Post-treatment planning for patients affected by lung cancer

This audit focuses on post-treatment planning for patients who have been diagnosed with lung cancer and completed active treatment with curative intent. All patients who are post-treatment for lung cancer should have a post-treatment plan in place.

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Published: 29 October 2021

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This audit focuses on post-treatment planning for patients who have been diagnosed with lung cancer and completed active treatment with curative intent. All patients who are post-treatment for lung cancer should have a post-treatment plan in place.

Transitioning from active treatment to post-treatment care is an important milestone in the long-term health of people with lung cancer, and consistent follow-up and surveillance is necessary to ensure equitable outcomes for those who have undergone curative-intent* treatment. However, there is variability in the provision of this care across the country, with many potential contributing factors, including:

  • Patient/whānau: co-morbidities, priorities and preferences, geographical and social isolation
  • Clinical pathway: expected or unexpected health complications
  • Cancer: histology, stage and prognosis, effectiveness of adjuvant and second-line interventions and surveillance
  • Access: availability of resources or services
  • Co-ordination: strength of links between tertiary, secondary and primary health services and community support services

* Curative-intent treatments in New Zealand include surgery, radical radiotherapy (including stereotactic ablative radiotherapy) or chemoradiotherapy (not always given with curative intent)

While follow-up of people treated for lung cancer has traditionally taken place in secondary care, in many instances this can be provided in the community, e.g. by a general practitioner or nurse practitioner, or via outpatient services with a clinical nurse specialist. One of the benefits of primary care-led follow-up is the provision of “survivorship” care that encompasses the patient’s cancer-related care, as well as management of co-morbidities and other health and wellbeing needs, including lifestyle interventions (e.g. smoking cessation, reducing alcohol intake, improved diet) and psychological support. Potential issues with primary careled follow-up include the time constraints on general practice and additional cost to patients of primary care appointments, which can be a significant factor. Telephone or virtual followup with a practice nurse at reduced cost may help to mitigate this.

For further information see “Lung cancer follow-up and surveillance: the role of primary care” available from https://bpac.org.nz/2021/lung-cancer-surveillance.aspx

Important criteria for a post-treatment plan for patients affected by lung cancer

The main goals of post-treatment care are to:

  • Prevent and detect recurrent or new cancers to enable timely and appropriate management
  • Prevent, identify and manage medical and psychosocial late or chronic effects of cancer and cancer treatment
  • Co-ordinate care between all providers to ensure the patient’s needs are met
  • Help the patient to gain greater independence and selfmanagement of their ongoing health and wellbeing

One approach for ensuring that patients are appropriately followed up is to establish a patient-specific post-treatment plan:

  • The primary care provider and patient should have access to a treatment summary – On completion of cancer treatment, it is the treating specialist’s responsibility to share a copy of the patient’s treatment summary with their primary care provider (this should be able to be accessed electronically via a shared record storage system); a plain language summary should also be provided to the patient and their family/whānau.
  • All patients should have a chest X-ray three months post-treatment – This is recommended by the National Lung Cancer Working Group and the chest X-ray should be reviewed by the treating specialist.
  • Physical symptoms and overall health are assessed and appropriate pharmacological inventions are initiated if required – This includes regular review of symptoms and signs that may indicate recurrence and need for further investigation, and review and management of any co-morbidities. Encourage appropriate lifestyle interventions (e.g. smoking cessation, reducing alcohol intake, improved diet) and recommend vaccinations, including annual influenza vaccination and COVID-19 vaccination.
  • Psychological symptoms and cognitive changes are considered – People who have undergone treatment for cancer may experience psychological symptoms such as fear of recurrence, insecurity about their future, guilt or shame, distress, depression and anxiety. Cognitive changes, including difficulty concentrating and short-term memory loss can be associated with chemotherapy.

In addition to these items which form this audit, whānau should be involved in the post-treatment plan. Check and document that the patient and their family/whānau Clinical Audit | Post-treatment planning for patients affected by lung cancer | 3 understand the diagnosis and treatment, that prognosis that has been discussed and if any advance care planning is in place. An ongoing follow-up plan should also be in place which should include the providers involved, the frequency/ duration of follow-up (typically five years) and clear lines of responsibility.

Summary

This audit focuses on whether a post-treatment plan was established for patients who have completed curative treatment for lung cancer.

Recommended audit standards

For the purposes of this audit, 100% of patients affected by lung cancer who have completed active treatment should have a post-treatment plan documented in their notes. This may not be achieved on the first cycle of the audit but should be the aim for the second cycle.

Eligible people

Any patient who has been diagnosed with lung cancer and has transitioned from active treatment to post-treatment care is eligible for this audit.

Identifying patients

You will need to have a system in place that allows you to identify eligible patients who have been diagnosed and treated for lung cancer and audit their clinical notes. Many practices will be able to identify patients by running a “query” through their PMS system, initially searching for all patients with lung cancer as a diagnosis. The clinical notes will need to be checked to identify those patients who have completed treatment.

Sample size

For the purposes of this audit, all eligible patients should be included.

Criteria for a positive result

You will need to access and review your patients’ clinical notes to complete this audit. For a positive result, each patient’s notes should include documentation of:

  • Receipt of a treatment summary
  • A chest X-ray three months post-treatment or a scheduled appointment
  • Physical symptoms and overall health are regularly assessed
  • Psychological symptoms and cognitive changes have been considered

Any patient whose notes do not contain the information described above should be flagged for review. Aim for a higher number of positive results in Cycle 2.

Data analysis

Use the sheet provided to record your data. A positive result is any patient post-lung cancer treatment who has evidence in their clinical notes of comprehensive treatment plan, as demonstrated by a “YES” in column E (which encompasses the criteria detailed in columns A–D). The percentage achievement can be calculated by dividing the number of patients with a positive result by the total number of patients audited.

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • Identifying barriers can provide a basis for change
  • What is achievable – find out what the external pressures on the practice are and discuss ways of wdealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practitioners complete the first part of the CQI activity summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder of the Audit of Medical Practice summary sheet.

Claiming credits for Continuing Professional Development (CPD)

This audit has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for 10 CME credits for a first cycle and 10 CME credits for a second cycle for Continuing Professional Development (CPD) purposes. The second cycle is optional and only two cycles are permissible.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the CPD Online Dashboard, under the Audit of Medical Practice section. From the drop down menu select “Approved practice/PHO audit” and record the audit name.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).
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