FOLLOW-UP OF BREAST CANCER: TIME FOR A NEW APPROACH?

After treatment for breast cancer women are monitored for recurrent disease by means of routine hospital-based follow-up appointments. The aim of this study is to determine the efficiency of this system, by establishing how recurrence presents to our hospital. The study comes at a time of increasing pressure on breast clinics from new patient referrals and the need, since April 1999, to see all cases classified as urgent within two weeks of referral. A consecutive series of 643 patients who presented with operable breast cancer between 1992 and 1998 were reviewed. Details about the 108 patients who had locoregional or metastatic relapse were obtained from our breast cancer database and their clinical records. Full data were available on 104 patients: 77 (74%) were seen at expedited (interval) appointments and a further 18 (17.3%) drew attention to symptoms at a routine visit. Two cases of locoregional recurrence were revealed by surveillance imaging. Unsuspected disease, locoregional in all cases, was detected on examination in 7 (6.7%) patients. The median time to presentation of recurrence was 19 months for metastatic and 18 months for locoregional disease. Breast cancer recurrence usually presents to an interval clinic. Most cases that are confirmed following a routine review are already symptomatic. Long-term routine hospital follow-up after treatment for breast cancer appears inefficient and unnecessary. Following liaison with local general practitioners we propose to discharge patients from routine review after two years. Thereafter they will have scheduled appointments with their GPs with immediate access to specialist review in the breast care unit if required.     

Feasibility of using a computer-assisted intervention to enhance the way women with breast cancer communicate with their physicians

This study was conducted to evaluate the feasibility of using a computer intervention to enhance communication between healthcare professionals and women with breast cancer. Additional aims were to measure the extent to which women achieved their preferred decisional roles and satisfaction with the clinical medical appointment. This two-arm randomized clinical trial design included a convenience sample of 749 women with breast cancer attending 3 urban Canadian outpatient oncology clinics. Most women were older than 50 years and had a high school diploma or greater (57%). Women in the control group completed measures of decision preference before their clinic appointments. Women in the intervention group were encouraged to use the information and decision preference profiles generated by the computer program at their clinic appointments. Levels of involvement in decision making and satisfaction were measured after the clinic appointments. Results showed that although the majority of women in both groups did assume their preferred roles in decision making, a significantly higher proportion of women in the intervention group reported playing a more passive role than originally planned. Both groups reported high satisfaction levels. Future research is required to study how this computer intervention could be used by clinicians to provide information and decision support to these women.     

Narrative research: a viable methodology for clinical nursing

TOPIC: Narrative research provides a reasonable methodology for gathering rich, multidimensional data in the clinical setting. PURPOSE: To familiarize nurses with the concept of narrative research, review pertinent narrative research literature, and identify some ways this methodology can be integrated into clinical nursing. SOURCES: A review of published literature from psychology, sociology, anthropology, and nursing, with citations from women with breast cancer. CONCLUSIONS: Narrative research can make a valid contribution to nursing science in language familiar to nurses and other healthcare professionals.     

Identifying the educational needs and concerns of newly diagnosed patients with breast cancer after surgery

Many factors may interfere with the ability of women newly diagnosed with breast cancer to cope with treatment. Nurses should be aware of patients' needs during this critical time. The purpose of this study was to identify the educational needs and concerns of newly diagnosed patients with breast cancer after surgery. A phone interview with patients was conducted approximately one week after breast cancer surgery. A convenience sample of 200 patients was recruited from four hospitals within a large midwestern healthcare system. The subjects were interviewed by breast health specialists and navigators involved in their education and support and were asked to participate in a short interview during a surgical follow-up phone call. Study results indicate that fear of recurrence and anxiety regarding postoperative treatments accounted for more than 65% of the responses to the question "What concerns you most about your new diagnosis?" Emotional, social, and physical limitations were identified as most important in dealing with a breast cancer diagnosis. As breast health specialists and navigators, nurses can improve the quality of care for women with breast cancer and their families by providing additional support services and post-treatment information during the initial education and follow-up call.     

Innovation in survivor care: group visits

The Centering Cancer Survivorship (CCS) follow-up care program is an innovation in healthcare delivery that meets the needs of cancer survivors and cancer centers. Piloted in a breast cancer clinic, the program provides an avenue for provision of psychological support and health-promotion activities, as well as surveillance for recurrence or late effects. The program empowers each survivor by enlisting her to produce a written breast cancer survivorship care plan for personal use and to share with her primary care provider. Concurrently, this innovation should enhance the viability of the primary cancer center by freeing appointment slots for oncologists who provide expensive therapies to newly diagnosed patients. The CCS program's central feature is the implementation of a multidisciplinary clinic designated specifically for breast cancer survivors in which follow-up care is provided through a group visit medical model. This model of care provides opportunities for health assessment, patient empowerment, and patient education within a framework of social support from peers with similar issues. The group visit model may be well suited to addressing the unique chronic healthcare needs of breast cancer survivors. Further evaluation is needed to verify cost-benefit analysis.     

Informational and emotional needs of long-term survivors of breast cancer

AIMS: This paper presents a review of the informational and emotional needs of long-term breast cancer survivors, with particular attention to the different needs of women according to their age and to critiquing healthcare provision to these women. BACKGROUND: Women with a history of breast cancer are the largest group of cancer survivors. While they may be disease-free, their cancer diagnosis has ongoing physical and psychosocial implications for their lives and well-being. METHODS: A literature search for the period 1985 to March 2004 was undertaken using the CINAHL, MEDLINE, CANCERLIT, PubMed and CUIDEN databases and the keywords long-term, breast cancer survivors, needs and social support. Hand-searching was also done, and reference lists of papers were examined for relevant studies. RESULTS: Survivors of breast cancer continue to experience informational and emotional needs during their long-term survivorship, and variation in the amount and type of support required is age-related. However, women's needs are often unmet by oncology teams and they have to find other sources of support, such as self-help groups. Thus, ongoing care is required after completion of medical treatment, and nurses have a significant contribution to make here. CONCLUSIONS: Nursing research on long-term breast cancer survivorship is limited. Future studies need to investigate the unmet needs of long-term survivors of breast cancer and, specifically, explore the kind of support women would like to receive from oncology teams, and particularly from breast cancer nurses.     

Care of women with breast cancer on a surgical ward: nurses' opinions of the need for support for women,relatives and themselves

BACKGROUND: In Sweden women with newly diagnosed breast cancer are admitted to surgical wards in order to undergo surgery and receive postoperative care. On these wards, nursing staff take care of women both with newly diagnosed breast cancer and those with cancer in advanced stages. Nurses have to meet the varying needs of patients and their relatives. AIM: To describe nurses' opinions of the need for care and support for women and their relatives in connection with surgery for breast cancer, as well as their own need for support on a surgical ward. METHODS: Thirty-one nurses from a surgical ward participated in semi-structured interviews. The interviews were tape-recorded and transcribed verbatim. Thereafter a step-by-step, qualitative content analysis was carried out. RESULTS: The nurses described the need to talk and receive information as being the most important among women and their relatives, as well as among themselves. Only a few nurses mentioned the need for physical care among the women. Contact with relatives was described as being almost nonexistent. There was a discrepancy between what nurses described as important needs and how these needs were provided for. CONCLUSION: This study shows that what the nurses described as being the most important needs, and the way how these needs were provided for, was more often seen from a theoretical point of view with few examples of self-experienced situations in the daily care. Needs among women and their relatives seemed to be not fully known to nurses and therefore, possibly, were not met. Nurses themselves had a pronounced need for support, which was sometimes unsatisfactorily met.     

Are we ready for personalized cancer risk management? The view from breast‐care providers

Personalized medicine, the tailoring of prevention and treatment, is the future of routine clinical practice. This approach has started to appear in genetic testing for predisposition to hereditary breast and ovarian cancer (HBOC). We explored how breast‐care providers perceived HBOC risk management, using grounded theory. This study found that the frontline healthcare providers perceived HBOC risk management as still being neglected in breast cancer care. Emerging challenges included treatment priority, hesitancy to deal with sensitive issues, easily missed risks, genetic data not being shared among multidisciplinary professionals, and patients being lost to follow‐up. Oncology nurses are ideally placed to facilitate communication and utilization of genetic information among multidisciplinary professionals. Specialized outpatient clinics need to be established to follow up individuals at high risk. There is a need to create a system to meet the future demands of personalized medicine in nursing practice.     

乳腺癌术后康复期患者对医护联合康复门诊需求的研究

目的深入了解乳腺癌术后康复期患者对医护联合康复门诊的需求状况,完善医护联合康复门诊的服务内容。 方法采用质性研究的现象学方法,选取13例乳腺癌术后患者进行半结构式深入访谈,并运用Colaizzi现象学7步分析法对资料进行分析。 结果提炼出3个主题和5个亚主题：延续性的患肢康复需求（患肢功能障碍的康复需求、淋巴水肿管理的需求）;多样化的信息需求（对健康生活方式的关注、对性健康及生育相关知识的需求、对辅助治疗相关知识的需求）;专业和持续的情感支持需求。 结论乳腺癌术后康复期患者对医护联合康复门诊存在较多方面的需求,应根据患者需求设置并细化门诊服务内容,为患者提供延续护理服务,改善乳腺癌术后患者的长期生活质量。     

Establishing comprehensive specialty follow-up clinics for long-term survivors of cancer Providing systematic physiological and psychosocial support

Late effects of multi-modality treatments may result in organ compromise or new primary cancers for a growing population of long-term survivors of cancer. It is estimated that there will be 180000–220000 childhood cancer survivors living in the United States in the year 2000. This number of survivors warrants program planning specific to their needs. Add to this the number of patients diagnosed with cancer as adults who have reached 5-year survival status, and the total population of long-term survivors of cancer justifies special programs to deal with the issues of survivorship. This paper addresses several questions: (a) What are the needs of cancer survivors? (b) Can these needs be met through specialty survivor clinics? (c) What are the benefits of survivor follow-up clinics? (d) Should survivor clinics for children and adults become standard care? The clinic structure and objectives, and daily procedures for a follow-up clinic in New York State are presented as one model of care. Benefits for a free-standing clinic also are discussed as well as financial considerations and directions for research.     

Healthcare and support needs of women with suspected breast cancer

AIM: This paper is a report of a study to investigate changes in the healthcare and support needs during the diagnostic period, and factors that affect these needs in women with suspected breast cancer. BACKGROUND: Although the needs of women with breast cancer are well recognized, few studies have examined the needs of women with suspected breast cancer during the diagnostic period. METHOD: This longitudinal study used an investigator-developed, self-administered questionnaire to collect data from 127 women in Taiwan on three occasions: notification of need for breast biopsy, before biopsy and after diagnosis. The data were collected from November 2004 to April 2005. FINDINGS: Participants had high need levels before and after diagnosis, with their top needs in the domains of healthcare services for diagnosis, follow-up and consultation, and information about the disease. They needed disease- and treatment-related information more than emotional support. Need levels were higher (P < 0.01) before diagnosis than after, highest before biopsy, and lowest after diagnosis. Furthermore, needs were higher (P < 0.01) before than after diagnosis for diagnostic services, disease information, and involvement of family and friends. Higher needs were found in married women with more education and no history of benign tumours. Need level did not differ statistically significantly by age, religious status, degree of social support, family history and breast symptoms. CONCLUSION: Need levels of women with suspected breast cancer vary during the diagnostic period, are highest before breast biopsy, and related to personal characteristics and cultural context. Therefore, during this period, nursing staff should provide patients and families with culturally sensitive, individualized, supportive care.     

Cancer screening in public health clinics: the importance of clinic utilization.

OBJECTIVES: To determine how screening for breast and cervical cancer in public health clinics was associated with overall clinic utilization. METHODS: Evidence of screening and clinic visits between June 1989 and May 1992 was obtained by medical record audit for a random sample of 1825 women aged 40 to 75 attending eight public health clinics in the San Francisco Bay Area. RESULTS: With an average number of visits (4 per year), women who did not receive a physical examination were much less likely than those who did to obtain a clinical breast examination (OR = 0.03), mammography referral (OR = 0.1), or a mammogram (OR = 0.4) within 2 years, or a Papanicolaou smear (OR = 0.1) within 3 years. Without a physical examination, the odds of screening or referral increased with the first visit (OR = 1.2 for referral, breast examination, and Pap; 1.3 for mammography), but with a decreasing marginal effect of each additional visit (ratio of successive one-visit OR values = 0.992 for referral and breast examination; 0.995 for Pap; 0.98 for mammography). With a physical exam, visits were associated with mammography only (first visit OR = 1.2; OR ratio = 0.992). CONCLUSIONS: In public health clinics, screening is associated either with receipt of routine care or repeated visits for treatment. Women who fall through the cracks are those who come to the clinic with a medical problem but otherwise receive few services. Interventions in public health clinics need to facilitate the provider's ability to use medically related visits as opportunities to increase adherence to screening recommendations.     

Coping with breast cancer in newly diagnosed Iranian women

AIM: This paper reports a study exploring how Iranian women coped with newly diagnosed breast cancer and provides a foundation for cultural-based care. BACKGROUND: Although research has indicated that coping strategies are associated with adaptation to breast cancer, and despite the number of women with newly diagnosed breast cancer increasing each year, there is no information on how Iranian women cope with breast cancer when compared with women of other cultures. METHOD: In this qualitative study, 19 women with newly diagnosed breast cancer were interviewed during the period May-September 2004 about coping with their disease. Interviews were analysed using a content analysis method. FINDINGS: The main themes emerging from this qualitative study included coping using a religious approach (acceptance of disease as God's will; spiritual fighting), thinking about the disease (positive thinking: positive suggestion, hope, intentional forgetfulness; negative thinking: hopelessness, fear, impaired body image), accepting the fact of the disease (active acceptance; passive acceptance), social and cultural factors and finally finding support from significant others. CONCLUSION: Understanding how Iranian women cope with diagnosis of breast cancer is important to nurses involved in the process of healing. The majority of strategies used by Iranian women were positive, and religious faith played a major role in this. The findings of the study can be used to design a nursing approach to improve successful coping in Iranian women suffering from breast cancer, and can provide nurses and other healthcare professionals with deeper understanding of these women as they face this diagnosis.     

Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire

BACKGROUND: A new model of comprehensive care nurse-led clinics has enabled experienced genitourinary medicine nurses to co-ordinate the first-line, comprehensive care of female patients presenting with sexually transmitted infections and other sexual health conditions and issues. AIM: This paper describes the development of a patient satisfaction questionnaire to compare the satisfaction of women attending nurse-led or doctor-led clinics at a central London genitourinary medicine clinic. METHODS: A previously validated questionnaire was adapted using the findings of qualitative interviews exploring patient expectations of the service. The draft questionnaire was tested for internal consistency, sub-scale homogeneity, construct validity and stability. The final version consisted of a 34 item, five-point Likert scale, which was found to be both reliable (Cronbach's alpha 0.91) and stable (test-retest 0.95). There was some evidence of construct validity. The questionnaire was then distributed to a convenience sample of 132 women attending a nurse-led clinic and 150 seen at a doctor-led clinic. RESULTS: There was a 90% response rate. The median total satisfaction scores, out of a total of five, were 4.47 and 4.30 for the nurse-led and doctor-led groups, respectively (P = 0.05). Significantly higher scores on the sub-scales measuring quality and competence of technical care (P < 0.001), provision of information (P = 0.01) and overall satisfaction (P = 0.01) were seen for the nurse-led group. No significant differences were found in the sub-scales measuring service attributes and specific attributes of interpersonal relationships. CONCLUSION: The rigorous development, piloting and testing phases of this satisfaction questionnaire led to reliable and valid results. This study demonstrated that nurse-led clinics within this service are an acceptable alternative to the existing doctor-led clinics.     

Role of the accident and emergency review clinic in UK service provision

Objectives: Selected patients attending accident and emergency (A&E) are seen again in the A&E review clinic for planned follow up. Despite the large number of patients being seen in these clinics, this area of A&E service provision has rarely been studied. The aim of this study was to determine the current provision of review clinic services in UK A&E departments, their organisation, and their perceived role in current practice.

Methods: Postal survey of all major UK adult and paediatric A&E units.

Results: Almost all major UK A&E departments have a review clinic service and almost three quarters see less than 10% as reviews in line with current guidance. Many departments feel their clinics are well run and fulfil their objectives. Others are under pressure from external sources to see more patients. Over a third of departments have no written policies or protocols guiding referral to these clinics.

Conclusion: Review clinics are an important part of the A&E service in the UK and minimum standards need to be set in the provision of these services. Further audit and research needs to be carried out on the review clinic service to guide its future development.

     

The role of the breast care nurse during treatment for early breast cancer: the patient's perspective

INTRODUCTION: Women who are diagnosed with breast cancer require the support of a range of people during their treatment. Although the role of the breast care nurse in providing support has recently been investigated in several Australian studies the patients' perspective on the role of the breast care nurse in Australian hospitals has not previously been described in detail. The aim of this paper is to explore patients' perspectives on the role of the breast care nurse. METHODS: In-depth interviews were conducted with 18 women who had completed treatment for early breast cancer. The women were asked to describe their experiences from the time of diagnosis through to treatment completion. Thematic analysis was used to analyse the data. FINDINGS: Breast cancer patients repeatedly emphasised the importance of the role of their breast care nurses throughout their experience of breast cancer. The support that breast care nurses provided incorporated the following components: communication, rapport and an awareness of the women's needs, availability, reassurance and practical information. CONCLUSION: This study provides an understanding of women's perspectives on the role of breast care nurses and confirms that breast care nurses play an important support role during the experience of early breast cancer. Oncology clinics should focus on ensuring that all women who are diagnosed with breast cancer have adequate access to the support that breast care nurses are able to provide.     

Understanding Factors Related to Women's Adherence to Colposcopy

Early detection can prevent death from cervical cancer, but success is dependent on women with abnormal cytology attending follow-up procedures, including colposcopy. Factors that influence adherence to colposcopy include age, race, education, socioeconomic status, smoking, chemical dependence, intimate partner violence and anxiety. Comprehension of abnormal Pap smear results and knowledge of current treatment guidelines and follow-up is important in the prevention of cervical cancer. Understanding factors that could inhibit adherence to colposcopy will allow for tailored communication and individualized treatment to prevent colposcopy default. Implementation of colposcopy clinics with designated nurses to track and monitor adherence could help.     

Routine follow-up after treatment for ovarian cancer in the United Kingdom (UK): Patient and health professional views

PurposeThe aim of this study was to explore patients and health professional's perceptions of follow-up service provision following treatment for ovarian cancer. In the United Kingdom, where this study took place, ovarian cancer is the most common gynaecological cancer in women. The causes are unknown, symptoms are often vague and most cases are diagnosed at an advanced stage. There is a high likelihood of disease progression and little evidence on the benefits of routine follow-up after treatment for gynaecological cancer.MethodTwo focus groups were conducted with patients (n = 6) and health professionals (n = 7) at a hospital in North-West England.ResultsFrom the patient group, three main themes emerged: reassurance, the need for support and information, and alternative approaches to follow-up care. Three main themes emerged from the health professional group: patient attendance at outpatient clinics to monitor for disease progression; the need to modernise the current system; and patients should be encouraged to self-manage their disease.ConclusionsThere were similarities and differences in perceptions of follow-up care procedures between the two focus groups. Patients placed importance on clinical examination in indicating disease recurrence, whereas health professionals viewed this as historical practice with no evidence base. Accurate information on how disease progression is monitored should be communicated to patients. A modified approach to follow-up procedures is suggested as a useful strategy to tailor services to individual needs and preferences, whilst responding to service demands.     

Are nurse-led chemotherapy clinics really nurse-led? An ethnographic study

BackgroundThe number of patients requiring ambulatory chemotherapy is increasing year on year, creating problems with capacity in outpatient clinics and chemotherapy units. Although nurse-led chemotherapy clinics have been set up to address this, there is a lack of evaluation of their effectiveness. Despite a rapid expansion in the development of nursing roles and responsibilities in oncology, there is little understanding of the operational aspects of nurses’ roles in nurse-led clinics.ObjectivesTo explore nurses’ roles within nurse-led chemotherapy clinics.DesignA focused ethnographic study of nurses’ roles in nurse-led chemotherapy clinics, including semi-structured interviews with nurses.SettingsFour chemotherapy units/cancer centres in the UKParticipantsPurposive sampling was used to select four cancer centres/units in different geographical areas within the UK operating nurse-led chemotherapy clinics. Participants were 13 nurses working within nurse-led chemotherapy clinics at the chosen locations.MethodsNon-participant observation of nurse-led chemotherapy clinics, semi-structured interviews with nurse participants, review of clinic protocols and associated documentation.Results61 nurse-patient consultations were observed with 13 nurses; of these 13, interviews were conducted with 11 nurses. Despite similarities in clinical skills training and prescribing, there were great disparities between clinics run by chemotherapy nurses and those run by advanced nurse practitioners. This included the number of patients seen within each clinic, operational aspects, nurses’ autonomy, scope of practice and clinical decision-making abilities. The differences highlighted four different levels of nurse-led chemotherapy clinics, based on nurses’ autonomy and scope of clinical practice. However, this was heavily influenced by medical consultants. Several nurses perceived they were undertaking holistic assessments, however they were using medical models/consultation styles, indicating medicalization of nurses’ roles.ConclusionsFour different levels of nurse-led chemotherapy clinics were identified, illustrating disparities in nurses’ roles. Although clinics are run by nurses they are often controlled by medical consultants, which can reduce nurses’ autonomy and negatively impact on patient care.