Colorectal Cancer Survivorship Care in the Veterans Affairs Healthcare System

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DESCRIPTION (provided by applicant): Colorectal cancer (CRC) is a common, morbid, and often deadly disease in veterans and non- veterans alike. Early detection and better treatment options have increased survival among CRC patients, expanding the need for continuing survivorship care. Among CRC survivors the two leading causes of death are secondary malignancies and comorbid conditions. To mitigate these problems, CRC survivors must adhere to surveillance colonoscopy at guideline-concordant time intervals for early detection of cancer recurrence, medications, and lifestyle recommendations. In the Veterans Affairs (VA) healthcare system, fewer than half of CRC survivors receive a guideline-concordant surveillance colonoscopy within 7-18 months following surgery. There is evidence both within VA and externally suggesting that CRC patients experience distress, fear over cancer recurrence, and depression that encumbers their ability to seek appropriate survivorship care. Little is known about CRC survivors' self- management practices. A better understanding is needed of the national VA CRC survivor cohort, their healthcare utilization patterns, perceived health needs and priorities in order to intervene to facilitate appropriate cancer survivorship care. As an initial step in a long-term veteran-centric research commitment, I propose three projects: Project 1: Utilizing national VA secondary databases, such as the VA Central Cancer Registry, Pharmacy Benefits Manager, and others, I will construct and characterize a national cohort of VA CRC survivors and their self-management behaviors, and define a non-cancer comparison group. Defining the current population of VA CRC survivors is a critical foundation for designing a self-management intervention for this populace. This project addresses: 1) the composition of survivors receiving care in the VA, 2) where are they receiving care, 3) the types of providers coordinating survivorship care, 4) what comorbid conditions affect CRC survivors, 5) body mass index and smoking status, 6) the medical possession ratio of CRC survivors' adherence to prescribed medications; and 7) how these factors compare between CRC survivors and a non-cancer comparison group. Project 2: I will assess VA CRC survivors' perceptions of self-management for survivorship care, including adherence to surveillance colonoscopy, medication adherence, and healthcare utilization. This will require a mixed methods approach encompassing telephone-based quantitative surveys among CRC survivors in VISN 6 and qualitative interviews for a subset of participants. Assessing CRC survivors' perception of self-management is a critical component in designing interventions that motivate patients to action for chronic disease management and cancer surveillance. This patient-reported information will assess perceived: 1) susceptibility and severity of cancer recurrence, 2) susceptibility and severity of common chronic diseases and CVD risk factors such as hypertension, hyperlipidemia, and diabetes, and 3) barriers and benefits of adhering to a survivorship self-management intervention. Project 3: Equipped with information from the first two projects, I will design and pilot-test a self- management intervention to motivate VA CRC survivors' adherence to a survivorship care plan. I will conduct a pilot test with 20 CRC survivors of a self-management intervention targeting increased adherence to: 1) prescription medications for CVD-related risk factors, and 2) surveillance colonoscopy for CRC surveillance. Intervention materials will also address lifestyle choices such as dietary and exercise patterns. This pilot test will elucidate whether the intervention is feasible for CRC survivors and whether short-term medication adherence and intent to undergo colonoscopy be attained. A self- management intervention targeted to this unique patient population will improve survivorship care quality.