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10/19/2017
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The Cancer Survivorship Initiative
Lisa D’Andrea RN, BSN, OCN, CNBN, CPN
Wilson Cancer Resource Center, Beaumont Troy
Assistant Nurse Manager, Oncology Nurse Navigator
and Breast Cancer Survivorship Clinic Facilitator
The Beaumont Survivorship Mission
The Cancer Survivorship Program will partner with patients, families and their healthcare providers to promote optimized health and
healing of mind, body and spirit.
We will support and empower patients through integrative practices and education before,
during and beyond treatment.
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Survivorship Statistics
Breast Cancer Stage 5 Year Relative Survival Rate
0 (in situ) 100%
l 100%
II 93%
III 72%
IV 22%
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- National Cancer Institute’s SEER Database 2014 (Survivorship, epidemiology, and end results)
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How Many People Survive 5 Years Or More after Being Diagnosed with Cancer of Any Site?
- Based on data from SEER 18 2007-2013. - Gray figures represent those who have died from cancer of any site. - Green figures represent those who have survived 5 years or more
Percent Surviving 5 Years 67.0%
Survivorship Statistics
Predicted Survivorship Forecast
• 15.5 Million 2016
• 26.1 Million 2040
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- National Cancer Institute , July 8, 2016
Benefits of Survivorship Practices
• Meets the standards and mandates of practicing institutions
• Qualifies institutions for accreditation eligibility
• Provides the patient with optimal outcomes
• Facilitates patient-provider relationships throughout the continuum of care
• It is the right thing to do for the patient
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Institutional Best Practices Patient Care Best Practices
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The Standards
Commission on Cancer
• Standard 3.3 Survivorship Care Plan: The cancer committee develops and implements a process to disseminate a comprehensive care summary and follow-up plan to patients with cancer who are completing cancer treatment.
- Commission on Cancer
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The Standards
NAPBC
• Standard 2.20 - A comprehensive breast cancer survivorship care process, including a survivorship care plan with accompanying treatment summary, is in place within six-months of completing active treatment and no longer than one-year from date of diagnosis. The survivorship care process is evaluated annually by the Breast Program Leader (BPL).
- National Accreditation Program for Breast Centers
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- Oncology Nursing Society
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“Every cancer patient looks forward to
the day when the doctor says that treatment is finally complete.
At that point, the end of cancer treatment signals the beginning of a new
journey: Survivorship”.
- National Comprehensive Cancer Network
The Patient’s Perception What does survivorship mean to your patient?
For those who have completed treatment, think for a moment… How do you think they feel?
Excited? Relieved? Grateful? Thankful?
Not always…
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The Burdens of Survivorship Physical
Pain, Fatigue, Lymphedema, Neuropathy, Vaginal Dryness, Chemo-Brain
Emotional
Anxiety, Fear, Anger, Guilt, Grief, Spirituality
Situational Returning to Work, Loss of Friendships/Relationships, Financial Disparities, Inability to Achieve Pleasure with
Intimacy
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Late Effects of Treatment • Blood Clots • Cardiac Toxicities • Infertility • Lymphedema • Neuropathies • Pulmonary Fibrosis • Premature Menopause • Secondary Malignancies
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Survivorship Models
• Oncology Nurse Navigator facilitated
• Oncology Nurse Practitioner facilitated
• Non-clinic / ONN one-on-one visits
• Others
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Breast Cancer Survivorship Clinic Overview
• Group education session – Survivors gather in the Wilson Cancer Resource Center
– Introduction of survivorship resources
– Brief educational session • Social worker
• Dietitian
• Sharing and Caring representative
• Group tour of Integrative Medicine department
• Private consultations – Nurse Navigator
– Physical Therapist
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Survivorship Clinic Facilitators
Oncology Nurse Navigator
Assess, support, educate, review NCCN guidelines, complete and review the survivorship treatment summary and care plan,
provide referrals, and reinforce physician follow-up
Physical Therapist
PT/OT assessment, review FACT-G document, provide recommendations for therapy, perform lymphedema
measurements, return to work readiness, suitability for exercise screening, exercise and wellness program
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Survivorship Clinic Facilitators
Dietitian
Dietary education, nutritional counseling, resources, recipes
Sharing and Caring Representative
Breast cancer education, resources, and support
Integrative Medicine Representative
Therapeutic massage, guided imagery, other services as needed
Social Worker
Financial resources, support groups, counseling
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Following the Clinic…
• The patient receives assistance with referrals and appointments
• The patient is referred to their appropriate treatment team physician for follow-up needs
• The patient receives a thank you letter and a copy of their treatment summary care plan
• The patient’s oncology treatment team, PCP and OB-GYN receive a letter and copy of the treatment summary care plan
• The patient is encouraged to visit the ONN as frequent as needed for ongoing support
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Fabulous Feedback!
• “Looking around at all of you here – I know that I am truly cared about.”
• “I feel better today just knowing that there are so many resources available for me now that I am finished with treatment.”
• “Beaumont is top notch! What an incredible program.”
• “This was great. I wish that my mother would have had this same opportunity when she was sick.”
• “Thank you for spending this time with me. I really am going to be alright.”
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The Key Elements of the SCP
• Demographic Information • Diagnosis • Pathology / Grade / Stage • Genetics • Personal and Family History • Surgical Intervention • Chemotherapy / Endocrine Therapy • Radiation Therapy • Post Treatment Concerns • Recommendations for Follow Up • Preventative Measures • Cancer Surveillance • Legal “clause”
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Legal clause: “This is a Clinical Summary and Care Plan, to be used as a guide. It is NOT a legal medical record. Should you require your medical records, please contact your physicians office(s) and/or hospital medical records.”
The Key Elements of the SCP
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- American Society of Clinical Oncology - CANCER.NET
Survivorship Care Plan Templates
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Survivorship Care Plan Templates
- Memorial Sloan Kettering - MSKCC.ORG
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American Society of Clinical Oncology
Care plan templates, guidelines for breast and colorectal cancer follow-up
Journey Forward
Tool for developing care plans based on ASCO recommendations Disease-specific treatment follow-up guidelines
National Comprehensive Cancer Network
Registration is required, but access to these guidelines is free.
LiveStrong Careplan Powered by Penn Medicine’s OncoLink
Patients can develop their own care plan to be reviewed by their healthcare team
Memorial Sloan Kettering Cancer Center
Treatment summary and care plan
- MSKCC.ORG
Survivorship Care Plan Resources
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Delivery of the Survivorship Care Plan
Upon completion of treatment, the oncology nurse navigator: • completes the document • reviews the document with the patient, and makes any
necessary changes • distributes a copy of the completed document to all of the
patient’s oncology treatment providers, the PCP and the patient • documents in the patient’s chart that the patient has received
the document (*or declined)
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Documentation Samples I met with this patient one on one during her Breast Cancer Survivorship Clinic visit. I provided her with resources, encouragement and emotional support. We discussed the importance of achieving her personal survivorship goals, and resources that are available to her. I reviewed the NCCN guidelines for breast cancer survivorship. She verbalized understanding of the recommendations for continued visits with her treatment team (breast surgeon, medical oncologist and radiation oncologist) at intervals that provide optimal surveillance. I reviewed her treatment summary and care plan, and answered all questions to her satisfaction. She, along with her primary care provider and her treatment team will receive a copy of this document. She expressed the following post-treatment concerns: ***. I provided her with non pharmacological interventions, and referred her to her respective treatment team providers. We reviewed the importance of incorporating exercise and a healthy diet into her lifestyle. She verbalizes that she is able to complete her ADLs without difficulty, and participates in the following enjoyable activities ***. She was encouraged to meet with me at any time with further questions/concerns/support needs.
Documentation Samples
Upon completion of *** cancer treatment, a survivorship care plan has been completed for this patient with the most current information available to date. I contacted this patient in an effort to deliver *** cancer survivorship care plan. This patient has declined all opportunities (clinic/one on one ONN visit/telephone consultation) at this time. This document has been routed to the patient's PCP and oncology treating physicians. *** was encouraged to contact me at any time for a thorough review of this document, ongoing support and resources.
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How we achieved it…
In an effort to provide our oncology patients with the most optimal survivorship outcomes, it is imperative that we collaborate with one another to build strong
working relationships.
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Beaumont Health System, Oncology
Survivorship Program Model
Page 1 of 1
Beaumont Hospital, Troy
Management Engineering (REW)
Cancer
Survivorship
Program
The Patient is the
Center of All
We Do
Oncology
Rehabilitation
Nutrition
Program
Psychosocial
Support
Program
Nutrition and
Cooking
Classes
(TR & GP)
Seminars /
Lectures
One-on-one
Consults
with Dietitian
Support
Groups
Acute Care
Therapy
Services
Community
Education
Outpatient
Therapy
Online
Resources
and Classes
Field Trips
i.e. Market
(RO)
Peer-to-
Peer
Support
Referrals:
Psycho-
social prof-
essionals
Long Term
Follow up
Follow up w/
Referring
Physician &
PCP Testing and
Late Effects
Follow Up
Link with
ONNs,
Genetics and
Resource
Center(s)
Referrals
as needed (Naturopaths,
Weight Control
Center, etc.)
PT and/or OT
Consultation/
Screening
Fatigue
Assessment
& Referrals
Research
Breast
Cancer
Patient
Surveillance
Version: 32Updated: March 30, 2017
Reviewed: March 30, 2017
Clinical
Summary &
Survivorship
Care Plan
Patient referral to program
Cancer
Survivorship
Clinics
Pediatric
Long Term
Follow up
Clinic
Spiritual
Care
Including:
Primary Care Neurology
Parenthood & Fertility Psychology
Endocrinology Orthopaedics
Cardiology Pulmonary
Gynecology Audiology
Sexual Health Nephrology/Renal
Others as needed
Sharing
and
Caring
Silver
Linings
Program
Coordination
Palliative
Care
Multi-
Disciplinary
Clinics
Community
Groups &
ACS
Financial
Assistance
Referrals
Smoking
Cessation
Referrals
IT
Cancer
Resource
Centers
Social
Work
Pediatric
Rehab
Home Care
Services /
Hospice
Clinical
Trials
Genetics
Navigation
Process
Integrative
Medicine
Clinical Massage Therapy Scar Therapy
Acupuncture Lymphatic Massage
Naturopathy Indian Head Massage
Guided Imagery Hydrotherapy
Reflexology Cranial Sacral Therapy
Reiki Energy Balancing M.D. Consults
MISSION: The Cancer Survivorship Program partners with patients, families and their healthcare
providers to promote optimized health and healing of mind, body and spirit. We support and
empower patients through integrative practices and education before, during and beyond treatment.
Educational
Programs
Work-
abilityPalliative
Care
Healing
Arts
Oncology
Residency
Program
Speech
Pathology
Survivorship
Exercise &
Wellness
Program
Pediatric
Rehab
Rehab
Services
(PT/OT/
SP)
Orthotics
&
Equipment
Groups/
Recreatio
n
SW/
Behavioral
Therapy
School
Support
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Breast Cancer Survivorship Clinic: Troy
Flow for 3 Patients/Clinic
Contacts: Dr. Brown, Angela DeLaere, Tom Lanni,
Lisa Muma, Jeanne Parzuchowski, Dr. Stromberg,
Ryan Wood, Reyna Colombo, Laurel Martinez, Lisa
D’Andrea, Gail Elliott-Patricolo, Kathy Warzybok
Patient referred
by physician or
self
Description: The process of
seeing a patient in the survivorship
long term follow up clinic following
their oncology treatment
Page 1 of 1
Beaumont Hospital, Troy
Management Engineering
Version: 9 – APPROVEDLast Edited: March 10, 2016
Legend: EndStart
Process
Process
StepDecision
Clinic Participants
Suite 350 Clerical Staff
Process
Change To Be
Made
Process
Change
Completed
Patient registered
and scheduled for
clinic via WCRC
Nurse Navigator (NN)
prepares for clinic by pulling
together forms, creating
clinical summary & care
plan and preparing for day
of clinic. Discuss care plan
with referring physician as
appropriate
Patient arrives in WCRC;
Clerical staff greets
patient, collects forms,
checks if FACT-G
completed and provides
any paperwork
Physical Therapist provides screening for
needs and recommendations (including back
to work) (will follow up with physician for
therapy prescription if needed)
and reviews FACT-G (paper) and
documents score in clinic note.
PT/OT prescription form completed – brought
to PT/OT clerical to fax and track.
Patient follows up with
physicians as appropriate
WCRC Nurse Navigator or Clerical
connects with patient by mailing or
emailing pre-clinic documents to
patient for completion prior to clinic
(to bring with them) and calls for
follow up as needed
NN and all clinicians
document clinic in Troy
Survivorship MDC Note
(ONC TR BREAST
SUR CLIN) in Epic
Clerical/NN
communicates patient
list and information to
clinic participants
Monday before
Thursday clinic
Patient schedules and
completes follow up testing
and any other support
services desired (nutrition,
counseling, resource center
information, integrative
medicine, rehab)
NN to forward clinical
summary and care
plan to referring
physician(s) as
needed
Nurse Navigator
Nurse Navigator provides:
(1) individualized clinical summary &
survivorship care plan for late effects from
medications, radiation and/or surgery
(2) education and information packet
(3) communication regarding follow up testing
and services as needed following NCCN
guidelines for surveillance – communicate
back to appropriate physician for follow up
Pre-clinic documents:
- Welcome letter
- Quality of life assessment:
FACT-G
Clinic preparation
documents:
- Clinical summary
and Care plan
Clinic documents:
- Education/Information - WCRC referral form
- PRA/SRA - Weight loss info
- Fertility info - Genetics info
- Consent form - Business cards
- Integrative Medicine Guided Imagery CD
- ACS referral form (if needed)
- NCCN guidelines (Breast Cancer Follow up Plan)
- Brochures: ACS, Integrative Medicine, Silver
Linings, Naturopathic Medicine, Exercise & Wellness,
Life After Treatment, Choices for Good Health,
Sharing & Caring, Spiritual Care
Clerical staff checks
out patient and
provides satisfaction
survey
Forms
Rehabilitation (PT) and
Nurse Navigator huddle
to discuss cases and
approach (Suite 350
small conference room)
Clerical/NN calls
patients to remind
about clinic and
paperwork
Dietitian provides
group education re:
nutrition
Integrative Medicine
staff provides
education session
Social Worker
provides group
education re:
psychosocial
support
Group Education
Session (WCRC)
[11:30am-12:30pm]
Clerical staff checks
patient in and escorts to
exam rooms; Asks
patient to complete
FACT-G if not done
already Integrative Medicine
staff provides tour of
department then
escorts patients to
Suite 350
Patients meet with
Nurse Navigator and
Physical Therapist
individually
(3 SURVIVORS)
Sharing & Caring
staff provides
education session Nurse Navigator and
Physical Therapist
regroup during and/or
at end of clinic
Clerical staff
scans in all forms
from clinic
(including FACT-
G)
WCRC Clerical provides
FACT-G forms back to
PT/OT during/after clinic
Individual Sessions (Suite 350)
[12:30pm-1:30pm]
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Barriers to Implementation
• Lack of resources
• Lack of funding
• Time constraints
• Lack of supportive structure
• Lack of standard processes
• Disengaged leaders or staff
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Empowerment
I would like to encourage all of you to empower yourselves! Identify your personal goals and address the barriers that are disrupting the
quality of your life as a survivor!
Through our survivorship programs, classes, support services and physician visits, help is available!
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A well developed survivorship program will meet the standards of your institution, and help your patients to
achieve the most optimal quality of life.
Questions
If you or anyone that you know could benefit
from oncology resources and support…
Please visit me in the
Wilson Cancer Resource Center.
248-964-3432
Thank you!
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• American College of Surgeons. Accessed 17 April 2017. • Cancer.Net. Accessed 17 April 2017 • "Comparison of CoC and NAPBC Survivorship Standards." Oncology Nursing Society.
https://www.ons.org/sites/default/files/Comparison_CoC_NAPBC_SurvivorshipStandards.pdf. Accessed 22 April 2017.
• "NAPBC Standards Manual 2014 Edition." American College of Surgeons. https://www.facs.org/~/media/files/quality%20programs/napbc/2014%20napbc%20standards%20manual.ashx. Accessed 8 May 2017.
• National Comprehensive Cancer Network. Accessed 3 February 2017.
• "Online Resources for Survivorship Planning." Memorial Sloan Kettering Cancer Center. https://www.mskcc.org/referring-
physicians/survivorship/survivorship-care-plan. Accessed 1 May 2017.
• "Survival Statistics." National Cancer Institute. https://seer.cancer.gov/statfacts/html/all.html. Accessed 23 April 2017.
• Wilson, Ian (Senior Corporate Counsel), Legal Affairs. Beaumont, Troy.
• Wood, Ryan (Manager) Management Engineering and Kaizen Improvement. Beaumont, Troy.
References
Recommended