Nurse-led virtual prostate cancer clinic for survivorship care: Qualitative study of patient experiences and needs

doi:10.21203/rs.3.rs-2925273/v1

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Nurse-led virtual prostate cancer clinic for survivorship care: Qualitative study of patient experiences and needs

https://doi.org/10.21203/rs.3.rs-2925273/v1

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Background: Prostate cancer survivors (PCa) can experience a range of unmet needs over a long horizon of survivorship. Thin healthcare services and specialist-led follow-up care models may not adequately address these needs. Digitally mediated nurse-led virtual care models may help support PCa survivors who have unmet survivorship needs in current healthcare systems.

Methods: This qualitative descriptive study explores 10 patients’ experiences with follow-up and virtual care, informing the design of a nurse-led virtual clinic (the “Ned Nurse” Clinic) to provide integrated healthcare services.

Results: Patient follow-up care experiences included uncertainty regarding care gaps despite new telemedicine modalities and the need for personalized wellbeing support. Patient recommendations for virtual care related to improving integration of existing care connections, supporting patient self-management, and addressing accessibility. Patients anticipate nurse-led PCa virtual care will: (1) clarify patient and provider roles and responsibilities; (2) improve care ease and access to care; (3) enhance mental wellbeing, and (4) reinforce continuity of care. Conclusion: Patients are keen to benefit from the flexibility and increased resources that digital health may provide, but remain concerned about digital literacy and service changes to support these innovations. Future work should evaluate the efficacy of digitally mediated nurse-led virtual care models to support PCa survivorship.

Health sciences/Health care/Health services

Health sciences/Urology/Prostate

digital health

prostate cancer

cancer survivorship

human-centred design

implementation

service design

self-management

patient participation

supportive care

technology

symptom management

quality of health care

delivery of health care

Healthcare services for prostate cancer (PCa) can better support PCa survivors through improved symptom management. Through digital health, nurses can oversee and provide more timely intervention. This study explored ten PCa patient experiences with follow-up care to inform how virtual care can provide better PCa support through a new nurse-led virtual clinic (“Ned Nurse”). Our results demonstrate that patients see value and potential in digitally-mediated nurse-led care to improve communication, clarify patient and provider roles, improve access to care, reinforce continuity of care, and provide enhanced mental wellbeing support. Patients also highlight the need for digital literacy considerations. This type of approach may improve quality of life and PCa follow-up care while extending the reach of resource-constrained healthcare systems.

Prostate cancer (PCa) is the most common non-skin cancer diagnosis for males in the US and Canada ^1,2. The 5-year survival rate is estimated to be 91% in Canada ³, indicating that survivorship care is a major focus of ongoing management and an increasing burden for thin healthcare services. After diagnosis and treatment, patients are transitioned to survivorship care which focuses on monitoring for disease recurrence, as well as assessing and managing treatment-related side effects in a timely manner. One challenge is that monitoring for disease recurrence may not focus enough on quality of life assessment and improvement strategies, which can be isolating and psychologically distressing ^4,5. A second challenge is that survivors often experience multifaceted physical and psychosocial side effects associated with PCa treatment (e.g., urinary function and incontinence, sexual dysfunction, bowel function, anxiety, and depression ⁶). Navigating dialogue about these needs, especially those related to psychological and sexual function concerns, can be awkward and difficult for survivors and caregivers ⁷. Survivors continue to report unmet needs at least 15 years post-diagnosis, which can result in wide-ranging effects to their quality of life ⁷.

These complex, unmet survivorship care needs can be compounded by existing systemic issues, including heavy reliance on a limited pool of specialist clinicians, unclear transitions of care after surgery or radiation, and limited time and scope of follow-up visits which cannot thoroughly address quality of life and psychosocial issues ⁸. Digital health interventions have provided an added opportunity to advance sustainable cancer survivorship care ⁹. Nurse-led digital health innovations have shown to target these gaps in unmet survivorship care needs by broadening the available skilled provider pool beyond specialists for patient-facing care (e.g., symptom monitoring, management, and psychosocial support ^10–13). However, equitable access to care continues to be an issue within both conventional specialist-led and virtual care services, as structural barriers (e.g., socioeconomic status, immigration status, neighbourhood disadvantage, geographic location) can prevent patients from accessing timely care ^14,15. Additionally, the digital divide, which are differences between those who have digital literacy and digital access and those who don’t, can compound these difficulties ^16,17. In relation to virtual care, the digital divide often affects communities that have been historically marginalized by the Canadian healthcare system, creating broader implications for health equity ¹⁸. These factors have resulted in high unmet needs across a multitude of domains ¹⁹.

In response to this problem, a consortium of patients, clinicians, and researchers at the University Health Network in Toronto, Canada designed and implemented a virtual follow-up care platform known as the Ned Clinic ¹⁰. We previously described healthcare professionals’ (HCP) perspectives about the challenges of current follow-up care models ²⁰. We sought their visions for a possible nurse-led model of care that incorporated scheduled wellness surveys, self-management strategies, and nurse-led care for patients to buttress the existing specialist model and improve patient quality of life. This paper focuses on the patient perspective to inform the design, development, and implementation of a virtual nurse-led model of care aimed to answer the following three research questions:

What are patient experiences and unmet needs related to PCa follow-up care?

What are patients’ experiences with and impressions of virtual PCa care?

How would patients prefer their needs and preferences to be integrated into a virtually-delivered nurse-led model of PCa digital care?

Conceptual framework and study design

This qualitative descriptive ²¹ study employed principles of human-centred design (HCD) to develop a pragmatic service grounded in user needs ²². We adopt the stance that service design is equally important and recursive to the technology and implementation processes that are critical to delivering and sustaining healthcare innovations into practice ²³. The Consolidated Framework for Implementation Research (CFIR, a determinant framework) and Proctor et al.’s implementation outcomes framework were applied to analyze patients’ stories of their experiences with follow-up care and virtual care ^24,25. The application of these frameworks allowed us to identify possible indicators for implementation success and important considerations for the Ned Nurse service design from the patient perspective.

Approval was obtained through Clinical Trials Ontario (CTO) with the UHN Research Ethics Board as the Board of Record (Project ID: 3238). This approval is a part of the larger CTO project portfolio, which maintains ethical oversight for all applicable activities associated with the Ned Nurse research programme.

Sampling

A convenience sample of 10 participants was taken to achieve thematic saturation, defined as “the degree to which new data repeat what was expressed in previous data”²⁶. Recruitment was performed through two pathways. Clinical site leaders at our participating sites in Ontario (University Health Network, Trillium Health Partners, and Niagara Health System) introduced the study to eligible patients. We also partnered with an external patient partner group to introduce the study and invite interested survivors to participate. Participants were deemed eligible for study participation if they self-defined as survivors of prostate cancer, were over 18 years of age, and could speak English. They were connected with our research coordinator, who introduced the study and obtained informed consent.

Data collection and analysis

Participant recruitment, informed consent processes, and data collection were conducted virtually. Data was collected via semi-structured interviews, each lasting about 60 minutes. Interviews were audio-recorded, then transcribed verbatim via transcription software (Microsoft Word, Redmond, Washington). Resulting transcripts were checked for accuracy by a member of the research team. The interview guide is available in Appendix 1. Demographic data was collected via the REDCap (Research Electronic Data Capture; Vanderbilt University) tool hosted at UHN, then analyzed via descriptive statistics (i.e., means and frequencies). The qualitative data analysis procedure and the positionality of the analysis team are reported in more detail in our previous paper describing the HCP perspective complement ²⁰. A brief summary is included here. Interview transcripts were analyzed via content analysis by three members of the research team ²⁷. The codebook was collaboratively generated, then iteratively refined during analysis via consensus discussions. We aimed to understand patient experiences and unmet needs with PCa follow-up care, while contextualizing their perceptions of the acceptability, appropriateness, and adoption (i.e., Proctor outcomes) of a potential nurse-led PCa virtual follow-up care system ²⁵. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines ²⁸ is used to guide reporting of the study results.

Our results are organized as follows. First, we provide context through an overview of sample demographics and patients’ qualitative self-assessment of their usage and comfort with digital health tools. Second, we describe patients’ uncertainty stemming from the current standard of follow-up care, persisting structural gaps despite new modalities for communication, and how patients actively manage their wellbeing but desire more system support. Third, we describe patients’ perceptions of the appropriateness, acceptability, and feasibility of the Ned Nurse clinic, and the need to support patient self-management.

Participant demographics and digital device use

The average age of participants was 66 years old. The majority of participants self-identified as white (n = 7, 70%), while a smaller number identified as Black or Asian (n = 3, 30%). All were retired and in married or common-law relationships. All participants felt generally comfortable with their digital devices, with a preference for desktops and laptops (n = 6, 60%). They frequently used their digital devices for seeking information (n = 10, 100%), storing information (n = 10, 100%), communicating (n = 8, 80%), scheduling (n = 8, 80%), and leisure activities (n = 8, 80%). Half of the participants (n = 5, 50%) also used their devices for health services.

The current standard of follow-up care creates uncertainty for patients

Participants perceived that standard follow-up care encompassed scheduled visits with their specialists (e.g., oncologists, urologists, surgeons) with bloodwork measuring prostate specific antigen (PSA) levels, which is standard clinical protocol in Ontario ²⁹. These visits previously occurred in-office, but largely transitioned to telemedicine (i.e. phone calls or video-conference) during the COVID-19 pandemic. In some cases, a significant portion of active surveillance was conducted by general practitioners, who acted as the first point of care for symptom assessments. Patients felt reassured by the anchoring of the visits, as they acted as confirmation from a trusted medical professional in regards to their prostate cancer status.

“I guess it's just the reassurance you hear from doctors. Although I know what my PSA was, that's fine. It's also good to hear reassurance from the medical professional.” - P002

However, they also felt a lack of clarity on several key care expectations, which affected their perception of the quality of care they received. Some communicated that they were frustrated with unclear timelines for the resolution of symptoms, especially if these symptoms persisted years after they finished treatment. Disappointment and anger were expressed when patients felt that their concerns were dismissed by their provider. They were frank about the perceived inadequacies of their care. These included different patient-provider expectations for treatments for side effects, different perceptions of symptom severity and quality of life impact, unclear timelines for the recovery of physical function, and ambiguity regarding the responsibility to coordinate care communication and health record documentation.

“I would like to have known what was going to happen after in a lot more detail... [my specialist] said, you're going to have some trouble with erectile dysfunction. You're gonna have trouble with incontinence but all bodily functions will return over a period of time... but there's no timetable given for that." - P006

Systemic gaps persist despite new telemedicine modalities

One benefit of telemedicine spotlighted by participants was the ability to communicate with their specialist in new ways beyond in-person visits. Patients believed that enhanced communication pathways would increase their access to their specialist - particularly valuable for participants living in rural or remote settings. Additionally, asynchronous methods of communication (e.g., email) and access to blood work requisitions without an in-person visit were deemed more efficient.

“Because of COVID, I guess everything we do right now is, initially there's an email. You send an email and … we get a very quick response. Like within a day or so if not the same day.” - P008

“When I have my PSA I'm subscribed to like I do it through Life Labs so ... I don't wait for the doc... I just go on and get it right away.” - P010

Although increased access was identified as a benefit of telemedicine, participants continued to report that they experienced gaps within the current healthcare system, including a general impression that there were insufficient resources to deliver high quality care. Some participants attested that long wait times for follow-up appointments continued to persist. Additionally, the focus on recurrence persisted through the move to telemedicine. This was compounded for those with infrequent (e.g., annual) follow-ups, who generally reported more negative experiences and perceptions about their care.

“I would say [the telemedicine visits are] a minute, but let's be charitable - two or three minutes. …I mean, it's it's basically ‘Your numbers are your numbers. Your numbers have been good. Do you have any problems? No, I don't have any problems right? Yeah thanks’” - P010

Patients manage their wellbeing but desire more systemic support

Within the current specialist-led system, patients noted that symptom self-management was an informally-communicated responsibility that they learned about from peer support. They felt that symptoms and after-treatment effects (e.g., erectile dysfunction, incontinence) were ignored unless they persistently sought provider attention.

“The biggest thing I learned again through my support group was... the hospital will spend the time with you, but it's up to you [to ask questions].” - P002

“The one thing that having been involved in a, uh, with peer support groups is that you learn an awful lot about being your own best advocate.” - P010

Moreover, participants reported “roller-coaster” psychological needs during the cycle of diagnosis, treatment, and follow-up care for PCa. Anxiety and worry about cancer recurrence were most frequently mentioned. Typical coping mechanisms included mindfulness and keeping an optimistic mindset.

“I would be really stressed out and then I would have my PSA test and then I would be even more stressed out waiting for the results and then I would get the results and then I would sort of come back down off the ledge ... it was sort of through psychotherapy and through self-reflection and evaluation, I decided I didn't want to be on that roller coaster every three to six months... I'm just gonna live today and live healthy today.”-P004

Participants were mindful of the “value in taking responsibility for your health” (P001). They reported that they strived to maintain healthy habits (e.g., exercise, diet, mindfulness, weight control, adequate sleep, family and social participation). This also included increasing their knowledge about living a healthy lifestyle, changing unhealthy behaviours, careful examination of medication intake, and making shared decisions with their HCPs. In particular, they described the need for connection and community through social support from family and the PCa survivor peer community.

“Especially that we're on things like quality of life which unfortunately, and you know, they I don't think the industry covers that completely. Everyone talks a good game, but it's not really covered...” - P001

“Surprisingly, when you share [your diagnosis] we find out about all the other people who has had prostate cancer or knows someone who's had prostate cancer.” - P004

Virtual care through a digital therapeutic: Assessing patient readiness

Patients want a nurse-led model to incorporate existing care connections

Patients perceived the Ned Nurse clinic as an acceptable care model and expressed their interest in the value added through this service. They hoped that this systemic change would increase the system’s ability to provide holistic care and wellbeing support.

“What I'm hoping in this Ned is that the nurse practitioner would then take an interest in the well-being of the patient. You know, I can actually discuss what I'm going through and feel that there is going to be some follow up.” -P001

These favourable perspectives also come with important considerations about personal preferences regarding the modality of their visits and strategies to manage continuity of care. Some expressed that they would be comfortable with only seeing a nurse, but would prefer one nurse for continuity of care rather than several staff rotating through the position. Others wanted to involve their specialist in their care to continue the relationship.

“I wouldn't mind waiting to see the doctor... I'm old fashioned that way ... I guess it's that human interaction I prefer ... As time goes on [younger men will] get into more technological means of communication. They’ll get used to it, but, I guess I'm in the old fashion group. I would still prefer seeing a person.” - P001

A nurse-led clinic should focus on supporting patient self-management

Patients envisioned a nurse-led clinic as support that would provide “somebody to… listen to your concerns and point you in the right direction” (P005). This support included education, resources to support wellbeing, and building community through peer support. Notably, they desired additional educational support beyond what the current system provides.

“Yeah, I think education [would] be great ... You can go through and you can pull all of this stuff together on the Internet yourself. But ... my clinic may have a different protocol ... or slightly nuanced or something so it would be good to get it from one place.” - P009

“So, if you’re in Toronto, they say there's always the PCa support [groups] through Toronto or Oakville or whatever ... Support groups you know or other information, would that be in your library too. ” - P002

Virtual nurse-led care facilitates self-assurance but must address accessibility

Speaking to patients’ perceptions of the appropriateness of a nurse-led model of service, they perceived the model being appropriate because: (1) they felt that nurses were a logical first point of contact, (2) the Ned Nurse clinic was compatible with their existing care workflows, and (3) they saw the value added and peace of mind of being able to connect with a nurse to manage their symptoms.

“I think what is most important is the psychological advantage of feeling that yes, there's someone I can come [to], I can contact and who will respond fast ... It gives you, I guess a little more confidence.” - P003

Patients also described the desire for inclusive support to mitigate care accessibility barriers. Patients indicated not only was it important to identify highly qualified personnel, but there were important health equity requirements for bridging the digital literacy gap (e.g., voice recognition and guidance). Patients noted considerations needed for lower barriers for older adults and groups on the other side of the digital divide.

“You know these are older guys... if something is not working, they probably tell one of their kids or grandkids… they wouldn't go to the support site and chat with the bot themselves... So if you can keep it as simple as possible and as intuitive as possible, that would make it easier.” - P003

Principal findings

This study corroborates existing evidence on patient perceptions of specialist-based PCa follow-up care models ²⁰, while providing new insights on telemedicine usage and anticipated barriers and facilitators to the implementation of a nurse-led model of survivorship care. Challenges described within the current model of specialist-based follow-up care are consistent with literature regarding limited resources, long wait times, fragmented care, ability to respond in a timely manner, and the need for improved supportive care resources ^4,5. These findings are reinforced in our recent paper describing the experiences and perspectives of HCPs on system challenges and the status quo ²⁰.

In considering the value-add of a virtual nurse-led model of care, patients anticipate that the following factors will facilitate use: (1) clarity of roles and responsibilities; (2) ease and accessibility of use; (3) enhanced mental health support, and (4) reinforcement and continuity of care. The promise of virtual care for patients is in its ability to provide more timely and targeted care. With a lack of capacity in the current specialist-led model, a nurse-led model may be better positioned to resolve challenges around timeliness.

Further, we provide patient recommendations on important aspects to consider in the design, development, and implementation of patient-facing digital health tools. Benefits of telemedicine include larger geographic reach, asynchronous communication with providers, and flexibility. This flexibility can also include allowing patients to submit patient-reported outcomes (PROs) when needed, at their own pace, without feeling rushed during irregular appointments. However, the digital divide shows that digital accessibility and its benefits accumulate for younger, higher socioeconomic-status, and white individuals ¹⁷. Incidence of PCa increases with advancing age, which is correlated with lower digital literacy ³⁰. However, the self-confidence to make health decisions based on online information appears to be the largest factor in health-related internet use for PCa survivors ³¹. We acknowledge that such an intervention cannot address all issues, but involving patients in the design of the care tool and service change, and providing accessible technical support to patients appears key to ensuring that any patient-facing digital tool proceeds beyond the pilot stage of implementation.

A checklist to assess an ecosystem’s patient readiness for virtual care

A sustainable system requires the consideration of perspectives from all affected stakeholders, which can encompass systemic communication, resource management, and care outcomes. We have synthesized a patient perspective list of important aspects to consider during the design, development, and implementation of these tools. Our five aspects (mapped onto Proctor outcomes ²⁵) are as follows and expanded on in Table 1: (1) functionality testing (acceptability), (2) ability to tailor care and usability (adoption), (3) fit for purpose (appropriateness), (4) patient readiness (feasibility), (5) patient training (penetration). While grounded in our results within the PCa context, this readiness checklist can be used broadly to assess the health ecosystem from the patient perspective to understand where resources and support are needed. It is not meant to be an exhaustive tool, but can act as a starting point to identify strengths and areas requiring additional support to improve acceptability, appropriateness, and feasibility of a new digital therapeutic.

Table 1

Patient Identified Facilitators for Proctor Outcomes - Readiness Checklist Assessment
Facilitator	Item	Description and designing for outcome
Functionality Testing Proctor Outcome: Acceptability	● Has the platform been user-tested for accessibility?	Participants are concerned that lower levels of digital literacy within the community would affect usage of a digital therapeutic for PCa follow-up care. Accessibility could be enhanced through digital literacy evaluations, accessibility evaluations, or site-specific pilot implementations (e.g.,^32,33). Usability can be assessed by usability testing with patients via think-aloud and other user testing methods (e.g., ^34,35).
Ability to Tailor Care Proctor Outcome: Adoption	● Does the system accommodate various stages of survivorship or disease progression? ● Are resources tailored for different stages? ● Has the platform been user-tested for usability?	Patients have varying survivorship self-management needs that require different responses. Ability to tailor care could be assessed by cataloguing the resources that are available to patients and categorizing these resources based on ability to deliver and what needs they are meant to serve (e.g.,^36–38).
Fit for Purpose Proctor Outcome: Appropriateness	● How has the system been assessed for appropriateness to meet specific population needs?	Patients envisioned a nurse-led clinic as valuable support for self-management. Fit for purpose could be assessed by implementing the system through a pilot project and completing an assessment via suitable methodologies, based on what outcomes the system is intended to improve or support (e.g.,^36,39).
Patient Readiness* Proctor Outcome: Feasibility	● Do patients feel prepared for onboarding?	Patients are confused about expectations for self-management, and would like clarity regarding what role they need to play in their care. Patient readiness could include qualitative assessment of whether they feel empowered to participate in this change in their care, and if they feel that their care provider supports this change (e.g., ³⁷).
Patient Training Proctor Outcome: Penetration	● Have patients received sufficient and appropriate training to onboard and use this platform?	Patient training could be assessed by investigating barriers and facilitators to technology adoption by patients, and designing mitigating strategies for barriers. (e.g.,^40–43).

* Patient readiness should be further specified based on patient needs assessment.

Strengths and limitations

Our qualitative description design allowed for the deep exploration of patient experiences and needs within PCa follow-up care, nurse-led care, and virtual care models. This allowed us to synthesize a patient-side readiness checklist that spotlights facilitators identified as important to patients. Findings are transferable to designing evidence-based, patient-oriented technology-based care platforms for cancer survivors. Considerations regarding study limitations are as follows. Our findings and implications are based on data collected in a developed, high-income setting. Transferability for developing and/or low- or medium-income settings may be more limited because of context characteristics. Additionally, prostate cancer survivorship is impacted by demographic factors such as race and ethnicity⁴⁴; these factors were not explicitly investigated within this study. This study was conducted during the beginning of the COVID-19 pandemic when virtual care was first widely introduced in the context of a public health emergency. Our data collection phase aligned with the implementation of virtual care modalities across broader health contexts, a systemic change that influenced participant experiences. However, the immediacy of these experiences may have increased patients’ motivation to participate in designing an accessible digital therapeutic.

Future directions

Future studies should examine the findings from other settings to validate the recommendations for technology-assisted telemedicine and facilitate the evolution of integrated widely accessible and ethnographically inclusive systems. This will benefit patients across communities, settings and ethnic populations globally. Second, perspectives from all stakeholders should be investigated to extend a holistic view of building human-oriented, highly adopted and well-accepted digital therapeutics. Virtual and digital interventions should be informed by the understanding of the experiences of the key stakeholders and recommendations from this and other exploratory investigations. Moreover, future investigation of digital therapeutics should address important considerations above and beyond feasibility, appropriateness, acceptability, and accessibility. More efforts are needed to build these innovations with efficacy, sustainability and scalability for a stronger healthcare system.

This study reveals that patient experiences with the introduction of virtual care modalities into the current standard of follow-up PCa care continue to underdeliver on care expectations. Major current experiences include: the current standard of follow-up care creates uncertainty, structural gaps persist despite new telemedicine modalities, and patients desire more systemic wellbeing support. The emerging virtual care model illuminates the potential of employing technology in PCa survivorship care to expand access and communication and coordinate and integrate resources to better support PCa survivors. Specifically, patients want virtual care to: incorporate existing care connections, support self-management, and address accessibility. Patients anticipate nurse-led PCa virtual care will: (1) clarify roles and responsibilities; (2) improve care and ease of access to care; (3) enhance mental wellbeing, and (4) reinforce continuity of care. Future work should evaluate pragmatic efficacy of digitally mediated nurse-led virtual care models to support PCa survivorship.

Acknowledgements

The authors would like to acknowledge the time and effort contributed to this research by the patients, providers, and administrators who were involved in this research. We also recognise the Ned product team (project managers, analysts, designers, and software developers) at the Centre for Digital Therapeutics (UHN) for their commitment to delivering a digital therapeutic intervention through digital health for prostate cancer survivors and their circle of care. This includes contributions from Danny Wang, Ryan Ho, and Adam Badzynski who supported study set-up and data collection. The study was funded by the CCS/CIHR Cancer Survivorship Team Grant (CCS:706713; CIHR: 168606). The funding agencies were not involved in the design or analysis of this study.

Author Contributions

RL, DW, RH, AB, DN, and KY contributed to the conceptualization and study design for this project. RL, DW, RY, DN, TJ, and KY contributed to data collection and analysis. TX, KY, and KP led the manuscript writing. QP conceived the rationale method design and oversaw the study. Additional methodological contributions for the Ned Clinic were from AB, JLB, DB-L, AHF and JAC. CN and DN led the study set-up including REB. All authors contributed to, reviewed, and approved the manuscript.

Conflict of Interest

QP, JAC, AB, AF and University Health Network jointly own intellectual property rights to the Ned platform. Under the respective agreements with their organizations, these individuals are entitled to personally benefit from any commercial use of the intellectual property.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request and with permission of the University Health Network Research Ethics Board.

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Yes there is potential Competing Interest. Drs. Quynh Pham, Joseph A. Cafazzo, Alejandro Berlin, Andrew Feifer, and the University Health Network jointly own intellectual property rights to the Ned platforms (including Ned Nurse). Under the respective agreements with their organizations, these individuals are entitled to personally benefit from any commercial use of the intellectual property.

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Nurse-led virtual prostate cancer clinic for survivorship care: Qualitative study of patient experiences and needs

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