September 2011 - Journal of Oncology Navigation & Survivorship

Seasons of Survival:Redefining the Paradigm for Cancer Survivorship for 2011

SPECIAL SECTION:Second Annual AONNConference Abstracts

© 2011 Green Hill Healthcare Communications,

LLC

SEPTEMBER 2011 www.AONNonline.org VOL 2, NO 5

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©2011 Genentech USA, Inc. So. San Francisco, CA All rights reserved. HER0000422100 6/11

Herceptin administration can result in sub-clinical and clinical cardiac failure. The incidence and severity was highest in patients receiving Herceptin with anthracycline-containing chemotherapy regimens. In a pivotal adjuvant trial, one patient who developed CHF died of cardiomyopathy

Evaluate cardiac function prior to and during treatment. For adjuvant therapy, also evaluate cardiac function after completion of Herceptin. Discontinue Herceptin for cardiomyopathy

Herceptin can result in serious and fatal infusion reactions and pulmonary toxicity. Discontinue Herceptin for anaphylaxis, angioedema, interstitial pneumonitis, or acute respiratory distress syndrome

Exposure to Herceptin during pregnancy can result in oligohydramnios, in some cases complicated by pulmonary hypoplasia and neonatal death

Exacerbation of chemotherapy-induced neutropenia has also occurred

Detection of HER2 protein overexpression is necessary for selection of patients appropriate for Herceptin therapy

The most common adverse reactions associated with Herceptin use were fever, nausea, vomiting, infusion reactions, diarrhea, infections, increased cough, headache, fatigue, dyspnea, rash, neutropenia, anemia, and myalgia

Boxed WARNINGS and Additional Important Safety Information Adjuvant indications

Your inspiration,

Live 24/7 support line

Live outreach call program

Text tips and email tailored to

HER journey

You guide your HER2+ breast cancer patients through their course of treatment with care and support. The HER Connection program can provide some extra help, including:


Please see brief summary of full Prescribing Information, including Boxed WARNINGS and additional important safety information, on the following pages.

Adjuvant indicationsHerceptin is indicated for adjuvant treatment of HER2-overexpressing node-positive or node-negative (ER/PR-negative or with one high-risk feature*) breast cancer:

As part of a treatment regimen containing doxorubicin, cyclophosphamide, and either paclitaxel or docetaxel

With docetaxel and carboplatin

As a single agent following multi-modality anthracycline-based therapy

* High-risk is defi ned as ER/PR positive with one of the following features: tumor size >2 cm, age <35 years, or tumor grade 2 or 3.

HER commitment


WARNING: CARDIOMYOPATHY, INFUSION REACTIONS, EMBRYO-FETAL TOXICITY, and PULMONARY TOXICITY Cardiomyopathy Herceptin administration can result in sub clinical and clinical cardiac failure. The incidence and severity was highest in patients receiving Herceptin with anthracycline containing chemotherapy regimens. Evaluate left ventricular function in all patients prior to and during treatment with Herceptin. Discontinue Herceptin treatment in patients receiving adjuvant therapy and withhold Herceptin in patients with metastatic disease for clinically significant decrease in left ventricular function. [see Warnings and Precautions and Dosage and Administration]Infusion Reactions; Pulmonary Toxicity Herceptin administration can result in serious and fatal infusion reactions and pulmonary toxicity. Symptoms usually occur during or within 24 hours of Herceptin administration. Interrupt Herceptin infusion for dyspnea or clinically significant hypotension. Monitor patients until symptoms completely resolve. Discontinue Herceptin for anaphylaxis, angioedema, interstitial pneumonitis, or acute respiratory distress syndrome. [see Warnings and Precautions] Embryo-Fetal Toxicity Exposure to Herceptin during pregnancy can result in oligohydramnios and oligohydramnios sequence manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death. [see Warnings and Precautions, Use in Specific Populations]

Incidence of CHF Study Regimen Herceptin Control 1 & 2a ACb→Paclitaxel+ Herceptin 2% (32/1677) 0.4% (7/1600) 3 Chemo→Herceptin 2% (30/1678) 0.3% (5/1708) 4 ACb→Docetaxel+ Herceptin 2% (20/1068) 0.3% (3/1050) 4 Docetaxel+Carbo+ Herceptin 0.4% (4/1056) 0.3% (3/1050)

Incidence NYHA I−IV NYHA III−IV Study Event Herceptin Control Herceptin Control 5 Cardiac (AC)b Dysfunction 28% 7% 19% 3% 5 Cardiac (paclitaxel) Dysfunction 11% 1% 4% 1% 6 Cardiac Dysfunctionc 7% N/A 5% N/A

1 Year Herceptin Observation

1 Year Herceptin Observation

Herceptin Paclitaxel Alone + ACb A

pain 22% 34% 22% 23% 18% syndrome 10% 12% 5% 12% 6% injury 6% 13% 3% 9% 4% reaction 3% 8% 2% 4% 2%C 7% 11% 1% 28% 7%

vomiting 8% 14% 11% 18% 9%

edema 10% 22% 20% 20% 17%

neuritis 2% 23% 16% 2% 2%

increased 26% 41% 22% 43% 29%

simplex 2% 12% 3% 7% 9%

infection 5% 18% 14% 13% 7%


Herceptin 2% (32/1677) 0.4% (7/1600) Herceptin 2% (20/1068) 0.3% (3/1050) Herceptin 0.4% (4/1056) 0.3% (3/1050)

N/A 5% N/A

1 Year Herceptin Observation Adverse Reaction (n= 1678) (n=1708)

CardiacHypertension 64 (4%) 35 (2%)Dizziness 60 (4%) 29 (2%)Ejection Fraction Decreased 58 (3.5%) 11 (0.6%)Palpitations 48 (3%) 12 (0.7%)Cardiac Arrhythmiasb 40 (3%) 17 (1%)Cardiac Failure Congestive 30 (2%) 5 (0.3%)Cardiac Failure 9 (0.5%) 4 (0.2%)Cardiac Disorder 5 (0.3%) 0 (0%)Ventricular Dysfunction 4 (0.2%) 0 (0%)Respiratory Thoracic Mediastinal DisordersCough 81 (5%) 34 (2%)Influenza 70 (4%) 9 (0.5%)Dyspnea 57 (3%) 26 (2%)URI 46 (3%) 20 (1%)Rhinitis 36 (2%) 6 (0.4%)Pharyngolaryngeal Pain 32 (2%) 8 (0.5%)Sinusitis 26 (2%) 5 (0.3%)Epistaxis 25 (2%) 1 (0.06%)Pulmonary Hypertension 4 (0.2%) 0 (0%)Interstitial Pneumonitis 4 (0.2%) 0 (0%)Gastrointestinal DisordersDiarrhea 123 (7%) 16 (1%)Nausea 108 (6%) 19 (1%)Vomiting 58 (3.5%) 10 (0.6%)Constipation 33 (2%) 17 (1%)Dyspepsia 30 (2%) 9 (0.5%)Upper Abdominal Pain 29 (2%) 15 (1%)Musculoskeletal & Connective Tissue DisordersArthralgia 137 (8%) 98 (6%)Back Pain 91 (5%) 58 (3%)Myalgia 63 (4%) 17 (1%)Bone Pain 49 (3%) 26 (2%)Muscle Spasm 46 (3%) 3 (0.2%)

1 Year Herceptin Observation Adverse Reaction (n= 1678) (n=1708)

Nervous System DisordersHeadache 162 (10%) 49 (3%)Paraesthesia 29 (2%) 11 (0.6%)Skin & Subcutaneous Tissue DisordersRash 70 (4%) 10 (0.6%)Nail Disorders 43 (2%) 0 (0%)Pruritis 40 (2%) 10 (0.6%)General DisordersPyrexia 100 (6%) 6 (0.4%)Edema Peripheral 79 (5%) 37 (2%)Chills 85 (5%) 0 (0%)Aesthenia 75 (4.5%) 30 (2%)Influenza-like Illness 40 (2%) 3 (0.2%)Sudden Death 1 (0.06%) 0 (0%)InfectionsNasopharyngitis 135 (8%) 43 (3%)UTI 39 (3%) 13 (0.8%)Immune System DisordersHypersensitivity 10 (0.6%) 1 (0.06%)Autoimmune Thyroiditis 4 (0.3%) 0 (0%)

Herceptin Single + Paclitaxel Herceptin ACb

Agenta Paclitaxel Alone + ACb Alone n = 352 n = 91 n = 95 n = 143 n = 135

Body as a Whole Pain 47% 61% 62% 57% 42% Asthenia 42% 62% 57% 54% 55% Fever 36% 49% 23% 56% 34% Chills 32% 41% 4% 35% 11% Headache 26% 36% 28% 44% 31% Abdominal pain 22% 34% 22% 23% 18% Back pain 22% 34% 30% 27% 15% Infection 20% 47% 27% 47% 31% Flu syndrome 10% 12% 5% 12% 6% Accidental injury 6% 13% 3% 9% 4% Allergic reaction 3% 8% 2% 4% 2%Cardiovascular Tachycardia 5% 12% 4% 10% 5% Congestive 7% 11% 1% 28% 7% heart failureDigestive Nausea 33% 51% 9% 76% 77% Diarrhea 25% 45% 29% 45% 26% Vomiting 23% 37% 28% 53% 49% Nausea and vomiting 8% 14% 11% 18% 9% Anorexia 14% 24% 16% 31% 26% Heme & Lymphatic Anemia 4% 14% 9% 36% 26% Leukopenia 3% 24% 17% 52% 34%Metabolic Peripheral edema 10% 22% 20% 20% 17% Edema 8% 10% 8% 11% 5%Musculoskeletal Bone pain 7% 24% 18% 7% 7% Arthralgia 6% 37% 21% 8% 9%Nervous Insomnia 14% 25% 13% 29% 15% Dizziness 13% 22% 24% 24% 18% Paresthesia 9% 48% 39% 17% 11% Depression 6% 12% 13% 20% 12% Peripheral neuritis 2% 23% 16% 2% 2% Neuropathy 1% 13% 5% 4% 4%Respiratory Cough increased 26% 41% 22% 43% 29% Dyspnea 22% 27% 26% 42% 25% Rhinitis 14% 22% 5% 22% 16% Pharyngitis 12% 22% 14% 30% 18% Sinusitis 9% 21% 7% 13% 6%Skin Rash 18% 38% 18% 27% 17% Herpes simplex 2% 12% 3% 7% 9% Acne 2% 11% 3% 3% < 1%Urogenital Urinary tract infection 5% 18% 14% 13% 7%


Herceptin +FC FC (N = 294) (N = 290) N (%) N (%)

Body System/ All Grades All Grades Adverse Event Grades 3 / 4 Grades 3/ 4

Investigations Neutropenia 230 (78) 101 (34) 212 (73) 83 (29) Hypokalemia 83 (28) 28 (10) 69 (24) 16 (6) Anemia 81 (28) 36 (12) 61 (21) 30 (10) Thrombocytopenia 47 (16) 14 (5) 33 (11) 8 (3)Blood And Lymphatic System Disorders Febrile Neutropenia _ 15 (5) _ 8 (3)Gastrointestinal Disorders Diarrhea 109 (37) 27 (9) 80 (28) 11 (4) Stomatitis 72 (24) 2 (1) 43 (15) 6 (2) Dysphagia 19 (6) 7 (2) 10 ( 3) 1 (≤1)Body as a Whole Fatigue 102 (35) 12 (4) 82 (28) 7 (2) Fever 54 (18) 3 (1) 36 (12) 0 (0) Mucosal Inflammation 37 (13) 6 (2) 18 (6) 2 (1) Chills 23 (8) 1 (≤1) 0 (0) 0 (0)Metabolism And Nutrition Disorders Weight Decrease 69 (23) 6 (2) 40 (14) 7 (2)Infections And Infestations Upper Respiratory Tract Infections 56 (19) 0 (0) 29 (10) 0 (0) Nasopharyngitis 37 (13) 0 (0) 17 (6) 0 (0)Renal And Urinary Disorders Renal Failure and Impairment 53 (18) 8 (3) 42 (15) 5 (2)Nervous System Disorders Dysgeusia 28 (10) 0 (0) 14 (5) 0 (0)

LVEF <50% and Absolute Decrease Absolute from Baseline LVEF Decrease

LVEF ≥10% ≥16% <20% and <50% decrease decrease ≥10% ≥20%

Studies 1 & 2b AC→TH 22.8% 18.3% 11.7% 33.4% 9.2% (n=1606) (366) (294) (188) (536) (148)

AC→T 9.1% 5.4% 2.2% 18.3% 2.4% (n=1488) (136) (81) (33) (272) (36)

Study 3 Herceptin 8.6% 7.0% 3.8% 22.4% 3.5% (n=1678) (144) (118) (64) (376) (59)

Observation 2.7% 2.0% 1.2% 11.9% 1.2% (n=1708) (46) (35) (20) (204) (21)

Study 4c TCH 8.5% 5.9% 3.3% 34.5% 6.3% (n=1056) (90) (62) (35) (364) (67)

AC→TH 17% 13.3% 9.8% 44.3% 13.2% (n=1068) (182) (142) (105) (473) (141)

AC→T 9.5% 6.6% 3.3% 34% 5.5% (n=1050) (100) (69) (35) (357) (58)


Herceptin +FC FC N (%)

B

S

2 (1) 43 (15) 6 (2) 7 (2) 10 ( 3) 1 (≤

Inflammation 37 (13) 6 (2) 18 (6) 2 (1)

Tract Infections 56 (19) 0 (0) 29 (10) 0 (0)

Impairment 53 (18) 8 (3) 42 (15) 5 (2)N

LVEF Decrease

LVEF ≥ <50% decrease decrease ≥

HERCEPTIN® [trastuzumab]Manufactured by:Genentech, Inc.A Member of the Roche Group1 DNA WaySouth San Francisco, CA 94080-4990

Initial US Approval: September 1998Revision Date: October 29, 2010Herceptin® is a registered trademark of Genentech, Inc.HER0000097200©2010 Genentech, Inc.


www.AONNonline.orgAONNAsizeJONS_83011

Best Practices

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A selection of member-submitted best practicesfor others to learn from and comment on.

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Nurse & Patient Navigator Association

Continuing EducationLearn how to advance your understanding of the complexities of cancer care through our live, online, and printed educational activities.

Networking OpportunitiesCoordinated events throughout the year both in person and online to help you connect withmembers and leaders.

Expert Opinion BlogsThought-provoking articles from the leadersin navigation and survivorship on varioussubject areas.

Community ResourcesA collection of resources to help you and yourpatients better navigate their cancer treatment.

PublicationsSubscriptions to the Journal of Oncology Navigation & Survivorship® and The OncologyNurse®-APN/PA.

� �� JONS_September 2011_v3_TON1110_FINAL 8/30/11 2:24 PM

10 SEPTEMBER 2011 • VOLUME 2, ISSUE 5 AONNONLINE.ORG

Editor-in-ChiefLillie D. Shockney, RN, BS, MASAdministrative Director University Distinguished ServiceAssociate Professor of Breast CancerAssociate Professor, Johns HopkinsUniversity School of MedicineDepartments of Surgery & Gynecologyand ObstetricsAssociate Professor, Johns HopkinsUniversity School of Nursing

Section EditorsBreast CancerSharon Gentry, RN, MSN, AOCN,CBCNBreast Health NavigatorDerrick L. Davis Forsyth Regional Cancer Center

Prostate CancerFrank delaRama, RN, MS, AOCNSClinical Nurse SpecialistOncology/GenomicsCancer Care ClinicPalo Alto Medical Foundation

Healthcare Disparities Linda Fleisher, PhD, MPHAssistant Vice PresidentOffice of Health Communications & Health DisparitiesAssistant ProfessorCancer Prevention & ControlFox Chase Cancer Center

AONN Research CommitteeElaine Sein, RN, BSN, OCN, CBCNSenior Project ManagerFox Chase Cancer Center Partners

Marcy Poletti, RN, MSN Program Administrator, OncologyServicesWake Forest University Baptist Medical Center

Penny Widmaier, RN, MSNNurse NavigatorBotsford Cancer Center

Executive Director, AONNSean T. [email protected]

MISSION STATEMENTThe Journal of Oncology Navi gation &Survivorship (JONS) promotes reliance onevidence-based practices in navigatingpatients with cancer and their caregiversthrough diagnosis, treatment, and survivor-ship. JONS also seeks to strengthen the roleof nurse and patient navigators in cancercare by serving as a platform for these pro-fessionals to disseminate original researchfindings, exchange best practices, and findsupport for their growing community.

Dear Colleague,

Ienthusiastically write to you today re -garding our Second Annual Navigationand Survivorship Conference, the offi-

cial national meeting of the Academy ofOncology Nurse Navigators (AONN). Inthis issue, we are proud to present theabstracts from the meeting and offer ourcongratulations to their authors.

As a member of the Leadership Councilfor AONN, the organization is near anddear to my heart as is the annual conference. I truly believe in the power of livemeetings as a way to stay connected to others in the navigation field. Such face-to-face opportunities also energize attendees (including me) by hearing about innova-tive ways we can enhance our navigator roles to benefit the patients we serve. Thereis strength in our numbers; the meeting and exchanging of ideas and best practicesis invaluable toward our goal of optimizing our ability to care for our oncologypatients. The many thought-provoking as well as inspiring presentations are all rel-evant to your practice. I encourage all of you to be active in the Academy.

Weren’t able to join us in San Antonio? We will publish proceedings from themeeting in our December 2011 issue. Want to be more connected? Be sure to followour conversations on our website: www.AONNonline.org.

On behalf of all of us at AONN and the Journal of Oncology Navigation &Survivorship, we consider it an honor to provide the place where your research, oper-ations management methods, ideas, opinions, and reactions are presented collec-tively, focusing on oncology navigation and survivorship. We truly appreciate yourcontributions and comments—keep ’em coming!

With best regards,

Lillie D. Shockney, RN, BS, MASEditor-in-Chief

A COMMUNITYCONNECTED

“I truly believe in thepower of live meetings asa way to stay connectedto others in the naviga-tion field.”

LETTERS FROM LILLIE


NAVIGATING PATIENTS ACROSS THECONTINUUM OFCANCERCARETM

• Coverage of all general sessions• Summaries of all breakout sessions• Take-aways from each presenter• Keynote spotlights• Overviews of the plenary presentations• Award recipient recognition

Highlights Include:

All clinical and nonclinical professionals involved or interested in patient navigationand survivorship.

• Oncology Nurse Navigators• Patient Navigators • Oncology Nurses & Nurse Practitioners

• Administrators • Oncology Social Workers • Case Managers • Practice Managers

Intended For:

AONNAsize83011

COMING IN NOVEMBER

Highlights from theSecond Annual Navigation and Survivorship Conference

� � � �� JONS_September 2011_v3_TON1110_FINAL 8/30/11 2:25 PM

Seasons of SurvivalRedefining the Paradigm for Cancer Survivorship for 2011 By Kenneth Miller, MDAdult Survivorship Clinic, Lance Armstrong Foundation, Dana-Farber Cancer Institute, Boston, Massachusetts

Irit Ben-Aharon, MD, PhDInstitute of Oncology, Davidoff Center, Rabin Medical Center, Beilinson Campus, Petah-Tiqva, Israel

Lindsay Haines, BAResearch Associate, Dana-Farber Cancer Institute, Boston, Massachusetts

M ore than 25 years ago, Dr FitzhughMullan described the seasons of sur-vival in a narrative of his personal

experience of being diagnosed and treated forcancer and facing the other side of the stetho-scope in the New England Journal of Medicine in1985.1 His description of cancer survivorshipincluded an individual’s experience across thecancer continuum, from initial diagnosisthrough the remainder of life. “It was desperatedays of nausea and depression. It was the elationat the birth of a daughter in the midst of treat-ment. It was the anxiety of my monthly chest x-rays.… It was survival, an absolutely predictablebut ill-defined condition that all cancer patientspass through as they struggle with their illness.”1“Seasons of Survival” was also one of the first

articles to describe the natural history of cancersurvivorship. That paradigm included 3 phases(Figure 1).1 During the past 3 decades, however,seminal advances in cancer detection and treat-ment have evolved. Improved understanding ofcancer biology and molecular profiling ofpatients’ tumors has led to more targeted thera-py. The 5-year survival rate of adult cancerpatients is growing steadily and currently is esti-mated at 64%.2 And the number of cancer sur-vivors grows constantly, increasing from 3 mil-lion in 1971 to an estimated 11.7 million in2007 (Figure 2).3 By 2020, it is estimated thatthere will be 20 million cancer survivors in theUnited States.Improvements in long-term survival rates vary

significantly among cancer types. Survival ratesof patients with chronic myelogenous leukemia(CML) have improved dramatically because ofhighly effective treatment, leading to a growingnumber of survivors living in remission. Survivalrates have improved somewhat less in breastcancer and even less in lung cancer (Figure 3).4

In total, however, the number of cancer sur-vivors who live beyond 5 years also has increased(Figure 4).4

A NEW PARADIGMIn light of the growing number of cancer sur-vivors and the practical issues of healthcaredelivery, we propose a revision in the seasons ofsurvival paradigm (Figure 5). The survivorshiptrajectory for individual cancer survivors is quitevariable, and the transitions may occur at differ-ent intervals. In addition, as some survivorsdevelop secondary malignancies, they essential-ly reenter acute survivorship. End of life also isencompassed within the cancer survivorshipexperience.

Acute SurvivorshipMany emotional aspects of the acute period ofcancer diagnosis and treatment have notchanged significantly in the past 25 years;although new drugs, dose intensity, and dosedensity have added new toxicities. Supportivecare has been improved greatly, however.

TransitionThe title of the Institute of Medicine’s 2005report, From Cancer Patient to Cancer Survivor:Lost in Transition, aptly describes what for manyis a difficult transition back to “normal” or a“new normal.”5

Extended Cancer SurvivorshipMullan described extended survivorship as aperiod of watchful waiting and uncertaintyabout the future. Traditionally this was consid-ered to be the 5-year period of observation aftera cancer diagnosis. Now it is clear that the riskmay drop off substantially before 5 years or maycontinue almost indefinitely.


SURVIVORSHIP


Chronic SurvivorshipA growing number of cancer survivors are livingwith cancer as a chronic disease. Patients withCML or gastrointestinal stromal tumors exempli-fy chronic cancer survivorship. Chronic survivor-ship also collectively refers to patients withmetastatic disease who live with cancer for anextended time because of the introduction ofnewer agents and protocols.

Permanent SurvivorshipMullan characterized this season as a time whencancer survivors experience less fear and anincreasing sense of permanency. This is a hetero-geneous group, however: some are “cancer freeand free of cancer,” whereas others are “cancerfree but not free of cancer”—either physically oremotionally. Some cancer survivors reenter theacute phase of survivorship when diagnosed witha second cancer or a secondary cancer related toprevious therapy.

Cancer Free and Free of Cancer. Cancer sur-vivors may be cured either surgically or by localor systemic therapy and live for many decades.Many do not experience late or long-term med-ical or emotional effects of the experience andcancer feels like a distant part of their past med-ical history.

Cancer Free But Not Free of Cancer. Aziz andRowland distinguished the term late effects as agroup of unrecognized toxicities that are absent orsubclinical at the end of therapy and becomemanifest later with the unmasking of potentialinjury due to any of the following factors: devel-opmental processes; the failure of compensatorymechanisms with the passage of time; or organsenescence.6 In contrast, the term long-term effectsrefers to any side effects or complications of treat-ment that begin during treatment and continueafter treatment has ceased.6 Some researchersclassify cognitive problems, fatigue, lymphedema,and peripheral neuropathy as long-term effects;others classify them as late effects.7-10

Second Cancers and Secondary Cancers. Thenumber of patients who develop second cancers isincreasing, estimated at 16% of the cancer inci-dents reported to the National Cancer Institute-Surveillance, Epidemiology and End Results pro-gram in 2004.11 Second cancers can reflect thelate effect of therapy (ie, radiation, chemothera-py, hormonal therapy), the results of habitualbehavior (eg, smoking, alcohol), host factors

SURVIVORSHIP

AONNONLINE.ORG JOURNAL OF ONCOLOGY NAVIGATION & SURVIVORSHIP 13

THE 3 SEASONS OF SURVIVAL DESCRIBED BY MULLEN IN 1985Figure 1

ESTIMATED CANCER SURVIVORS IN THE UNITED STATES Figure 2

MORTALITY RATES FOR CHRONIC MYELOGENOUSLEUKEMIAFigure 3A

Source: Reference 1.




(ie, cancer syndromes), environmental determi-nants, and synergism between the risk factors.12

End of LifeEnd of life is part of cancer survivorship, either dur-ing acute survivorship if the cancer progressesdespite treatment, after a survivor is living withcancer as a chronic survivor, after relapse fromextended survivorship, or after some period as a per-manent survivor. Although a great deal is knownabout end-of-life care for patients who have beentreated actively for cancer, less is known about how

the dying experience may be different or special forpermanent cancer survivors and their caregiversafter having faced the possibility of dying years ordecades before.

IMPLICATIONS FOR PRACTICE More than 25 years have passed since Mullan’slandmark article. The chance of living beyondacute cancer survivorship has increased as has thetotal number of permanent survivors. Recent datasuggest quantitative and qualitative shifts in thecomposition of the prevalent population of cancersurvivors. The revised paradigm for the seasons ofsurvival presented here differs from the model pro-posed by Mullan, by recognizing the significantperiod of transition after the completion of treat-ment; the heterogeneity of permanent, long-termcancer survivors; and the growing group of patientsin chronic survivorship who are living with cancer.Comprehension of the seasons of survival alongwith the individuality of survivors and their diversi-ty of needs may enhance our ability to provideneeds-based care for cancer survivors.Care of cancer survivors includes attention to all

seasons of survival.13,14 Surveillance for recurrence is important, as are treatment of cancer-relatedadverse events and other comorbidities, surveil-lance to detect second and secondary cancers, andeducation to optimize health and enhance qualityof life. Potentially, reducing comorbidities mayreduce the risk and severity of late or long-termeffects on a survivor’s health.15Cancer survivorship programs can impact cancer

survivors during one or more of the seasons of sur-vival. Although it may be difficult to try to serve allcancer survivors in each and every season of sur-vivorship, because their needs for surveillance fordisease recurrence differ, health education, healthbehavior improvement, and secondary preventioncan benefit any cancer survivor. Survivorship pro-grams have an opportunity to tailor the types ofservices they offer to cancer survivors during the dif-ferent seasons of survival based on the perceivedand expressed needs of their medical communityand, more importantly, their patients.g

REFERENCES1. Mullan F. Seasons of survival: reflections of a physician withcancer. N Engl J Med. 1985;313:270-273.2. Oeffinger KC, McCabe MS. Models for delivering survivor-ship care. J Clin Oncol. 2006;24:5117-5124.3. Altekruse SF, Kosary CL, Krapcho M, et al. SEER CancerStatistics Review, 1975-2007, National Cancer Institute.

Su r v ivo r Sh ip


MORTALITY RATES FOR BREAST CANCERFigure 3B

MORTALITY RATES FOR LUNG CANCERFigure 3C





Su r v ivo r Sh ip

Bethesda, MD, http://seer.cancer.gov/csr/1975_2007/, based onNovember 2009 SEER data submission, posted to the SEER web-site, 2010.4. SEER Cancer Statistics Review, 1975-2007, National CancerInstitute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2007/,based on November 2009 SEER data submission, posted to theSEER website, 2010.5. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: TheNational Academies Press; 2005.6. Aziz NM, Rowland JH. Trends and advances in cancer survivor-ship research: challenge and opportunity. Semin Radiat Oncol.2003;13:248-266.7. Loescher LJ, Welch-McCaffrey D, Leigh SA, et al. Survivingadult cancers. Part 1: physiologic effects. Ann Intern Med.1989;111:411-432.8. Welch-McCaffrey D, Hoffman B, Leigh SA, et al. Survivingadult cancers. Part 2: psychosocial implications. Ann Intern Med.1989;111:517-524.9. Herold AH, Roetzheim RG. Cancer survivors. Prim Care.1992;19:779-791.10. Marina N. Long-term survivors of childhood cancer. The med-ical consequences of cure. Pediatr Clin North Am. 1997;44:1021-1042.11. Ries LAG, Melbert D, Krapcho M, et al; eds. SEER CancerStatistics Review, 1975-2004, National Cancer Institute. Bethesda,MD, http://seer.cancer.gov/csr/1975_2004/, based on November2006 SEER data submission, posted to the SEER website, 2007.12. Travis LB, Rabkin CS, Brown LM, et al. Cancer survivorship—genetic susceptibility and second primary cancers: research strate-gies and recommendations. J Natl Cancer Inst. 2006;98:15-25.13. Given LS, Black B, Lowry G, et al. Collaborating to conquercancer: a comprehensive approach to cancer control. CancerCauses Control. 2005;16(suppl 1):3-14.14. Pollack LA, Greer GE, Rowland JH, et al. Cancer survivorship:a new challenge in comprehensive cancer control. Cancer CausesControl. 2005;16(suppl 1):51-59.15. Aziz NM. Cancer survivorship research: state of knowledge,challenges and opportunities. Acta Oncol. 2007;46:417-432.

THE NEW PARADIGM OF “SEASONS OF SURVIVAL”Figure 5

LENGTH OF SURVIVAL FOR ALL CANCER SURVIVORS, 2007Figure 4



Journal of Oncology

The Official Journal of the Academy of Oncology Nurse NavigatorsNAVIGATION & SURVIVORSHIP

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�� JONS_September 2011_v3_TON1110_FINAL 8/30/11 2:25 PM Page 18


SECOND ANNUALCONFERENCE ABSTRACTS

From Clinical Trials to Commercial Use: A Nurse Navigation Strategy to Promote EarlyIntervention and Consistent Management of Adverse Reactions in the Outpatient SettingEileen Dehm, RN, BSN; Matthew Burke, MBA, RN, MSN, APRN-BCSmilow Cancer Hospital at Yale, New Haven, Connecticut

Background: The clinical foundation of most academic medical centers is their clinical trials. These highly regulated programs offer controlledaccess to investigational drugs to patients who have failed standard-of-care therapy. The implementation and daily management of patientson clinical trials is led by a research nurse. After a drug becomes commercially available, research nurse involvement is no longer available.The expertise of the research nurse was valuable to both patients and infusion nurses. Confusion may occur for nurses who previously infuseda drug on a clinical trial and now request information about the “new” drug they are infusing “off-protocol.” Although the US Food and DrugAdministration’s (FDA) Risk Evaluation and Mitigation Strategies (REMS) are valuable tools and help to ensure patient safety, these tools oftenstop short of being practical in day-to-day clinical practice. Purpose: The field of oncology has had several new agents approved recently,including ipilimumab (Yervoy, Bristol-Myers Squibb), denosumab (Xgeva, Amgen), and sipuleucel-T (Provenge, Dendreon). The oncology nursenavigator (ONN) can serve as a liaison between the clinical trials operation and the development of protocols and education models for acommercial drug. Using the resources available through the drug manufacturer and a close review of the clinical trial protocols, the ONN candevelop personalized education programs. Methods: We used an ONN to facilitate enrollment of patients and caregivers for support andresources available from Bristol-Myers Squibb for ipilimumab, FDA-approved for stage IV metastatic melanoma. Ipilimumab is associated withimmune-related response patterns and immune-mediated adverse reactions, both of which require a new approach for optimal management.Results: By engaging patients to participate in personalized support programs, patients have demonstrated confidence in recognizing symp-toms early and effectively communicating them to the clinical management team, allowing for timely interventions and often preventing com-plications and costly hospitalizations. Conclusion: ONNs can take the lead in assuring that all patients and nurses are prepared adequatelyfor treatment with a newly approved drug after the restrictions and support disappear. This need for enhanced patient management presentsan interesting and exciting role for ONNs.

Patient Navigators Can Provide Education for Cancer Patients Effectively Regarding TreatmentCompliance and Available Support Services If Standard Operating Procedures and TreatmentAlgorithms Are in Place Katie A. Finn, PN; Taylor Teschner, PN; Sheldon Reeves, PN; Kathryn Ankner, PN; Adrienne Holding, RN;Kathleen T. Finn, NPBoston Medical Center, Massachusetts

Background: Patient navigators (PNs) have become valued members of the cancer multidisciplinary team as they help patients work their waythrough diagnosis and treatment, and into survivorship. Our PN model was developed based on 2 important criteria: (1) our effective clinicalresearch nurse model; and (2) the identified needs of our diverse patient population. Boston Medical Center’s PN program involves multipledepartments: medical oncology, urology, otolaryngology, breast health, and primary care. Since the development of our program, the PN rolehas expanded to include patient education, which complements education by the clinical team. Standard operating procedures and diseasealgorithms are in place to standardize and train new navigators and to provide consistent exceptional care. Methods: By attending the multidis-ciplinary patient conferences, support groups, and other survivorship activities, PNs are very knowledgeable regarding treatment plans, barriersto care, and the benefits of support groups and alternative treatments for the patient with cancer. Patient education is considered to be part of ateam approach and goes beyond diagnosis and treatment; it involves assisting and empowering patients to identify and use available resources.Transportation is one of our largest patient needs, with more than 5000 rides provided during 2010. Assisting patients with their transportationneeds reinforces the importance of adhering to treatment schedules and follow-up appointments and provides the tools for patients to work towardscheduling their own transportation. Introducing patients to other support services and resources provides a comprehensive care plan whichimproves patient satisfaction, decreases the no-show rate, and increases treatment compliance. Services and resources include clinical trials staff;support groups; our Medical Legal Partnership Program; social work services; the food pantry; alternative treatments such as massage, acupunc-ture, and meditation; spiritual care; and American Cancer Society onsite representatives. Results and Conclusions: Patients who are part of thePN program show an average “no-show” rate of ~4% compared with patients not in the PN program who have a “no-show” rate of ~13%.In addition, since the inception of the PN program, ~11% of navigated patients have participated in a clinical trial, with 75% being of a minor-ity population. In conjunction with other staff, a patient’s educational needs are assessed on a continuous basis and remain a top priority to deter-mine effective coping strategies, resources, and support to a diverse patient population who typically deal with multiple life challenges. Closeto 100% of patients in the PN program reported a positive experience and found the overall relationship with their PN very educational andempowering as they cope with their current disease and prepare for life as a survivor.

CATEGORY I: Patient Education

JONS_September 2011_v3_TON1110_FINAL 8/30/11 2:25 PM Page 19



Education to Create Well-Informed Patients in a Women-Only Hospital SettingCarol Paschall, RN; Michelle Moore, MPHSt. Joseph’s Women’s Hospital, Tampa, Florida

Background: At St. Joseph’s Women’s Hospital, we realized that patients were having trouble navigating the system, especially breastand surgical patients. In the past, breast patients were sent to our Breast Center for screening and received information on navigationservices if abnormal results were noted. Then, they were not seen again until they returned for surgery. At current, we navigateWomen’s Surgical Services patients (breast, gynecology, and urodynamic). The goal of our mission-driven organization is not justabout getting patients in for services, but keeping them well informed and appropriately cared for along the way. “An educated patientdoes much better from an outcome standpoint if they know what to expect.” Objectives: (1) Educate to the process women who arescheduled for surgery. (2) Keep in contact with the patient through the continuum of care. (3) “An educated consumer is a happy con-sumer.” Methods: (1) Produce an education brochure to introduce the patient to the navigation process. (2) Cover frequently askedquestions. (3) Produce a YouTube video and DVD to be handed out at the physician’s office at the time the decision was made tohave surgery. Results: At current, these 3 items are completed. In addition, a database was developed to track patients from begin-ning to end and help keep the navigator informed/on task. Outcomes: Baseline: 0% navigated after breast biopsy. Target: Increase50% by December 31, 2011; to 90% by December 31, 2012. Just installed database system July 1 (data incomplete). Baseline:Before March 15, 2010, 11% of patients were navigated to receive a Reach to Recovery volunteer visit. Reach to Recovery is aneducation program offered to patients to link them to the American Cancer Society for further information and hospital-based supportprograms. Target: After identifying that postsurgical breast patients were being missed due to decreased staff, the nurse navigator ini-tiated a program to link more patients with Reach to Recovery. Current: In 2010, 77 (47%) patients received a Reach to Recoveryvolunteer visit. In 2011, the program is on track for an 84% increase in Reach to Recovery visits made before patient discharge.Conclusions: We closed the information gap, helped physician offices to streamline their surgical patients, created consistent mes-sages/patient education, and enhanced patient knowledge while improving outcomes.

The Use of Interval Education in the Navigation of Breast Cancer PatientsJane Zubia, RN, OCN, CBPN I-C; Laura Beaupre, BSN, OCN, CBPN-IC; Diane McHugh, BSN, OCN, CBPN-IC;Raizalie Roman-Rosado, BSN, OCN, CMSRN; Nadesda Mack, RN, BSN, MBA, OCNLehigh Valley Health Network, Allentown, Pennsylvania

Background: Feedback from breast cancer survivors via survey followed by a focus group revealed that the information given to themas newly diagnosed breast cancer patients was overwhelming—too much information, not given at the proper time, and they didn’tremember it. This feedback prompted us to create an educational program to address these issues. Interval education, the provisionof education in a specific and focused fashion at key times, from diagnosis through survivorship, can be beneficial and effective.Objective: We strove to create an educational program that met the needs of patients diagnosed with breast cancer throughout thecourse of their cancer journey. Methods: An education program was developed organizing content according to what the patient canexpect at each step in his or her cancer journey. Appropriate content was presented to the patient at the appropriate time, that is,time of diagnosis, treatment, and survivorship. Education topics included: initial diagnosis overview and assessment of treatment bar-riers; surgical options; preoperative information; postoperative healing; radiation treatment; chemotherapy side effects; and survivor-ship. Several strategies were used with the goal of offering a program that addressed the needs of the patients. These included class-room teaching as well as individual sessions. Education also took place via telephone contact. Our program was supported andreinforced by educational materials approved by the hospital’s division of education to ensure that our patients received culturally, lin-guistically, and medically appropriate information. In addition, at our preoperative class, we offer hands-on experience in handlingdrains, prostheses, and accessories. A lymphedema therapist and a breast cancer survivor were present during these sessions. Results:In the initial survey, only 27% of patients felt well informed when asked: “How prepared were you for your surgery and how youwould feel afterwards?” After implementation of the education program, a repeat survey found that 83% of preoperative class atten-dees felt well prepared. Conclusions/Implications: The education program resulted in patients feeling better prepared for surgery. Theuse of interval education, providing information approriate to the most immediate needs at the appropriate time, was successful forpatients receiving surgery for breast cancer.

CATEGORY I: Patient Education



SECOND ANNUAL CONFERENCE ABSTRACTS

Demonstrating Patient-Centered Care at Billings ClinicKaryl Blaseg, RN, MSN, OCN; Kathryn Aders, RN, BSN; Jennifer Finn, LCSW, OSW-C; Dona Oliver, RN, MSN,MBA; Alison Weber, RN, BSN; Deborah White, RN, BSN, OCN, CCM; Lora Wingerter, RN, BSN, OCN Smilow Cancer Hospital at Yale, New Haven, Connecticut

Background: The American College of Surgeons’ Commission on Cancer currently is revising its cancer program standards. Three newstandards have been drafted that pertain to patient navigation, psychosocial distress screening, and survivorship care plans. This posterhighlights 3 strategies implemented as part of our commitment to comprehensive care for cancer patients across the continuum.Objectives: (1) Describe the evolution of a navigation program that spans the continuum and involves individualized care planningand education for patients/families while minimizing barriers and maximizing outcomes. (2) Identify a standard process to screen forpsychological, emotional, physical, and spiritual distress and engage an interdisciplinary team to reduce suffering and symptoms asso-ciated with cancer treatment. (3) Discuss preliminary findings regarding the impact of survivorship plans and treatment summaries tobreast cancer and lymphoma survivors, their primary care providers, and their family caregivers. Methods: Descriptive processes willbe outlined related to the evolution of our navigation program, the implementation of distress screening and a symptom care team,and the provision of survivorship plans and treatment summaries. In addition, tools will be shared, as well as basic statistics relatedto sources of distress, satisfaction scores with survivorship plans/treatment summaries, and Functional Assessment of Cancer Therapy-General (FACT-G) scores. Results: Tools to be shared include a patient navigation acuity scale, a patient navigation satisfaction sur-vey, a distress tool, and research tools used in our survivorship study. Results include percent of patients with distress scores of 4 ormore, most common physical and psychosocial sources of distress, protocols developed, satisfaction levels with survivorship plans,and most common issues identified by survivors at 1, 3, and 6 months posttreatment. Conclusion: In addition to providing psycho -social support to address the needs of our patients, these programs help demonstrate compliance with national recommendations relat-ed to patient-centered care, which from an accreditation perspective, are increasingly recognized as essential cancer program com-ponents. Several lessons have been learned in each area that would be beneficial to discuss with other conference participantsinterested or involved in similar initiatives.

A Professional Model for Practice: Kolcaba’s Comfort Theory and the Breast Health NurseNavigatorSharon Lieb Inzetta, RN, MS; Pam Mascari, RN, NP; Laurie Kaps-Keller, RN, MS; Ellen Shinoskie, RN, BSN; Jill Brehm, RN, BSN; Mary Grace Bernert, RN, BSNMount Carmel Women’s Health Centers, Columbus, Ohio

Background: Currently there is no standard definition for a patient navigator. Defining a breast health nurse navigator (BHNN) andadopting a theoretical framework1 and model development to guide professional practice has been a collaborative project for ourMount Carmel Women’s Health Centers (East and West in Columbus, St. Ann’s in Westerville, Ohio). Increasing staff and communi-ty awareness for the BHNN has become vital as the shift in the paradigm of care moves toward survivorship care planning. We havebeen able to provide breast healthcare across an ongoing lifetime continuum for our patients, beginning with an abnormal mammo-gram, breast biopsy, pre- and postoperative education followed by support, and community programs throughout our patient’s ongo-ing survivorship. The role of BHNN is professional and specialized, functioning as part of a multidisciplinary team. The BHNN usesa holistic, collaborative, and communicative approach to identify the patient’s comfort needs. The BHNN develops and implementsindividualized comfort interventions, coordinating breast care by enhancing patient comfort. Enhanced comfort strengthens the patient’shealth-seeking behaviors. Increased health-seeking behaviors result in improved patient and nurse satisfaction. As a result of thisincreased patient satisfaction, patients return to this “comfortable” safe place, entrusting the BHNN and the healthcare system for theirfollow-up, preventive, and ongoing survivorship care. The BHNN is an ideal example of the move to redefine nursing as a professionrather than a job. As we continue to work toward shared governance and magnet readiness, defining nursing roles and adoptingindividual professional practice models for each nursing specialty area is essential. The BHNN role at Mount Carmel has existed formore than 20 years, yet the role has continued to grow and change to meet our patients’ needs. The BHNN functions as a memberof an interdisciplinary team involved in providing evidence-based care for our breast cancer patients. The Women’s Health Centershave shifted care delivery from site-specific to across-the-system, helping to assure continuity of care across all 3 hospital sites. As staffis shifted based on patient volumes, our care delivery is facilitated with scheduling patients in the most efficient and timely manner,keeping patients in the Mount Carmel system and ensuring customer satisfaction. Objectives: (1) Define the BHNN role. (2)Differentiate the 4 types of patient comfort and possible outcomes with comfort care delivery. (3) Discuss “Gift of Grace” Comfort BearProgram. Methods: (1) Collaboration and shared decision-making between clinical leader, Pam Mascari, RN, NP, and BHNNs to

CATEGORY II: Psychosocial Support




coordinate, clarify, and define the role of BHNN. Developed professional practice model for care, grounded in Kolcaba’s ComfortTheory. Goals attained for targeting best practice and same standard-of-care delivery across all sites. (2) Shift in care delivery fromsite-specific to system definition of BHNN, which helps to assure continuity of care across all 3 hospital sites. As staff is shifted basedon patient volumes, our care delivery is facilitated with scheduling patients in the most efficient and timely manner, keeping patientsin the Mount Carmel system and ensuring customer satisfaction. (3) BHNN collaborated with the Mount Carmel Hospital Foundationand Susan G. Komen for the Cure—Columbus developing grant-sponsored programs to meet the needs of our breast cancer survivors.(4) Initiated “The Gift of Grace” Comfort Bear Program, with funding awarded through application to the Mount Carmel Foundation.Results: (1) Developed BHNN model to guide professional practice. (2) BHNN participated in community-wide survivorship planningcommittee, Komen Medical/Survivorship Advisory Councils. (3) The aquatic program, lymphedema arm classes/clinics, breast can-cer exercise classes and gentle yoga have all received grantee awards for the 2011/2012 grant cycles. (4) “The Gift of Grace”Comfort Bear Program funding has shifted to be self-sustaining through patient, family, and community support. Conclusions: TheBHNN model uses Kolcaba’s Comfort Theory to guide nursing interventions that identify patients’ physical, psychosocial, sociocultu-ral, and environmental comfort needs. Meeting our patients’ comfort needs has resulted in improved overall patient and healthcareprovider satisfaction, thereby improving overall intuitional integrity. Our customer satisfaction scores have been mea sured in the upper90th percentile consistently over the past 5 years. We have used our “The Gift of Grace” Comfort Bear Program to foster an environ-ment of security and comfort. Reference: 1. Kolcaba K. Comfort Theory and Practice: A Vision for Holistic Health Care and Research.New York, NY: Springer Publishing; 2002.

Nurse Navigation for Surveillance of Nodules Found on Nonscreening ImagingGean Brown, RN, OCN; Lisa Cull, RN, MSN; Robert Wolek, MDMiddlesex Hospital, Middletown, Connecticut

Objective: To ensure appropriate follow-up for the multiple incidental pulmonary nodules found on imaging studies. Materials andMethods: A lung nurse navigator program was established at Middlesex Hospital in 2005. Part of the navigator’s role was to imple-ment surveillance on lung nodules found through computed tomography (CT). The program was instigated because radiologistsexpressed concern that not all abnormal findings reported were receiving the recommended follow-up.1 The nurse navigator and aradiologist met to plan a process through which all abnormal findings would be tracked and followed. From this, they developed adatabase accessible to both the radiologist and the nurse navigator, which ensures appropriate follow-up in collaboration with the pri-mary care physician. Fleischner Society guidelines were implemented for all identified lung nodules, and pulmonary consults wereoffered as appropriate. Fleischner Society guidelines were established to provide recommendations for follow-up and management ofnodules smaller than 8 mm detected incidentally at nonscreening CT.2 Results: The collaboration of the lung nurse navigator, radiolo-gy physicians, pulmonologists, and the emergency department physicians has increased the number of patients referred to the lungsurveillance program at our institution by 75% overall. The quality-assurance program was started in June 2010, and more than 500patients have been screened through the program. If further surveillance is warranted, patients are placed on the surveillance portionof the lung program. In January 2010, before the initiation of the quality-assurance program, there were only 7 patients on the surveil-lance portion of the lung program. This number increased to 37 patients in January 2011, an increase of 82%. This quality-assuranceprogram has been used by 100% of the radiologists. The program has not only increased the number of referrals to the lung program,both for surveillance and for the lung cancer portion of the program, but also has created an increased collaboration among the nursenavigator and the physicians in the community, as evidenced by the increase in the number of calls from primary care physicians tothe lung nurse navigator. Conclusions: Nurse navigators can play an important role in lung nodule surveillance, which benefits thepatients as well as the physicians. The recommendation for follow-up of pulmonary nodules has been set by the American College ofChest Physicians3; but uniform follow-up is not always the case. Primary care physicians look for guidance from radiologists as to therecommended follow-up of abnormalities. Likewise, emergency department physicians, upon finding incidental nodules, are lookingfor a system in which follow-up is ensured. The quality-assurance program at Middlesex Hospital, led by the lung nurse navigator, pro-vides this vital service. References: 1. Godoy MC, Naidich DP. Subsolid pulmonary nodules and the spectrum of peripheral adeno-carcinomas of the lung: recommended interim guidelines for assessment and management. Radiology. 2009;253:606-622. 2. MacMahon H, Austin J, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a state-ment from the Fleishner Society. Radiology. 2005;237:395-400. 3. Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patientswith pulmonary nodules: when is it lung cancer? ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest. 2007;132(3suppl):108S-130S.

CATEGORY II: Psychosocial Support

CATEGORY III: Tracking Processes




Outcomes Management in Oncology Patient NavigationElizabeth Hassen, RN, MSN, OCN; Sharon Bartelt, RN

Spartanburg Regional Healthcare System, Spartanburg, South Carolina

Background: Navigators educate and assist patients through their continuum of care from diagnosis, during treatment, and throughout survivor-ship. At Spartanburg Regional Healthcare System, the success of the breast and lung nurse navigator programs led to a goal of increasing thenurse navigation roles to include other cancer sites. To validate the impact of oncology patient nurse navigators, MIDAS was used to collect dataon the number of patients served and nurse–patient encounters, including visits during treatment, phone calls, educational sessions, and casemanagement work such as referrals to a social worker, community resources, and/or other disciplines such as genetics and dietetics. These datawere used to validate quality outcomes and the return on investment (ROI). A reduction in the number of admissions results in cost avoidancethroughout the navigated patient’s continuum of care. Patient and physician satisfaction surveys also were used to validate the increased qualityof care and satisfaction with oncology patient navigators. Objectives: (1) To determine if positive ROI results are associated with navigated oncol-ogy patients. (2) To identify the patient and physician level of satisfaction when using oncology patient nurse navigators to provide a continuumof care.Methods: The methods used to collect data included gathering data from the MIDAS database, the STAR database, and patient andphysician satisfaction surveys. The data gathered from the STAR database included emergency room visits and admissions during cancer treat-ment for those patients with prostate and colorectal cancer diagnosis. All data were reviewed and analyzed for a 6-month period prior to nav-igation services and for 6 months after implementation of navigation services at Spartanburg Regional’s Gibbs Cancer Center. Patient satisfac-tion surveys were distributed to 30% of navigated patients. Physician satisfaction surveys were distributed to those who had utilized the servicesof an oncology nurse navigator. Results: The analysis of MIDAS data revealed total interventions for a 6-month period were 891 for breast, 658for prostate, 321 for lung, and 113 for colorectal navigation. The case management hours revealed 236, 242, 38, and 306 hours, respec-tively, during this same period. Case intensity in hours is directly related to intensity of services required of the navigated patient. Only 2 patientswere admitted during their treatment for prostate cancer after the implementation of an oncology nurse navigator compared with 13 patients theprevious 6 months. Six colorectal patients were admitted compared with 15 the previous 6 months. Decreased admission rates resulted in costavoidance and enhanced quality of care. There was 36% return on patient satisfaction surveys, which revealed 100% of patients “stronglyagreed” or “agreed” that the oncology nurse navigator had a positive impact on their care, and all would refer a relative/friend to the GibbsCancer Center. The physician satisfaction surveys, with a 100% return, showed all physicians “strongly agreed” the services of a navigator werevaluable. Conclusions: Oncology patient navigation is a valuable service that positively impacts care. Results demonstrate reduced admissions,enhanced satisfaction, and improved quality of care. This leads to the conclusion that oncology patient navigators provide important education,resources, support, and coordination of care throughout the continuum.


Effects of a Multidisciplinary Breast Cancer Clinic in an Appalachian-Based Medical CenterJennifer A. Ingham, CNP; Stacey L. Daughtery; Rickey C. Myhand, MD; Wilbur E. Sever, DO; Darla K. Cremeans, RN

Adena Health System, Chillicothe, Ohio

Background: Adena Health System is a not-for-profit 250-bed institution that provides healthcare for a 13-county region in southeast AppalachianOhio. Access to healthcare in rural settings is an ongoing challenge. Several barriers to healthcare access affect this region. Socioeconomic bur-den and lack of higher education are 2 of the most dominant barriers. In December 2009, we held our first Multidisciplinary Breast CancerClinic (MDBCC). Objectives: The goal of the MDBCC is to facilitate prompt diagnosis and effective treatment. When a patient has a breastbiopsy they are asked if they would like a phone call with the pathology results. To date, every patient has chosen to be called with results. Thebreast care navigator tracks all the breast biopsy pathology results and, when there is a positive pathology report, it is given to a medical oncol-ogist who calls the patient with the requested phone call. The breast care navigator then calls the patient and offers an appointment in theMDBCC, provides the patient with her phone number, and mails the patient educational material on the diagnosis, along with the pathologyreport. The MDBCC is coordinated by the breast care navigator who meets with the patient the morning of the clinic. The MDBCC is staffedby a team of physicians consisting of surgeons, medical oncologists, and radiation oncologists. Each physician meets with the patient individu-ally, completes an assessment, and educates the patient on his or her specialty. All patients seen that day are discussed by the team at the noonbreast tumor board, with input from pathology and radiology to tailor a treatment plan for each patient. After the conference, the recommenda-tions are discussed with the patient before treatment is initiated. Materials and Methods: In a retrospective review, we evaluated the effect of theMDBCC on days to diagnosis and days from diagnosis to treatment. Since December 2009, there have been more than 90 breast cancerpatients evaluated in the MDBCC. We randomly selected 60 breast cancer patients treated prior to MDBCC, between 2008 and 2009, and66 patients evaluated at the MDBCC between December 2009 and 2011 from the tumor registry database. Results: The average number of




days to diagnosis pre-MDBCC was 15.5 days compared with 4 days post-MDBCC. In 2008/2009, the average days to treatment (pathol-ogy result to a port placement, surgery, or chemotherapy) was 18 days compared with 12 days post-MDBCC. Discussion: The developmentof the MDBCC has proven to be a successful team-oriented approach to breast cancer diagnosis and treatment. Time to diagnosis and initia-tion of treatment has improved. Providing patients with access to multiple specialists and forming a treatment plan the same day improves qual-ity of care and lessens economic burden.


“No Woman Left Behind” Patient NavigationBarbara R. McHale, BS, RN, OCN, CBCN; Sabrina Mosseau, BS, RN, OCN; Regina Fendorak, RN, OCN

Northeast Health Samaritan Hospital, Troy, New York

Background: This program was designed and implemented to ensure that medically underserved women who fall between the cracksin the healthcare system receive the care they deserve. The organization looked at barriers these women were encountering and seta goal to provide adequate information and access to effective cancer screening, diagnosis, and treatment services in an equitableand timely manner. In September 2006 a team was formed to look at barriers to effective care. The team consisted of the patientnavigator, the manager of the Women’s Health Center, the director of the Cancer Center, the lead radiologist, and a clinical nursespecialist. The patient navigator, instrumental in achieving patient-centered care, led the team and acted as an advocate for thepatients. The patient navigator does not direct care but acts as a liaison between patients and the medical team. The patient naviga-tor assists in scheduling timely appointments with surgeons, medical oncologists, and radiation oncologists. Their primary care physi-cian is kept involved with the patients’ status and treatment recommendations. Being a certified medical oncology nurse and breastcare nurse, the patient navigator can clarify information given to the patient on disease management and outcomes. In addition, poten-tial barriers are identified, such as insurance issues or lack of insurance, financial concerns, transportation issues, disease manage-ment, support services, and communication/cultural needs. The areas of concern identified to be of top priority included: improvingthe return rate for annual screening mammograms, improving access timeline from problematic diagnostic mammogram to biopsy, andimproving the timeframe in which pathology results communicated to the patient and a navigator assigned. Objectives: (1) Intent ofnavigation—”No Woman Left Behind” is an education, outreach, and navigation program designed to give medically underservedwomen the skills they need to get the healthcare they deserve. Our mission is to remove barriers and challenge ourselves to exceedexpectations. (A summary poster of the initiatives listed below, plan, data, and outcomes will be provided.) (2) Measurable outcomesto remove barriers and to exceed expectations included: (A) improving the return rate for annual mammography screening; (B) improv-ing access timeline from problematic diagnostic mammogram to biopsy procedure and pathology to be no more than 9 businessdays; (C) decreasing wait time from biopsy to pathology results and communication to patient and navigator to be no more than 2business days. Outcomes: (A) Improving the return rate for annual mammography screening. Patient return rate increased from 60%in 2006 to 80% in 2007 to 92% in 2009, and then decreased to 88% in 2010. The 2010 decrease resulted from a local OB/GYNoffice investing in a digital mammography unit, with patients not returning to our center as in previous years. Barriers identified includ-ed patients who chose to seek services at different institutions and some doctors’ offices were at capacity and unable to give patientsa script and perform clinical breast examination in a timely manner. The interventions instituted included postcard reminders sent to allpatients the month before their due date, a secretary call directly after postcards are sent out, and a staff member call to doctors’offices directly for scripts. (B) Improving access timeline from problematic diagnostic mammogram to biopsy procedure and patholo-gy. This access timeframe varied from an average wait time of 12 business days in 2007 to 13 business days in 2008 to 9.3 busi-ness days in 2009, to 11 business days in 2010. The 2010 increase was noted to be in direct correlation to patient preferenceand request of a second opinion. Barriers to care included patients who chose to wait a long period of time for a biopsy as theygather second opinions and whether the doctor’s office was willing to see a patient immediately to do a history and physical. Theinterventions instituted included giving a standardized communication form to the doctor and the patient, staff calls to the doctor’soffice daily to determine patient status, and use of physician assistants to do surgical clearance. (C) Decreasing wait time from biop-sy to pathology results and communication to patient and assignment of navigator. The timeframe in which pathology results werecommunicated to a patient was 11.6 business days in 2007, 8 business days in 2008, 3 business days in 2009, and 1.86 busi-ness days in 2010. The main barrier was a lack of timeliness in communication of results to the patient by the doctor’s office, delay-ing subsequent referral to the navigator. The interventions instituted included having the radiologist communicate pathology results topatients and immediately instituting a consult with a navigator. Conclusions: The “No Woman Left Behind” patient navigation program hashad the impact of sustaining changes, increasing access, community visibility, and patient trust. The documented improvement in return ratefor screening mammograms from 60% to 88% to 92%, the improvement noted in patient access timeline from problematic mammogram tobiopsy from 12 days to 11 days, and the improvement in which pathology results were communicated to patient and a navigator wasassigned went from 11.6 days to 1.86 days. This has led to retention of patients, referral of new patients, and downstream financial rev-enue for the facility. The increase in the referral base by 15% allowed us to purchase a second digital mammography unit.




Time Interval as a Quality Measure: What Is Our Baseline Prior to Nurse NavigatorImplementation? Miral Amin, MD1; Mohua Basu1; Sharla Gayle Patterson, MD2; Heather Pinkerton, RN, BSN, OCN1; Mylin Ann Torres, MD1; Mary Newell, MD1; Ruth O’Regan, MD3; Christine McCarthy, MS, APRN-BC1; Robin Tarpley, RN, BHS1; Sheryl G. A. Gabram, MD, MBA3

1Emory University School of Medicine, Atlanta, Georgia; 2Emory University, Jackson, Mississippi; 3Georgia Cancer Center for Excellenceat Grady Memorial Hospital, Atlanta, Georgia

Background: There are various outcome measures to evaluate the quality of multidisciplinary care for breast cancer patients. TheNational Consortium of Breast Centers defines “quality” of breast cancer care as “accurate evaluation and appropriate services in atimely manner.” Objectives: In a tertiary academic center, a diverse referral pattern possibly influences time to treatment. We chooseto examine 2 outcome mea sures before the start of a nurse navigator: Time from initial diagnosis to first consultation and if the pre-treatment consultation for those receiving neoadjuvant chemotherapy or hormonal therapy included all subspecialists. Methods:Electronic medical records of female patients with breast cancer seen during January through June 2010 were reviewed. Patients withstage IV breast cancer were excluded. Results: In total, 150 patients were divided into 4 categories: external pathology consult (B1),internally diagnosed with a primary care physician (PCP) at our institution (B2), evaluated by a surgical oncologist before the biopsy(B3), and internally diagnosed with PCP outside of the institution (B4). For B2, B3, and B4, we examined the time intervals to first sur-gical oncology appointment after diagnosis as shown in the Table. For all patients (n = 10) who received neoadjuvant therapy, 1patient saw a surgical oncologist, medical oncologist, and radiation oncologist; 9 patients saw 2 subspecialties prior to initiation offirst treatment. Conclusions: Patients are seen within an average of 2 weeks whether they are diagnosed internally (B2, B3) or exter-nally (B4). The group seen by a surgical oncologist prior to biopsy (B3) was seen sooner. For the patients receiving neoadjuvant ther-apy, 10% saw all 3 specialties prior to initiation of therapy. In July 2010, a nurse navigator was added to the care team. With thisnew position, our goal is to decrease the time from biopsy to visit by 33% and have 100% of patients receiving neoadjuvant therapyevaluated by all 3 specialists prior to treatment. In addition, in January 2011, we implemented an e-mail–based patient satisfactionsurvey that is sent to all patients with whom the nurse navigator interacts. One of the questions on the survey asks for patients to ratetimeliness of their care and ability to obtain appointments as soon as they wanted. Results from the first 3 months of 2011 show thatpatients rate their satisfaction in these 2 areas as either “satisfied” or “extremely satisfied.” Our intent is to quantify the effect of a nursenavigator in a large academic center as a quality metric in improving care.


B2 (n = 19) B3 (n = 20) B4 (n = 17) All patients (B2 + B3 + B4; n = 56)

Time (days) Mean (range in days)

14 3 to 22

9 2 to 21

14 6 to 33

12 2 to 33

Boston Medical Center Cancer Care Patient Navigation Program: Tracking Processes Acrossthe Continuum of Care Sheldon Reeves, PN; Kathryn Ankner, PN; Taylor Teschner, PN; Katie A. Finn, PN; Adrienne Holding, RN;Kathleen T. Finn, NP

Boston Medical Center, Massachusetts

Background: Our patient navigation (PN) program is based at Boston Medical Center (BMC), a private, not-for-profit academic med-ical center and the primary teaching affiliate for Boston University School of Medicine. PN programs exist in multiple departments atBMC, including medical oncology, urology, otolaryngology, breast health, and primary care. The Cancer Care Patient NavigationProgram, housed in the chemotherapy clinic, was developed in 2005. The BMC PN program tracks patients throughout the continu-um of care, from a suspicious finding at a community health center, up until completion of treatment and survivorship. Methods: BMCis affiliated with 15 community health centers throughout the city of Boston. Through this relationship, BMC has created a 2-way com-munication system between the diverse patient populations and the PN program. By hosting monthly community health center PN train-

Table TIME INTERVALS TO FIRST SURGICAL ONCOLOGY APPOINTMENT AFTER DIAGNOSIS

B2 indicates internally diagnosed with a primary care physician at institution; B3, evaluated by a surgical oncologist before biopsy; B4, internallydiagnosed with primary care physician outside of institution.




ings, the BMC navigators have created multiple standardized procedures to ensure optimal patient care. On a cancer diagnosis, thepatient is entered into the PN program and is followed through his/her possible surgeries, treatment plan, follow-up appointments,and survivorship. With the advancement of this program, BMC navigators have standardized and tracked their practice and devel-opment through myriad systems. These systems include algorithms, Excel spreadsheets, designated navigator medical documentationin electronic medical records, written standard operating procedures, and the computation of monthly provider clinic no-show rates.To keep all of these procedures consistent, BMC navigators attend weekly meetings with the BMC research nurse navigator to dis-cuss patient progress. To track patients throughout their time at BMC, multiple tracking tools are used to follow progress, but also toprovide feedback to the PN program for improvement. Examples of these tracking tools include receiving monthly clinical statisticalupdates, recording attendance at support groups, providing feedback surveys to patients, large enrollment of patients in clinical tri-als, and attending weekly multidisciplinary tumor board conferences to identify new patients. Navigators keep daily calendars of allpatients who are currently enrolled in the program that include clinical appointments, radiology scans, and treatment information.Results and Conclusions: Patients and caregivers are considered survivors upon diagnosis; therefore, every BMC cancer patient iswelcomed into the survivorship program. Whether it is support groups, annual luncheon celebrations, or traveling with patients to acomplimentary spa day, patients provide support and encouragement to other patients, caregivers, and family members. Oncologypatients can be tracked across the continuum of care through the plethora of tools used by the cancer care PNs that begin at thehealth center and continue on through survivorship.


A Path to Improving the Continuum of Care: Developing a Survivorship ClinicA. Vance, RN; C. Copertino, RN, MS, OCN, OCN; S. O’Connor, RN, MSN, OCN; M. Willingham, CRNP

Anne Arundel Medical Center, Annapolis, Maryland

Background: Anne Arundel Medical Center’s (AAMC) tumor registry data indicated a growing population of cancer survivors. A survivorneeds assessment and literature review was conducted. We found that survivors are being followed inconsistently by cancer specialistscompared with primary care providers. Survivors are often unfamiliar with the details of their treatment history and are unable to shareaccurately pertinent medical information with their healthcare providers. Primary care providers are often unfamiliar with cancer treatmentsor with recommendations regarding screening for long-term complications of cancer and treatment regimens. Purpose: To create a sus-tainable Breast Cancer Survivorship Clinic. Methods: A survivorship program includes key elements to ensure a successful and sustainableprogram. A literature review and patient needs assessment was conducted. Key staff attended the George Washington Cancer Institute’sExecutive Training on Navigation and Survivorship. This 2-day seminar helped define a framework and featured organizations with oper-ational survivorship clinics. A project team was created and included a nurse practitioner, nurse navigator, administrative director, med-ical oncologist, and primary care physician. The project team defined the goals of the survivorship program, focusing on our commitmentto support survivors as they progress through the years, especially the long-term effects of treatment on their physical and psychosocialwell-being. A crucial step was to research possible funding sources, both internal and through grants. AAMC applied for a grant throughthe Susan G. Komen Foundation. AAMC was awarded a 1-year grant to assist with the implementation of our survivorship clinic withmatching funds from the hospital. The breast survivorship clinic visit consists of a consultation with the nurse practitioner and the oncologysocial worker. Patients and physicians including primary care receive “Survivor Path,” an end-of-treatment care summary and individual-ized recommendations. Recommendations for follow-up care and survivor education materials are customized to the needs of each patientbased on his or her disease and its treatment. Promotional materials were made available to patients in waiting rooms of oncology andprimary care providers. Physician continuing medical education and lunch-and-learn sessions were coordinated to establish a dialogueand educate both primary care and specialty practices. The survivorship program was presented at all tumor boards to ensure uniformknowledge across the health system. Results: The Breast Cancer Survivorship Clinic has been created and will begin scheduling patientson September 19, 2011. We have collaborated with medical, radiation, and surgical oncologists and primary care providers in ourmarket. The treatment summary and care plan format has been developed, and we will be promoting the clinic to our survivors by sched-uling visits 4 to 6 weeks after completion of active treatment. It is necessary to provide ongoing assessment and evaluation to improveand expand the program. The ultimate success of the program will rely upon ongoing executive sponsorship, objective evaluation, sus-tainable funding and, most importantly, tangible patient benefits. Conclusions/Implications: The creation of the Breast Cancer SurvivorshipClinic has been a work of collaboration, teamwork, and patient-centered care. The clinic is projected to see between 25 and 50 patientsin the first 6 months and provide care plans to the survivors and their primary care providers. Outcomes to be monitored will be compli-ance with follow-up appointments; participation in the nutrition, exercise, and support care programs; and patient and provider satisfac-tion scores at first visit, 6 months, and 1 year.




Testing an Optimal Model of Patient-Centered Cancer CareBeth Lapham, BA; Ellen Canfield, RN; Lynn Flaherty, RN; Jennifer Min, RN; Kathryn Horner, MS; Ed Wagner, MD, MPH

Group Health Research Institute, Seattle, Washington

Objective: The early phases of cancer care have received relatively little research attention. The period of time surrounding the diag-nosis and shortly thereafter involves information-seeking, momentous decision-making, and navigation among multiple providers at atime of intense emotional stress. The purpose of this 5-year proposal is to develop and test the efficacy in a randomized, controlledclinical trial of an oncology nurse navigator (ONN) program to support cancer patients early in their course. Our primary goal is toassess the impact on quality of life, quality of care, and other outcomes of an ONN program for newly diagnosed breast, colorec-tal, and lung cancer patients. Methods: We enrolled 108 eligible primary care providers from 11 group health (GH) clinics. Theseproviders were randomized, and their newly diagnosed lung, breast, and colorectal cancer patients either receive enhanced usualcare or the ONN program. First, potential participants were ascertained rapidly from newly diagnosed lung, breast, and colorectalcancers using automated pathology data. Invitation letters were mailed to each of these patients. Second, the enrolled patients in theintervention group were assigned an ONN, who works with them for approximately 16 weeks. Both groups are mailed a packet ofcancer care information specific to the patient’s type of cancer. To study the outcomes, we administered questionnaires to all studypatients and their respective clinicians at baseline, at 4 months, and at 12 months. Results: Our project team has developed an earlycancer notification system based on automated data that can identify new breast, colorectal, and lung cancer diagnoses within 3days of biopsy. We have successfully implemented an ONN program that addresses patient questions, symptoms, psychosocialneeds, and facilitates timely, coordinated care. The recruitment phase of the study has just been completed, and we currently havebaseline data on all 250 enrollees and preliminary follow-up data on most participants. Conclusions: The ONN program has beenwell-received in the GH delivery system. The process of continuing improvement to the intervention has helped to make the ONN pro-gram a very effective support tool for cancer patients. We currently are working with the GH leadership to translate the results of thisstudy into an ONN program that is a standard part of cancer care at GH.

CATEGORY IV: Original Research

Influencing Factors for a Contralateral Prophylactic MastectomySharon Gentry, RN, MSN, AOCN, CBCN; Daria Kring, PhD, RN

Derrick L. Davis Forsyth Regional Cancer Center, Winston-Salem, North Carolina

Background: Patients with unilateral breast cancer sometimes choose contralateral prophylactic mastectomy as a surgical choice. Therates of contralateral prophylactic mastectomy have increased over the past decade, despite knowledge that the survival is equal withbreast-conserving surgery followed by radiation therapy. Choosing a prophylactic mastectomy has been linked to family history, genet-ic testing, use of magnetic resonance imaging, patient socioeconomic factors, and tumor type. The decision-making process aboutbreast surgery is multifactorial, with rational pros and cons as well as an effective and intuitive process involving psychosocial con-texts and life circumstances. The voice of the patient is almost invisible in the literature as explanations are given for the increase inbilateral mastectomy rates. Objective: Our institution’s contralateral prophylactic rates have increased over the past years, as reflectedacross the United States. This study sought to understand the decision-making process of women with breast cancer who choose abilateral mastectomy. Methods: Interpretive phenomenology was the qualitative approach used to understand what influences the deci-sion for prophylactic contralateral mastectomy choice and to describe the experience surrounding the choice. Patients were recruitedfrom the 2009 breast surgical patients who chose a bilateral mastectomy at a regional cancer center. Data were collected from in-person interviews that were audiotaped and transcribed verbatim. Researchers analyzed and identified themes influencing surgicalchoice from the transcripts using Riessman’s narrative analysis method. Results and Conclusions: Fourteen patients with breast cancer,ranging in age from 38 to 70 years, participated in the study. Listening to the voice of the patient, 4 central themes emerged. InnerBeing included fear of recurrence and the internal emotions associated with the decision-making process. Outer Being described bodyimage and physical appearance concerns. Personal Meaning showed how significant relationships influenced the choice. PracticalMeaning was the rational knowledge and education received from the healthcare team and other sources. This research portrays thecomplexity and deeply personal decision-making process for bilateral mastectomy. Although current research has focused on the prac-tical and empirical aspects of prophylactic mastectomy, these findings suggest the need for a more holistic and insightful approach tosurgical choice.




Background: Mismatch repair (MMR) protein –deficient colorectal cancer (CRC), which accounts for 15% to 20% of all CRC, can besporadic or genetic, due to Lynch syndrome (LS). Loss of MMR proteins can be detected by their absence of staining on immunohis-tochemistry (IHC). Previously, all MMR-deficient CRC were tested for LS by genetic testing. With the advent of BRAF testing, genetictesting for LS can be avoided. In addition, detection of BRAF mutations may have therapeutic implications. We sought to investigatethe contribution of BRAF V600E mutations due to MLH1-deficient CRC and incidence of LS among all newly diagnosed CRC.

Methods: All CRC betweenMarch 2010 and Dec ember2010 were tested for MMR pro-tein (MLH1, MSH2, MSH6, andPMS2) deficiency by IHC.Absence of MLH1 promptedBRAF V600E mutation testing. IfBRAF was mutant, further testingwas stopped. Absence ofMSH2, MSH6, and MLH1 withnormal BRAF prompted completemutational analysis of the missinggene. If patients had MMR-profi-cient tumors but met modifiedBethesda criteria, LS genetic test-ing was pursued. Results: Resultsare in the Table. Conclusion:BRAF was mutated in 77% ofpatients with absence of MLH1.These patients were elderly andpredominantly women with right-sided CRC.

CATEGORY IV: Original Research

Incidence and Characteristics of BRAF V600E Mutation in Colorectal Cancer with Mismatch Repair Protein Defect Due to Loss of MLH1: A Prospective Evaluation of 104Consecutive PatientsSameer Mahesh, MD; Elisabeth Hanna, BSN, RN, CGRN; M. Salman Khan, DO; Pars Ravichandran, MD; Fred Slezak, MD

Summa Health Systems, Akron, Ohio

From Breast Cancer Screening to Definitive Diagnosis: Strategies for Successfully Serving the UnderservedDawn Parsons, RN, OCN; Diana Phillips, MAHS; Joni Watson, MSN, RN, OCN

Seton Family of Hospitals, Shivers Center, Austin, Texas

Background: Uninsured patients receive half the care of their insured counterparts, leading to poorer health outcomes as a result ofdelayed diagnoses. Breaks in cancer care impact survival rates and quality of life. The Seton Healthcare Family, the only NationalCancer Institute Community Cancer Centers Program (NCCCP) site in the Southwest, has provided breast cancer care spanning thefull cancer continuum to low-income and uninsured women across central Texas since 1987. Objectives: This presentation discussesSeton’s successful efforts to expand culturally appropriate breast cancer outreach to high-risk, diverse, and underserved women resid-ing in central Texas and focus on factors supporting navigation of women with an abnormal screening result to definitive diagnosis ina timely manner with a lost-to-follow-up rate less than 1%. Methods: Seton’s mobile mammography program, with support from Komenfor the Cure—Austin and the National Breast Cancer Foundation, couples screening mammography with breast health education andclinical breast exam by specially trained registered nurses. By offering culturally appropriate, free breast services in partnership withrespected community sites, Seton provides accessible services to underserved women in their communities. Women with abnormalresults are navigated to definitive diagnosis by the same screening nurse. Detailed protocols and breast diagnostics funding facilitate

Table RESULTS OF MMR PROTEIN–DEFICIENCY TESTING IN CRCNumber (n) 104Median age (years) 71Stage (%) 0 = 4; I = 22; II = 31; III = 30; IV = 13MMR status Deficient, 14%; proficient, 86%MMR-deficient (n = 18)

Absence of MLH1 and PMS2, 15; MLH1, 1; MSH2, 1; MSH2 and MSH6, 1

MLH1-deficient (n = 16)

BRAF mutation, 13; BRAF wild type, 3

Characteristics of MLH1-deficient CRC

BRAF mutation (n = 13)

BRAF wild type (n = 3)

Median age 80 67 Sex Female, 12; male, 1 Female, 1; male, 2Location Right-sided, 12;

left-sided, 1Right-sided, 2; left-sided, 1

LS genetic testing (n = 9)

Negative, 8. Mutation of uncertain significance, 1. One patientwith BRAF wild type, absent MLH1/PMS2 did not have Colaris testing.

CRC indicates colorectal cancer; LS, Lynch syndrome; MMR, mismatch repair.




CATEGORY V: Screening Programs

Screening Mammograms at No Cost for Uninsured Women in Suburban/Rural Counties Barbara Quast, RN1; Terry Wilson-Gray2

1Lake Pointe Medical Center/Breast Center, Rowlett/Rockwall/Forney, Texas; 2Bridge Breast Network, Dallas, Texas

Objectives: (1) Provide low-income uninsured women, aged 40 years and older, living in suburban/rural counties, with screeningmammograms, at no cost, with funding from the Bridge Breast Network. (2) Complete intake form, interviewing women for breastproblems and family history, performed by the cancer nurse navigator. (3) Complete breast cancer risk assessment (optional) on allwomen having a screening mammogram. (4) Provide additional diagnostic services to women with abnormal screening mammogramswith diagnostic intake referral from the Bridge Breast Network. Methods: The Bridge Breast Network has received a special grantfrom the Cancer Prevention and Research Institute of Texas to provide women aged 40 years and older living in Rockwall and 5 addi-tional suburban/rural counties with screening mammograms at no cost. Early detection is the key to survival and effectively reducingcancer mortality. Cancers detected earlier lead to more successful treatment. Women living in rural areas, however, may have finan-cial, geographic, cultural, and other barriers that hinder utilization of cancer prevention and treatment services. Since 1992, theBridge Breast Network has worked tirelessly at the mission of saving lives by providing low-income uninsured women with diagnos-tic and treatment services for breast cancer. The Bridge sees, however, a growing number of women being diagnosed with late-stagebreast cancer. As a result, the Bridge decided to take a proactive approach and reach out before breast health issues arise. TheBridge, in partnership with Lake Pointe Health Network, have made it possible for more women living in these counties to receivebreast cancer screening, diagnostics, and treatment services at no cost. Information on this project has been provided to physician prac-tices, clinics, and community organizations through marketing and press releases. Women may call the Bridge or the cancer nurse navi-gator at Lake Pointe Health Network and be interviewed while completing an intake form. The Bridge sends an approval referral to thecancer nurse navigator at Lake Pointe, and the screening mammogram can be scheduled at one of Lake Pointe’s 3 imaging centers. Allpatients have the option of completing a breast cancer risk assessment, using the Gail model at the time of their screening mammogram.For women at high risk, they also receive a letter from the cancer nurse navigator on managing their risk, including screening guidelinesprovided for all women. If additional diagnostic exams are recommended, the Bridge is contacted for a referral for diagnostic exams.Results: From March 2011 to date, 52 screening mammograms have been provided by Lake Pointe to underserved uninsured women.All women requiring diagnostic services have been referred to the Bridge for approval for additional mammograms, ultrasounds, andbreast biopsies. Conclusions: Providing underserved uninsured women with screening mammogram services leads to early detection ofbreast cancer, successful treatment, and reduction in mortality in communities where services and resources are limited.

compliance with diagnostic testing. Multiple reminder efforts encourage yearly screening participation per national guidelines. Results:From April 1, 2010, to March 31, 2011, 1828 women were screened at 121 sites in 7 federally designated medically underservedcounties, with 56% of participants Hispanic, 26% non-Hispanic Caucasian, 13% Asian, and 5% African American. In total, 203women had an abnormal result, and all were navigated to a definitive diagnosis. Grants covered costs of nearly 700 diagnostic pro-cedures and more than 300 physician office visits. Women progressed from abnormality detection to definitive diagnosis in an aver-age of 24 days. The program also averages a 38% screening return rate over the past 5 years. Conclusions: Seton’s breast cancerscreening program is a community-centric initiative focused on long-term health behavior changes based on trust developed throughcommunity linkages, removal of financial barriers, effective processes, and consistent relationships between clients and skilled nursenavigators. As a result of the success of this screening model, Seton has developed programs replicating that same model for othertypes of disease-specific screenings (cervical and skin) for high-risk underserved populations. Seton’s model has been shared with otherNCCCP sites and is replicable by other organizations.




CATEGORY VI: Community Outreach

Nurse Management and Evaluation of a Computed Tomography Lung Screening Program ina Community Hospital SettingPamela C. Matten, RN, BSN, OCNSt. Joseph Hospital, Orange, California

Background: As the most lethal cancer in the world, lung cancer presents an enormous healthcare challenge. Recent research from theNational Lung Screening Trial indicates “Screening with the use of low-dose CT [computed tomography] reduces mortality from lung can-cer.”1 Evidence indicates diagnosis of lung cancer through CT lung screening may require community hospitals to implement CT lung screen-ing programs. Objectives: Nurse navigators are involved directly in development and enhancement processes aimed at improving clinicaloutcomes for oncology patients. The nurse navigator educates patients about cancer prevention, screening, diagnosis, treatment options,and the importance of early detection of cancer. Methods: St. Joseph Hospital, Orange, California, has maintained a CT lung screeningprogram since 2004. The thoracic nurse navigator is responsible for implementation, management, and evaluation of the program. Shetracts suspicious nodules, facilitates case presentations at weekly multidisciplinary conferences, and coordinates additional testing. She par-ticipates in marketing strategies to bring screening awareness to the community. Results: The nurse navigator faces significant challengeswith patient compliance to repeat scans at 3, 6, or 12 months. Interventional tactics to encourage patient compliance need to be imple-mented. Strategic planning should include expansion and flexibility to modify screening programs as evidence points toward national screen-ing guidelines. Conclusions: The widespread adoption of CT lung screening at community hospitals is forthcoming. The nurse navigators’role, experience, and ability to act as the liaison between patient and physicians make them ideal candidates to implement and managea CT screening program in a community hospital setting. Reference: 1. National Lung Screening Trial Investigators. Reduced lung cancermortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.

Esta en Sus Manos! It’s in Your Hands!Lenore McGonigle, MEdLehigh Valley Hospital’s Breast Health Outreach Program, Allentown, Pennsylvania

Background: In the United States, health disparities exist in mammography rates for Latinas compared with other ethnic groups. In addi-tion, breast cancer is the most commonly diagnosed and the leading cause of cancer deaths among Latina women.1 In 2008, uponexamination of rates in our community, the city of Allentown, we learned that 40% of eligible Latina women had not had a mammogramin the past 12 months. Methods: Through our breast health outreach program, Esta en Sus Manos! It’s in Your Hands!, Lehigh ValleyHospital has had the opportunity to address this disparity by reaching deep into our community to ensure that women receive breast healtheducation and linkage to breast health services, regardless of their ability to pay. Our efforts have been supported by funding from theAvon Foundation Breast Care Fund, Susan G. Komen for the Cure—Philadelphia, and the National Community Cancer Centers Program.With this funding we have been able to provide culturally and linguistically appropriate breast health outreach and education to morethan 3000 women in our community, resulting in 1537 women receiving a mammogram since implementation of the program in 2009.Effective strategies for this evidence-based program include using the Promotora/Community Health Worker model, providing presenta-tions at key community hubs, working in concert with community partners, that is, trusted community entities, offering nontraditional hoursof service to increase accessibility, telephone appointment reminders, and educating and empowering women in the community to serveas breast health advocates. Seamless transition to a breast health services nurse navigator when a woman has an abnormal mammo-gram further supports our program. Results: Our Promotoras are embraced by the women in our community and have touched them inways beyond breast health outreach. They serve as so much more than educators and recruiters and are viewed as a reliable resourcefor health and social services information. It should be noted that in addition to breast health outreach, it is our overarching goal to linkwomen without a primary care provider to a medical home in our community. With persistence, compassion, and guidance through thebarriers to care, our Promotoras have gained trust and, ultimately, have had a positive influence on the health status of our community.Conclusions: This poster will highlight the role of the Promotora/Community Health Worker, strategies for accessing the targeted popula-tion, successes, challenges, and lessons learned. Reference: 1. Corcoran J, Dattalo P, Crowley M. Interventions to increase mammogra-phy rates among U.S. Latinas: a systematic review. J Womens Health (Larchmt). 2010;19:1281-1288.


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September 2011 - Journal of Oncology Navigation & Survivorship

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