JONS April 2013 Vol 4 No 2

April/May 2013

www.AONNonline.org

Resources from Pharmaceutical Companies

Resources of Potential Benefit to You and to the Patients You Navigate

Genetic Counseling

2013 NCCN Guidelines Mention Gene Panels

meeting coverage

38th Annual Congress of the Oncology Nursing Society

SURVIVORSHIP

Healthcare Providers’ Knowledge of the Benefits of Cancer Rehabilitation

Navigating Patients Across the Continuum of Cancer Caretm

Š 2013 Green Hill Healthcare Communications, LLC

Vol 4, No 2

2ND ANNUAL

s JO erie View NS s o t -o nli he nli ne ne a .co t m

CONQUERING THE CANCER CARE CONTINUUM

™

CONQUERING THE CANCER CARE CONTINUUM CONQUERING CANCER CARTHE C E CONT I

A 6-part series

The publishers of The Oncology Nurse-APN/PA, The Oncology Pharmacist, and Personalized Medicine in Oncology are proud to present our 2nd annual Conquering the Cancer Care Continuum series.

Upcoming topics include:

• Palliation • Pain management • Hospice care • Treatment planning • Survivorship care • Biosimilars in supportive care

™

Challenges Patients Face in Cancer Care: Implications for the Healthcare Team Lea Ann Hansen, PharmD, BCOP Associate Professor, Virginia Commonwealth University

cancer.1 More than half are living well beyond 5 years ancer is an illness associated with substantial physical, emotional, social, and financial ramafter diagnosis. Women comprise a majority of longifications for affected individuals and their term survivors due to the favorable outcomes with families. In a significant number of cases, the diagnosis breast, cervical, and uterine cancers.2 The number of of cancer is either preceded by a period people living with a history of cancer

of gradual, nonspecific symptoms or is projected to grow considerably over

discovered by routine screening, and the next 20 years for 2 major reasons. individuals are then thrust into a First, the number of Americans over whirlwind of diagnostic testing, inage 65 is predicted to double between vasive procedures, and complicated the years 2000 and 2030.3 Consetreatments with very little warning or Lea Ann Han quently, as a disease primarily of older sen Associate , Pha opportunity to assimilate their circumProfessor, rmD, BCOP adults, cancer will also increase. SecVirginia Commond, stances. Frequently, a multidisciplinary as the effectiveness of cancer onweal versity ™ th Uni approach to treatment is necessary, retreatments improves, the number of he past dec ade has seen quiring patients to engage with numerthe utilizat a drapatients matic upscured of the disease will inion of spe urgan e in ous medical teams comprising several crease, and even larger percentage cialty pha types of Medic rma are Moder the cies Lea Ann Hansen, rapeutic for all different specialties, often in different those for can will be living longer with disease nization Ac modalitie as “athe cer. The BCOP PharmD, t defined s, inc t D drug wit cost of can luding multiple par a specialty locations. Many patients have beenabout $125 bill receiving “linesâ€? of h plan-nego cer carewhile ceed $40 drug ion in 201 may rise from tiated pric 0 0 to (first-line, relatively healthy prior to the cancer lion eventbyand second-line, etc) fine over time. per Themonth.â€? 2 Oth es that exthethere7 bilend of the therapy$20 spe er health cial dru dec ade. demand plans ma gs differe fore are not sophisticated consumerstim ofe,medical overall specialtyserBy that for oncology services is expected totyiny dently dru gs . In genera are accon predic ounhealthcare vices. Consequently, it is incumbent crease byted 48% l, they are t for 2 of toby 2020, while the supply of oncologists high cost, adminis eve ry 5 tered by inje pha increase lars spent.

4 1 professionals to be able to facilitate patients’ transition cy dolby The purpos willrma ction - only 14% based on current patterns. or infusion, require e of this arti special han to expand ersity intoBCO carePin order to minimize theirisdistress the need for a wide varietyor are used lain maxicle underscore dling, the evoluti These statistics en, PharmD, Commonwealth Univ for comple 80%, cialty pha on nia their clinical outcomes.

Lea Ann Hans ssor, Virgimize from 17% toand other support personnel torequire x diseases of range the of ens health professionals spe rmacycatio Profe regim that special mo ption andnthe Associate on assumeach oral mediand can nitoring. functio term serv col Anscomm Challenges exist beyond diagnosis play a part .2-4 t initial e in the around 50% In onitin enabling treatmenthe beand every patient to re- ogy, however, the d mic trea ge woul syste tme avera ts for an and nt agen most com with of can to the agents disp ance nt scenario period as well.

According to ceive quality all of their needs discNational aantic cerr care that addresses uss nistr mon thee pot to oral ensed by he predomina treatment been renc involved admi entthroughout adheindividandthat a specialty disease, has of the illness. Patients deial ofefit macy pro the traditionally (NCI), million llen pharges oftothe highlythan 12cha s the continuum severityben vider (SP by more the of cancer has Cancer Institute thesyst rapy ate othe due indic P) poi er, ies em are the new high targeted from of view e. Stud venous chem United States fine quality of care based on are their ability to5: are a history untru nt.livingntwith the of theofpatproven agents tha er the patie tion of intra uals in the py ient. t are adm ly monitored for cancer thera tered ora inisnnel who close lly. After adherence rates5 rence has trained perso in an The Evo a system view . Nonadhe atic redures took place lution of 15% to 97% Green Hill outc Healthcare omes Communications, LLC of the literature, Spec e When these proce infuDrugs an one academ group of y iated with wors or in a hospital d Specialtbeenialt assoc authors pro ic with and s the oncologist’s office of Ph state y pos se arm critical des ed the mo disea Lea Ann acy sive education st in a number of Hansen criptors er hossion center, exten , high More of a spe There is drug to be 3 ician visitsPha rmD, BCO , ly was possible. cialty a lack of : increased phys stays, P consen patient and fami specialty ly comsus on the • High cos , longer hospital drug. The n rates ver, an increasing definition t (prescri Food andpitalizatio recently, howe not defined ptions cos of a ased morof one or Drug Ad than $600 ening, and incre t more wors the term. involves the use min toDifficult disease istration has per month third • Init mon situation onesyn dmin me iall ony self-a ately ) dic y, mous wit the.6 labe ation del Appl roxim cations and h biotech tality ivery, suc was more oral medi teins pro in the uallcation-related— Special handlin nology pro s of allvirt h as duced by eous therapies g requiring ducts, eith medi y n recombin two-third erdue istered subcutan strict tem monoclon pro-to medicatio control t responant DNA ations are perature al antibo ent. The direc — hospitaliztechnique dies produc home environm bridomas, admincost of $100 bil- Restricted location —at sa or ed dher but this acquisition and h ence for medicat cellular hy- ose of this ar- or distribu is no lon nonawit and sibility for drug nts ion 7 The purp Lillie patie ger preparatio tion the D. Shockn theannu site ng to case.ally. n en, lion eptsRestric The 200general conc— Hans istration is shifti AnnRN if avail, BS,PMAS Leaey, ted locatio ibe 7 ort network, n for medic ticle is to descr PharmD, BCO 20 their social supp rch related totration than atio resea more n , the adm n part 2 of e and nt time inisrenc

adhe Green Hill incidence, risk facour Conquregarding patient able. At the prese oved for TheHea are ering the Ca er treatmen seri1). ion, ns are FDA appr addit wed.icat ncer Care Co t. lem lthc foc le es,Inthe to canc reviemun oral medicatio beCom us rence er (Tab is will ions on adhe canc of pai t , ntin prob LLC matic tumo n manageque that treatmen nces of this uum imprsrov examine the first-line ementstors, and cons ement. Despit ts are used for subsequentlyinability to ove in pha e dra other oral agen well asl surg rcome it effe this series will ment. Acrmaceu intica a number of dieclini last article to initia treatical proceduresThe rence and whcal l age ctively ile in ntsg,adhe design mizin Netor are refractory we still hav as maxi e a erlon toices helfor have relapsed monly resp great pain. Family , fearing they will pract g way the best ed p control pai prehensive Canc me ond that the National Comcessful onound in the to go to be.sucn, comp behsalf of our patoutcomes cording to the ness their ir greatest mbers, too, comall of 25% I ien nloved one fea was rec are admi ately ly watching ts. in great pai r is having to witwork, approxim

ent pipelineent

lopm ute

deve 1 s

and n withou a few min of an old rch ease the suf inue. th Organ-

oncology resea

likely to cont , black-and-wh

fering. Fam t a way to the World Heal so the trend isern movie.s the ite wes increased fear these ily memb t-ce was defined by to which a person’s beistered orally, lity come A cowboy had Adheren wil nsibi l by be respo nt a in the adgun been shot2003 as the “exte be final images ers slingernot witness bef With this shift , and a diet, and/or cations may ore mediatte ization in as wing rtor the follo the ance re n, tow ir antic loved one they mpted n or, doctakin ens that Many org - g medicatio possibility that to requi ove havi regim dies. ially for ctly, especfrom his che rence torem long- the oped measu anizations have dev ministered corre another cow bullet ates of adhest, elestimwo rem the all ent Over g. boy gave unded tools and tice guidel LLC repeated dosin pra munications, ine to drink and man a botHealt tle ofhcare whCom helping pro s for the purpos ciskey reen a kni feHill G e of to bite vid his

THE QUERING N O C ANCER CARE C

NUUM

™

Conveni ence, C The Imp halleng es a Patient ct of Specialty , and Cost Con Care Pharma cies on tainment:

TU U M CONTIN

SECOND y ISSUE IN THE 20 ncer Therap 13 SERIES ence to Ca er SE C O N dh na No D ANN Impact of UAL

T

CONQUERING T CANCER CAREHE CONTI

NUUM

Introduc tion to O ncology Pain Ma nageme nt

™

I

ers effectiv teeth. I’m betwee age pain ass ely manociated wit was how peo sure back in the day n its treatm h cancer and this ent quor to numple coped with pain provide you . The following art – hard to bite b them and someth liwit h a wealth of icles mation ass ing on. inforociated wit Today all This is far from ideal. and guidel h these too ine hospital env patients who ent that though s. They also promo ls er a tful care be an inpatie ironment, whether te sure that nt it Lillie D. Sho all of us add taken to entheir doctor unit or a clinic visit be ckney, RN cancer pat wit ress with , , BS, MAS our ients the pain measu are asked to comple h experienci pai rement too te ng and imp n they are of whether l that provid a to lement wa the relieve it. gree. Patien y are presently in es some expression ys Pain pai physical end time, psycholog steals away social what to circ ts have trouble, how n, and to what deica le tually absent urance and can ma l well-being, and pain was bad (a happy face or a ever, interpreting ke quality ver of life virand adequa for some patients. cause they in the morning but y sad face) if their Ac te cur tre ate atm too not so bad assessment ent for effe ment nee doctor. Fur k a pain pill before now bed to be pri ctive pain thermore, orities for the cancer ma is this info coming to see the viewed by all of us wo nagefield. any rma rking in I feel confide and sometim one during their visi tion actually rent you wil t? Sometim es provoking es it is, Certainly it is not. and contain l find these article one s will assist of the cer patien you in rea ing valuable informa thought ts is the fea greatest fears express ssessing you tion that well as dev ed by canr of pain and r current pat elo pin g mo suffering and future patien re effectiv ients as e the fectively ma ts have quality of life ways to help your naged. by having pain efŠ 2013 Gre en Hill Hea lthcare Com munication s, LLC

TO VIEW THE SERIES ONLINE PLEASE LOG ON TO:

www.JONS-online.com JONSAsize CCC_060413

LETTERS FROM LILLIE

Editor-in-Chief

Dear Reader,

Lillie D. Shockney, RN, BS, MAS

On behalf of myself and the wonderful AONN staff and Leadership Council that I have the privilege of working with, we hope that you are enjoying the new features and benefits we have been launching for you through the AONN website. Our goal is to continue to develop more sophisicated and easy-to-navigate website content that provides our members more knowledge and networking opportunities, as well as the ability to access resources of benefit to you and to your patients. (And if you haven’t yet taken a look at the redesigned website, carve out a few minutes and take a look. It is worth your time.)

We have set up our first VIGs—virtual interest groups—initially focusing on the larger volume organ site cancers. There will be many more to follow, as well as VIGs for those working in the area of community outreach, survivorship care, and other phases of a patient’s continuum of care. I’d like to personally hear from you regarding what types of VIGs you feel would be of specific benefit to you within the type of navigation role you serve. My e-mail is shockli@jhmi.edu.

We are continuing to build the resource database for you that will truly be a wealth of information at your fingertips to provide solutions to the barriers you experience that prevent cancer patients from receiving the cancer treatment they need and deserve.

Now, on to this issue of JONS. We have 3 topics of focus for you to read about. There is an article on cancer rehabilitation that is of particular importance, since it will likely impact your role as a navigator. We learned a lot by surveying the AONN membership about their knowledge and understanding of cancer rehabilitation. The Commission on Cancer has incorporated into its accreditation standards specific requirements regarding this aspect of cancer care. Those who serve as navigators are in the perfect clinical position to improve clinical outcomes for your patients by referring patients early on, even before they begin to get under way with any treatment.

There is also an article that provides insight into the new NCCN guidelines on genetic and familial high-risk patient populations and what these new guidelines may mean for patient care. Commonly, patients are tested for genes that are specifically grouped by organ site (like breast cancer genes—BRCA1 and BRCA2). We will likely see consideration in the future to more broadly counsel and test patients for multiple categories. You will learn why in the article.

And we have added a new feature—Resources from Pharmaceutical Companies. You may not know about the resources, but they can benefit you from an educational perspective and your patients from a resource perspective. The first one provides you insight into what Pfizer Oncology offers. Plan to be surprised!

We are each privileged to be in the lives of cancer patients during the most vulnerable time of their (and their loved ones’) lives. Though your days may be long and frustrating at times, know that you are making a difference and take pride in doing so. g With kind regards,

Lillie D. Shockney, RN, BS, MAS Editor-in-Chief

Lillie D. Shockney, RN, BS, MAS University Distinguished Service Assoc Prof of Breast Cancer, Depts of Surgery & Oncology; Admin Director: Johns Hopkins Breast Clinical Programs; Johns Hopkins Cancer Survivorship Programs; Assoc Prof, JHU School of Medicine, Depts of Surgery & Gynecology and Obstetrics; Assoc Prof, JHU School of Nursing shockli@jhmi.edu

Section Editors

Breast Cancer Sharon Gentry, RN, MSN, AOCN, CBCN Breast Health Navigator Novant Health Derrick L. Davis Cancer Center

Cancer Rehabilitation & Survivorship Julie Silver, MD Assistant Professor Harvard Medical School

Prostate Cancer Frank delaRama, RN, MS, AOCNS

Clinical Nurse Specialist Oncology/Genomics, Cancer Care Clinic Palo Alto Medical Foundation

Genetic Counseling

Cristi Radford, MS, CGC Gene Mavens, LLC Sarasota, FL

Healthcare Disparities Linda Fleisher, PhD, MPH

Asst VP, Office of Health Communications and Health Disparities Asst Prof, Cancer Prevention and Control Fox Chase Cancer Center

Health Promotion and Outreach Iyaad Majed Hasan, MSN, FNP

Director and Nurse Practitioner Survivorship Clinic and Program Cleveland Clinic, Taussig Cancer Center

Thoracic Oncology Pamela Matten, RN, BSN, OCN St. Joseph Hospital, Orange, CA

AONN Research Committee Marcy Poletti, RN, MSN

Program Administrator, Oncology Services Wake Forest University, Baptist Medical Center

Elaine Sein, RN, BSN, OCN, CBCN

Senior Project Manager Fox Chase Cancer Center Partners Program

Penny Widmaier, RN, MSN Nurse Navigator Botsford Cancer Center

Mission Statement

The Journal of Oncology Navi­gation & Survivorship (JONS) promotes reliance on evidence-based prac­ tices in navigating patients with cancer and their caregivers through diagnosis, treatment, and survivorship. JONS also seeks to strengthen the role of nurse and patient navigators in cancer care by serving as a platform for these professionals to disseminate original research findings, exchange best practices, and find support for their growing community.

JONS-online.com journal of Oncology Navigation & Survivorship

3

™

PUBLISHING STAFF Senior Vice President, Sales & Marketing Philip Pawelko phil@greenhillhc.com Vice President/Director of Sales & Marketing Joe Chanley joe@greenhillhc.com Group Director, Sales & Marketing John W. Hennessy john@greenhillhc.com Publishers Cristopher Pires cris@engagehc.com Russell Hennessy russell@greenhillhc.com Lou Lesperance lou@greenhillhc.com Editorial Director Kristin Siyahian kristin@greenhillhc.com

6 Resources of Potential Benefit to You and to the Patients You Navigate

Editorial Assistant Jennifer Brandt

Genetic Counseling

The Lynx Group President/CEO Brian Tyburski Chief Operating Officer Pam Rattanonont Ferris Vice President of Finance Andrea Kelly Director, Human Resources Blanche Marchitto Associate Editorial Director, Projects Division Terri Moore Director, Quality Control Barbara Marino Quality Control Assistant Theresa Salerno Director, Production & Manufacturing Alaina Pede Director, Creative & Design Robyn Jacobs Creative & Design Assistant Lora LaRocca Director, Digital Media Anthony Romano Web Content Managers David Maldonado Anthony Travean Digital Programmer Michael Amundsen Senior Project Manager Andrea Boylston Project Coordinators Deanna Martinez Jackie Luma Executive Administrator Rachael Baranoski Office Coordinator Robert Sorensen Green Hill Healthcare Communications 1249 South River Road - Ste 202A Cranbury, NJ 08512 phone: 732-656-7935 fax: 732-656-7938

April/May 2013 • Volume 4, Issue 2

April/May 2013 • Vol 4, No 2

Resources from Pharmaceutical Companies

Copy Editor Rosemary Hansen

Production Manager Stephanie Laudien

4

Table of ConTents

Part 1 of a 5-Part Series

Lillie D. Shockney, RN, BS, MAS

8

2013 NCCN Guidelines Mention Gene Panels Cristi Radford, MS, CGC

SURVIVORSHIP

Healthcare Providers’ Knowledge of the Benefits 12

of Cancer Rehabilitation Lillie D. Shockney, RN, BS, MAS; Julie K. Silver, MD; Elissa Bantug, MHS;

Laurie Sweet, PT; R. Samuel Mayer, MD; Michael Friedman, PT, MBA

commentary

21 Lung Cancer Screening in the “Real World”

and the Role of Nurse Navigators David E. Gerber, MD; Alletrice O. Gillam, RN, BSN, OCN;

Heidi A. Hamann, PhD

meeting coverage

38th Annual Congress of the Oncology 25 Nursing Society

ABOUT THE COVER Wild Water

Mixed Media by a Person Diagnosed with Cancer Arizona Artwork from the Lilly Oncology On Canvas: Expressions of a Cancer Journey Art Competition (www.LillyOncologyOnCanvas.com).

Journal of Oncology Navigation & Survivorship, ISSN 2166-0999 (print); ISSN 2166-0980 (online), is published 6 times a year by Green Hill Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Telephone: 732.656.7935. Fax: 732.656.7938. Copy­right ©2013 by Green Hill Health­care Com­muni­cations, LLC. All rights reserved. Journal of Oncology Navigation & Survivorship logo is a registered trademark of Green Hill Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the publisher. Printed in the United States of America.

EDITORIAL CORRESPONDENCE should be ad­­dressed to EDITORIAL DEPARTMENT, Journal of Oncology Navigation & Survivorship (JONS), 1249 South River Road, Suite 202A, Cranbury, NJ 08512. E-mail: jbrandt@the-lynx-group.com. YEARLY SUBSCRIPTION RATES: United States and possessions: individuals, $50.00; institutions, $90.00; single issues, $5.00. Orders will be billed at individual rate until proof of status is confirmed. Prices are subject to change without notice. Correspondence regarding permission to reprint all or part of any article published in this journal should be addressed to REPRINT PERMISSIONS DEPART­MENT, Green Hill Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. The ideas and opinions expressed in JONS do not necessarily reflect those of the editorial board, the editorial director, or the publisher. Publication of an advertisement or other product mention in JONS should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturer with questions about the features or limitations of the products mentioned. Neither the editorial board nor the publisher assumes any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosage, the method and duration of administration, or contraindications. It is the responsibility of the treating physician or other healthcare professional, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Every effort has been made to check generic and trade names, and to verify dosages. The ultimate responsibility, however, lies with the prescribing physician. Please convey any errors to the editorial director.

AONNonline.org

Visit tHe neW onLine resourCe for nurses And tHe entire MuLtipLe MyeLoMA CAre teAM

“Quality care is everyone’s business.”

Beth Faiman, RN, MSN, APRN, BC, AOCN Nurse Practitioner, Multiple Myeloma Program Cleveland Clinic Taussig Cancer Institute Cleveland, OH

Value-BasedCare in Myeloma

™

resourCe Center for pAyers, proViders, And tHe entire CAnCer CAre teAM

Value-Based Care in Myeloma delivers exclusive interviews and perspectives related to cost, quality, and access issues. special sections for VA-based clinicians, advanced practice nurses, and pharmacists will also focus on the unique challenges in the management of multiple myeloma.

www.ValueBasedMyeloma.com Value-Based Care in Myeloma is a publication of engage Healthcare Communications, a member of the Lynx Group. © 2012 All rights reserved.

VBCC0112_VBMAsizeGH

Resources from Pharmaceutical Companies

Resources of Potential Benefit to You and to the Patients You Navigate Part 1 of a 5-Part Series

Lillie D. Shockney, RN, BS, MAS, Johns Hopkins University School of Medicine, Baltimore, Maryland

M

ost navigators are familiar with the large national patient advocacy organizations that provide various resources for patients that can expedite our ability to reduce barriers impeding diagnosis and treatment, but there are actually additional resources that you may not be aware of that I want to tell you about. These resources are from pharmaceutical companies and other device and laboratory testing companies. Although there are a lot of restrictions in place today regarding how we are and are not to “interact” with for-profit companies connected to cancer care, I think that you will be happily surprised (as I was) to see that there are several resources that are not associated directly with these companies’ for-profit status! This is part 1 of a 5-part series that I will be bringing to you as we expand everyone’s knowledge about access to services that can benefit our patients with cancer.

This is part 1 of a 5-part series that I will be bringing to you as we expand everyone’s knowledge about access to services that can benefit our patients with cancer.

This particular pharmaceutical company, Pfizer Oncology, offers a series of educational programs targeted to navigators like ourselves, so that we can become more knowledgeable about our field of navigation and patient advocacy. Pfizer offers support services for patients through the First Resource program. The services provided include reimbursement support, alternate funding assistance, appeals support, copay assistance, and free medications. These services are available for the insured, underinsured, and the uninsured. All of the details can be accessed at www.firstresourceprogram.com.

Art of Active Listening: Delivering Emotionally Charged News • Enhance participant communication skills when discussing a new and/or serious diagnosis and handling difficult questions • Apply empathic counseling skills with a patient facing a serious health diagnosis

6

April/May 2013 • Volume 4, Issue 2

• Formulate a sensitive response to patients adjusting to a difficult prognosis • Support patients so they are better able to understand their medical status and participate in their own care

Advancing Concepts in Survivorship Care • Issues that confront patients with cancer in the United States and trends in survivorship care • Treatment advancements changing the patient pathway • The link between survivorship care, patient navigation, and personalized care • What to consider when developing a survivorship program Personalized Medicine in Cancer Care • Paradigm shifts in perspectives on cancer and treatment • Overview of personalized medicine in oncology • Goals of personalized medicine • Biomarker testing: types of biomarkers, challenges with biomarkers, potential patient concerns Raising Awareness in Clinical Trials • Only a small percentage of adults diagnosed with cancer participate in clinical trials • Healthcare professionals will learn to identify and overcome the barriers to clinical trial participation • Clinical trials give patients access to innovative approaches that may increase their chances of success while advancing science Optimizing Quality Goals through Electronic Medical Records • An explanation of health information technology (HIT) and why it has become so important in healthcare • Incentives to encourage oncology practices to adopt meaningful use of HIT • Measures to help with adoption, implementation, and enhancement of an electronic medical record (EMR) system

AONNonline.org

Resources from Pharmaceutical Companies

• Potential quality care benefits of using EMRs in oncology practices: coordination of care, clinical pathways and guidelines, adverse events management, adherence, e-prescribing

Older Adult Sensitivity Training • Epidemiology of aging addresses most common health conditions in older adults and their unique needs • Portrait of older adults explores the older population through case studies and discussion groups • Effective communication skills identify barriers and teaches foundational techniques • Older adult sensitivity strategies provide learning opportunities through simulation activities • Role of caregiver identifies challenges caregivers face and intervention strategies for success • Supporting the patient experience in the oncology setting Patient Navigation: Advancing Personalized Care • The broadening scope of patient navigation and its increasing importance in patient management • The link between patient navigation and survivorship care

IN G TO W

RAWIN OUR Dok written byrector of AONN ENTER D. Shockna boey, Program Di

Promoting Patient Adherence • Adherence rates cited in various published oncology studies • Potential barriers to adherence • Accurately measuring patient adherence • Using patient consultations to improve adherence through objective and subjective evidence • Helpful communication techniques to promote ­adherence An impressive list to say the least! The Academy of Oncology Nurse Navigators will be reaching out to Pfizer leadership to offer several of these educational programs for our conference in November 2013 as well as locally, regionally, and in the form of webinars. These are unbranded programs! g

These ONS 38th Annual Congress attendees visited the AONN exhibit and each won a book written by Lillie Shockney

Lillie

Lillie

• The challenges to organizations and patient navigators of the changing healthcare system and growing population of cancer survivors • How patient navigators can help improve cancer care as advances in treatments become more personalized • The importance of standards of care in patient navigation • Ensuring high quality in patient navigation programs

, MAS er RN, BS ssor of Breast Canc Profe ckney, D. Shohed Service Associate r ams

Robin Green Corona, CA

Katie McCreath Saint Joesph, MO

Cente Progr Breast Distinguis Oncology vorship ry, Hopkins er Survi UniversitySurgery and tor, Johns Hopkins Canc Depts of Surge of Depts ative Direc tor, Johns of Medicine, ol Administr ative Direc JHU SchoObstetrics Administr Professor, y and Nursing Associate & Gynecolog School of JHU Oncology Professor, Associate Maryland ore, Baltim

ted y selec doml be ran ced at 2013. un rs will Winne and annoday, April 27, Satur on on 12 no

Jena Buchanan Cary, NC

Mary Manuel Oakland, CA

We look forward to seeing you at the AONN meeting November 15-17, 2013, in Memphis

JONS-online.com journal of Oncology Navigation & Survivorship

7

Genetic Counseling

2013 NCCN Guidelines Mention Gene Panels Cristi Radford, MS, CGC Sarasota, Florida

I

n March, the National Comprehensive Cancer Network (NCCN) guidelines for genetic/familial high-risk assessment for breast and ovarian cancers were updated.1 Among the updates is a section on “gene panels.” Gene panels allow multiple genes to be analyzed simultaneously for mutations, at a cost that is often comparable to testing for a single inherited condition. In the case of cancer risk assessment, gene panels contain genes associated with an increased risk of developing cancer. For example, the panel may be targeted for a particular disease type, such as one containing a multitude of genes that are all associated with a high risk of colon cancer, or it may be targeted for several disease types, such as breast cancer, colon cancer, and ovarian cancer. Further, each laboratory selects which genes are included on their panels; thus, it cannot be assumed that a “colon panel” or a “breast panel” at various laboratories will include the same genes. Genes included on breast/ovarian panels include ATM, BARD1, BRIP, CDH1, CHEK1, CHEK2, MLH1, MSH2, MSH6, MUTYH, MRE11A, NPN, PALB2, PMS2, PTEN, RAD50, RAD51B, RAD51C, RAD51D, STK11, and TP53.1

Gene panels allow multiple genes to be analyzed simultaneously for mutations, at a cost that is often comparable to testing for a single inherited condition.

One premise behind cancer panels is reflected in the statement “individually rare, collectively common.” This concept is best illustrated by a study conducted by Walsh and colleagues,2 in which 360 women with primary ovarian, peritoneal, or fallopian tube carcinoma were screened for mutations in 21 genes. Participants were not selected on the basis of age or family history. Approximately 1 in 4 women (82/360, 24%) were found to carry a germline, lossof-function mutation. Mutations in BRCA1/2 accounted for 18% of the mutations, while mutations in 10 other genes accounted for the remaining 6%. Thus, although the non-BRCA mutations could be considered individually rare, ranging from 0.03% to 1.4%, the chance of carrying a

8

April/May 2013 • Volume 4, Issue 2

mutation became more common when they were analyzed collectively.

Additionally, gene panels are also providing more insight into the phenotypes of hereditary cancer syndromes.

Gene panels allow a clinician to cast a wider net and analyze genes that may have been low on their differentials list or not on it at all. This was also demonstrated in the Walsh study, where of the 3 individuals found to have a mutation in TP53, which is associated with Li-Fraumeni syndrome, none actually met the testing criteria for Li-Fraumeni syndrome. Additionally, whereas only 2 individuals were found to have germline mutations associated with Lynch syndrome and both mutations were in MSH6, neither of these individuals had a family history of Lynch syndrome.

Furthermore, if genetic testing had relied on an age less than 60, 30 individuals (>35%) with germline mutations would have been missed.

To further understand the applications of gene panels, consider Marie’s family history. Marie reports being recently diagnosed with invasive lobular breast cancer at age 34.

She has one brother, aged 38, who has a daughter, aged 12.

Her mother, aged 67, has a large family with no reported cancers. Her father, aged 68, has no siblings. His father (Marie’s paternal grandfather) died at age 85 from complications of a stroke. His mother (Marie’s paternal grandmother) died from cancer at age 44; the type of cancer is unknown, but the family believes it was “stomach or abdominal.” Additionally, Marie has a history of a thyroid nodule and reports a history of skin biopsies that “weren’t melanoma.” Based on reported information, your differentials may include BRCA1/2, P53, and CDH1.1 Additionally, depending on the skin findings and/or your degree of suspicion, you may also be interested in testing for PTEN and moderate penetrance breast cancer genes. Prior to the development of next-generation sequencing technologies, testing all of these genes would most likely have been cost and time prohibitive. However, with the advent of gene panels, a clinician now has the option of testing for BRCA1/2 mutations and then proceeding with a gene panel for other breast cancer genes. Currently, due to restrictive patents, BRCA1/2 is not clinically available on a gene panel.

As a result of the new technology, researchers and cli-

AONNonline.org

Genetic Counseling

nicians are beginning to see a shift in how inherited cancer is investigated and diagnosed. Gene panels provide the following benefits: (1) simultaneously testing multiple genes can be more time and cost-effective; (2) when clinical criteria are uncertain or multiple differentials are present, gene panels can aid in clinical diagnosis; and (3) as many high-risk patients are negative for BRCA1/2 mutations, gene panels provide an expanded method of screening for less common mutations. However, as with any new technology, there are also limitations, including a higher chance of obtaining a variant of uncertain significance (VUS) result or finding a mutation in a gene with undefined cancer risks and/or medical management guidelines.

Listed below are a number of issues a provider should consider when developing a genetic testing strategy: Laboratory and Gene Analysis Considerations • Does the panel of interest contain all of the genes in your differential diagnosis?

• What is the turnaround time (TAT) for the test?

If you were to order an analysis of each gene individually rather than as part of a panel, would the TAT be longer or shorter?

• What is the out-of-pocket cost for the patient?

If you were to order an analysis of each gene individually rather than as part of a panel, would the expense be more or less?

• Can you find out the cost to your patient before the test is performed? Does the laboratory stand by its quote?

• What findings are reported (eg, polymorphisms, mutations, and/or variants of uncertain significance)? Are all findings confirmed and how?

• How often is the result “VUS” reported? What is the laboratory’s experience interpreting VUS results?

How often do they reclassify VUS results? What is the notification process? Are their internal studies available to your patient to help reclassify a VUS? Does the laboratory provide you with resources to help you determine the functional significance of the VUS? • What regions of the genes are analyzed? Is rearrangement analysis performed?

Counseling Considerations • As multiple genes are analyzed at the same time, what is your pre- and posttest genetic counseling strategy?

• How would the test result impact your patient’s medical management?

• How crucial is TAT in medical management decisionmaking for the patient?

• Do you know of available research studies/cancer registries to help further delineate the risks associated with various genes?

• The level of risk conveyed with a particular gene may not be well defined and, therefore, guidelines on risk management may not be available. How would you counsel an individual who receives a positive, negative, or VUS result? How would you counsel his or her family members?

• Does the mutation track with the cancers in the family?

As a result of the new technology, researchers and clinicians are beginning to see a shift in how inherited cancer is investigated and diagnosed.

Take-Home Messages • Gene panels allow a clinician to cast a wider net. This can be useful when syndromes have overlapping phenotypes, family history is uncertain, or there are multiple genes in your differential diagnosis.

• Although gene panels appear promising, limitations include a higher chance of receiving a VUS result and the possibility of finding a mutation in a gene with cancer risks that aren’t well defined. g References

1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Breast and Ovarian.

Version 1.2013. http://www.nccn.org/professionals/physician_gls/recently_ updated.asp. Accessed March 12, 2013.

2. Walsh T, Casadei S, Lee MK, et al. Mutations in 12 genes for inherited ovarian, fallopian tube, and peritoneal carcinoma identified by massively parallel sequencing. Proc Natl Acad Sci U S A. 2011;108(44):18032-18037.

Visit our user-friendly website.

www.AONNonline.org

In addition to Web-only exclusives, news coverage, journal articles, contests, and polling questions, you’ll have the opportunity to participate in a number of activities offered!

JONS-online.com journal of Oncology Navigation & Survivorship

9

Fourth Annual Navigation and

November 15-17, 2013 • The Peabo PRELIMINARY AGENDA* FRIDAY, NOVEMBER 15 12:00 pm - 12:30 pm Welcome • Conference Co-Chairs: Sharon Gentry, RN, MSN, AOCN, CBCN Lillie D. Shockney, RN, BS, MAS 12:30 pm - 2:00 pm PRE-CONFERENCE WORKSHOPS Basic Navigation Track • Tricia Strusowski, MS, RN • Nicole Messier, RN, BSN OR Advanced Navigation Track • Elaine Sein, RN, BSN, OCN, CBCN • Danelle Johnston, RN, MSN, OCN, CBCN 2:00 pm - 2:45 pm BREAK IN THE EXHIBIT HALL 2:45 pm - 3:30 pm General Session 1: Top 10 Best Practices • Moderators – Conference Co-Chairs: Sharon Gentry, RN, MSN, AOCN, CBCN Lillie D. Shockney, RN, BS, MAS 3:30 pm - 5:00 pm Administrator’s Track • Mandi Pratt-Chapman, MA • Michele O’Brien, MSN, ACNS-BC, RN, BA OR

5:00 pm - 6:00 pm 6:00 pm - 8:00 pm

Case Manager’s Track FREE TIME Welcome Reception/Posters in the Exhibit Hall

SATURDAY, NOVEMBER 16 6:30 am - 7:30 am

Breakfast/Product Theater (non–CME-certified activity) 7:45 am - 8:00 am Welcome and Introductions • Conference Co-Chairs: Sharon Gentry, RN, MSN, AOCN, CBCN Lillie D. Shockney, RN, BS, MAS 8:00 am - 8:30 am General Session 2: The Future of AONN (The AONN Business Meeting) • Sharon Gentry, RN, MSN, AOCN, CBCN • Lillie D. Shockney, RN, BS, MAS 8:30 am - 9:15 am General Session 3: Community Needs and Navigation • Lillie D. Shockney, RN, BS, MAS, on behalf of the Global Breast Health Initiative • Jennifer Klemp, PhD, MPH, MS 9:15 am - 10:00 am General Session 4: Development and Application of Evidence-Based Guidelines in Cancer Care: The NCCN Perspective • Liz Danielson, MHA 10:00 am - 10:45 am BREAK IN THE EXHIBIT HALL 10:45 am - 11:30 am Keynote: Update on Guidelines • Linda Ferris, PhD 11:45 am - 12:45 pm Lunch/Product Theater (non–CME-certified activity) 1:00 pm - 1:45 pm General Session 5: Onco-Politic Barriers • Dan O’Connor 1:45 pm - 2:30 pm General Session 6: Addressing Disparities of Care • Swann Arp Adams, PhD, MS • Michelle Weaver Knowles, RNC, BSN

2:30 pm - 3:15 pm 3:15 pm - 3:45 pm 3:50 pm - 4:35 pm

4:35 pm - 5:20 pm 5:30 pm - 7:30 pm

General Session 7: Oncology Medical Home BREAK IN THE EXHIBIT HALL General Session 8: Meeting the Needs of the Adult and Child Survivor Throughout the Life Span • Christy Roberts, RN, BSN, OCN General Session 9: The Role of Complementary Therapies in Navigation • Linda Lee, MD, AGAF Poster Award Reception

SUNDAY, NOVEMBER 17 6:30 am - 7:30 am

Breakfast/Product Theater (non–CME-certified activity) 7:45 am - 8:00 am Welcome and Introductions • Conference Co-Chairs: Sharon Gentry, RN, MSN, AOCN, CBCN Lillie D. Shockney, RN, BS, MAS 8:30 am - 8:45 am General Session 10: Navigator’s Role in Tumor Boards • Laurie Mathis, RN, BS, MAS 8:45 am - 10:30 am DISEASE SITE–SPECIFIC BREAKOUTS • Breast Cancer Navigation & Survivorship • Karen Dow Meneses, PhD, RN, FAAN • Vinnie Myers • Thoracic Oncology Navigation • Gean Brown, RN, OCN • GI & Colorectal Cancer Navigation • Darcy Doege, RN, BSN • Kristen Vogel, MS, CGC • GYN Cancers Navigation • Penny Daugherty, BSN, RN, OCN • Prostate Cancer Navigation • Head, Neck, & Neuro Navigation • Tamara Bowen, RN, BSN, MHA • Pediatric Oncology • Kathy Ruble, RN, CPNP, PhD • Hematology/Oncology Navigation • Melanoma Navigation • Sherry Riggins, RN, BSN, OCN 10:30 am - 11:15 am BREAK IN THE EXHIBIT HALL 11:15 am - 12:00 pm General Session 11: Understanding the Role of the Primary Care Physician • Michael Kolodziej, MD 12:15 pm - 1:15 pm Lunch/Product Theater (non–CME-certified activity) 1:30 pm - 2:15 pm General Session 12: Navigator’s Role in End-of-Life Care • Lillie D. Shockney, RN, BS, MAS 2:15 pm - 3:00 pm General Session 13: Music & Medicine: A Dynamic Partnership • Deforia Lane, PhD, MT-BC 3:00 pm - 3:15 pm Conclusion of the Conference/Final Remarks • Conference Co-Chairs: Sharon Gentry, RN, MSN, AOCN, CBCN Lillie D. Shockney, RN, BS, MAS *Preliminary agenda, subject to change.

Survivorship Conference

ody Memphis • Memphis, Tennessee CONFERENCE CO-CHAIRS Program Director: Lillie D. Shockney, RN, BS, MAS University Distinguished Service Associate Professor of Breast Cancer Depts of Surgery and Oncology Adm Director, Johns Hopkins Breast Center Adm Director, Johns Hopkins Cancer Survivorship Programs Associate Professor, JHU School of Medicine Depts of Surgery, Oncology & Gynecology and Obstetrics Associate Professor, JHU School of Nursing Baltimore, MD

FACULTY* Swann Arp Adams, PhD, MS Tamara Bowen, RN, BSN, MHA Gean Brown, RN, OCN

Penny Daugherty, BSN, RN, OCN Darcy Doege, RN, BSN Karen Dow Meneses, PhD, RN, FAAN Linda Ferris, PhD Sharon Gentry, RN, MSN, AOCN, CBCN

Jennifer Klemp, PhD, MPH, MS Michael Kolodziej, MD Deforia Lane, PhD, MT-BC Linda Lee, MD, AGAF

CONFERENCE OVERVIEW

AONN’s Fourth Annual Conference will continue to advance the navigation profession by expanding the scope of educational sessions, networking opportunities, and poster presentations. In addition, this year’s conference will address the evolving challenges of program improvement, the role of personalized medicine, and implementing best practices in navigation, survivorship, and psychosocial care.

TARGET AUDIENCE

This activity was developed for oncology nurse navigators, patient navigators, social workers, and case managers.

CONTINUING EDUCATION INFORMATION

Learning Objectives Upon completion of this activity, the participant will be able to: • Discuss the evolution of the role of navigation in healthcare.

• Assess strategies for navigating diverse patient populations by cancer type and environmental factors.

• Define methods for providing patient support and guidance in the age of personalized cancer care.

• Evaluate best practices regarding survivorship and psychosocial care.

Nicole Messier, RN, BSN Vinnie Myers Michele O’Brien, MSN, ACNS-BC, RN, BA

Liz Danielson, MHA

Danelle Johnston, RN, MSN, OCN, CBCN

Sharon Gentry, RN, MSN, AOCN, CBCN Breast Nurse Navigator Derrick L. Davis Forsyth Regional Cancer Center Winston-Salem, NC

Laurie Mathis, RN, CBCN, OCN

Dan O’Connor Mandi Pratt-Chapman, MA Sherry Riggens, RN, BSN, OCN Christy Roberts, RN, BSN, OCN Kathy Ruble, RN, CPNP, PhD Elaine Sein, RN, BSN, OCN, CBCN Lillie D. Shockney, RN, BS, MAS Tricia Strusowski, MS, RN Kristen Vogel, MS, CGC Michelle Weaver Knowles, RNC, BSN *For full information visit www.aonnonline.org

SPONSORS

This activity is jointly sponsored by Medical Learning Institute Inc, Center of Excellence Media, LLC, and Core Principle Solutions, LLC.

COMMERCIAL SUPPORT ACKNOWLEDGMENT

Grant requests are currently being reviewed by numerous supporters.

Support will be acknowledged prior to the start of the educational activities.

REGISTERED NURSE DESIGNATION

Medical Learning Institute Inc. Provider approved by the California Board of Registered Nursing, Provider Number 15106, for up to 16.25 contact hours.

2013 CONFERENCE REGISTRATION

www.aonnonline.org /conference

L-AONN-13_Ksize 50813

Survivorship

Healthcare Providers’ Knowledge of the Benefits of Cancer Rehabilitation Lillie D. Shockney, RN, BS, MAS, Johns Hopkins University School of Medicine Julie K. Silver, MD, Harvard Medical School Elissa Bantug, MHS, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center Laurie Sweet, PT, The Johns Hopkins Hospital R. Samuel Mayer, MD, Johns Hopkins University School of Medicine Michael Friedman, PT, MBA, The Johns Hopkins Hospital Introduction: Cancer survivor numbers are increasing due to enhanced treatment and an aging population; however, survivors often suffer ongoing side effects from cancer and its treatments. Nurses and other key oncology staff are instrumental in working with cancer patients to help screen them for and refer them to critical support services, such as cancer rehabilitation. The purpose of this study was to address whether healthcare providers, particularly oncology nurses, have adequate knowledge about the benefits of cancer rehabilitation to facilitate appropriate patient referrals.

Methods: Members of the Academy of Oncology Nurse Navigators (AONN) were e-mailed and invited to fill out an online survey based on relevant research literature, clinical experience, and expert opinion from multidisciplinary perspectives. Questions included a self-assessment of knowledge about cancer rehabilitation.

Results: The survey was voluntarily completed by 401 members of the AONN. The majority of respondents were registered nurses (60.3%), and 34.4% identified themselves as oncology nurse navigators. Most of the respondents work in community hospitals (56.6%), academia (16.5%), or freestanding oncology practices (9.7%). When asked “How would you rate your own knowledge about the benefits of and appropriate referrals for cancer rehabilitation?” only 13.2% rated their knowledge in the highest category, “Extremely Knowledgeable.” When asked how they would rate their colleagues’ knowledge, only 4.5% considered their colleagues “Extremely Knowledgeable.” Overall, approximately 50% of the participants rated their own knowledge of the benefits of cancer rehabilitation and referrals in the lowest 2 knowledge categories. The participants generally rated their colleagues’ knowledge even lower, with 66% rating their colleagues in the lowest 2 knowledge categories. Finally, when asked how important the role of nursing navigation is when accessing cancer rehabilitation services, 90% of respondents found it to be “Very Important” or “Important,” while only 10% rated it as “Somewhat Important” or “Not Important.”

Conclusion: Approximately half of the oncology healthcare provider participants rated their own knowledge about the benefits of cancer rehabilitation and appropriate referrals for care as relatively low. Overall, they rated their colleagues’ knowledge even lower than their own. Successful patient-centered cancer care that provides optimal functional and quality-of-life outcomes must incorporate cancer rehabilitation into the care continuum. This study suggests that many oncology healthcare professionals may benefit from further education about the benefits of evidence-based cancer rehabilitation care.

M

ore than 40% of individuals born today will develop some type of cancer during their lifetime.1 It is estimated that 66% of the approximately 12 million individuals living with a diagnosis of cancer today will survive at least 5 years after their diagnosis.1 In 2010, Mariotto and colleagues reported that healthcare costs for approximately 13.8 million cancer survivors were estimated to be $124.57 billion.2 Their research demonstrated that based on current growing incidence and improved survival rates, by 2020 the volume of cancer survivors will swell to at least 18.1 million, generating an annual cost of $157.77 billion that year.2 Indirect costs of cancer survivorship (eg,

12

April/May 2013 • Volume 4, Issue 2

lost wages, caregiver burdens, transportation, and adaptive equipment) are difficult to quantify in the United States with its decentralized healthcare system. However, in Poland health economists estimate that work loss due to cancer accounts for 0.8% of its gross domestic product (GDP).3 With a US GDP of approximately $15 trillion, the equivalent cost would be $120 billion.

The World Health Organization (WHO) defines rehabilitation as “processes intended to enable people with disabilities to reach and maintain optimal physical, sensory, intellectual, psychological and/or social function.”4 Historically, nursing, medical, and allied health students

AONNonline.org

Survivorship

have been educated about rehabilitation as it relates primarily to neuromusculoskeletal impairments. The focus of education about these conditions is how to diagnose and treat impairments as well as assist patients with their physical activity level—returning them as closely as possible to their premorbid functional baseline. Regardless of whether a patient has an acute or chronic illness or injury, rehabilitation interventions focus on function and a return to usual daily activities. An interdisciplinary team approach is most advantageous for providing comprehensive care.

Cancer rehabilitation programs were established in the 1970s after research started to demonstrate the efficacy of interventions.5,6 As new studies were published, hospitals and cancer centers developed some rehabilitation services that were usually for either specific patient populations (eg, breast cancer survivors) or particular problems (eg, treating lymphedema). Unfortunately, clinical services may not have kept up with the rapidly growing body of research that supports cancer rehabilitation interventions. In fact, according to a recent meta-analysis of cancer rehabilitation literature (1743 publications retrieved from 19672008), cancer rehabilitation publications have grown 11.6 times while the whole field of disease rehabilitation has grown only 7.8 times.7 As mentioned, despite the growing research supporting cancer rehabilitation care, clinical services may not be keeping up. Certainly, there is reason to conclude from the recent literature that many patients have unmet rehabilitation needs. For example, in a 2008 study Cheville and colleagues found that in 163 women with metastatic breast cancer, 92% had at least one physical impairment, and overall 530 impairments were identified.8 More than 90% of the participants needed cancer rehabilitation services, but fewer than 30% received this care. In a 2011 study by Thorsen and colleagues evaluating 1325 survivors of the 10 most prevalent cancers, 63% reported the need for at least 1 rehabilitation service, with physical therapy being the most frequently reported need (43%).9 In that study, 40% of the participants reported unmet rehabilitation needs.

The importance of screening individuals for both physical and psychological impairments and then facilitating appropriate referrals to qualified healthcare providers who are trained to treat them is critical to optimal cancer care.10 Because cancer survivors often have multiple impairments that affect many different organ systems, using a “problem-focused” approach within a single rehabilitation discipline is often not as effective as a more comprehensive approach by a team of professionals. Today, there is a growing trend toward developing cancer survivorship resources, including evidence-based cancer rehabilitation interventions, as a distinct part of cancer care.11 Similar to patients in other models of care, such as those for stroke,

spinal cord injury, or orthopedic rehabilitation, cancer survivors are ideally treated by an interdisciplinary team that includes, but is not limited to, physiatrists, rehabilitation nurses, physical therapists, occupational therapists, and speech language pathologists. For example, it is somewhat common for a breast cancer patient to experience arm and shoulder range-of-motion issues from surgery, fatigue from radiation, and peripheral neuropathy from chemotherapy. An interdisciplinary approach would allow for these diverse needs to be addressed.12 Similarly, a head and neck cancer survivor may have multiple impairments including speech and swallowing issues as well as cervical range-of-motion limitations. Indeed, cancer survivors are often “complex” patients who have undergone significant physical and emotional trauma and therefore have multiple sequelae. If the goal of optimal function is to be achieved, this complexity requires interventions from more than 1 rehabilitation discipline.

Cancer rehabilitation programs were established in the 1970s after research started to demonstrate the efficacy of interventions. As new studies were published, hospitals and cancer centers developed some rehabilitation services that were usually for specific patient populations.

Likely many barriers exist to cancer rehabilitation care.13 One barrier to these unmet needs may be a lack of healthcare providers’ awareness of the benefits of rehabilitation for survivors. Another barrier may be a lack of understanding of the unmet need for these services. Barriers may result from oncology providers believing that treatment-related sequelae are expected and normal and simply need to be tolerated by patients. This translates into a general lack of understanding of the role that rehabilitation may have in reducing or even preventing side effects that are physically challenging and psychologically disabling.14 The aim of this study is to address whether healthcare providers—particularly oncology nurses and a subset of this group, navigators—have adequate knowledge about the benefits of cancer rehabilitation to facilitate appropriate referrals (ie, to navigate patients to this care).

Numerous professional organizations in the United States have recognized the need for formal cancer rehabilitation programs and “best practices” care models. For example, the Oncology Nursing Society (ONS) and the As-

JONS-online.com journal of Oncology Navigation & Survivorship

13

Survivorship

Figure 1 Survey of Participants’ Practice Setting Community Hospital Academic Medical Center Freestanding Oncology Group Practice City Hospital Freestanding Breast Center Other

8 (2.0%)

46 (11.5%)

15 (3.7%)

39 (9.7%)

227 (56.6%)

66 (16.5%)

sociation of Rehabilitation Nurses (ARN) have issued a joint position paper recognizing the importance of and need for cancer rehabilitation.15 The American Academy of Physical Medicine and Rehabilitation (AAPMR) and the American Physical Therapy Association (APTA) have de-

Cancer rehabilitation is one of the key services that must be provided by all CoC-accredited institutions, and nursing navigation is considered an important trend in the provision of high-quality cancer care. veloped special interest groups for their clinicians who are focusing on cancer rehabilitation in their practices. The American Occupational Therapy Association (AOTA) has identified cancer rehabilitation as an emerging area of practice, and the American Speech and Hearing Association (ASHA) produced a treatment efficacy summary on swallowing disorders for head and neck cancer.16 The American College of Surgeons’ Commission on Cancer (CoC) has made cancer rehabilitation a key service that accredited fa-

14

April/May 2013 • Volume 4, Issue 2

cilities must offer either onsite or by referral.17 As the interest in conducting survivorship care research grows, particularly in the face of the anticipated oncology specialist shortage that will likely result in survivors not being seen as often or perhaps at all by their oncologist, there is a need to focus on the role that rehabilitation may play in improving care. Oncology nurses, particularly navigators, are at the forefront of assisting patients in getting the best possible care and addressing their needs during and after treatment.

Therefore, it is imperative that they have an in-depth understanding of the benefits of cancer rehabilitation and facilitate appropriate referrals to rehabilitation medicine professionals (particularly physiatrists and physical, occupational, and speech therapists).11 Cancer rehabilitation is one of the key services that must be provided by all CoC-accredited institutions, and nursing navigation is considered an important trend in the provision of high-quality cancer care. In fact, the CoC has announced that patient-centered care is the focus of the new accreditation requirements, and documented navigation is part of these requirements.17 Many hospitals and cancer centers have already seen the value of having nurses drive the navigation process, and others are moving toward fulfilling this new requirement by implementing nursing navigation. Further, implementation of the survivorship care plan, another new CoC requirement, will almost certainly help demonstrate the success of navigation for an individual patient, for hospitals, and even entire systems of care. In addition, the survivor care plan will clearly document whether patients were referred for rehabilitation services. Despite the focus on patient-centered navigation care with implementation of a survivorship care plan that should document rehabilitation services when appropriate, many survivors may not currently, or even in the future, receive appropriate evidence-based rehabilitation interventions.

Methods: The research team developed a unique survey on the basis of the relevant research literature, clinical experience, and expert opinion from multidisciplinary perspectives. Ethics approval was obtained from the Johns Hopkins University Internal Review Board. The Academy of Oncology Nurse Navigators (AONN) distributed a dedicated e-mail link to 10,037 potential participants, including members and e-mail subscribers, and posted the survey link in their e-newsletter. All potential respondents were invited to participate in the 25-question online survey beginning in February 2012. The AONN was founded in 2009 and consists of more than 2000 members. Membership is open to all nurse, social work, and lay professional navigators. In addition, the organization welcomes any healthcare professional or advocate.

Results: The survey was voluntarily completed by 401 healthcare professionals, and all participants completed the

AONNonline.org

Survivorship

Figure 2 Reported Volume of New Cancer Patients Diagnosed Annually 120

Number of participants

entire survey without skipping any questions. The majority of the respondents, 242 (60.3%), were registered nurses.

Participants could select more than 1 professional category description. One hundred thirty-eight (34.4%) participants identified themselves as oncology nurse navigators, and 29 (7.2%) as nurse practitioners. Non-nurse participants offered numerous descriptions of their professional roles including, but not limited to, researcher or research coordinator (6), social worker (4), registered dietician (3), physician (1), psychologist (1), physical therapist (1), occupational therapist (1), wellness coach (1), quality improvement coordinator (1), and certified tumor registrar (1).

The majority of the participants, 227 (56.6%), reported that they worked at a community hospital (Figure 1). The next most common practice setting, reported by 66 (16.5%) participants, was an academic medical center. In the “Other” category, the most commonly listed settings were National Cancer Institute (NCI)-designated comprehensive cancer centers (5; 1.2%) and Veterans Administration/military institutions (4; 1.0%). More than 1 of 4 participants reported working in a high-volume setting with more than 1000 new cancer patients diagnosed annually (Figure 2).

One of the central questions in the survey was, “How would you rate your own knowledge about the benefits of and appropriate referrals for cancer rehabilitation?” Only 53 (13.2%) of the healthcare professionals rated their knowledge in the highest category of “Extremely Knowledgeable” (Table 1). Interestingly, in a follow-up question about how the participants would rate their current colleagues’ knowledge about the benefits of and appropriate referrals for cancer rehabilitation, the ratings were even lower, with only 18 (4.5%) stating that their colleagues were “Extremely Knowledgeable” (Table 1). At the other end of the spectrum, 62 (15.5%) participants rated their own knowledge in the lowest category, “Not Very Knowledgeable,” and an even higher number, 96 (23.9%), rated their colleagues’ knowledge in this lowest category.

A third question, designed to determine how the participants defined the role of nursing navigation in relation to accessing cancer rehabilitation services, was “How important is the nurse navigator’s role in helping patients access cancer rehabilitation services?” More than half of the participants, 225 (56.1%), believed that the nurse navigator role was “Extremely Important,” and 136 (33.9%) selected “Important”—for a total of 361 (90.0%) rating the role of nurse navigators in the top 2 categories of importance (Table 2). Alternately, only 10% of the participants rated the role of nurse navigator in helping patients to access cancer rehabilitation services as a relatively low priority.

In summary, the results of this survey demonstrated that the participants rated their own knowledge of cancer rehabilitation higher than that of their colleagues, and the vast

106 (26.4%)

100 74 (18.5%)

80

88 (21.9%)

74 (18.5%)

60

59 (14.7%)

40 20 0

>1000

601-1000

301-600

1-300

Not sure

Number of new cancer patients diagnosed annually

Table 1 Reported Knowledge About Cancer Rehabilitation How would you rate your own knowledge about the benefits of and appropriate referrals for cancer rehabilitation?

Number of Participants

Percent of Participants

Extremely Knowledgeable

53

13.2

Knowledgeable

157

39.2

Somewhat Knowledgeable

129

32.2

Not Very Knowledgeable

62

15.5

At your current institution, how would you rate your colleagues’ knowledge about the benefits of and appropriate referrals for cancer rehabilitation?

Number of Participants

Percent of Participants

Extremely Knowledgeable

18

4.5

Knowledgeable

118

29.4

Somewhat Knowledgeable

169

42.1

Not Very Knowledgeable

96

23.9

majority of responders believed that nurse navigators have a critical role in helping patients to access these services.

Discussion: It is important for all oncology healthcare professionals to understand the role of evidence-based cancer rehabilitation. Oncology nurse navigators may be uniquely positioned and qualified to facilitate referrals for this care across the cancer care continuum. Therefore,

JONS-online.com journal of Oncology Navigation & Survivorship

15

Survivorship

Table 2 R eported Importance of Nurse Navigator in Facilitating Cancer Rehabilitation How important is the nurse navigator’s role in helping patients access cancer rehabilitation services?

Number of Percent of Participants Participants

Extremely Important

225

56.1

Important

136

33.9

Somewhat Important

34

8.5

Not Important

6

1.5

their knowledge of the application and value of cancer rehabilitation services is critical to the success of treatment and optimal patient outcomes. Gaining a better understanding of oncology healthcare professionals’ knowledge and referral practices, with particular attention to nurse navigators, may help in identifying deficits that need to be addressed within the current training curriculum as well as in continuing education once in practice. There is no doubt that cancer rehabilitation is an important component of survivorship care.10 This is the first study designed to evaluate a group of oncology healthcare professionals’ assessment of their knowledge about cancer rehabilitation.

AONN members were asked to rate their own knowledge and that of their colleagues about cancer rehabilitation.

When given the choices “Extremely Knowledgeable,” “Knowledgeable,” “Somewhat Knowledgeable,” or “Not Very Knowledgeable,” only 13.2% of participants rated their knowledge about the importance of cancer rehabilitation in the highest category of “Extremely Knowledgeable,” which translated to 86.8% rating themselves as less than extremely knowledgeable. When asked how participants would rate their colleagues’ knowledge, only 4.5% stated that their colleagues were “Extremely Knowledgeable,” which translated to 95.5% of the participants rating their colleagues as less than extremely knowledgeable.

Overall, approximately 50% of the participants rated their own knowledge of the benefits of cancer rehabilitation and referrals for care in the lowest 2 knowledge categories. The participants generally rated their colleagues’ knowledge even lower—with approximately 2 of 3 (66%) rating their colleagues in the lowest 2 knowledge categories.

Lack of knowledge about the benefits of and appropriate referrals for cancer rehabilitation may present a major barrier to the provision of this type of medical treatment. It makes sense that all healthcare professionals involved in cancer care should be extremely knowledgeable about appropriate referrals for cancer rehabilitation treatment. The results of this study are concerning and suggest that there

16

April/May 2013 • Volume 4, Issue 2

is significant room for improvement in meeting this standard and thereby helping to address the unmet rehabilitation needs of survivors.

Nurse navigators play a central role in patient-centered care. Although most healthcare professionals (90% in this study) would agree that oncology nurse navigators should play a critical role in helping patients to access cancer rehabilitation care, nearly 10% of the respondents rated this as “Not Important.” These results confirm the need to further educate healthcare professionals about cancer rehabilitation. Navigation through a complex oncology care continuum, including cancer rehabilitation, is of utmost importance for the best possible outcomes for patients with regard to both quantity and quality of life.

Oncology nurse navigators may have an opportunity to proactively refer patients to cancer rehabilitation programs or service-lines in order to reduce or prevent long-term side effects. Short- and long-term side effects may otherwise go undertreated and perhaps even totally unaddressed. These referrals may also decrease physical, emotional, and financial hardships. The nurse navigator can play an integral part in the assessment and referral process on behalf of newly diagnosed cancer patients, as well as those who have completed treatment and were not afforded the opportunity to receive cancer rehabilitation care.

The first consideration for referral to cancer rehabilitation may be made at the initial contact with the patient. For example, a woman who was just diagnosed with breast cancer and will be undergoing a mastectomy and other treatments may be entering surgery with preexisting shoulder problems (eg, rotator cuff impingement) that postoperatively could lead to more significant shoulder complications including adhesive capsulitis (“frozen shoulder”). Therefore, screening the individual, identifying the impairment, and then facilitating an early referral to cancer rehabilitation, perhaps even before treatment begins or during treatment, may be warranted. This is not to suggest delays in cancer treatment as that may produce adverse outcomes.18 Cancer prehabilitation may also improve functional outcomes—helping newly diagnosed patients to become as physically and emotionally strong as possible prior to the start of oncology interventions.19,20 Unlike the traditional process during which a patient becomes physically deconditioned as a result of treatment, surgery, and/or a sedentary lifestyle, ideal cancer rehabilitation would be introduced early, perhaps even at the prehabilitation stage, so that the patient could maintain function and activity levels during and after treatment.

The philosophy regarding the timing of making a cancer rehabilitation referral and the expectations and outcomes of rehabilitation medicine is changing. Historically the mission of cancer treatment was survival. Patients who

AONNonline.org

Survivorship

were survivors of their disease were advised to accept their “new normal,” which would consist of whatever their physical functioning and emotional well-being became as an outcome of their “successful” cancer treatment. The translation for new normal may be considered to be a medical end point at which further treatment will not improve health outcomes. For many survivors, the advice to accept a new normal or medical end point is offered too soon and without implementation of evidence-based rehabilitation interventions that may improve outcomes. Long after treatment, cancer patients often experience a plethora of side effects, including fatigue, shortness of breath, cardiac complications, pain, depression, range-of-motion limitations, and cognitive functioning problems. Practitioners often view survival as the end point, without enough regard for these quality-of-life issues that remain after cancer treatment ends or, at least, without a thorough understanding of what rehabilitation treatment may provide.

Ideally, the care goals would include preventing as much deconditioning as possible during acute cancer treatments and thereby requiring less reconditioning after treatment is completed. Utilizing this model, the mission is to be proactive in minimizing fatigue, peripheral neuropathy, insomnia, decline in function, lymphedema, pain, and other common side effects associated with some forms of cancer treatment. As the number of individuals diagnosed with cancer has steadily increased along with the number of cancer patients surviving long term, the goals (beyond survival) mandated by patients have evolved.21 Cancer patients today express their opinions and expectations that survival is just 1 component of a good outcome. Quality of life is of utmost importance to cancer survivors.

In summary, this study found that approximately half of the oncology healthcare provider participants rated their own knowledge about the benefits of cancer rehabilitation and appropriate referrals for care as relatively low. Overall, they rated their colleagues’ knowledge as even lower than their own. There is emerging evidence that a large majority of cancer patients could benefit from cancer rehabilitation. Successful patient-centered cancer care that provides optimal functional and quality-of-life outcomes must incorporate cancer rehabilitation into the care continuum.

This study suggests that many oncology healthcare professionals may benefit from further education about the benefits of evidence-based cancer rehabilitation care. g Acknowledgement: The authors acknowledge and thank Julie A. Poorman, PhD, for her assistance with manuscript preparation.

Disclosures: Lillie D. Shockney, RN, BS, MAS, is the program director for AONN; Julie K. Silver, MD, is

co-founder of Oncology Rehab Partners; Laurie Sweet, PT, is an employee of The Johns Hopkins Hospital. All other authors have nothing to disclose.

Corresponding author: Lillie D. Shockney, RN, BS, MAS, Johns Hopkins University School of Medicine, 601 N Caroline St, Room 4161, Baltimore, MD 21287; e-mail: shockli@jhmi.edu.

The Role of the Nurse Navigator in Cancer Rehabilitation The nurse navigator is well positioned to intervene on behalf of the patient in recommending (or, in some settings, actually executing) a referral to cancer rehabilitation. The goals of the rehabilitation interventions are to prevent deconditioning and short- and long-term side effects and to maintain activities of daily living (ADLs) and instrumental activities of daily living (IADLs) that include not only such tasks as dressing and bathing, but also grocery shopping, returning to work, and other higher level functioning. However, this position requires nurse navigators to be very knowledgeable about the important role that rehabilitation plays in cancer treatment and includes a special need to understand the value of being proactive instead of reactive in making a referral. There is both the need and opportunity for nurse navigators to be skilled at identifying impairments and referring patients appropriately for services to treat these impairments.22

Sample Screening Tool for Cancer Rehabilitation Consultations It is important to work with the rehabilitation staff to identify patients who would benefit most from their services. Appendix A (page 19) provides a sample of the quick screening tool that is used at Johns Hopkins to quickly assess whether breast cancer patients should be referred for rehabilitation.

References

1. Surveillance, Epidemiology and End Results. SEER Stat Fact Sheets: All Sites. http://seer.cancer.gov/statfacts/html/all.html. Published 2011. Accessed March 28, 2012.

2. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst.

2011;103(2):117-128. Erratum published in J Natl Cancer Inst. 2011;103(8):699.

3. Macioch T, Hermanowski T. The indirect costs of cancer-related absenteeism in the workplace in Poland. J Occup Environ Med. 2011;53(12):1472-1477.

4. Medical care and rehabilitation: what WHO is doing. World Health Organization Web site. http://www.who.int/disabilities/care/activities/en/. Updated 2012. Accessed August 22, 2012.

JONS-online.com journal of Oncology Navigation & Survivorship

17

Survivorship

5. Dietz JH Jr. Rehabilitation of the cancer patient. Med Clin North Am. 1969;53(3):607-624.

6. Lehmann JF, DeLisa JA, Warren CG, et al. Cancer rehabilitation: assessment of need, development, and evaluation of a model of care. Arch Phys Med Rehabil. 1978;59(9):410-419.

7. Ugolini D, Neri M, Cesario A, et al. Scientific production in cancer rehabilitation grows higher: a bibliometric analysis. Support Care Cancer. 2012; 20(8):1629-1638.

8. Cheville AL, Troxel AB, Basford JR, Kornblith AB. Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. J Clin Oncol. 2008;26(16):2621-2629.

9. Thorsen L, Gjerset GM, Loge JH, et al. Cancer patients’ needs for rehabilitation services. Acta Oncol. 2011;50(2):212-222.

10. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. In press.

11. Silver JK, Gilchrist LS. Cancer rehabilitation with a focus on evidence-based outpatient physical and occupational therapy interventions. Am J Phys Med Rehabil. 2011;90(5 suppl 1):S5-S15.

12. Silver JK. Rehabilitation in women with breast cancer. Phys Med Rehabil Clin N Am. 2007;18(3):521-537.

13. Silver JK. Strategies to overcome cancer survivorship care barriers.

PM&R. 2011;3(6):503-506.

14. Binkley JM, Harris SR, Levangie PK, et al. Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer. Cancer. 2012;118(8 Suppl):2207-2216.

15. Oncology Nursing Society and Association of Rehabilitation Nurses: joint position on rehabilitation of people with cancer 2006. Oncology Nursing Society. http://www.ons.org/publications/media/ons/docs/positions/ rehabilitation.pdf. Accessed April 1, 2013.

16. Ashford JR, Logemann JA, McCullough G. Treatment efficacy summary: swallowing disorders (dysphagia) in adults. American Speech-Language-Hearing Association Web site. http://www.asha.org/uploadedFiles/public/TESDysphagiain Adults.pdf. Accessed August 22, 2012.

17. Cancer Program Standards 2012: Ensuring Patient-Centered Care. V1.1.

American College of Surgeons. Commission on Cancer. http://www.facs.org/ cancer/coc/programstandards2012.pdf. Accessed August 22, 2012.

18. Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305(22):2335-2342.

19. Mayo NE, Feldman L, Scott S, et al. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery. 2011;150(3):505-514.

20. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options and improve physical and psychological health outcomes. Am J Phys Med Rehabil. In press.

21. Cheema FN, Abraham NS, Berger DH, et al. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults. Ann Surg. 2011;253(5):867-874.

22. Schmitz KH, Stout NL, Andrews K, et al. Prospective evaluation of physical rehabilitation needs in breast cancer survivors: a call to action. Cancer. 2012;118(suppl 8):2187-2190.

WCMC_2013Conf_horizontalV382012_Layout 1 8/20/12 9:44 AM Page 1

SECOND ANNUAL CONFERENCE

2013 WORLD CUTANEOUS MALIGNANCIES CONGRESS

TM

• Melanoma • Basal Cell Carcinoma • Cutaneous T-Cell Lymphoma

• Squamous Cell Carcinoma • Merkel Cell Carcinoma

July 26-28, 2013 Hyatt Regency La Jolla • at Aventine 3777 La Jolla Village Drive • San Diego, California

18

April/May 2013 • Volume 4, Issue 2

AONNonline.org

Survivorship

Appendix A Sample Screening Tool for Cancer Rehabilitation Consultations

Screening Tool for Cancer Rehabilitation Program Referral Please check yes or no for the following questions. Answer of yes to any of the questions or a check of any of the Problem List items qualifies for referral to Cancer Rehabilitation.

Yes

No

Can you return to your usual activities?

Are you experiencing pain that is limiting your ability to perform daily activities?

Are you tired or experiencing fatigue that is limiting your ability to perform daily activities?

Are you having difficulty with memory or concentration?

Are you having problems with balance or coordination?

Problem List h Difficulty returning to premorbid activities

h Scar adhesions (postsurgical)

h Weakness/paralysis

h Shoulder problems

h Fatigue

h Postmastectomy pain syndrome (PMPS)

h Musculoskeletal or neuropathic pain

h Brachial plexopathy (eg, radiation-induced)

h Cognitive problems

h Urinary incontinence

h Perceptual problems

h Compression neuropathy

h Balance problems

h Bowel/Bladder incontinence

h Gait problems

h Swallowing issues

h History of falls

h Speech problems

h Sensory deficits

h Limited jaw excursion

h Speech issues

h Difficulty with cervical range of motion

h Swallowing problems

h Muscular asymmetry

h Difficulty w/ADLs (dressing/bathing, etc.) or shoulder problems

h Lymphedema

h Difficulty w/IADLs (chores/shopping, etc.) h Adaptive equipment needs h Durable medical equipment (DME) needs h General deconditioning (needs instruction on an appropriate exercise program)

h Postmastectomy pain syndrome h Radiation fibrosis syndrome (RFS) h Chemotherapy-induced polyneuropathy (CIPN) h Lumbosacral plexopathy h Scapular winging h Other:________________________

JONS-online.com journal of Oncology Navigation & Survivorship

19

Journal of Oncology

NAVIGATION & SURVIVORSHIP

速

The Official Journal of the Academy of Oncology Nurse Navigators 速

Submita Manuscript! www.AONNonline.org/manuscripts

The ONLY journal focused on patient navigation and survivorship care in oncology patients If you have any questions about the Journal of Oncology Navigation & Survivorship, please contact our editorial department at editorial@greenhillhc.com

JONSAsize60413

commentary

Lung Cancer Screening in the “Real World” and the Role of Nurse Navigators David E. Gerber, MD, Department of Internal Medicine (Division of Hematology-Oncology), Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas Alletrice O. Gillam, RN, BSN, OCN, Outpatient Lung/ENT Clinic, Parkland Health & Hospital System, Dallas, Texas Heidi A. Hamann, PhD, Department of Clinical Sciences (Division of Behavioral & Communication Sciences), Department of Psychiatry (Division of Psychology), Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas

S

ince the publication of the positive results of the National Lung Screening Trial (NLST)—the first lung cancer screening trial to demonstrate a reduction in lung cancer mortality—in the New England Journal of Medicine in 2011,1 several uncertainties regarding implementation of widespread lung cancer screening have arisen. Questions have focused on cost-effectiveness,2-4 the importance of smoking cessation,5 the high rate of false-positive screening studies,6,7 and the complexity and risks of subsequent biopsies and invasive staging procedures.8 However, little attention has been focused on protocol adherence and other navigational needs involved in such a program. Lung cancer screening represents a complex, multistep process, entailing at minimum 3 annual computed tomography (CT) scans, as well as additional imaging and/or biopsies for the projected 40% of individuals with suspicious radiographic findings.1 Given this complexity, characteristics of the target population, and experience in other cancer screening modalities, we anticipate that adherence will be a major factor in the feasibility and impact of lung cancer screening. We suggest that the unique skills of nurse navigators will be needed to guide patients through the complex screening protocol and assist with psychosocial and behavioral aspects.

WHAT DID THE NATIONAL LUNG SCREENING TRIAL SHOW? In this multicenter study,1 over 53,000 high-risk participants were randomized 1:1 to annual chest x-ray (CXR) or low-dose helical CT scans for 3 years. Eligible patients were ages 55 to 74 years, had smoked at least 30 pack-years, had quit within the previous 15 years if former smokers, had no prior history of lung cancer, and had not undergone a chest CT in the preceding 18 months. In the CT arm, 24% of the screening studies were positive, of which 96% were false positives. There was a 20% reduction in lung cancer mortality and a 6.7% reduction in all-cause mortality in the CT arm. Impressively, adherence to the screening protocol across the 3 rounds was 95% in the CT arm and 93% in the CXR arm.

WHO PARTICIPATED IN THE NLST? From August 2002 through April 2004, eligible participants were enrolled at 33 primarily academic centers in the United States.1 Recruitment strategies included direct mailings, local radio and newspaper advertisements, community outreach programs, and websites.9 Targeted recruitment of minority populations included translation of recruitment materials into multiple languages, advertising at minority-focused conferences, and using minority “ambassadors” in community settings. Approximately 60% of participants were men, and the mean age of the entire cohort was 60 years. Over 90% were white, 4% were black, and 2% were of Hispanic or Latino ethnicity.

How do these characteristics compare with the overall NLST-eligible US population? Reviewing the Census Department’s Tobacco Use Supplement of the Continuing Population Survey for 2002-2004 (the years of NLST recruitment) and focusing on NLST age and smoking history requirements, NLST participants were slightly younger but had similar sex and race/ethnicity distributions.9 However, NLST subjects were substantially more educated, with only 79% of the NLST-eligible US population having a high school diploma (compared with almost 94% of NLST participants) and 14% having at least a college degree (compared with 32% of NLST participants). NLST participants were less likely than the NLST-eligible population to be current (as opposed to former) smokers (48% vs 57%, respectively).9 AN NLST-ELIGIBLE POPULATION MAY BE AT HIGH RISK FOR NONADHERENCE AND HAVE UNIQUE BEHAVIORAL RESOURCE NEEDS In the setting of a prospective clinical trial, NLST subjects were likely to have been highly motivated, monitored closely, and offered necessary behavioral and psychosocial resources. Outside of such a context, it is not known to what extent an eligible population will adhere to annual CT screens and subsequent evaluation of positive scans.

Disparities in smoking status and education between

JONS-online.com journal of Oncology Navigation & Survivorship

21

commentary

NLST participants and screening-eligible individuals raise adherence concerns. Numerous studies have demonstrated that current smoking is associated with reduced adherence to medical recommendations, including breast, cervical, and colorectal cancer screening.10-16 For example, the Year 2000 Cancer Control Module of the National Health Interview Survey (CCM-NHIS) showed 12-month interval repeat mammography rates for 55- to 79-year-old women of 36% among current smokers compared with 44% of <6 year quitters and 58% of 6+ year quitters.15 In addition, among Spanish participants in the International Early Lung Cancer Action Program (I-ELCAP; a consortium of lung cancer screening sites), former smokers had better adherence to screening than did current smokers.17 Lower education is also a well-established predictor of nonadherence for breast, cervical, and colorectal cancer screenings.18,19 For example, CCM-NHIS data noted 12-month interval repeat mammography adherence of 35% among those with less than a high school education, compared with 63% of college graduates.15 Within an Early Lung Cancer Action Program study in the United States, a college degree was also predictive of adherence to the CT screening process.20

Across all aspects of the cancer care continuum (eg, screening, treatment, follow-up), nurse navigators provide instrumental and emotional support, address barriers to patient care, coordinate referrals, and strengthen patient-provider relationships.

It is also not clear to what extent behavioral and psychosocial aspects (eg, smoking cessation, fears about lung cancer) will be addressed in lung cancer screening outside of a clinical trial setting. Lung cancer screening has been described as an important “teachable moment” in which smokers may be cognitively and psychologically primed for evidence-based cessation education and psychosocial interventions.21 A recent cost-effectiveness model for lung cancer screening clearly demonstrated the financial benefits of increased rates of smoking cessation among screening participants,2 and commentators have advocated for the addition of evidence-based cessation interventions to screening programs. However, it is not yet clear how smoking cessation and other behavioral resources would be incorporated into screening efforts or who would lead them.

22

April/May 2013 • Volume 4, Issue 2

HOW CAN NURSE NAVIGATION BE INCORPORATED IN LUNG CANCER SCREENING? Across all aspects of the cancer care continuum (eg, screening, treatment, follow-up), nurse navigators provide instrumental and emotional support, address barriers to patient care, coordinate referrals, and strengthen patient-provider relationships.21-23 Navigation strategies have improved adherence to established screening processes for other malignancies, with the greatest impact among underserved populations. Across studies, navigation programs have resulted in substantial increases in breast, colon, and cervical cancer screening rates.22-24 For example, one randomized controlled trial demonstrated substantial improvements in colorectal cancer screening rates associated with culturally appropriate navigation (27% vs 12% for controls).25 Although not explicitly labeled as navigation, a nursing intervention approach was associated with increased adherence in Spanish sites of the I-ELCAP trial.17 Many aspects of nurse navigation for lung cancer screening could mirror features of these established, evidence-based models in other cancer screening contexts while also adding components specific to the screen-eligible population. Nurse navigators could help patients consider, schedule, and complete the CT screening tests. For patients who need follow-up care, nurse navigators could also help coordinate multiple medical services. In general, nurse navigators can assist patients through the sometimes overwhelming healthcare system as their medical needs are identified through the screening process. Behavioral and psychosocial education would be critical components of the effort, with particular focus on lung cancer risk reduction through the provision of evidence-based smoking cessation information and referrals to smoking cessation clinics. Nurse navigators are also able to provide monitoring of cessation adherence and other medically suggested lifestyle changes. This model would be consistent with emerging evidence that navigators in primary care and community medicine settings have important roles in facilitating smoking cessation and other health behavior changes.26,27 Throughout the process, navigators could also address logistic (eg, financial, transportation) and psychosocial (eg, anxiety, fear) barriers that may interfere with successful adherence to the lung cancer screening protocol and smoking cessation.

In conclusion, if lung cancer screening becomes widely implemented, experience with screening for other malignancies suggests that real-world adherence rates will be considerably less than the 95% in the NLST. In addition, behavioral needs, such as smoking cessation education, will be important issues to address in screening settings.

Nonadherence—whether it takes the form of patients failing to undergo follow-up scans, declining recommended

AONNonline.org

commentary

procedures such as biopsy, not seeking treatment for diagnosed disease, or never initiating the screening protocol— will threaten to undermine the mortality reduction achieved in the highly controlled NLST. Furthermore, lung cancer screening without significant risk reduction through smoking cessation will not maximize the mortality and cost benefits of the protocol. While it took decades after widespread implementation of other cancer screening programs to investigate the role of nurse navigation, given the increasing public focus on the cost and quality of medical care, it is not only reasonable but also imperative to consider and evaluate this approach early in the implementation of lung cancer screening. g Disclosures: David E. Gerber, MD, reports receiving support through a National Cancer Institute (NCI) Cancer Clinical Investigator Team Leadership Award (1P30 CA14254301 supplement) and the North and Central Texas Clinical and Translational Science Initiative (NCTCTSI) (KL2RR024983).

Alletrice O. Gillam, RN, BSN, OCN, has nothing to disclose.

Heidi A. Hamann, PhD, reports receiving support through a grant from the National Lung Cancer Partnership and its North Carolina Chapter.

Corresponding author: Heidi A. Hamann, PhD, Departments of Clinical Sciences and Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390; e-mail: heidi.hamann@utsouthwestern.edu.

References

1. Aberle DR, Adams AM, Berg CD, et al, for the National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.

2. McMahon PM, Kong CY, Bouzan C, et al. Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol. 2011;6:1841-1848.

3. Pyenson BS, Sander MS, Jiang Y, et al. An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost. Health Aff (Millwood). 2012;31:770-779.

4. Goulart BH, Bensink ME, Mummy DG, et al. Lung cancer screening with low-dose computed tomography: costs, national expenditures, and cost-effectiveness. J Natl Compr Canc Netw. 2012;10:267-275.

5. Evans WK, Wolfson MC. Computed tomography screening for lung cancer without a smoking cessation program—not a cost-effective idea. J Thorac Oncol. 2011;6:1781-1783.

6. Arenberg D, Kazerooni EA. Setting up a lung cancer screening program. J Natl Compr Canc Netw. 2012;10:277-285.

7. Sox HC. Better evidence about screening for lung cancer. N Engl J Med. 2011;365:455-457.

8. Wiener RS, Schwartz LM, Woloshin S, et al. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155:137-144.

9. Aberle DR, Adams AM, Berg CD, et al. Baseline characteristics of participants in the randomized national lung screening trial. J Natl Cancer Inst.

2010;102:1771-1779.

10. Lin JH, Zhang SM, Manson JE. Predicting adherence to tamoxifen for breast cancer adjuvant therapy and prevention. Cancer Prev Res (Phila). 2011; 4:1360-1365.

11. Nielsen MJ, Nørgaard M, Holland-Fisher P, et al. Self-reported antenatal adherence to medical treatment among pregnant women with Crohn’s disease. Aliment Pharmacol Ther. 2010;32:49-58.

12. Selvin E, Brett KM. Breast and cervical cancer screening: sociodemographic predictors among white, black, and Hispanic women. Am J Public Health. 2003;93:618-623.

13. Rakowski W, Clark MA, Ehrich B. Smoking and cancer screening for women ages 42-75: associations in the 1990-1994 National Health Interview Surveys. Prev Med. 1999;29:487-495.

14. Rakowski W, Clark MA, Truchil R, et al. Smoking status and mammography among women aged 50-75 in the 2002 behavioral risk factor surveillance system. Women Health. 2005;41:1-21.

15. Rakowski W, Breen N, Meissner H, et al. Prevalence and correlates of repeat mammography among women aged 55-79 in the Year 2000 National Health Interview Survey. Prev Med. 2004;39:1-10.

16. Subramanian S, Amonkar MM, Hunt TL. Use of colonoscopy for colorectal cancer screening: evidence from the 2000 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2005;14:409-416.

17. Montes U, Seijo LM, Campo A, et al. Factors determining early adherence to a lung cancer screening protocol. Eur Respir J. 2007;30:532-537.

18. Klabunde CN, Cronin KA, Breen N, et al. Trends in colorectal cancer test use among vulnerable populations in the United States. Cancer Epidemiol Biomarkers Prev. 2011;20:1611-1621.

19. Pruitt SL, Shim MJ, Mullen PD, et al. Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review. Cancer Epidem Biomar. 2009;18:2579-2599.

20. Wildstein KA, Faustini Y, Yip R, et al. Longitudinal predictors of adherence to annual follow-up in a lung cancer screening programme. J Med Screen. 2011;18:154-159.

21. Taylor KL, Cox LS, Zincke N, et al. Lung cancer screening as a teachable moment for smoking cessation. Lung Cancer. 2007;56:125-134.

22. Paskett ED, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;61:237-249.

23. Burhansstipanov L, Dignan MB, Schumacher A, et al. Breast screening navigator programs within three settings that assist underserved women. J Cancer Educ. 2010;25:247-252.

24. Han HR, Lee H, Kim MT, et al. Tailored lay health worker intervention improves breast cancer screening outcomes in non-adherent Korean-American women. Health Educ Res. 2009;24:318-329.

25. Percac-Lima S, Grant RW, Green AR, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009;24:211-217.

26. Andrews JO, Felton G, Ellen Wewers M, Waller J, Tingen M. The effect of a multi-component smoking cessation intervention in African American women residing in public housing. Res Nurs Health. 2007;30:45-60.

27. Martinez-Bristow Z, Sias JJ, Urquidi UJ, et al. Tobacco cessation services through community health workers for Spanish-speaking populations. Am J Public Health. 2006;96:211-213.

JONS-online.com journal of Oncology Navigation & Survivorship

23

Call for Papers The Journal of Oncology Navigation & Survivorship® (JONS), launched in 2010, is the nation’s first peer- reviewed clinical journal for Oncology Nurse Navigators. As this critical area of specialty and expertise grows, research and sharing of best practices are integral to both improving the clinical care of cancer patients as well as expanding the existing literature and knowledge base.

Our goal at JONS is to help facilitate that growth.

Readers are invited to submit articles that fit into the following topics: • Patient Education • Navigation Processes and Outcomes Measures • Continuity of Care • Working with a Multidisciplinary Oncology Team • Screening Programs • Transitional Processes into Survivorship Care • Community Outreach • Long-Term Follow-Up • Psychosocial Issues • Patient Surveillance • Emotional Support • Patient Adherence • Facilitation of Treatment Decision Making • Any other topic relevant and of importance • Tumor Board Processes to the specialty • Caring for the Underserved Papers can be in the following form: • Original Research • Review Article (a synopsis/review of current literature in a specific area of research) • Case Study • “How To” article designed to transfer successes to fellow practitioners

Each manuscript is subject to an internal review to see that it fits the scope of and mission of our journal.

Papers that pass the initial review could be subject to a blinded peer review; final acceptance is based on that review.

If you are interested in submitting a paper or have any questions, please feel free to visit our website www.JONS-online.com or e-mail our editorial department at jbrandt@the-lynx-group.com.

24

April/May 2013 • Volume 4, Issue 2

AONNonline.org

ONS MEETING COVERAGE

Survivorship Plans: The Devil Is in the Details

By Alice Goodman

A

lthough planning for survivorship care is recognized as an important part of the continuum of cancer care, end-of-treatment summaries (TSs) and survivorship care plans (SCPs) are not universally provided to cancer patients, even at centers of excellence. That situation is about to change over the next few years, however, because the Commission on Cancer (CoC) says that these plans will be mandatory by 2015.

The CoC recommends that the plan be given to the patient on completion of treatment. It should include a record of the care received, important disease characteristics, and a written follow-up plan. TSs and SCPs should facilitate shared care coordination between oncology specialists and primary care providers (PCPs).

The details of SCPs still need to be worked out, according to Deborah K. Mayer, PhD, RN, AOCN, FAAN, associate professor at UNC-Chapel Hill School of Nursing in North Carolina. Speaking at the 38th Annual Congress of the Oncology Nursing Society, Mayer said, “The development and implementation of survivorship plans cannot be done by nurses alone. It requires teamwork.”

The end of treatment is the best opportunity for providing an SCP, she said. “At that time, I map out what is next for the patient. Often I have to review the treatment they received and why they got it. After the treatment is over, they are hit with the reality and may seem depressed. I use this as a transition visit,” she said.

Mayer advised making a special appointment to present the treatment summary and survivorship plan, with a written copy for the patient and spouse or caregiver. One must also make sure that the PCP receives the summary and the plan. It does not matter which template is used for the summary, but the information should be simple and clear to both the patient and the PCP, especially avoiding “oncospeak” with abbreviations that others may not understand, Mayer continued.

“Studies suggest that patients only retain about 10% of what you tell them at visits, so it is important to have a written plan about what treatments they have had and what will happen next, as well as the order of what will happen next,” she explained.

Even though randomized controlled trials have yet to show significantly improved outcomes with survivorship plans, the results of smaller studies suggest that end-oftreatment visits with SCPs lead to high patient satisfaction, reduced patient anxiety/unmet needs, and improved preparedness to manage healthcare. PCPs like them too, she said.

“Survivorship planning makes good common and clinical sense,” Mayer said.

The treatment summary and SCP should be simplified and should include the diagDeborah K. Mayer, PhD, RN, nosis, the basics of treatment AOCN, FAAN received, and the potential side effects and complications. “I would discourage you from making the plan longer and more complex than it needs to be,” she told listeners.

Templates are available from several organizations, including the American Society of Clinical Oncology and Journey Forward, but these templates may be too complicated or long for practical utility, she continued. “The template should be patient- and primary care provider-friendly and no longer than 2 pages for the treatment summary if possible,” Mayer added.

Overly detailed technical information is not helpful, she said. In the template Mayer developed for breast cancer patients, she spells out relevant medical terms and explains what they mean; for example, that “ER-positive” means that the tumor is sensitive to hormones.

Mayer predicted that, as experience is gained with SCPs, templates for survivorship plans will eventually become more simplified and standardized and integrated into electronic health records.

“Surgical oncologists and radiation oncologists typically provide summary notes at the end of treatment, but medical oncologists rarely do this. If they did, your survivorship care plan would take about 15 minutes to prepare,” she said.

Taking care of a cancer patient after treatment can become a bit of a turf war between the oncologist and the PCP. “Tumor groups at your hospital need to decide when survivors should move on to the PCP,” she said. “We need to prevent the gap between oncology and primary care from developing.”

Mayer suggested up-front partnering with the PCP when the patient begins treatment and when he or she ends it. “This could avoid the need for specialists to treat hypertension or other common conditions that the PCP can manage,” she explained. “All forms should include the name and contact information of the PCP, and the nurse should make sure that the PCP gets the notes on the patient.”

Survivorship plans for advanced metastatic cancer patients are a neglected topic thus far. The CoC has not

JONS-online.com journal of Oncology Navigation & Survivorship

25

ONS MEETING COVERAGE

provided any recommendations for this group of patients.

“The needs of the advanced cancer patient will be different,” she predicted.

However, at some centers hospice and palliative care specialists are called in earlier in the course of the disease.

“We can facilitate those discussions, and this could affect their planning,” she said.

Remaining issues regarding implementation of SCPs that need to be addressed in each practice setting are: • Which patients will receive a treatment summary and an SCP?

• When will they receive it?

• Who will develop it?

• Who will deliver it?

• Who will get a copy of it?

• Where will the plan be filed, how will it be updated, how will it be tracked?

Remaining challenges include implementation issues, educating patients and providers about survivorship care, and evaluating effectiveness.

“Many are preparing to meet the CoC 2015 standard and will need to address these challenges,” Mayer noted. g

Incorporating Caregivers Improves Physical Activity and Quality of Life in Patients With Cancer (Poster 116124)

By Alice Goodman

R

eal-life experience translated into a research interest for Fedricker Barber, RN, ANP, AOCNP, of the MD Anderson Cancer Center in Houston, Texas. About 10 years ago, her husband was diagnosed with prostate cancer and was treated with 6 months of antianFedricker Barber, RN, ANP, AOCNP drogen hormone therapy. During that relatively short course of treatment, he gained a lot of weight and was very tired. Barber was concerned, because he was a young man in his late 40s, and she knew that lack of exercise and weight gain were associated with the risk of developing heart disease, diabetes, a second primary cancer, and cancer recurrence. So she sprang into action, so to speak.

“This is my passion, being an advocate of physical activity for cancer patients. When I saw what was happening to my husband, I decided to become part of the solution. I helped him by buying exercise videos and doing the exercises with him,” she explained. “I emphasized to him that exercise would improve his immune system, reduce his fatigue, and prevent muscle wasting.”

The effort bore fruit. She found that her participation encouraged him to exercise, and soon he was losing weight and gaining energy.

This experience led to her “passion,” incorporating care-

26

April/May 2013 • Volume 4, Issue 2

givers and spouses of cancer patients into an exercise plan in her practice. “I give all patients an education sheet on physical activity, even if they are advanced cancer patients. Exercise helps fatigue, mood, function, and sleep.

Some patients think that if they have fatigue they should stay in bed, but the opposite is true. If you exercise, the fatigue is reduced,” she explained.

Exercise has been found to prevent the recurrence of cancers of the gastrointestinal tract, ovaries, esophagus, and breast. It also helps reduce some of the late effects of cancer treatment, such as poor wound healing, bowel urgency, and outlet obstruction. “And, it helps build up immune function,” she continued.

At the 38th Annual Congress of the Oncology Nursing Society, Barber presented a poster on the relationships between adult cancer survivors’ and caregivers’ social support, self-efficacy for physical activity, and quality of life (QOL), as well as actual physical activity behavior. The sample included 101 cancer survivors and caregivers with a median age of 62 years. Physical QOL was significantly higher in caregivers than in cancer survivors at baseline, but after 1 month of caregivers exercising with their patients, no differences in this parameter were observed between the 2 groups. Social support from caregivers or friends in performing physical activity was found to improve participation in physical activity.

“We found that cancer survivors and their caregivers rely on social support to encourage and motivate them to participate in physical activity. These findings suggest that priority should be given to strategies that encourage physical activity for both cancer survivors and their caregivers,” she said. g

AONNonline.org

ANNUAL CONFERENCE

"! !

!

!

Professor Rob Coleman, MBBS, MD, FRCP Yorkshire Cancer Research Professor of Medical Oncology Director, Sheffield Cancer Research Centre Associate Director, National Institute for Health Research Cancer Research Network Department of Oncology, Weston Park Hospital Sheffield, United Kingdom

*

3:00 pm - 7:00 pm

Registration

5:30 pm - 7:30 pm

Welcome Reception and Exhibits

7:00 am - 8:00 am

Symposium/Product Theater

8:15 am - 8:30 am

Welcome to the Second Annual Conference of the Global Biomarkers Consortiumâ&#x20AC;&#x201D;Setting the Stage for the Meeting Professor Rob Coleman, MBBS, MD, FRCP

8:15 am - 11:45 am

General Session I â&#x20AC;˘ Personalized Medicine in Oncology: Evolution of Cancer Therapy from Nonspecific Cytotoxic Drugs to Targeted Therapies â&#x20AC;˘ Taking Stock of Molecular Oncology Biomarkers â&#x20AC;˘ Genomics â&#x20AC;˘ Bioinformatics â&#x20AC;˘ Validating Biomarkers for Clinical Use in Solid Tumors - Professor Rob Coleman, MBBS, MD, FRCP â&#x20AC;˘ Validating Biomarkers for Clinical Use in Hematologic Malignancies Jorge E. Cortes, MD â&#x20AC;˘ The Challenges of Biomarker-Based Clinical Trials â&#x20AC;˘ Keynote Lecture: Understanding Cancer at the Molecular Level

12:00 pm - 1:00 pm

Symposium/Product Theater/Exhibits

1:15 pm - 4:30 pm

This activity is jointly sponsored by Medical Learning Institute Inc, Center of Excellence Media, LLC, and Core Principle Solutions, LLC.

General Session II â&#x20AC;˘ Introduction to Case Studies - Jorge E. Cortes, MD â&#x20AC;˘ Case Studies: Optimal, Value-Based Use of Molecular Biomarkers in Oncology: The Expertâ&#x20AC;&#x2122;s Perspective on How I Treat My Patients, Part I â&#x20AC;˘ Lung Cancer â&#x20AC;˘ Breast Cancer â&#x20AC;˘ Multiple Myeloma â&#x20AC;˘ Prostate Cancer â&#x20AC;˘ Leukemia â&#x20AC;˘ Lymphoma â&#x20AC;˘ Panel Discussion: Management Controversies and Accepted Guidelines for the Personalized Management of Solid Tumors and Hematologic Malignancies â&#x20AC;˘ Keynote Lecture: The Medical-Legal Issues Surrounding the Use of Biomarkers in Oncology

4:30 pm - 6:30 pm

Meet the Experts/Networking/Exhibits

Jorge E. Cortes, MD Chair, CML and AML Sections D.B. Lane Cancer Research Distinguished Professor for Leukemia Research Department of Leukemia, Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston, TX

The only global meeting dedicated to advancing the understanding of value and clinical impact of biomarker research in oncology. Guided by the expertise of leaders in this field, participants will receive a thorough understanding of the current and future landscape of the relevance of tumor biomarkers and how to effectively personalize cancer care in the clinical setting.

This meeting will be directed toward medical oncologists and hematologists, pathologists, geneticists, advanced practice oncology nurses, research nurses, clinical oncology pharmacists, and genetic counselors involved in the management of patients with solid tumors or hematologic malignancies, and interested in the use of molecular tumor biomarkers to help optimize patient care.

Upon completion of this activity, the participant will be able to: â&#x20AC;˘ Assess emerging data and recent advances in the discovery of molecular biomarkers and their impact on the treatment of patients with solid tumors or hematologic malignancies â&#x20AC;˘ Discuss the role of molecular biomarkers in designing personalized therapy for patients with solid tumors or hematologic malignancies â&#x20AC;˘ Outline the practical aspects of integrating molecular biomarkers into everyday clinical practice in the treatment of patients with cancer

Grant requests are currently being reviewed by numerous supporters. Support will be acknowledged prior to the start of the educational activities.

7:00 am - 8:00 am

Symposium/Product Theater

8:15 am - 11:45 am

General Session III â&#x20AC;˘ Review of Saturdayâ&#x20AC;&#x2122;s Presentations and Preview of Today - Jorge E. Cortes, MD â&#x20AC;˘ Case Studies: Optimal, Value-Based Use of Molecular Biomarkers in Oncology: The Expertâ&#x20AC;&#x2122;s Perspective on How I Treat My Patients, Part II â&#x20AC;˘ Melanoma â&#x20AC;˘ Colorectal Cancer and Other GI Malignancies â&#x20AC;˘ MDS â&#x20AC;˘ Myeloproliferative Neoplasms â&#x20AC;˘ Keynote Lecture: Promises and Challenges of Personalized Medicine in Improving Cancer Care â&#x20AC;˘ Tumor Board: Challenging Cases in the Use of Biomarkers in Managing Solid Tumors (attendee-contributed cases) â&#x20AC;˘ Tumor Board: Challenging Cases in the Use of Biomarkers in Managing Hematologic Malignancies (attendee-contributed cases)

12:00 pm - 1:00 pm

Symposium/Product Theater/Exhibits

1:15 pm - 3:00 pm

General Session IV â&#x20AC;˘ Keynote Lecture: Making Personalized Medicine a Reality: The Realization of Genomic Medicine â&#x20AC;˘ The Future of Personalized Medicine: Measuring Clinical Outcomes â&#x20AC;˘ Cost-Effective Technologies That Can Drive Therapeutic Decision Making â&#x20AC;˘ Regulatory Perspectives on PMO â&#x20AC;˘ PMO: The Payerâ&#x20AC;&#x2122;s Perspective â&#x20AC;˘ Panel Discussion: Can We Afford PMO? A Value-Based Analysis â&#x20AC;˘ Practical Considerations in Incorporating PMO into Everyday Cinical Management â&#x20AC;˘ Reimbursement Challenges

â&#x20AC;˘ Closing Remarks

3:00 pm

Departures

The Medical Learning Institute Inc designates this live activity for a maximum of 12.5 AMA PRA Category 1 Creditsâ&#x201E;˘. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Medical Learning Institute Inc and the Center of Excellence Media, LLC. The Medical Learning Institute Inc is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Medical Learning Institute Inc Provider approved by the California Board of Registered Nursing, Provider Number 15106, for 12.5 contact hours.

The Medical Learning Institute Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Completion of this knowledge-based activity provides for 12.5 contact hours (1.25 CEUs) of continuing pharmacy education credit.

The Universal Activity Number for this activity is (To be determined).

CONFERENCE REGISTRATION

EARLY BIRD REGISTRATION NOW OPEN! $175.00 until June 30, 2013

www.globalbiomarkersconsortium.com

*Agenda is subject to change.

P O

PERSONALIZED MMEDICINE IN ONCOLOGY

With biomarker testing in advanced non–small-cell lung cancer (NSCLC)...

You can help improve patient outcomes through a multidisciplinary approach ~1 in 5 patients with advanced NSCLC has a tumor with EGFR (ErbB1) mutations or ALK rearrangements1-6

[V WH[PLU[Z

,.-9 4 VY (32

You play a critical role as part of the multidisciplinary team that identifies biomarkers to diagnose and treat advanced NSCLC

Visit

LetsTestNow.com

t Expert commentary t Relevant case studies t Insights about your role in biomarker testing t The benefits of a multidisciplinary approach

References: 1. Riely GJ. Second-generation epidermal growth factor receptor tyrosine kinase inhibitors in non-small cell lung cancer. J Thorac Oncol. 2008;3(suppl 2):S146-S149. 2. Herbst RS, Heymach JV, Lippman SM. Lung cancer. N Engl J Med. 2008;359(13):1367-1380. 3. Rosell R, Moran T, Queralt C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. N Engl J Med. 2009;361(10):958-967. 4. Kwak EL, Bang Y-J, Camidge DR, et al. Anaplastic lymphoma kinase inhibition in non-small-cell lung cancer. N Engl J Med. 2010;363(18):1693-1703. 5. Data on file. Synovate US Oncology Monitor (USTOM), Jan-Dec 2011.

6. National Cancer Institute. Lung cancer. Non-Small Cell Lung Cancer Treatment (PDQ). Cellular classification of NSCLC. http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional /page2. Accessed January 18, 2012.

Copyright ©2012. Boehringer Ingelheim Pharmaceuticals, Inc. All rights reserved. (5/12) OC209900PROF-A

™