Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

Intraspecific Behavioural Diversity in a Freshwater Zooplankton: A study of the fitness consequences of vertical migration behaviour for distinct morphs of Daphnia pulicaria

The literature on niche separation and coexistence between species is large, but there is widespread variation in behavioural strategy between individuals of the same species that has received much less attention. Understanding what maintains this diversity is important because intraspecific behavioural diversity can affect population dynamics and community interactions. Multiple behavioural strategies can arise either as phenotype-dependent ‘conditional strategies’, where phenotypic variation causes individuals to adopt different strategies for optimizing fitness, or as internally-independent ‘alternative strategies’, where multiple fitness peaks exist for individuals and strategic ‘choice’ remains plastic. Though intraspecific variation in stable phenotypes is known to maintain intraspecific behavioural diversity through conditional strategies, when internal conditions are highly plastic or reversible, it is not clear whether individual behaviours are maintained as conditional strategies, or as alternative strategies of equal fitness. In this study, I combine an observational and experimental approach to identify the likely mechanisms maintaining behavioural diversity between hemoglobin-rich and hemoglobin-poor morphs in a natural population of Daphnia pulicaria. In Round Lake, individuals with low hemoglobin migrate daily from the hypolimnion to the epilimnion, whereas individuals with high hemoglobin remain in the hypolimnion. Using high-resolution depth and time sampling, I discovered behavioural diversity both within and among hemoglobin phenotypes. I tested the role of hemoglobin phenotype in maintaining behavioural diversity using automated migration robots that move individuals across the natural environmental gradients in the lake. By measuring the fitness of each morph undergoing either a natural migration behaviour, or the migration of the opposite morph, I found that the fitness of hemoglobin rich and poor morphs in their natural behaviour does not differ, but that Hb-rich individuals can obtain equal fitness from either behaviour, while Hb-poor morphs suffer substantial drops in survivorship in the alternate migration behaviour. Thus, migration behaviour in this system exists as a conditional strategy for some individuals, and as alternative strategies of equal fitness for others. The results of this study suggest that individual limits in the expression of highly flexible internal conditions can reinforce intraspecific behavioural diversity. Few studies have measured the fitness consequences of switching migration strategies and this study provides a rare example in the field.

AN INVESTIGATION ON ROUTINE FOLLOW-UP CARE FOR HEAD AND NECK CANCER

BACKGROUND: Follow-up care aims to provide surveillance with early detection of recurring cancers and to address treatment complications and other health issues in survivorship. It is assumed that follow-up care fulfills these aims, however little evidence supports routine surveillance detecting curable disease early enough to improve survival. Cancer survivors are a diverse patient population, suggesting that a single follow-up regimen may not meet all patients’ follow-up needs. Little is known about what effective follow-up care should include for head and neck cancer patients in a Canadian setting. Identification of subgroups of patients with specific needs and current practices would allow for hypotheses to be generated for enhancing follow-up care. OBJECTIVES: 1a) To describe the follow-up needs and preferences of head and neck cancer patients, 1b) to identify which patient characteristics predict needs and preferences, 1c) to evaluate how needs and preferences change over time, 2a) to describe follow-up care practices by physician visits and imaging tests, and 2b) to identify factors associated to the delivered follow-up care. METHODS: 1) 175 patients who completed treatment between 2012 and 2013 in Kingston and London, Ontario were recruited to participate in a prospective survey study on patients’ needs and preferences in follow-up care. Bivariate and multivariate analyses were employed to describe patient survey responses and to identify patient characteristics that predicted needs and preferences. 2) A retrospective cohort study of 3975 patients on routine follow-up from 2007 to 2015 was carried out using data linkages across registry and administrative databases to describe follow-up practices in Ontario by visits and tests. Multivariate regression analyses assessed factors related to follow-up care. RESULTS: 1) Patients’ needs and preferences were wide-ranging with several characteristics predicting needs and preferences (ORECOG=2.69 and ORAnxiety=1.13). Needs and preferences declined as patients transitioned into their second year of follow-up (p<0.05). 2) Wide variation in practices was found, with marked differences compared to existing consensus guidelines. Multiple factors were associated with follow-up practices (RRTumor site=0.73 and RRLHIN=1.47). CONCLUSIONS: Patient characteristics can be used to personalize care and guidelines are not informing practice. Future research should evaluate individualized approaches to follow-up care.