Components Of Survivorship Care Research Articles

Discussions of Cancer Survivorship Care Needs: Are There Rural versus Urban Inequities?

Rural cancer survivors may face greater challenges receiving survivorship care than urban cancer survivors. To test for rural versus urban inequities and identify other correlates of discussions about cancer survivorship care with healthcare professionals. Data are from the 2017 Medical Expenditure Panel Survey (MEPS), which included a cancer survivorship supplement. Adult survivors were asked if they discussed with a healthcare professional 5 components of survivorship care: need for follow-up services, lifestyle/health recommendations, emotional/social needs, long-term side effects, and a summary of treatments received. The Behavioral Model of Health Services guided the inclusion of predisposing, enabling, and need factors in ordered logit regression models of each survivorship care variable. A significantly lower proportion of rural than urban survivors (42% rural, 52% urban) discussed in detail the treatments they received, but this difference did not persist in the multivariable model. Although 69% of rural and 70% of urban ssurvivors discussed in detail their follow-up care needs, less than 50% of both rural and urban survivors discussed in detail other dimensions of survivorship care. Non-Hispanic Black race/ethnicity and time since treatment were associated with lower odds of discussing 3 or more dimensions of survivorship care. This study found only a single rural/urban difference in discussions about survivorship care. With the exception of discussions about the need for follow-up care, rates of discussing in detail other dimensions of survivorship care were low among rural and urban survivors alike.

High cardiovascular disease mortality after penile squamous cell carcinomas diagnosis: Results from the United States SEER population, 2005-2016.

BackgroundCancer survivorship care is an emerging and necessary component of oncology management. To explore cardiovascular disease (CVD)-specific mortality and prognostic factors among patients with penile squamous cell carcinomas (PSCC). These results aid clinicians in furtherly understand this disease’s prognosis.MethodWe analyzed Surveillance, Epidemiology and End Results Program data for 2668 PSCC cases diagnosed between 2005 to 2016. We calculated standardized mortality ratios (SMRs) of CVD and all-cause mortality, comparing PSCC patients with general population men. A cumulative mortality curve and competitive risk regression model were utilized to evaluate the prognostic factors of CVD-specific death.ResultsDeath distribution is as follows: PSCC (42.4%), other causes (21.3%) CVD (19%), and other cancers (17.3%). PSCC patients are more like to die from CVD (SMR=3.2, 95%CI: 3.1-3.3) and all-cause death compared with the general population. Meanwhile, patients undergoing surgery show a relatively higher CVD-specific mortality than the general population (SMR=2.7, 95%CI: 2.4-3.2). In the competitive risk model, higher CVD mortality is associated with age, region, year of diagnosis, stage, and marital status (all P<0.05). Patients with the localized stage show a higher risk of CVD-specific death than those with regional or distant stage.ConclusionOur study mainly reveals that cardiovascular disease was the important cause of death and higher CVD-specific mortality among PSCC patients. Several associated factors related to CVD-specific death are also identified. In the future, more work in educating health care professionals on the components of survivorship care is needed to meet the long-term and late effects cancer patients experience.

Defining and measuring quality cancer survivorship care: An environmental scan.

219 Background: It is recognised that current models of survivorship care are suboptimal and unsustainable. The landmark Institute of Medicine (IOM) report ‘From Cancer Patient to Cancer Survivor: Lost in Transition’ suggested four essential components of survivorship care: prevention of recurrent and new cancers; surveillance for recurrent or second cancers; intervention for consequences of cancer and its treatment, and coordinated care between health providers. The report also recommended “quality of survivorship care measures should be developed... and quality assurance programs implemented to monitor and improve the care that all survivors receive.” Nekhlyudov et al (JNCI 2019) built on the IOM’s recommendations to develop a quality of cancer survivorship care framework. We undertook an environmental scan to understand how quality survivorship care is conceptualised internationally, and what metrics are available. Methods: This scan comprised limited literature review, review of organisations’ websites, and expert consultation to source documents that described and measured quality survivorship care. Documents were assessed against the domains proposed by Nekhlyudov et al. Metrics were categorised as policy, process or outcome measures. Results: The search yielded 40 documents from six countries. There was agreement that quality survivorship care is founded on the IOM elements, expanded by Nekhlyudov et al. The review also noted risk stratification/personalised pathways of care and patient self-management as other elements of quality care. Many countries have proposed or implemented quality measures, with greater emphasis on processes over outcome assessments. Only the USA was found to have implemented policy measures. In the process domain, frequently reported metrics included completion of needs assessments and survivorship care plans, and adherence to recommended follow up guidelines. Regarding outcome measures, patient-reported outcomes and experiences were commonly proposed, however there was a lack of specific elements, or recommended instruments. Conclusions: There is broad agreement on what constitutes quality survivorship care internationally. Future work should consider policy or structural elements that support optimal care. Findings from this scan will inform a modified reactive Delphi study to establish consensus-based criteria for high quality survivorship care. Additional work should consider how to define and implement metrics of quality care, and how to use metrics to improve survivors’ outcomes.

Survivorship Care Plans: Reaching a Benchmark and Striving to Achieve Intent

Survivorship care plans (SCPs) have been endorsed by major oncologic organizations despite challenges in implementation and unclear patient-specific benefits. In January 2020, the Commission on Cancer removed a 2018 provision that required accredited programs to deliver SCPs to eligible patients. Programs must determine whether to continue SCP use or begin de-implementation. We detail a framework to increase SCP delivery for programs continuing to provide SCPs as a component of survivorship care and suggest a patient-centered approach to evaluate continued utility amidst updated national standards. We surveyed medical, surgical, and radiation oncologists at our academic and community sites to identify barriers to SCP use and performed a Pareto analysis to highlight the most notable barriers. We then designed an intervention that used SCP templates within the medical record, disease-specific recommendations, delegation to nonphysician staff, and provider education. We monitored our intervention via a statistical process control analysis and assessed patient perceptions of SCP usefulness via a questionnaire. Before implementing our process improvements, our SCP completion rate during a 10-month period was 45%. During the 6-month period after our intervention, the SCP completion rate increased to 89%. Greater than 80% of patients who had recently received an SCP found the information helpful and were satisfied with the amount of information received. More than 40% did not remember receiving their original SCP. We demonstrated a feasible method for increasing SCP delivery for all cancers across a cancer network and used a patient-specific questionnaire to assess continued value amidst changing national standards.

Abstract B010: Association of cancer survivors' sociodemographic characteristics with survivorship care patterns

Abstract Cancer survivors may have unique medical care needs due to chronic/late-occurring effects of cancer or cancer treatment. “Shared care,” which involves delivery of components of survivorship care by both oncologists and primary care providers (PCPs), may lead to increased coordination of care and may better address survivors' needs. However, little is known regarding potential disparities in receipt of shared care among cancer survivors. We examined associations between cancer survivors' sociodemographic characteristics and their receipt of shared care. SEER-CAHPS data, linking NCI's Surveillance, Epidemiology, and End Results (SEER) registry data, Medicare claims, and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses, were used. Individuals age &amp;gt;65 years at diagnosis in 2000-2011 SEER-CAHPS with breast, cervical, colorectal, lung, renal, or prostate cancers or hematologic malignancies who responded to a Medicare CAHPS survey &amp;gt;18 months after diagnosis were included. Individuals were classified in four mutually exclusive survivorship care patterns: Shared Care, Oncologist-led, PCP-led, or Other survivorship care, based on the proportions of their oncologist, PCP, and other physician encounters in Medicare claims data. Differences in survivorship care pattern by sex, age, education, race/ethnicity, and dual Medicare-Medicaid status were examined. Among the 10,132 survivors included in the study, 15.1%, 10.0%, 32.7%, and 42.2% received Shared Care, Oncologist-led, PCP-led, and Other care patterns, respectively. Compared with survivors in Shared Care, significantly greater proportions of those in the PCP-led pattern were over age 85 (24% PCP-led vs. 16% Shared Care), female (55% PCP-led vs. 44% Shared Care), and had high school or less educational attainment (52% PCP-led vs. 46% Shared Care). A significantly smaller proportion of survivors in the Oncologist-led pattern were older than age 85 (12% Oncologist-led vs. 16% Shared Care). Significantly more of those in the Other survivorship care pattern compared with Shared Care were older than age 85 (21% Other vs. 16% Shared Care) and non-Hispanic White (87% Other vs. 81% Shared Care), and fewer survivors in the Other care pattern had high school or less educational attainment (42% Other vs. 46% Shared Care). Overall, we found few significant and consistent associations between sociodemographic characteristics and receipt of Shared Care among cancer survivors in the SEER-CAHPS data set. However, these characteristics may influence type of survivorship care pattern received. Further research is needed to examine the role of patient characteristics in receiving different survivorship care patterns. Citation Format: Michael T. Halpern, Julia Cohen, Lisa M. Lines, Michelle A. Mollica, Erin E. Kent. Association of cancer survivors' sociodemographic characteristics with survivorship care patterns [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B010.

QIM19-141: SOAR (Survivors Overcoming and Achieving Resilience)

Background: There are 4 components of survivorship care: prevention, surveillance, interventions, and coordination between oncology and primary care/specialists. As part of the initial visit in Moffitt’s survivorship program, we provide a comprehensive and personalized care plan to our patients with a focus on wellness. We understand the transition from active treatment into the extended phase of survivorship can be fraught with many unexpected physical, emotional, psychological, and social challenges, yet this could also be a critical period where survivors are uniquely positioned to adopt healthy and resilient behaviors. We want to help patients be empowered through knowledge from interactive and multidisciplinary classes and we aim at improving their quality of life. Methods: We created an 8-week curriculum customized and designed for breast cancer survivors by experts in nutrition, social work, physical therapy, yoga, arts in medicine, and survivorship medicine with utilization technique–driven live food demonstrations. The core message of the series is further echoed and instilled by use of weekly journaling and guidance on how to practice the techniques following each class. Results: We completed one 8-week course. 15 patients were enrolled in the program; of these 9–12 participants consistently presented to the sessions. Sessions consisted in education regarding nutrition, emotional health, exercise, mindfulness, and medical management after completing cancer treatment. To further determine the impact of sessions, we are measuring change in health-related quality of life through the RAND-36 questionnaire with a precourse survey and a postcourse survey. As we continue our sessions and our patient population increases, we expect to have substantial data to report on the impact of this curriculum. Conclusions: It is estimated that there are more than 3.1 million women in the United States with history of breast cancer. Development of a multidisciplinary program focused in comprehensive care for breast cancer survivors may improve quality of life. These techniques can positively impact the transition from active treatment and position survivors to be better managers of their wellness.

An overview of the unique challenges facing African-American breast cancer survivors.

The existence of cancer disparities is well known. Focus on alleviating such disparities centers on diagnosis, treatment, and mortality. This review surveyed current knowledge of health disparities that exist in the acute survivorship period (immediately following diagnosis and treatment) and their contributors, particularly for African-American breast cancer survivors (AA-BCS). Utilizing the ASCO four components of survivorship care, we explore disparities in surveillance and effects of cancer and therapies that AA-BCS face within the acute survivorship period (the years immediately following diagnosis). A literature review of PUBMED, Scopus, and Cochrane databases was conducted to identify articles related to AA-BCS acute survivorship. The search yielded 97 articles. Of the 97 articles, 38 articles met inclusion criteria. AA-BCS experience disparate survivorship care, which negatively impacts quality of life and health outcomes. Challenges exist in surveillance, interventions for late effects (e.g., quality-of-life outcomes, cardiotoxicity, and cognitive changes), preventing recurrence with promotion of healthy living, and coordinating care among the healthcare team. This overview identified current knowledge on the challenges in survivorship among AA-BCS. Barriers to optimal survivorship care inhibit progress in eliminating breast cancer disparities. Research addressing best practices for survivorship care is needed for this population. Implementation of culturally tailored care may reduce breast cancer disparities among AA-BCS.

Searching for Survivor-Specific Services at NCI-Designated Comprehensive Cancer Centers: A Qualitative Assessment.

Background: Cancer survivorship presents unique medical, psychosocial, and logistical challenges for survivors, their caregivers, and clinicians. NCI-designated Comprehensive Cancer Centers (CCCs) serve a unique role in the delivery of cancer care because they not only provide care but also serve as a model for community oncologists and clinics through the development and dissemination of standards of care. Survivors, their caregivers, and clinicians look to CCCs to provide information about how to navigate the transition from active to posttreatment care. However, there is wide variability in the types of resources CCCs make available on their websites. The goal of our assessment was to understand the types of posttreatment survivor-specific resources CCCs are providing on their website. Methods: We analyzed the websites of the 47 CCCs to evaluate survivor-specific resources around the 4 components of survivorship care described by the Institute of Medicine guidelines for survivorship care plans: surveillance, prevention, intervention, and coordination. Results: Of the 47 CCCs, 74.5% (n=35) had discoverable survivor-specific services on their websites. Despite our inclusive approach to coding, few websites contained extensive information targeted at survivors, their caregivers, or clinicians. Only the coordination and intervention elements were discussed by at least half of the CCCs. From the vantage point of cancer survivors, their lay caregivers, loved ones, or clinicians, there is limited information about survivor-specific services on the websites of the 47 CCCs. This dearth of information translates into substantial work for these groups to find the resources they may need. Conclusions: The CCCs have an opportunity to serve as information hubs and to lessen the amount of work associated with survivorship. As models of cancer care delivery, the CCCs can also set the standard for community oncologists and clinics for delivery of care that improves the quality of life for survivors.

Fertility and cancer: Understanding the barriers to accessing information and resources.

116 Background: Some cancer treatments may lead to infertility in individuals diagnosed during their reproductive years. Infertility can affect a cancer survivor’s long-term quality of life by causing depression as well as reduced life satisfaction and increased anxiety. Addressing fertility concerns is a major component of survivorship care. Methods: In 2017 LIVESTRONG launched a national survey to assess whether patients are being informed about potential fertility risks due to a cancer diagnosis and/or related treatments; whether they are receiving necessary education and access to resources to make informed decisions about fertility preservation; and the financial burden of fertility preservation. A total of 1,064 people diagnosed with cancer between ages of 15-39 during 2006 to 2017 responded to the survey. Results: Seventy-nine percent of respondents said a health professional had discussed fertility issues with them, but only 51% were referred to a fertility specialist. Respondents diagnosed between 2011 and 2017 were more likely to report fertility discussions compared to those diagnosed between 2006 and 2010 (84% vs. 69%; p&lt;.001), and to be referred to a fertility specialist (58% vs. 33%, p &lt;.0001). More educated respondents and those with health insurance at time of diagnosis were more likely to report fertility discussions than those who did not (96% vs. 85%; p=.04). The most frequently discussed topics were possible risks to fertility (89%), methods of fertility preservation (70%), whether the respondent wanted any/or more children (64%), and timing for fertility preservation (50%). Insurance and financial issues were less frequently discussed: costs of fertility preservation (37%), insurance coverage (26%), and financial assistance (30%). Forty-four percent did not take steps to preserve their fertility. Conclusions: Many respondents reported not preserving fertility before treatment because they were not referred to a fertility specialist (30%) or insurance did not cover the costs (20%). All patients diagnosed in their reproductive years should be informed of infertility risks and receive information/resources on preservation options, regardless of education, income level, and insurance status.

Evaluating the patient-centered quality of cancer survivorship care models.

48 Background: With 15.5 million cancer survivors in the U.S., cancer is increasingly viewed as a chronic illness that requires systematic, coordinated care. Yet research has not determined what models of survivorship are most effective in providing high quality, patient-centered care. This study evaluates the quality of three models of cancer survivorship care using a newly developed patient-centered measure. Methods: We conducted a comparative effectiveness study with 32 cancer programs distributed across 3 distinct models of survivorship care: 1) Consultative Specialized Survivorship Clinic; 2) Longitudinal Specialized Survivorship Clinic; and 3) Oncology-Embedded Survivorship Clinic with Referrals. We developed the Patient-Prioritized Measure of High Quality Survivorship Care (PPM), a scale comprising 9 patient-prioritized components of survivorship care. We enrolled 991 survivors of breast, colorectal and prostate cancer across these programs and followed them over 6 months collecting self-reported data on quality of survivorship services. Results: Preliminary results suggest statistically significant differences across models of care for six PPM components. Model 1 is more likely than the other two models to provide a full spectrum of services (p=0.0001), mental health and social support (p&lt;0.0001), and information and resources for patients in survivorship (p=0.0002). Model 2 is better than model 3 at providing a medical home (0.04), and outperforms both other models at coordinating care and transitions (p=0.0059). Both Models 1 and 2 are better than model 3 in ensuring productive patient-provider interactions (p=0.006). Conclusions: It appears that certain models of survivorship care are better at specific domains of patient-centered quality, suggesting cancer centers should consider their organizational context and their patients’ needs before committing to a particular model of care.

Utilizing design theory to create a patient-centered palliative care model in cancer survisorship care.

164 Background: Palliative medicine (PM) is an essential component of survivorship care from point of diagnosis. While PM is philosophically committed to supporting patient and family survivorship goals, very few programs incorporate patient and family input into the formation of a patient-centered model of care for symptom management and quality of life. We utilized design theory to develop novel interventions for primary and specialist PM delivery. Methods: Baseline data collected in Fall 2014 revealed a need for assistance navigating support services as well as barriers to PM integration including branding, lack of primary palliative skills, and poor understanding of outcomes of PM integration. In February 2015, we convened a multidisciplinary group of 25 patients, family members, oncology clinicians and experts in patient experience and health services research, to evaluate current state data and formulate ideas for optimizing PM to support symptom management and quality of life. During a 1-day workshop, the group generated interventions for primary and specialist PM. Small teams were assigned to pilot projects based on these recommendations. Proposed solutions are being tested from July - October 2015. Results: The design team generated five focus areas for meeting patient needs and overcoming barriers: standard processes for access to PM, education on primary PM, rapid reporting of outcomes, relationship-building with referring clinicians, and improved access to primary and specialist palliative resources. Three interventions are being developed to address these: 1. A subspecialist “hub” that allows single referrals and streamlined access to supportive care, 2. a novel two-question probe about goals conducted by the oncologist, and 3. a peer support system between PM social work and nursing staff to proactively manage patients with complex needs. Conclusions: Patient and family-centered PM mandates a novel approach. Design theory allows for clear delineation of problem areas, generation of multiple solution sets, and rapid testing and refinement prior to large-scale adoption. A participatory design approach emphasizes user values and limitations and creates values-based solutions.

Appropriateness of cardiovascular care in elderly adult cancer survivors

Research suggests that the quality of non-cancer-related care among cancer survivors (CS) is suboptimal. Secondary disease prevention is an important component of survivorship care that has not been previously evaluated. Our aims were (1) to assess the utilization of and adherence to medications and treatments for the secondary prevention of myocardial infarction (MI) in CS versus non-cancer patients (NCP) and (2) to compare temporal trends in cardiovascular care between these two patient cohorts. Linking data from Medicare, pharmacy assistance programs, and cancer registries, we calculated the percentage of individuals receiving preventive medications (statins, β-blockers, angiotensin-converting enzyme inhibitors) and revascularization interventions (angioplasty, stent, bypass surgery) within 90 days after acute MI in CS and propensity score-matched NCP. We assessed trends over time and determined predictors of appropriate preventive care using modified Poisson regression. We identified 1,119 CS and 7,886 NCP. Compared to NCP, more survivors received statins (38 vs. 31 %) and β-blockers (67 vs. 59 %), but fewer underwent bypass surgery (1.5 vs. 2.8 %) after MI. From 1997 to 2004, both survivors and NCP were increasingly prescribed medications to prevent future coronary events. Over the same time period, receipt of bypass surgery was significantly lower among survivors. Co-morbidities, such as depression and lung disease, and demographic factors, such as advanced age and female, were associated with underuse of preventive care among survivors when compared to NCP. Use of preventive medications and procedures has generally improved, but uptake of bypass surgery among CS still lags behind NCP.

Abstract A51: Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors.

Abstract Background: Of the 13.7 million cancer survivors in the United States, 22% are breast cancer survivors. By 2050, this number is expected to double. The 2005 Institute of Medicine's Report “From Cancer Patient to Cancer Survivor: Lost in Transition,” identified 4 essential components of survivorship care. Central to this includes the coordination between specialists and primary care providers. Primary Care Providers (PCPs) often play a critical role in the follow-up care for patients with chronic diseases. Cancer survivorship can now be viewed as a chronic disease however PCPs have little access to training and education in survivorship care. By offering culturally appropriate and trusted care in a setting that is familiar and accessible to their patients, PCPs in the community setting are in a unique position to impact cancer follow-up care for their patients. Thus greater involvement by community PCPs is likely to impact cancer survivorship disparities. We sought to survey PCP attitudes regarding cancer survivorship care delivery. Methods: The Illinois Breast and Cervical Cancer Program (IBCCP) is part of the Center for Disease Control's National Breast and Cervical Cancer Early Detection Program. This program provides access to breast and cervical cancer screening services to underserved women. Illinois has 36 lead agencies. A 10-question survey based on the National Cancer Institute's Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) was given to IBCCP providers. Providers were surveyed about their attitudes and self-efficacy as well as preferences for breast cancer care delivery. The SPARCCS surveyed over 1000 PCPs on their knowledge and attitudes on breast cancer survivorship care. 83% of SPARCCS PCPs work in either private practice or as part of a large healthcare system. Results: 110 PCPs completed the IBCCP survey. 54% (n=59) were physicians, 28% (n= 31) nurse practitioners, and 17% (n= 19) identified as other. 94.5% (n= 104) of the respondents reported having patients with a breast cancer history. Compared to PCPs in the original SPARCCS survey, 37% IBCCP providers' preferred oncologists take primary responsibility (SPARCCS 25%, p=0.0057) and 13% IBCCP providers' preferred survivorship care be delivered in specialized survivorship clinics led by a clinician other than a physician (SPARCCS 4%, p=0.0002). The other survivorship care model preference differences were not statistically significant. Overall, community-PCPs surveyed preferred follow-up care be delivered through specialized clinics and/or by cancer specialists. Conclusions: Limited information exists regarding the role of community PCPs in breast cancer survivorship follow-up care for the underserved. Most providers in our survey stated they preferred follow-up care be delivered by the cancer specialist or through specialized survivorship clinics. The role to which improving provider knowledge, attitudes, and self-efficacy can impact preferences for care delivery needs to be explored. Citation Format: Zakiya Moton, Danielle Weston, Rebecca McFarland, Tamara Hamlish, Daniel Johnson, Maureen Mencarni, Shannon Lightner, Jean Becker, Funmi Olopade, Susan Hong. Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A51.

Breast cancer survivors' perceptions of survivorship care options.

As the number of breast cancer survivors increases, a durable model of comprehensive survivor care is needed, incorporating providers and/or visit types both within and outside of oncology. The objective of this study was to explore survivors' comfort with different clinician types or with a telephone/Internet-based virtual visit as components of survivorship care. Breast cancer survivors participating in a general survivorship survey completed an additional breast cancer-specific questionnaire evaluating the self-perceived impact of follow-up visits to various clinician types, or follow-up by a virtual visit, on survival, worrying, and stress related to cancer. A total of 218 breast cancer survivors completed the questionnaire. Most favored medical oncologist follow-up visits over those with primary care physicians (PCPs) or nurse practitioners (NPs) in terms of reduced worrying about cancer (odds ratio [OR], 2.21; P < .001), reduced stress around the visit (OR, 1.40; P = .002), and improved effect on cancer survival (OR, 2.38; P < .001). However, the majority also displayed substantial comfort with both PCPs and NPs in the same domains. Patients rated a virtual visit as having a less favorable impact on cancer survival and cancer-related worrying compared with in-person visits with clinicians. Breast cancer survivors are comfortable with both PCPs and NPs providing follow-up care, although they indicate a preference for medical oncologists. Given patients' negative impressions of a virtual visit, increased familiarity with and research investigating this emerging concept are needed. The NP-led survivorship clinic model, with increased guidance for PCPs, offers a promising route for improving quality of and satisfaction with survivor care.