With the advancement of early cancer diagnosis and treatment modalities, the number of cancer survivors has grown totaling 38 million worldwide with 13.7 million cancer survivors in the United States (US) as of 2012. More than 2.5 million of these are breast cancer survivors, making up 18% of the survivorship population in the US and 1.5 million worldwide. Breast cancer survivors need ongoing health care during survivorship. In 2006, The Institute of Medicine (IOM) recommended that all cancer survivors, along with their health care providers, be given a survivorship care plan on completion of active treatment that incorporates cancer treatment, potential consequences, specific follow-up and preventative health maintenance information. This plan also provides information regarding employment, health insurance, and psychosocial support in the community. A survivorship care plan (SCP), when individualized and utilized effectively, may maximize health outcomes and positively impact the quality of life of breast cancer survivors.
To examine and synthesize the best available evidence regarding the impact of an individualized care plan on the quality of life of adult female breast cancer survivors.
Types of participants
This review considered studies that included adult female breast cancer survivors, 18 years of age and older.
Types of interventions
This review considered individualized survivorship care plans as the additional intervention provided to adult female breast cancer survivors receiving the standard or routine care.
Types of outcomes
The outcomes examined are quality of life as it relates to physical, psychosocial and sexual health as measured by validated and reliable tools.
Types of studies
This review considered randomized controlled studies, and then other research designs such as non-randomized control trials, quasi-experimental, cohort case control, and cross sectional studies.
The search strategy aimed to find both published and unpublished studies in the English language from 1980 to present. The databases searched were CINAHL, PubMed, Embase, PsycINFO and Cochrane Central Register of Controlled Trials (CENTRAL), Academic Search Premier, Health Source: Nursing/Academic Edition, ProQuest, Sage, and Salem Health. A search of the gray literature and electronic hand searching of relevant journals was also performed.
The studies selected for retrieval were critically appraised by two independent reviewers using the Joanna Briggs Institute's standardized critical appraisal instruments.
Data was extracted from studies included in this review using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MASTARI).
Studies were found to have significant heterogeneity between populations, interventions and outcomes. The findings are presented in narrative format as statistical meta-analysis was not possible.
One randomized control trial (RCT) and one study, consisting of two small RCTs and one pre-experimental study, were included. The single RCT found no statistically significant differences or clinically important differences between the groups that received the intervention (SCP) and the control group (no SCP) based on the outcome variables of cancer-related distress, any of the secondary outcomes, or quality of life. More of the intervention group than the control group identified the primary care provider as being primarily responsible for follow-up by a difference of 9.6% (98.7% more than 89.1%), with a 95% confidence interval (CI) 3.9 to 15.9; p = .005. All patients showed a non-clinically important improvement in the impact of event scale (IES) scores and its subscales over time.
In the second study, older breast cancer survivors aged 65 and over were recruited for three pilot studies (two small randomized clinical trials and one pre-experimental study) conducted in the US. In all three pilot studies, the breast cancer survivors' symptoms of distress significantly decreased and symptom management behaviors positively increased in the intervention group. In the third pilot study there was also a statistically significant decrease in negative mood symptoms. There was no statistically significant change in specific quality of life measures in all three pilot studies. Based on participants' very positive ratings and feedback, the intervention was assessed as feasible and acceptable.
There is a paucity of evidence on the effectiveness of survivorship care plans. In the two studies selected for inclusion, the first one found no significant difference or change in measured patient outcomes.
The second suggests that it is important to understand the older breast cancer survivor beliefs about symptoms and how these beliefs motivate the symptom management behaviors. Such knowledge could lead to better assessment and symptom management interventions when caring for older cancer survivors.
Implications for practice
An individualized SCP can promote a schedule and a pathway for breast cancer survivors to improve their quality of life and transition into an active role in their own health care. Breast cancer survivors can use an individualized care plan to acquire health care and health-promoting behaviors, and obtain appropriate psychosocial resources. In addition, the individualized care plan can be shared with health care providers to facilitate coordinated post survivorship care.
Implications for research
The research is scarce and barriers to implementation of SCPs have been identified. Utilizing and evaluating the effectiveness of the SCP has been difficult. Examining cost effectiveness needs to be considered. More research is needed that can identify strategies to transition adult breast cancer survivors and modifying lifestyle behaviors with optimal use of individualized SCPs.