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Best Practices in Patient Navigation – Second Issue: Supportive Care Edition

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The Role of the Oncology Nurse Navigator in Improving Supportive Care

Barbara Barnes Rogers, CRNP, MN, AOCN, ANP-BC 

A nurse/patient navigator is defined by the Academy of Oncology Nurse & Patient Navigators as “a medical professional whose clinical expertise and training guides patients and their caregivers to make informed decisions, collaborating with a multidisciplinary team to allow for timely cancer screening, diagnosis, treatment, and increased supportive care across the cancer continuum.”1 In essence, nurse navigators guide patients through the healthcare system and help them to overcome barriers to optimal care.2 The navigation of patients with cancer requires extensive knowledge, specialized skills, and good clinical judgment, which can improve outcomes.3,4 Oncology nurse navigators (ONNs) must be able to recognize and address numerous complications that occur during and after treatment, including myelosuppression and pain.

Myelosuppression

Myelosuppression is one of the most significant complications of cancer and its treatment.5-7 Specific types of myelosuppression include anemia, thrombocytopenia, and neutropenia. The management of anemia may involve the use of transfusions, erythropoietin growth factors, and vitamin repletion.8 One responsibility of the ONN is patient education regarding the potential causes of anemia and options for managing the condition. Patients must understand the importance of correcting anemia and be given strategies for minimizing symptoms. The ONN is also instrumental in educating patients on the risks and benefits of transfusions and erythropoietin growth factors, which can help them decide between these 2 supportive care options.5,8 Educating patients on fatigue management programs may also guide patients to resources that will help them manage fatigue related to anemia and other factors.9

Patients who are prescribed chemotherapy, or those whose bone marrow is affected by malignancies, may experience thrombocytopenia. Currently there is no available growth factor that can be routinely used for stimulating the growth of platelets, and patients with severe thrombocytopenia may require platelet transfusion.10 Prophylactic platelet transfusions are sometimes appropriate for patients who have chemotherapy-induced thrombocytopenia and those with thrombocytopenia who are scheduled for surgery or other invasive procedures.11 The role of the ONN includes educating the patient on the steps involved in platelet transfusion, the duration of benefit from this procedure, potential complications, and thrombocytopenia precautions, which include avoiding injury that may lead to bleeding.8

Neutropenia is a common complication in patients with cancer who are undergoing chemotherapy. This condition may be the result of bone marrow suppression or bone involvement with malignant cells. The prophylactic use of granulocyte colony-stimulating factors (G-CSFs) has been shown to reduce the incidence, length, and severity of chemotherapy-induced neutropenia.6 The role of the ONN in this setting may include advising patients on the potential risk for developing neutropenia, precautionary measures, the importance of monitoring blood counts, and the implementation of G-CSFs. In addition, the nurse navigator may assist patients in obtaining G-CSFs for self-injection, to avoid repeated trips to the medical care facility for treatment. Strategies for minimizing side effects related to G-CSFs are also an important component of education. Patients who are at risk for developing neutropenia must also be taught the importance of preventing infection.7,8

The prevention of myelosuppression and its complications should begin at the planning phase of treatment and continue throughout therapy and potentially beyond, if symptoms persist after treatment. Once treatment is under way, the ONN can also serve to communicate symptoms and other information (eg, insurance issues, learning issues that may impact self-injection) to other members of the oncology team to promote optimal care.

Pain

Unmanaged pain has been identified as a major barrier in the overall care of patients with cancer.12 It is estimated that >70% of patients with cancer will experience chronic pain associated with their disease and that the majority of these individuals will receive inadequate interventions for this pain.12 Effective pain management requires a comprehensive approach. The European Society for Medical Oncology has published guidelines for the management of pain related to cancer.13 The Oncology Nursing Society has also developed a position paper on cancer pain management,14 and it has reviewed the evidence regarding various approaches to pain management in one of its Putting Evidence Into Practice publications.15 These resources recommend the development of a pain management plan during the first meeting with the patient and ongoing assessments during the full trajectory of the disease.14,15 Clinicians should consider 3 specific areas when they evaluate the effectiveness of a pain management plan: (1) the effectiveness of the analgesic regimen; (2) the safety and tolerability of the analgesic regimen; and (3) the impact of the plan on the patient’s need and ability to function.15 ONNs need to establish pain management goals with their patients and use broader outcomes than simply pain intensity. The interventions should not only provide pain relief but also address the patient’s physical functioning, emotional functioning, self-ratings of global improvement, and satisfaction with treatment and side effect management.15

Conclusion

The care of patients with cancer requires a multidisciplinary approach that addresses the treatment of the disease itself and the management of complications such as myelosuppression and pain. Unfortunately, poor communication between healthcare providers or a lack of resources for patients may lead to suboptimal outcomes.16 ONNs are instrumental in promoting high-quality and efficient care by educating patients, locating and providing necessary resources, and facilitating more effective communication among the cancer care team. *


References

1. Academy of Oncology Nurse & Patient Navigators. Helpful Definitions. www.aonnonline.org/about/helpful-definitions/. Accessed August 31, 2015.
2. Psooy BJ, Schreuer D, Borgaonkar J, Caines JS. Patient navigation: improving timeliness in the diagnosis of breast abnormalities. Can Assoc Radiol J. 2004;55:145-150.
3. Gilbert JE, Green E, Lankshear S, et al. Nurses as patient navigators in cancer diagnosis: review, consultation and model design. Eur J Cancer Care (Engl). 2011;20:228-236.
4. Seek A, Hogle WP. Modeling a better way: navigating the healthcare system for patients with lung cancer. Clin J Oncol Nurs. 2007;11:81-85.
5. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Cancer and Chemotherapy-Induced Anemia. Version 1.2016. www.nccn.org. Accessed August 24, 2015.
6. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Myeloid Growth Factors. Version 1.2015. www.nccn.org. Accessed August 24, 2015.
7. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Prevention and Treatment of Cancer-Related Infections. Version 2.2015. www.nccn.org. Accessed August 24, 2015.

8. Erb CH, Vogel WH. Management of the complications of hematologic malignancy and treatment. In: Olsen MM, Zitella LJ, eds. Hematologic Malignancies in Adults. Pittsburgh, PA: Oncology Nursing Society; 2013:537-562.
9. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Cancer-Related Fatigue. Version 2.2015. www.nccn.org. Accessed August 24, 2015.
10. Slichter SJ. Evidence-based platelet transfusion guidelines. Hematology Am Soc Hematol Educ Program. 2007:172-178.
11. Schiffer CA, Anderson KC, Bennett CL, et al. Platelet transfusion for patients with cancer: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19:1519-1538.
12. Latchman J. Improving pain management at the nursing education level: evaluating knowledge and attitudes. J Adv Pract Oncol. 2014;5:10-16.
13. Ripamonti CI, Santini D, Maranzano E, et al. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol. 2012;23(suppl 7):139-154.
14. Oncology Nursing Society. Position paper: Cancer pain management. www.ons.org/advocacy-policy/positions/practice/pain-management. Accessed August 24, 2015.
15. Oncology Nursing Society. Putting Evidence Into Practice. Pain: Chronic pain. www.ons.org/practice-resources/pep/pain/chronic-pain. Accessed August 24, 2015.
16. Miaskowski C. Outcome measures to evaluate the effectiveness of pain management in older adults with cancer. Oncol Nurs Forum. 2010;37(suppl):27-32.

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