Managing the Breast Cancer Survivor in Primary Care

Early detection and improved treatments for breast cancer are increasing survival rates, thereby growing the number of survivors to almost 4 million in the United States. Continuing care after treatment is frequently provided in primary care. Evidence-based care includes a history review, physical examination, and imaging for recurrence and new cancers, along with health maintenance and health promotion. Additionally, survivors often experience long-term side effects from their disease and/or treatment, affecting health and quality of life. This article provides a synopsis of breast cancer treatment-related side effects and current evidence-based guidelines to assist the primary care provider caring for survivors.     

Second Primary Malignancies in Cancer Survivors

Advances in early detection and treatment of cancer have resulted in a growing population of cancer survivors across the United States. Cancer survivors may be at increased risk for the development of a second primary malignancy as a result of environmental factors, genetic predisposition, or as a late effect of the cancer treatment they received. This review examines the risk for second primary malignancy and necessary screening in the six cancers with the highest 5-year survival rates, including: breast cancer, Hodgkin's lymphoma, melanoma, prostate, testicular, and thyroid cancer.     

Using Trauma-Informed Care to Address Sexual Assault and Intimate Partner Violence in Primary Care

Interpersonal trauma has long-lasting effects on mental and physical health and is associated with acute and chronic negative health outcomes. Primary care providers can improve health care outcomes by using trauma-informed care to recognize, acknowledge, and respond appropriately to trauma survivors. Routine trauma screening in the primary care setting should be done in a safe environment and with a team approach. This article will offer guidance on screening for and responding to sexual assault and intimate partner violence using trauma-informed principles with the goal of promoting health and healing for survivors.     

老年人多发性原发性癌：文献复习及8例报告

本文报告老年人多发性原发性癌(以下简称MPC)8例,复习了国内有关的文献报道。对文献中211例及本文的8例进行了综合分析,着重讨论了老年人MPC的发病情况、好发部位、诊断、治疗及预后。     

Hormonal breast cancer agents: implications for the primary care provider

PURPOSE: Over 2 million breast cancer survivors are in the United States, making women with breast cancer the largest group of cancer survivors. The purpose of this article is to review the current knowledge regarding survivorship issues in women with early-stage, estrogen receptor-positive breast cancer, focusing on advances in hormonal therapies for reducing risk of recurrence. DATA SOURCES: Published research studies, clinical treatment guidelines, and ongoing clinical trials. CONCLUSIONS: Innovations in antiestrogenic and estrogen modulator therapies are an important aspect of ongoing care after primary breast cancer treatment. Primary care providers may play an important role in monitoring potential complications of antiestrogenic treatment. IMPLICATIONS FOR PRACTICE: This article reviews the current state of the science in hormonal breast cancer agents for breast cancer survivors. With the high incidence and prevalence of breast cancer, primary care providers need to be aware of the potential short- and long-term health risks and benefits of hormonal therapies for breast cancer survivors.     

Early Palliative Care Initiation: Role of the Primary Care Clinician

Palliative care provided to patients with chronic life-limiting illnesses shows improvement in symptom management, quality of life, and caregiver support while reducing cost of care. Early initiation of palliative care faces a multitude of barriers in the primary care setting, including provider confidence, coordination and implementation, education, and family and patient misconceptions. A team-based approach along with additional education, clear referral triggers, and resources for advanced-care planning discussions allows providers to overcome many of these barriers. With the population’s advancing age, it is essential that primary care providers are properly prepared for early initiation of palliative care.     

Posttreatment breast cancer surveillance and follow-up care experiences of breast cancer survivors of African descent: an exploratory qualitative study

Breast cancer survivors are at considerable risk for breast cancer recurrence and at higher risk of developing a new breast cancer compared with women never diagnosed. It is recommended that survivors undergo careful breast cancer surveillance as cancers detected early are more treatable. However, data indicate that surveillance among African American survivors, particularly mammography, is lower than that of white survivors. There is little published work focusing on general experiences of posttreatment breast cancer surveillance among survivors of African descent. In the current qualitative pilot study, key informant interviews were conducted in order to explore the following: (1) the extent of posttreatment surveillance information provided to or obtained by survivors of African descent; (2) the actual follow-up care received by survivors in the past year; and (3) factors that are either motivators of or barriers to care. Participants were 10 African American and African Caribbean breast cancer survivors. Survivors reported a number of factors that motivated them in obtaining follow-up care: a desire to maintain good health, concern about recurrence, support from healthcare providers, familial relationships, relationships with other survivors, and religious/spiritual faith. Survivors also reported barriers to care: fear of recurrence, low support from family and friends, lack of information about posttreatment follow-up care, and medical care costs. These results represent formative work that may inform similar studies examining factors in breast cancer surveillance and follow-up care in larger samples of survivors of African descent.     

Recognizing health risks in childhood cancer survivors

PURPOSE: To provide information about the special health needs of childhood cancer survivors through a discussion of Wilms' tumor, a common childhood renal tumor, and case studies of two survivors of Wilms' tumor, who encountered significant health problems as adults. This information may be generalized to many cancer survivors. DATA SOURCES: Actual case studies as well as extensive review of the current literature on childhood cancer survivorship. CONCLUSIONS: Adult healthcare practitioners may help to decrease morbidity of childhood cancer survivors in adulthood when they are knowledgeable about the risks of this population. Resources are readily available, both in the medical literature and on the Internet. IMPLICATIONS FOR PRACTICE: With well-established success in the treatment of childhood cancer, there are many young and middle-aged adult survivors of the disease. However, as many as two-thirds of survivors may have chronic long-term effects of treatment. Most survivors eventually discontinue follow-up with their pediatric oncologists and receive primary health care from adult providers, many of whom are unaware of survivors' health risks. Awareness of primary care providers regarding the special health needs of childhood cancer survivors is critical to decrease morbidity and improve quality of life. The ever-increasing number of childhood cancer survivors is creating a public health issue as they transition into adulthood.     

Underutilization of Primary Care Providers in Treating Opiate Addiction

There are inadequate numbers of care providers or treatment programs to treat opioid abuse. Although many primary care nurse practitioners care for patients who are dependent on or abuse opioids, they are not allowed to prescribe the schedule 3 medications to treat them. This option is available to primary care physicians with additional training. This article discusses the effectiveness of opioid substitution therapy in a primary care setting, the patient populations, patient satisfaction, and barriers preventing primary care providers from providing treatment to opioid patients. Nurse practitioners can help overcome some of these barriers and improve access to this underserved population.     

Primary care health issues among men who have sex with men

PURPOSE: The purpose of the article is to examine "appropriate" health care for men who have sex with men (MSM), which is not to suggest "special" health care. As a group, MSM are at increased risk for sexually transmitted infections, anal cancer, and mental health disorders. Focus areas in this article will address health issues that the primary care nurse practitioner (NP) may encounter in clinical practice: anal carcinoma, sexually transmitted diseases (STDs), high-risk sexual practices, depression, and substance abuse were topics chosen for inclusion in this article. These topics were among those highlighted in the Healthy People 2010 Companion Document for LGBT Health, which served to examine the healthcare disparities and lack of access to needed services related to sexual orientation. DATA SOURCE: Extensive literature review of research articles, journals, clinical practice guidelines, books, and public health department Internet Web sites. CONCLUSIONS: There are unique health disparities that exist for MSM related to social, emotional, and mental health factors, in addition to physical issues such as STDs. There is an increasing need for primary care providers to be aware of these disparities, as well as the factors that influence these disparities, in order to provide multidimensional care and health counseling that is unique to NP practice. IMPLICATIONS FOR PRACTICE: Both the primary care NP and the patient should be aware of the unique healthcare issues among MSM that should be incorporated into the patient's routine health maintenance program. As primary care providers, it is within the standards of practice for NPs to provide culturally competent care, along with health promotion and disease prevention for MSM.     

Adolescent cancer survivors' experiences of supportive care needs: A qualitative content analysis

Supportive care is an important strategy that can help cancer survivors manage changes and problems during their follow‐up care. Identifying patients' care needs is one of the primary steps of the nursing process to plan effective nursing interventions. The aim of this study was to explore adolescent cancer survivors' supportive care needs. Purposeful sampling was adopted to select 49 participants from hospitals to participate in face‐to‐face, semistructured interviews. The qualitative content analysis method was conducted for data analysis. Ten subcategories and four main categories – empathetic care, information about survival period, instrumental support, and cooperation in care – were extracted from the data. These four categories formed a major theme, “supportive care”, as the primary healthcare need. This study highlights that supportive care should be developed collaboratively by family and healthcare providers to meet the needs of adolescent cancer survivors. Survivors' strengths and limitations should be identified, and then supportive care can be provided, such as giving appropriate information, enabling survivors to access supportive networks, and improving survivors’ confidence and autonomy with their self‐management.     

Transitional care for young adult survivors of childhood cancer

OBJECTIVES: To review the obstacles and barriers to providing optimal care to young adult cancer survivors and discuss the transition from pediatric to adult health care system. DATA SOURCES: Published articles and textbook chapters. CONCLUSIONS: More than 70% of children diagnosed with cancer between birth and 14 years of age will be cured of their primary disease. Because of multiple physical and psychosocial risk factors imposed by their therapy and previous disease, childhood cancer survivors require life-long care. IMPLICATIONS FOR NURSING PRACTICE: Health care providers must be aware of the unique needs of these individuals for life-long follow-up and assist in facilitating this transition process.     

Cancer survivors.

Cancer survivorship is becoming a newly defined entity. Cancer therapies can produce many late physical effects by adversely affecting every organ system. Psychosocial issues that have been studied include: psychiatric, self-concept, school performance, and behavioral adjustment, employment and insurance discrimination, and marital status. Quality-of-life assessments in adult survivors is comparable to controls but is diminished for children with disease or treatments that affect the CNS. The greatest fear for cancer survivors is the 10 to 20 times greater risk of SMN as compared with persons with no history of cancer. Infertility and sexual dysfunction are real concerns for survivors that usually go unexpressed. Some cancers have a familial predisposition; however, treatments do not appear to increase the risk of birth defects or childhood cancers in the offspring. Lower socioeconomic status adversely affects cancer survival because of lost opportunities for cancer screening, other diseases, and untreated cancer. The primary care physician can competently care for cancer survivors and should emphasize health promotion and risk prevention behaviors, topics especially applicable for this patient population.     

The Role of Primary Care Providers for Uveitis

Uveitis, a treatable sight-threatening condition, may often be misdiagnosed and treated as pink eye, a common ophthalmic condition encountered in the primary care setting. Although more than 50% of cases of uveitis are idiopathic, a variety of underlying medical conditions, such as genetic, traumatic, systemic immune-mediated conditions, or infectious mechanisms can trigger uveitis. An accurate and prompt diagnosis is critical for initiating vision-saving treatment. Because a high percentage of uveitis was reported in the primary care setting, the role of primary care providers should focus on identifying the condition, initiating first-line therapy, and promptly referring to an ophthalmologist.     

Survivorship care: models and programs

OBJECTIVES: To review models of care for adult cancer survivors and the challenges in program development. DATA SOURCES: Review of the literature. CONCLUSION: As the number of cancer survivors continues to grow, so does the need to develop unique evidence-based programs and services for this population. Survivorship should become a distinct phase of care and include: surveillance for recurrence, evaluation of and treatment for medical and psychosocial consequences of treatment, recommendations for screening for new primary cancers, health promotion recommendations, and provision of a written care plan to the patient and other health professionals. IMPLICATIONS FOR NURSING PRACTICE: Many challenges remain to evaluating care models and actualizing clinical services nationally, but oncology nurses are uniquely positioned to take the lead in the care of cancer survivors of all ages.     

Primary Care and Mental Health: Overview of Integrated Care Models

Primary care nurse practitioners are in a visible and critical position to screen, diagnose, and treat common mental health conditions. Integrated care models occur on a continuum from simple communication between providers to fully integrated interprofessional teams. Regardless of integration model available to the primary care nurse practitioner, mental health disorders should be appropriately identified and treated using evidence-based approaches. This clinical feature introduces the primary care nurse practitioner to various integrated care models and provides a brief overview regarding screening, diagnostic, and intervention recommendations, as well as potential future directions for education, training, and research.     

Recent Developments in Oncology Immunotherapy,Adverse Effects Part 2

Immunotherapy has emerged as a promising treatment for cancer survivors in the past few years. This new treatment is associated with unique immune-related toxicities that can range from mild to life-threatening. Early recognition, referral, and monitoring by primary care nurse practitioners may improve the quality of life and survival of cancer survivors.     

HIV in Primary Care: Case Study of Common Chronic Comorbidities

This article provides information to increase the knowledge, skills, and confidence of primary care nurse practitioners managing chronic conditions for persons living with HIV (PLWH). A case study is presented, followed by discussion of common chronic disease processes related to the patient: chronic kidney disease, diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, and mental health. PLWH are at increased risk for non-HIV–related comorbidities. Nurse practitioners practicing in primary care settings are ideal providers to manage chronic conditions in PLWH.     

Hepatitis C Management Simplification From Test to Cure: A Framework for Primary Care Providers

This article proposes a strategy for primary care providers to begin treating patients with hepatitis C virus (HCV). We are motivated by the need to expand HCV treatment and by developments that have simplified treatment for most patients. This article presents 5 steps to achieving quality HCV treatment in the primary care setting: (1) accurate diagnosis via reflex testing; (2) risk stratification and identifying comorbidities via pretreatment evaluation; (3) simple, once-daily, pan-genotypic HCV treatment regimens; (4) minimized on-treatment monitoring: and (5) posttreatment monitoring and high-quality care for comorbidities such as cirrhosis and injection drug use. We provide indications for referral to specialists: notably children, patients with genotype 3 and cirrhosis, advanced liver or kidney disease, previous treatment failures, drug interactions with recommended regimens, and hepatitis B co-infection. Finally, potential barriers for providers are discussed, as well as further research findings and policy interventions that can promote HCV treatment in the primary care setting. We believe that a substantial portion of patients with HCV can be treated safely and effectively by nonspecialists and that the engagement of primary care providers is critical to efforts to end the HCV epidemic.