From Prevention to Palliative Care: Optimizing the Breast ... · From Prevention to Palliative...
Transcript of From Prevention to Palliative Care: Optimizing the Breast ... · From Prevention to Palliative...
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From Prevention to Palliative Care: Optimizing the
Breast Cancer Patient Experience with Nurse Navigation
Darcy Burbage, MSN, RN, AOCN, CBCN
Oncology Nurse Navigator
Helen F. Graham Cancer Center & Research Institute
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Objectives • Discuss strategies to overcome barriers to successful
implementation of the NN role in breast cancer programs.
• Identify strategies to improve BrCa screening and coordination of care for patients.
• Outline emerging treatment options.
• Identify key components for patients as they transition through the continuum of care.
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Role of NN in Breast Care • Define patient population
– Dependent upon your institution
– Will help you delineate your role
– Community needs assessment
– Patient advisory board
• Budget
• Staffing
• Define metrics
• Build relationships/collaborations
Korber, S.F., Padula, C., Gray, J., & Powell, M. (2011). A breast navigator program: Barriers, enhancers, and nursing interventions.
Oncology Nursing Forum, 38 (1), 44-50.
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Case Study
• J.S. 57 y.o. AA presented w/palpable lump b/w sx mammo
• Bx + IDC ER/PR+/HER2-
• 2 daughters; 1 son; 3 sisters; 3 nieces
• Genetic counseling performed; testing negative
• Stage III IDC; s/p MRM w/implant reconstruction
• DD AC followed by 12 wks Taxane
• XRT
• AI for 5 years
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Screening and Early Detection of Breast Cancer
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Comparison of BrCa Screening Guidelines
Recommended ACOG ACR/SBI ACS AMA NCCN USPSTF
Age to Start Mammograms 40 40
45 Individual
choice 40-44 40 40 50
Age to Stop Mammograms
Annual as long as
woman is in good health
When life expectancy
is < 5-7 years
When life expectancy is
< 10 years
When life expectancy
is < 10 years
Upper age limit not
established 74
Interval Annual AnnualAnnual 45-54; 1-2 years 55+ Annual Annual 2 years
American Cancer Society. http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-
early-detection-acs-recs
American College of Gynecology. http://acog/org/About--ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advisory-on-Breast-
Cancer-Screening.
American College of Radiology. http://www.jacr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BreastCancerScreening.pdf
American Medical Association. http://www.ama-assn.org/resources/doc/csaph/x-pub/a12-csaph6-screeningmammography.pdf
National Comprehensive Cancer Network. http://www.nccn.org/breastcancerscreening
United States Preventive Task Force. http://www.uspreventiveservicetaskforce.org/Page/Document/UpdateSummaryFinal/breast-
cancer-screening1.
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Screening & Early Detection • Controversies between guidelines
• Risk Assessment– Risk prediction models (Gail Risk/Tyrer-Cuzick)
– Genetic Counseling & Testing
• Risk Factors– Non-modifiable
– Modifiable
• Risk Reduction– Interventions to modify risk
– Health promotion to reduce risk
American Cancer Society. Breast Cancer Facts & Figures 2017-2018. Atlanta: American Cancer Society, Inc. 2017.
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NN to coordinate care
as directed by MD
Educate patients
RE: Diagnosis and Treatment
Provide emotional support
Review Resources
Follow-up phone calls throughout treatment -Confirm readiness for subsequent treatment modalities -Assess compliance with recommended treatment plan -Review questions
-Refer to Survivorship Nurse Navigator-End of Treatment Counseling-SCP
Review pathology
Other Practices
Self Referrals
TumorConference
MDC
CHOE
Initial Visit
-Assess needs using Insight- Determine preliminary treatment plan
Make referrals- Rehab- Social Work- Psychology-Community Resources
Provide emotional support
Review resources & make referrals as
needed
End of Treatment
Inpatient
Supportive and Palliative Care
Navigation throughout the Breast Cancer Continuum
Burbage, D., et al. (2016). Optimizing Breast Cancer Nurse Navigation Using a Lean Six Sigma Approach.
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Treatment Considerations
• Staging
• Molecular profiling
• Unique populations
• Clinical trials
• NCCN Treatment Guidelines
– Surgery, Chemotherapy, Radiation Therapy, Endocrine Therapy
• Prehabilitation
• Supportive & Palliative Care
AJCC (2018). Breast Cancer Staging System.
Hu, X., Huang, W., & Fan, M. (2017). Emerging therapies for breast cancer. Journal of Hematology and Oncology, 10, 1-17.
NCCN (2019). National Comprehensive Cancer Network. Breast Cancer Treatment Guidelines.
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Treatment Considerations • Approved Chemotherapy Regimens for Adjuvant, Recurrent & Stage IV Breast
Cancer• Multiple regimens exist
• Dependent upon stage, molecular status of tumor and,
• Individual patient variability, prior treatments, existing co-morbidities
• Targeted therapies based on biology of cancer: anti-HER2 targeted therapy drugs, PD-L1-inhibitors
• Emerging Chemotherapy Options• PARP Inhibitors
• CDK 4/6 Inhibitors
• Immunotherapy
• Selected Androgen Receptor Modulators (SARMs)
AACR (2019). Current, New and Emerging Therapies. Retrieved from www.aacr.org
NCCN (2019). National Comprehensive Cancer Network. Breast Cancer Treatment Guidelines.
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Breast Cancer Risk Stratification Based on Acuity
Insurance
**Comorbid diseases:1. COPD2. CHF/CAD3. Uncontrolled Diabetes 4. Renal Failure5. Morbid Obesity6. Mobility Issues7. Cognitively Impaired
Product limited
in some way
Uninsured or Undocumented
Medicare
Surgical Procedures
Co-morbids**
Anti Estrogen
None
0
Screened positive for
distress
0 1Social Factors* >2
Uncontrolled Psych D/O or other sig dx
>2
*Social Factors:1. Homeless or vulnerable2. Single and/or no support
at home3. Literacy4. 1 Language not English5. < 40 yrs or > 65 yrs 6. Non-Hispanic Black7. Transportation Issues
Substance Use Disorder
Commercial/non-mang
Medicare
Not active, but last used w/in 1
yr
Active
PsychiatricDisorder
AdjuvantTreatment
Chemo and or Radiation
Neo-Adjuvant ChemoTNBC
1
Lumpectomy w/wo SLNB
Mastectomy w/Recon-
struction
Mastectomy w/o Recon-
struction
Level 1
Current – %
Goal -25%
Level 2
Current - %
Goal- 35%
Level 3
Current -%
Goal - 35%
Stage IV
Level 4
Current-
Goal - 5%
None
Risks
Burbage, et al., (2016). Optimizing Breast Cancer Nurse Navigation. Wagner, E.H., Ludman, E.J. et al. (2014). Nurse navigators role in early cancer care: A randomized, controlled trial. JCO, 32 (1), 12-18.
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Potential Physical Effects of Breast Cancer
Martz, C.H. & Kirby, K. (2011). Symptom Management. In S. Mahon (Ed.). Breast Cancer (2nd ed., pp.141-177). Pittsburgh, PA: Oncology Nursing Society.
• Hot flashes
• Vaginal Dryness
• Osteoporosis
• Weight changes
• Acute effects
• Early Menopause
• “chemo-brain”
• Fatigue
• Neuropathy
• Weight changes
• Same as surgery, plus
• Fatigue
• Skin changes
• ↓ ROM
• Cording
• Lymphedema
• Pain/Numbness
• Changes in sensation
Surgery Radiation
Anti-EstrogenChemo
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Potential Psychosocial Effects of Breast Cancer
• Anxiety, Fear of recurrence
• Body image concerns
• Intimacy, sexuality, fertility
• Changes in relationships
• Changes in responsibilities
• Financial/employment/health & life insurance concerns
• Survivor’s guilt
Campbell-Enns, H. & Woodgate, R. (2016). The psychosocial experiences of women with breast cancer across the
lifespan: A systematic review. Psycho-Oncology, retrieved March 10, 2019 from https://doi.org/10.1002/pon.4281
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Potential long-term & late effects of treatment• It’s all relative
• Risk depends upon
– Overall health before treatment
– Treatment received
• Long-term effect
– Develop during treatment and may become chronic, linger on, or improve over time
• Fatigue/Anxiety
• Late effect
– Delayed; can surface months or years after treatment is completed
• Cardiac issues/Depression
Rowland, J., Hewitt, M., & Ganz, P. (2006). Cancer survivorship: A new challenge in delivering quality cancer care. Journal of Clinical Oncology, 24, 5101-5104.
Morgan, M. (2014). Improving Survivorship Care for Patients with Cancer. National Comprehensive Cancer Network (NCCN).
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Survivorship Treatment Summary
and Follow-Up Care Plan
• Multiple free templates available that meet CoC criteria
• Documents stage of cancer, treatments received and
ongoing treatment & side effects
• EB surveillance guidelines
• Symptoms to report
• Treatment team contact information
Riley, A. (2018). How to meet the needs of 18 million (and counting) cancer survivors. Oncology Advisory Board Survivorship Seminar.
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Surveillance and health promotion • Annual mammogram
• Medical history and physical exam every 3 to 6 months for 3 years, then every 6 months for 2 years, then annually
• Annual gynecologic exam for women with uterus on tamoxifen
• Baseline bone mineral density determination for women on aromatase inhibitor and periodically thereafter
• Continue with regular medical and dental screenings
• Genetic counseling/testing
• Report any new or persistent symptom, including anxiety/distress
• Implement healthy lifestyle choices
http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf; Retrieved March 30, 2019.
What to know: ASCO’s guideline of follow-up care for breast cancer. (2009, June). Retrieved March 30, 2019 from http://www.cancer.net/patient/publications+and+resources/what+to+know.
Rock, C., et al (2012). Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians, 62(4), 243-274.
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Hawley, P. (2015). Retrieved from:
http://www.virtualhospice.ca/en_US/Main+Site+Navigation/Home/For+Professionals/For+Professionals/The+Exchange/Current/The+Bow+Tie+Model+of+21st+Century+Palliative+
Care.aspx
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The Spectrum of Metastatic Breast Cancer
• Rapid development of metastases
• Shorter disease-free interval
• Extensive visceral involvement
• Resistance to endocrine therapy
• Long disease-free interval
• Later recurrence of metastases
• Bone and soft tissue disease
• Sensitive to endocrine therapy
IndolentVirulent
Slide credit: clinicaloptions.com
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Lessons Learned
• Not a one size fits all approach to navigation• Anticipate growing pains • Ask your patients and colleagues • Define population as well as role of all team members• Focus on what’s best for the patients in your community
• Determine metrics• Utilize existing resources • Evaluate model of navigation • Communicate and celebrate success!
American College of Surgeons (2012). Cancer program standards: Ensuring patient-centered care. Retrieved from https://www.facs.org/quality-programs/cancer/coc/standardsSmith, J. & Kautz, D. (2015). A literature review of the navigator role: Redefining the job description. Journal of Oncology Navigation and Survivorship, 6(2), 24-33.
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Nurse Navigator Led Patient Outcome Measures• Provider and patient satisfaction scores have been maintained between 98% to 100% since implementation of
the breast care/cancer nurse navigator role.
• Breast biopsy turnaround time has decreased from 18 days to 5 days.
• Comprehensive lymphedema program developed with greater than 80% reduction in overall volumetric measurements and revenue generating of $2,500 per average 14 visit treatment program.
• Reduced same day biopsy cancellation rates referred from outside facilities from 11% to 2% therefore saving the institution $3,000 per cancelled case.
• ED visits 31.1% vs 58.3%
• Admissions 26.7% vs 33.3%
• Readmissions at 30 days: 15.0% vs 31.0%
Koprowski, C., Johnson, E.J., Sites, K., & Petrelli, N. (2018). The SCOOP Pathway. Oncology Issues, 33(6), 19-27. Lee, et al (2011). Effects of nurse navigators on health outcomes of cancer patients. Cancer Nursing , 34 (5), 376-384.
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What’s the future look like for breast cancer nurse navigation?
• Group visits
• How do we utilize the power of technology better?
• Long-term survivors & those living with metastatic breast cancer
• Improved collaboration with our non-oncology colleagues for transitions of care/managing co-morbidities
• How do you balance volume/acuity with limited resources?
• To be continued…
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Thank you!