Background: With preventive screening, increased focus on early detection, and advances in treatment in lung cancer, the multidisciplinary approach at Lehigh Valley Health Network Cancer Institute (LVHN-CI) continues to evolve, providing innovative care to this patient population. According to US Preventive Services Task Force, “low-dose computed tomography has shown high sensitivity and acceptable specificity for the detection of lung cancer in high-risk persons.”1 Also, “the number and proportion of patients diagnosed with early-stage disease are anticipated to increase.”2 The thoracic multidisciplinary clinic (T-MDC) has experienced changes leading to continuous evolution of the role of the thoracic-oncology nurse navigator (T-ONN). “Oncology nurse navigators play a critical role in cancer screening and coordination of services.”3
Objectives: Identify the multiple roles of the T-ONN. Demonstrate the impact of the increase in early detection on the T-MDC and on the T-ONN role.
Methods: Prior to the emphasis on low-dose CT (LDCT) screening, the T-MDC predominantly saw patients with stage IIIA-III-B disease. Since the increased focus on LDCT, more patients with stage 1 thoracic cancer with high-risk comorbidities are referred to the MDC for team evaluation and discussion of treatment options, including stereotactic body radiation therapy and robotic surgical options. The LDCT program LungRads 4 cases (L-RADS4) are reviewed in T-MDC for team recommendations. In 2018, an increase in the amount of LDCTs led to a higher number of L-RADS4 cases reviewed, contributing to early-stage diagnosis. The T-ONN has a dual role as T-MDC Clinic Coordinator and also as navigator for patients throughout treatment. The T-ONN prepares cases for review and moderates at pulmonary tumor board. A radiologist focusing on LDCT has joined the thoracic team. The T-ONN is point of contact for the radiologist and primary care physician, and is responsible to track data and outcomes for L-RADS4 cases, ensuring follow-up.
Results: The total number of lung cancers at LVHN-CI increased from 408 in 2016 to 522 in 2017, and an annualized number of 430 for 2018. The number of visits to T-MDC was 359 from 2016 to 2018, with an average of 120 per year. The number of LDCT L-RADS4 has increased each year: 2016-12; 2017-17; 2018-35.
Conclusions: The T-MDC’s increase in volume and complexity contributed to the hiring of 1 additional full-time employee (FTE) for a total of 2 FTE T-ONNs plus cross-training of additional ONNs to cover the T-MDC, to allow for increased patient visits per clinic. The workload of the T-ONN has increased with added responsibilities, including increased preparation time, additional coordination of patient visits, ensuring appropriate imaging and testing are completed, and increased caseloads for ongoing navigation services. The T-ONNs participated in Lung Disease Management Team meetings in order to develop a workflow for the L-RADS4 population. An LVHN Network goal of increasing lung screenings ensures continued referrals to the T-MDC. This goal includes development of a comprehensive lung health program, including adding a nurse practitioner and support staff to follow all high-risk patients and ensure referrals to appropriate multidisciplinary care.
- Final Update Summary: Lung Cancer: Screening. US Preventive Services Task Force. www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening. July 2015.
- Tandberg DJ, Tong BC, Ackerson BG, Kelsey CR. Surgery versus stereotactic body radiation therapy for stage I non-small cell lung cancer: a comprehensive review. Cancer. 2018;124:667-678.
- Doerfler-Evans RE. Shifting paradigms continued—the emergence and the role of nurse navigator. J Thoracic Dis. 2016:8(suppl 6):S498-S500.