Discussion
cancers, anxiety, cancer, breast, prostate and colorectal cancer, breast, colorectal and/or prostate cancer, Cancer
CANCER, CANCERS, CANCER
In the primary care–based BETTER WISE intervention, PPs held visits focussed on prevention and screening, and including a cancer surveillance component for participants who were breast, colorectal and/or prostate cancer survivors. Visits were guided by an evidence-based general prevention and screening algorithm as well as by a cancer surveillance algorithm for cancer survivors that was based on review and harmonization of high-quality cancer survivorship guidelines. We evaluated BETTER WISE in a cluster randomized trial using two composite indices (a general composite index applicable to all BETTER WISE participants and a cancer survivor composite index only applicable to those patients who are cancer survivors), as well as through qualitative evaluation. Among our 80 cancer survivors for whom we had 12-month follow-up data (42 in intervention group, 38 in control group), differences between the two study arms were not statistically significant at 12 months; however, promising results prior to the COVID-19 pandemic suggested that pandemic-related system shutdowns likely played a substantial role in this finding. Only 17 cancer survivor participants reached the 12-month outcome prior to the pandemic being declared, which affected the power of the study to detect any between-group differences. Qualitative analysis showed that patients, PPs and physicians generally viewed BETTER WISE positively and appreciated the comprehensive, patient-centred and evidence-based approach. PPs noted that extensive time, training and experience were needed for their role to be successful to support care for cancer survivors. Some cancer survivors were not as engaged in BETTER WISE, particularly if it was earlier in their cancer journey or if they already felt well supported by their oncology team, but BETTER WISE created an opportunity to ensure cancer survivors, particularly those without a documented care plan, were receiving evidence-based cancer surveillance.Qualitative findings reinforced that the COVID-19 pandemic impacted BETTER WISE; the pandemic led to system-wide pauses and delays in prevention and screening, and to social isolation, which may have taken an even higher toll on cancer survivors. The PP visits may have been a helpful touchpoint during times of social isolation. It has been documented that cancellation and postponement of cancer testing due to the pandemic resulted in increased fear and anxiety for many patients across Canada [Family physicians play a critical role in cancer survivorship care, and studies have shown that preventive services for cancer survivors are more likely to be provided when the survivor is followed by both an oncologist and a family physicians, rather than just one or the other [This study had several limitations. First, as discussed, the timeline of our trial included a period where screening and prevention activities were put on pause at a system level, affecting our study outcome in both arms. Anecdotally, we heard from participating clinics that when screening and prevention were resumed, there was more of a focus on catching up those who were overdue, which meant our control group likely did not receive usual care. Second, this sub-analysis was underpowered. We expected a total of 295 cancer survivors but only 115 were randomized, for which only 80 provided 12-month follow-up data and only 17 provided 12-month data prior to the COVID-19 pandemic. Third, some BETTER WISE visits were conducted in person, and some were conducted virtually due to the pandemic. We do not have data to determine if one visit type performed better than the other for cancer survivors. Finally, we limited our study to survivors of breast, prostate and colorectal cancer, and did not include other cancer survivors. However, these cancers are among the most common in Canada and have multiple high-quality guidelines to guide survivorship care.In April 2020, the editors of the Journal of Cancer Survivorship published a commentary reminding healthcare providers that cancer survivors need tailored, patient-centred care during the trying times of the pandemic and beyond [