Navigators can make a difference in negotiating the labyrinth of oncology clinical trials. Facilitating insurance coverage when a cancer patient chooses to enroll in a clinical trial is perhaps the [ Read More ]
September 2016 VOL 7, NO 8
Cancer Survivorship for the Oncology Nurse Navigator-Certified Generalist
Mandi Pratt-Chapman, MA, Associate Center Director, Patient-Centered Initiatives & Health Equity, GW Cancer Center, Washington, DC
It is an exciting time to be part of cancer survivorship care! Due to better screening, earlier diagnosis, and improved treatments, cancer patients are living longer. Survival rates for adults diagnosed with cancer have increased from 49% in the 1970s to 69% from 2005 to 2011.1 Cancer survivorship is rapidly evolving, with new cancer survivorship care guidelines issued very recently. It is important to stay up-to-date on new information to ensure that practice keeps pace with new guidelines for care. This learning guide will provide some key updates for leaders of cancer survivorship care in the clinical setting.
What Kind of Care Should Cancer Survivors Receive?
In 2005, the Institute of Medicine (IOM) issued the landmark report, From Cancer Patient to Cancer Survivor: Lost in Transition. In that report, the IOM outlined 4 major components of cancer survivorship care, including2:
- Prevention and detection of new cancers
- Surveillance for cancer spread and recurrence
- Interventions for long-term and late effects of cancer and its treatment
- Care coordination between specialists and primary care clinicians
The IOM report recommended that all cancer patients receive a treatment summary and follow-up care plan that together comprise what is known as a survivorship care plan. In 2012, the American College of Surgeons Commission on Cancer made survivorship care planning a requirement for accredited cancer programs (Standard 3.3).3
Nine years after the landmark IOM report on survivorship, the Agency for Healthcare Research and Quality reported in Models of Cancer Survivorship Care that the timing, content, and structure of survivorship care were still uncertain. Further research is needed to determine what processes of care result in improved patient outcomes.4 Research to date has shown that cancer survivorship care can be delivered well by oncologists, nurse practitioners, primary care clinicians, and physician assistants. A major study found that follow-up by oncologists yielded more surveillance than follow-up by their primary care colleagues; however, overall health outcomes did not differ based on the clinician providing survivorship care.5 Another study also showed no difference in outcomes based on who provided follow-up care; however, patient satisfaction was higher for those followed by primary care.6
The Role of the Oncology Nurse Navigator-Certified Generalist and New Clinical Care Guidelines
What we do know is that oncology nurses and nurse navigators provide critical support to cancer survivors by educating patients, providing symptom management, coordinating follow-up care, and supporting shared decision-making to ensure patient preferences and values are reflected in care.
Cancer survivors have physical, social, psychological, and spiritual needs.2 Cancer survivors are at risk for a plethora of impacts, including fatigue, pain, sexual dysfunction, and depression—to name just a few. These impacts are based on a variety of factors, including tumor type, treatment modality and dosage, and preexisting comorbidities. New cancer survivorship clinical care guidelines can help clinicians provide evidence-based care for their patients. The National Comprehensive Cancer Network7 and the American Society of Clinical Oncology8 offer symptom-based guidelines for cancer survivorship care. The American Cancer Society (ACS) provides holistic cancer survivorship guidelines by tumor type that cover management of long-term and late effects, psychosocial care, health promotion, and care coordination. ACS guidelines are easily accessible and available free online:
- ACS/ASCO Breast Cancer Survivorship Care Guideline: bit.ly/BrCaCare
- ACS Prostate Cancer Survivorship Care Guidelines: bit.ly/ACSPrCa
- ACS Colorectal Cancer Survivorship Care Guidelines: bit.ly/acscolorc
- ACS Head and Neck Cancer Survivorship Care Guideline: bit.ly/acsheadneck
To aid in the dissemination of the ACS guidelines, the GW Cancer Institute released The National Cancer Survivorship Resource Center Toolkit: Implementing Clinical Practice Guidelines for Cancer Survivorship Care that includes highlights from each of the ACS cancer survivorship guidelines as well as clinician and patient checklists.9
Edward is a 62-year-old widower who just finished treatment for stage IIIA colorectal cancer. His treatment included surgery followed by adjuvant chemotherapy and pelvic radiation. Edward has a permanent colostomy and suffers cognitive challenges because of the treatment. He was laid off from his job and is concerned about his ongoing healthcare needs given the change in the cost and coverage of his health insurance as a result of transitioning from employer-based insurance to a marketplace health plan. Edward has a history of depression, which worsened when his wife died just prior to his own diagnosis of cancer.
Check Your Knowledge
1. You are asked to provide a survivorship care plan (SCP) for Edward. What do you include in Edward’s SCP?
a. Summary of treatment modalities, dates, and dosages
b. Surveillance and screening schedule
c. Information about risks for long-term and late effects
d. All of the above
2. What is your role in Edward’s psychosocial care?
a. Provide cognitive behavioral therapy for Edward since he has a history of depression and is at heightened risk for recurrence as a cancer survivor
b. Give Edward your direct line in case he is feeling depressed and needs to talk
c. Ensure Edward is assessed for depression and anxiety and refer to a mental health colleague for follow-up
d. Tell the doctor that there are new survivorship care guidelines that include psychosocial care to guide the clinical visit
3. Which long-term and late effects are most likely to impact Edward’s quality of life?
a. Lymphedema and cognitive deficits
b. Depression and cognitive deficits
c. Vertigo and rectal bleeding
d. Hot flushes and colostomy complications
4. Patient-centered care increases patient adherence to treatment?
5.Five-year relative survival for pediatric and adult cancer patients are currently at 69%?
1, d; 2, c; 3, b; 4, a; 5, b.
- American Cancer Society. Cancer Facts & Figures 2016. Atlanta, GA: American Cancer Society; 2016. www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf.
- Institute of Medicine. From Cancer Patient to Cancer Survivor: Lost in Transition. 2005.
- American College of Surgeons. Cancer Program Standards: Ensuring Patient-Centered Care. 2016 ed. www.facs.org/quality%20programs/cancer/coc/standards.
- Viswanathan M, Halpern M, Swinson Evans T, et al. Models of Cancer Survivorship Care (Technical Briefs, No. 14). Rockville, MD: Agency for Healthcare Research and Quality (US); March 2014. www.ncbi.nlm.nih.gov/books/NBK196214/.
- Cheung WY, Aziz N, Noone A, et al. Physician preferences and attitudes regarding different models of cancer survivorship care: a comparison of primary care providers and oncologists. J Cancer Surviv. 2013;7:343-354.
- Khatcheressian JL, Smith TJ. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006;24:835-837.
- National Comprehensive Cancer Network. NCCN Clinical Guidelines. www.nccn.org/professionals/physician_gls/f_guidelines.asp#survivorship.
- American Society of Clinical Oncology. Patient and Survivor Care. www.asco.org/practice-guidelines/quality-guidelines/guidelines/patient-and-survivor-care.
- GW Cancer Institute. The National Cancer Survivorship Resource Center Toolkit: Implementing Clinical Practice Guidelines for Cancer Survivorship Care. https://smhs.gwu.edu/gwci/survivorship/ncsrc/national-cancer-survivorship-center-toolkit.
Resources and Additional Reading
Epstein RM, Fiscella K, Lesser CS, et al. Why the nation needs a policy push on patient-centered care. Health Affairs. 2010;29(8):1489-1495.
GW Cancer Institute. Cancer Survivorship E-Learning Series for Primary Care Providers. www.cancersurvivorshipcentereducation.org.
Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. National Academies Press. January 2014.
Pratt-Chapman M. Cancer survivorship: the role of the nurse navigator. Journal of Oncology Navigation & Survivorship. 2015;6(6):14-18.