informa-tion was needed. The reasons for excluding the studies were recorded to enable transparency of the selection process.
The Critical Appraisal Skills Programme (CASP) is a widely available appraisal tool developed by Oxford University, which includes eight checklists for the different types of studies [23]. The RCTs were appraised by the CASP Randomised Controlled Trial Checklist (see Appendix 2). The CASP comprises of 11 questions that assist a systematic thinking about the paper. The Health Care Practice R&D Unit (HCPRDU) has developed three checklists, with 6, 6, 7 sections respectively, to appraise quantitative, qualitative and mixed-method studies [24]. Thus, other studies were appraised with one of the HCPRDU checklists according to the research methodology (see Appendix 3, 4). Häggman-Laitila et al. [25] evaluated the studies by selecting a score from 0 to 2 points in a systematic review, and this method was utilised and adapted for this review. For all studies, each question on the appraisal tools was scored from “0” to “2” separately and then the total scores were calculated. Among them, “0” means many limitations, “1” means some limitation, and “2” means excellent.
Data collection and synthesis of the findingsGough et al. [26] argue that the content of both quantita-tive and qualitative studies should be described and coded first, then the data extracted from these descriptions can be synthesised into the findings. Therefore, the the-matic analysis, which is a widespread analytical method
to accommodate a diversity of studies including both experimental and observational studies [27], was used in this review. Besides, since the data in the selected stud-ies are not sufficiently similar to allow for meta-analysis, the narrative approach was utilised in this review [28]. First, one author extracted the information and the other author verified all the information, the disagreements were solved by discussion; second, after a comprehensive understanding of all the results and a critical scrutiny of the themes was achieved, the final theme was summa-rised from all the papers in order to answer the research question; finally, the sample size, the study design, the limitation, and the quality of evidence were considered when there were conflicting themes, and the study with larger sample size or better quality might contribute more to the conclusion. The main review focus on the objectives of the systematic review, and the subgroup analysis were also included when they important to answer the ques-tions of the review questions.
ResultsA total of 1,888 records were identified through six data-bases, with 521 records identified through hand searching two oncology journals and citation tracking. All records were imported into Endnote, and 1,698 records were adopted after removing the duplicates by Endnote and scanning the title and authors. Then, the remaining 1,698 records were reviewed according to the eligibility criteria by two steps. First, the title and abstract of the records were reviewed in Endnote. Next, the potential studies were downloaded, and the full-text reviewed. Finally, twelve studies met the inclusion criteria, eight of which were RCTs, three of which were observational quantitative studies, and one was a mixed-method study. The selection process is illustrated in Figure 1. The study description based on the PICO framework is illustrated in Tables 2 and 3. Besides, the essence of shared care that includes the methods of communication, the major care provider, and the length of follow-up is described in Table 4.
Data extraction and quality appraisalAll studies except the mixed-method study [29] were con-sidered as excellent or good quality, and were included. To keep a balance between having confidence about the findings by only including good quality evidence and com-prising enough evidence in order to answer the research question, only those studies which were considered as bad quality were excluded [30]. As a result, this review finally includes seven RCTs reported in eight papers and three descriptive quantitative studies. One RCT was reported in two papers which assessed different types of outcomes [31, 32]. The results of the quality appraisal of the studies can be found in Tables 5 and 6 (included studies), and Appendix 7 (excluded study), and the examples of the appraisal process with the checklist can be found in Appendix 5, 6, and 7.
Effectiveness of shared carePhysical and psychological health statusA total of seven papers assessed whether shared care could improve the survivors’ health status, including both physical and psychological improvements. Among
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 4 of 17
those six papers that detected the quality of life, five papers detected the differences between the two arms at the end of the intervention, and one paper compared the outcomes between the beginning and the end of the shared care, but none of these papers detected any sig-nificant difference [31, 33–37]. As for the survivors’ psy-chological status, the two papers evaluated the survivors’ psychological distress level, finding no significant differ-ence between the intervention group and control group [31, 37]. Besides, the paper that assessed the survivorship worries found no difference before and after the shared care, but there was a borderline difference between the two groups after the shared care [38]. Turning to the sur-vivors’ physical conditions, the paper that evaluated the survivors’ performance status found no significant differ-ences between the two arms [33]. Further, the study used a non-inferiority design to evaluate the number of recur-rences, death, and the serious clinical event could not
demonstrate whether the intervention group was worse than the control group [35].
Satisfaction, attitudes and needs towards health careSeven out of eleven papers evaluated the survivors’ attitudes and needs toward the shared care. The results include the satisfaction with the follow-up [34, 37, 38], the satisfaction towards the PCPs [36], the attitudes toward the cooperation between health providers [33], the attitudes toward the information they received [39], survivorship unmet needs [37], and the preference for the care provider [37, 38]. From the survivor report results, the cooperation between health care practitioners improved (p = 0.025 and p = 0.004 in two out of four items) in the intermediate outcomes [33], and Emery et al. found the survivors in the shared care group would prefer shared care in the follow-up after the study (p = 0.07) [37]. Apart from these, the studies found no other significant differences between the two arms.
Figure 1: PRISMA flow diagram.
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 5 of 17
Tabl
e 2
: Ove
rvie
w o
f the
incl
uded
rand
omis
ed c
ontr
olle
d st
udie
s.
Aut
hor,
yea
r,
coun
try
Sam
ple
and
sett
ing
Inte
rven
tion
gro
upCo
ntro
l gr
oup
Leng
th o
f fol
low
-up
, inc
lusi
on t
ime
Canc
er t
ype
Out
com
esCo
nclu
sion
Berg
hold
t, et
al.
[31,
32]
, 20
12, 2
013,
D
enm
ark
955
new
ly d
iagn
osed
ca
ncer
pat
ient
s (≧
18 y
ears
) tre
ated
in
a p
ublic
regi
onal
ho
spit
al fr
om M
ay
2008
to F
ebru
ary
2009
and
323
Dan
ish
gene
ral p
ract
ices
(GP)
w
ere
enro
lled
to th
e tr
ial.
n =
486,
two
nurs
es w
ith
onco
logi
cal e
xper
ienc
e in
vite
d th
e pa
tien
ts to
join
an
inte
rvie
w
abou
t reh
abili
tati
on n
eeds
, an
d pa
tien
ts w
ere
sugg
este
d to
co
nsul
t the
ir G
P w
hen
nece
ssar
y.
n =
469,
us
ual c
are
mon
ths,
all
pati
ents
w
ere
diag
nose
d as
ca
ncer
wit
hin
the
prev
ious
3 m
onth
s
All
canc
ers
exce
pt
carc
inom
a in
si
tu a
nd n
on-
mel
anom
a sk
in c
ance
rs
No
sign
ifica
nt d
iffer
ence
s be
twee
n tw
o gr
oups
wit
h EO
RTC
QLQ
-C30
su
rvey
at 6
mon
ths
or 1
4 m
onth
s,
and
POM
S at
14
mon
ths.
No
sign
ifica
nt d
iffer
ence
s be
twee
n tw
o gr
oups
wit
h th
e nu
mbe
r of
G
P pr
oact
ive
cont
act n
or p
atie
nts’
pa
rtic
ipat
ion
in r
ehab
ilita
tion
ac
tivi
ties
.
The
mul
tim
odal
in
terv
enti
on c
ould
not
be
nefit
pat
ient
s w
ith
heal
th-r
elat
ed q
ualit
y of
life
or
psyc
holo
gica
l di
stre
ss. I
t cou
ld n
ot
impr
ove
GP
proa
ctiv
e co
ntac
t nor
pat
ient
s’
part
icip
atio
n in
reh
abili
-ta
tion
act
ivit
ies,
nei
ther
.
Nie
lsen
, et a
l. [3
3], 2
003,
D
enm
ark
248
canc
er p
atie
nts
(≧18
yea
rs) f
rom
the
onco
logy
dep
artm
ent
of a
uni
vers
ity
hosp
ital
be
twee
n A
ugus
t 199
8 an
d D
ecem
ber 1
998.
n =
127,
the
inte
rven
tion
in
clud
es th
ree
elem
ents
: pro
vide
G
P an
d pa
tien
ts w
ith
stan
dard
-is
ed k
now
ledg
e pa
ckag
e, b
uild
th
e co
mm
unic
atio
n ch
anne
ls
betw
een
hosp
ital
and
GP,
and
en
cour
age
pati
ents
to c
onta
ct
thei
r GPs
whe
n th
ey h
ad h
ealt
h-ca
re p
robl
ems.
n =
121,
no
rmal
pr
oced
ure
6 m
onth
s, b
oth
prim
ary
canc
er a
nd
recu
rren
t can
cer
pati
ents
wer
e in
clud
ed
All
type
s of
ca
ncer
exc
ept
lym
phom
a
Pati
ents
’ att
itud
es to
war
d th
e sh
ared
car
e an
d th
eir
GPs
is
mor
e po
siti
ve in
the
inte
rven
-ti
on g
roup
at 3
mon
ths
in 2
of
4 it
ems
(p <
0.0
5), a
nd p
atie
nts
cont
acte
d w
ith
thei
r G
Ps m
ore
than
the
cont
rol g
roup
(p <
0.0
5).
How
ever
, no
sign
ifica
nt d
iffer
ence
s w
ere
dete
cted
in q
ualit
y of
life
or
perf
orm
ance
sta
tus
betw
een
two
grou
ps. T
he s
ubgr
oup
anal
yses
in
dica
ted
that
men
and
you
ng
pati
ents
(18–
49 y
ears
) ten
t to
rate
th
e sh
ared
car
e m
ore
posi
tive
ly.
Shar
ed c
are
coul
d en
hanc
e th
e in
volv
e-m
ent o
f pri
mar
y ca
re
and
pati
ents
, whi
ch
influ
ence
d th
e pa
tien
ts’
atti
tude
tow
ard
heal
th-
care
ser
vice
s po
siti
vely
, es
peci
ally
for
men
and
yo
ung
pati
ents
.
Hol
teda
hl,
et a
l. [3
4],
2005
, Nor
way
91 a
dult
can
cer
pati
ents
(≧18
yea
rs) i
n a
univ
ersi
ty h
ospi
tal
wer
e en
rolle
d fr
om
Oct
ober
199
9 to
Sep
-te
mbe
r 200
0.
n =
41, t
wo
30 m
inut
es v
isit
s w
ere
cond
ucte
d by
GP
and
phys
icia
n se
para
tely
. The
topi
c is
abo
ut p
atie
nts’
exp
erie
nces
re
late
d to
can
cer.
Besi
des,
pa
tien
ts w
ere
enco
urag
ed to
co
ntac
t the
ir G
Ps if
they
had
any
he
alth
-rel
ated
pro
blem
.
n =
50, n
ot
men
tion
ed
abou
t the
ca
re c
on-
tent
.
6 m
onth
s, b
oth
prim
ary
canc
er
and
recu
rren
t ca
ncer
pat
ient
s w
ho h
ad fi
nish
ed
canc
er th
erap
y w
ere
incl
uded
All
type
s of
ca
ncer
exc
ept
pre-
can
cero
us
cond
itio
ns
such
as
in s
itu
cerv
ical
can
cer
Ther
e w
as n
o si
gnifi
cant
diff
eren
ce
betw
een
two
arm
s in
qua
lity
of
life,
pat
ient
s’ s
atis
fact
ion,
or
the
cons
ulta
tion
tim
es w
ith
GP
at s
ix
mon
ths.
The
rel
ativ
es’ s
atis
fact
ion
impr
oved
in th
e in
terv
enti
on g
roup
at
six
mon
ths
(P =
0.0
18).
Som
e pa
tien
ts m
ight
be
nefit
from
the
GP
follo
w-u
p, b
ut th
e im
prov
emen
ts w
ere
not
iden
tifie
d th
is s
tudy
. Be
side
s, th
e in
terv
en-
tion
did
not
gen
erat
e cl
oser
con
tact
bet
wee
n pa
tien
ts a
nd th
eir
GPs
.
(con
td.)
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 6 of 17
Aut
hor,
yea
r,
coun
try
Sam
ple
and
sett
ing
Inte
rven
tion
gro
upCo
ntro
l gr
oup
Leng
th o
f fol
low
-up
, inc
lusi
on t
ime
Canc
er t
ype
Out
com
esCo
nclu
sion
Gru
nfel
d,
et a
l. [3
5],
2006
, Can
ada
968
earl
y-st
age
brea
st
canc
er p
atie
nts
from
si
x ca
ncer
cen
tres
w
ere
enro
lled
from
Ja
nuar
y 19
97 to
June
20
01.
n =
483,
the
fam
ily p
hysi
cian
re
ceiv
ed a
one
-pag
e gu
idel
ine
from
the
canc
er c
entr
e. T
he
guid
elin
e in
clud
ed fo
llow
-up
arra
ngem
ent,
refe
rral
inst
ruc-
tion
, and
dis
ease
rele
vant
in
form
atio
n. T
he p
atie
nts
rece
ived
follo
w-u
p ca
re fr
om
thei
r fam
ily p
hysi
cian
.
n =
485,
th
e pa
tien
ts
rece
ived
fo
llow
-up
care
from
ca
ncer
ce
ntre
From
less
than
2
year
s to
5 y
ears
, pa
tien
ts w
ho h
ad
been
dia
gnos
ed
wit
h ca
ncer
from
9
to 1
5 m
onth
s ag
o an
d ha
d co
m-
plet
ed tr
eatm
ent 3
m
onth
s ag
o
earl
y st
age
brea
st c
ance
rTh
e pe
rcen
tage
of r
ecur
renc
e,
deat
h, a
nd s
erio
us c
linic
al e
vent
in
sha
red
care
gro
up w
ere
11.2
%,
6.0%
, and
3.5
%, r
espe
ctiv
ely,
co
mpa
red
to 1
3.2%
, 6.2
%, a
nd
3.7%
, res
pect
ivel
y, in
con
trol
gro
up.
The
heal
th-r
elat
ed q
ualit
y of
life
th
at a
sses
sed
by S
F-36
and
HA
DS
betw
een
two
arm
s di
d no
t sho
w
sign
ifica
nt d
iffer
ence
s.
The
shar
ed c
are
follo
w-
up d
id n
ot in
crea
se
the
risk
of i
mpo
rtan
t re
curr
ence
-rel
ated
se
riou
s cl
inic
al e
vent
or
heal
th-r
elat
ed q
ualit
y of
life
for
brea
st c
ance
r pa
tien
ts.
Blaa
uwbr
oek,
et
al.
[36]
, 20
08,
Net
herl
ands
( his
tori
cal
cont
rol
desi
gn)
121
adul
t sur
vivo
rs
(≧18
yea
rs) w
ho u
sed
to b
e di
agno
sed
as
child
hood
can
cer i
n a
paed
iatr
ic o
ncol
ogy
depa
rtm
ent a
nd d
id
not j
oin
any
follo
w-u
p st
udy
agre
ed to
ent
er
the
stud
y in
200
4 an
d 20
05.
n =
121,
thre
e vi
sits
wer
e ca
r-ri
ed o
ut d
urin
g th
ree
year
s pe
riod
. Vis
it 1
and
vis
it 3
wer
e co
nduc
ted
by a
n on
-sit
e fa
mily
do
ctor
at t
he m
edic
al c
entr
e,
visi
t 2 w
as c
ondu
cted
by
the
loca
l fam
ily d
octo
r. A
sses
s-m
ents
, sur
vey,
and
indi
vidu
al-
ised
follo
w-u
p su
gges
tion
wer
e pr
ovid
ed in
thes
e vi
sits
.
The
data
fr
om
anot
her
mat
ched
st
udy
in th
e N
ethe
rlan
ds
was
use
d as
con
trol
gr
oup
data
.
year
s, a
ll pa
tien
ts
had
been
trea
ted
in
the
hosp
ital
at l
east
5
year
s ag
o
All
child
hood
ca
ncer
s an
d La
nger
hans
-ce
ll hi
stio
cy-
tosi
s, e
xcep
t ce
ntra
l ner
v-ou
s sy
stem
tu
mou
rs
At v
isit
1, p
atie
nts
in in
terv
enti
on
arm
sho
wed
low
er le
vel o
f hea
lth-
rela
ted
qual
ity
of li
fe w
ith
RAN
D-3
6 su
rvey
com
pare
d to
con
trol
gro
up
data
, but
no
sign
ifica
nt d
iffer
ence
s w
ere
dete
cted
at v
isit
3. P
atie
nt s
at-
isfa
ctio
n w
as a
sses
sed
at v
isit
2, a
nd
89 (8
8%) o
f the
101
pat
ient
s w
ere
sati
sfie
d w
ith
shar
ed c
are
mod
el.
Shar
ed c
are
invo
lved
pa
edia
tric
onc
olog
ists
an
d fa
mily
doc
tors
can
be
use
d in
the
long
-ter
m
follo
w-u
p in
chi
ldho
od
canc
er p
atie
nts.
Emer
y, e
t al.
[37]
, 201
7,
Aus
tral
ia
pros
tate
can
cer
pati
ents
wit
h lo
w
risk
or m
oder
ate
risk
feat
ures
wer
e re
crui
ted
from
two
rura
l and
four
urb
an
med
ical
cen
tres
from
N
ovem
ber 2
011
to
July
201
3.
n =
45, a
GP
visi
t was
con
duct
ed
to re
-eng
age
thei
r rel
atio
n-sh
ip w
ith
pati
ents
. Bes
ides
, the
tr
eatm
ent c
entr
e pr
ovid
ed a
SCP
to
the
pati
ents
and
thei
r GPs
, an
d a
regi
ster
and
reca
ll sy
stem
w
as b
uilt
to e
nhan
ce G
Ps’ a
nd
pati
ents
’ com
plia
nce.
Aft
er th
at,
GP
repl
aced
two
hosp
ital
rout
ine
follo
w-u
p vi
sits
at 6
mon
ths
and
9 m
onth
s.
n =
43,
usua
l ca
re (t
he
pati
ents
vi
site
d th
e ho
spit
al
spec
ialis
ts
ever
y th
ree
mon
ths)
mon
ths,
all
pati
ents
ha
d co
mpl
eted
cu
rati
ve in
tent
tr
eatm
ents
wit
hin
the
prev
ious
8
wee
ks
Pros
tate
ca
ncer
wit
h lo
w ri
sk o
r m
oder
ate
risk
feat
ures
, ex
pect
the
met
asta
tic
dise
ase
No
sign
ifica
nt d
iffer
ence
s be
twee
n tw
o gr
oups
wit
h th
e H
AD
S, th
e Ca
SUN
, the
EPI
C, a
nd th
e PS
Q-1
8 re
sult
s. B
ut th
e in
terv
enti
on g
roup
ha
d a
pref
eren
ce o
f sha
red
care
th
an c
ontr
ol g
roup
(P <
0.0
01),
and
shar
ed c
are
cost
s le
ss th
an u
sual
ca
re.
Shar
ed c
are
mod
el c
ould
no
t ben
efit
pro
stat
e ca
ncer
pat
ient
s w
ith
dist
ress
, unm
et n
eeds
, ca
ncer
-spe
cific
qua
lity
of
life,
or
sati
sfac
tion
, but
it
is fe
asib
le a
s to
pro
vide
a
sim
ilar
outc
ome
wit
h le
ss m
oney
.
(con
td.)
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 7 of 17
Aut
hor,
yea
r,
coun
try
Sam
ple
and
sett
ing
Inte
rven
tion
gro
upCo
ntro
l gr
oup
Leng
th o
f fol
low
-up
, inc
lusi
on t
ime
Canc
er t
ype
Out
com
esCo
nclu
sion
May
er, e
t al.,
[3
8], 2
016,
U
nite
d St
ates
37 c
ance
r pat
ient
s (≧
21 y
ears
) who
had
co
mpl
eted
cur
ativ
e in
tent
trea
tmen
t in
a ca
ncer
hos
pita
l wer
e re
crui
ted.
n =
20, t
he re
sear
ch n
urse
in th
e ho
spit
al m
ade
a dr
aft S
CP, t
hen
the
onco
logy
nur
se p
ract
itio
ner
mad
e a
40 m
inut
es tr
ansi
tion
vi
sit w
ith
the
pati
ent a
nd re
vise
d th
e SC
P. T
he fi
nal S
CP w
as s
ent
to b
oth
pati
ents
and
thei
r PCP
s.
Besi
des,
the
PCPs
rece
ived
rele
-va
nt k
now
ledg
e ab
out f
ollo
w-u
p.
Aft
erw
ards
, the
PCP
s ca
rrie
d ou
t a
sem
i-str
uctu
red
follo
w-u
p vi
sit
wit
h pa
tien
ts w
ithi
n fo
ur w
eeks
.
n =
17, t
he
sam
e w
ith
inte
rven
tion
gr
oup
but
wit
hout
GP
visi
t
6 w
eeks
, all
pati
ents
ha
d co
mpl
eted
cu
rati
ve in
tent
tr
eatm
ents
wit
hin
the
prev
ious
4 to
6
wee
ks
All
type
s of
ca
ncer
exc
ept
met
asta
tic
canc
er
All
pati
ents
rep
orte
d ha
ving
less
co
ntra
dict
ory
info
rmat
ion
abou
t ca
re (P
< 0
.000
1) a
nd e
xpec
ted
less
follo
w-u
p fr
om o
ncol
ogis
ts
(P =
0.0
3) a
t 6 w
eeks
. All
PCPs
felt
m
ore
conf
iden
t (P
= 0.
01) a
bout
su
rviv
orsh
ip c
are.
How
ever
, the
PCP
vi
sit h
as li
ttle
eff
ect o
n th
e re
sult
s,
exce
pt m
akin
g a
bord
erlin
e di
ffer
-en
ce w
ith
wor
ry le
vel (
P =
0.05
).
The
SCP
coul
d im
prov
e pa
tien
ts’ a
nd P
CP’s
co
nfid
ence
in s
urvi
vor-
ship
info
rmat
ion,
but
no
sig
nific
ant b
enef
it
was
iden
tifie
d ab
out G
P vi
sit.
This
is a
pilo
t stu
dy,
a la
rger
stu
dy s
houl
d ex
plor
e th
e ch
ange
s in
th
e fu
ture
.
GP
= ge
nera
l pra
ctit
ione
r. EO
RTC
QLQ
-C30
= th
e Eu
rope
an O
rgan
isat
ion
for
Rese
arch
and
Tre
atm
ent o
f Can
cer
Qua
lity
of L
ife Q
uest
ionn
aire
Cor
e 30
. PO
MS
= Pr
ofile
of M
ood
Stat
es S
cale
. RA
ND
-36
= RA
ND
36-
Item
Hea
lth
Surv
ey. S
CP: s
urvi
vors
hip
care
pla
n. H
AD
S =
14-it
em H
ospi
tal A
nxie
ty a
nd D
epre
ssio
n Sc
ale.
CaS
UN
= U
nmet
nee
ds w
ere
asse
ssed
wit
h th
e Ca
ncer
Sur
vivo
rs’ U
nmet
Nee
ds
mea
sure
. EPI
C =
Expa
nded
Pro
stat
e Ca
ncer
Inde
x Co
mpo
site
. PSQ
-18
= 18
-item
Sho
rt-fo
rm P
atie
nt S
atis
fact
ion
Que
stio
nnai
re. S
F-36
= M
edic
al O
utco
mes
Stu
dy S
hort
For
m 3
6-It
em G
ener
al H
ealt
h Su
rvey
.
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 8 of 17
Tabl
e 3
: Ove
rvie
w o
f the
oth
er s
tudi
es.
Aut
hor,
yea
r,
coun
try
Rese
arch
de
sign
Sam
ple
and
sett
ing
Proc
edur
es (I
nter
vent
ion
and
com
pari
son)
Leng
th o
f fol
low
-up
, ons
et t
ime
Canc
er t
ype
Out
com
esCo
nclu
sion
Han
an, e
t al.,
[29]
, 20
14, I
rela
nd
Des
crip
tive
, si
ngle
-cen
tre,
m
ixed
m
etho
ds
The
com
mun
ity
nurs
e to
ok th
e re
spon
sibi
lity
of m
anag
emen
t of
canc
er p
atie
nts
inst
ead
of h
ospi
tal n
urse
s,
and
the
visi
t was
co
nduc
ted
at p
atie
nts’
ho
me.
The
rese
arch
incl
uded
a
six
mon
ths
skill
s tr
aini
ng
(fro
m s
peci
alis
t can
cer
staf
f) fo
r com
mun
ity
nurs
es, s
peci
fic re
ferr
al
form
, and
pro
vide
d ho
spi-
tal s
uppo
rt fo
r com
mun
ity
nurs
es in
urg
ent s
itua
tion
by
pho
ne. T
he p
atie
nts
wer
e to
ld th
at th
e m
edic
al
onco
logi
sts
still
took
the
resp
onsi
bilit
y of
them
. Th
e pa
tien
ts w
ere
maj
orly
m
anag
ed b
y co
mm
unit
y nu
rses
.
5 ye
ars,
not
m
enti
oned
Not
men
tion
ed
Qua
ntit
ativ
e ou
tcom
es:
Com
mun
ity
nurs
e-le
d ca
ncer
car
e w
as
com
pare
d w
ith
hosp
ital
act
ivit
y da
ta
befo
re th
e pr
ogra
mm
e (b
asel
ine)
, in
the
mid
dle
of th
e pr
ogra
mm
e (a
fter
th
e si
x m
onth
s tr
aini
ng),
and
five
year
s af
ter
the
base
line.
The
com
mun
ity
nurs
es d
eliv
ered
saf
e ca
ncer
car
e, a
nd
the
hosp
ital
att
enda
nces
was
dec
reas
ed.
The
com
mun
ity
nurs
es h
ad m
ore
conf
iden
ce in
can
cer
man
agem
ent.
Qua
litat
ive
outc
omes
: Th
e pa
tien
ts r
epor
ted
a sh
orte
r tr
avel
to
hea
lth
care
, and
impr
oved
qua
lity
of
life.
The
y ha
d co
nfid
ence
in c
omm
unit
y nu
rses
, and
they
indi
cate
d th
eir
sens
e of
aut
onom
y in
crea
sed.
Shar
ed c
are
appr
oach
wit
h tr
aini
ng c
omm
unit
y nu
rses
cou
ld b
enef
it
both
pat
ient
s an
d he
alth
car
e pr
ovid
ers.
Blaa
uwbr
oek,
et a
l. [3
9], 2
012,
N
ethe
rlan
ds
Des
crip
tive
, si
ngle
-cen
tre,
qu
anti
tati
ve
80 c
hild
hood
can
cer
surv
ivor
s (≧
18 y
ears
) w
ho u
sed
to b
e di
ag-
nose
d in
a lo
ng-t
erm
fo
llow
-up
clin
ic a
nd
did
not j
oin
any
follo
w-
up s
tudy
and
thei
r fa
mily
doc
tors
(n =
79)
jo
ined
this
stu
dy fr
om
Sept
embe
r 200
8.
The
rese
arch
team
( h
ospi
tal s
peci
alis
ts)
cons
truc
ted
a pe
rson
alis
ed
SCP
and
sent
the
prin
ted
book
let t
o th
e pa
tien
ts.
The
plan
was
als
o ac
ces-
sibl
e th
roug
h a
secu
re
web
site
to th
e su
rviv
ors
and
thei
r fam
ily d
octo
rs.
Besi
des,
the
rese
arch
team
as
ked
the
surv
ivor
s to
m
ake
a ha
lf-ho
ur m
eeti
ng
wit
h th
eir f
amily
doc
tors
, th
ey w
ould
rem
ind
the
sur-
vivo
rs a
gain
if th
ey d
id n
ot
mee
t the
ir fa
mily
doc
tors
si
x m
onth
s la
ter.
Follo
w-u
p w
as d
one
prim
arily
by
the
fam
ily d
octo
r.
one
year
, at
leas
t 5 y
ears
of
f-tre
atm
ent
All
type
s of
ca
ncer
exp
ect
cent
ral n
ervo
us
syst
em tu
mou
rs,
surv
ivor
s of
all
thre
e le
vels
of r
isk
wer
e in
clud
ed
( low
-ris
k,
med
ium
-ris
k,
and
high
risk
)
The
fam
ily d
octo
rs w
ere
aske
d to
fini
sh
an in
form
atio
n fo
rm a
bout
the
scre
en-
ing
and
the
addi
tion
al te
st r
esul
ts.
Besi
des,
an
18-it
em q
uest
ionn
aire
and
a
14-it
em q
uest
ionn
aire
wer
e us
ed to
as
sess
sur
vivo
rs’ a
nd fa
mily
doc
tors
’ vi
ews,
res
pect
ivel
y, a
bout
the
web
site
an
d th
e pr
ovid
ed in
form
atio
n, th
e la
te
effe
cts
wer
e al
so c
olle
cted
by
the
fam
ily
doct
ors.
Out
com
es:
73 s
urvi
vors
and
72
fam
ily d
octo
rs
com
plet
ed th
e st
udy.
97%
of t
he
surv
ivor
s th
ough
t the
follo
w-u
p w
as
bene
ficia
l, bu
t 11%
of t
he s
urvi
vors
felt
th
at th
e in
form
atio
n w
as in
adeq
uate
. 82
% o
f the
sur
vivo
rs b
elie
ved
in th
eir
fam
ily d
octo
rs’ a
bilit
y in
the
follo
w-u
p.
How
ever
, 77%
of s
urvi
vors
felt
wor
ried
ab
out t
he r
eaw
aken
ed m
emor
ies
abou
t th
e di
seas
e.
The
shar
ed c
are
wit
h w
eb-b
ased
SCP
is
avai
labl
e in
the
long
-te
rm c
ance
r fo
llow
-up
of a
dult
s w
ith
child
hood
can
cer,
and
mos
t sur
vivo
rs
and
fam
ily d
octo
rs
wer
e sa
tisf
ied
wit
h th
is m
odel
. Bes
ides
, bo
th s
urvi
vors
and
th
e fa
mily
doc
tors
th
ough
t the
ir
rele
vant
kno
wle
dge
impr
oved
thou
gh
this
pro
cess
. The
ne
gati
ve e
ffec
t was
th
e fo
llow
-up
mig
ht
reaw
aken
sur
vivo
rs
of b
ad m
emor
ies
abou
t dis
ease
.
(con
td.)
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 9 of 17
Aut
hor,
yea
r,
coun
try
Rese
arch
de
sign
Sam
ple
and
sett
ing
Proc
edur
es (I
nter
vent
ion
and
com
pari
son)
Leng
th o
f fol
low
-up
, ons
et t
ime
Canc
er t
ype
Out
com
esCo
nclu
sion
60 fa
mily
doc
tors
(83%
) fin
ishe
d al
l the
re
com
men
ded
test
s. 9
5% o
f the
fam
ily
doct
ors
felt
the
follo
w-u
p w
as m
ore
bene
ficia
l and
83%
felt
thei
r kn
owl-
edge
of l
ate
effe
cts
incr
ease
d. B
esid
es,
93%
of t
he fa
mily
doc
tors
felt
con
fi-de
nt a
bout
man
agem
ent o
f fol
low
-up
if th
ey r
ecei
ved
the
SCP.
Berg
er, e
t al.,
[40]
, 20
17, F
ranc
e D
escr
ipti
ve,
sing
le-c
entr
e,
quan
tita
tive
150
child
hood
can
cer
surv
ivor
s (≧
18 y
ears
) an
d th
eir G
Ps (n
= 1
06)
invo
lved
in th
is s
tudy
fr
om D
ecem
ber 2
010
to Ju
ne 2
013.
The
se
surv
ivor
s w
ere
from
a
regi
on c
ance
r reg
istr
y an
d di
agno
sed
of
canc
er b
efor
e 15
yea
rs
old.
The
paed
iatr
ic o
ncol
ogis
t an
d th
e in
tern
ist i
nvit
ed
the
surv
ivor
s to
join
a
cons
ulta
tion
, in
whi
ch th
e pr
acti
tion
ers
expl
aine
d th
e m
edic
al h
isto
ry a
nd
pote
ntia
l lat
e ef
fect
s to
th
e su
rviv
ors.
Add
itio
nal
test
s w
ere
cond
ucte
d ba
sed
on th
e co
nsul
tati
on.
Besi
des,
the
med
ical
doc
tor
prov
ided
the
cons
ulta
tion
su
mm
arie
s an
d re
com
men
-da
tion
s ab
out f
ollo
w-u
p (r
ecom
men
dati
on c
ard)
for
the
surv
ivor
s an
d th
eir G
Ps.
The
med
ical
doc
tor w
ould
ca
ll th
e G
Ps if
they
did
not
re
spon
d to
the
stud
y at
fir
st.
One
yea
r, di
ag-
nose
d as
pri
mar
y ca
ncer
from
Ja
nuar
y 19
87 to
D
ecem
ber 1
992.
All
type
s of
ca
ncer
exp
ect
leuk
aem
ia
120
surv
ivor
s fin
ishe
d th
e ni
ne-
ques
tion
sat
isfa
ctio
n fo
rm, 1
07 o
f the
m
(89%
) wer
e sa
tisf
ied
wit
h th
e co
nsul
ta-
tion
. 86%
of t
he s
urvi
vors
foun
d th
e re
com
men
dati
on c
ard
was
use
ful.
Mor
e th
an 7
5% fe
lt th
eir
lifes
tyle
cha
nged
su
ch a
s ph
ysic
al a
ctiv
ity
and
diet
s. T
ype
of c
ance
r an
d tr
eatm
ent w
ould
influ
-en
ce th
e sa
tisf
acti
on w
ith
the
follo
w-u
p (p
< 0
.05)
. The
sur
vivo
rs w
ho r
ecei
ved
chem
othe
rapy
felt
mor
e sa
tisf
acti
on
wit
h th
e sh
ared
car
e (p
= 0
.03)
.10
6 G
Ps fi
nish
ed th
e fiv
e ar
eas
sati
sfac
-ti
on s
urve
y, 6
3 of
them
(59%
) rep
orte
d th
ey w
ere
not p
rovi
ded
enou
gh in
for-
mat
ion
abou
t the
pat
ient
’s tr
eatm
ent,
82 o
f the
m (7
7%) r
epor
ted
lack
of l
ate
effe
ct o
f che
mot
hera
py. B
ut m
ost o
f th
em fe
lt th
e re
com
men
dati
on c
ard
was
use
ful (
61%
), ov
er 8
0% o
f the
m
appr
ecia
te th
e co
llabo
rati
on a
nd a
vail-
abili
ty o
f con
tact
wit
h ho
spit
al.
The
long
-ter
m
follo
w-u
p by
co
llabo
rati
on o
f GP
and
hosp
ital
spe
cial
-is
t was
feas
ible
an
d co
uld
bene
fit
child
hood
can
cer
surv
ivor
s an
d fa
mily
ph
ysic
ians
.
Lund
, et a
l. [4
1],
2016
, Den
mar
kD
escr
ipti
ve,
mul
ti-c
entr
e,
quan
tita
tive
530
canc
er p
atie
nts
from
thre
e ho
spita
ls
wer
e tr
ansf
erre
d to
th
eir G
Ps a
nd in
vite
d to
join
the
shar
ed c
are
follo
w u
p be
twee
n Se
ptem
ber 2
011
and
Mar
ch 2
012,
the
follo
w-
up la
sts
for t
hree
yea
rs.
The
urol
ogic
al s
peci
al-
ists
dev
elop
ed fo
llow
-up
reco
mm
enda
tion
s fo
r ev
alua
ting
pat
ient
and
GP
com
plia
nce,
incl
udin
g th
e sc
hedu
le o
f fol
low
-up
and
the
inst
ruct
ions
of r
efer
ral.
The
pati
ents
wer
e tr
ans-
ferr
ed to
thei
r GPs
.
3 ye
ars,
wit
h or
w
itho
ut re
laps
ePr
osta
te c
ance
r42
6 (8
0.8%
) pat
ient
s w
ere
anal
ysed
, 39
0 pa
tien
ts (9
1.5%
) wer
e ra
ted
as
“acc
epta
ble”
or
“goo
d” c
ompl
ianc
e (t
he
com
plia
nce
was
rat
ed a
s fo
ur c
olum
ns:
unkn
own,
poo
r, ac
cept
able
, and
goo
d);
a to
tal o
f 393
GP
(92.
3%) w
ere
rate
d as
“g
ood”
or
“acc
epta
ble”
com
plia
nce
(the
co
mpl
ianc
e w
as r
ated
as
four
col
umns
: un
know
n, p
oor,
acce
ptab
le, a
nd g
ood)
.
Shar
ed c
are
mod
el is
a
safe
app
roac
h w
ith
high
rat
e of
pat
ient
an
d G
P co
mpl
ianc
e
GP
= ge
nera
l pra
ctit
ione
r. SC
P: s
urvi
vors
hip
care
pla
n.
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 10 of 17
Tabl
e 4
: Ess
ence
of s
hare
d ca
re.
Aut
hor,
yea
r,
coun
try
Maj
or
follo
w-u
p ca
re
prov
ider
in
shar
ed c
are
Oth
er
follo
w-u
p ca
re p
rovi
der
in s
hare
d ca
re
Met
hod
of s
hare
d ca
re in
volv
emen
tN
umbe
r of
form
al
inte
ract
ion
betw
een
diff
eren
t ca
re
prov
ider
s, c
omm
uni-
cati
on t
ool b
etw
een
care
pro
vide
rs
Num
ber/
freq
uenc
y of
inte
ract
ion
betw
een
pati
ents
an
d pr
imar
y ca
re
in in
terv
enti
on
grou
p
Num
ber/
freq
uenc
y of
inte
ract
ion
betw
een
pati
ents
an
d pr
imar
y ca
re
in c
ontr
ol g
roup
Dif
fere
nce
betw
een
two
grou
ps
Han
an, e
t al.
[29]
, 201
4,
Irel
and
Com
mun
ity
nurs
esO
ncol
ogy
day-
war
d nu
rses
, sp
ecia
list
canc
er s
taff
The
shar
ed c
are
incl
uded
a s
ix m
onth
s sk
ills
trai
ning
(fro
m s
peci
alis
t can
cer s
taff
) for
com
-m
unit
y nu
rses
, spe
cific
refe
rral
form
, and
pro
-vi
ded
hosp
ital
sup
port
for c
omm
unit
y nu
rses
in
urg
ent s
itua
tion
by
phon
e. T
he p
atie
nts
wer
e to
ld th
at th
e m
edic
al o
ncol
ogis
ts s
till
took
the
resp
onsi
bilit
y of
them
.
Mor
e th
an o
nce,
skill
trai
ning
, pho
ne,
and
reso
urce
boo
k
Not
men
tion
edN
ot m
enti
oned
Not
men
tion
ed
Berg
hold
t, et
al.
[31,
32]
, 20
12, 2
013,
D
enm
ark
Gen
eral
pra
cti-
tion
erTw
o ho
spit
al
nurs
es w
ith
onco
logi
cal
expe
rien
ce
The
hosp
ital
nur
ses
sugg
este
d pa
tien
ts to
con
-su
lt th
eir G
Ps w
hen
nece
ssar
y. E
qual
ly, t
hey
also
en
cour
aged
the
GPs
to b
e pr
oact
ive
to o
ffer
sup
-po
rt to
thei
r pat
ient
s, a
nd s
end
the
GP
an e
mai
l, w
hich
incl
ude
the
pati
ents
’ inf
orm
atio
n.
Onc
e,Em
ail a
nd p
hone
Pati
ents
rep
orte
d:
168
cont
acts
(101
GP
proa
ctiv
e co
ntac
t, 61
.1%
) G
P re
port
ed:
379
cont
acts
(232
G
P pr
oact
ive
cont
act,
61.2
%)
Pati
ents
rep
orte
d:
156
cont
acts
(81
GP
proa
ctiv
e co
ntac
t, 51
.9%
) GP
repo
rted
: 37
3 co
ntac
ts (2
06
GP
proa
ctiv
e co
ntac
t, 55
.2%
)
No
sign
ifica
nt
diff
eren
ces
in b
oth
pati
ents
rep
orte
d an
d G
P re
port
ed
cont
acts
.
Nie
lsen
, et a
l. [3
3], 2
003,
D
enm
ark
Both
hos
pita
l sp
ecia
lists
and
G
Ps
/Tr
ansf
erri
ng k
now
ledg
e an
d in
form
atio
n fr
om
hosp
ital
to G
P, b
uild
ing
com
mun
icat
ion
chan
-ne
ls, e
ncou
ragi
ng p
atie
nts
to c
onta
ct th
eir G
Ps
Onc
e,or
dina
ry m
ail
Not
men
tion
edN
ot m
enti
oned
Mor
e pa
tien
ts h
ad
cont
act w
ith
thei
r G
P in
inte
rven
tion
gr
oup
(p =
0.0
49
at 3
mon
ths,
p =
0.
046
at 6
mon
ths)
Hol
teda
hl,
et a
l. [3
4],
2005
, Nor
way
Both
GP
and
hosp
ital
ph
ysic
ian
/Th
e G
P w
as a
sked
to in
itiat
e a
cons
ulta
tion
with
pa
tient
s. Th
e pa
tient
s w
ere
enco
urag
ed to
con
-ta
ct th
eir G
Ps if
they
hav
e he
alth
rela
ted
prob
lem
.
Onc
e,un
clea
rTh
e av
erag
e co
nsul
-ta
tion
tim
e w
as 1
.26
per
pati
ents
The
aver
age
cons
ul-
tati
on ti
me
was
1.0
4 pe
r pa
tien
ts
No
sign
ifica
nt
diff
eren
ce b
etw
een
two
arm
s
Gru
nfel
d,
et a
l. [3
5],
2006
, Can
ada
Fam
ily
phys
icia
nPr
acti
tion
er in
ca
ncer
cen
tre
The
fam
ily p
hysi
cian
rece
ived
a o
ne-p
age
guid
elin
e fr
om th
e ca
ncer
cen
tre.
The
gui
de-
line
incl
uded
follo
w-u
p ar
rang
emen
t, re
ferr
al
inst
ruct
ion,
and
dis
ease
rele
vant
info
rmat
ion.
Onc
e,un
clea
rN
ot m
enti
oned
Not
men
tion
edN
ot m
enti
oned
Blaa
uwbr
oek,
et
al.
[36]
, 20
08,
Net
herl
ands
Both
pae
diat
ric
onco
logi
sts
and
fam
ily d
octo
rs
/Th
e m
edic
al c
entr
e ad
vise
d th
e pa
tien
ts to
mee
t th
eir f
amily
doc
tors
. The
pat
ient
info
rmat
ion
and
the
test
resu
lts
wer
e sh
ared
by
med
ical
ce
ntre
and
pri
mar
y ca
re.
Mor
e th
an o
nce,
em
ail o
r tel
epho
neN
ot m
enti
oned
N
ot m
enti
oned
Not
men
tion
ed (con
td.)
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 11 of 17
Aut
hor,
yea
r,
coun
try
Maj
or
follo
w-u
p ca
re
prov
ider
in
shar
ed c
are
Oth
er
follo
w-u
p ca
re p
rovi
der
in s
hare
d ca
re
Met
hod
of s
hare
d ca
re in
volv
emen
tN
umbe
r of
form
al
inte
ract
ion
betw
een
diff
eren
t ca
re
prov
ider
s, c
omm
uni-
cati
on t
ool b
etw
een
care
pro
vide
rs
Num
ber/
freq
uenc
y of
inte
ract
ion
betw
een
pati
ents
an
d pr
imar
y ca
re
in in
terv
enti
on
grou
p
Num
ber/
freq
uenc
y of
inte
ract
ion
betw
een
pati
ents
an
d pr
imar
y ca
re
in c
ontr
ol g
roup
Dif
fere
nce
betw
een
two
grou
ps
Emer
y, e
t al.
[37]
, 201
7,
Aus
tral
ia
Both
hos
pita
l sp
ecia
lists
and
G
Ps
/Th
e tr
eatm
ent c
entr
e fa
xed
a SC
P to
the
GP.
The
re
gist
er a
nd re
call
syst
em s
ent G
P fo
llow
-up
rem
inde
r let
ters
.
Mor
e th
an o
nce,
fa
x, le
tter
Not
men
tion
edN
ot m
enti
oned
Not
men
tion
ed
May
er, e
t al.
[38]
, 201
6,
Uni
ted
stat
es
Both
hos
pita
l nu
rses
and
GPs
/H
ospi
tal n
urse
s pr
ovid
ed S
CP to
bot
h pa
tien
ts
and
PCPs
, the
y al
so c
ondu
cted
a tr
ansi
tion
vis
it
wit
h th
e su
rviv
ors.
The
PCP
car
ried
out
a s
emi-
stru
ctur
ed fo
llow
-up
visi
t wit
h su
rviv
ors
(tal
king
po
ints
wer
e de
velo
ped
by th
e ho
spit
al).
Mor
e th
an o
nce,
Elec
tron
ic h
ealt
h sy
stem
, mai
l, or
em
ail,
web
site
s
Not
men
tion
edN
ot m
enti
oned
Not
men
tion
ed
Blaa
uwbr
oek,
et
al.
[39]
, 20
12,
Net
herl
ands
Fam
ily d
octo
rsLo
ng-t
erm
fo
llow
-up
clin
ic
The
rese
arch
team
(hos
pita
l spe
cial
ists
) con
-st
ruct
ed a
per
sona
lised
SCP
web
site
whi
ch w
as
acce
ssib
le to
the
fam
ily d
octo
rs. B
esid
es, t
he
rese
arch
team
ask
ed th
e su
rviv
ors
to m
ake
a ha
lf-ho
ur m
eeti
ng w
ith
thei
r fam
ily d
octo
rs,
they
rem
inde
d th
e su
rviv
or a
gain
if th
ey d
id n
ot
mee
t the
ir fa
mily
doc
tors
six
mon
ths
late
r.
Mor
e th
an o
nce,
secu
re w
ebsi
te o
r let
ter
Not
men
tion
edN
ot m
enti
oned
Not
men
tion
ed
Berg
er, e
t al.
[40]
, 201
7,
Fran
ce
GP
A p
aedi
atri
c on
colo
gist
and
an
inte
rnis
t
The
med
ical
doc
tor p
rovi
ded
the
cons
ulta
tion
su
mm
arie
s an
d re
com
men
dati
ons
abou
t fol
low
-up
for t
he s
urvi
vors
and
thei
r GPs
. The
med
i-ca
l doc
tor w
ould
cal
l the
GPs
if th
ey d
id n
ot
resp
ond
to th
e st
udy
at fi
rst.
Onc
e,
uncl
ear
Not
men
tion
edN
ot m
enti
oned
Not
men
tion
ed
Lund
, et a
l. [4
1], 2
016,
D
enm
ark
GP
Hos
pita
l ou
tpat
ient
ur
olog
ical
sp
ecia
lists
The
urol
ogic
al s
peci
alis
ts d
evel
oped
follo
w-u
p re
com
men
dati
ons
for e
valu
atin
g pa
tien
t and
GP
com
plia
nce,
incl
udin
g th
e sc
hedu
le o
f fol
low
-up
and
the
inst
ruct
ions
of r
efer
ral.
Onc
e,un
clea
rN
ot m
enti
oned
Not
men
tion
edN
ot m
enti
oned
GP
= ge
nera
l pra
ctit
ione
r. SC
P: s
urvi
vors
hip
care
pla
n.
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 12 of 17
Tabl
e 5
: Cri
tica
l rev
iew
of t
he R
CTs
wit
h Cr
itic
al A
ppra
isal
Ski
lls P
rogr
amm
e (C
ASP
).
Sect
ion/
Que
stio
nSc
ore
Berg
hold
t,
et a
l., 2
012
[3
1]
Berg
hold
t,
et a
l., 2
013
[3
2]
Nie
lsen
, et
al.,
20
03
[3
3]
Hol
teda
hl,
et a
l., 2
00
5
[34
]
Gru
nfel
d,
et a
l., 2
00
6
[35
]
Blaa
uwbr
oek,
et
al.,
20
08
[3
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Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 13 of 17
Some studies used a descriptive way to assess the satisfac-tion of survivors and got similar results. First, Blaauwbroek et al. found that 88% of the survivors who completed the questionnaire were satisfied with the follow-up [36], while Berger et al. found a similar result in that 89% of the survivors who finished the questionnaire were satisfied with the health care [40]. Second, more than 80% of the survivors were generally satisfied with the information they received in the follow-up in two studies, and 71% of the survivors followed the instructions [39, 40]. Third, Blaauwbroek et al. reported that survivors were more aware of the benefits of follow-up (90.2%), and 73.6% of the survivors were more confident with the GPs’ capac-ity [39]. The only disadvantage of shard care reported in all eleven studies was that 15.3% of the childhood cancer survivors mentioned that the information they received reminded them of the negative memories from the past [39]. Finally, the subgroup analysis found that the men and younger age group (18–49 years) were significantly more satisfied with the shared care and found it easier to accept the GPs as their care provider [33], and the diagno-sis and the treatment could affect the satisfaction with the follow-up (p < 0.05) [40].
Care referral and continuity of careThe studies evaluated the continuity of care in different aspects, such as the primary care practitioner’s confidence in survivorship knowledge, their attitudes toward the follow-up and the information they received during the follow-up, and the frequency that survivors participated in the follow-up, but no significant differences were found between the intervention group and control group [32, 38]. Besides, most studies used descriptive data to report the outcomes. Blaauwbroek et al. found that 71.7%–77.4% of family doctors reported that their knowledge and abil-ity of providing follow-up care were improved [39], and Lund et al. reported that 91.5%–92.3% could follow the follow-up recommendations [41]. Besides, Blaauwbroek
et al. found that 82% of the family doctors were satisfied with the cooperation and the information they received [36]. Another study reported that 61% of GPs consid-ered the information they received and 82% ranked the collaboration with hospital as helpful, 59%–77% of the general practitioners stated that they received insufficient information in different aspects. Furthermore, GPs recom-mended that specific cancers needed particular follow-up more than other cancers such as more GPs considering that renal tumour survivors needed more specific care than lymphomas survivors (p = 0.013) [40].
The cost of shared careOnly one paper compared the cost of shared care with usual care and found that shared care was cheaper than usual care [37]. In the Emery et al. study, a multisite ran-domised controlled trial which included patients of two rural and four urban treatment centres was conducted. Five routine follow-up visits were carried out in both two groups, and two hospital visits were replaced by GP in the experimental group. At the end of the research, the shared care spent $323 less than usual care for each patient in the one-year follow-up.
The care in the shared care group and control groupThe interventions were complex. Three trials implemented the shared care with a clear division of tasks by hospital specialists and primary care physicians [34, 36, 37], while the other seven trials implemented the shared care by intending to transfer the follow-up care to primary care providers smoothly with specified information exchange [31–33, 35, 38–41]. The hospital centre and primary care formally communicated with each other more than once in four out of eleven trials [36–39], but the others only involved one formal communication [31–35, 40–41]. The cancer survivors in the control group were followed up by usual care [31–33, 37] or in the hospital [35] in most of the trials. However, one study [38] did not include
Table 6: Critical review of the quantitative studies with Health Care Practice R&D Unit (HCPRDU).
Question Score
Blaauwbroek, et al., 2012
[39]
Berger, et al., 2017
[40]
Lund, et al., 2016
[41]
(1) Study overview 2 2 1
(2) Study, setting, sample and ethics
2 2 1
(3) Ethics 2 0 1
(4) Group comparability and outcome measurement
1 1 1
(5) Policy and practice implica-tions
1 1 2
(6) Other comments 2 1 2
Total score (maximum 12)
10 7 8
“0” represents many limitations, “1” represents some limitation, “2” represents excellent.
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic ReviewArt. 2, page 14 of 17
survivors in the control group but applied the data from another matched study in the same country as the control group. Besides, two studies did not clearly describe the content of the control group [34, 38].
DiscussionThis review included 11 papers that evaluated shared care in the continuity of care for cancer survivors. These studies conducted shared care with various and complex multifac-eted interventions for improving the follow-up of cancer survivors, especially their quality of life and depression. An overview of the results in the selected studies suggests that survivors and general practitioners reported favour-ing shared care, and the survivors who had experienced shared care had a stronger preference for shared care in the future. However, there were no significant differences in terms of quality of life, mental health outcomes, unmet needs, and serious clinical events between shared care and usual care. One important confounding factor might be that the patient-reported results could have been affected by the lack of confidence in primary care [42] since it is impossible to blind the survivors.
Although only 11 papers were included in the present review, the overall sample size and the quality of studies constitutes an overview with a preliminary picture of the possible way to conduct shared care and the effectiveness of shared care. Two models of shared care were identified as offering potential to improve the monitoring of cancer survivors: the transference of survivors, which lies within the information exchange; and the coordination of assess-ments and treatments, which allows distant health pro-fessionals to conduct the monitoring alternately. Several interventional strategies that were utilised played a role in enhancing the efforts in terms of care cooperation: (1) sur-vivorship care plan; (2) referral and consultation visit; (3) improving the knowledge of PCPs; (4) enhancing patient’s confidence in health care practitioners, especially in PCPs; (5) building the communication channel between health care professionals; and (6) the register and recall system.
The studies that assessed the continuity of care found that shared care could meet the requirements of follow-up, and the PCPs felt their knowledge was improved and that they had the capability of providing healthcare with the support of hospital specialists. Blaauwbroek et al. found that 77.4% of the PCPs considered that they had the capacity of providing follow-up if the SCP was avail-able [39], while another survey found that only 40% of the PCPs felt confident of their knowledge in the follow-up of cancer survivors in the usual care [43]. Besides, the only study that compared the cost of shared care to usual care found that the shared care on average reduced costs by $323 per patient at one-year follow-up [37].
Although only those studies that were rated as “good” or “excellent” were included in this review, several stud-ies had major limitations, such as the sample size being insufficient [34, 38], the significant differences at the baseline [33], and the outcome assessor not being blinded in most of the trials. Besides, there were only six RCTs that compared shared care with usual care, and many of the results were illustrated within a descriptive method. Thus,
the small number of available studies could not provide a solid foundation for this review. Furthermore, there were various types of outcomes that were detected in the stud-ies, so many of the results could not be regrouped based on the considerable heterogeneity. Besides, all the stud-ies were conducted in developed countries, and most of the studies were performed in city settings, so the results might not apply to other undeveloped countries or rural regions. Further limitations include that only papers writ-ten in English were included and the author appraised the papers without blinding to the published journal or the writers.
ConclusionsImplications for practiceThe present review shines a light on improving the follow-up, with current evidence indicating that shared care is an affordable model as well as being feasible and accept-able for cancer survivors. It enables GP’s involvement in survivorship care and help the cooperation between hos-pital and primary care. Although the evidence showed that the effectiveness of shared care is similar to hospital follow-up, the strategies we identified from the included studies could be useful to all stakeholders of health care and provide a preference for implementing new strategies in cancer follow-up to address the sustainable burden of hospitals. Due to limited evidence of financial analysis, we could not make conclusion that shared care is cheaper than usual care, but it is potentially contributing to help resolve the stabilised health care costs. However, more solid evidence about the effectiveness of shared care is needed before it can be routinely implemented.
Implications for researchAlthough the results of this review do not confirm that shared care is more effective than usual care in the management of follow-up in cancer survivors, several key elements have been identified in shared care: the consultation meeting, the formal transferring of docu-ments, encouraging communication between the survi-vors and the practitioners, and the length of follow-up. Besides, the communication channel and register and recall system are also considered as important elements in shared care. The research gaps of the included stud-ies also indicate the directions that future studies need to address. First, further RCTs with sufficient sample size are needed to explore the health-related cost of shared care and the clinical outcomes. Second, the differences in the subgroup indicate that individual follow-up should be conducted based on the diagnosis, treatment, age, and gender. Third, the follow up should be modified accord-ing to the specific health care needs in different time frames since diagnosis [44].
Additional FilesThe additional files for this article can be found as follows:
• Appendix 1. MEDLINE (Ovid) and HMIC search strategy. DOI: https://doi.org/10.5334/ijic.3954.s1
Zhao et al: The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review Art. 2, page 15 of 17
• Appendix 2. Critical Appraisal Skills Programme (CASP) Randomised Controlled Trials Checklist. DOI: https://doi.org/10.5334/ijic.3954.s1
• Appendix 3. Health Care Practice R&D Unit ( HCPRDU) quantitative research checklists. DOI: https://doi.org/10.5334/ijic.3954.s1
• Appendix 4. Health Care Practice R&D Unit (HCPRDU) mixed methods research checklists. DOI: https://doi.org/10.5334/ijic.3954.s1
• Appendix 5. Example of using CASP RCT checklist to appraise a selected RCT. DOI: https://doi.org/10.5334/ijic.3954.s1
• Appendix 6. Example of using HCPRDU quantitative research checklists to appraise a selected quantitative study. DOI: https://doi.org/10.5334/ijic.3954.s1
• Appendix 7. Example of using HCPRDU mixed methods research checklists to appraise a selected mixed methods’ study. DOI: https://doi.org/10.5334/ijic.3954.s1
AcknowledgementsI would like to acknowledge the help of my supervisor, Ms. Alison Brettle, for her professional instructions and for walking me through all the stages during the writing-up process. She has spent a lot of time reading through the drafts and providing insightful criticism. Without her continuous encouragement and expert guidance, I would not have completed this research. I also want to express my great gratitude to my friend, Ms. Yanni Wu, who has provided great support during my study.
ReviewersDr Irene Ngune, School of Pharmacy, Faculty of Health Sciences, School of Nursing, Midwifery and Paramedicine.
Ana Rodríguez Cala, Director of Strategy and Corporate Social Responsibility at the Catalan Institute of Oncology (Institut Català d’Oncologia), Spain.
Competing InterestsThe authors have no competing interests to declare.
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How to cite this article: Zhao, Y, Brettle, A and Qiu, L. The Effectiveness of Shared Care in Cancer Survivors—A Systematic Review. International Journal of Integrated Care, 2018; 18(4): 2, 1–17. DOI: https://doi.org/10.5334/ijic.3954
Submitted: 14 December 2017 Accepted: 25 September 2018 Published: 12 October 2018
Copyright: © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.
OPEN ACCESS International Journal of Integrated Care is a peer-reviewed open access journal published by Ubiquity Press.