We are into the final countdown with just a few weeks before our Sixth Annual Academy of Oncology Nurse & Patient Navigators (AONN+) Conference in Atlanta! This issue of the [ Read More ]
August 2015 VOL 6 NO 4
Category III: Quality, Outcomes, and Performance Improvement
- D1. Application of Lean Methodology to Improve Quality and Efficiency
- D2. Assessing and Understanding the Rehabilitation Needs of Patients with Cancer: A Rapid-Learning System Pilot
- D3. Bridging the Gap in Access to Ancillary Services for Newly Diagnosed Patients with Breast Cancer
- D4. Colon Cancer Quality Improvement: Timeliness to Diagnosis
- D5. Correlations Between Functional Interleukin-1 and Changes in Fatigue and Quality of Life in Children and Adolescents with Cancer
- D6. Developing a Highly Successful Navigation Program: Lessons Learned in the First 3 Years
- D7. Developing a Shared-Care Pathway for Enhancing Collaboration and Communication Between Oncology and Primary Care
- D8. Development and Evaluation of Free Evidence-Based Online Training
- D9. Development of a Pathway for Patients with Head and Neck Cancer to Improve Outcomes
- D10. Efficacy of Transdermal Granisetron Patch in Controlling Chemotherapy-Induced Nausea and Vomiting in Patients with Gastrointestinal Cancer
- D11. Efficacy of a Transdermal Granisetron Patch in Controlling Chemotherapy-Induced Nausea and Vomiting in Patients with Hematologic Cancer
- D12. Evaluating Survivorship Program Outcomes Through Qualitative Metrics
- D13. Evolving the Role of Oncology Nurse Navigator in Metastatic Non–Small-Cell Lung Cancer Molecular Diagnostic Process
- D14. Fast-Track Coordinator: An Innovative Model for Veteran Cancer Care Coordination
- D15. Improving Patient Care and Coordination Outside of Clinic Hours: Oncology Nurse Weekday, After-Hours, and Weekend Phone Call Coverage Program for a Multisite Oncology Practice
- D16. Increasing Referrals to the Genetic Counseling Program for All Patients with Ovarian, Fallopian Tube, and Primary Peritoneal Cancers
- D17. Levels of Cytokines IL-10 and IL-12p70 Show Correlation with Sleep and Quality of Life in Children and Adolescents with Cancer
- D18. Measuring the Impact on Time to Care: Nurse Navigation in the Breast Care Continuum
- D19. Multidisciplinary Approach to Improving Patient and Family Access to Supportive Services in an Academic Medical Center
- D20. Navigator-Led OncoFertility Preservation Program
- D21. Patient Perspective and Quality of Life: US Results from the First Global Neuroendocrine Tumor Patient Survey
- D22. Promoting and Developing Oncology Nurse Navigators Within the Penn Cancer Network
- D23. Sarcoma Survivors: Impact of Advanced Practice Nurse Clinic on Discovery of Needs
- D24. Screening Patients for Cancer Rehabilitation Needs in a Community Hospital Cancer Center
- D25. Setting the Course: Creating the Oncology Nurse Navigator Role in a Community Patient-Centered Specialty Practice
- D26. The Hendrick Cancer Center Navigation-to-Survivorship Program
- D27. The Impact of a Nurse Navigator in Developing a Head and Neck Cancer Program
- D28. The Multidisciplinary Team in Neuroendocrine Tumor Management: US Results from the First Global Neuroendocrine Tumor Patient Survey
- D29. Time Line from an Abnormal Mammogram to Biopsy
- D30. Validation of the STAR Program Physical Impairment and Functional Assessment Screening Tool: Improves Access to Cancer Rehabilitation Care and Identifies Physical Impairments
Enza Esposito-Nguyen, RN, MSN, ANP-BC; Lavinia Dobrea, RN, MS, OCN
The Center for Cancer Prevention and Treatment, St. Joseph Hospital, Orange, CA
Background: A growing volume of molecular diagnostic testing driven by the introduction of innovative targeted therapies in oncology has created additional operational pressures on healthcare delivery organizations and has raised concerns about the quality and efficiency of associated processes.
Objectives: To apply lean methodology using metastatic non–small-cell lung cancer (NSCLC) as a pilot disease state to evaluate current molecular testing processes, identify and quantify existing inefficiencies, design an improved process, and assess scalability of the pilot site for application across other tumor sites.
Methods: A modified lean methodology was used. Semistructured one-on-one interviews with a multidisciplinary team (MDT) of stakeholders representing oncology, pathology, interventional radiology, pulmonology, and administration were conducted. MDT-based value stream mapping workshops were conducted to describe the “current” and design the “future” state of molecular testing processes in patients with metastatic NSCLC. Patient chart reviews and operational data from a reference laboratory were evaluated to identify baseline inefficiencies and apply new process implementation of successful metrics.
Results: Interviews with 25 MDT stakeholders revealed a substantial variability in the molecular diagnosis processes and a lack of coordinated communication across disciplinary silos. Specifically, the consensus-derived “current” state map identified appropriate biopsy tissue (quality and quantity) and inconsistent protocol utilization among the major inefficiencies resulting in repeat biopsies. Analysis of records examining repeat biopsy rates and turnaround times confirmed the findings from the lean exercise. Development and implementation of the MDT-based molecular testing protocol, including the introduction of a tissue acquisition protocol, were identified as target areas for process variability improvement.
Conclusion: Inefficiencies exist in molecular testing processes and need to be identified and minimized as the burden of molecular testing increases. This pilot successfully employed a modified lean methodology to identify areas of improvement in the molecular testing process in patients with NSCLC and could be replicated in other relevant disease states. Program evaluation is under way to quantify the impact of this initiative on operational and patient care metrics.
Matthew R. LeBlanc, RN, BSN, OCN
DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, MD
Background: Today, electronic medical records (EMRs) function mostly as digital repositories of medical information, an analog of their paper forbearers. EMRs have yet to fulfill their promise of not only efficiently storing data, but of helping us to use data to inform understanding and guide clinical decision-making. Detailed information is collected about patient demographics, comorbidities, treatment, and outcomes every time a patient touches the system. The sum of individual patient records begins to look a lot like a research database—ever growing and reflective of actual clinical care. This mountain of data represents a mostly missed opportunity for inquiry and discovery. This study is based on data of patients with cancer collected routinely at a community cancer center’s radiation clinic.
Objective: To analyze the data related to the patient’s rehabilitation needs that were collected during routine clinical practice to better understand the rehabilitation needs of patients with cancer.
Methods: Patients are screened for rehabilitation needs using the STAR (Survivorship Training and Rehab) Program’s Physical Impairment and Functional Disability Screening Tool as they move through radiation treatment. This screening tool consists of 17 questions and screens for 13 types of potential rehabilitation needs. “Yes” answers on the screening tool indicate the presence of a symptom and trigger further assessment by oncology providers and interventions when deemed appropriate. The information collected is used to inform comprehensive individual patient care and was recorded and analyzed to inform future care decisions.
Results: In this study, 583 patients were screened for their rehabilitation needs at multiple points along their treatment, completing a total of 785 screenings. The top 4 symptoms reported included musculoskeletal pain (52%), cognitive impairment (39%), deconditioning (38%), and peripheral neuropathies (32%). The number of symptoms reported increased with the stage of cancer. On average, patients with lung cancer reported 4.5 symptoms, the most symptoms of any group, followed by patients with head and neck cancer, with an average of 3.92 symptoms per patient.
Conclusion: Reducing our patients’ suffering starts with understanding when and how they suffer. Increasingly, data collected through clinical practice represent a missed opportunity to further meaningful clinical understanding. This study shows that data collected through routine clinical practice at a community cancer center’s radiation clinic can be used to improve individual care, and to further understand the needs of a patient population. This study represents an early step toward building a system in which the ocean of collected data is fully used to rapidly inform and improve care.
Meghan Crockett, RN, BSN, OCN; Patricia Frey, RN, BSN; Marianne Huml, MS, APN, AOCN; Cheryl Ylinen, RD, CSO, LDN, CNSC; Craig Pressley, LCSW; Susan Chalkey, RN, BSN, CN-BN; Mary Jane Hill, APN; Kristen Hogberg, OTR/L, MSHA, CLT-LANA
Northwestern Medicine Cancer Center, Warrenville, IL
Background: When patients with breast cancer are diagnosed and receive initial care in a surgeon’s office before being referred to a comprehensive cancer center (CCC), ancillary support services are not directly available to them. Patients remain unaware until they present to a CCC and are seen by the medical oncology, radiation oncology, or infusion team members. This was identified as a gap in care.
Objective: To close the gap in care for patients with breast cancer receiving care at the surgeon’s office before being referred to a CCC.
Methods: An interdisciplinary team, including oncology nurse navigators, social workers, dietitians, occupational therapists, and financial counselors, was created. This team began a Support Services Clinic (SSC) for newly diagnosed patients with breast cancer. Patients were referred by the oncology nurse navigator at the surgeon’s office after the initial visit. The oncology nurse navigator at the CCC serves as the coordinator for the SSC. During the 2-hour SSC visit, the occupational therapist performs a preoperative lymphedema risk assessment followed by appointments with the ancillary team members. Team members introduce themselves and their role and provide their contact information. The dietitian provides information on healthy eating and nutrition tips for patients with cancer. The social worker performs a distress screening and, if necessary, the patient is referred to appropriate resources. Additional programs offered to patients include the Living-Well Cancer Resource Center and the American Cancer Society. Patients complete a brief survey at the end of the visit.
Results: When asked if patients were initially aware of the services available to them at the CCC, 100% of the patients stated that they were not. Patients were then asked to rate the time spent at the appointment on a scale of 1 (not helpful) to 5 (very helpful). Ninety-two percent rated the time spent as 5. Patients were asked to rate the value of the information provided by each team member. This rating also used a scale of 1 (not at all valuable) to 5 (very valuable). All members of the team were rated as 5 by 90% of patients.
Conclusion: Patients who received care at the surgeon’s office before being referred to the CCC were unaware of the ancillary support services available to them. The SSC proved valuable to patients. As a result of this study, we are expanding the SSC to cancer diagnoses beyond breast cancer.
Amanda Recchini, BSN, RN, OCN; Gean Brown, MSN, RN, OCN
Middlesex Hospital Cancer Center, Middletown, CT
Background: Colon cancer is the third most frequently diagnosed cancer in the United States, with an estimated 96,830 cases diagnosed annually, according to the 2014 data from the National Comprehensive Cancer Network (NCCN). A literature review that looked at the time to diagnosis of patients with colorectal cancer nationally was completed. The goal of this review was to establish benchmarks that could be used to assess the strengths and weaknesses of the workup process at Middlesex Hospital. Unfortunately, the literature on the topic was very limited.
Objectives: To look at the timeliness of workup for a patient from the time of symptoms or screening colonoscopy to the start of treatment, and to identify areas for improvement, including timeliness to diagnosis and ensuring accordance with NCCN guidelines.
Methods: The Middlesex Hospital Tumor Registry ran a report on all patients diagnosed with colon cancer between January 1, 2011, and December 31, 2012, who had their workup and at least some of their first course of treatment at Middlesex Hospital. A chart review was done to look at the number of days from their gastrointestinal (GI) appointment to colonoscopy, date of colonoscopy, date of surgery, number of days from surgical consult to resection, and referral to a nurse navigator. Also included was whether a carcinoembryonic antigen (CEA) was drawn before treatment, and the number of days from diagnosis to treatment. These data were used as a benchmark to compare future data once improvements were implemented.
Results: The number of days from patients’ first contact with the system (for evaluation of symptoms or screening colonoscopy) to their first treatment from 2011 to 2012 showed the median of 31 days with a midspread of 12 to 58 days. The 2014 data showed an improvement of 18 days with a midspread of 8 to 28 days. From 2011 to 2012, 38% of patients were referred to the nurse navigator, and in 2014, 60% of patients were referred. The median number of days from GI appointment to colonoscopy from 2011 to 2012 was 21.5, and in 2014 the median was 15 days. From 2011 to 2012, 65.5% of patients had a CEA drawn before treatment, which increased to 88.9% in 2014. The number of colonoscopies performed from 2011 to 2012 was 5690 compared with 5836 in 2014.
Conclusion: These results showed 2 opportunities for improvement. The first was to see if the addition of a gastroenterologist would increase access to timely colonoscopies. The second opportunity was to increase the number of patients receiving a CEA before treatment per the NCCN guidelines. With the addition of 2 new gastroenterologists and the creation and implementation of an order set, improvement in the timeliness to diagnosis has been noted. To increase CEA compliance, educational information was distributed to the surgical and medical oncology offices. All areas showed improvement after the implementation of the action plan. The results of this study were shared at our Cancer Committee, surgical section meeting, and with Middlesex GI to show the impact it has had.
Emilana de Omena Bomfim, RN, MS, PhD Candidate1; Elen Anatriello, BS, MSc, PhD2; Michelle Darezzo Rodrigues Nunes, RN, MSc, PhD3; Jordana Carvalhaes de Moraes, undergraduate nursing student4; Michel Marcossi Cintra, undergraduate nursing student4; Luis Carlos Lopes Júnior, RN, MSc, PhD candidate4; Michele da Silva Miyauti, RN, MSc5; Regina Aparecida Garcia de Lima, RN, PhD4; Lucila Castanheira Nascimento, RN, PhD4; Milena Flória-Santos, MSc, PhD4
1University of Saskatchewan, College of Medicine, Saskatoon, Saskatchewan, Canada; 2Federal University of São Paulo, São José dos Campos, Brazil; 3University of the State of Rio de Janeiro, Maracanã, Brazil; 4Ribeirão Preto College of Nursing, University of São Paulo, Brazil; 5Baxter International Inc, Ribeirão Preto Area, São Paulo, Brazil
Background: Several studies have explored the hypothesis of involvement of the immune system in cancer-related fatigue (CRF) and health-related quality of life (HRQOL) in adults with cancer via release of cytokines. However, how the immune system may produce these outcomes remains a largely unanswered question. Furthermore, research on fatigue in children and adolescents with cancer has primarily included self-reports of this symptom, with scarce but increasing data exploring biologic variables related to CRF.
Objectives: To investigate the plasma levels of the cytokines interleukin (IL)-8, IL-1β, IL-6, IL-10, tumor necrosis factor-α, and IL-12p70 and correlate them with fatigue and quality of life in children and adolescents with cancer.
Methods: To comprehensively examine the influence of cytokines in CRF and HRQOL in children and adolescents with cancer, we investigated the plasma levels of pro- and anti-inflammatory cytokines and their correlation with fatigue and HRQOL in this population. This is a quantitative, descriptive, cross-sectional study conducted at the Clinical Hospital of the Faculty of Medicine of Ribeirão Preto at the University of São Paulo. Plasma levels of 6 cytokines were measured via flow cytometry. Consecutive newly diagnosed patients with cancer were recruited between January 2013 and March 2014. Patients aged 8 to 18 years and those who have started at least 1 session of chemotherapy or radiotherapy were enrolled. The study protocol was approved by the institutional research ethics board of the School of Nursing of Ribeirão Preto under protocol number 085/2012.
Results: The final sample consisted of 33 hospitalized children and adolescents aged 8 to 18 years. We found a correlation between general fatigue and IL-1β (r = –0.361; P = .039), and a correlation with quality of life was also noted with IL-1β (r = –0.382; P = .028). The results of this study indicate that there may be a relationship between cytokines, fatigue, and HRQOL in children and adolescents with cancer. Also, when analyzed, the correlation between fatigue and some confounding variables, such as blood cells, showed a link between general fatigue and neutrophils (r = –0.360; P = .040).
Conclusion: The link between general fatigue and neutrophils is a novel find in this population with cancer, implicating a possible IL-hematologic pathway for CRF. Our study suggests a potential role for cytokines in developing cancer-related symptoms, thus supporting the utility of the neuroimmunologic approach to the discovery of biomarkers linked to the clusters of cancer-related symptoms.
Heather Sheaffer, DSW, LCSW; Trish Gambino, RN, MSN; Eleanor Miller, RN, MSN, OCN; Peg Rummel, RN, MHA, OCN, NE-BE
Abramson Cancer Center, Penn Medicine, Philadelphia
Background: Developing a successful navigation program takes vision as well as thoughtful day-to-day operations. A navigation program at the Abramson Cancer Center (ACC) of Penn Medicine grew from that concept. It was developed and implemented to facilitate access to care.
Objectives: To describe the ACC Navigation Program created to facilitate access to patient care, and to present the journey of developing a navigation program to meet the goals of your cancer center or cancer program.
Methods: The ACC’s Patient and Family Services program was reorganized in structure and personnel in January 2012. At that time, 4 nurse navigator positions were created to meet the access and care coordination needs of patients and families. They are experts in navigating complex healthcare situations; they use their nursing skills to facilitate and reinforce plans of care, to negotiate barriers to treatment, and to refer patients and families to supportive services. Strategically, referral sources for navigation services at the ACC vary and include patients, families, providers, call centers, community contacts, and websites. The majority of website contacts is patients “shopping” for a provider, often seeking a second opinion or a clinical trial, which are highly desirable referrals. The navigators are skilled at marketing the ACC and in expediting appointments, which translates to patients choosing Penn Medicine after contact with the navigator. Patients may connect (or reconnect) with a navigator at any point in their cancer care.
Results: This mix of interactions has led to a highly successful program that can be replicated in other centers. An analysis of the contribution margin of the ACC Navigation Program at Penn Medicine has shown that it quickly became highly successful, demonstrating a $16-million return on investment in 2 years and a significant, double-digit decrease in outmigration of patients who worked with the navigator. The requests from patients and providers for navigation grew exponentially, demonstrating the value of navigation to the patient and provider experience. The program has become a focus of the cancer care at Penn Medicine. The key questions for discussion in creating a navigation program include—(1) What are the appropriate credentials for a navigator? (2) What populations should be navigated? (3) Will the navigator connect with all patients in those populations? (4) How do you handle patients who are not followed by a navigator? (5) What is the role of the navigator on the team? (6) Will the navigator schedule or order necessary tests? (7) How do you “prove” the value of your navigation program? (8) How do you communicate that success? (9) How do you grow the program?
Conclusion: Conceptualizing and building a successful navigation program that grows with your cancer center is possible with careful planning and standardized daily operations of the navigator. The ACC program can be replicated across the country.
Deborah Christensen, BSN, RN, OCN; Katie Wahler, BSN, RN, OCN
Intermountain Southwest Cancer Center, St. George, UT
Background: Patients with cancer and their healthcare providers can be confused about when and how partnering in medical care happens. Some studies indicate that as few as 16% of patients with cancer perceive a pattern of shared care between their primary care provider (PCP) and oncologist. In one study, more than 50% of the 42 patients stated they preferred survivorship care and surveillance to be done by their oncologists because of perceived lack of care continuity and PCP involvement in the original oncology treatment. However, one-third of those patients believed that there was a role for the PCP to supplement oncology care.
Objectives: Nurse navigators at Intermountain Southwest Cancer Center set out to (1) identify key points where effective communication could take place between oncology and primary care, (2) develop methods for communication delivery and timing, and (3) inform oncologists and PCPs on the usefulness of the navigator to enhance communication, care coordination, and comprehensive patient care.
Methods: The nurse navigators partnered with oncologists to build on an already successful navigation pathway. Specific to enhancing oncology and PCP collaboration, the new pathway included (1) specific touch points in the treatment trajectory when communication was completed by the navigator and sent to the patient’s PCP, and (2) the completion of a treatment summary and care plan sent to the PCP at the conclusion of the patient’s oncology treatments. Communication templates and a survivorship summary were built into the oncology electronic medical record to help streamline the process. Another patient-centered addition to navigation was scheduling advance care planning visits to occur after patients were in treatment and after the initial shock of a cancer diagnosis had passed. The shared-care pathway was presented to the medical community during a continuing medical education poster and podium presentation.
Results: Nurse navigators now fax letters to the referring PCP, documenting when the navigator first saw the patient and when the patient is scheduled for the initial oncology consult. When active treatment is complete, the navigator prepares and reviews a treatment summary and care plan with the patient and sends a copy to the patient’s PCP. Anecdotally, patients have expressed satisfaction with the end-of-treatment visit and summary review. The shared-care process will be evaluated after a formal survey of patient and provider satisfaction with navigation at the cancer center.
Conclusion: Navigation has been shown to positively impact quality patient care. With the inclusion of key points in time where navigators assist in communication and collaboration between PCPs and the oncology team, it is expected that patients and healthcare providers will be more confident in understanding and supporting the unique needs of survivorship.
Mandi Pratt-Chapman, MA1; Anne Willis, MA2; Shaira Morales3; Monique House, MPH, CHES3
1George Washington University Cancer Institute, Washington, DC; 2Patient-Centered Programs, George Washington University Cancer Institute, Washington, DC; 3Health Care Professional Education, George Washington University Cancer Institute, Washington, DC
Background: As the field of patient navigation has quickly evolved over the past 25 years, no clear professional standards have been developed for patient navigators who do not hold a clinical license. To advance as a field and most effectively meet the needs of patients, more clarity is needed around the patient navigator’s unique role on the healthcare team and the patient navigator’s scope of practice. In 2014, the George Washington University Cancer Institute established the first-ever Oncology Patient Navigator Competencies as a first step in creating clarity around the patient navigator’s role. To create more standardization across the profession, we created the first-ever free online training program for nonclinically licensed patient navigators using consensus-based competencies.
Objective: To train nonclinically licensed patient navigators through a free online training program.
Methods: We developed a competency-based curriculum by developing learning objectives for each competency and then creating content to correspond with each learning objective. The training content was reviewed by 6 patient navigation experts for accuracy and relevancy. Content was then made interactive using Adobe Captivate and created into an online course using the LearnSomething learning management system.
Results: Launched in May 2015, the 20-hour “Oncology Patient Navigator Training: The Fundamentals” program contains 20 lessons covering an overview of patient navigation and training, the basics of healthcare and patient navigation, and enhancing communication, professionalism, and practice. Each lesson includes a preassessment and postassessment to measure knowledge change as well as a quiz to measure the learner’s knowledge of the content. Each lesson also includes an interactive, multimedia presentation with learning checkpoints and case studies. We will present evaluation results related to knowledge change from pre- and postassessments; assessments of whether new skills were learned, whether knowledge base was enhanced, whether content is useful and relevant to professional development, and whether new strategies, skills, or information will be applied; and knowledge quizzes to assess competency.
Conclusion: Patient navigators need to be equipped with the skills and knowledge to effectively and efficiently navigate patients across the care continuum. The Oncology Patient Navigator Training: The Fundamentals program trains patient navigators for their role and helps to provide consistency across the profession by creating a baseline for the patient navigator role.
Margaret Rummel, MHA, OCN, NE-BC; Audrey Caspar-Clark, RD, LDN, CSO; Tracy Lautenbach, MSW, LCSW, OSW-C; Katrina V.B. Claghorn, MS, CSO, LDN
Abramson Cancer Center, Penn Medicine, Philadelphia, PA
Background: Head and neck cancer (HNC) and its treatment is complex and significantly affects the quality of life of the patient and the caregiver. The HNC team at the Abramson Cancer Center and Penn Medicine Radiation Oncology identified gaps and fragmented care that impacted patients’ treatment course. In 2012, a nurse navigator was hired for this patient population to help improve patients’ access to care and eliminate the barriers that impede care.
Objectives: The 4 goals for this project were (1) to develop a comprehensive approach to coordinating a personalized plan of care, (2) to develop a patient-centered guide for patients and their caregivers to navigate the complexity of HNC treatments along the continuum of care, and to ensure that all components of care are met in a timely and coordinated manner, (3) to develop a standardized order set in the electronic medical records (EMRs) that included treatment options from diagnosis through survivorship, and (4) to standardize educational materials across all providers.
Methods: The HNC team met on an ongoing basis to develop the pathway that is used by providers caring for patients with HNC. We identified all necessary services that were involved during their treatment course. An order set was developed in the EMR to consult the nurse navigator and all necessary services to expedite referrals. Symptom management education materials were standardized to ensure consistency across clinics. These were made available through the EMR, and a web-based tool was developed with OncoLink for patients to use to manage their plan of care. A weekly meeting with the HNC radiation oncologists was established to review patients who were initiating treatments, those receiving active treatment, and during posttreatment. The nurse navigator serves as the liaison between all members of the multidisciplinary HNC team.
Results: The nurse navigator has played a significant role in improving access to care for patients. Results of a small study of patients with HNC whose care was managed by a nurse navigator were more likely to receive all their care at the University of Pennsylvania versus unnavigated patients who only had surgery at the University of Pennsylvania but then sought treatment locally. A chart review also showed a significant increase in downstream revenue for patients managed by a nurse navigator. In addition, patients have regular and consistent access to the same person to answer questions and provide education.
Conclusion: Having a nurse navigator as part of the multidisciplinary team has a significant impact on keeping patients on treatment and in follow-up care. Patients who were navigated with appropriate and timely referrals were more likely to start treatments faster, which helps to prevent outmigration. It was shown that navigated patients generated more downstream revenue.
Loretta Williams, PhD, APRN1; Christine Brown, RN, BSN, MA2; Deborah Braccia, RN, MPA, PhD2
1Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston; 2Medical Affairs, ProStrakan Inc, Bedminster, NJ
Background: Patients with gastrointestinal (GI) cancer are at risk for chemotherapy-induced nausea and vomiting (CINV) because of their use of highly emetogenic chemotherapy regimens. Patients with GI cancer can also experience limited gut motility and absorptive capacity, potentially decreasing the effectiveness of oral medications. A granisetron transdermal system (GTS) has been shown to be as effective as oral granisetron (OG) in controlling CINV across multiple tumor types.
Objective: To examine the efficacy, safety, and patient satisfaction with GTS compared with OG in patients with GI cancer.
Methods: A randomized phase 3 study compared GTS (7-day application) to OG (2 mg daily for x days) in patients with cancer receiving moderately or highly emetogenic chemotherapy for 3 to 5 days. This post hoc analysis was limited to data from patients with GI cancer (N = 53). Rates of complete control (CC: no vomiting, mild nausea, no rescue medication), complete response (CR: no vomiting, no rescue medication), rescue medication, and patients’ global satisfaction using GTS or OG were compared.
Results: A total of 53 patients with GI cancer (27 patients using GTS, 26 using OG) were included. The majority of patients (43 [81%]) received cisplatin-based chemotherapy; 94% received highly emetogenic chemotherapy. The CC and CR rates were similar in the GTS (both 70%) and OG (CC, 69%; CR, 73%) groups. Lack of rescue medication was similar for GTS and OG (81% for both; P = .95), and patients’ global satisfaction did not differ (8.50 cm vs 8.22 cm; P = .48). The only GTS-related adverse event was 1 case of constipation.
Conclusion: GTS may be an effective option for controlling CINV in patients with GI cancer who are at high risk for CINV. Blinded, randomized, placebo-controlled trials in larger samples of patients are needed to confirm these preliminary results.
Karen A. Pekle, ANP, BS, BSN, MS1; Doris Wong2; Deborah Braccia, RN, MPA, PhD2
1New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY; 2ProStrakan Inc, Bedminster, NJ
Background: Multiday, highly emetogenic chemotherapy regimens are commonly used in the management of hematologic malignancies. Despite progress in prophylaxis, chemotherapy-induced nausea and vomiting (CINV), especially during the delayed phase, can remain a significant barrier to attaining planned chemotherapy doses on time for some patients. A granisetron transdermal system (GTS) has been shown to be as effective as oral granisetron (OG) in controlling CINV across multiple tumor types.
Objective: To examine the efficacy and safety of GTS in patients with hematologic cancer.
Methods: A randomized phase 3 study has been published comparing GTS (7-day application) and OG (2 mg daily) in patients receiving moderately or highly emetogenic chemotherapy for 3 to 5 days. Data for this post hoc analysis were limited to patients with a primary tumor diagnosis of lymphoma (N = 51), leukemia (N = 27), or multiple myeloma (N = 5). The rates of complete control (CC: no vomiting, mild nausea, no rescue medication) and complete response (CR: no vomiting, no rescue medication) using GTS or OG were compared during the acute phase (first 24 hours) and the delayed phase (days 2-5) after chemotherapy. The need for rescue medication and patient assessment of response to therapy were also compared.
Results: A total of 83 patients with hematologic cancer (31 GTS, 52 OG) were included. The majority of patients received a noncisplatin regimen with corticosteroids (59 patients, 71%). Patients received chemotherapy for 3 days (37 patients [45%]) or 4 to 5 days (46 patients [55%]). During the acute phase of CINV, the CC rate (94%) and CR rate (94%) in the GTS group were similar to the rates in the overall population (94% and 95%, respectively). There was no difference in CC and CR between GTS and OG in the acute phase (P = .90 and P = .59, respectively). In the delayed phase, GTS resulted in rates of CC of 87% and CR of 90% compared with CC of 77% and CR of 81% with OG (P = .26 and P = .25, respectively). Use of rescue medication and patient assessment of overall response to therapy were not different between the arms (P = .60 and P = .92, respectively). GTS was well tolerated; the only treatment-related adverse event was 1 case of mild constipation.
Conclusion: This retrospective analysis suggests that GTS may be an appropriate option for the prevention of CINV in patients with hematologic cancer. A trend toward improved control in the delayed phase was observed. Further investigation of a benefit in delayed CINV for hematologic malignancies may be warranted.
Catherine Creme Henry, MA1; Janine Guglielmino, MA1; Kathy Meyers, PhD2; Arin Ahlum Hanson, MPH, CHES1; Amy Grillo1
1Living Beyond Breast Cancer, Bala Cynwyd, PA; 2Independent Researcher, Philadelphia, PA
Background: The organization Living Beyond Breast Cancer (LBBC) provides education and support services for patients with breast cancer. LBBC’s programs and services are delivered across many platforms, including online, live, over the phone, and in print. To effectively assess the knowledge acquisition, quality-of-life improvements, and the anticipated positive health behaviors of participants, a comprehensive qualitative evaluation tool was needed to compare within and across the program’s platforms.
Objectives: To enable participants to understand the model LBBC developed to evaluate its multiplatform survivorship programming, to identify stakeholders and goals in survivorship programming at their institutions, and more effectively evaluate outcomes.
Methods: The LBBC staff identified the audiences served by LBBC programs, the overarching program goals and outcomes for participants, and the types of feedback that are necessary for future program planning. A landscape analysis of peer organizations explored other models for survivorship program evaluation, and identified the types of program outcomes that are reported to key stakeholders in grant writing, annual reports, and descriptions of organizational impact.
Results: LBBC programs are live, archived, in print, and online simultaneously. Pre- and postprogram testing of participants was not a viable option. A qualitative postprogram evaluation tool was developed to measure knowledge acquisition, quality-of-life improvements, and anticipated positive health behaviors. The tool is distributed online and in print. A monthly drawing for a $25 gift card incentivizes participation. Through the development of a qualitative evaluation tool to measure survivorship program outcomes, LBBC is able to report on the effectiveness of its programs and services to program participants, funders, and other key stakeholders. Through this tool, LBBC measures knowledge acquisition, quality-of-life improvements, and anticipated positive health behaviors, while also collecting information about the participants’ demographics and breast cancer history.
Conclusion: The intentional design of the tool allows LBBC to analyze the outcome differences among the program’s delivery platforms, audience types, and participant demographics (eg, education level, age at diagnosis, time since diagnosis). The nurse navigators who are responsible for survivorship programming may also consider a qualitative postprogram evaluation as a useful tool for assessing the program outcomes and reporting progress toward goals to funders and other stakeholders.
Enza Esposito-Nguyen, RN, MSN, ANP-BC; Lavinia Dobrea, RN, MS, OCN
The Center for Cancer Prevention and Treatment, St. Joseph Hospital, Orange, CA
Background: Molecular diagnostics–based targeted therapies have been shown to improve patient outcomes. The growing volume of molecular testing is contributing to the operational burden on healthcare delivery and adding new steps to the patient journey through cancer diagnosis and treatment.
Objective: To identify opportunities for the nurse navigator to improve operational efficiencies and patient experience using molecular diagnostics in metastatic non–small-cell lung cancer (NSCLC) as a pilot disease state.
Methods: A lean project was implemented and a value stream mapping exercise was conducted across a multidisciplinary team to describe the “current” and design the “future” state of the molecular testing process in NSCLC. Current and future state maps were evaluated to identify actionable opportunities for an existing nurse navigator in terms of institutional operational efficiency and patient experience.
Results: Lack of coordinated communication across disciplinary silos, inconsistent protocol utilization, and appropriateness of biopsy tissue (quality and quantity) were identified among the major inefficiencies that contribute to patients multiple and potentially redundant encounters with the healthcare delivery system and referrals for repeat biopsies. The nurse navigator is the central glue in a thoracic oncology program, and is well- positioned to disseminate the results of a lean exercise to improve quality and quantity of biopsy rates. Furthermore, she or he can collaborate with clinical research to expand and improve a tissue acquisition protocol.
Conclusion: Inefficiencies exist in molecular testing processes and need to be identified and minimized as the burden of molecular testing increases. Oncology nurse navigators may have an opportunity to improve the quality of a molecular diagnostics and tissue acquisition program for patients with metastatic NSCLC through collaboration with clinical research and other disciplines. Program evaluation is under way to quantify the impact of this initiative on operational and patient care metrics.
Sonya Curry, MSN ACNS-BC; Jennifer Smith, MSN, CNP
Louis Stokes Cleveland Veteran Affairs Medical Center, OH
Background: Timely access and adequate communication are essential to and facilitate quality cancer care. Oncology nurse navigators improve care and are vital for vulnerable patient populations, such as veterans. Providers at the Louis Stokes Cleveland Veterans Affairs Medical Center (LSCVAMC) voiced concerns that the process for patients with a cancer-related concern was fragmented, leading to potential delays in cancer care. Veterans said that they did not have a primary point of contact to discuss their healthcare issues. The LSCVAMC has implemented a fast-track coordinator (FTC) position to address these concerns and to expedite care for veterans with cancer. The FTC consult assists in expediting a cancer workup. This novel system provides an opportunity to increase patient satisfaction, maximize efficiency, reduce the time to diagnosis, and decrease the time to first cancer treatment.
Objective: To describe how an innovative FTC uses the FTC consult to expedite care and increase communication for veterans with a cancer concern.
Methods: The FTC is the primary point of contact for veterans, their families, and providers from the initial cancer-related concern to diagnosis. The FTC process is initiated by the FTC consult from the triaging oncologist by creating an alert in the electronic medical record (EMR). After entering the FTC consult, the FTC makes initial contact with the veteran to ensure the veteran understands the role of the FTC, to identify barriers to care, and to coordinate care. The FTC continuously monitors the progression of diagnostic testing to ensure timeliness and prompt identification of delays and concerns. If a cancer diagnosis is received, the FTC facilitates a case presentation to a multidisciplinary tumor board and guides the care based on those recommendations. During the diagnostic process, the FTC communicates the care process to the healthcare team using EMR documentation and alerts. After a diagnosis of cancer is made or is ruled out, the veteran is handed off in the EMR to the appropriate services.
Results: In the first few weeks of the FTC using the FTC consult, there was 1 consult weekly; currently, 2 veterans are being referred weekly. A total of 10 patients have been referred since the implementation of the FTC template consult. The current system has streamlined the process, and veterans have expressed satisfaction with having a primary point of contact.
Conclusion: The FTC process has the potential to greatly improve cancer care and to improve communication for veterans with a cancer concern. The FTC will monitor and track the progression of patients. These data will allow the LSCVAMC to identify areas of delay and the potential for improvement to ensure continuous quality improvement in our cancer care.
Jessica Engel, DNP, MS, RN, APNP, AOCNP, CBCN, FNP-BC
Stevens Point Cancer Care, Marshfield Clinic, Stevens Point, WI
Background: Patients with cancer have needs around the clock, many of which are unanticipated and urgent. Therefore, management of patient phone calls by a knowledgeable provider is essential to providing patients with appropriate information, guidance, and reassurance, especially for calls placed to the clinic after hours and on weekends. Historically, our oncology clinics have been staffed with a triage nurse to manage patient phone calls during the day, with evening and weekend calls covered by oncology physicians. In 2012, the Marshfield Clinic instituted after-hours call coverage incorporating oncology nurses into this program.
Objectives: To describe the Marshfield Clinic oncology service line enhanced program for after-hours call coverage with respect to managing the patient call volume and improving quality of patient care and coordination, as well as the role of oncology nurse navigators within this program.
Methods: The Marshfield Clinic is a multisite system of healthcare in central, western, and northern Wisconsin, with 12 sites providing cancer care. One oncology nurse is responsible for system-wide after-hours call coverage weekly, and carries a pager during that time. Nurses are trained and they follow clinic phone triage guidelines and protocols. When a patient calls the after-hours phone number, the call is first triaged by the nurse who manages the call. If the nurse requires further direction, the oncology physician on call is available for consult. All calls are documented on a form and in the medical record. Collected information includes the reason for the call, whether or not the physician was contacted, the intervention made, and time taken. Routine audits of the calls are made to ensure that guidelines are being followed and that documentation is complete.
Results: Information collected as part of this program for purposes of quality assessment and outcome measurement was evaluated from January 2013 to May 31, 2015. In 2013, 1082 patient calls were accepted, with an average of 20.4 calls weekly. Physician notification occurred at an average of 3.2 calls weekly. The most frequent reasons for calling were fever (12%), medication clarification (9.5%), and pain (12.8%). In 2014, 1164 calls were made, averaging 22.4 calls weekly with physician notification 5.9 times weekly. The most common concerns were fever (10.5%), medication clarification (9.2%), and pain (8.9%). Thus far in 2015, there have been 444 calls at an average of 21 calls weekly with physician notification 3 times weekly. The most common concerns were fever (10%), medication clarification (11.5 %), and pain (10.0%).
Conclusion: An after-hours and weekend call coverage program incorporating oncology nurses is feasible and successful in managing patient call volume, improving patient care and coordination, improving physician call satisfaction, increasing nurses’ knowledge and experience, and improving documentation. Oncology nurses are able to support and guide patients the majority of the time by utilizing nursing protocols and guidelines; when physician consultation is required, this is done easily and effectively.
Candace Bashaw RN, BSN, OCN
Levine Cancer Institute-Concord, Carolinas HealthCare System, NC
Background: The National Comprehensive Cancer Network (NCCN) guidelines for 2015 recommend that all patients with a personal history of invasive ovarian, fallopian tube, and primary peritoneal cancers should be referred to and screened by a genetic counselor to determine if genetic testing is appropriate for them, and to discuss the implications of testing and abnormal results with the patient and the family. This testing includes screening for BRCA1 and BRCA2 mutations, Lynch syndrome, and other genetic syndromes. The referral rate for the Levine Cancer Institute-Concord (LCI-Concord) to the genetic counselor fell well below the NCCN recommendations. LCI-Concord has a full-time genetic counselor and a gynecology nurse navigator. We collected data from March 2013 to February 2014 to assess the referral rate. During that time, 23 patients were diagnosed with ovarian, fallopian tube, or primary peritoneal cancer. Of those 23 patients, only 14 (60%) were given written or verbal information about the genetic counselor program. Eight (35%) patients were seen by the genetic counselor; 7 patients were tested, and 1 had an abnormal result.
Objectives: To increase the number of patients getting verbal or written information about the genetic counselor program to 75%, and to increase the number of patients who follow up with the genetic counselor to 50%.
Methods: To improve the referral rate, we used the Plan, Do, Study, Act model. We decided that the gynecology nurse navigator would provide written or verbal information about the free genetic counselor program to appropriate patients and help to facilitate appointments. Patients were given pamphlets about the program and contact information for the genetic counselor. To eliminate potential barriers to follow-up, the genetic counselor program was discussed with patients to help dispel myths, including high copays for testing and discrimination from insurance companies. The emphasis was on helping patients understand the purpose of testing not only for themselves, but for other potentially affected family members. The timing of these conversations and appointments was key, making sure that the patient was receptive to the information, and that appointments with the genetic counselor were convenient for the patient and family members who also wished to be involved.
Results: The data we collected from March 2014 to February 2015 showed that 20 patients had a qualifying diagnosis for genetic counseling. A total of 15 (75%) patients were given written or verbal information on the genetic counselor program, 10 (50%) patients followed up with the genetic counselor, and 2 (10%) patients had abnormal results. Our referral rate has increased from 35% to 50%. Patients who were given appointments with the genetic counselor instead of being responsible for scheduling their appointments themselves were more likely to follow up. There are still some barriers to the process, including patients expiring very quickly after diagnosis and patients who live out of the immediate area who are lost to follow-up, but we are continuing to address those barriers.
Conclusion: With the process being driven by the gynecology nurse navigator, the goals for 2015 for the genetic counseling program include increasing the rate of patients who receive information about the program to 100%, and increasing our referral rate to 75%.
Emilana de Omena Bomfim, RN, MS, PhD Candidate1; Elen Anatriello, BS, MSc, PhD2; Michelle Darezzo Rodrigues Nunes, RN, MSc, PhD3; Jordana Carvalhaes de Moraes, Undergraduate Nursing Student4; Michel Marcossi Cintra, Undergraduate Nursing Student4; Luis Carlos Lopes Júnior, RN, MSc, PhD Candidate4; Michele da Silva Miyauti, RN, MSc5; Regina Aparecida Garcia de Lima, RN, PhD4; Lucila Castanheira Nascimento, RN, PhD4; Milena Flória-Santos, MSc, PhD4
1University of Saskatchewan, College of Medicine, Saskatoon, Saskatchewan, Canada; 2Federal University of São Paulo, São José dos Campos, Brazil; 3University of the State of Rio de Janeiro, Maracanã, Brazil; 4Ribeirão Preto College of Nursing, University of São Paulo, Brazil; 5Baxter International Inc, Ribeirão Preto Area, São Paulo, Brazil
Background: It is well known that sleep and several cancer-related symptoms, such as fatigue and pain, have a reciprocal and closed link with immune responses. For example, sleep deprivation can disrupt cellular immune responses by shifting T helper (Th) cell activity toward a Th2 cytokine profile, which may affect patients’ health-related quality of life (HRQOL). To date, no study has comprehensively examined the influence of cytokines on sleep and HRQOL.
Objective: To investigate the plasma levels of the cytokines interleukin (IL)-8, IL-1β, IL-6, IL-10, tumor necrosis factor-alpha, and IL-12p70 and correlate them with sleep and HRQOL in children and adolescents with cancer.
Methods: This is a quantitative, descriptive, cross-sectional study conducted at the Pediatric Oncology Service at the University Hospital of the Ribeirão Preto School of Medicine in Brazil from January 2013 to March 2014. Consecutive newly diagnosed patients with cancer were recruited between January 2013 and March 2014. In the study, 4 mL of blood was collected for measurement of patients’ cytokines, and clinical data were collected from the patient’s files for characterization and identification. To evaluate sleep patterns, we used a wrist actigraph. The flow cytometry technique was used to evaluate the cytokine dosage. The study protocol was approved by the Institutional Research Ethics Board of the School of Nursing of Ribeirão Preto (under the protocol # 085/2012).
Results: We found a correlation between the percentage for sleep quality and IL-10 (r = –0.384; P = .048), as well as a correlation between sleep efficiency and IL-10 (r = –0.452; P = .018). The cytokine IL-12p70 showed a correlation with sleep duration (r = –.604; P = .001). Furthermore, a correlation between HRQOL and IL-1β was noted (r = –0.382; P = .028).
Conclusion: These results indicate that there may be a relationship between cytokines and sleep in children and adolescents with cancer. These results also provide support to the hypothesis that cancer-related symptoms are correlated, at least in part, to the cytokine–immunologic system. However, deeper examinations regarding the role of cytokines in the development of cancer-related symptoms are needed to allow any kind of causation conclusions, as well as to allow the development of personalized and evidence-based interventions.
Sharon Lieb Inzetta, RN, MS, CBCN, CN-BN; Melanie Lynch, MD; Heidi Eve-Cahoon, RN, MSN, CNP, CBCN; Marlo Schmidt, MS, MBA; Laura Musarra, BS, MBA
Breast Center, Summa Akron City Hospital, Akron, OH
Background: Historically, barriers to cancer care delivery have been well-documented in the United States. Breast care delivery was identified as problematic for patients in our regional city hospital, and was found to impact overall patient satisfaction. Timeliness to care delivery before having a dedicated imaging nurse navigator was 29 days from abnormal imaging to the actual breast biopsy. Outmigration and loss of patients to competitive systems approached 30% of the overall breast center volumes before a dedicated nurse navigator was in the breast center. Focus groups from the local community met and identified barriers to breast care delivery, as (1) breast care that was difficult to access, (2) an overall lack of education and awareness of breast care delivery, (3) timeliness for breast care delivery was problematic, and (4) fears and anxiety existed when an abnormal finding was identified on breast imaging and was recommended for follow-up. The Breast Access Project was developed to target process improvement for breast care delivery at Summa Health System.
Objectives: To (1) develop and define the role of the nurse navigator across the breast care continuum; (2) develop a Navigation Care Model utilizing Kolcaba’s Comfort Theory 2003 to guide practice; (3) improve timeliness for breast care delivery facilitating progression along the ongoing care continuum, including screening, diagnostic, biopsy, treatment, and survivorship breast care needs; (4) provide education and support for breast care prevention, screening, and treatment; and (5) improve timeliness of breast care delivery, which will impact outmigration of patients.
Methods: A dedicated breast care nurse navigator was hired in October 2014 for the Breast and Imaging Center at City Hospital. Targeting timeliness for care at the point of biopsy recommendation was identified as a primary goal for improving breast care delivery and overall patient satisfaction. A diagnostic plan of care was developed and piloted for impacting care delivery and referrals. The care plan provides a way to communicate to referring physicians and for patients with suspicious breast imaging to leave with a definitive plan of care for follow-up. A tracking system was developed for monthly reporting on the progress of improving access to breast care and the impact of navigation. Timeliness for care delivery has been tracked monthly and reported to the breast program and hospital system leadership.
Breast specialists were identified and a standardized Summa Breast Center Referral form was developed. The breast program leadership adopted 48 hours as the benchmark for timely access to a breast specialist. All new breast referrals would have a breast specialist consult within 48 hours, facilitated by the nurse navigator.
Results: The program has resulted in the implementation and development of a Navigational Model of Care (Kolcaba’s Comfort Theory 2003). Data collection began to be reported and measurable results were seen in the first 3 months of 2015. Data showed a significant improvement in navigational impact for timeliness to breast care delivery. Before adding a dedicated imaging navigator, the time line for abnormal imaging and diagnostic recommendation to biopsy was 29 days. After an imaging navigational process was implemented, a data collection tool was developed and analysis was done for data collection for 3 sequential months. The most recent results show 7.6 days from the time of abnormal imaging and biopsy recommendation to when a biopsy was performed. Days to surgical consult were shortened after the nurse navigator began facilitating referrals. Loss of patients/outmigration for breast care follow-up occurred. Data collection expanded to include tracking time to pathology and time to surgery. Reduction in overall outmigration of patients with breast cancer from Summa Health System has been impacted. The diagnostic plan of care was piloted and implemented. Patient satisfaction surveys and educational materials for patient navigation were developed.
Conclusion: Measurable results have demonstrated that a dedicated imaging nurse navigator has been able to impact timeliness for breast care delivery across an ongoing continuum. Initial results support improvement in timeliness for breast care delivery from diagnostic mammogram to biopsy, from biopsy recommendation to referral to a breast specialist, and biopsy to treatment planning.
Kristie Coles, RN, BSN, OCN
University of Virginia Health System, Charlottesville
Background: Financial stress is consistently identified as a stressor by patients and by families at the University of Virginia (UVA) Emily Couric Clinical Cancer Center (ECCCC). This stressor is especially notable in our neuro-oncology patient population, because these patients are often experiencing new cognitive deficits that complicate their abilities to follow through on instructions and tasks. They often need support navigating complex financial options pertaining to disability issues. Recent staffing changes and the redefinition of the roles at ECCCC revealed gaps in support services for our outpatient neuro-oncology patients.
Objective: To determine the appropriate standard of care for the neuro-oncology patient population and the appropriate support services using a risk stratification model.
Methods: An interdisciplinary team was formed to review the current state and to identify key stakeholders, patient needs, and missing resources. The group met first on a bimonthly and then on a weekly basis to discuss various issues and to develop an action plan. Initially we thought the primary focus was to address the issues of disability and how to best help our patient population navigate the different facets of disability. This led to a discussion on how to define disability. We decided to include short-term disability, long-term disability, Social Security disability, Medicare, Medicaid, the Family and Medical Leave Act, and UVA financial screening for patients without insurance or for those who are underinsured. As the discussions continued, we realized we needed to look at the entire process of referrals for all of our support services, and not limit our focus to the financial aspects.
Results: The primary outcome was the creation of a new workflow that enables the clinical team to identify high-risk patients and to proactively refer patients to the support services they need. This model also aligns with the existing distress screening workflow. In addition, this project led to the creation of updated and expanded educational materials for patients and staff.
Conclusion: Although this new process was initially created to better meet the needs of the neuro-oncology patient population, it can be used for all patients receiving care at ECCCC. This process will need to be reviewed on an annual and an as-needed basis to ensure its currency. Furthermore, job descriptions will need to be modified as responsibilities change to ensure fluidity when new personnel are hired.
Lucy Gansauer, MSN, RN, OCN
Gibbs Cancer Center, Spartanburg Regional, SC
Background: The National Comprehensive Cancer Network (NCCN) guidelines require that fertility preservation be an essential part in the management of adolescent young adults (AYAs) with cancer. AYA patients face loss of fertility and disruption in their education, career, or social interactions. Research has revealed that initial fertility preservation discussions can be overwhelming, and patients do not comprehend the impact of their treatment on their fertility. Loss of fertility has been shown to lead to regret, distress, and significant impact on quality of life in survivors.
Objective: To describe the development of a program that provides fertility education, referral, and preservation to all AYA oncology patients meeting NCCN guidelines.
Methods: A nurse-led evidence-based practice team was developed, and a nurse navigator–led OncoFertility Program was developed and implemented. The team consisted of 3 nurse navigators and a research nurse. This program was designed in collaboration with local reproductive endocrinology staff, local gynecology physicians, and medical oncologists.
Results: The OncoFertility performance improvement was a complete success. The accomplishments by this clinical nurse–driven team included the development of (1) a new screening process based on national guidelines for oncology patients, (2) an educational tool to guide and document the nurse navigator in educating the patient on their fertility preservation options and patient educational material, (3) a protocol for assessing patient interest in fertility preservation that asks patients whether they have completed their family, and whether having a biologically related child is important to them in the future, (4) a memorandum of understanding with the reproductive endocrinologist’s office for timely referrals, (5) a training program for nurse navigators, and (6) a nurse navigator–led program approved by the leadership and the Cancer Care Committee.
Conclusion: The quality, outcomes, and performance improvement (QOPI) data started to improve in the spring of 2013 and reached 100% by the fall of that year. Patients meeting the QOPI age criteria had documented evidence in their electronic medical record of measures including “infertility risks discussed prior to chemotherapy with patients of reproductive age” and “fertility preservation options discussed or referral to specialist.” Nationally, these measures remain at less than 35%. Our program has a positive impact on the quality of life of AYA patients with cancer. The goal was to inform all patients of their risk for infertility and to provide education to empower the patient to make an informed decision for fertility preservation; the goal was not to bank a certain number of sperm collection or eggs. However, to date, we have realized a great deal of satisfaction from more than 6 patients who successfully banked their sperm or eggs, allowing them to have biologically related children in the future.
Catherine Bouvier1; John Leyden, MD2; Maia Sissons, BA1; Teodora Kolarova, MA3; Grace Goldstein, MA4
1NET Patient Foundation, Hockley Heath, Warwickshire, United Kingdom; 2The Unicorn Foundation, Mosman, New South Wales, Australia; 3Association of Cancer Patients & Friends, Sofia, Bulgaria; 4The Carcinoid Cancer Foundation, White Plains, NY
Background: Neuroendocrine tumors (NETs) negatively impact patients’ emotional well-being and their daily lives. Although the incidence of NETs is increasing (in part because of growing awareness), only a few, small (N <20) qualitative studies have documented the experience of living with NETs. We present data from a large NET patient survey on quality of life (QOL) and the patient perspective, representing a collaboration between the International Neuroendocrine Cancer Alliance (INCA) and Novartis Pharmaceuticals.
Objectives: To describe the daily burden of living with NETs and to identify key improvements to help patients live better with their disease.
Methods: An anonymous survey of 1928 patients with NETs from more than 12 countries (Americas, Asia, Europe, Oceania), including 758 patients from the United States, was conducted from February to May 2014. The survey was about the experience of patients with NET; was conducted by Hall & Partners on behalf of INCA/Novartis; and was funded by Novartis. US analyses were performed separately relative to QOL and the medical team interactions.
Results: US patients reported that NETs negatively impacted numerous aspects of their lives, including finances (59%), emotional health (58%), leisure activities (54%), social life (51%), and ability to care for their family (39%). Patients reported making several lifestyle and work-related changes as a result of their NETs, including dietary modifications (64%), time (57%) and money (60%) for travel to medical appointments, and limitations on their physical activity (57%) and social life (46%). Employed patients (N = 316) reported that they required accommodations, such as flexible schedules or working from home (30%), reduced hours (21%), or having to stop working for a period of time (16%). Patients experienced many fear-related emotions regarding NETs, including being concerned (60%), uncertain (46%), and scared (28%). Patients reported anxiety and stress (58%), worry about the uncertainty of their future (57%), confusion about their NET management (47%), and feelings of isolation from their family and friends (26%). Patients felt that healthcare professionals in general were very supportive (47%), yet only somewhat aware of NETs (58%) and only somewhat understanding of the impact NETs have on patients’ lives (50%). Oncologists and hematologists (74%) and nurses and nurse practitioners (74%) were seen as having the most understanding of how NETs affect patients. However, only 27% of patients listed nurses or nurse practitioners as part of their medical team versus oncologists or hematologists (87%). Patients also required additional information regarding NETs; 42% of patients felt they were unable to get answers to their questions about NETs, and 55% felt they did not receive sufficient information to educate them about NETs after their diagnosis. Patients suggested various improvements to enhance QOL, including increased awareness of NETs (42%) and materials (37%) to help communicate with others about their disease, a better understanding of the steps they can take to manage their treatment-related symptoms (40%), and a more knowledgeable medical team (40%).
Conclusion: The findings from this large patient survey demonstrate the substantial negative impact NETs have on patients’ daily lives. Nurses play a vital role in providing patient support through understanding, and education is a key area for improvement in the management of NETs.
Margaret Rummel, MHA, OCN, NE-BC; Eleanor Miller, MSN, OCN, CBCN; Patricia Gambino, RN, MSN; Heather Sheaffer, DSW, LCSW
Abramson Cancer Center, Penn Medicine, Philadelphia
Background: The Penn Cancer Network (PCN) is a select group of community hospitals throughout Pennsylvania, New Jersey, and Delaware that collaborate with the Abramson Cancer Center to provide excellence in patient care in our region. The Abramson Cancer Center of the University of Pennsylvania is the cornerstone of the PCN, offering subspecialty care that is not usually available at most community hospitals, vast research and technological resources, and programmatic support for one of the nation’s foremost cancer centers. An opportunity was identified to offer professional development and education for the oncology nurse navigators at the PCN sites and the Abramson Cancer Center.
Objectives: To provide ongoing educational programs and networking opportunities specifically for oncology nurse navigators, and to assist in developing the role of the oncology nurse navigator within the PCN and help in programmatic development to meet the Commission on Cancer standards for navigation.
Methods: The Department of Patient and Family Services took ownership of developing programs for nurse navigators within the PCN in 2012. Surveys were initially done to identify interests and gaps in education so that speakers are pertinent to the group. Our programs are biannual, and continuing education credits are awarded. Each agenda has a theme and focuses on disease sites to provide new education. The nurse navigators at the Abramson Cancer Center organize the schedule and agenda with support from the administration.
Results: Programs have been offered twice annually since 2012, and efforts are made for each agenda to have a balance of speakers from the University of Pennsylvania and PCN hospitals. Past topics have included hematologic malignancies, CART-19 therapy, personalized medicine, updates in head and neck cancer, managing boundaries, and integrative therapies. Throughout the day-long meeting there is time for networking and discussion, as well as updates from the Academy of Oncology Nurse & Patient Navigators and other organizations that promote navigation. Program evaluations are completed at the end of the day, and feedback has been positive thus far. The nurse navigators all look forward to these days with others who have become a valuable professional network of education and support.
Conclusion: By developing and hosting a biannual PCN navigator program, navigators at the Abramson Cancer Center and the PCN sites are able to come together to further collaborate and share information. Highlights of various disease programs and initiatives have been valuable for professional development and education to directly apply to our daily practice and patient care. The support and collaboration we offer to fellow navigators is important to continue advancing our role as oncology nurse navigators.
Rupa Ghosh-Berkebile, MS, CNP, AOCNP1; Amy Rettig, MSN, ACNS-BC, PMHNP-BC, CBCN1; Denise Schimming, MS, RN, CNP2
1Division of Musculoskeletal Oncology, The Ohio State University Wexner Medical Center/James Cancer Hospital and Solove Research Institute, Columbus; 2Stefanie Spielman Comprehensive Breast Center, The Ohio State University Wexner Medical Center/James Cancer Hospital and Solove Research Institute, Columbus
Background: In the past several decades, therapeutic advances in surgery and systemic therapies have allowed increasing numbers of adult and pediatric patients to achieve long-term survival in bone and soft-tissue sarcoma. Currently, very little is known about the sarcoma survivor. On average, approximately 12,000 cases of sarcoma are diagnosed in the United States annually, accounting for 1% of all cancer diagnoses. Historically, cancer survivors are referred back to their primary care provider after treatment. However, many primary care providers are uncomfortable managing the unique short- and long-term effects of a rare cancer. Symptoms can be caused by late effects of cancer, surgery, chemotherapy and radiation, or a combination of treatment modalities. Based on these issues, our survivorship clinic is well-suited to differentiate these symptom profiles and support primary care providers.
Objectives: To develop an advanced practice nurse–led survivorship clinic for sarcoma survivors, address the short- and long-term effects of sarcoma and its treatment, and discover the unique needs of the sarcoma survivor population.
Methods: The Supportive Care Screening tool, which included the Distress Thermometer from the National Comprehensive Cancer Network for the first 6 months, was used to evaluate survivorship and determine survivorship needs. Since that time, only the Supportive Care Screening tool was used, focusing on specific distress concerns and not overall distress. A referral program to other disciplines was established to address specific survivor concerns.
Results: The clinic opened in August 2012. Within the first 4 months of the clinic’s opening, 32 new survivorship patients were seen. Patients’ ages ranged from 30 to 59 years, with a mean age of 49 years and median age of 51 years. From 2012 to 2014, there were 83 new survivorship visits, and a random sampling of 16 new survivor visits were reviewed. This snapshot showed that our population experienced sleep disturbances, muscle weakness/chronic pain, neuropathic pain, cardiac and bowel/bladder complications, decreased mobility, body image concerns, sexual dysfunction, and fertility issues. This group also expressed concerns about fear of recurrence, being overwhelmed, current health issues, financial concerns, and employment issues. Eleven patients were referred to various specialties, including internal medicine (N = 2), genetics (N = 2), oncology rehabilitation (N = 2), registered dietitian (N = 1), psychosocial oncology (N = 4), financial counseling (N = 1), dentistry (N = 1), and otolaryngology (N = 1).
Conclusion: Our sarcoma survivorship clinic supports the unique needs and provides a navigation relationship for the sarcoma survivor. It is difficult to differentiate between surviving sarcoma and surviving sarcoma treatment. Further study is needed to refine our knowledge about the sarcoma survivor and the different challenges that a long-term survivor and a recent posttreatment survivor may face.
Matthew R. LeBlanc, RN, BSN, OCN
DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, MD
Background: A large and growing population of cancer survivors is living with significant disabilities from their cancer and its treatment. Effective rehabilitation interventions exist, but they remain underutilized.
Objective: To pilot a patient screening and provider education program aimed at identifying the diverse rehabilitation needs of patients with cancer to increase the appropriate rehabilitation interventions.
Methods: Patients with cancer were screened for rehabilitation as they moved through radiation treatment to increase awareness of their potential rehabilitation needs and to drive appropriate interventions. Screening was coupled with oncology provider education about physical rehabilitation needs, rehabilitation interventions, and their benefits for patients with cancer. Rehabilitation referrals and the diversity of referral indications were used as outcome measures.
Results: A total of 583 patients were screened during the 6-month pilot, and 9 educational events occurred. The top 3 impairments reported by patients were musculoskeletal pain (52%), cognitive impairment (39%), and deconditioning (38%). In the 6 months before the screening and education pilot, 104 patients with cancer were referred for rehabilitation interventions. During the pilot, 189 patients were referred for rehabilitation services (an increase of 82%). In the next 6-month time period, 279 patients were referred (an increase of 168% over the prepilot time period). Lymphedema accounted for 18% of self-reported symptoms, yet made up 69% of prepilot referral indications. Lymphedema referrals represented 52% and 48%, respectively, of total oncology rehabilitation referrals in the next 6-month periods during and after intervention, even as the number of lymphedema referrals increased absolutely. Total referrals increased, as indication variety also increased.
Conclusion: Patients with cancer can have impairments and disabilities that are often unaddressed, even when effective interventions exist. This pilot program of rehabilitation needs screening and oncology provider education was successful in identifying a variety of indications for cancer rehabilitation, resulting in an increased use of rehabilitation services.
Lorene Barulich, MSN, RN, OCN
Buffalo Medical Group, PC, Orchard Park, NY
Background: When suspicious imaging or initial cancer diagnoses are made, patients do not know where to turn or which direction to go, often depending on the referrals of their providers or on suggestions by family members and friends who have walked the path before them. The American Society of Clinical Oncology has distinguished that practices with a Quality Oncology Practice Initiative (QOPI) certification demonstrate quality, improved efficiency and effectiveness, practice improvement, and public trust. The National Committee for Quality Assurance has expanded on the medical home model to recognize specialty practices, such as oncology, for their commitment to patient access, communication, and care coordination with a Patient-Centered Specialty Practice (PCSP) designation. Community practices with such certifications may be overlooked when nationally recognized programs are located within their geographic region. As defined by the Oncology Nursing Society’s advisory team, nurse navigators use the nursing process to provide the tools patients and their caregivers need to make informed decisions with education, community and support resources, and psychosocial care throughout all cycles of the cancer continuum.
Objectives: To describe how (1) incorporating the guidelines set forth for the QOPI and PCSP certifications places the nurse navigator in a unique role to assist the patient and family along their cancer journey by offering best practices while simultaneously contributing to the ongoing standards of care; and how (2) community practices with the highest-level certifications and nurse navigator or care coordinator teams may be able to offer the same standard of care patients are accustomed to without “feeling like a number” or “being herded like cattle,” as we are often told.
Methods: The QOPI core objectives that are met by the cancer care coordinator (nurse navigator) start with initial contact within 24 to 48 hours of receiving a new patient referral to the group, reaching out to patients via phone and mail to introduce the program team, and distributing a health history questionnaire. Before the initial consult, which is scheduled within 1 week from the referral date, questions and concerns are addressed at this time to set the foundation for a rapport. At the time of consult, the patient will meet with the care coordinator team for scheduling tests, scans, and procedures, as needed, by a medical assistant in addition to treatment plan education, community and support resources, guidance, distress measurement, and survivorship information from the oncology nurse navigator. The financial navigator contacts patients once the treatment plans are entered to determine their financial assistance needs in relation to their insurance coverage and drug costs.
Results: Colleen, a 45-year-old woman, was diagnosed with breast cancer in 2014. At her initial contact with the nurse navigator, she was “emotionally drained” from fear of the unknown and was overwhelmed with friends “telling her what to do and where to go.” A local community practice was near her home, and she preferred to stay close instead of traveling 1 hour to the nationally renowned center of excellence where her friend received treatment for a similar diagnosis. Colleen described frequent feelings of doubt about her decision to be treated in the community, because of her friends’ questions. At that time Colleen was out of work, unsure how she was going to pay for her rent and her bills, let alone chemotherapy. The care coordinator team started working before the initial consultation to ease her distress, educate her, and empower her. Once her treatment began, the navigators were able to teach her and her friends about the treatment plan, what to expect, symptom management, when to call the office, offer foundation assistance, and connect with a social worker to provide the information she needed for public assistance programs. By navigating the cancer care system one step at a time, Colleen has lowered her National Comprehensive Cancer Network distress thermometer reading from a 9 to a 2, stating that she feels empowered and an active part of her cancer care team. Colleen has also encouraged other patients to consider the community practice, because she has “no regrets.”
Conclusion: Providing cancer care in a community setting (outside of a hospital or a nationally recognized center of excellence) may seem like a destroyer fighting cancer in the shadows of a battleship. With experienced oncology navigator teams on board, however, quality, cost-effective care can help patients win the battle with knowledge, care, support, and empowerment close to the comforts of home.
Tiffany Smith, RN, OCN
Hendrick Cancer Center/Hendrick Health System, Abilene, TX
Background: The Hendrick Cancer Center has been proactively seeking effective solutions to reduce cancer incidence rates, improve mortality rates, and increase overall quality of life (QOL) for survivors. A community Health Needs Assessment was conducted by Hendrick Medical Center in 2013. The focus was to identify barriers that keep residents from obtaining health services. The assessment showed that community members do not value the importance of adopting healthy lifestyles or getting recommended screenings. These findings indicated the need to offer education and support to the community. Based on interviews with 39 key community leaders, issues were identified regarding health and QOL and barriers to improving health and QOL for residents of the primary community. The 4 components to the Hendrick Cancer Center Navigation-to-Prevention and Survivorship program include outreach education and prevention; breast, colon, and cervical cancer awareness; navigation to cancer screening services; and navigation to survivorship.
Objectives: The purpose of the program is to assess the effectiveness of a navigation-to-survivorship program on QOL from diagnosis to wellness, and to demonstrate an increase in QOL (physical, social, and psychological well-being) from the time of diagnosis to cancer survivorship. Through effective navigation and access to services, we hope to increase the number of patients receiving navigation and survivorship services.
Methods: Survivorship has emerged as a crucial component of the Hendrick Cancer Center’s efforts to capture and care for our newly diagnosed patients. We begin their cancer journey with a plan for their survivorship. We are providing education regarding screenings and are assessing them for individual needs before, during, and after treatments. Referrals are made based on those needs. Evaluation efforts are measured by the Functional Assessment of Cancer Therapy General (FACT-G) scale, which is a questionnaire given to patients at the completion of treatment to establish a baseline. The survivors are reassessed at 3, 6, and 12 months posttreatment. The success of the program will be evident by an increase in QOL from baseline. Evaluation of patients enrolled in our navigation-to-survivorship program will be recorded in our navigation software with reporting functions.
Results: The baseline for navigation or survivorship enrollment was 0. We currently have 176 patients enrolled in our program. Among these 176 patients, 269 barriers to care were identified, and 276 actions were taken through referrals and/or education. The FACT-G survey has been beneficial to our navigator in assessing what needs to be addressed with the patient. Our baseline FACT-G scores, which are done on the day of the last treatment, will be their first score. By addressing the survivors’ concerns at this time, and by meeting their individual needs, we have increased the scores when reassessing at 3 months.
Conclusion: Navigation to clinical services for patients with cancer can have a significant effect on the QOL and continuity of care. The success of this program is evident by the increase in QOL from patients’ baseline FACT-G score. By teaching and assessing individual needs, we are preparing our patients for life as a survivor, and giving our community members the knowledge they need to live healthier lifestyles.
Dorothy Morrone, RN, MS, OCN; Maritza Chicas, RN, BSN, OCN; Jane Zubia, RN, OCN, CN-BN; Kathleen Sevedge, RN, MA, AOCN; Laura Beaupre, RN, BSN, OCN, CN-BN; Raizalie Roman, RN, BSN, OCN; Janie Connor, RN, BSN, OCN
Department of Cancer Support Services, Cancer Program, Lehigh Valley Health Network, Allentown, PA
Background: A survey of staff and providers showed that patients with head and neck cancer were a priority for navigation, their needs were not met, and the care coordination was fair to poor. The head and neck nurse navigator used the survey results to identify gaps in service and care to prioritize the needs of this population.
Objectives: To identify and remove barriers to care, improve communication among team members and collaboration between departments, increase referrals to appropriate support services, provide education to team members, increase awareness in the community, and measure patient satisfaction.
Methods: The navigator organized a multidisciplinary case conference that meets twice monthly. Invited members include a speech therapist, radiation and medical oncology nurses, dietitian, social worker, counselor, and bilingual nurse navigator. Increased attention to referrals prompted the navigator to initiate holding the Ear, Nose, and Throat (ENT) Tumor Board monthly instead of quarterly. The navigator participated in the creation of a head and neck order set and in improving the consistency of ordering procedures, referrals, and appointments. The navigator plays a key role in supporting patients with combined modality treatment during a single point of access consult, where patients see radiation and medical oncologists in separate appointments on the same day. The navigator met with dietitians and speech therapists to facilitate classes for clinical staff. Three classes were held; the topics were nutrition and rehabilitation. The navigator, outreach coordinator, and dental clinic staff collaborated to plan and execute an oral screening, which is now an annual event. The navigator also supported the development of the first Lehigh Valley Health Network team, “Voices of Cancer,” to participate in the Oral Cancer Foundation annual walk. A satisfaction survey is sent to each patient at the end of treatment.
Results: A postimplementation survey showed higher scores for “needs of head and neck patients being met” and for “coordination of care.” The number of diagnosed ENT Tumor Board cases increased from 16 annually to 58 annually. Eleven patients were seen in point-of-service appointments between January and May 2015. Referrals to support the services increased from 134 in July to September 2013 to 268 from January to March 2014. Three oral screenings have been held. The total number of patients screened were 111, and 13 were referred for further care. Patient satisfaction scores are high, with positive comments.
Conclusion: The navigator drives the success of a head and neck cancer program as evidenced by improved coordination of care, increased multidisciplinary collaboration, and high patient satisfaction.
Catherine Bouvier1; Teodora Kolarova, MA2; Grace Goldstein, MA3; John Leyden, MD4; Maia Sissons, BA1
1NET Patient Foundation, Hockley Heath, Warwickshire, United Kingdom; 2Association of Cancer Patients & Friends, Sofia, Bulgaria; 3The Carcinoid Cancer Foundation, White Plains, NY; 4The Unicorn Foundation, Mosman, New South Wales, Australia
Background: Neuroendocrine tumors (NETs) are a diverse group of malignancies associated with a broad range of symptoms; patients typically receive care from numerous healthcare providers. Treatment in a multidisciplinary team setting improves timely access to coordinated healthcare, as supported by guidelines published by the North American Neuroendocrine Tumor Society. We present data from a large patient survey on providers’ interactions and access to medical care in patients with NETs, representing a collaboration between the International Neuroendocrine Cancer Alliance (INCA) and Novartis Pharmaceuticals.
Objective: To describe the impact of care on US patients with NETs at a multidisciplinary specialist center.
Methods: An anonymous survey of 1928 patients with NETs from more than 12 countries (Americas, Asia, Europe, Oceania), including 758 patients from the United States, was conducted from February to May 2014 on patients’ experiences with NETs. The survey was conducted by Hall & Partners on behalf of INCA/Novartis, and was funded by Novartis. US analyses were performed separately relative to the medical team interactions, treatment access, and NET specialist center care. All comparisons are significant at the P <.05 level.
Results: A wide spectrum of providers were involved in managing patients with NETs. Patients reported seeing a mean of 3 providers for ongoing NET management, including oncologists or hematologists (87%), general practitioners (GPs) or primary care physicians (PCPs; 53%), surgeons (37%), nurses or nurse practitioners (NPs; 27%), and physician assistants (PAs; 15%). Patients saw nurses or NPs most often (median time between visits, 1 month), followed by PAs (2 months), oncologists or hematologists (3 months), GPs or PCPs (4 months), endocrinologists (5 months), and surgeons or other specialists (6 months). The majority (62%) of patients had visited a NET specialist center. About half (53%) of the patients visited at least once annually, with a mean of 3.6 visits annually (range, 0-30 times). Patients who visited versus those who did not visit an NET specialist center at least once annually saw a wider range of providers (eg, surgeons, 43% vs 30%; gastrointestinal specialists, 40% vs 26%; endocrinologists, 29% vs 15%, respectively), traveled longer distances to see their NET medical team (mean distance, 214 miles vs 76 miles), received a wider range of tests annually (mean, 5.9 vs 5.0), and were more likely to rate the quality of available NET treatments as good or very good (57% vs 45%). Specialist center visitors were also more likely than nonvisitors to believe that they are knowledgeable about available NET treatment options (83% vs 68%) and less likely to desire better access to NET experts (56% vs 69%), more knowledgeable NET providers, or a better coordinated and aligned medical team (47% vs 56%).
Conclusion: The findings from this large survey demonstrate the benefits of care by a NET specialist team, including enhanced knowledge, treatment access, and coordinated care. Because patients see nurses most often, it also indicates the need for nurse education in NETs to ensure optimal care. Room for improvement in collaborative care and an understanding of patients’ needs were also identified.
Jolene Lambert, RN, OCN
Holyoke Medical Center, MA
Background: I have been in the navigator role for patients with breast cancer for 3 years. When I was hired as a navigator at the Women’s Center, Holyoke, MA, I decided to review all charts of patients with breast cancer to familiarize myself with all these patients. What I discovered was astonishing. Women were waiting approximately 26 days from their abnormal mammogram result to biopsy. I took my concern that this was too long to the director of oncology. We formed a committee that includes radiology, administration, the tumor registrar, and me, the nurse navigator.
Objective: To reduce the time from an abnormal mammogram result to biopsy.
Methods: The pathways of patients receiving mammograms were studied. It was noticed that patients with abnormal mammogram results were sent a letter that took 3 days to arrive. If the patient did not call back, the center sent a letter to the primary care provider after 3 weeks. The patient was called back 5 weeks later, and at week 6, a certified letter was sent to the patient. If additional imaging was needed, it would take 3 to 14 days for the patient to return. If a biopsy was recommended, it would be booked within 1 to 2 weeks. As a method of evaluation of successful breast cancer navigator program implementation, the elapsed time from an abnormal mammography result to additional imaging, to biopsy, and to surgery was measured.
Results: As we studied these pathways further, the committee decided that a navigator was definitely needed for the Women’s Center. Once a breast cancer navigator was employed at the Women’s Center in May 2014, patients with abnormal mammogram results were called the same day. Appointments were made for additional imaging within 2 days, and with immediate reading by a radiologist. When a positive result was found, the radiologist talked with the patient and a biopsy appointment was made within 2 days (not more than a 3-day wait). With the help of the navigator, we were able to streamline the process from a 5- to 8-week wait from an abnormal mammogram result to biopsy to a 5-day wait. The elapsed time from mammography to imaging to biopsy to surgery greatly improved after implementation of a breast cancer navigator program. The number of patients that were called within 0 to 5 days was 58 in 2011, 59 in 2012, 210 in 2013, and 392 in 2014.
Conclusion: One challenge in caring for patients with cancer is not just giving quality care but also timely care. After a Commission on Cancer (CoC) survey, our study has been chosen for review by the CoC Program Review Subcommittee for possible posting on the CoC Resource Library website, along with the appropriate acknowledgment of our program.
Amy DeRamus, LPTA, BS1; Carol Riggins, RN, MSN, GCNS-BC, OCN2; Katherine Rice, RN, BSN, OCN2; Kristina Jones, MSPT1; Maureen Mahland, MSPT1
1Centra Rehabilitation, Lynchburg, VA; 2Centra Alan B. Pearson Regional Cancer Center, Lynchburg, VA
Background: Research has demonstrated a gap in care between the evidence-based need for rehabilitation and the delivery of these services to cancer survivors. Many patients experience lingering adverse effects that are caused by their disease or its treatment. These impairments may result in significant distress and decreased quality of life for survivors. Screening for physical and functional impairments at key intervals during treatment allows providers to address the impairment by referring patients for rehabilitation interventions and improving access to rehabilitation care and outcomes.
Objective: To identify physical and functional impairments in a population of cancer survivors who are undergoing radiation treatment using the STAR Program Physical Impairment and Functional Assessment Screening Tool (PIFAST).
Methods: The PIFAST, a 12-question patient response tool, was used for patients receiving treatment in radiation oncology to screen for potential physical impairments. The results were tracked during a 10-month period, from August 2014 to May 2015. The screenings were performed at the first and last treatment visits and at 1 month follow-up posttreatment.
Results: A total of 1329 screenings were performed at key intervals during radiation treatment, and 77% (N = 1026) of the patients in radiation oncology who were screened reported at least 1 functional impairment. The average number of reported impairments was 3.4, for a total of 3942 impairments. Of the patients who were screened, 52% (N = 694) reported that their impairments began after their cancer diagnosis. The top 4 physical impairments were pain (48.5%), neuropathy (36.3%), fatigue (33.3%), and weakness (29.4%). The identification of these impairments led to a 221% increase in referrals to rehabilitation services.
Conclusion: Screening for functional impairments using the STAR Program PIFAST identified that the majority of cancer survivors who receive radiation therapy have at least 1 physical impairment, and that it is common for them to have multiple impairments. In this patient population, the most common physical impairments were pain, neuropathy, fatigue, and weakness. Identifying these impairments can allow oncology care providers to address them by referring patients for rehabilitative interventions. In turn, this may decrease the gap in care by improving access and continuity to care by creating more comprehensive oncology care.
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