Earlier this year, oncology navigators from across the country attended the AONN+ Virtual Midyear Conference. This monograph will review the proceedings from 4 key sessions at the conference covering topics of smoking cessation, making a business case for financial navigation, screening in the covid era, and geriatric oncology.
Cigarette smoking is the single most important cause of disease and premature death in the United States, killing about half a million people per year, including about 40,000 who die of illnesses related to secondhand smoke. However, healthcare providers receive very little, if any, training on how to help people quit smoking, according to Kevin Scott Ferentz, MD, who ran the smoking cessation program at the University of Maryland for 25 years.
The percentage of smokers has gone down in the United States, from about 43% in 1966 to 14% in 2019, and there has been a gradual decline in cigarettes smoked per day. Although much of this is attributed to quitting smoking (there are now more people in America who have quit smoking than are currently smoking), people have also actually changed the way they smoke as cigarettes have become more expensive: inhaling deeper and holding their breath longer to maintain their nicotine levels.
Additionally, the use of e-cigarettes is increasing among America’s youth, and e-cigarette users are 4 times more likely to start smoking cigarettes 2 to 3 years down the road.
When it comes to getting people to quit smoking, remaining positive is key, according to Dr Ferentz. Attempting to scare smokers into quitting will only lead them to smoke, but focusing on the positive impacts—like feeling better and saving money—can be incredibly effective. Additionally, many smokers don’t know that the effects on health from smoking are reversible if they quit. When a smoker stops smoking, cough and exercise tolerance improve within days to weeks, the risk of heart disease is reduced by 50% within 1 year, the risk of lung cancer is reduced by 50% within 10 years, and mortality rates of ex-smokers are the same as never-smokers within 10 to 15 years after quitting.
Although a cigarette contains about 4000 chemicals, nicotine is the ingredient that causes the addiction and fulfills the 3 criteria for what makes a drug addictive: dependence, tolerance, and withdrawal. Smoking a cigarette stimulates the sympathetic and parasympathetic nervous systems at the same time, causing simultaneous feelings of relaxation and stimulation. According to Dr Ferentz, that’s precisely why people use nicotine.
Research has shown that at least 70% of smokers want to quit, about half make an attempt each year, and even minimal input from a health professional almost doubles the quit rate. It’s advised that every single patient who smokes be counseled on how to quit smoking, as patients see their healthcare providers as authority figures with access to credible sources of health information.
At a minimum, patients who are trying to quit smoking should receive counseling that includes firm, unambiguous advice (“I’m your doctor; I’m telling you to QUIT!”), written materials (eg, Clearing the Air: Quit Smoking Today, available at www.cancer.gov, and websites like www.smokefree.gov and www.smokingstopshere.com), setting a quit day, and setting a follow-up visit (or warning the patient you will ask about progress at a future visit). He also emphasized the fact that a small amount of time spent with more smokers will yield more ex-smokers than intensive efforts with a few.
Without using scare tactics, the damaging health effects of smoking should be personalized for each patient (citing any symptoms that could be attributed to smoking from their personal history, physical exams, or labs), but they should also be reminded of the many benefits of quitting, including improvements to both their health and finances.
Instilling confidence in patients is of utmost importance, because people quit when they have confidence in their ability to quit. Express your confidence in them, remind them that millions of others have quit, and that past attempts at quitting are only learning experiences. Also reassure them that there are ways to deal with nicotine dependence besides behavior modification, and offer nicotine replacement therapy medications like bupropion (Zyban) or varenicline (Chantix). When used together, medication and behavioral counseling have been shown to at least double a person’s chances of quitting, but fewer than one-third of adults who try to quit smoking are offered both.
Address the concerns patients may have around quitting, including withdrawal (tell them it’s short-lived, about 2-3 days), cravings (generally only last 3-5 minutes and diminish rapidly), tension (validate and normalize it, help them find other ways to cope), and weight gain (this is not inevitable, and about one-third of people who quit actually lose weight).
Emphasize the importance of actually quitting, not just cutting down, as cutting down only leads to people inhaling deeper, holding their breath longer, smoking more of the cigarette, and maintaining their nicotine levels. Setting a quit day is imperative.
When a patient is ready to try to stop smoking, Dr Ferentz says they should “study” for a week prior to actually quitting, so they can address the 3 components of addiction: physiological (feeling sick after quitting), psychological (ie, I smoke because I’m stressed), and behavioral (ie, I smoke when I’m in the car).
Before actually attempting to quit, patients should write down their reasons for quitting on an index card. Next, they should identify their triggers over the course of 4 days by writing down where they were, who they were with, what they were doing, etc, every time they smoked a cigarette. Then, next to each trigger, they should write down how they can avoid or cope with that trigger (eg, if a person smokes while on the phone, they can pick up a pen and doodle instead).
They should also develop a support system (tell everyone they’re quitting), set up a self-reward system (for a day, week, month, year without smoking), and importantly, make a written commitment to a quit day. Lastly, a follow-up visit should be set up with all patients at 1 month after the quit day.
According to Dr Ferentz, if the patient doesn’t show up in a month, this typically means they haven’t quit smoking; but don’t give up, simply talk about it again at their next visit. If the patient does show up, whether or not they actually quit, this means that they’re serious about quitting; continue to encourage them, refine their coping strategies if necessary, set a new quit day if they’ve started smoking again, and remind them to take it 1 day at a time.
Making a Business Case for Financial Navigation
The term “financial navigation” is now commonplace in the healthcare system, particularly in the world of oncology, where financial toxicity can be a devastating side effect of treatment. Although the benefits of financial navigation to patient quality of life are now generally well understood, many cancer programs still struggle to show its value. But by making a business case for financial navigation and actually demonstrating a potential return on investment, financial navigators can demonstrate their value, and in turn, add more financial navigators to the cancer care team.
To do this successfully, financial navigators must be expertly trained on the ins and outs of the complex healthcare system in the United States, and they must be able to convey that expert-level understanding to their patients, according to Dan Sherman, MA, LPC, a financial navigator and founder and president of the NaVectis Group.
Generally speaking, financial navigational services are centered around guiding patients through the extremely complicated healthcare system in the United States. This should not only lower the financial burden put on the patient, as patients often experience a decrease in income, increased expenses, and an inability to pay bills and set money aside for retirement during cancer treatment, but it should also lower their stress levels, increase feelings of security, and improve their quality of life. But from a business/financial standpoint, these efforts should also increase revenue for a cancer center while protecting oncology providers.
Most oncology providers in the United States have financial counselors in place who have expertise in enrolling patients into charity programs, setting up payment plans, and facilitating Medicaid enrollment for eligible patients, but patients need more than that in terms of financial services.
When individuals are highly skilled in this area—people like financial navigators and financial advocates—they can also help to enroll patients into copay assistance programs, patient assistance programs and, when necessary, programs that assist patients with their basic needs.
But perhaps more impactful is their ability to help patients optimize their insurance plans, which is beneficial to both the patient and the provider. Insurance optimization is centered around educating the patient about their coverage so they can completely optimize their benefits and receive the top-tier coverage offered by their plan. Although it may sound counterintuitive, another benefit of financial navigation is limiting the use of free drug programs, as copay assistance programs are often a better financial decision and can save patients a substantial amount of money in out-of-pocket expenses.
Again, to do this for patients, financial navigators must have an expert-level understanding of the different types of coverage available to patients for the services that they need. According to Mr Sherman, patients should be able to expect competency and confidence on the part of their providers when it comes to navigating the healthcare system, just as they expect their oncologists to be knowledgeable about their cancer.
When provided in the oncology setting, financial navigation services also improve access to care. About half of all oncology patients are enrolled in the Medicare system, but Medicare coverage is complex and widely misunderstood. For example, out-of-pocket responsibilities differ significantly between a Medicare Advantage plan and a Medicare supplemental plan, and a financial navigator might be the only person who can educate the patient on which plan is in their best financial interest.
Financial toxicity negatively affects patients’ physical and mental state, as well as their social well-being, so financial navigation simultaneously improves quality of life while leading to better health outcomes. Research has also revealed a lower level of treatment adherence among patients who experience financial toxicity, resulting in lower-quality cancer care services. And over time, the effects of financial toxicity actually led to increased mortality among patients with cancer.
The research linking financial navigation and patient satisfaction is still relatively sparse, but current research does show that patient navigation in general has led to significantly improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in both fee-for-service and alternative payment models.
According to Mr Sherman, this supports the argument for robust staffing of patient navigation programs, but the most surefire argument for financial navigation remains the financial return on investment for the provider. If financial navigation services are provided to patients at a high level, also utilizing complementary copay assistance and patient assistance, this should result in 1 full-time employee for every 800 to 1000 oncology patients coming through a healthcare system per year. In this scenario, the expected return on investment that a financial navigator will generate for a provider should be somewhere between $500,000 and $750,000 per year.
Screening in the Covid Era
The COVID-19 pandemic led to a drastic decrease in cancer screening and prevention efforts, and according to experts, the long-term impacts could be quite substantial. It has been well established that cancer screenings can help to identify malignancies early, allowing for earlier treatment and a decreased risk of dying of late-stage disease, especially among people who have a higher risk for certain cancers (including older individuals, people with a family history or personal history of cancer, and people who are exposed to tobacco smoke, certain chemicals, and other cancer-causing agents). But when lockdowns and fears of leaving home became widespread, preventive cancer screenings took a backseat.
According to Andi Dwyer, program director of the Colorado Cancer Screening Program at CU Anschutz, navigators are crucial to reigniting cancer screening and early detection efforts in the United States, particularly through increasing education and awareness in the form of community outreach.
Navigators help to bridge gaps in care, provide a line of communication between the patient and the provider, and aid in the uptick of cancer prevention and detection, often through staying informed on who is eligible for cancer screening and keeping patients apprised of that knowledge. But as was the case with many professions, navigation was vulnerable during the pandemic. However, the significant dip seen in preventive cancer screenings nationwide also served to highlight the vital role of navigators in facilitating cancer screening and prevention efforts.
Cancer death rates in the United States dropped almost 30% between 1999 and 2019, and this was attributed largely to successful cancer screening efforts. Although 2020 set back these efforts substantially, data show that reigniting these efforts as soon as possible may be able to make up for lost time.
Patient navigation in cancer screening has been shown to improve health outcomes and satisfaction, reduce overall healthcare costs, and benefit the most vulnerable populations, in large part due to navigators’ aptitude for working with the people making up varying populations. Even if they don’t have a strong healthcare background, cultural competence can be key for connecting with a population, and when navigators are well matched with the populations they are serving, the uptake of preventive screening is often even more substantial.
The negative impact of COVID-19 on cancer screenings was largely due to elective medical procedures—including nonemergency screening procedures—being banned. Adding to these restrictions were insurance and financial changes, particularly patients losing insurance coverage through their employers, as well as “pandemic behaviors” that led to putting off healthcare, and increased drinking and smoking (often due to stress and idle time), and more sedentary lifestyles.
The pandemic didn’t slow down the incidence of cancer, but together, these factors led to a decrease in cancer screening rates and referrals.
The National Cancer Institute estimates that the impact of delayed cancer screening and treatment due to the pandemic could translate to almost 10,000 excess deaths over the next decade from breast and colon cancers alone. However, not everyone diagnosed with cancer will die of it, and the estimates for missed or delayed cancer diagnoses due to reductions in cancer screening and monitoring are even higher than estimates for excess deaths.
Many experts agree that postponing cancer screenings was prudent at one time due to the risks of COVID-19 exposure, but now it’s crucial that navigators—and other providers—step in to help bridge the gap caused by the elective procedure ban and help Americans return to some semblance of “normalcy.” It’s important that navigators don’t wait for patients to come to them; instead, they should use a proactive approach, encouraging patients to return to screening by providing direct communication and guidance, as well as continued follow-up.
Navigators are in a unique position to do this, as many of them continued to provide care to their patients during the pandemic via telehealth. As they are well informed about their patients’ whereabouts, as well as their fears and concerns around COVID exposure, they can again open up conversations with their patients about the importance of preventive cancer screenings. To allay some of their fears about exposure, navigators can remind patients of the precautions now in place, such as facial coverings, physical distancing, and prescreening for COVID-related symptoms before cancer screening appointments.
But when combined with barriers, misinformation, and fear, even the precautionary measures meant to protect people can overwhelm patients, again underlining the important role of the navigator in ensuring that patients overcome the barriers standing in the way of regular cancer screenings.
Navigation provides a safety net for the most vulnerable populations and is a proven method to increase cancer screening rates, but navigators cannot do it alone: aligning national partnerships with state and local efforts will be crucial to sustaining navigation and community health work postpandemic, now with a particular focus on COVID vaccine uptake, vaccine hesitancy, and health literacy.
Combating ageism is crucial to achieving person-centered and age-friendly cancer care, according to Sarah H. Kagan, PhD, RN, a gerontology clinical nurse specialist at Penn Medicine. Ageist messages (eg, older people burden our society with overuse of healthcare) are prevalent, particularly in the world of oncology, and can lead to significantly worse health outcomes among patients. But unfortunately, many cancer navigators and other providers don’t know how to address this particular type of discrimination.
Ageism is a general term to describe discrimination based on perceptions of age. But it’s important to note that it can be both positively and negatively intended (or completely unintended), and it can be implicit or explicit in nature. It has been shown to negatively affect health outcomes, and it can exist in individuals, institutions, and cultures. However, in healthcare, it typically goes unacknowledged.
Although we do live in an aging society, the majority of cancer care provided in the United States is not age-friendly, and ageism remains a major problem. Currently, 16% of the US population is over the age of 65 (though in many areas of the country that proportion is much greater), the majority of cancer diagnoses occur in older people, and the majority of people surviving cancer are older. But according to Dr Kagan, ageism is more to blame for worse health outcomes than actual chronological age. She even argues that chronological age should not be used as an identifier, because it is not relevant to health status.
The idea of person-centered care first came about in the care of people living with dementia. But according to Dr Kagan, the opportunity to bring it into oncology care on a broad scale lies in the hands of those working in nursing and other supportive care fields.
Importantly, person-centered care and patient-centered care are not the same, and the difference is important. The main goal of patient-centeredness is a functional life for the patient, whereas the main goal of person-centeredness is a meaningful life for the patient (not simply a functional life).
Age-friendly care is a broader term that reframes care for older people (not synonymous with “geriatric oncology”), and it is built around dismantling ageism through a person- and family-centered approach.
Achieving person-centered and age-friendly cancer care lies in “engaging our inner patient.” Since all of us—including healthcare providers—are people who need, seek, and receive healthcare, we can typically empathize with what it feels like to be the patient. Most of us have, at one point or another, felt anxious (or even powerless) about some aspect of our health, and we all hope to find a clinician who understands us.
Dismantling ageism through an age-friendly care approach can be challenging since ageism is still not widely acknowledged in society. According to Dr Kagan, evidence shows that it is still ubiquitous in healthcare, and is the last widely accepted form of discrimination in our society.
Ageism is generally expressed in 1 of 3 different ways: negative with intent to harm (ie, verbal or financial abuse, physical harm), ambivalent and beneficent with implied intent to protect (ie, “elder speak,” coddling), and emerging from the elder and entailing elder identity (ie, negative stereotypes, practices that exclude elders). Although the first category is rarely seen in healthcare, ageism with implied intent to protect is commonly seen in the form of “elder speak,” as though one is speaking to a small child.
Internalized ageism (termed negative age-related self-stereotyping) is common around the world, and particularly in cancer care. On an institutional/structural level, this type of ageism is seen in age restrictions on clinical trials or even clinical programs, but on a personal level, it’s commonly seen when a person deems themselves “too old for that,” or incapable of doing something “at my age.”
But ageism cannot simply be blamed on the fact that the population is aging. Ageism is a product of cultural forces, not demographics, and in addition to making people ill, it makes them feel depressed and lacking in purpose. According to Dr Kagan, navigators play a crucial role in changing that mindset.
Anti-ageism has been shown to increase motivation among older people, and research shows that some of the health effects of ageism may be modifiable or even reversible. If people are taught to dismantle ageism and think positively about themselves, they’re more motivated to take care of themselves, to be physically active, and to engage with others as they grow older.
This points to the importance of education around ageism. Although skepticism around changing the culture of ageism in the United States does exist, even more research has shown that anti-ageist healthcare is possible, practical, and cost-effective.
The 4 Ms of age-friendly cancer care—What Matters, Mobility, Mentation, and Medication—are meant to drive care improvement in US hospitals and clinics by attaching clinical screening tools to each “M.” This framework was designed by Age-Friendly Health Systems, a national healthcare quality initiative aimed at ensuring success through universal screening, focal assessments, targeted referrals, and consistent evaluation at both the individual and program levels.
According to Dr Kagan, every patient encounter should begin with asking the patient what matters (not only in terms of goals of care, but also personal wishes and dreams, health and general literacy, and communication preferences). If “what matters” to a patient necessitates referrals to other providers (eg, social workers, palliative care, chaplains), navigators should facilitate that, also keeping in mind that “what matters” is complex and shifts as life evolves. These conversations should be accompanied by a frailty screen for all patients, as screening for frailty helps to appraise risk.
Screening for mobility (focusing on getting people more mobile as well as prehabilitation and rehabilitation), mentation (identifying and treating depression, dementia, and hearing impairment), and medication (reviewing medication lists to identify polypharmacy and potential inappropriate medications) should follow a similar format and should be accompanied by key referrals, when necessary.
In dismantling ageism and turning toward person- and family-centered cancer care, navigators should replace “do they need it?” thinking with “why would they not need it?” For example, asking “Why would this patient not need physical therapy?” can help to create routine support for mobility, and navigators should limit the mentioning of age except where necessary for record keeping. Continue to use the self-check: “Would I believe/think/do this if this person were young?” Change the language used at work and at home (instead of “elderly,” simply use person/people or “older adult/people” when necessary), and finally, challenge others to change theirs.