Optimizing stratified cancer survivorship care through multimorbidity risk prediction

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There is a critical need to optimize systematic care for medically vulnerable childhood cancer survivors, the complexity of which is rooted in the significant overall multimorbidity survivors experience. Yet, depending on a variety of risk factors, subsets of survivors experience vastly different disease burdens, making access to informed, high-quality survivorship care essential to early identification and mitigation of late morbidity. Most community providers, however, see only a few survivors in their practices, each varying by cancer type, treatment era, and treatment exposures, and thus endorse discomfort managing survivors due to unfamiliarity with the guidelines' specific surveillance recommendations. Furthermore, the ability of most healthcare systems to provide preventative and treatment services in the form of a multidisciplinary, survivorship medical home to all individuals remains limited due to the complexity of implementing guidelines in non-specialized clinics. To accommodate such constraints, some have adopted basic, risk-stratified models of care to allocate the most resource-intense, survivorship specialty care to those at highest risk of chronic health conditions (CHCs). These approaches have largely stratified survivors using only basic treatment exposures and incidence and prevalence of individual CHCs, overlooking multimorbidity due to multiple CHCs and health-related quality of life (HRQoL). The ability to stratify survivor groups based on risk of multimorbidity would both simplify and optimize a) personalized survivorship care based on individual survivors' risks and needs, and b) resource allocation to those most likely to benefit from routine care in a survivorship medical home. To begin to address these needs, we propose using the SJLIFE cumulative burden personalized risk-prediction model to establish low, moderate, and high CHC burden profiles among childhood cancer survivors to identify risk-stratified groups that will inform survivorship healthcare delivery and intervention. We propose additional incorporation of HRQoL into the tiered- care selection to identify survivors likely to benefit from higher-tiered survivorship care who would otherwise be misclassified by models only considering CHCs. The proposed study will result in a stratified survivorship care approach that considers the multimorbidity of cumulative burden and HRQoL, characteristics which are key to its effective dissemination and implementation in practice.