Category VI: Research, Quality, Performance Improvement

October 2023 Vol 14, No 10 —October 26, 2023

F1 Doctor-Patient Relationships and Patient Satisfaction in Multiple Myeloma: Implications of Shared Decision-Making and Racial Disparities

Marsha G. Calloway-Campbell, JD; Patricia Alejandra Flores Pérez, MD; Rachel Jensen, BS1; Ana Sofia Capdevila Ponce de Leon, MBA; Jay R. Hydren, PhD; Jennifer M. Ahlstrom, BA; Jorge Arturo Hurtado Martínez, MD

1HealthTree Foundation; HealthTree for Multiple Myeloma, Lehi, UT

Background: Multiple myeloma (MM) is a complex hematologic malignancy, and treatment decisions at relapse or refraction play a critical role in patient outcomes. HealthTree Cure Hub is a patient-derived, patient-driven clinical cancer information platform that empowers patients to contribute to myeloma research.

Objective: To survey MM patients within the HealthTree Cure Hub platform to gain insights into their decision-making process and satisfaction with treatment decisions, which is crucial for improving care.

Methods: Five hundred sixty-two MM patients participated in the survey; 50% of participants were female, with a mean age of 65.48 ± 8.74 years. The survey included MM patients with a history of relapsed/refractory (RR) diseases. Two hundred fifty-three of the participants answered 4 key questions that were analyzed using linear regression and correlation analysis to explore the relationships between the level of education for treatment decisions, comfort with the final treatment decision, time given between treatments, and time used for decision-making. Black or African American (AA), Hispanic or Latino/a (HL), and White patients were identified, and their responses were analyzed. Demographics were available for 191 patients: 169 (88%) were White, 11 (5.7%) AA, and 15 (7.8%) HL.

Results: At first RR, participants showed a comfortability with their treatment decision-making of 4.33 ± 0.76 (scale 1-5, with 1=very uncomfortable and 5=very comfortable); education level satisfaction was 3.96 ± 0.83 (scale 1-5), and patients were given 2.9 ± 1.5 weeks to make a decision, for which 2 ± 1.35 weeks were utilized. AA patients reported a lower education level satisfaction score (3.5 ± 0.53) compared to HL (4.15 ± 0.8) and White (4.05 ± 0.9) participants. Regression analysis indicated that the level of education satisfaction has a positive impact on predicting satisfaction with the final treatment decision (β coefficient 0.46; P <.001).

Conclusion: This study provides valuable insights into the decision-making process of MM patients at the time of RR. The results highlight the importance of patient education, with higher levels of education positively influencing comfort with treatment decisions. AA patients reported a lower education level satisfaction score compared to their HL and White counterparts. Additionally, the findings emphasize the significance of sufficient time allocation for decision-making, as longer intervals are associated with increased comfort. Healthcare providers should focus on patient education and ensure adequate time for informed decision-making to enhance patient satisfaction with treatment outcomes in MM at relapse.


Sweeney NW, Ahlstrom JM, Davies FE, Thompson MA. HealthTree Cure Hub: a patient-derived, patient-driven clinical cancer information platform used to overcome hurdles and accelerate research in multiple myeloma [published correction appears in JCO Clin Cancer Inform. 2022;6:e2200053]. JCO Clin Cancer Inform. 2022;6:e2100141. doi: 10.1200/CCI.21.00141

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F2 Implementation of an Oncology Navigation Council

Kelly Filer, BSN, RN, CCM; Catherine Oplinger, MSN, RN, OCN, AMB-BC

Sidney Kimmel Cancer Center at Jefferson Health, Philadelphia, PA

Background: The necessity for organization among the navigators at Sidney Kimmel Cancer Center (SKCC) at Jefferson Health became evident as additional locations were added to the cancer center’s quickly growing list of geographic locations. Currently, the SKCC enterprise includes 6 cancer center locations throughout southern New Jersey and eastern Pennsylvania. The enterprise patients often interact with providers from surgical, medical, and radiation oncology in separate locations and across state borders. The necessity for seamless communication and coordination between care teams has become crucially important, particularly for patients receiving treatments at more than one location.

Objective: To develop an enterprise-wide council for oncology navigation using the Oncology Navigation Standards of Professional Practice, with the goal of promoting seamless transitions across state and county borders from one oncology specialty to another within the enterprise.

Methods: The fundamentals for development of the new council are based on the application of the Oncology Navigation Standards of Professional Practice. The council appointed chairpersons, created a format for official meetings, and organized shared resources. The council chairpersons developed a plan of regularly scheduled meetings to endorse the team to come together, interact, and create relationships, highlighting the importance of a unified team.

A comprehensive council-member contact list was established including nurse navigators, patient navigators, and social work providers. The council contact information was disbursed across the enterprise. The council hosts monthly council video meetings and in-person quarterly meetings, beginning in March 2022. The council meetings’ focus is to optimize transitions of care for our patients when moving from one center location or provider to another. Monthly council ongoing topics include updates from our director, navigation-sensitive projects, educational opportunities, and team-building events. A web-based shared file was created for all navigation council members in which navigation-specific resources and educational opportunities are located and available to share. The file is accessible and modifiable for updates by all the members of the council.

Results: Eleven months after the navigation council was established, an assessment questionnaire of the council members’ impression of the council was conducted. An anonymous, subjective survey consisting of 5 questions with a Likert-style reply was dispersed via email to council members. The council members were given 2 weeks to reply. There are 31 council members and 29 respondents, excluding the 2 authors of this project. The results are generally encouraging. The council overall favored the Oncology Navigation Standards of Professional Practice as the most important guiding principles. A strong sense of community among the navigation council also was noted by member respondents. This finding is especially satisfying for the authors of the project, as this was a significant reason the council was developed. Additionally, and perhaps most importantly, the council strongly agreed that council members have promoted better care coordination for their patients across the enterprise. An agreeable result of education opportunities was recognized as valuable to the council. Lastly, an area of improvement identified is to make the shared resources file more easily accessible.

Conclusion: It is the opinion of these authors that a navigation council was successfully established at SKCC. The positive impacts of the new navigation council included navigator engagement as well as the ability to better communicate and coordinate patient care. The oncology navigation council at SKCC will continue to grow and evolve in the future. The council is looking forward to continued collaboration with their constituents.


The Professional Oncology Navigation Task Force. Oncology navigation standards of professional practice. Clin J Oncol Nurs. 2022;26(3):e1-e12. doi: 10.1188/22.CJON.E1-E12

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F3 Measuring the Effects and Resolution of the Nurse Navigator Role for Patients With Abnormal Breast Imaging

Sylvia Brown, MS, RN, OCN, CNL, ONN-CG; Angela Williams, MBA, BSN, BS, RN; Belle Ouko Kendrick, MSN, RN, OCN, ONN-CG

MD Anderson Cancer Center, Houston, TX

Background: In a large, National Cancer Institute–designated cancer hospital, breast screening patients who have abnormal breast imaging had a low return rate with the recommendation to have additional imaging. A review of baseline data was conducted, revealing only 25% of patients return to the original institution to complete a diagnostic workup.

Objectives: To (1) develop and implement the role of the nurse navigator in the Undiagnosed Breast Clinic to address barriers to care through coordination, education, and healthcare services; and (2) increase patient adherence to recommended follow-up after an abnormal finding, with the goal of a 50% increase over a 2-year period.

Methods: A quantitative descriptive research design was utilized, and data were collected from a radiology reporting system of suspicious mammogram results (ie, BI-RADS 0) from 2019 to 2023. The nurse navigator began proactively reaching out to referring physicians and patients by phone within 24 hours of an abnormal finding, providing results, education, and assisting with coordination of care. Through a multidisciplinary team approach, the nurse navigator coordinated with breast imaging, healthcare teams, and other navigators throughout the system to ensure accurate and timely care. As noted in the article by Raich et al, literature indicates an increase in patient adherence through navigation. Specifically, “patient navigation can potentially impact cancer care across the entire continuum, including screening rates, resolution of screening abnormality, diagnosis to initiation of treatment, treatment adherence and completion, survivorship, and end-of-life care.”

Results: The nurse navigator role had a positive impact on increasing patient return to diagnostic imaging and biopsies through physician relationship building, direct patient follow-up, and diligent follow-through. Data collected from 2019 to 2023 revealed a 56% increase in patient return from baseline (21% vs 77%, respectively). Of 1395 completed mammograms in 2019, 352 women completed diagnostic follow-up, compared to 849 of 1102 patients returning to date in 2023. The positive relationships built between nurse navigators and patients through this initiative showed a positive impact on increased timely follow-up, as well as on the navigator-patient relationship and the early detection of breast cancer.

Conclusion: The role of the nurse navigator is to provide evidence-based information regarding screening, diagnosis, treatment, and survivorship care. The nurse navigator serves as an advocate, providing education for shared decision-making and care coordination, and supporting patients through all aspects of care. As stated by Ferrante et al, patient navigation is an effective strategy to improve timely diagnostic resolution, significantly decrease anxiety, and increase patient satisfaction among women with abnormal mammograms. This study provides evidence of the positive effect of implementation of the nurse navigator role in patients with abnormal mammographic findings.


Raich PC, Whitley EM, Thorland W, Valverde P, Fairclough D; Denver Patient Navigation Research Program. Patient navigation improves cancer diagnostic resolution: an individually randomized clinical trial in an underserved population. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1629-1638. doi: 10.1158/1055-9965.EPI-12-0513.

Ferrante JM, Chen P-H, Kim S. The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial. J Urban Health. 2008;85(1):114-124. doi: 10.1007/s11524-007-9228-9

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F4 Navigating Patients on Tumor Treating Fields Therapy in the United States: Patient Satisfaction, Education, and Usage Experience

Heather Johnson, BSN, RN1; Eleni T. Batzianouli, MS2; Shermona Shockley, MHA, MSN, BSN1; Anne Thomas, BS, RN, OCN1; Peggy Frongillo, BSN, RN1; N. Renae Adams, BSN, RN1; Huda Ismail Abdullah, PhD1

1Novocure Inc, New York, NY; 2Novocure GmbH, Root, Switzerland

Background: Tumor Treating Fields (TTFields) therapy is a noninvasive, locoregional treatment approved in several countries globally, as well as by the US Food and Drug Administration, for newly diagnosed glioblastoma (GBM), recurrent GBM, and pleural mesothelioma. Oncology nurse navigators enhance patients’ treatment experience by providing education on TTFields therapy and practical resources. TTFields therapy usage positively correlates with enhanced survival; patient education on this relationship is integral to maximize usage and, therefore, survival benefit.

Objective: To evaluate real-world TTFields therapy usage, patient education regarding therapy, and overall satisfaction with therapy among a cohort of US patients with GBM.

Methods: In 2022, real-world experiences of 1332 US patients with GBM receiving TTFields therapy (NovoTTF-200A; Novocure® GmbH) were analyzed according to time on therapy: first-time users (n=403), ~60 days posttreatment initiation (n=554), and 6 months from treatment start (n=375). Patient satisfaction surveys were conducted via mail (73%) or online (27%).

Results: Overall, 54% of first-time users decided to use TTFields therapy within 1 week; the most common reason for delaying treatment was to obtain additional information (n=43). Education on, and comfort with, the device was important; most first-time patients recommended in-person assistance (85%) over online assistance for treatment initiation. Among 6-month users, there was a high rate of satisfaction with patient resources (rated very/somewhat useful: brochures, 83%; website, 84%; patient video, 83%). Important information for new users included hands-on experience, comfort and scalp skincare tips, patient testimonials, troubleshooting guidance, and advice for integrating TTFields therapy into daily life. Most 60-day users (92%) agreed that monthly usage data were valuable. Overall satisfaction was high across all 3 cohorts but decreased marginally in 6-month users. Lifestyle integration, device logistics, skin irritation, and unawareness of the positive correlation between usage and long-term survival outcomes were areas requiring improved educational efforts.

Conclusion: Effective patient/caregiver/healthcare provider education on TTFields therapy is critical for ensuring informed decision-making, usage, and overall satisfaction. Oncology nurse navigators represent a vital link between the healthcare provider and patient and, as such, should be an integral component in the GBM patient education process. Patient education and satisfaction may optimize TTFields therapy usage through increased awareness of the relationship between usage and survival outcomes. Therefore, long-term TTFields therapy users should receive ongoing education and encouragement to maintain usage, thus maximizing survival outcomes. Further education for oncology nurse navigators to gain a deeper understanding of TTFields therapy will enhance patient/caregiver education and awareness.

Funding: This research was sponsored by Novocure Inc. All authors are employees of Novocure Inc.


Anadkat MJ, Lacouture M, Friedman A, et al. Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region. Front Oncol. 2023;12:975473. Accessed June 1, 2023.

Ceresoli GL, Aerts JG, Dziadziuszko R, et al. Tumour Treating Fields in combination with pemetrexed and cisplatin or carboplatin as first-line treatment for unresectable malignant pleural mesothelioma (STELLAR): a multicentre, single-arm phase 2 trial. Lancet Oncol. 2019;20(12):1702-1709. Accessed June 1, 2023.

Gordils-Perez J, Schneider SM, Gabel M, Trotter KJ. Oncology nurse navigation: development and implementation of a program at a comprehensive cancer center.Clin J Oncol Nurs. 2017;21(5):581-588. Accessed June 1, 2023.

Lacouture ME, Anadkat MJ, Ballo MT, et al. Prevention and management of dermatologic adverse events associated with Tumor Treating Fields in patients with glioblastoma. Front Oncol. 2020;10:1045. Accessed June 1, 2023.

Muñoz R, Farshidpour L, Chaudhary UB, Fathi AH. Multidisciplinary cancer care model: a positive association between oncology nurse navigation and improved outcomes for patients with cancer. Clin J Oncol Nurs. 2018;22(5):E141-E145. doi: 10.1188/18.CJON.E141-E145

Stupp R, Taillibert S, Kanner A, et al. Effect of Tumor-Treating Fields plus maintenance temozolomide vs maintenance temozolomide alone on survival in patients with glioblastoma: a randomized clinical trial. JAMA. 2017;318(23):2306-2316. doi: 10.1001/jama.2017.18718

Stupp R, Wong ET, Kanner AA, et al. NovoTTF-100A versus physician's choice chemotherapy in recurrent glioblastoma: a randomised phase III trial of a novel treatment modality. Eur J Cancer. 2012;48(14):2192-2202. Accessed June 1, 2023.

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F5 No More Sticky Notes! Creating an Evidence-Based, Electronic, Standardized Process for Oral Chemotherapy

Charleen Tuthill, BSS; Michelle Jensen, RN; Patricia Johnson, BS, RN, OCN, CBCN, ONN-CG

UVM Health Network – CVPH, Plattsburgh, NY

Background: Oral chemotherapy accounts for 50% of newly prescribed cancer treatments. Patients report convenience and flexibility of home administration, citing reduced barriers to treatment. Studies report barriers to adherence related to symptom management. Standardizing processes can reduce processing time, increase compliance and safety, and improve the experience for patients and staff.

Objective: To create a standardized process led by an oral chemotherapy nurse navigator (OCNN) that accounts for all patients prescribed oral oncolytics; improves order-to-delivery time; assures appropriate pharmacy utilization; retains revenue within the organization’s network facilities; improves adherence to treatment plan and patient safety; and improves the experience of patients and staff.

Methods: The current process was defined, and issues and barriers were outlined using a Plan-Do-Study-Act (PDSA) process. A dedicated OCNN was tasked with creating a standardized workflow. In collaboration with the electronic medical record (EMR) vendor, a report was generated identifying all patients who were prescribed an oral oncolytic. Parameters were set in the EMR to create prompts for refill and compliance call reminders. Network specialty pharmacies were contacted, and a pharmacy care coordinator (PCC) team was established to process all prescriptions, including insurance verification, utilization of appropriate specialty pharmacy, co-payment verification, and patient assistance with co-payment and drug assistance programs. Communication lines were established to inform the patient and team regarding drug delivery. All information is scanned into the EMR, improving documentation, safety, and communication. The workflow is organized and well documented, leading to increased staff satisfaction.

Results: The standardized process replaced a paper-based system using notebooks and sticky notes. The EMR report identified 140 patients on oral chemotherapy. All patients were easily tracked, and the OCNN was prompted to make compliance calls and refill reminders. Compliance calls improved safety, as patient treatment was withheld based on reported symptoms. Through the team approach, prior authorization time was reduced from 10 to 14 days to 2 to 3 days, and appropriate pharmacy use increased from 60% to 100%, resulting in a greater than 80% reduction in processing fees for each prescription. Patients were alerted to medication delivery and received them in a timely manner. The process decreased risk to the patient and the organization, and improved the experience for patients and staff.

Conclusion: Standardizing the process for oral chemotherapy prescription processing and compliance checks through the PDSA tool improved patient safety, the experience of patients and staff, and retained revenue within the organization network. The OCNN is able to identify, track, and monitor adherence for each patient throughout the treatment plan. The process is outlined in detail, allowing covering nurses to seamlessly complete the work; in addition, the process could be used across the network facilities. Next steps include tracking the outcome of compliance calls related to symptom management and the percentage of patient treatments withheld due to information gathered during the call.


Jacobs JM, Ream ME, Pensak N, etal. Patient experiences with oral chemotherapy: adherence, symptoms, and quality of life. J Natl Compr Canc Netw. 2019;17(3):221-228. Accessed June 13, 2023.

Marshall VK, Vachon E, Given BA, Lehto R. Impact of oral anticancer medication from a family caregiver perspective. Oncol Nurs Forum. 2018;45(5):597-606. Accessed June 13, 2023.

Oncology Nursing Society. Oral anticancer medication toolkit. ONS 2022. Accessed June 13, 2023.

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Last modified: November 2, 2023

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