Lisa Shalkowski, RN, BSN, MSM Barbara Francks, RN, BSN, CBCN Virtua’s breast care program strategy evolved from a fragmented process involving over 60 steps that resulted in random referrals, limited [ Read More ]
December 2012 VOL 3, NO 6
Navigation in the Age of Personalized Medicine
Ms Shockney discussed how having navigators intervene very early on in the cancer continuum to establish survivorship care can affect treatment, outcomes, and complications, illustrating her points with composite care studies. All of her patients are referred to a rehab medicine consultation before surgery. She showed the difference in outcomes when a nurse navigator performs a proactive assessment and the recommended steps are taken vs the results of a reactive approach to survivorship care, resulting in measurable differences in quality of life.
A video illustrated the unique needs of patients with metastatic breast cancer who participated in a metastatic couples retreat. (Ms Shockney had been conducting retreats for patients with stage I through III cancer and was always asked by patients with metastatic disease when there would be one for them.) The retreat included separate groups for men and women as well as sessions during which all got together to share what had happened in their respective groups. There were workshops to make cards for children—for birthdays, communion, marriage, and the birth of their first child—for patients who likely will not live to participate in these milestones with their children. The retreat was provided free through donations, fundraising, and grants.
Ms Gentry summarized the qualities that make cancer care personalized, such as targeting treatments to the patient’s particular disease, eg, by knowing the molecular subtype of the tumor and ensuring affordable and timely care. The treatment and the patient are 2 interacting parts. The treatment factor includes tumor biology, targeted agents, toxicities, trials, and informatics; and the patient factor includes age, comorbidities, prognosis, personal values, and resources.
Ms Gentry described the Choosing Wisely® campaign that is meant to help patients choose care that is evidence-based, will be helpful, will not be redundant, will not be harmful, and is necessary. She listed the top 5 practices that ASCO considers inappropriate, which are:
- Treatments at the end of life
- Imaging for early-stage prostate cancer
- Imaging for early-stage breast cancer
- Follow-up tumor markers and test for breast cancer survivors
- White blood cell growth factors in infection prevention
Ms Gentry discussed the rationale behind these recommendations, which in general are considered inappropriate because they do not prolong life, may lead to false positives, are costly, and may cause harm.
Also inappropriate are cancer-directed treatments at the end of life for patients with solid tumors who have a low performance status, have not benefited from prior evidence-based interventions, and who are not eligible for clinical trials. There are exceptions to these, eg, a patient with HER2-positive breast cancer, or with multiple myeloma, or if low performance status is due to noncancer-related conditions. These recommendations interface with the navigation role in that they are measurable, provide educational opportunities, and allow navigators to interact with other members of the healthcare team.