Cancer aftercare through the General Practice: a blended lifestyle medicine approach

Early detection and improved treatment have led to an increasing number of cancer survivors, currently 800.000 people. After the ending of the primary treatment survivors experience the negative effects of their illness and treatment. A healthy lifestyle (e.g., Smoking, Nutrition, Alcohol and Physical Activity) has potential in attenuating the effects of cancer and its treatments. Besides a healthy lifestyle may prevent cancer recurrence, other lifestyle-related co-morbidities and improves quality of life (QoL). Survivors have expressed the need for lifestyle support; only 11% manages to meet all the healthy lifestyle advice. To address survivors’ needs an online Cancer Aftercare Guide (CAG) was developed, tested and found effective in improving physical activity, and vegetable and fruit intake. After treatment survivors make a transition from oncology care back to primary care-based care. Patients voiced a need for a 'quarterback' to help guide them through the next phase of recovery - finding health after cancer and prevention of recurrence. General practice professionals (GPPs) are valued by survivors for providing aftercare and lifestyle guidance because of their established relationship and accessibility, and could be a vital part of survivorship and health after cancer. Yet, there are many barriers to lifestyle guidance being integrated into primary care such as limited appointment time and lack of relevant programs to manage lifestyle guidance. Thus, although Dutch health authorities and guidelines emphasize the value of GPPs in cancer aftercare including lifestyle improvement, it is not yet routine care. A tool to ease the integration of survivors’ lifestyle support into general practice is the aforementioned CAG. It is an online personalized self-management program on healthy lifestyle issues and other main cancer problem areas as fatigue. CAG proved its effectiveness and feasibility when offered to patients at their last hospital treatment contact. Though available online, a trigger is needed to improve reach, use and effects. We hypothesize that by combining CAG with personal face-to-face GP consultation in a blended approach, GPPs are provided with a minimal time investment tool to systematically pay attention to survivors’ lifestyle issues and other problems in a cost-effective way. Primary purpose: 1) to extend and integrate the tested online CAG into the primary care-based cancer aftercare; 2) to evaluate this blended approach primarily on acceptability and feasibility for cancer survivors and their GPPs, survivors’ reach and (cost-)effectiveness in terms of lifestyle behavior change (at 6 and 12 months follow-up). The most important secondary outcomes are biomarkers related to lifestyle change. This approach is expected to offer survivors and GPPs an accessible (cost-)effective tool to promote and sustain a healthy lifestyle and to ultimately reduce disease burden and health care costs. The project has 4 work packages (WPs): WP1 entails interviews on the organization and needed materials in the blended-care approach. Interviews will involve GPPs (e.g., GP & nurses), oncology rehabilitation specialists and survivors. Deliverables include materials and procedures to be used in blended care. WP2 concerns a pretest and pilot study on feasibility in GP practices and a sample of their survivors. WP3 includes an RCT (with GP practice as randomization level) among 381 cancer survivors to test (cost-)effectiveness, feasibility, use and appreciation of the new approach. With posttests in patients on effects (primarily lifestyle behaviors), costs (e.g., health care, productivity loss, delivery cost) and cost-effectiveness related factors (such as QoL, Qaly) after 6 and 12 months, the treatment group will be compared with an usual care waiting list control group. We will analyze GPPs’ and survivors’ experiences with the new approach, and the extent GPs/survivors used it. WP4 entails a dissemination inventory in GPPs, cancer survivors and stakeholders to list facilitating and hindering factors for broad-scale implementation of the blended approach in broad-scale primary care. Intended results: A feasible and (cost-)effective approach by which GPPs can guide cancer survivors with lifestyle changes to attenuate current and prevent future health problems. Relevance: This study will provide enormous benefits for the national prevention of health problems in cancer survivors. It increases our knowledge about blended care approaches to address lifestyle change in primary care. Blended care is expected to better fulfill cancer survivors’ needs. By combining GPP care with the CAG, cancer survivors can rely on the (medical) expertise of their GPPs and can use the CAG, 24/7, on aspects relevant to recovery. Implementation: As the project aims to provide GPPs with a tool to help cancer survivors with recovery and the prevention of further health problems, implementation will be a focus in all project WPs.