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Once seen as the equivalent of a death sentence, today a diagnosis of cancer more likely means dealing with a chronic disease with exacerbations and remissions. Breakthroughs in treatment are increasing the number of survivors each year. In fact, there are now more than 12 million cancer survivors in the United States and very likely include people you know. Advances in early detection and in treatment approaches have made a difference in the more common cancers such as breast, colon and prostate cancers. However, cancer is not a single disease and some cancers remain difficult to diagnose and treat. Two well-publicized examples of late include Senator Edward Kennedy’s death from brain cancer and Patrick Swayze’s death from pancreatic cancer a relatively short time after diagnosis. While there remain significant unknowns about cancer, we do firmly appreciate today that cancer is a result of genetic mutations—some caused by environmental factors, some by random errors, and some inherited.

The most common cancers in women are breast, lung and colon cancers. For men, it is prostate, lung and colon cancer. In both women and men, most fatalities are caused by lung cancer, although the correlative numbers are waning as the smoking rate decline.

With an estimated 1.5 million new cases of cancer expected for 2009, access to and cost of cancer care are still huge concerns. The table below includes a list of organizations that assist people with financial needs. Many nurses who care for people with cancer are not specialized in cancer care, and the Oncology Nursing Society (ONS) is developing educational resources for generalist nurses. Likewise, case managers benefit from understanding recent advances in cancer care and collaborating with oncology nurses. The following material highlights the current state of cancer care and future trends.

DIAGNOSIS

Genetic Markers

Discoveries in genetic research continue to expand our knowledge of how cancer is linked to an individual’s genes, environment and lifestyle. This information will lead to identification of individuals and their families who are at risk for cancer and determine personalized screening interventions. However, no single predictor or screening test will identify every cancer. The research on how good cells go bad is increasing the understanding of how cancer cells develop and is leading to improved targeted treatments.

Digital Mammography

Breast cancer is the second leading cause of cancer death in women today and it is estimated that more than 192,000 new cases of breast cancer will be diagnosed this year alone. A recent advancement for breast cancer screening is the use of digital mammography (DM). An electronic image of the breast is produced with an X-ray machine and is stored digitally. Two advantages of DM include electronic transmission and image manipulation, which allows for improved image analysis.

A 2005 National Cancer Institute (NCI) study showed that DM demonstrated significant improvement in breast cancer screening for women in three categories: those under the age of 50, those with dense breast tissue, and those who are pre- or perimenopausal.

TREATMENT

Targeted Therapies

According to the NCI, more than 200 types of cancer, and numerous subtypes, exist today. Advancements in targeted therapies are vital to the goal of individualized cancer prevention, diagnosis, treatment and survivorship. The ability to target specific cells allows physicians to treat patients with the most effective therapy and prevent unnecessary side effects and costs due to ineffective treatment. These therapies block tumor growth, disrupt blood vessel development and cause cancer cell death. Common drugs and their targets include Arimidex® for the treatment of breast cancer, Gleevac® used to treat leukemia, and Erbitux® for the treatment of colorectal cancer.

Oral Agents

Until recently, patients undergoing chemotherapy faced daily or weekly intravenous infusions at a clinic, treatment center or physician’s office. This often meant traveling away from home and the added stress for patients and families. Today, many chemotherapeutic agents are available in pill form, and it is estimated that by 2013 one quarter of all chemotherapy will be in oral form. In fact, the potential exists that in the future patients will have limited contact in cancer care settings and instead will be managed in their home communities.

Benefits to providers include individualized treatment that is effective and convenient, flexibility in drug dosages within a treatment cycle, and the opportunity to boost the number of patients treated for their cancer in light of the increase in the aging baby boomers. The use of oral therapy is convenient for patients undergoing treatment and it eliminates the need for intravenous access or travel to physician offices. However, oral therapy is not without its challenges, which include concerns about patient adherence to the treatment regimen, increased need for patient education and support, and the current lack of reimbursement for oral therapy. Non-oncology nurses may be the health care professional responsible for providing comprehensive education and reinforcing the importance of adhering to the medication schedule.

Nanotechnology

According to the NCI Alliance for Nanotechnology in Cancer, strides in this field have the potential for huge advances in cancer diagnosis and treatment.
Nanoscales, devices that are up to 10,000 times smaller than a human cell, give scientists the capability to examine and interact with cancer cells during the first stages of cancer development. Future goals of the Alliance include the development of devices that have the capacity to deliver treatment directly to cancer cells and avoid damaging healthy tissue.

Symptom Management

Given that patients are receiving aggressive treatment for longer periods of time, it is not surprising that the severity of side effects has intensified. A growing trend in cancer care is the increasing use of symptom management clinics to treat side effects that occur during and after therapy. Common treatment-related symptoms include pain, nausea, vomiting, anxiety, depression and neuropathy. In addition to oncologists and advance practice nurses, this multidisciplinary specialty practice may include such disciplines as pharmacy, social work, and psycho-oncology, and offer services such as acupuncture, yoga, lymphodema and massage therapy.

End of Life Care

Improvements in cancer treatment have many people living longer with a chronic illness. However, end-of-life services are available to patients and families when the decision has been made to transition from curative therapy to medically supportive care. Medicare, Medicaid and most private insurers have a hospice benefit which covers most of the care costs for life-limiting diseases. Hospice will work with families for those without insurance coverage.

End-of-life services focus on managing the patient’s symptoms as well as providing psychological and spiritual care to the patient and family. Typical life expectancy is six months or less when referrals are made, and patient services can be provided in many settings including the home, hospice inpatient centers, hospitals and skilled nursing facilities. Hospice also provides support, assistance and bereavement care to families up to 12 months after death.

TRENDS

Gero-oncology

Given that cancer is predominantly a disease that occurs in the later decades of life, integrating gerontology and oncology knowledge is critical. Not only cancer treatments but supportive care therapies may affect seniors differently than middle-agers. For some cancers, like prostate, watchful waiting may be the better course of action. Issues faced by seniors include multiple co-morbidities, symptom management, survivorship, psychosocial needs, financial concerns and family support issues.

Evidence-based Care and CER

As it is with health care in general, providing care that is evidence-based is integral to cancer care. Five years ago, ONS undertook the development of a resource for nurses that identified the level of evidence for nursing interventions specific to an oncology nursing-sensitive patient outcome. The Putting Evidence into Practice (PEP) initiative was initially launched in card form and is now in book form with resources for 16 nursing-sensitive patient outcomes. The results of comparative effectiveness research (CER) will influence a broad range of diseases. In cancer care, the cost of treatment often exceeds insurance coverage for those who have insurance and devastates many families’ finances. CER should produce critical evidence when there is more than one treatment choice.

Survivorship

Given the chronic nature of many cancers, attention to survivorship issues has gained increased national attention. Managing a person’s cancer extends far beyond the acute phase, and coordination of resources and a follow-up plan are necessary. People with cancer not only need to understand their diagnosis and treatment, they also need to know potential long-term effects, recommended cancer screening and recurrence surveillance, and the schedule for tests and exams. In addition to the medical issues faced by a long-term survivor, other challenges include medical insurance access, emotional well-being, work opportunities, and family stress. Who follows the long-term patient survivor is a possible dilemma. Although the patient may no longer need the expertise of an oncologist and could be followed by a primary care physician, transitioning away from the cancer setting can be difficult. An emerging trend is the development of survivor clinics managed by oncology nurse practitioners.

Patient Navigation

In cancer care delivery organizations, the patient navigator is a newer role. Originally conceptualized by Dr. Harold Freeman, the navigator was a layperson from the community who helped people navigate the complex health care system to receive the care they need. Other versions of the role have developed. All aim to assist patients through the numerous potential barriers, including access to care, financial concerns related to treatment and transportation, and language and cultural issues. Nurses who were formerly care coordinators or case managers are transitioning to navigators. Social workers also are filling the navigator
role. Although this trend began within cancer care, it is now present in other chronic disease specialties as well.

THE ONCOLOGY NURSE AS A RESOURCE

The standard for delivering cancer care is the interprofessional team. Not only does cancer diagnosis and treatment require various medical specialists, but the patient and family also need their diverse expertise. It is estimated that by 2020 the number of people living with cancer will increase by 81 percent, while the number of physicians in all the oncology specialties will significantly decrease. This imbalance will provide multiple opportunities for nurses, particularly advanced practice nurses, to have a positive impact on the care provided to cancer patients and to act as a resource for nursing colleagues in other sectors.

Oncology nurse practitioners are a key to meeting the needs of this growing population now living with a “chronic disease.” In addition to expertise in performing medical procedures like bone marrow biopsies and paracentesis, oncology nurse practitioners are experts at symptom management.

Clinical nurse specialists are essential for providing in-depth, evidence-based education to patients and families before, during and after treatment, and likewise providing a sense of continuity throughout the process. In addition, they will be vital in educating non-oncology nurses on critical aspects of cancer care across health care systems.

Although a long way from being able to understand every cancer, scientists envision a day when that will be possible. With the large baby boomer population beginning to reach their later decades, experts are already predicting that even though the incidence of cancer will not increase, the sheer numbers will. Navigation of complex organizations, coordination of care during treatment, and survivorship plans will be essential elements of the cancer care delivery system.

RESOURCES FOR CASE MANAGERS

Oncology Nursing Society - www.ons.org
National Cancer Institute - www.cancer.gov
American Cancer Society - www.cancer.org/docroot/home/index.asp
Patient Advocate Foundation - www.patientadvocate.org
Susan G. Komen for the Cure - ww5.komen.org
Cancer Care - www.cancercare.org
Partnership for Prescription Assistance - www.pparx.org
Patient Access Network Foundation - www.panfoundation.org
Lance Armstrong Foundation - www.livestrong.org
American Psychological Oncology Society - www.apos-society.org