Clinic Reported Facilitators and Barriers to Pediatric Cancer Survivor Care Delivery among Survivorship Clinics: A Fishbone Analysis

Background: Childhood cancer survivors need regular, long-term survivor care. The Children’s Oncology Group (COG) recommends that pediatric cancer patients receive ongoing, evidence-based surveillance for late-effects beginning two years after cancer therapy completion. A third of survivors are not engaging in long-term survivorship care. This study assessed barriers and facilitators to follow-up survivorship care through the perspectives of pediatric cancer clinic representatives. Methods: : As part of a hybrid implementation-effectiveness trial, a representative from 12 participating pediatric cancer survivor clinics completed a survey about site characteristics, and a semi-structured interview on barriers and facilitators to survivor care delivery at their institution. Interviews were grounded in the socio-ecological model (SEM) framework and utilized a Fishbone diagram to identify the root causes of a problem. We ran descriptive statistics and conducted thematic analyses of the interview transcripts to create two meta-Fishbone diagrams. Results: : Participating clinics (n=12) have existed for at least five years (mean=30, range= 5-97), and half (50%) report seeing 100-200 survivors annually. In the Fishbone diagram, top facilitators were in the SEM domain of Organization, specifically with familiar staff (100%), resource utilization (92%), survivorship-exclusive staff (83%), and clinic processes (83%). Common barriers were in the domains of Organization, Community, and Policy which included technology limits (92%), scheduling issues (92%), insufficient funding/insurance (92%), and distance/transportation (100%). Conclusion: Using the Fishbone diagram was instrumental in understanding multilevel contextual issues related to survivor care delivery for pediatric cancer clinics. Future efforts can develop education, processes, and services to promote cancer follow-up care.