Supportive and Palliative Care research group: research projects
Below is a list of research projects in the field of supportive and palliative care.
BMH - Nursing - Supportive and Palliative Care: research - Ongoing studies
Comparing telephone and hospital follow-up for women with breast cancer: A randomised controlled trial
Abstract
Background
Most recurrences of breast cancer occur as interval events between hospital follow-up visits and yet the historical practice of bringing women back to hospital clinics at regular intervals for a number of years persists. Visits are of short duration with little opportunity to discuss information needs or concerns.
Aim/Research question
This study aims to evaluate an intervention delivered by breast specialist nurses over the telephone and presents a radical shift from a medically focused model of follow-up care (looking for recurrent disease) to an information model of care that provides a quality service for patients.
Methodology description
The study was a randomised controlled trial (RCT). Patients were randomised to either telephone or hospital follow-up. A research instrument (the Information Needs Questionnaire) was adapted for use as a clinical guide to telephone appointments. In depth training to develop the role of specialist breast care nurses was provided. The study was primarily quantitative but there were a number of qualitative components as in depth interviews were conducted with patients who had experienced telephone follow-up and with specialist breast care nurses who administered the intervention.
Sample group description
The sample included patients who had completed primary treatment for breast cancer (surgery, radiotherapy, chemotherapy) and were currently well with no signs of recurrent disease. Participants were at low-moderate risk of recurrence as defined by TNM and Nottingham Prognostic Index criteria as well as consultation with medical colleagues. Participants also needed to have access to a telephone and adequate hearing ability.
Outcome measure description
Outcomes focused on information provision, psychological morbidity, patient satisfaction, time to detection of recurrence and cost effectiveness.Outcome measures were administered at 3 time points: baseline, mid and end trial.
Findings
A total of 374 study participants at two study locations were randomised to either telephone or hospital follow-up. In excess of 500 telephone appointments were conducted and audio-recorded. Data on 500+ hospital appointments were also collected. There were no differences in psychological morbidity between groups i.e. the telephone group were no more anxious as a result of foregoing clinical examination and face to face contact. Levels of patient satisfaction were significanlty higher in the telephone group. There were no significant differences in time to detection of recurrence between groups. The main findings have recently been published in the British Medical Journal (February 2009). Qualitative aspects of the study are still in the process of analysis. The study was registered with the NCRI (Trial ID 1477).
Conclusions and implications for further research
The telephone intervention was developed from a history of work in this field that established treatment decision making preferences and information needs of women with breast cancer at different stages of the disease trajectory. In this way the intervention was patient led, not health professional led. This study showed positive outcomes for telephone follow-up by specialist nurses and this innovative approach has broader applicability for other patient groups in the cancer field and beyond.
Funding body
Medical Research Council Health Services Research Award to Dr Kinta Beaver; Rosemere Cancer Foundation project grant
Members of the project
| Name | Role |
|---|---|
| Professor Kinta Beaver | Principal investigator |
| Professor Graham Dunn | Investigator |
| Professor Karen Luker | Investigator |
| Susan Williamson | Research associate |
| Sandy Foster | Research assistant |
| Mary Twomey | Research associate |
Purpose of investigation
This study evaluates an intervention designed to provide a streamlined, clinically appropriate and cost effective service that meets the needs of patients and reduces the burden on outpatient staff. The focus is on follow-up service provision for women treated for breast cancer and utilises the skills of specialist breast care nurses. The hypothesis is that a telephone follow-up intervention administered by specialist breast care nurses is equivalent to traditional hospital follow-up.
Background to the study
Traditionally patients have been asked to attend hospital clinics for routine surveillance, although medically intensive approaches to follow-up fail to impact on survival statistics or quality of life and stretch the resources of surgical and oncology departments. Patients find attendance to be anxiety provoking, expecting recurrent disease to be detected, although women themselves detect most recurrences of breast cancer between hospital visits. If hospital follow-up visits are not instrumental in detecting recurrent disease then it could be argued that visits should be an opportunity to meet the information and psychosocial needs of patients but there is little evidence to suggest that this takes place.
Rarely do studies focus on psychosocial aspects of follow-up service provision although the value of specialist breast nurses in providing psychological support for women with breast cancer has been demonstrated. There are important economic implications of senior medical staff providing routine follow-up care but economic evaluations of different follow-up strategies are few.
Follow-up service provision for women with breast cancer is medically focused on tests and investigations aimed to diagnose recurrent disease, despite a lack of evidence that routine hospital follow-up achieves this aim. This study provides an innovative means of providing follow-up care by telephone that maintains quality service provision within current resources and utilises the skills of specialist breast nurses. Telephone interventions for cancer patients have been shown to be feasible, well accepted and potentially cost effective in allowing patients to maintain their privacy and remain in familiar surroundings and may be particularly suitable for patients who are uncomfortable with face to face consultations.
Pilot work
Two pilot studies have been undertaken to inform the design and development of the current intervention study.
- Beaver K, Twomey M, Witham G, Foy S, Luker K (2006). Meeting the information needs of women with breast cancer: piloting a nurse led intervention. European Journal of Oncology Nursing. 10, 378-390
- Beaver K, Luker KA. (2005) Follow-up in breast cancer clinics: reassuring for patients rather than detecting recurrence. Psycho-Oncology. 14; 94-101
Design
The study is a randomised controlled trial with two arms: an experimental (intervention) arm in which participants receive a telephone follow-up intervention and a control arm where participants receive current standard hospital follow-up.
Sample
The sample includes patients who have completed treatment for breast cancer at two study locations. Patients were recruited from surgical and oncology clinics.
Inclusion criteria
- Patients who have a known diagnosis of breast cancer and have concluded primary active treatment (e.g. surgery, radiotherapy, chemotherapy).
- Patients who are attending outpatient clinics for the purposes of surveillance.
- Patients who are defined as low/moderate risk of recurrent disease, using criteria approved by clinicians at the current study location based on the TNM (Tumour, Node, Metastases) classification system and the Nottingham Prognostic Index.
- Patients who have access to a telephone.
The telephone intervention
The intervention is carried out by specialist breast nurses and consists of telephone follow-up at specified intervals, consistent with current hospital follow-up policy. Patients randomised to the intervention group are sent appointment cards with a date and time for their telephone appointments. The intervention tool used in pilot work was refined and developed to encompass aspects of follow-up service provision related to psychosocial and clinical aspects of care including information provision, psychosocial needs, support, reassurance and a general assessment of patients’ physical health. Standard protocols related to mammography examination were unaltered.
Outcome measures
- Meeting information needs
- Psychological Morbidity
- Time to detection of recurrence
- Cost effectiveness
Analysis
In an 'intention to treat' analysis, data are analysed according to the intervention group to which participants were randomised, whether they actually received that intervention or not. While this maintains the comparability of the groups formed by randomisation, it may result in a conservative analysis biased towards the null hypothesis of no difference between the groups in a standard comparison13. In an equivalence trial, however, the effect is to increase the chance of accepting the alternative hypothesis of equivalence between the groups. Therefore, analysis will be undertaken on both an 'intention to treat' basis and a 'per protocol' basis, where participants are analysed according to the intervention they actually received.
Outputs
- Beaver, K., Tysver-Robinson, D., Campbell, M., Twomey, M., Williamson, S., Hindley, A., ... Luker, K. (2009). Comparing hospital and telephone follow-up after treatment for breast cancer: Randomised equivalence trial. BMJ, 338(7690), 337-340. DOI: 10.1136/bmj.a3147. Publication link: 8e2c755c-7e9b-49ed-99a0-6597281d9fe7