Integrated Supportive Care Pathway (ISCP) for Advanced Cancer: A design-and-evaluation plan for reducing unmet needs and supporting families

General
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Integrated Supportive Care Pathway (ISCP) for Advanced Cancer: A design-and-evaluation plan for reducing unmet needs and supporting families

A new, evidence-informed approach is being developed to address unmet supportive care needs for people with advanced cancer and their informal caregivers. The Integrated Supportive Care Pathway (ISCP) combines routine screening for unmet needs, early structured family meetings, and caregiver-focused navigation, with longitudinal evaluation to learn for whom it works, under what conditions, and at what cost.

What is the ISCP?

The ISCP brings together three core components that have shown promise in prior research:

  • Routine unmet-need screening at regular points in care to identify psychological, informational, physical, and practical needs.
  • Early structured family meetings to align goals, clarify roles, and surface caregiver and patient concerns.
  • Caregiver-focused navigation to connect informal caregivers with resources, supports, and care-team communication.

These components are designed to be evaluated over time, with outcomes such as unmet needs, distress, quality of life, caregiver burden, and healthcare utilization tracked longitudinally to understand impact and cost considerations.

Evidence base and knowns vs uncertainties

  • Unmet supportive care needs are common among people with advanced cancer and their informal caregivers, spanning multiple domains and linked with higher distress. This underpins the rationale for routine screening and proactive support.01-04
  • Structured family meetings in palliative and advanced cancer contexts show potential benefits, including better alignment of goals and clearer identification of needs, though evidence is heterogeneous and context-dependent.05
  • There is supportive evidence for the individual components (screening, family meetings, caregiver navigation) across studies, but direct evidence for a fully integrated ISCP is not yet established and requires prospective evaluation.06
  • Validated measurement frameworks exist for needs, distress, quality of life, caregiver burden, and healthcare utilization, enabling longitudinal assessment, but cross-study instrument heterogeneity calls for standardization in a local evaluation plan.07-09
  • Economic and real-world implementation data for scalable supportive care interventions remain limited; robust economic analyses and pragmatic implementation research are needed.10

Knowns and uncertainties will be clearly labeled in communications to avoid overstatements about ISCP efficacy and to guide transparent fundraising and evaluation planning.

Local context and rationale

Locally, ISCP aims to complement existing cancer care pathways by systematizing screening and caregiver support within routine care workflows. This aligns with funder and community expectations for person-centered care, dignity, and measurable improvements in patient and family experience. The plan emphasizes transparency about evidence limitations and a phased approach to implementation with rigorous evaluation.

How ISCP would work in practice

  • Screening cadence: routine unmet-need screening at key care touchpoints (e.g., on entry to palliative or advanced treatment pathways, and at regular intervals thereafter).
  • Timing of family meetings: early conversations after ISCP activation, with follow-up meetings as needs evolve.
  • Roles: dedicated navigators to support caregivers, trained clinicians to lead family meetings, and integration with the care team to ensure timely responses to identified needs.
  • Training and resources: workforce development for screening administration, family-meeting facilitation, and navigator roles; IT tools to document needs and track referrals.

Evaluation plan and outcomes

  • Primary outcomes: unmet supportive care needs, caregiver distress, patient quality of life, caregiver burden.
  • Secondary outcomes: healthcare utilization (e.g., emergency visits, hospitalizations), satisfaction with care, and process measures (screening completion, meeting attendance, navigator engagement).
  • Design considerations: longitudinal, pragmatic evaluation with standardized instruments to enable comparability; explicit labeling of knowns vs uncertainties; mixed-methods components to capture contextual factors.

Implementation considerations and scalability

  • Workforce implications: define navigator roles and required training; plan scalable models with phased pilots.
  • IT and integration: ensure screening data capture integrates with existing EHRs and care coordination workflows while safeguarding privacy.
  • Equity and adaptability: tailor ISCP components to diverse populations and care settings; monitor barriers and facilitators to equitable access.
  • Phased rollout: implement in pilot sites, with ongoing process evaluation and cost-effectiveness analyses to inform broader adoption.

Safety, ethics, and messaging guardrails

  • Protect privacy and dignity; use non-sensational language and avoid patient-identifiable information.
  • Label knowns vs uncertainties clearly; avoid implying guaranteed outcomes; present evaluation plans and potential process improvements instead.
  • Cite sources and provide URLs where platform permits; ensure alignment with local branding and regulatory requirements.

Call to action and next steps

  • Donate to support local, privacy-respecting cancer care and supportive services.
  • Learn about unmet-need screening, family meetings, and caregiver navigation in ISCP.
  • Share this post to raise awareness and advocate for dignified, person-centered care.
  • Join our updates list to follow ISCP development, pilots, and evaluation plans.
  • Explore resources on caregiver support and patient-centered communication.

Visual and accessibility plan

  • Neutral infographic outline: ISCP components (screening, family meetings, navigation) and a simplified evaluation framework; include alt-text for accessibility.
  • Caregiver-support illustration concepts with high contrast, legible typography, and descriptive captions.

Short actionable references (PMIDs with links)

Note: The ISCP concept relies on evidence for its components and calls for prospective evaluation to determine effectiveness, generalizability, and cost implications in local settings.