Adapting and implementing evidence-based breast cancer follow-up in primary care

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PROJECT SUMMARY/ABSTRACT Breast cancer survivors are a growing population and their symptom burden is significant. Despite growing evidence on specific symptoms and risk management strategies, efforts to translate knowledge into practice have produced suboptimal results. Primary care is an ideal receptor site for breast cancer survivors, with studies demonstrating the effectiveness of primary care based survivorship care. Nevertheless, over the past decade, the emphasis on survivorship care plans and survivorship models has not had an evident impact on primary care breast cancer survivorship care processes. Over the past two decades, primary care practices have redesigned structures and care processes to deliver care to different complex populations; however, breast cancer survivors are not among them. Many currently proposed and tested strategies are considered oncology-centric and do not fit well within the real world contexts of primary care practices. Results from our recent research studies indicate that breast cancer survivorship is not considered clinically actionable even among primary care practices with advanced staffing models. Therefore, capacity building and stakeholder- informed strategies are needed to enhance the translational potential of survivorship evidence into primary care practices. This project uses a “designing for dissemination” perspective, blending the implementation Exploration, Planning, Implementation and Sustainment (EPIS) framework and the primary care Practice Change Model (PCM) as a theoretical basis for understanding multilevel factors impacting the implementation of cancer survivorship guidelines in primary care. These perspectives help frame and identify mismatches among existing policy, practice, provider, and patient motivators to translate the evidence into clinically actionable primary care practice change strategies. Using a blended implementation/primary care practice change conceptual framework, this project aims to: (1) engage diverse primary care stakeholders in identifying actionable, practice-based activities for provision of long-term breast cancer survivorship care in primary care using depth interviews; (2) prioritize, synthesize, and identify actionable activities for providing care to long- term cancer survivors in primary care by engaging key stakeholders using modified online Delphi methods and concept mapping; and (3) implement and evaluate actionable breast cancer survivorship symptom and risk management activities using a hybrid type 1 effectiveness-implementation cluster study design with waitlist control in 26 primary care practices. Study results are poised to have profound impact on implementation strategies used throughout the U.S. to provide long-term care for patients with a history of breast cancer.