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Keywords:

  • Cancer survivor;
  • survivorship;
  • nurse practitioner;
  • primary care;
  • models of care

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

Purpose: To examine the important role that primary care nurse practitioners (NPs) have in providing long-term surveillance and health maintenance for breast, prostate, and colorectal cancer survivors throughout the continuum of cancer care.

Data sources: MEDLINE, CINAHL, MD-Consult, and Cochrane's databases were utilized with the inclusion of primary research and critical research reviews from January 1995 through March 2008. Select organizational websites were also cited.

Conclusions: Cancer patients experience changes in the focus of their care when management shifts from the treatment of cancer to management of treatment side effects and outcomes, to survivorship care, and to secondary cancer treatment. NPs have a strong impact on cancer survivorship care by serving in various roles and settings throughout the cancer trajectory to improve patient outcomes.

Implications for practice: Cancer survivorship care expands beyond specialty settings, into primary care. NPs have a key role in ensuring continuity of care for patients with cancer. Models of care that promote continuity and high quality of care for patients with cancer include the shared-care and nurse-managed health center models. The formal collaborative plan of care is essential in long-term cancer survivorship care.

Historically, nurse practitioners (NPs) have fulfilled primary care needs for underserved populations. With the influence of managed care and the increase in chronic care demands, NPs also have expanded beyond primary care practice to focus on specialty populations. The role expansion of NP care has contributed to increased healthcare access and improved patient outcomes in general (Lenz, Mundinger, Kane, Hopkins, & Lin 2004) and for oncology patients (McDermott Blackburn, 1998) in particular.

It is estimated that the number of people living with cancer in 2004 totaled 10,326,000, with over 55% of their cancers being breast, prostate, or colorectal (National Cancer Institute, 2007). Cancer survivors have care needs beyond cancer treatments and management of treatment side effects, including enhanced long-term follow-up care and surveillance for cancer reoccurrence (Earle & Neville, 2004; Houldin, Curtiss, & Haylock, 2006; Leigh, 1998; Oeffinger & McCabe, 2006) that may or may not be part of follow-up care provided by specialists.

The purpose of this article is to examine the key roles primary care NPs can have in long-term surveillance and health maintenance of cancer survivors throughout their continuum of care. Breast, colon, and prostate cancer are the focus of this review because of the higher prevalence of these three cancers in the general adult population (American Cancer Society, 2007). In this review, adult is defined as late adolescent through older adult cancer survivors (i.e., 18 years of age and older). The current roles of NPs within various adult care settings will also be examined, along with evidence and implications of collaborative patient care services among primary care NPs, oncology nurse specialists, oncologists, and physician primary care providers. Models of care where NPs can bridge the gap between specialist care and primary care, increase surveillance and decrease secondary complications related to breast, colon, and prostate cancer, and their treatments are proposed based on findings in the literature.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

In reviewing the literature, MEDLINE, CINAHL, MD-Consult, and Cochrane's databases were utilized with the inclusion of primary research and critical research reviews from January 1995 through March 2008. Search terms included cancer survivor, survivorship, NP, primary care, and model of care. From the articles retrieved, referenced sources were examined for inclusion. Select organizational websites also have been cited.

Complexity of managing health for cancer survivors

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

The National Cancer Institute defines the complex nature of cancer survivorship as follows:

In cancer, survivorship covers the physical, psychosocial, and economic issues of cancer, from diagnosis until the end of life. It includes issues related to the ability to get health care and follow up treatment, late effects of treatment, second cancers, and quality of life. (National Cancer Institute, n.d., Survivorship)

The report of a study by the Institute of Medicine and the National Research Council of the National Academies From Cancer Patient to Cancer Survivor: Lost in Transition (Hewitt, Greenfield, & Stovall, 2006) recommends that the components of survivorship care include: prevention, detection, and surveillance of new or recurrent cancers; interventions relating to consequences of cancer and related treatments; and coordination of care between specialists and primary care providers.

Provider involvement in cancer survivorship care is essential for promoting and overseeing healthy lifestyle adaptations necessary to decrease susceptibility to risk of cancer recurrence and post cancer treatment complications, as well as secondary illness unrelated to cancer diagnosis. A summary of lifestyle adaptations from the American Institute for Cancer Research (2008) is provided in Table 1. Also, the primary care providers perform oversight of and screening for the following: bone loss (Chen et al., 2005); body image changes; lymphedema; sexual dysfunction; fatigue (Kornblith et al., 2003); weight gain; cardiovascular disease; and diabetes (Herman, Ganz, Peterse, & Greendale, 2005).

Table 1.  Cancer screening, complications, and lifestyle adaptations for cancer survivors
 BreastProstateColorectal
  1. Note. Adapted from Kattlove and Winn (2003). PCP, primary care provider.

Focused follow-up surveillance for PCP• Physical exam every 6 months for 5 years, then annually • Mammography annually • Self-breast exam monthly• Prostate-specific antigen every 6 months for 5 years, then annually • Digital rectal exam annually• Carcinoembryonic antigen test every 3 months for 2 years then every 6 months for 3–5 years • Colonoscopy after 1 year, then at 3 years, then every 5 years
Secondary cancer risksBreast, ovarian, and colorectal cancersBladder cancerMetachronous colorectal cancer
Treatment complications• Osteoporosis • Lymphedema • Body image disturbance • Fatigue • Pain • Disturbed sleep pattern• Sexual dysfunction • Fatigue • Incontinence• Body image disturbance • Sexuality • Fatigue • Nutrition
Lifestyle adaptations for cancer prevention• Diet—choose mostly plant foods, limit red meat, and avoid processed meat • Physical activity—be physically active every day in any way for 30 min or more • Weight management—maintain a healthy weight throughout life • Avoid tobacco use  

Overall, quality of life (QOL) is an ongoing concern for cancer survivors. Areas for primary care providers to consider in cancer survivors are given by Betty Ferrell's QOL model applied to cancer survivors, which includes: physical, social, psychological, and spiritual well-being. Evidence shows a significant improvement in outcomes when QOL concerns are routinely addressed by practitioners (Ferrell, Smith, Cullinane, & Melancon, 2003). Additional efforts to focus on psychosocial implications of cancer care were initiated by the National Comprehensive Cancer Network's Panel on Distress Management with the establishment of standards and clinical practice guidelines for psychosocial care. According to these guidelines, components of psychosocial distress include physical, psychological, and reentry concerns (transitioning to healthy status within a social context). A number of assessment tools are available to assist with identification of QOL concerns in the cancer population. A comprehensive review of QOL tools can be found in a recent review article (Halyard & Ferrans, 2008). Periodic assessment of QOL during primary care visits provides another opportunity for early diagnosis of change in health status.

Survivorship care effectiveness

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

Gaps in care management are commonly reported among oncologists and primary care providers throughout the follow-up period of cancer care (Earle & Neville, 2004; Houldin et al., 2006; Oeffinger & McCabe, 2006). Earle and Neville (2004) found that simply monitoring the cancer survivor's chronic conditions and the provision of routine preventative exams were not adequate; the focus of care often reflected the individual's history of cancer but lacked other preventative measures and had very limited surveillance of acute and chronic co-morbid conditions. The highest level of long-term care was achieved when both oncologists and primary care physicians jointly followed cancer survivors, with follow-up by primary care physicians alone being the next most effective. The lowest level of care effectiveness was provided when the patient was followed only by an oncologist. This variation in surveillance and care effectiveness puts many cancer survivors at increased risk for secondary complications and cancer reoccurrence (Earle & Neville). The literature summarized in Table 2 represents an overview of studies on various models of care management for cancer patients.

Table 2.  Publications in models of care for the management of cancer survivors
ArticleAimsStudy designModel of careMain findings
Bryant-Lukosius et al., 2007Identify and describe role structures and processes and their impact on job satisfaction among oncology advance practice nurses in Ontario.Mailed self-report questionnaire (n= 73) of oncology advance practice nurses in Ontario.Nurse practitioner.67% were satisfied with current role and had no plans to seek new employment. Insufficient administrative support (42%), insufficient resources to fulfill role expectations (36%), personal growth and/or career advancement (33%), and perceptions that the role demands were negatively affecting their health (25%) were reasons given for looking for new employment.
Earle & Neville, 2004Use of administrative claims data to compare a cohort of colorectal carcinoma survivors to matched controls with no history of cancer in order to evaluate noncancer care received and the effect of physician specialty on delivery of care.Medicare-eligible individuals with colorectal carcinoma history (n= 14,884) were randomly paired with Medicare-eligible controls (n= 16,659) with no cancer history. Two-year comparisons of related health services received were interpreted by univariate analyses.Comparison of subspecialties of medical oncology, surgeons, radiation oncologists, and primary care physicians.Colorectal carcinoma survivors were associated with lower rates of receipt of necessary care. Optimal services were provided when such individuals were seen by an oncologist and primary care provider.
Koinberg, Fridlung, Engholm, & Holmberg, 2004Compare nurse-led follow-up on demand versus physician follow-up after breast cancer treatment.Stage I or II breast cancer women randomized, longitudinal, and multicenter study between 1991 and 2001 at three hospitals in Sweden (nurse group n= 133; physician group n= 131).Follow-up care provided by oncologist or surgical physician compared to on demand specialist nurse.Women reported statistically similar scores on Anxiety and Depression Scale and Satisfaction and Accessibility Scale both the physician's group and nurse's group by means of hospital. No differences were noted between time of recurrence or death.
Loftus & Weston, 2001Review of literature regarding the role of the advanced practitioner in nurse-led oncology clinics.Review of literature specific to United Kingdom.Nurse-led clinics; doctor versus nurse-led radiotherapy clinics; nurse-led lung and breast cancer clinics.Several models of care are reviewed, demonstrating implications for practice, and educational institutions.
Mahon, Williams, & Spies, 2000Describe the extent to which healthcare providers recommend the screening strategies for early detection for breast, gynecologic, and colorectal cancer, and for osteoporosis in long-term survivors of breast, ovarian, or endometrial cancer.Survey of random sample of nurses (n= 321) from the Oncology Nursing Society.Outpatient oncology nurses.Performed: Mammogram (range 74.2%–87.7%), breast exam (range 73.9%–83.7%), Pap and pelvic exam (range 61.8%–85.2%), flexible sigmoidoscopy/ colonoscopy (range 20.2%–27.7%), bone mineral density testing (range 16.9%–19.0%), and height measurement (range 22.5%–28.3%). Less than one-third of survivors offered counseling on strategies to promote bone health.
McKenna, McCann, McCaughan, & Keeney, 2003Describe a single-case study evaluating the role and work of an oncology nurse practitioner.Single-case study: descriptive information about NP and semi-structured qualitative interviews of randomized patients (n= 15), managers, and health care. Professionals (selected purposively) who worked with “the post holder” (NP).Oncology nurse practitioner clinic.Findings resulted in positive feedback for such a clinic and demonstrated utilization of high-quality services in a remote rural area. Personal attributes for an NP in such a clinic include flexibility, communication skills, and ability to work independently and as a team.
Moore et al., 2002To assess the effectiveness of nurse-led follow-up in the management of patients with lung cancer. Measures include: patient satisfaction, provider satisfaction, survival, symptom-free survival, progression-free survival, use of resources, and cost comparison.Randomization of lung cancer patients (n= 203) at three local hospitals and one cancer hospital, stratified to hospital and treatment intent. General practitioners’ (n= 144) satisfaction with follow-up in a nurse-led or conventional medical model.Nurse-led cancer follow-up versus conventional medical follow-up in lung cancer patients.Nurse-led follow-up was acceptable to lung cancer patients and general practitioners and led to positive outcomes.   General practitioners reported 46% preference in follow-up care provided by both an oncologist and clinical nurse.
Moore et al., 2006Describe the preparation and development of a model of nurse- led follow-up care for lung cancer; identify key nursing interventions provided within nurse-led lung cancer follow-up care.Continuation of Moore et al., 2002, utilizing patient case notes (n= 51), semi-structured interviews with nurse specialists (n= 2) and study coordinators (n= 2), and team meetings (n= 8).Nurse specialist-led follow-up care in lung cancer.Role of lung cancer nurse specialist in the United Kingdom.   Themes relating to the process of developing a nurse-led lung cancer follow-up role: “training,”“becoming credible,”“emotional burden,” and “making a difference.”
Pennery & Mallet, 2000Ascertain patients’ perceptions of routine follow-up care after completion of treatment for breast cancer.Cross-sectional, descriptive interview survey of a stratified systematic sample of patients (n= 24).General practitioners.Follow-up services lacked supportive psychosocial measures. The exploration of alternative systems to incorporate comprehensive and psychosocial care.

Researchers have examined the inconsistency of follow-up care, supporting efforts by the American Society of Clinical Oncology to develop evidence-based guidelines for the long-term care of cancer survivors (Houldin et al., 2006). In addition, the Oncology Nursing Society published entry-level competencies for specialized oncology NPs in an effort to standardize the quality of care provided (Cohen et al., 2007).

Healthcare providers now often consider cancer a chronic illness, but the trend has been slow to generate the ongoing monitoring needed to effect positive outcomes for survivors. The Centers for Disease Control and Prevention (2004) has implemented a National Action Plan for Survivorship to address unmet needs, strengthen public health entities, and enhance the role of clinicians in cancer survivorship. The plan encompasses an infrastructure of public health at the national, state, and local levels. NPs and other providers can contribute by understanding, implementing, and further disseminating these strategies at the primary care and specialty levels. Select strategies applicable to primary care are listed in Table 3.

Table 3.  Examples of strategies from the national action plan for cancer survivorship
  1. Note. Adapted from A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies. Centers for Disease Control. Department of Health & Human Services. 2004.

Suggested strategies for primary care
 • Develop and maintain patient navigation systems that can facilitate optimum care for cancer survivors.
 • Develop and disseminate public education programs that empower cancer survivors to make informed decisions.
 • Conduct research on preventive interventions to evaluate their impact on cancer survivorship issues.
 • Educate policy makers and decision makers about the role and value of providing long-term follow-up care, addressing quality-of-life issues and legal needs, and ensuring access to clinical trials and ancillary services for cancer survivors.
 • Empower survivors with advocacy skills.
 • Educate decision makers about economic and insurance barriers related to health care for cancer survivors.
 • Establish and disseminate guidelines that support quality and timely service provisions to cancer survivors.

Approaches to decrease barriers to optimal survivorship care continue to evolve with the following foci: improving healthcare access; expanding education and research; and integrating a wellness model of care (Houldin et al., 2006). Nursing and premedicine programs have begun incorporating components of survivorship care into curricula worldwide. In addition, more organizations are becoming involved in survivorship care, as groups such as the Livestrong Survivorship Center of Excellence Network (Lance Armstrong Foundation, n.d., Survivorship centers) and the National Cancer Institute's designated cancer centers (National Cancer Institute, n.d., Cancer centers) continue to raise standards for providing cancer care. It is essential that providers identify and use available resources (see Table 4) to ensure high-quality care.

Table 4.  Survivorship resources for providers
Organizations Key resources URL access
American Cancer Society• Cancer Survivorship Network • Making treatment decisions • Clinical trialshttp://cancer.org/
Cancer Action Network• Stay up-to-date on political news • Join federal campaignshttp://www.acscan.org/
Centers for Disease Control and Prevention• National action plan for cancer survivorshiphttp://www.cdc.org/
Lance Armstrong Foundation• Livestrong survivorship notebook • Livestrong Survivorship Center of Excellence Network • Cancer support for professionalshttp://www.livestrong.org/
National Cancer Institute• Types of cancers • Clinical trials • Cancer topics • Cancer survivorship researchhttp://www.cancer.gov/
National Comprehensive Cancer Network• Clinical practice guidelines • Clinical trials • Patient resourceshttp://www.nccn.org/
Oncology Nurse Practitioner Competencies• Health promotion, prevention, and treatment • NP–Patient Relations • Teaching–coaching • Professional role • Negotiating healthcare delivery systems • Quality of healthcare practice • Diverse populationshttp://www.ons.org/clinical/Professional/QualityCancer/documents/NPCompentencies.pdf

Standardization of care and recommendations for comprehensive care after the acute cancer treatment period are limited (Hudson, 2005). Federal legislative actions proposed in 2007 in the House of Representatives (H.R. 1078) and in the Senate in 2008 (S. 2790) were titled “The Comprehensive Cancer Care Improvement Act”; however, neither resolution was approved (personal communication, November 5, 2008, Senator Mac Baucus office). Legislative initiatives provide a strong base for interdisciplinary initiatives that could standardize and improve the quality of cancer survivor care. Gaps in care continue to negatively impact continuity of care, and provider involvement in political action remains critical.

Nurse practitioners as healthcare providers for cancer survivors

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

As advanced practice nurses, primary care NPs manage acute and chronic illnesses, with an emphasis on health education, compliance facilitation, and coordination of care plans (Loftus & Weston, 2001). Care provided by NPs has been found analogous to care provided by physicians. Research comparing physician and NP care indicates similarity in patients’ perceived health (Pinkerton & Bush, 2000), level of satisfaction in provider care (Lenz et al., 2004; Pinkerton & Bush), cost effectiveness (Faithfull, Corner, Meyer, Huddart, & Dearnaley, 2001), and primary care outcomes (Lenz et al.). Utilization of health services such as primary care, specialty, emergency, and urgent visits by patients of NPs are similar to those of physicians (Lenz et al.).

The continuity of cancer care is significantly enhanced when primary care NPs and oncology NPs are involved in patient care across settings. NPs assume a variety of cancer-related roles including cancer specialists, educators, researchers, and consultants, which extends across settings to radiation clinics, hospitals, oncology clinics, and primary care settings. Primary care NPs who recognize their role in cancer survivorship care have the ability to significantly impact long-term outcomes. From the time of diagnosis through the follow-up period, NPs have been praised for their focus on the psychosocial implications of cancer care, a dynamic component that is often under emphasized, resulting in poor patient outcomes and QOL (Carroll-Johnson, Gorman, & Bush, 2006). Primary care NPs have a significant role also because they manage comorbid conditions and long-term sequelae of cancer treatments and provide referral of cancer patients to specialty care providers, including oncology NPs. Certification as an advance practice nurse in oncology care requires completion of additional education. Criteria to meet certification requirements and prepare for testing are available through the Oncology Nursing Certification Corporation (2004).

Primary care approaches to survivorship care

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

The role of a primary care NP can expand to provide support across various models of cancer care, with emphasis on collaboration during and throughout the transition period from specialist back to primary care; in short, occurring at no defined time following oncological treatments (Oeffinger & McCabe, 2006). During this potentially uncoordinated period of health care, cancer survivors and families rely on the collaboration of all healthcare providers to ensure continuity of care and optimal outcomes. Approaches to care of cancer survivors could be enhanced by the application of tested models of care delivery.

Shared-care model

Shared-care models have been developed between primary care providers and specialists in the chronic management of diabetes (Holm, Lassen, Husted, Christensen, & Heickendorff, 2002), coagulation therapy (Renders et al., 2003), and congestive heart failure (Diller, Smucker, & David, 1999). Within this model of care, both the specialist and primary care provider have distinct roles in patient care and disease management (Oeffinger & McCabe, 2006; Smith, Allwright, & O’Dowd, 2007). For example, a primary care provider may consult an endocrinologist for the management of a patient with uncontrolled diabetes. Correspondence from the specialist is then communicated to the primary care provider, who would maintain responsibility for the overall healthcare needs of the patient.

When a shared-care model does not exist, oncologists commonly take on primary responsibility for patient diagnosis, treatment, and follow-up care. During the treatment phase of specialty care, the primary care provider has an unclear role that can result in limited health maintenance care for the patient. Providers often neglect collaboration regarding cancer management and long-term treatment of sequelae when the transition from specialty to primary care is not clearly defined. Snyder and colleagues (2008) examined preventative services and utilization of healthcare providers by colorectal cancer survivors. Survivors in this study were followed yearly starting at 1-year post diagnosis and ending at 5 years post diagnosis. Findings revealed that preventative services decreased with each consecutive year following diagnosis and cancer-related screenings decreased as oncologists became less involved in direct patient care.

Oeffinger and McCabe (2006) described the unique role NPs contribute in an oncology shared-care model, emphasizing the transition from oncology care to primary care following the treatment of cancerous disease. In this model, the oncology NP keeps an open dialog with primary care, translating risk factors, and potential late effects of treatments for the primary care provider to oversee and monitor. The shared-model emphasizes optimal long-term outcomes for cancer survivors, while providing a potential reduction in specialist burden, allowing other patients to be seen by specialists and waiting times to be decreased.

Nurse-managed health centers

Nurse-managed health centers are primary care centers, providing services, often including cancer care, that are not being sufficiently met within the surrounding communities. Certified registered NPs provide primary care, while other advanced practice nurses, registered nurses, health educators, and collaborating physicians contribute to the overall management of acute and chronic conditions (Hansen-Turton & Kinsey, 2001).

A recent study using the National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) reported nurse-managed health centers’ outcomes exceeded the HEDIS 50th percentile for managing chronic diseases such as asthma, diabetes, and hypertension (Barkauskas, Pohl, Benkert, & Wells, 2005). Nurse-managed oncology centers are predominately being utilized outside of the United States and have been shown to be acceptable and comparable to conventional medical care (Moore et al., 2002, 2006; Sharples et al., 2002). Current literature reveals a growing number of centers. Patients who transition from an oncologist's care to primary care through an oncology nurse-managed center have enhanced long- and short-term outcomes, including symptom management of disease and treatments, monitoring for reoccurrences, and ensuring long-term healthcare needs are achieved (Cox & Wilson, 2003; Flynn & Whitehead, 2006; Knowles et al., 2007).

Nurse-managed oncology centers provide care to patients for the management and surveillance of disease and adverse effects related to treatments. A review by Loftus and Weston (2001) found that oncology nurse-managed health centers have been created to address the perceived unmet needs of patients, improve quality of care, and decrease potential patient complications. In addition, the nurse-managed model of oncology care has shown a decrease in patient waiting times, increased assurance and consistency of contact with healthcare professionals, improved coordination of care pathways, facilitation of compliance, and promotion of health and educational activities.

Implications for practice

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

Cancer patients are living longer than any other time in history, with 67% of diagnosed individuals living beyond 5 years from diagnosis (National Cancer Institute, n.d., Surveillance). Surveillance of the patient for diagnosis and treatment of secondary complications of cancer needs to be integrated into the patient's general primary care, because these sequelae may occur many years following cancer diagnosis and treatments. The Institute of Medicine's report, From cancer patient to cancer survivor: Lost in transition (2006), illustrates possible effects of radiation therapy, chemotherapy, and hormonal therapy for various organ systems. Hudson (2005) provides an overview of specific cancers with detailed indications for populations at risk for late effects, possibly impacting developmental growth, vital organ function, fertility and reproduction, and development of secondary carcinogenesis.

Recent recommendations by the Institute of Medicine (Hewitt et al., 2006), encourage oncology specialists to construct a summary care plan for all cancer patients and their primary care providers. A personalized survivorship care plan provides patients and their primary care providers with written information regarding type of cancer, treatment regiments, total received doses of radiation and/or chemotherapy, acute reactions to treatments, potential long-term effects of treatments, follow-up care, health maintenance and well-being recommendations, available community resources, legal information regarding employment and access to health insurance, and provider contact information. This valuable care summary gives providers not involved in direct cancer care the personal information that is easily interpreted and updated as survivorship care progresses. The useful and adaptable tool helps to limit long-term complications if utilized effectively between providers. If the specialist practice does not develop a personalized plan of care, the primary care provider can initiate collaboration and coordination of care by providing the specialist with the plan for primary care, requesting input from the specialist (Earle, 2006; Gilbert, Miller, Hollenbeck, Montie, & Wei, 2008; Hewitt et al.; Leigh, 1998).

To prepare individualized care plans and deliver patient appropriate education effectively, it is imperative that providers follow recommendations established by organizations such as the National Comprehensive Cancer Network (Table 3). Information is accessible online by cancer type and includes national treatment guidelines, surveillance measures, management of disease recurrence, staging guidelines, and additional recommendations upon which to base clinical decisions (National Comprehensive Cancer Network, 2008). As new guidelines develop and/or change, providers may adapt care to reflect the latest recommendations. Alliances between primary care providers and specialists are necessary to assure effective and consistent survivorship care.

Educating patients and families throughout the continuum of cancer care regarding health maintenance, self-management, and long-term sequelae of disease is crucial to improving patient care outcomes. Resources available for individuals impacted by cancer include: the National Cancer Institute's Facing forward: Life after cancer treatment (National Cancer Institute, n.d., Facing forward) and the Livestrong survivorship notebook (Lance Armstrong Foundation, n.d.). Resources such as these provide individuals with the ability to gain an understanding of outcomes to treatments and an appreciation of the value of their survivorship care, empowering them to be more actively involved in the post cancer phase of care.

Finally, to develop the critical mass of NPs necessary to achieve a significant presence in cancer care, nurses and NPs may need to pursue further education. Family and adult NPs may seek additional clinical experiences and continuing education in care of oncology patients to better integrate survivorship care into their general practice. In addition, educational opportunities to receive master's and post master's oncology NP certificates exist at various universities. Specialization as an Advanced Oncology Certified Nurse Practitioner (AOCNP) is available for NPs through the Oncology Nursing Certification Corporation (2004). The specialized NP may work in oncology clinics, nurse-managed oncology centers, and comprehensive survivorship centers, all of which contribute to the magnitude of survivorship care.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References

Cancer patients experience changes in the focus of care when management shifts from the treatment of cancer, to management of treatment side effects and outcomes, to survivorship care, and to secondary cancer treatment. Evidence suggests that providers are not consistently providing patients with the necessary continuity of care over the long term or the monitoring required for optimal health outcomes over time (Earle & Neville, 2004; Hudson, 2005). Given the impact of this unmet need on the quality of care for cancer patients, providers are challenged to consider transition to a stronger model of care.

Increased involvement of NPs in primary care and specialty settings can close some of the gaps in health care through collaborative and comprehensive care (Lachance, 2005). Evidence-based guidelines, such as the National Comprehensive Cancer Network (2008) and the Oncology Nursing Society's Oncology nurse practitioner competencies (2007) provide guides to assist providers in delivering consistent and safe care for cancer survivors. NPs have an important opportunity to assume roles that influence the management of cancer treatment through various models of care, including the nurse-managed model and the shared-care model. Preparation of NPs for care of patients after treatment of cancer is critical if they are to continue to serve as advocates, actively demonstrate the holistic model of care fundamental to NP practice, and be accountable for improved outcomes in the ever-growing population of cancer survivors.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Complexity of managing health for cancer survivors
  5. Survivorship care effectiveness
  6. Nurse practitioners as healthcare providers for cancer survivors
  7. Primary care approaches to survivorship care
  8. Implications for practice
  9. Conclusions
  10. References