1. Putting it all together: Personalized care
for cancer survivors
Carrie Tompkins Stricker, PhD, CRNP,
AOCN®
Chief Clinical Officer
On Q Health, Inc.
Oncology Nurse Practitioner
Penn’s Abramson Cancer Center

2. Disclosures
• On Q Health, Inc.
– Officer and stock owner

3. Objectives
• Identify barriers to the delivery of quality
care for post-treatment cancer survivors
• Identify at least two strategies to overcome
these barriers

4. http://seer.cancer.gov/csr/1975_2008/http://seer.cancer.gov/csr/1975_2008/,,
Why care about cancer survivorship care?
**13.7million*13.7million*
as of 1/1/12as of 1/1/12
•Myriad potential long-term & late effects ofMyriad potential long-term & late effects of
treatmenttreatment
•Prevalent unmet needsPrevalent unmet needs
•Gaps in quality and coordination of careGaps in quality and coordination of care
•Work force issues will exacerbate problemsWork force issues will exacerbate problems

5. Cancer Survivorship Care
Hewitt, Greenfield, & Stovall (2005).Hewitt, Greenfield, & Stovall (2005). From Cancer Patient to Cancer Survivor: Lost inFrom Cancer Patient to Cancer Survivor: Lost in
Transition.Transition. The National Academies Press: Washington, D.C.The National Academies Press: Washington, D.C.

6. Why the unique emphasis on
cancer survivorship care?

8. Background
• Cancer survivors have unique needs
– Less contact with oncology team during the
survivorship period
– Complex medical and non-medical issues
• Symptoms, function, recovery, late effects
– Many needs remain unmet in current
health care system
– Coordination of care for cancer survivors
remains problematic
• Under- and over-utilization of services
- Ganz PA, Casillas J, & Hahn EE (2008). Ensuring Quality Care for Cancer Survivors: Implementing the
Survivorship Care Plan. Seminars in Oncology Nursing 24(3): 208-217
- Hewitt, Greenfield, & Stovall (2005). From Cancer Patient to Cancer Survivor: Lost in
Transition. The National Academies Press: Washington, D.C.; - Grunfeld & Earle, 2010.

9. Survivorship care:
What are its components?
• Prevention of new & recurrent cancers, and of
other late effects
• Surveillance for cancer recurrence, or second
cancers; assessment for medical and
psychosocial late effects
• Intervention for consequences of cancer & its
treatment, including symptoms and medical &
psychosocial problems
• Coordination between specialty & primary
care
•Institute of Medicine & National Research Council, 2006Institute of Medicine & National Research Council, 2006

10. Survivorship care
• How are we doing?

11. Cancer symptoms are prevalent &
inadequately managed
• N = 158 diverse survivors
(M = 4.1 years from Dx)
• >95% experience > 1
symptom
– Average = 10 symptoms
• Symptoms were identified
in most but
undermanaged
– 50% had little to no
improvement in outcomes
after discussion
– Only 8% were referred to
supportive care services
Palmer, Jacobs, Mao, & Stricker (2012).

12. Identifying Potential Solutions

13. IOM Recommendation #1:
• Health care providers… & other
stakeholders should work to raise
awareness of cancer survivors needs…
and act to ensure the delivery of
appropriate cancer survivorship care

14. IOM Recommendation #2:
“Patients completing primary treatment should be
provided with a comprehensive 1) treatment
summary & 2) follow-up (survivorship) care plan
that is clearly and effectively explained.”
– Cancer type, treatments, complications, & (potential)
consequences, incl. late effects
– Timing, content, & coordination of follow-up care,
surveillance, & recommended health promotion
– Resources & referrals, incl. psychosocial services
•Hewitt, Greenfield, & Stovall (2006).Hewitt, Greenfield, & Stovall (2006). From Cancer Patient to Cancer Survivor: Lost inFrom Cancer Patient to Cancer Survivor: Lost in
•Transition.Transition. The National Academies Press: Washington, D.C. (p. 151).The National Academies Press: Washington, D.C. (p. 151).

15. Survivorship Care Plans
Mandatory for Many by 1/1/15
• 71% of cancer patients are treated in CoC
accredited centers
• Commission on Cancer (CoC) Standard 3.3
– Published implementation date of Jan 1, 2015
– The cancer care committee develops and implements
a process to disseminate a comprehensive care
summary & follow-up plan to patients with cancer
completing cancer treatment
• Updated on 9/9/14
– 10% of all patients by 1/1/15, 100% by 1/1/19
– Focus on high volume malignancies first
•Commission on Cancer, 2011. Cancer Program Standards: Ensuring Patient – Centered CareCommission on Cancer, 2011. Cancer Program Standards: Ensuring Patient – Centered Care

16. Commission on Cancer
Standard 3.3 (updated 9/9/14)
• A survivorship care plan
– Is prepared by the principal provider(s) who
coordinated the oncology treatment
– Is given to patients who have completed active
therapy with curative intent
– Contains a record of care received, important
disease characteristics, and a written follow-up
plan
• ASCO data set will be the minimal content for the
treatment summary and survivorship care plans required
by Standard 3.3.
•Commission on Cancer, 2011. Cancer Program Standards: Ensuring Patient – Centered CareCommission on Cancer, 2011. Cancer Program Standards: Ensuring Patient – Centered Care

17. CoC Standard 3.3:
Necessary data elements defined by
ASCO 2014
http://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdfhttp://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdf

18. ASCO Treatment Summary
- now with less granularity
http://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdfhttp://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdf

19. ASCO updated treatment
summary data elements
• Stage of disease at diagnosis (e.g. I-III)
• Surgery (yes/no)
– If yes, location, date (MM/YYYY)
• Chemotherapy (yes/no)
– If yes, individual names of agents; end date(s)
(MM/YYYY)
• Radiation (yes/no)
– If yes, anatomical area; end date(s)
(MM/YYYY)

20. ASCO Follow up Care Plan
- now more emphasis on a personalized plan
• Oncology team member contacts
• Schedule of follow up visits*
• Cancer surveillance tests for recurrence
• Cancer screening for early detection of new primaries
• Possible symptoms of cancer recurrence to report
• Late- and/or long-term effects (symptoms to report)
• A list of items (e.g. emotional or mental health,
parenting, work/employment, financial issues, and
insurance)
• Health behaviors and promotion
•*who, how often, and where*who, how often, and where

21. Survivorship care planning resources
• American Society of Clinical Oncology
– Treatment plan and summary templates
• Breast, colorectal, & general cancer templates
• www.asco.org/treatmentsummary
• Journey Forward
– http://www.journeyforward.org/
• LIVESTRONG Care Plan
– http://www.livestrongcareplan.com
• Commercially available software
– On Q Health, Equicare CS

22. Survivorship care plans (SCPs):
Time-consuming & inefficient
• Study evaluating SCP delivery in n = 13
academic & community cancer centers
– Reach
• 61.5% of sites serve <10% of breast survivors
• Little focus on symptoms, genetics, coordination of
care; most on treatment summary (TS)
– Average time to prepare/deliver SCP
• 2 ½ - 3 hours per patient
• Much of this in TS creation & in personalization
of SCP
•Stricker C, Jacobs L, Risendal B, et al: Journal of Cancer Survivorship 5:358-370, 2011.Stricker C, Jacobs L, Risendal B, et al: Journal of Cancer Survivorship 5:358-370, 2011.

23. Survivorship care plans (SCPs):
“Helpful, but not good enough”
• Key patient perspectives on SCPs
delivered in the same study (n = 210)
– Information helpful; “wish I had received it
sooner”
– So much information is overwhelming
– Desire for more personalized information
– Need for more actionable information
• What to do, what to report
Unpublished data; Stricker, Jacobs, Palmer et alUnpublished data; Stricker, Jacobs, Palmer et al

24. Expanding our vision of survivorship
• Cancer survivor (NCCS definition)
– Anyone diagnosed with cancer, from the
time of diagnosis and for the balance of life
• Many critical “survivorship” issues must
be addressed from time of diagnosis
– e.g., fertility, genetics, education about
potential symptoms and late effects

25. IOM Quality Care Report
“Patient Engagement - Goal 1
– "The cancer care team should collaborate with
their patients to develop a care plan that reflects
their patients' needs, values, and preferences,
and considers palliative care needs and
psychosocial support across the cancer care
continuum
– The cancer care team should communicate and
personalize this information for their patients at
key decision points along the continuum of
cancer care, using decision aids when available

26. Quality care across the cancer
care continuum
• Innovative solutions are needed

27. The On Q Care Planning System (CPS)TM
allows
cancer teams to deliver personalized care plans to
patients in real-time
•Aligned with national quality standards, including
CoC accreditation mandates
•Drive patient engagement and quality outcomes,
clinician efficiency, and lower costs
To deliver our care plans, we collect patient-
reported outcomes (PROs) and clinical information for
use by our proprietary rules engine
•3030
New solution: On Q Health, Inc.

28. Enters limited clinical data*
On Q Rules Engine App generates
CDS for oncologists via a customized
draft patient care plan
that incorporates relevant oncology
quality standards, current research
On Q Rules Engine App generates
CDS for oncologists via a customized
draft patient care plan
that incorporates relevant oncology
quality standards, current research
•PROPRIETARY & CONFIDENTIALPROPRIETARY & CONFIDENTIAL •3131CDS = Clinical Decision Support
*Temporary solution until HL-7 interfaces are available.
Patient completes a
disease and
treatment-specific
questionnaire on a
mobile device at
each visit.
Care Team
Patient
Oncologist finalizes
and nurse counsels
patient on care plan
recommendations
What is the On Q CPS™?
Patient e-reports outcomes of
previously recommended
interventions.
Patients to receive a care plan
at each clinical encounter with
their oncologist.

29. • On Q CPSTM
care plans helps drive quality
across the cancer care continuum, from
diagnosis through survivorship and palliative
care
– On Q surveys and care plans are sensitive to
context of cancer type, treatment, and point in
the care continuum
– On Q surveys integrate patient goals, concerns,
and preferences
– On Q care plans offer localized resources
•3232

30. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3333
On Q CPSTM
continuously updates
evidence-based content
Professional Society Guidelines Patient Education and Resources

31. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3434
•
On Q CPS™ drives adherence to most
quality initiatives

32. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3535
•For select topics, On Q offers accredited training for our clinician usersFor select topics, On Q offers accredited training for our clinician users
On Q CPS™ covers 65
symptoms/supportive topics…and
expanding

33. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3636

34. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3737

35. • On Q offers survivorship care plans as one
component of its care planning system
• How are On Q survivorship care plans different?
– Highly personalized based on individual patient data
– Prospective, longitudinal; tracks adherence
– Bulleted key points, not text heavy; links to more
comprehensive patient education materials
– Comprehensive and continuously updated content
library
– In addition to survivorship care plan, provides
supportive care plan for active issues
•CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3838
On Q Survivorship Care Plans

36. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •3939
On Q CPSTM
Treatment Summary

37. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •4040
On Q CPSTM
surveillance plan is
directive and highly customized

38. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •4141
On Q CPSTM
Late effects education
is personalized and succinct

39. • Other aspects of On Q survivorship care plans
– Customized education about potential late effects
for which individual survivor is at risk
– Health promotion
• Health behavior recommendations
• Health maintenance (e.g., other cancer screenings and
non-cancer screenings)
– Complementary supportive care plan for active
management of existing symptoms and supportive
care issues
•CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •4242
On Q CPSTM
Survivorship Care Plans

40. •CONFIDENTIAL AND PROPRIETARYCONFIDENTIAL AND PROPRIETARY •4343
On Q CPS Helps to Address Cancer
Care Challenges
Quality In = Quality Out

41. Conclusions
• Cancer survivorship begins at the time of
diagnosis, despite it being a distinct phase
of the cancer care trajectory
• Cancer survivors experience myriad unique
needs that often remain unmet
– Capturing survivors voices is imperative
• Systematic yet personalized approaches
are needed to improve quality
• Nurses are well prepared to play a critical
role in improving cancer survivorship care &
outcomes