1019 - Addressing Follow-Up Gaps in Prostate Cancer Survivorship Care: A Nurse-Led Pilot Program in a Developing Country

Purpose/Objective(s): Regular follow-up is critical for prostate cancer survivors to detect recurrences, manage side effects, and improve quality of life. However, in Chile, no formal survivorship program exists within the healthcare system. Follow-up is managed in tertiary care centers, but specialist shortages and increasing patient volumes create significant barriers, particularly for those receiving radiotherapy (RT). This study aims to evaluate the impact of a nurse-led survivorship care model in addressing follow-up gaps in prostate cancer patients treated with RT.

Materials/Methods: A pilot follow-up program was implemented in a radiotherapy department staffed by four full-time uro-oncology radiation oncologists. The study included non-metastatic prostate cancer patients who received definitive RT or post-operative RT, with or without androgen deprivation therapy. The intervention was led by a part-time advanced practice nurse (APN) and focused on three key areas: (1) early detection of disease recurrence, (2) identification of RT-related toxicities requiring specialist intervention, and (3) enhancement of clinical data collection for outcome monitoring. A structured patient records system was utilized to facilitate timely referrals to specialists when necessary. Patient outcomes from January 2022 to June 2023 were compared with a retrospective cohort of patients managed exclusively by oncologists from January 2020 to December 2021, with a primary focus on follow-up adherence and care capacity.

Results: During the pilot program's implementation (January 2022–June 2023), the number of prostate cancer patients requiring follow-up increased by 43% (from 283 to 497), mirroring a similar rise in patients treated with radiotherapy (RT) compared to the January 2020–December 2021 period. Despite this, the proportion of patients without follow-up showed only a modest increase, from 30% to 38%. Specialist capacity remained unchanged in absolute terms, leading to a relative reduction in the percentage of patients followed exclusively by oncologists (70% to 43%). The nurse-led program accounted for 20% of total follow-ups, effectively mitigating a projected 40% drop in overall follow-up capacity. Among nurse-managed patients, 94% adhered to scheduled visits, and 15% required specialist referral due to significant RT-related toxicities or PSA progression.

Conclusion: A nurse-led survivorship program effectively reduced follow-up gaps, enhanced patient adherence, and optimized specialist resource utilization in a high-demand RT setting. The model demonstrated feasibility and scalability, particularly in environments with workforce shortages. Future directions include evaluating patient-reported outcomes, cost-effectiveness, and the integration of AI-driven digital tools to ensure sustainable and equitable long-term survivorship care.