Background
Cancer survivorship has recently emerged as an important aspect of cancer patient trajectory. Cross-sectional studies and registry-based data analyses have documented that cancer survivors present with a variety of troubles that can lead to a decrease in their health-related quality of life (HRQoL). Compared to that of solid tumors (notably breast cancers), lymphoma survivorship has received little attention, but studies examining the course of morbidity in Non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) survivorship have revealed that these patients experience psychological disorders (e.g., anxiety, depression, post-traumatic stress disorder [PTSD]) [
1‐
3], delayed return to work [
4], and a subsequent decrease in their HRQoL [
3,
5]. Beside these complications, other severe concerns include the development of cardiovascular diseases and second malignancies, while relapse also remains possible, especially during the first 24-months post-therapy [
6].
Since the development of therapies to treat NHL and HL patients, the number of survivors has increased and is now estimated at 170,000 cases in the USA [
1], 38,000 in Germany [
7] and 35,000 in France [
8]. However, one of the main difficulties in managing cancer survivorship is how to detect complications such as those listed above. Addressing this requires a consideration of the role of each care provider who is in contact with cancer survivorship patients. In theory, cancer patient survivorship surveillance involves a fair and effective collaboration between oncologists, general practitioners (GPs) and potentially other specialists depending on the nature of any complications. Oncologist contact is mainly through scheduled regular visits whereas GPs mainly operate as the first point of contact for patients experiencing symptoms related or not to cancer or treatment. This so-called “shared care” model has been supported by public health decision-makers and is largely favored by GPs. However, this model has been seriously questioned on the basis of several considerations related to both GPs and hospital insufficiencies. When surveyed, GPs reported not feeling comfortable with cancer survivorship management [
9]. In general, GPs are thought to be poorly informed about the nature and risk of late complications, especially delayed adverse effects of therapies [
10,
11], and they are not familiar with the psychological and social aspects of cancer patients [
9]. Thus, it is not surprising that the majority of patients prefer to be followed-up by their oncologist rather than their GP, as has been reported for breast cancer survivors [
12]. These considerations may also explain why the shared care model is less popular in the oncologist community [
13]. However, it has become more and more evident that oncologist-based survivorship follow-up also suffers from a number of flaws since, despite being the most common model used, it appears that hospital follow-up is cursory and poorly adapted to the detection and graduation of psychological disorders, professional difficulties and HRQoL degradation [
14]. Moreover, relapse or associated diseases, if they occur, are often diagnosed outside of a review visit [
15]. Thus, the standard hospital-based protocol of appointments is possibly not the most productive and effective health care model for cancer survivorship. In a large recent survey dealing with gynecological cancer follow-up in the United Kingdom, Leeson et al. described a switching of practices, with traditional follow-up being replaced by telephone follow-up in 25 % of cases [
16].
Telephone intervention, generally performed by specialized nurses (nurse coordinators [NC]), has been used at different stages in the cancer patient trajectory, including the early steps of diagnosis (the concept of a “Patient Navigator”) [
17], during the management of advanced cancers [
18], and whilst undergoing psychotherapy treatment for PTSD [
19]. Most of these studies have shown clinical benefits. In a previous report, we described the Ambulatory Medical Assistance (AMA) project, a new modality of patient management for diffuse large B-cell lymphoma (DLBCL) patients undergoing therapy with R-CHOP or R-CHOP-derived protocols. AMA is based on scheduled appointments for patient phone calls from home with a NC during their active treatment phase. AMA has been found to be feasible and very effective in both its triage function and in saving medical time [
20]. Moreover, it appears that AMA not only generates great satisfaction among patients and caregivers but has also improved chemotherapy observance, reduced secondary hospitalization and, perhaps, decreased the toxic death rate [
20].
Based on the success of AMA, we designed the AMA-AC (Ambulatory Medical Assistance - After Cancer) model, a variant of the shared care model which is based on close collaborations between a NC and the patient’s GP for the surveillance of lymphoma survivors. The present study is based on an ongoing prospective cohort of 115 lymphoma patients treated with anthracycline-containing regimens. This study was aimed at investigating whether AMA-AC is a feasible procedure for monitoring a patient’s physical, psychological and social events during the first year after therapy.
Discussion
The aim of this prospective cohort study was to investigate the feasibility of using the AMA-AC procedure to monitor lymphoma survivors for any physical, psychological and social events that occurred during their first year after therapy. The implementation of the AMA-AC procedure showed not only that it could be feasibly used for this purpose but also that it is transferable into clinical daily practice.
All patients voluntarily entered into the study and accepted the conditions of the program, that they would be mainly monitored by their GP and the NC, with the oncologist being available only upon request. This unrestricted approval could be due to the climate of confidence established between the patient and the NC during the active phase of treatment as part of the AMA process [
20]. Indeed, we believe that AMA during the active phase (now designated as AMA1 in our institution) played an important role in the success of this AMA-AC program, and that AMA1 and AMA-AC are highly complementary (all patients enrolled in AMA-AC were initially enrolled in AMA1). The fact that the majority of our patients were well-educated and young (a median age of 55 years) may have also facilitated not only acceptance but also adherence. This selection bias could raise some concerns with respect to the generalizability of our findings. Thus, it remains possible that in a wider population a loss of adherence could occur concerning one or several components of the procedure such as attending GP appointments, taking NC calls or returning self-reported questionnaires. It is also important to note that all GPs participated in the AMA-AC, a total of 113 GPs (2 of whom each monitored 2 patients). This high rate of GP acceptance (113/113) probably reflects the motivation of GPs to contribute to survivorship management in association with the oncology hospital unit according to the “shared care” model. AMA-AC is a time-consuming procedure, requiring a mean of 55 min per quarter per patient, without taking into account the time spent by the patient in completing the auto-questionnaires (PCL and SF-36). Of these 55 min, the largest time contribution was from the NC (30 min) followed by the GP (15 min) and finally the oncologist (10 min). Compared to the standard surveillance performed in our department (a 30 min visit every 3 months for the first year, then every 6 months for 5 years), there was a significant reduction in medical time with the oncologist (30 % reduction). The fact that the total time spent for patient management in AMA-AC was higher that than of our standard surveillance procedure would be expected to correlate with the superiority of AMA-AC in gathering information of different types and from different sources. Medico-economic evaluation of AMA-AC is beyond the scope of our study. However, one can speculate that the increased total time spent for patient management might be largely counterbalanced by the decrease in transportation costs. It is also possible that the limitation of visits would result in decreased absenteeism and subsequently an improved productivity for young and professionally active patients. These questions deserve more specific investigation.
This study has shown that AMA-AC could be an effective procedure for detecting physical events during the early trajectory of lymphoma survivorship. Until now, the occurrence or persistence of morbid manifestation had not been thoroughly examined during this period by prospective studies. Our prospective study shows a high occurrence of disabling symptoms, with those related to the treatment of arthralgia as the most frequent (64 %). We also found an unexpectedly high rate of ulcer and gastritis symptoms (17 %), probably due to corticosteroids administered during the active treatment phase. The high rate of infection (about 40 %) occurred in the context of moderate or mild hypogammaglobulinemia, suggesting the presence of other mechanisms of immunosuppression, perhaps due to profound and durable B-cell depletion induced by rituximab. Sexual dysfunction was also frequent, as previously reported [
38]. However, the most disabling complication was neuropathy (24 %), as also previously reported [
39,
40].
Newly-diagnosed comorbidities were unexpectedly high, particularly cardiovascular diseases and second cancers (almost 20 % of patients). This unprecedented finding is intriguing since the majority of our patients were relatively young, in good health, with a low CCI. It is possible that comorbidities have been underestimated in the early trajectory of lymphoma patients treated with R-CHOP or R-CHOP-derived. The CT scan performed at 6 months allowed the detection of pancreatic tumours (
n = 2), asymptomatic severe biliary disease (
n = 1) and a pulmonary embolism (
n = 1). However, in terms of quality of lymphoma surveillance the CT scan was poor, in agreement with other studies which do not support the use of routine CT scan imaging for the follow-up of DLBCL [
15]. In the context of the frequent non-haematological complications observed, AMA-AC was found to be helpful in facilitating the coordination between the GP, the oncologist and the relevant specialist in order to define priorities and new trajectories. However, it is interesting to note that, in most cases, even when these complications were diagnosed by the GP, the oncologist was requested before the patient was referred to another specialist. The reason for this is that GPs tend to relate symptoms to relapse before considering the possibility of associated diseases, including the most frequent (vascular complications and second cancers). This experience places the AMA unit in a central position for general medical management, this role being reinforced by the special links established with the patient along their trajectory.
Furthermore, based on psychometric measurements it seems that AMA-AC may also be an effective procedure for detecting psychological disorders (e.g., anxiety, depression and PTSD). These complications are thought to be underestimated in cancer survivorship, mainly because hospital-based follow-up is poorly adapted. This is due in part to heavy overbooking of the oncology unit but is also related to the lack of education or even interest of oncologists in onco-psychology. This latter statement is reflected in the negative perception of patients in terms of the role of the oncologist in managing such complications [
41‐
43], and suggests the need for the development of new interventions such as AMA-AC to address the psychosocial and physical concerns throughout the course of the cancer trajectory [
41]. Our study found that 42 % of patients presented with at least one psychological disorder during the first year of follow-up. These results are in agreement with retrospective transversal and longitudinal studies dealing with both HL and NHL [
2,
3,
44‐
46]. However, our prospective study shows that the development of psychological disorders in lymphoma survivorship changes over time and that psychological support is essentially needed at the beginning of the after-cancer trajectory as has been described for other cancers including breast and ovarian cancers [
47].
AMA-AC also appears to be an effective method for monitoring social changes including absenteeism and return to work. Among the patients in employment, 73 % returned to work within 12 months. This percentage was higher in HL compared to NHL, as previously reported [
48], and this rate is also in agreement with a recent Danish registry study (1,741 patients) [
4]. Due to the relatively low number of patients monitored in our study, it is not possible to draw any conclusions about the possible role of AMA-AC in facilitating return to work. However, we found AMA-AC to help facilitate communication and coordination between oncologists, NCs, GPs and occupational health professionals, which is helpful for adapting the return to work to the patient’s physical and mental capacities.
AMA-AC appears to be a simple procedure for monitoring HRQoL in routine practice. In lymphoma patients, HRQoL has been mainly investigated through cross-sectional studies and less frequently in prospective studies. From these previous studies, it appears that up to one third of patients experience an alteration in their HRQoL which is severe compared to other cancers, some of which are more aggressive [
49], and is often enduring [
1]. The present study shows that, although HRQoL improved between M0 and M12, it remained significantly affected one year after completion of treatment in about 20 % of patients even when the PCS and MCS scores were not adjusted for age.
Multivariate analysis allowed us to identify a number of risk factors associated with the occurrence of psychological disorders. HL appears to be a significant parameter, as has previously been suggested [
50]. Female gender also appears to be an independent risk factor, as suggested by a recent meta-analysis [
51]. Lower MCS after completion of chemotherapy is also highly predictive of the occurrence of psychological disorders. These results suggest that patients with a combination of risk factors (female, advanced HL, with lower MCS after therapy - in most cases associated with poor tolerability) would benefit from adequate psychological support during the early trajectory.
Our study suffers from several limits. First, our cohort presented some degree of heterogeneity in terms of histology subtype, chemotherapy and risk of relapse, even though all patients presented with advanced diseases and were treated with prolonged anthracycline-based chemotherapy. Moreover, several characteristics reflect a patient selection bias such as age, education level and fitness. These parameters, as well as the introduction of AMA1 in our institution, may have affected the acceptance and adherence to the AMA-AC procedure. The next step in determining the usability of AMA-AC is to assess the medico-economics and to conduct a satisfaction survey for patients and GPs. We are currently performing several studies to investigate these important aspects.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
GC, GL, FD and MR participated in the study design. GC, GL, LO and CR collected data. GC and MR controlled the database. MR, SL, and GC performed data analysis and interpreted the results. CG, GL, MR, SL and FD prepared the manuscript draft. GC, MR, SL, GL, LO, CR, MLM and FD revised the manuscript. All authors read and approved the final manuscript.