What is the role of case management in the treatment of patients with lung cancer?
Optimal care of patients with advanced lung cancer, perhaps lung cancer at any stage, requires integrated inputs from a range of clinicians. In addition, there are time-critical and generally novel requirements of patients themselves as they both navigate to the clinical assessment, diagnostic test or treatment and do their best to anticipate and then experience a combination of the effects of the disease itself, and of treatment.
At its simplest implementation, case management can be limited to navigation. This is in essence facilitating steps in management – whether that be arranging referral, any associated transport and providing such information to ensure that the steps are carried out. No specific clinical care is provided and such a role could be filled by an individual with sound administrative skills. A step up would be an Oncology Nurse Navigator – a registered nurse with cancer-specific training who guides and supports patients through the chalenges of having cancer. In its fullest implementation, one sees the Lung Cancer Specialist Nurse (LCNS). A LCNS is part of a multi-disciplinary team and uses experience and clinical skills as well as navigational understanding to contribute to optimising care. The required skill set will depend on the context of care. Some may cover the full spectrum of lung cancer and others concentrated on more specific settings such as Thoracic Surgery or Palliative Care. In most models, the LCNS becomes a primary point of health care contact.
Given the high level of acceptance of the role of Breast Cancer nurses, it should not surprise that a Lung Cancer Nurse would be effective, if in a different fashion. Both diseases represent a challenge to the navigational skills of naïve patients. There are also differences. The effect of disease and treatment on body image in critical for many women facing breast cancer and its treatment options. In many cases there is some time to allow the best choice to be made. In contrast, the lung cancer journey after diagnosis can a characterised by rapidly changing physical and emotional symptoms.
In the United Kingdom, the role of the lung cancer nurse is highly developed. There is an auditable standard that least 80% of patients are seen by a lung cancer specialist nurse. In a national audit in 2011, the number actually seen was 75% and this has risen by about 5% each year since 2008. Compared to patients who had not been seen by a LCNS, those who were seen were twice as likely to receive active treatment. This might be partly explained by a centre-effect, LCNS being connected to centres and patients too unwell for treatment not reaching these. However, anecdotes and blogs subsequent to the release of these data suggest that this is not the sole explanation and the difference persisted after allowance for age and performance status strongly suggesting that this is a real effect.
One of the casual criticisms of the UK implementation of the LCNS model, was that the LCNS would simply be the compassionate face for care poorly delivered and that it was a cheap substitute for modernizing the nature of treatment. The latest audit clearly puts that concern to rest.
One of the challenges in validating the effect of case management or a LCNS is that these are usually just one of a range of interventions delivered simultaneously. Therefore, the specific effectiveness of components or aspects is difficult to determine or prove. This is essentially the finding of an attempted systematic review of case management in cancer (although this was not specifically focused on lung cancer). There are flaws in much of the limited literature in this area. There is generally little evidence in relation to lung cancer. Some of the problems include failure to recruit target numbers, small proportions of lung cancer subjects, in addition to the challenge of determining what aspect of a multi-pronged intervention had a specific effect.
Lung cancer nurse specialists in initial care
The evidence for this rests with the UK national lung cancer audit. It is true that the patients who were not treated may have self-selected themselves and thus had no chance to have nurse contact. However, where recorded this was not reflected in performance status. Given that Australian studies have shown low and inconsistent rates of active treatment it would be wrong to assume that the audit findings in the UK in this regard have no applicability to the local setting.
The UK standard of 80% involvement of LCNS at the time of lung cancer diagnosis is not a rational one in Australia where lung cancer diagnosis is more de-centralised.
With the above caveat, including a LCNS in the care of patients from early in the diagnosis-decision making stage may be highly valuable.
By extension of the universal acceptance of the role of breast care nurses, it seems more than probable that patients with lung cancer would benefit in a similar fashion.
Lung cancer nurse specialists in the follow-up setting
Compared to other case management scenarios in lung cancer care this has evaluated in a well designed and executed study. Compared to usual lung cancer clinic care, patients whose primary follow-up after initial treatment was conducted by a Lung Cancer Nurse had symptoms identified sooner and received more supplementary radiotherapy. Satisfaction was high and intervention patients scored better with respect to emotional functioning and breathlessness. Satisfaction was high. Implementation of this model of care may be difficult in Australia in the fee-for-service care model rather than the Outpatient Clinic model in the UK. It would also be affected by the skill level of the nurse and may be influenced by the medical comparator – rotating registrar vs consultant.
When a clinical problem develops, the threshold for a patient to contact a nurse is lower than that for contacting a doctor whom they often wish not to trouble.
As lung cancer nurses are introduced to the Australian setting, careful planning will optimise the benefit in improved patient care.
In the rural setting, the lung cancer case load may not be sufficient to justify a lung cancer specific nurse and the optimal plan. may be to increase educational standards of existing nurses with more general roles.
Evidence summary and recommendations
Lung cancer nurses can be integral to the care of patients with lung cancer in centres where there is a significant lung cancer case load.
| After initial treatment, follow-up by a lung cancer nurse is acceptable to patients, is associated with early recognition of symptoms and results in improved symptom and emotional outcomes.
Lung cancer nurses should be involved in the follow-up care of patients with lung cancer in centres where there is a significant lung cancer case load.
The model of implementation should be flexible.
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