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Survivorship
A Call for Improved Guidelines for Adult Cancer Survivors By John Schieszer
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here is a lack of guidelines when it comes to standard of care for adult cancer survivors, and it is time to start thinking about establishing such guidelines, according to nurse practitioner Richard Boyajian, who is Clinical Director of Adult Survivorship at Dana-Farber Cancer Institute, Boston, Massachusetts. He said establishing appropriate guidelines could potentially reduce morbidity and mortality. “Posttreatment standards of care are something that I am a big believer in,” said Boyajian. “We know that on-treatment is a very well-tuned machine, especially in radiation oncology where things are really run very well and very systematically. The problem is when the patient finishes treatment, and that is when the wheels basically fall off the cart.” He said most cancer patients are just told to come back in a few months to see if their disease has returned after completing treatment. Instead, he said, better treatment plans are needed. Boyajian said that there is no standard approach to posttreatment care today.
Oncology nurses need guidelines or a blueprint to follow so they know what they can and should be doing for cancer survivors after treatment.
Boyajian presented an educational session on adult cancer survivors entitled “Adult Cancer Survivors: One Size Does Not Fit All” at the 53rd Annual Meeting of the American Society for Radiation Oncology (ASTRO). He said establishing posttreatment management guidelines for cancer survivors can help empower patients and their families. In addition, such guidelines could be designed to improve coordination of care and communication. He said that ultimately this entire issue is about improving quality of life and potentially reducing morbidity and mortality. “The nurses as usual need to do a lot of the work to get this done. Survivorship is not something that a lot of physicians are
that interested in. There are select handfuls of physicians who have an interest, but the nurses seem to be the passionate ones about survivorship, and what I am trying to do is give them a framework to create these standard guidelines within their own practice,” explained Boyajian. Currently, Boyajian does not expect that there will be national guidelines developed. He said there are not enough evidence and research studies on which to base recommendations. However, Boyajian said cancer patients cannot wait until research studies are completed. “So, I am a big believer in consensus guidelines at your institute. It doesn’t matter if you are at a private practice or a major cancer center,” said Boyajian in an
interview with The Oncology NurseAPN/PA. “Basically, you need to set up guidelines for your practice on how you will follow an individual patient.” He said that in 1971 there were about 3 million cancer survivors in the US, but today there are more than 12 million. Boyajian said a patient diagnosed with cancer at age 35 may have a cumulative risk of a solid cancer of 36% by the age of 75. Boyajian said oncology nurses need guidelines or a blueprint to follow so they know what they can and should be doing for cancer survivors after treatment. He said patients need to be properly assessed for their individual risks and then managed appropriately by a team of healthcare providers. Boyajian said this issue is only starting to come to the forefront, and he hopes that there will be a grassroots effort that comes from oncology nurses to establish guidelines at their individual healthcare centers. “With the aging of the baby boomers, there are going to be more cancer patients and there is not going to be enough providers,” said Boyajian. “So, as the number of survivors grows, they are taking up more and more of the providers’ time. There needs to be a way to transition these patients off the physicians’ schedule.” He said that is where oncology nurses can play a central role and help improve survivorship care. ●
Nuts and Bolts of Survivorship Care Plan Explored By Alice Goodman
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lobally, there are 20 million cancer survivors, and the number of survivors is expected to grow because people are living longer as a result of newer and better therapies. Many survivors have little or no understanding of the physical, psychosocial, and economic issues that face them for the rest of their lives. Nurses can play a major role in planning survivorship care to help survivors negotiate the next stages of their lives and enjoy a good quality of life. At the recent Oncology Nursing Society Institutes of Learning meeting, Stacie Corcoran, RN, MS, AOCNS, Nurse Leader of the Survivorship Program at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City, discussed the definition of survivorship, the components of a treatment summary and care plan, and how to set up a survivorship program. To give some idea of the scope of survivorship issues, a 2005 poll by the Lance Armstrong Foundation (LIVESTRONG POLL) found that 53% of about 1000 cancer survivors reported
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secondary health problems (including pain, sexual dysfunction, relationship problems, fertility issues, fear of recurrence, depression, and financial concerns), and 49% reported that their nonmedical cancer needs were not being met. Seventy percent reported that oncologists failed to offer support for
Many survivors have little or no understanding of the physical, psychosocial, and economic issues that face them for the rest of their lives.
health problems secondary to cancer, and only 30% reported that oncologists were willing to discuss these problems. To bridge this gap, support has been growing among different agencies (including the American Cancer Society, Centers for Disease Control and Pre-
vention, and Institute of Medicine) for planning survivorship care. “We know that cancer and its treatments have a potential wide range of effects, and there is limited information and lack of guidelines for assessment, prevention, and management,” Corcoran said. “The survivorship period offers many opportunities to improve health and quality of life in the domains of physical, social, psychological, and spiritual well-being.” Survivors can experience long-term psychological and physical sequelae that include late and long-term effects such as fatigue, pain, weight gain, early menopause, anxiety, and depression. Specific issues are associated with different cancer types and treatments; for example, prostate cancer survivors may experience sexual dysfunction, urinary incontinence, and radiation proctitis. Lung cancer survivors may deal with reduced lung function, renal impairment, pain, neuropathy, and cognitive loss. Essential components of a survivorship care program include screening for
new cancers, surveillance for recurrence, identification and interventions for consequences of cancer and treatment, health promotion strategies, and last but not least, coordination of care between specialists and primary care providers. There are several models for survivorship care, but having a nurse practitioner as provider for the posttreatment follow-up offers some advantages. This facilitates shared care and coordinates transition from acute curative therapy to short- and long-term follow-up. A nurse practitioner can coordinate care and ensure continuity by communicating a plan of care to the patient’s primary care provider. Centers such as MSKCC are in a better position to offer survivors expanded patient services that may not be available at smaller and/or more rural centers. But other resources in communities may offer support, such as local chapters of the American Cancer Society and CancerCare, support groups for specific cancers, and even the local health club. There is no “one prescription fits all” for survivorship care, and different cen-
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