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Survivorship Program Cancer Rehabilitation and Survivorship... Continued from page 18 even the cancer itself.10 Nevertheless, the term chemobrain has increasingly become more publicized, particularly among the breast cancer community.11 Although chemobrain was first identified and named by breast cancer survivors, the same constellation of symptoms also affects other cancer patients. A typical patient with chemobrain may report some or all of the concerns listed in Table 2. Chemobrain has been reported to affect up to 75% of cancer patients and is often quite distressful.12 Symptoms persist in 17% to 34% of patients well after treatment has ended.13 Research on treatment options for cancer-related cognitive changes is still in its infancy. Proposed interventions include various cognitive-behavioral strategies and pharmacologic options, with medications such as methylphenidate and modafinil. These interventions are still undergoing clinical testing and, therefore, should be considered on a case-bycase basis. At Cedars-Sinai Medical Center, we have begun a 6-week psychoeducational series to provide strategies in coping with the symptoms of chemobrain. After carefully screening participants
for potentially reversible medical contributors to cognitive dysfunction and neuropsychological testing to identify any objective cognitive impairment, patients may enroll in this program, called Emerging from the Haze. In collaboration with our neuropsychology service, the series provides tools to cope with the common issues that cancer survivors face that are believed to affect cognition. Topics addressed in the program include: • Relaxation techniques • Cognitive strategies for attention, memory, and executive function • Exercise • Sleep hygiene • Nutrition • Cognitive-behavioral therapy • Time management and balancing of life priorities. We are gathering quality-of-life data to measure the benefit of this program. Based on initial impressions, the program appears promising. Conclusions As part of the cancer center’s commitment to treating the whole patient, not just the disease, the Samuel Oschin Comprehensive Cancer Institute at
Table 2 Typical Concerns Reported by Patients with “Chemobrain”
challenge and an opportunity for the oncology rehabilitation community. ●
• Memory lapses • Difficulty concentrating or staying focused on a task • Trouble remembering details such as names, dates, or phone numbers • Difficulty multitasking such as carrying a conversation and following a cooking recipe • Slower processing speeds • Difficulty with word retrieval
References
Cedars-Sinai Medical Center has worked to develop programs with the goal of helping cancer survivors live their lives to the fullest. Rehabilitation is an active process. Whereas chemotherapy, surgery, and radiation are often passive interventions from the perspective of the patient, exercise programs, psychoeducational series, and expressive arts programs are rehabilitation programs that require engagement and responsibility on the patient’s part. Achieving the capacity to meet the complex rehabilitation needs of a growing population of cancer survivors and identifying the most cost-effective and beneficial programs represents a major
1. American Cancer Society. Cancer Facts & Figures 2010. Atlanta, GA: American Cancer Society; 2010. 2. National Cancer Institute. SEER Cancer Statistics Review, 1975-2006. seer.cancer.gov/csr/1975-2007/index. html. Accessed March 8, 2010. 3. Cole RP, Scialla SJ, Bednarz L. Functional recovery in cancer rehabilitation. Arch Phys Med Rehabil. 2000;81: 623-627. 4. Institute of Medicine. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2005. 5. Jane H. Art therapy and cancer care. Alternative and Complementary Therapies. 2010;16:140-144. 6. Luzzatto P, Gabriel B. The creative journey: a model for short-term group art therapy with posttreatment cancer patients. Art Therapy: Journal of the American Art Therapy Association. 2000;17:265-269. 7. Campbell J. The Hero with a Thousand Faces. 2nd ed. Princeton, NJ: Princeton University Press; 1968. 8. Trask PC. Quality of life and emotional distress in advanced prostate cancer survivors undergoing chemotherapy. Health Qual Life Outcomes. 2004;2:37. 9. Oh B, Butow P, Mullan B, et al. Impact of medical qigong on quality of life, fatigue, mood and inflammation in cancer patients: a randomized controlled trial. Ann Oncol. 2010;21:608-614. 10. Ferguson RJ, Riggs R, Ahles T, Saykin AJ. Management of chemotherapy-related cognitive dysfunction. In: Feuerstein M, ed. Handbook of Cancer Survivorship. New York: Springer; 2006. 11. Hurria A, Somlo G, Ahles T. Renaming “chemobrain.” Cancer Invest. 2007;25:373-377. 12. Vardy J, Wong K, Yi QL, et al. Assessing cognitive function in cancer patients. Support Care Cancer. 2006;14:1111-1118. 13. Ahles TA, Saykin AJ. Candidate mechanisms for chemotherapy-induced cognitive changes. Nat Rev Cancer. 2007;7:192-201.
A Model of Survivorship Care... Continued from page 20 the disease management teams, reinforcing the notion to both referring physicians and patients that the survivorship NP is an extension of overall cancer care. At the independent NP visit, the essential components of survivorship care, as outlined in the Table (page 14), are discussed. The NP prepares and reviews a survivorship care plan with the patient and provides the patient with a copy. A copy is also sent to the patient’s primary care provider along with the current visit note identifying any concerns and clarifying the NP’s role as a provider. Each time the patient is seen, a copy of the visit note is sent to the primary provider. Routine interdisciplinary referrals are made to both institutional and external resources, which may include nutritionists, wound and ostomy nurses, sexual health clinicians, fertility specialists, clinical geneticists, rehabilitation medicine services, dermatologists, integrative medicine programs, mental health workers, smoking cessation counselors, and cancer screening programs. Each survivorship clinic began as a pilot program with simple metrics of feasibility, sustainability, and satisfaction identified for evaluation. Ongoing monitoring includes physician transfer of eligible patients, patient agreement to move to a new NP provider and
educational initiatives regarding survivorship care and late treatment effects have been expanded for patients and families, MSKCC clinicians, and community providers. A webpage, called Living Beyond Cancer (www.mskcc.org/ mskcc/html/58022.cfm) provides resources for patients and professionals.
reschedule follow-up appointments, and administrative support with space and other resources. Each pilot program was evaluated at the end of 1 year, and a determination made about its success prior to making it a permanent part of hospital operations. To date, there are eight NPs delivering disease-specific survivorship care to the following cancer populations: breast (three NPs), colorectal, thoracic, urology, bone marrow transplant, and radiation oncology (prostate). In 2009, the NPs collectively saw more than 6000 survivors and had a greater than 90% average rescheduling rate, significant measures of referring physician and patient satisfaction. A case study of a colorectal cancer survivor in the MSKCC program further demonstrates the role of the survivorship NP (sidebar, page 20).
In 2009, the NPs collectively saw more than 6000 survivors and had a greater than 90% average rescheduling rate, significant measures of referring physician and patient satisfaction.
Summary The survivorship program at MSKCC is committed to the expansion of survivorship research and education as well as clinical care. The survivorship clinics have served as platforms for clinical research as each patient visit creates data on posttreatment outcomes. A growth in the center’s survivorship research community, with increased funding and individual studies, has been an additional outcome of the program. In addition,
MSKCC has benefited from funding and collaboration with the Lance Armstrong Foundation and is designated as a LIVESTRONG Center of Excellence. This funding has, in particular, supported an investment in various New York City community cancer survivorship programs for the underserved. Care of cancer survivors has advanced in recent years, largely in response to demands of patient advocates in pursuit of a better quality of life after cancer
treatment. The growing need to address patient concerns as well as the sheer number of survivors in the healthcare system has created an opportunity for development of creative care-delivery strategies. The MSKCC program has standardized follow-up care for populations of cancer survivors to address patient needs systematically. The use of specially trained advanced practice nurses as providers has maximized the institution’s dual goals of improving quality of care and providing more efficient, yet comprehensive services. The NP-led clinics have demonstrated that instituting a formal survivorship plan of care and using the unique skills of NPs can be an effective means of helping patients to achieve maximal recovery with the necessary tools for long-term survival. ● References
GREEN HILL HEALTHCARE COMMUNICATIONS
1. Institute of Medicine. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2005. 2. Kattlove H, Winn RJ. Ongoing care of patients after primary treatment for their cancer. CA Cancer J Clin. 2003;53:172-196. 3. Ganz PA, Casillas J, Hahn EE. Ensuring quality care for cancer survivors: implementing the survivorship care plan. Semin Oncol Nurs. 2008;24:208-217. 4. Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol. 2006;24:5117-5124. 5. Earle CC. Failing to plan is planning to fail: improving the quality of care with survivorship care plans. J Clin Oncol. 2006;24:5112-5116. 6. Houlihan NG. Transitioning to cancer survivorship: plans of care. Oncology (Williston Park). 2009;23(8 suppl):42-48.
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