When we think about improving clinical outcomes and increasing survival of cancer, usually we are referring to the oncologists’ roles in selecting the right treatment plan, perhaps enrolling patients in clinical trials that may give them an edge over standard treatment today, or even thinking about such things as improved technology that enables healthcare providers to make the diagnosis sooner. And all of this is certainly true. However, the nurse navigator has a key role as well, or can if she or he chooses to, regarding these important measurable indicators of successful cancer treatment. How? Read on.
The National Comprehensive Cancer Network (NCCN) has developed and routinely updates the treatment guidelines that are to be followed by the oncology team taking care of cancer patients. There are specific treatment pathways for each type of cancer, and within that cancer category, also be the stage of the disease. These treatment planning details were developed with a primary goal in mind—if we can help ensure that the patient receives the care outlined, then we can ensure that the treatment was appropriate and complete. These treatment guidelines match to higher survival rates. And we know that if a patient does not receive all of the treatment needed, then the patient is at risk of recurrence of the disease, at risk of not getting rid of the cancer to begin with, and has an increased risk of mortality.
The nurse navigator can be instrumental in reviewing the NCCN treatment guidelines with the patient and her family. (These guidelines are online at www.nccn.org in both a format written for healthcare professionals as well as translated into ones easier for the patient to understand). Reiterating the importance of receiving the treatment (surgery, chemotherapy, radiation, hormonal therapy, and perhaps other treatments) and explaining the reasons why can help to ensure that a patient embraces the treatment that lies ahead. The role of the nurse navigator is to ensure that the appropriate consultations happen across the continuum of care, beginning with the initial consultation. She can also help to troubleshoot any barriers that may exist, which would prevent the patient from adhering to the treatment guidelines (eg, if the patient has no transportation she may not come for her daily radiation treatments). So it takes several things to happen to make sure the patient is receiving the appropriate treatment, in an efficient manner and delivered completely. Below are the steps for breast cancer patients.
- Arrange for a consultation with a breast surgical oncologist for a discussion about the biopsy results and what surgical treatment is needed.
- Educate the patient about the breast cancer surgery, making sure that she understands how the recommendation was made and ensuring her input in the decision takes place.
- Coordinate her preoperative tests and arrange the surgery date.
- Provide preoperative teaching for the patient and family members.
- Arrange for her postoperative appointment with the surgeon, and follow up to review the pathology results in advance of the appointment so that if there are any unanticipated results (such as the sentinel node being positive on final review when it was negative on frozen section), there is a plan of care formulated before her being seen postoperative (ie, arrangements for surgery again to do an axillary node dissection).
- Arrange for her postoperative consultations with the medical oncologist and the radiation oncologist.
- Ensure these appointments are kept and coordinate any tests that may need to be done in preparation for the consultations (all pathology prognostic factors are known, staging work-up tests are ordered and have taken place)
- Again ensure the patient is educated about the adjuvant treatment she is advised to receive and screen her for any barriers that may prevent her from having these treatments—all of them as defined by the chemotherapy regimen and/or radiation therapy regimen she is advised to receive.
- Be available to address questions for the patient as she continues her journey with treatment after surgery.
- Follow up with the patient regarding the appointments required after completion of the acute adjuvant therapies, to ensure that she is recovering well (ie, when is she due to a mammogram again? Does she have any side effects that are causing problems posttreatment that need to be medically managed?)
- For patients who are hormone receptor-positive, also ensure that she is well educated about the importance of hormonal therapy and its value in prevention of recurrence. (This is a particularly vulnerable area because she will be seen far less frequently and the menopausal side effects may tempt her to not take the medication as prescribed.)
To determine the impact of your role on clinical outcomes and survival, it is useful to review 50 medical records of patients who completed their cancer treatment before you began navigation. Take a look and document, with the help of the tumor registry staff, the frequency at which patients did not receive specific recommended adjuvant therapies. For example, you may find that patients with stage II and III breast cancer who underwent lumpectomy only received radiation therapy 70% of the time. The tumor registry staff tracks these patients long-term from a survival perspective, so you will be able to get longitudinal data as well about recurrence and survival statistics. Then track the patients you navigated, and record information by stage of disease. With what frequency are these navigated patients receiving all the treatment needed, as recommended in the NCCN treatment guidelines? What is their recurrence rate and survival?
Sometimes we (or perhaps leadership) underestimate the value of a nurse navigator when looking at the tasks performed day to day. By reviewing information aggregately, however, a big impact can be demonstrated—the value of saving lives.