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Survivorship Program A Model of Survivorship Care... Continued from page 15 models were developed for the care of pediatric cancer survivors, where there was early recognition of the need to monitor for late treatment effects. Most of these programs are directed by a pediatric oncologist and coordinated by an NP, and about half include other mental health providers and other specialties.4 Disease-specific models were the first example of adult survivorship care programs. Oeffinger and McCabe described three distinct adult care models.4 As in
the pediatric programs, NPs play a central role in care delivery. Their first care model is the most basic and is described as a one-time consultative visit to a survivorship care provider, often an NP. A summary of cancer treatment and a plan for monitoring late effects are developed, and needs-based counseling and health promotion recommendations are provided. Their second care model is an NP-led clinic that functions as an extension of the care continuum. The NP
Case study A 58-year-old woman who presented in May 2006 with a 6-month history of rectal bleeding was diagnosed with locally advanced rectal carcinoma. She was treated with neoadjuvant chemotherapy and radiation followed by abdominal perineal resection with pelvic sidewall dissection and posterior vaginectomy. The pathology report revealed no residual carcinoma, and surgical margins were free of dysplasia; lymph nodes were negative; the vaginal mucosa was unremarkable. Adjuvant chemotherapy was given and tolerated well. She had not had a follow-up bone densitometry. The patient was followed by her colorectal surgeon for 2 years and transferred to the survivorship NP on the colorectal service. Her initial survivorship visit was in October 2009. The patient’s medical history is significant for earlystage ovarian cancer treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy and adjuvant chemotherapy (1999) and partial thyroidectomy for a goiter (2005). Comorbidities include hypertension, hypothyroidism, and osteopenia. Obstetrical history: G1 P1, vaginal delivery. She reports no gynecologic examination or mammogram in more than 3 years and has not seen her primary care doctor in 2 years. She has no family history of cancer. She is married with one adult daughter aged 33 years, works fulltime as a hair dresser, denies alcohol, drug, or tobacco use, and does not exercise regularly. Assessment revealed the following findings. • Review of systems: obesity secondary to high-fat diet and sedentary lifestyle; dyspareunia secondary to radiation, surgery; decreased libido; uncontrolled bowel movements through stoma; fatigue • Psychosocial assessment: anxiety related to fear of rectal cancer recurrence or a new cancer; relationship concerns related to absence of sexual activity; body image changes from stoma, weight gain • Physical examination: well-healed incision, no hernia on incision sites with stoma upright, and no peristomal hernia; body mass index, 30.1 (obese); blood pressure, 160/94 • Vaginal examination: negative except for tenderness during examination • Diagnostic testing: carcinoembryonic antigen (CEA), within normal limits: 1.6 ng/mL (range, 5 ng/mL); computed tomography scan chest, abdomen, and pelvis, no evidence of disease recurrence; colo noscopy overdue The possible physical late effects of rectal cancer treatment include bowel and bladder dysfunction, sexual
delivers ongoing care that includes a standard set of survivorship services and a follow-up care plan. Contact with the primary care provider is reestablished by the NP, with sharing of patient information and care guidelines. This facilitates shared care and a potential return to community follow-up care based on the patient’s risk for recurrence and late effects. Their most complex care model is a specialized multidisciplinary survivor program similar to the pediatric pro-
dysfunction, adhesions, hernia, dietary changes, and peripheral neuropathy due to chemotherapy. Psychosocial effects include body image changes and fears about recurrence and development of second cancer. Our patient was found to have the following problems. • Treatment effects: sexual dysfunction (dyspareunia); bowel dysfunction (uncontrolled bowel movements); hernia (hernia repair x 1) • Psychosocial: body image changes (stoma and weight gain); relationship changes (decreased libido); anxiety (fears of recurrence) The nurse practitioner summarized the visit findings with the patient and reviewed a survivorship care plan, which was sent to the primary care provider with a copy of the visit notes. • Obesity: counseled on diet/exercise; educational materials provided on diet and exercise; patient was referred to a nutritionist • Dyspareunia: counseled about vaginal health strategies related to dryness and vaginal dilatation; referred to Women’s Sexual Health Program • Healthcare maintenance: annual mammogram, gynecological examination and Pap smear, also bone densitometry; encouraged to continue calcium and vitamin D supplements; referred to new gynecologist • Anxiety: referred to social worker • Comorbidities: instructed to follow up with primary care provider for management of hypertension and thyroid replacement medications • Counseling: screening colonoscopy for family especially her daughter; routine use of sun screen; annual influenza vaccination • Surveillance: patient was scheduled to return in 6 months with a CEA at the visit; colonoscopy scheduled prior to next visit The patient returned for her follow-up visit with the nurse practitioner 6 months later. Her colonoscopy was negative for recurrent or new disease. She had seen her primary care provider, who adjusted her thyroid replacement and antihypertensive medications. Bone densitometry showed stable osteopenia. She had seen the gynecologist and had negative examination and cytology findings. She had multiple visits, along with her husband, in the Women’s Sexual Health Program for counseling and for vaginal dilatation management. She had seen the social worker and joined a regular support group for cancer survivors through her community center. She had also joined Weight Watchers and started a daily walking regimen; she had lost 6 pounds. The patient will return for regular visits with the survivorship nurse practitioner.
grams. This model includes physicians with training and experience in the care of cancer survivors, NPs, and other mental health and consulting specialists. The team provides risk-based care. One example of this resource-intense model is the clinic that provides care for the adult survivors of pediatric cancers. Survivorship model of care at MSKCC: adult-onset cancer clinics The clinical survivorship program for adult-onset cancers at MSKCC began in 2005. A pediatric long-term follow-up clinic had long been established and served as a resource for development of the adult program. Led by Mary McCabe, director of the Cancer Survivorship Initiative, a multidisciplinary steering committee developed a model of care to best meet the defined needs of adult patients and the institution. An institutional needs assessment and patient focus groups guided development and expansion of support programs and greater access to services for survivors and families. The overall goals of the clinical program are to extend the continuum of care by defining survivorship
NPs were selected as the survivorship care providers based on their educational preparation in holistic care and the hospital’s positive experience with NPs in acute care over many years. care for each disease specialty and to transition patients along the continuum from the oncology provider to the survivorship NP, who facilitates communication with the primary care provider (Figure, page 14). The program is designed to provide comprehensive follow-up care with a standard set of services that addresses survivors’ specific medical, psychosocial, functional, educational, and spiritual needs. Patient eligibility for transfer to survivorship care and standard follow-up guidelines are determined by the disease management team for that patient population. NPs were selected as the survivorship care providers based on their educational preparation in holistic care and the hospital’s positive experience with NPs in acute care over many years. The survivorship NPs receive intensive training in survivorship care and the particular needs of the patient population. They practice in the clinical areas assigned to Continued on page 21
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September 2010 I VOL 3, NO 6
GreeN HILL HeALtHCAre COmmUNICAtIONS