From Prevention to Palliative Care: Optimizing the

Breast Cancer Patient Experience with Nurse Navigation

Darcy Burbage, MSN, RN, AOCN, CBCN

Oncology Nurse Navigator

Helen F. Graham Cancer Center & Research Institute

Objectives • Discuss strategies to overcome barriers to successful

implementation of the NN role in breast cancer programs.

• Identify strategies to improve BrCa screening and coordination of care for patients.

• Outline emerging treatment options.

• Identify key components for patients as they transition through the continuum of care.

Role of NN in Breast Care • Define patient population

– Dependent upon your institution

– Will help you delineate your role

– Community needs assessment

– Patient advisory board

• Budget

• Staffing

• Define metrics

• Build relationships/collaborations

Korber, S.F., Padula, C., Gray, J., & Powell, M. (2011). A breast navigator program: Barriers, enhancers, and nursing interventions.

Oncology Nursing Forum, 38 (1), 44-50.

Case Study

• J.S. 57 y.o. AA presented w/palpable lump b/w sx mammo

• Bx + IDC ER/PR+/HER2-

• 2 daughters; 1 son; 3 sisters; 3 nieces

• Genetic counseling performed; testing negative

• Stage III IDC; s/p MRM w/implant reconstruction

• DD AC followed by 12 wks Taxane

• XRT

• AI for 5 years

Screening and Early Detection of Breast Cancer

Comparison of BrCa Screening Guidelines

Recommended ACOG ACR/SBI ACS AMA NCCN USPSTF

Age to Start Mammograms 40 40

45 Individual

choice 40-44 40 40 50

Age to Stop Mammograms

Annual as long as

woman is in good health

When life expectancy

is < 5-7 years

When life expectancy is

< 10 years

When life expectancy

is < 10 years

Upper age limit not

established 74

Interval Annual AnnualAnnual 45-54; 1-2 years 55+ Annual Annual 2 years

American Cancer Society. http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-

early-detection-acs-recs

American College of Gynecology. http://acog/org/About--ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advisory-on-Breast-

Cancer-Screening.

American College of Radiology. http://www.jacr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BreastCancerScreening.pdf

American Medical Association. http://www.ama-assn.org/resources/doc/csaph/x-pub/a12-csaph6-screeningmammography.pdf

National Comprehensive Cancer Network. http://www.nccn.org/breastcancerscreening

United States Preventive Task Force. http://www.uspreventiveservicetaskforce.org/Page/Document/UpdateSummaryFinal/breast-

cancer-screening1.

Screening & Early Detection • Controversies between guidelines

• Risk Assessment– Risk prediction models (Gail Risk/Tyrer-Cuzick)

– Genetic Counseling & Testing

• Risk Factors– Non-modifiable

– Modifiable

• Risk Reduction– Interventions to modify risk

– Health promotion to reduce risk

American Cancer Society. Breast Cancer Facts & Figures 2017-2018. Atlanta: American Cancer Society, Inc. 2017.

NN to coordinate care

as directed by MD

Educate patients

RE: Diagnosis and Treatment

Provide emotional support

Review Resources

Follow-up phone calls throughout treatment -Confirm readiness for subsequent treatment modalities -Assess compliance with recommended treatment plan -Review questions

-Refer to Survivorship Nurse Navigator-End of Treatment Counseling-SCP

Review pathology

Other Practices

Self Referrals

TumorConference

MDC

CHOE

Initial Visit

-Assess needs using Insight- Determine preliminary treatment plan

Make referrals- Rehab- Social Work- Psychology-Community Resources

Provide emotional support

Review resources & make referrals as

needed

End of Treatment

Inpatient

Supportive and Palliative Care

Navigation throughout the Breast Cancer Continuum

Burbage, D., et al. (2016). Optimizing Breast Cancer Nurse Navigation Using a Lean Six Sigma Approach.

Treatment Considerations

• Staging

• Molecular profiling

• Unique populations

• Clinical trials

• NCCN Treatment Guidelines

– Surgery, Chemotherapy, Radiation Therapy, Endocrine Therapy

• Prehabilitation

• Supportive & Palliative Care

AJCC (2018). Breast Cancer Staging System.

Hu, X., Huang, W., & Fan, M. (2017). Emerging therapies for breast cancer. Journal of Hematology and Oncology, 10, 1-17.

NCCN (2019). National Comprehensive Cancer Network. Breast Cancer Treatment Guidelines.

Treatment Considerations • Approved Chemotherapy Regimens for Adjuvant, Recurrent & Stage IV Breast

Cancer• Multiple regimens exist

• Dependent upon stage, molecular status of tumor and,

• Individual patient variability, prior treatments, existing co-morbidities

• Targeted therapies based on biology of cancer: anti-HER2 targeted therapy drugs, PD-L1-inhibitors

• Emerging Chemotherapy Options• PARP Inhibitors

• CDK 4/6 Inhibitors

• Immunotherapy

• Selected Androgen Receptor Modulators (SARMs)

AACR (2019). Current, New and Emerging Therapies. Retrieved from www.aacr.org

NCCN (2019). National Comprehensive Cancer Network. Breast Cancer Treatment Guidelines.

Breast Cancer Risk Stratification Based on Acuity

Insurance

**Comorbid diseases:1. COPD2. CHF/CAD3. Uncontrolled Diabetes 4. Renal Failure5. Morbid Obesity6. Mobility Issues7. Cognitively Impaired

Product limited

in some way

Uninsured or Undocumented

Medicare

Surgical Procedures

Co-morbids**

Anti Estrogen

None

0

Screened positive for

distress

0 1Social Factors* >2

Uncontrolled Psych D/O or other sig dx

>2

*Social Factors:1. Homeless or vulnerable2. Single and/or no support

at home3. Literacy4. 1 Language not English5. < 40 yrs or > 65 yrs 6. Non-Hispanic Black7. Transportation Issues

Substance Use Disorder

Commercial/non-mang

Medicare

Not active, but last used w/in 1

yr

Active

PsychiatricDisorder

AdjuvantTreatment

Chemo and or Radiation

Neo-Adjuvant ChemoTNBC

1

Lumpectomy w/wo SLNB

Mastectomy w/Recon-

struction

Mastectomy w/o Recon-

struction

Level 1

Current – %

Goal -25%

Level 2

Current - %

Goal- 35%

Level 3

Current -%

Goal - 35%

Stage IV

Level 4

Current-

Goal - 5%

None

Risks

Burbage, et al., (2016). Optimizing Breast Cancer Nurse Navigation. Wagner, E.H., Ludman, E.J. et al. (2014). Nurse navigators role in early cancer care: A randomized, controlled trial. JCO, 32 (1), 12-18.

Potential Physical Effects of Breast Cancer

Martz, C.H. & Kirby, K. (2011). Symptom Management. In S. Mahon (Ed.). Breast Cancer (2nd ed., pp.141-177). Pittsburgh, PA: Oncology Nursing Society.

• Hot flashes

• Vaginal Dryness

• Osteoporosis

• Weight changes

• Acute effects

• Early Menopause

• “chemo-brain”

• Fatigue

• Neuropathy

• Weight changes

• Same as surgery, plus

• Fatigue

• Skin changes

• ↓ ROM

• Cording

• Lymphedema

• Pain/Numbness

• Changes in sensation

Surgery Radiation

Anti-EstrogenChemo

Potential Psychosocial Effects of Breast Cancer

• Anxiety, Fear of recurrence

• Body image concerns

• Intimacy, sexuality, fertility

• Changes in relationships

• Changes in responsibilities

• Financial/employment/health & life insurance concerns

• Survivor’s guilt

Campbell-Enns, H. & Woodgate, R. (2016). The psychosocial experiences of women with breast cancer across the

lifespan: A systematic review. Psycho-Oncology, retrieved March 10, 2019 from https://doi.org/10.1002/pon.4281

Potential long-term & late effects of treatment• It’s all relative

• Risk depends upon

– Overall health before treatment

– Treatment received

• Long-term effect

– Develop during treatment and may become chronic, linger on, or improve over time

• Fatigue/Anxiety

• Late effect

– Delayed; can surface months or years after treatment is completed

• Cardiac issues/Depression

Rowland, J., Hewitt, M., & Ganz, P. (2006). Cancer survivorship: A new challenge in delivering quality cancer care. Journal of Clinical Oncology, 24, 5101-5104.

Morgan, M. (2014). Improving Survivorship Care for Patients with Cancer. National Comprehensive Cancer Network (NCCN).

Survivorship Treatment Summary

and Follow-Up Care Plan

• Multiple free templates available that meet CoC criteria

• Documents stage of cancer, treatments received and

ongoing treatment & side effects

• EB surveillance guidelines

• Symptoms to report

• Treatment team contact information

Riley, A. (2018). How to meet the needs of 18 million (and counting) cancer survivors. Oncology Advisory Board Survivorship Seminar.

Surveillance and health promotion • Annual mammogram

• Medical history and physical exam every 3 to 6 months for 3 years, then every 6 months for 2 years, then annually

• Annual gynecologic exam for women with uterus on tamoxifen

• Baseline bone mineral density determination for women on aromatase inhibitor and periodically thereafter

• Continue with regular medical and dental screenings

• Genetic counseling/testing

• Report any new or persistent symptom, including anxiety/distress

• Implement healthy lifestyle choices

http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf; Retrieved March 30, 2019.

What to know: ASCO’s guideline of follow-up care for breast cancer. (2009, June). Retrieved March 30, 2019 from http://www.cancer.net/patient/publications+and+resources/what+to+know.

Rock, C., et al (2012). Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians, 62(4), 243-274.

Hawley, P. (2015). Retrieved from:

http://www.virtualhospice.ca/en_US/Main+Site+Navigation/Home/For+Professionals/For+Professionals/The+Exchange/Current/The+Bow+Tie+Model+of+21st+Century+Palliative+

Care.aspx

The Spectrum of Metastatic Breast Cancer

• Rapid development of metastases

• Shorter disease-free interval

• Extensive visceral involvement

• Resistance to endocrine therapy

• Long disease-free interval

• Later recurrence of metastases

• Bone and soft tissue disease

• Sensitive to endocrine therapy

IndolentVirulent

Slide credit: clinicaloptions.com

Lessons Learned

• Not a one size fits all approach to navigation• Anticipate growing pains • Ask your patients and colleagues • Define population as well as role of all team members• Focus on what’s best for the patients in your community

• Determine metrics• Utilize existing resources • Evaluate model of navigation • Communicate and celebrate success!

American College of Surgeons (2012). Cancer program standards: Ensuring patient-centered care. Retrieved from https://www.facs.org/quality-programs/cancer/coc/standardsSmith, J. & Kautz, D. (2015). A literature review of the navigator role: Redefining the job description. Journal of Oncology Navigation and Survivorship, 6(2), 24-33.

Nurse Navigator Led Patient Outcome Measures• Provider and patient satisfaction scores have been maintained between 98% to 100% since implementation of

the breast care/cancer nurse navigator role.

• Breast biopsy turnaround time has decreased from 18 days to 5 days.

• Comprehensive lymphedema program developed with greater than 80% reduction in overall volumetric measurements and revenue generating of $2,500 per average 14 visit treatment program.

• Reduced same day biopsy cancellation rates referred from outside facilities from 11% to 2% therefore saving the institution $3,000 per cancelled case.

• ED visits 31.1% vs 58.3%

• Admissions 26.7% vs 33.3%

• Readmissions at 30 days: 15.0% vs 31.0%

Koprowski, C., Johnson, E.J., Sites, K., & Petrelli, N. (2018). The SCOOP Pathway. Oncology Issues, 33(6), 19-27. Lee, et al (2011). Effects of nurse navigators on health outcomes of cancer patients. Cancer Nursing , 34 (5), 376-384.

What’s the future look like for breast cancer nurse navigation?

• Group visits

• How do we utilize the power of technology better?

• Long-term survivors & those living with metastatic breast cancer

• Improved collaboration with our non-oncology colleagues for transitions of care/managing co-morbidities

• How do you balance volume/acuity with limited resources?

• To be continued…

Thank you!