• Jessica Corner PhD BSc RGN

    1. Professor of Cancer Nursing, Director and Deputy Dean (Nursing), Centre for Cancer and Palliative Care Studies, and Director of the Macmillan Practice Development Unit, Institute of Cancer Research, London.
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The metaphors of warfare which surround cancer are as strong today as they were 20 years ago when Susan Sontag (1977) wrote Illness as Metaphor. Cancer, in the closing days of the 20th century remains much feared, and associated with inevitable death. Living with cancer is conceptualized as a battle or fight, people with the disease are in turn victims and heroes, as they battle for their own survival. Care for people with cancer remains piecemeal, and people with cancer continue to report delays in diagnosis, insensitive communication by doctors and other health professionals, and a lack of sufficient information and support ( National Cancer Alliance 1996).

The UK Health Service is mobilizing its response to the problem of cancer; massive re-organization following the Calman-Hine (1995) proposals and wider health reforms following the government White Paper ( Department of Health 1997). The tripartite structure proposed for cancer services (specialist cancer centres, smaller cancer units treating common cancers, and primary care) has broad appeal and may serve as a template for other diseases. The health regions have set about implementing the structure. Specialist care for all is, at least in theory, now possible.

As re-organization has progressed a number of challenges have become apparent. The Calman-Hine framework was early on recognized as powerful in lobbying for more cancer doctors, and a more organized medical training structure. What was not recognized was that nursing, placed centre stage in the Calman-Hine proposals all be it as something of an after-thought, was likely to be vastly deficient. Far too few specialist cancer nurses exist to meet the minimum requirements of implementation ( Ferguson 1996). Training provision nationally, the skill level of the nursing workforce, and the need for strong clinical leadership, remain major concerns in achieving high quality, effective cancer treatment and care in the UK. Unlike for medicine, the skill shortage in nursing is so enormous, and the mechanisms for national workforce planning for nursing so inadequate, that an effective response may be too difficult to galvanise. `Quick fit' solutions may be found, leaving cancer services much poorer than Sir Kenneth Calman's vision intended.

Despite this, health care promises one of the most exciting decades yet for cancer nursing, and since cancer has historically offered nursing as a whole a visionary lead, benefits may accrue across the whole health care sector. Cancer nurses have for some time delivered cancer treatment in the form of chemotherapy. As technology progresses, drug delivery systems increasingly mean that chemotherapy can be given by continuous infusion, transferring the setting for treatment from hospital to home. Refinements in drugs, chemotherapy regimes and techniques for managing side-effects, mean that for the majority, treatment can be managed as an outpatient. Cancer treatment settings are becoming much less institutions, and much more centres of expertise, where people with cancer attend briefly and intermittently to have investigations and discuss treatment options with the cancer team. Cancer treatment is sandwiched between meetings with nurse specialists for support and information. Visits to the cancer centre also offer the chance to participate in cancer support groups, physical or complementary therapies. Cancer centres will increasingly become a resource for coping with the disease, where knowledge and expertise can be found, but the person with cancer will remain firmly in charge and possibly self- administer their treatment. Specialist nurses will act as the co-ordinator of this treatment journey.

Among a number of cancers, a surge in numbers of men developing prostate cancer is anticipated (predictions suggest 1 in 4 men may be affected by 2018). Increasing numbers of people needing treatment, will challenge centres offering radiotherapy. For many, prostate cancer treatment requires daily attendance for radiotherapy treatment over 6 weeks, with careful monitoring during this time for treatment toxicity. The management of prostate cancer will have to change. Unlike with chemotherapy treatment, nurses have yet to be utilized in managing radiotherapy care. Evidence from a study by Faithfull (1998) suggests that advanced nurse practitioners may be effective in managing patients during radiotherapy treatment and offer cheaper care than their medical counterparts. In other situations, nurses will increasingly be responsible for diagnostic services, since this may be the only means by which established standards for waiting times will be met. Pilot schemes, such as nurse-led rapid diagnostic services, appear to show their safety and acceptability ( Garvican et al. 1998 ).

After treatment, recovering, readjusting to normal life, and learning to live with the fear of cancer returning, can be very difficult (Wells 1994). Follow-up, where people are monitored for signs of the disease returning over months or years, has until recently been the norm. Guidelines ( Department of Health 1997), based on systematic reviews of research evidence, suggest that such follow-up is costly and offers no benefit since most people with recurrent cancer discover this for themselves, rather than this being detected during routine visits to hospital outpatient clinics. It has been suggested that follow-up should be transferred to general practitioners, but pressure on primary care services may make this difficult. A number of studies are under way to explore how specialist nurses could contribute in this area. Specialist nursing could transform follow-up, reorienting care to assisting people to monitor themselves, and also providing open access to support, information and investigation of symptoms which suggest the cancer may have reoccurred, should the need arise. These may prove cost-effective while also offering ongoing support and peace of mind to people who would prefer to maintain contact with the cancer centre (studies suggest that this may be at least a third) ( Grunfeld et al. 1996 ). For others, putting cancer behind them will be important. Here specialist nurses offering a liaison service with primary care and general practitioners could help bridge the gap between sectors of care. More comprehensive care by specialist nurses, from prevention and diagnosis, to palliative care, might also be facilitated by specialist nurses placed in primary care localities. The UK charity Macmillan Cancer Relief are evaluating a pilot of such a role in the Hadleigh Practice in Dorset.

As new roles for nurses in cancer care are developing, so too are cancer nurses developing the evidence base for their practice. Cancer nursing is being embraced as a therapy ( Corner 1997), with a number of areas of care led by nurses who are practising according to well-developed therapeutic principles and with evidence for the effectiveness of these therapies; for example the management of symptoms such as breathlessness ( Corner et al. 1996 ), fatigue ( Krishnasamy 1997, Richardson & Ream 1997), and problems such as lymphoedema ( Badger 1997), as well as therapeutic communication and help with emotional distress. Two Macmillan Cancer Relief funded specialist nursing research units, in London and in Manchester, have been established and are dedicated to responsive research programmes aimed at developing the practice of Macmillan nurses in cancer and palliative care. This exemplary project will in time make a significant contribution to the research basis in UK cancer care.

Cancer nursing has achieved an enormous amount, health care reforms continue to offer cancer nurses great potential for further developing their role, and to develop services which are more responsive to the needs of people with cancer. What is needed now, is a genuine commitment by health service policy makers and managers to nursing leadership in service provision, and the facilities to create a cadre of specialist nurses genuinely able to take their place as equals in the multidisciplinary cancer treatment team for the future.