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| ID | Type | Description | Link |
|---|---|---|---|
| IRB00110605 | Other Identifier | JHMIRB | |
| R-1410-24904 | Other Grant/Funding Number | Patient-Centered Outcomes Research Institution |
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| Name | Class |
|---|---|
| Patient-Centered Outcomes Research Institute | OTHER |
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OBJECTIVE: The purpose of this study is to identify an SCP process that is patient-centered, effective in promoting appropriate survivorship care and can be successfully implemented for patients with different types of cancer who are being treated in a broad range of clinical settings. There is a need for research related to SCP that prioritizes outcomes that are most highly valued by patients, caregivers and clinical stakeholders.
BACKGROUND: Each year, approximately 1.6 million people are diagnosed with cancer and the relative 5-year survival rate across all cancer types approaches 70%. As of 2014, there were almost 15 million Americans living with a history of cancer. Cancer survivors face a variety of health care needs, including surveillance for recurrence, treatment for long-term and late effects of cancer and its treatment, general primary and preventive care, management of any comorbidities, encouragement of healthy lifestyle behaviors, and attention to psychosocial issues. In 2005, the Institute of Medicine (IOM) report 'From Cancer Patient to Cancer Survivor: Lost in Transition' highlighted the challenges that cancer survivors face as they transition from acute treatment. The completion of acute cancer treatment is a critical juncture at which patients are in need of better support and communication to ensure optimal health and quality of life outcomes as they transition to long-term survivorship. Cancer survivors face substantial deficiencies in the quality of care that they receive, including both underuse of recommended care and overuse of services that are not recommended for routine follow-up. The 2005 IOM report called for all patients completing acute treatment to be provided with a survivorship care plan (SCP) that summarizes treatments received and outlines future healthcare priorities in order to facilitate effective management of health care between survivors and their oncology and primary care providers.
STUDY PROCEDURES: The primary aim of this trial is to assess whether there is a difference among three SCP models of varying levels of resource intensity and patients' receipt of recommended health services in the months following completion of acute treatment. The investigators will conduct a randomized controlled trial (RCT) to measure whether the provision of the SCP to the survivor and primary care provider (PCP) is associated with survivors' receipt of cancer follow-up care as outlined on their SCP (primary outcome). Avoidance of non-recommended care, receipt of recommended primary and preventive care, and patient-reported outcome measures will serve as secondary endpoints.
Participants in the RCT will have been treated for breast, prostate, or colorectal cancer. This RCT will be conducted in four oncology clinics in two medical systems. The investigators will enroll survivors of Stage I-III breast, prostate, or colorectal cancer who are completing treatment and transitioning to long-term survivorship, and use a stratified randomization to assign participants to one of three study conditions (Arms A, B or C). This study will focus specifically on the period following completion of acute treatment (e.g., surgery, radiation, and chemotherapy); patients receiving long-term adjuvant endocrine/antibody therapies will also be eligible.
The proposed trial will be conducted at Johns Hopkins Medical Institution (JHMI) and Peninsula Regional Medical Center (PRMC). JHMI is a large, academic medical center in an urban setting with distinct treatment programs based on disease site. At JHMI, the investigators will recruit from the Breast Cancer Program, the Genitourinary Cancer Program (prostate cancer), and Gastrointestinal Cancer Program (colorectal cancer). These programs operate across disciplines (e.g., medical, radiation, and surgical oncology) but separately from each other, enabling evaluation of 3 separate clinical settings within JHMI. In addition, the trial will include the PRMC Richard A. Henson Cancer Institute, a community cancer program located in the rural area of Maryland's eastern shore. At PRMC there is a single general oncology practice. The four programs differ in the extent to which survivorship care planning is already a part of routine care. As yet, none of the clinics in this study has a consistent format for the delivery of SCP universally at the completion of acute treatment. The study design (cancer types, clinical systems and SCP models) is intended to enable the development of real-world best practices for the implementation of SCPs and assess whether these are consistent or vary across a wide range of clinical contexts and survivor characteristics.
Each participant will be followed for 18 months, with the number of visits dependent on the randomization arm (described below). The investigators will abstract 18 months of follow-up data for enrolled patients from medical records, as well as from patient reports of health service use; data will be collected at months 6, 12, and 18. The investigators will obtain and abstract medical records guided by the information in the summary document (see Health Services Use Summary included as a supplemental study document) and from the patient using provided tracking tools of providers they have seen, tests they have undergone, etc. (see Tip Sheet in supplemental study documents). Patient-reported outcomes will be collected at baseline, 6, 12, and 18 months primarily via a REDCap form, with telephone or in-person data collection as a back-up when needed.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| ARM A; Care Plan Only | Experimental | SCP document delivered to the patient & Primary Care Provider |
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| ARM B; Care Plan During Visit | Experimental | SCP document provided to the patient in an in-person survivorship visit and copy sent to PCP |
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| ARM C; Care Plan During Visit + Additional Visit | Experimental | SCP document provided to the patient in an in-person survivorship visit with an additional follow-up visit and copy of the document sent to PCP |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Care Plan Only | Behavioral | Patient participants randomized to Arm A will be sent a copy of the SCP within 3 months of completion of treatment and a copy will be added to their medical record. A copy of the SCP will also be sent to the PCP on record. The SCP will be completed by a nurse, nurse practitioner, or physician assistant. The SCP will be accompanied by a cover letter that will be signed by a member of the clinical team. |
| Measure | Description | Time Frame |
|---|---|---|
| Number of Participants Compliant With Follow-up Care Visits | The primary outcome classifies patients as compliant or non-compliant based on whether they were compliant on all visits, tests/procedures, and non-oral medication recommendations included in their care plans. | 18 Months |
| Measure | Description | Time Frame |
|---|---|---|
| Number of Participants Who Received an Annual Physical Exam | This secondary outcome classifies participants as having had an annual physical exam based on medical record review. This outcome was operationalized as a dichotomous variable (received recommended primary care: yes/no). Participants were included in this analysis if they had a primary care visit recommended on their survivorship care plan. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Katherine C Smith, PhD | Johns Hopkins Bloomberg School of Public Health | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins | Baltimore | Maryland | 21231 | United States | ||
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 18792791 | Background | Beckjord EB, Arora NK, McLaughlin W, Oakley-Girvan I, Hamilton AS, Hesse BW. Health-related information needs in a large and diverse sample of adult cancer survivors: implications for cancer care. J Cancer Surviv. 2008 Sep;2(3):179-89. doi: 10.1007/s11764-008-0055-0. Epub 2008 Jun 3. | |
| Background | Dunn, R., Crowley, S., & Janz, N. (2011). Impact of a transition visit on addressing quality of life and readiness to assume greater self-management among breast cancer survivors. Psycho-Oncology, 20(S1), S91. | ||
| 17352831 |
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| ID | Title | Description |
|---|---|---|
| FG000 | ARM A (Care Plan Only) | SCP document delivered to the patient & Primary Care Provider Care Plan Only: Patient participants randomized to Arm A will be sent a copy of the SCP within 3 months of completion of treatment and a copy will be added to their medical record. A copy of the SCP will also be sent to the PCP on record. The SCP will be completed by a nurse, nurse practitioner, or physician assistant. The SCP will be accompanied by a cover letter that will be signed by a member of the clinical team. |
| FG001 | ARM B (Care Plan During a Visit) | SCP document provided to the patient in an in-person survivorship visit and copy sent to PCP Care Plan During a Visit: Patient participants randomized to Arm B will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider on record. The visit will be scheduled after consent is signed and will occur between 1 and 3 months after completion of treatment. The visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. |
| FG002 | ARM C (Care Plan During a Visit With an Additional Visit) | SCP document provided to the patient in an in-person survivorship visit with an additional follow-up visit and copy of the document sent to PCP Care Plan During a Visit with an Additional Visit: Participants randomized to Arm C will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider. The visit will be scheduled after consent is signed and will occur between 1-3 months after completion of treatment. The initial visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. Patients will also receive a follow up survivorship visit 7-10 months after the end of treatment that will focus on a review of the SCP and offer the opportunity to ask about any persistent or emerging issues. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
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| ID | Title | Description |
|---|---|---|
| BG000 | ARM A - Care Plan Only | SCP document delivered to the patient & Primary Care Provider Care Plan Only: Patient participants randomized to Arm A will be sent a copy of the SCP within 3 months of completion of treatment and a copy will be added to their medical record. A copy of the SCP will also be sent to the PCP on record. The SCP will be completed by a nurse, nurse practitioner, or physician assistant. The SCP will be accompanied by a cover letter that will be signed by a member of the clinical team. |
| Units | Counts |
|---|---|
| Participants |
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| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Number of Participants Compliant With Follow-up Care Visits | The primary outcome classifies patients as compliant or non-compliant based on whether they were compliant on all visits, tests/procedures, and non-oral medication recommendations included in their care plans. | The primary analysis was by intention to treat. To be included, participants had to have received an SCP and have data from 18 months of follow-up. Four patients (3 from Arm A and 1 from ARM C) were not included in the primary outcome analysis because there were no recommendations listed in their care plans. | Posted | Count of Participants | Participants | 18 Months |
|
18 months
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | ARM A - Care Plan Only | SCP document delivered to the patient & Primary Care Provider Care Plan Only: Patient participants randomized to Arm A will be sent a copy of the SCP within 3 months of completion of treatment and a copy will be added to their medical record. A copy of the SCP will also be sent to the PCP on record. The SCP will be completed by a nurse, nurse practitioner, or physician assistant. The SCP will be accompanied by a cover letter that will be signed by a member of the clinical team. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Katherine C. Smith | Johns Hopkins School of Public Health/SKCCC | 443.927.3350 | ksmit103@jhu.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Nov 10, 2017 | Feb 8, 2023 | Prot_SAP_000.pdf |
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| ID | Term |
|---|---|
| D009369 | Neoplasms |
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| Care Plan During a Visit | Behavioral | Patient participants randomized to Arm B will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider on record. The visit will be scheduled after consent is signed and will occur between 1 and 3 months after completion of treatment. The visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. |
|
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| Care Plan During a Visit with an Additional Visit | Behavioral | Participants randomized to Arm C will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider. The visit will be scheduled after consent is signed and will occur between 1-3 months after completion of treatment. The initial visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. Patients will also receive a follow up survivorship visit 7-10 months after the end of treatment that will focus on a review of the SCP and offer the opportunity to ask about any persistent or emerging issues. |
|
|
| 18 Months |
| Number of Participants Who Received Tests and Procedures Recommended on Their Survivorship Care Plan | These data are generated through electronic medical record review. This outcome is operationalized as a dichotomous variable (received recommended tests and procedures: yes/no). | 18 Months |
| Number of Participants Who Received Cancer-related Tests Consistent With Overuse | This analysis compared potential overuse of surveillance tests between cancer types (breast, prostate and colorectal). This outcome will be operationalized as a dichotomous variable (did not receive inappropriate care: yes/no). The outcome relates to participants who received care not specified on their care plan and on a guideline predetermined list of "not recommended surveillance. This was determined through a physician chart review. | 18 Months |
| Patient-reported Outcomes: Preparing for Life as a (New) Survivor (PLANS) | PLANS is a cancer survivorship questionnaire with 2 items specifically related to survivorship care planning. These items are 'I feel prepared for what to expect over the next year' (score range 1-4 with 4 being a more positive score) and 'There is a well-coordinated plan for my cancer care' (score range 1-10 with 1 being "Not at all confident and 10 being "Extremely confident". | 18 Months |
| Patient-reported Outcomes: Assessment of Survivor Concerns (ASC) | The outcome is a sum score of a 5-item scale with a minimum score of 5 and a maximum score of 20 with a higher score indicating greater worry (worse outcome). | 18 Months |
| Patient-reported Outcomes: Follow-up Care Use Among Survivors (FOCUS)-Information Needs Module | Questionnaire asking about informational needs on 12 topics. Responses for each question can be yes/no/not sure. Reported the total number of health needs responded to as "yes". Outcome is a sum of reported needs. Score range from 0-12 with a higher score reflecting more informational needs. | 18 Months |
| Peninsula Regional Medical Center |
| Salisbury |
| Maryland |
| 21801 |
| United States |
| Background |
| Gotay CC, Pagano IS. Assessment of Survivor Concerns (ASC): a newly proposed brief questionnaire. Health Qual Life Outcomes. 2007 Mar 13;5:15. doi: 10.1186/1477-7525-5-15. |
| 23542954 | Background | Hershman DL, Greenlee H, Awad D, Kalinsky K, Maurer M, Kranwinkel G, Brafman L, Jayasena R, Tsai WY, Neugut AI, Crew KD. Randomized controlled trial of a clinic-based survivorship intervention following adjuvant therapy in breast cancer survivors. Breast Cancer Res Treat. 2013 Apr;138(3):795-806. doi: 10.1007/s10549-013-2486-1. Epub 2013 Mar 31. |
| Background | Hewitt, M., Greenfield, S., & Stovall, E. (Eds.). (2005). From cancer patient to cancer survivor: lost in transition. National Academies Press. |
| 23021856 | Background | Kent EE, Arora NK, Rowland JH, Bellizzi KM, Forsythe LP, Hamilton AS, Oakley-Girvan I, Beckjord EB, Aziz NM. Health information needs and health-related quality of life in a diverse population of long-term cancer survivors. Patient Educ Couns. 2012 Nov;89(2):345-52. doi: 10.1016/j.pec.2012.08.014. Epub 2012 Sep 28. |
| 15893218 | Background | Mallinger JB, Griggs JJ, Shields CG. Patient-centered care and breast cancer survivors' satisfaction with information. Patient Educ Couns. 2005 Jun;57(3):342-9. doi: 10.1016/j.pec.2004.09.009. |
| 15513791 | Background | Nelson DE, Kreps GL, Hesse BW, Croyle RT, Willis G, Arora NK, Rimer BK, Viswanath KV, Weinstein N, Alden S. The Health Information National Trends Survey (HINTS): development, design, and dissemination. J Health Commun. 2004 Sep-Oct;9(5):443-60; discussion 81-4. doi: 10.1080/10810730490504233. |
| 28410187 | Background | Smith KC, Tolbert E, Hannum SM, Radhakrishnan A, Zorn K, Blackford A, Greco S, Smith K, Snyder CF. Comparing Web-Based Provider-Initiated and Patient-Initiated Survivorship Care Planning for Cancer Patients: A Randomized Controlled Trial. JMIR Cancer. 2016 Aug 30;2(2):e12. doi: 10.2196/cancer.5947. |
| BG001 | ARM B - Care Plan During a Visit | SCP document provided to the patient in an in-person survivorship visit and copy sent to PCP Care Plan During a Visit: Patient participants randomized to Arm B will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider on record. The visit will be scheduled after consent is signed and will occur between 1 and 3 months after completion of treatment. The visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. |
| BG002 | ARM C - Care Plan During a Visit With an Additional Visit | SCP document provided to the patient in an in-person survivorship visit with an additional follow-up visit and copy of the document sent to PCP Care Plan During a Visit with an Additional Visit: Participants randomized to Arm C will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider. The visit will be scheduled after consent is signed and will occur between 1-3 months after completion of treatment. The initial visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. Patients will also receive a follow up survivorship visit 7-10 months after the end of treatment that will focus on a review of the SCP and offer the opportunity to ask about any persistent or emerging issues. |
| BG003 | Total | Total of all reporting groups |
| years |
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| Sex: Female, Male | Count of Participants | Participants |
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| Ethnicity (NIH/OMB) | Count of Participants | Participants |
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| Race (NIH/OMB) | Count of Participants | Participants |
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| Region of Enrollment | Count of Participants | Participants |
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| OG001 | ARM B - Care Plan During a Visit | SCP document provided to the patient in an in-person survivorship visit and copy sent to PCP Care Plan During a Visit: Patient participants randomized to Arm B will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider on record. The visit will be scheduled after consent is signed and will occur between 1 and 3 months after completion of treatment. The visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. |
| OG002 | ARM C - Care Plan During a Visit With an Additional Visit | SCP document provided to the patient in an in-person survivorship visit with an additional follow-up visit and copy of the document sent to PCP Care Plan During a Visit with an Additional Visit: Participants randomized to Arm C will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider. The visit will be scheduled after consent is signed and will occur between 1-3 months after completion of treatment. The initial visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. Patients will also receive a follow up survivorship visit 7-10 months after the end of treatment that will focus on a review of the SCP and offer the opportunity to ask about any persistent or emerging issues. |
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| Secondary | Number of Participants Who Received an Annual Physical Exam | This secondary outcome classifies participants as having had an annual physical exam based on medical record review. This outcome was operationalized as a dichotomous variable (received recommended primary care: yes/no). Participants were included in this analysis if they had a primary care visit recommended on their survivorship care plan. | Posted | Count of Participants | Participants | 18 Months |
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| Secondary | Number of Participants Who Received Tests and Procedures Recommended on Their Survivorship Care Plan | These data are generated through electronic medical record review. This outcome is operationalized as a dichotomous variable (received recommended tests and procedures: yes/no). | Only participants who had any tests or procedures recommended on their personalized survivorship care plan were included in the analysis | Posted | Count of Participants | Participants | 18 Months |
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| Secondary | Number of Participants Who Received Cancer-related Tests Consistent With Overuse | This analysis compared potential overuse of surveillance tests between cancer types (breast, prostate and colorectal). This outcome will be operationalized as a dichotomous variable (did not receive inappropriate care: yes/no). The outcome relates to participants who received care not specified on their care plan and on a guideline predetermined list of "not recommended surveillance. This was determined through a physician chart review. | Only participants with a history of breast, colorectal, or prostate cancer were analyzed. The protocol specified that this analysis would be by cancer type, not study arm as surveillance tests analyzed were not specified on survivorship care plans. | Posted | Count of Participants | Participants | 18 Months |
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| Secondary | Patient-reported Outcomes: Preparing for Life as a (New) Survivor (PLANS) | PLANS is a cancer survivorship questionnaire with 2 items specifically related to survivorship care planning. These items are 'I feel prepared for what to expect over the next year' (score range 1-4 with 4 being a more positive score) and 'There is a well-coordinated plan for my cancer care' (score range 1-10 with 1 being "Not at all confident and 10 being "Extremely confident". | Analysis includes participants who completed the PLANS data at 18 months post baseline | Posted | Mean | Standard Deviation | score on a scale | 18 Months |
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| Secondary | Patient-reported Outcomes: Assessment of Survivor Concerns (ASC) | The outcome is a sum score of a 5-item scale with a minimum score of 5 and a maximum score of 20 with a higher score indicating greater worry (worse outcome). | Participants who completed Patient Reported Outcomes data at 18 months | Posted | Mean | Standard Deviation | score on a scale | 18 Months |
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| Secondary | Patient-reported Outcomes: Follow-up Care Use Among Survivors (FOCUS)-Information Needs Module | Questionnaire asking about informational needs on 12 topics. Responses for each question can be yes/no/not sure. Reported the total number of health needs responded to as "yes". Outcome is a sum of reported needs. Score range from 0-12 with a higher score reflecting more informational needs. | Analysis is of the participants who completed Patient Reported Outcomes data collection at 18 month timepoints | Posted | Mean | Standard Deviation | units on a scale | 18 Months |
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|
| 0 |
| 126 |
| 0 |
| 126 |
| 0 |
| 126 |
| EG001 | ARM B - Care Plan During a Visit | SCP document provided to the patient in an in-person survivorship visit and copy sent to PCP Care Plan During a Visit: Patient participants randomized to Arm B will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider on record. The visit will be scheduled after consent is signed and will occur between 1 and 3 months after completion of treatment. The visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. | 0 | 125 | 0 | 125 | 0 | 125 |
| EG002 | ARM C - Care Plan During a Visit an Additional Visit | SCP document provided to the patient in an in-person survivorship visit with an additional follow-up visit and copy of the document sent to PCP Care Plan During a Visit with an Additional Visit: Participants randomized to Arm C will receive a copy of the SCP during an in-person 'stethoscope free' visit with a nurse, nurse practitioner, or physician assistant. A copy of the SCP will be added to the medical record and a copy will be sent to the primary care provider. The visit will be scheduled after consent is signed and will occur between 1-3 months after completion of treatment. The initial visit will focus on review of the SCP content and offer an opportunity for patients to ask questions about any aspect of the plan or associated treatment and survivorship issues. Patients will also receive a follow up survivorship visit 7-10 months after the end of treatment that will focus on a review of the SCP and offer the opportunity to ask about any persistent or emerging issues. | 0 | 127 | 0 | 127 | 0 | 127 |
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