Interventions to Support Transitions in Care Among Patients With Cancer: A Scoping Review

Overview

Journal Cancer Med

Specialty Oncology

Date 2025 Feb 28

PMID 40018786

Authors

Negar Rezaei

Jaling Kersen

Abigail Thomas

Stefan Kurbatfinski

Diane Lorenzetti

Khara Marissa Sauro

Affiliations

Soon will be listed here.

Abstract

Background: The cancer journey from diagnosis through survivorship is complex and involves care from many healthcare providers across a variety of settings. Navigating the transitions between care providers and settings can be improved through interventions. The objective of this study was to map and characterize evidence on interventions to improve transitions in care among patients with cancer.

Method: Six databases were searched to identify relevant studies that described or evaluated interventions to support transitions in care for patients with cancer. Data on the interventions, the type of transition in care, type of cancer, and outcomes (including measure of effectiveness) were abstracted. Data were synthesized and analyzed using descriptive statistics.

Result: Of the 38,876 data sources identified, 150 were included. Most included studies were from the United States and were observational studies exploring interventions to facilitate the transition from treatment to survivorship (followed by interventions for the transition from hospital to home) among patients with breast cancer (followed by gastrointestinal cancers, lung cancers, and hematologic cancers). Interventions that were found to be effective were most commonly those that facilitated the transition from diagnosis to treatment and for the transition from hospital to home.

Conclusion: This comprehensive synthesis is an important resource for those trying to improve transitions in care for patients living with and beyond cancer. Despite the large body of evidence identified, gaps remain; there is a paucity of studies exploring transitions in care during cancer treatment and among some cancers (e.g., brain tumors, head and neck, pancreatic).

References

Thompson J, Coleman R, Colwell B, Freeman J, Greenfield D, Holmes K . Preparing breast cancer patients for survivorship (PREP) - a pilot study of a patient-centred supportive group visit intervention. Eur J Oncol Nurs. 2013; 18(1):10-6. DOI: 10.1016/j.ejon.2013.10.004. View

Coulourides Kogan A, Koons E, Enguidanos S . Investigating the impact of intervention refusal on hospital readmission. Am J Manag Care. 2017; 23(12):e394-e401. PMC: 5839474. View

Lee S, Jetelina K, Marks E, Shaw E, Oeffinger K, Cohen D . Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol. BMC Cancer. 2018; 18(1):1204. PMC: 6278055. DOI: 10.1186/s12885-018-5118-7. View

Li H, Shu Q, Chen Q, Gong X, Liu Y, Li Y . Application effect of team systematic management model on discharge readiness and quality of discharge guidance for rectal cancer patients. Minerva Med. 2021; 113(3):595-597. DOI: 10.23736/S0026-4806.20.07253-5. View

Horwitz L, Meredith T, Schuur J, Shah N, Kulkarni R, Jenq G . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2008; 53(6):701-10.e4. DOI: 10.1016/j.annemergmed.2008.05.007. View

Grant M, De Rossi S, Sussman J . Supporting models to transition breast cancer survivors to primary care: formative evaluation of a cancer care Ontario initiative. J Oncol Pract. 2015; 11(3):e288-95. DOI: 10.1200/JOP.2015.003822. View

Kersen J, Kurbatfinski S, Thomas A, Ibadin S, Hezam A, Lorenzetti D . Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review. BMJ Open. 2024; 14(12):e078210. PMC: 11647354. DOI: 10.1136/bmjopen-2023-078210. View

Morita T, Fujimoto K, Namba M, Sasaki N, Ito T, Yamada C . Palliative care needs of cancer outpatients receiving chemotherapy: an audit of a clinical screening project. Support Care Cancer. 2007; 16(1):101-7. DOI: 10.1007/s00520-007-0271-6. View

Ziebland S, Grunfeld E, Hall A . Patients' views of routine hospital follow-up: a qualitative study of women with breast cancer in remission. Psychooncology. 1998; 7(5):436-9. DOI: 10.1002/(SICI)1099-1611(1998090)7:5<436::AID-PON319>3.0.CO;2-C. View

10.

Ehab J, Powers B, Kim R, Haider M, Utuama O, Chin A . Integrating a Disease-Focused Tumor Board as a Delivery-of-Care Model to Expedite Treatment Initiation for Patients With Liver Malignancies. Ann Surg Oncol. 2021; 29(4):2371-2380. DOI: 10.1245/s10434-021-10909-y. View

11.

Kucharczuk C, Lightheart E, Kodan A, Haynes C, Rabatin S, Burke J . Standardized Discharge Planning Tool Leads to Earlier Discharges and Fewer Readmissions. J Nurs Care Qual. 2021; 37(1):54-60. DOI: 10.1097/NCQ.0000000000000558. View

12.

Sauro K, Bagshaw S, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J . Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open. 2019; 9(3):e024159. PMC: 6429967. DOI: 10.1136/bmjopen-2018-024159. View

13.

Taggart J, Chin M, Liauw W, Goldstein D, Dolezal A, Plahn J . Challenges and solutions to sharing a cancer follow-up e-care plan between a cancer service and general practice. Public Health Res Pract. 2021; 31(2). DOI: 10.17061/phrp31122108. View

14.

Duffy A, Bemben N, Li J, Trovato J . Facilitating Home Hospice Transitions of Care in Oncology: Evaluation of Clinical Pharmacists' Interventions, Hospice Program Satisfaction, and Patient Representation Rates. Am J Hosp Palliat Care. 2018; 35(9):1181-1187. DOI: 10.1177/1049909118765944. View

15.

Hulbert-Williams N, Norwood S, Gillanders D, Finucane A, Spiller J, Strachan J . Brief Engagement and Acceptance Coaching for Hospice Settings (the BEACHeS study): results from a Phase I study of acceptability and initial effectiveness in people with non-curative cancer. BMC Palliat Care. 2021; 20(1):96. PMC: 8235846. DOI: 10.1186/s12904-021-00801-7. View

16.

Oyesanya T, Loflin C, Byom L, Harris G, Daly K, Rink L . Transitions of care interventions to improve quality of life among patients hospitalized with acute conditions: a systematic literature review. Health Qual Life Outcomes. 2021; 19(1):36. PMC: 7845026. DOI: 10.1186/s12955-021-01672-5. View

17.

Ezendam N, Nicolaije K, Kruitwagen R, Pijnenborg J, Caroline Vos M, Boll D . Survivorship Care Plans to inform the primary care physician: results from the ROGY care pragmatic cluster randomized controlled trial. J Cancer Surviv. 2014; 8(4):595-602. DOI: 10.1007/s11764-014-0368-0. View

18.

Curcio K, Lambe C, Schneider S, Khan K . Evaluation of a cancer survivorship protocol: transitioning patients to survivors. Clin J Oncol Nurs. 2012; 16(4):400-6. DOI: 10.1188/12.CJON.400-406. View

19.

Grainger M, Hegarty S, Schofield P, White V, Jefford M . Discussing the transition to palliative care: evaluation of a brief communication skills training program for oncology clinicians. Palliat Support Care. 2010; 8(4):441-7. DOI: 10.1017/S1478951510000313. View

20.

Abraham J, Nguyen V, Almoosa K, Patel B, Patel V . Falling through the cracks: information breakdowns in critical care handoff communication. AMIA Annu Symp Proc. 2011; 2011:28-37. PMC: 3243259. View