Team Members Implementing Breast Cancer Survivorship Programme @ National Cancer Centre Singapore Dr Ho Gay Hui & Ms Tan Beng Le Surgical Oncology & Nursing Ms Tan Beng Le Ms Mabel Tan May Leng Ms Clair Khoo Ms Chan Mei Mei Dr Ho Gay Hui A/Prof Koong Heng Nung Dr Oey Chung Lie Dr Kathleen Thung Dr Khoo Sork Hoon Advanced Practice Nurse Advanced Practice Nurse (Intern) Advanced Practice Nurse, School of Health Sciences (Nursing), Nanyang Polytechnic Deputy Director, Nursing Senior Consultant, Surgical Oncology Head & Senior Consultant, Surgical Oncology, NCCS Senior Resident Physician Resident Physician Resident Physician The Need for Breast Cancer Survivorship Programme Breast cancer has been the TOP cancer among females in Singapore for many years. Almost 700 new cases of breast cancer seen by Surgical Breast Service on Outram Campus annually. From 2004-2008, NCCS treated approx 6,000 breast cancer patients and to date, 85% of them are surviving (> 5000 survivors). Cancer Survivorship Issues Medical / Physical cancer recurrence pain, lymphoedema of the arm, cardiac dysfunction lack of energy, feeling unwell fertility issues Psychological fear of cancer recurrence or cancer spreading depression, anxiety, uncertainty, isolation, sadness altered body image Social changes to lifestyle changes in interpersonal and sexual relationships concerns regarding health or life insurance employment, financial situation Existential and Spiritual sense of purpose or meaning appreciation of life The Need for Breast Cancer Survivorship Programme Rapidly growing pool of breast cancer survivors, requiring life-long follow-up Culturally, cancer survivors do not feel comfortable to be followed-up by GP or Family Physician. They prefer to be followed-up by cancer specialists at NCCS The Solution The Advanced Practice Nurse (APN)-led Breast Cancer Survivorship Programme (BCSP) - aims to provide holistic and quality care for survivors. Successful management of breast cancer includes enhancing quality of life and reducing unmet needs. 1
Role of APN Performs clinical assessment of patient for cancer recurrence & treatment-related side-effects: Provides general health education, eg, healthy lifestyle Recommends cervical & colorectal cancer screening, based on MOH GCP Guidelines Discusses patient s concerns & clinico-radiological findings with Dr Orders appropriate tests & imaging Coordinates follow-up care Referrals to other specialists when necessary Aug 2006 Oct 2006 Oct 2006 - Oct 2007 Nov 2007 Apr 2008 Apr 2008 Sep 2008 Milestones Proposal to School of Nursing, NYP Collaborative Agreement between NCCS and NYP APN Internship & On-The-Job Training Applied for Healthcare Quality Improvement & Innovation Fund Grant, Ministry of Health (Apr 2008 July 2012) Piloted APN-led Breast Cancer Survivorship Programme @ NCCS Applied to Cancer Research & Education Fund, NCCS Visits to Memorial-Sloan Kettering Cancer Center, New York City, & John Hopkins Avon Foundation Breast Center, Baltimore Conceptualisation & Preparatory Work Designed standardised follow-up protocol for APNs use to ensure systematic approach in clinical assessment. Developed a protocol and workflow for the management of survivors with abnormal FOBT results. Collaboration with SingHealth polyclinics to make Faecal Occult Blood Test (FOBT) and Pap smear more convenient for survivors. Breast Cancer Survivorship Programme @ National Cancer Centre Singapore Patient Eligibility Criteria Patients who are under the care of Surgical Oncology Dept at NCCS No evidence of recurrence for at least 5 years since diagnosis/treatment Singapore citizens or residents No history of other types of cancer Do not have complex medical co-morbidities or physical disability Clinical Review by APN Performs health assessment: takes medical history performs physical examination reviews test results, eg., mammography, BMD Provides general health education - healthy lifestyle, diet, exercise, etc Recommends PAP smear and Faecal Occult Blood Test (FOBT) or screening colonoscopy, if appropriate 2
Breast Cancer Survivorship Programme @ NCCS On the day of doctor s appointment, APN reviews the survivor Breast Cancer Survivorship Programme @ NCCS On the day of doctor s appointment, APN reviews the survivor APN discusses patient s concerns, clinical findings and test results with Dr APN discusses patient s concerns, clinical findings and test results with Dr Dr reviews patient Dr reviews patient APNs track results of cancer screening tests & inform survivors; arrange further tests if necessary. APNs develop patient educational materials. APNs maintains a database. BCSP @ NCCS From April 2008 to July 2012, 313 breast cancer survivors participated in the programme with 792 clinic visits. Outcome of Our Survivors Recurrence of breast cancer 7 Mean age: Mean disease-free survival: Stage of disease at diagnosis: 62 years 11 years (max 25 years) New breast cancer 4 New colorectal cancer 3 New endometrial cancer 1 New stomach cancer 1 New thyroid cancer 1 Outcome of Our Survivors Results of Screening Tests No. of Examinations Abnormal Result Outcome of Survivors with Abnormal Results No. of Examinations Abnormal Result Outcome of Survivors with Abnormal Results Mammogram 779 Clinical Breast Examination 792 10 (3.3%) 3 (1.0%) Needle biopsy results: - 3 new breast cancer - 1 recurrent cancer - 6 benign conditions Needle biopsy results: - 1 new breast cancer - 2 benign conditions Pap smear 119 FOBT (Faecal Occult Blood Test) 1 (0.8%) 201 26 (13%) Colonoscopy 9 0 CIN III (pre-malignant cervical cancer) Colonoscopy findings: - 1 pre-cancerous polyp - 25 Benign findings (piles, polyps, etc) or normal 9 Benign findings (piles, polyps, etc) or normal 3
Patient Satisfaction with & Acceptability of the APN-Led Breast Cancer Survivorship Programme Objectives Determine level of patient satisfaction with and acceptance of care provided by APNs. Ascertain information needs of these survivors. Patient Satisfaction with & Acceptability Reference to published literature, modified for local context. 26-item questionnaire structured with positive words and measured using Likert scale format. Questionnaire available in English or Chinese Patient satisfaction level was evaluated based on survivors perceptions of: APN s communication skills APN s clinical knowledge and skills APN s adequacy in general health education Survivor s acceptance to long term follow-up care by APN alone, and see doctor only when necessary. Survivor s perception of the importance of various information needs. Medical care provided by APN was equivalent to that by Dr 4
103 consecutive patients were interviewed on the day of clinic appointment between 1 Oct 2009 31 Mar 2010 Survivors Assessment of APNs APNs had good clinical knowledge and skills: 100% APNs had good communication skills: 99% APNs provided adequate general health education: 98% Median age: Median Disease-free survival: 60 yrs 7 yrs Medical care provided by APNs was equivalent to that provided by the doctor: 90% Proportion of survivors who felt comfortable to be checked by an APN alone and only see the doctor when necessary for their future visit: 60% The relationship of acceptance to follow-up care by APN alone & be referred to the Dr only when necessary and others possible factors Possible Factors Statistic tests p value Age Group Fisher s Exact Test 0.079 Disease_Free (Year) Mann-Whitney U Test 0.784 Education Level Fisher s Exact Test 0.061 Employment Status Chi-Square Test 0.432 Presence of Financial Difficulty Fisher s Exact Test 0.396 Stage of Disease at Diagnosis Chi-Square Test 0.372 Type of Surgery Received Fisher s Exact Test 0.916 Chemotherapy Chi-Square Test 0.053 Results of Survey 99% survivors were satisfied with the care provided by APNs 84.5% survivors rated the care they received from as good or excellent. 75% would recommend the programme to others who require breast cancer follow-up care. Radiation Therapy Chi-Square Test 0.694 Hormonal Therapy Chi-Square Test 0.269 Rank Item % of pats ranked as Important 1 Long-term side effects of treatment, eg, arm swelling, pain, numbness,etc 85.4 2 Fear of recurrence of breast cancer 80.6 3 Lifestyle changes after breast cancer diagnosis, eg, diet, exercise 4 Hereditary factors, eg, could the cancer be passed on to family members? 77.7 57.3 5 Feeling fatigued and decreased physical function 53.4 6 Depression / anxiety 50.5 7 Breast cancer related resources and support groups 49.5 8 Use of complementary therapy / traditional medicine 40.8 9 Acceptance by family and friends 35.9 10 Body image concerns, eg, breast reconstruction 33.0 11 Sexual health and fertility 21.4 Brochure to introduce BCSP to new survivors Brochure on Cervical & Colorectal Cancer Screening Guidelines 5
DVD to address the top 3 information needs Breast Cancer Survivorship Forum 2012 Summary The Breast Cancer Survivorship Programme can provide comprehensive and quality care for breast cancer survivors; APNs complement the doctors. Implementation of BCSP @ NCCS as a standard of care for breast cancer survivors in August 2012. Future Directions To establish BCSP as the main programme to provide long-term follow-up care for breast cancer survivors @ NCCS, across the various clinical depts Establish collaboration with NHG polyclinics to enhance convenience for FOBT and Pap smear tests To expand the scope of APN-led clinical review: - psychosocial health assessment Acknowledgements Ms Chua Gek Phin & Ms Chan Mei Mei, Dept of Nursing, NCCS Ms Wong Luan Wah, Director, School of Health Sciences (Nursing), Nanyang Polytechnic Healthcare Quality Improvement & Innovation Fund, MOH Cancer Research & Education Fund, NCCS Conduct research on survivorship issues, eg. QoL To establish survivorship programmes for other tumour types 6
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