Identifying critical points in post-PCa treatment support

In October last year I delivered a presentation to a group of around 100 urology nurses attending the New Zealand Urological Nurses Society (NZUNS) North Island Study Day.

Whilst my session was entitled ‘Post prostate cancer treatment surveillance and support,’ I never intended to simply present evidence-based guidelines on international prostate cancer follow-up protocols. I instead aimed to combine this material with content meant to encourage the audience to reflect on how they, as nurses with advanced practice skills, contribute to prostate cancer follow-up in their various workplaces.

I asked them to consider if their healthcare team optimally utilise the personnel, communication modalities and locations that are available, for them to deliver high-quality, timely follow-up care to their patients.

My presentation focused on a new model for cancer care in New Zealand (NZ) which calls for a wider level of involvement of a more diverse range of clinicians based on cancer patients’ needs and complexity. The 2012 document advocates general practitioners and nurse specialists with oncology training having key involvement in the follow-up of cancer patients. It recognizes the impact of the rising number of cancer survivors in NZ as a result of an aging population, earlier diagnosis and advances in oncology treatment.

The document also challenges us to move away from the traditional model of hospital-based follow-up care provided by specialists in outpatient clinics since this mode of care delivery places a significant burden on resources, and is of debatable value for many cancers in terms of early diagnosis of recurrence and survival.

Alternative models Various alternative models of cancer follow-up have emerged, including nurse specialist-led, primary care-led, telephone and /or internet based, and patient-initiated follow-up. There are also various combinations of these that exist as ‘shared care’ models. Each utilises appropriate monitoring and post-treatment follow-up strategies to achieve many goals.

One important objective is to detect signs of disease progression or recurrence in a timely manner. Another is to assist patients with management of treatment related morbidity using evidence-based strategies. Alongside both of these aims, the healthcare provider also endeavours to address the individual’s psychosocial needs.

Cox and Wilson (2003) stressed the single most important factor in improving the follow-up care of cancer patients is targeting and responding to the needs of vulnerable groups. In New Zealand, District Health Boards consider how best to meet the follow-up needs of their cancer population based on multiple patient-focused factors including ethnicity, first language, geography and socioeconomic status. Health care teams aim to identify what supportive care packages are needed and at what time in the cancer treatment and recovery pathway they should be delivered.

Critical points in the prostate cancer trajectory have been identified as pre-treatment (dealing with a new cancer diagnosis and information needs pertaining to decision making), mid-treatment (management of acute side effects) completion of treatment (uncertainty in the future and management of on-going side effects) and post-treatment (anxiety about cancer recurrence and prognosis).

Patients report one of the benefits of cancer follow-up as ‘a feeling of being kept an eye on.’ This perception increases their sense of security and confidence, and is often associated with reduced physical and psychological distress. Patients also value continuity of care following cancer treatment, with many reporting that they found it harder to ask questions or discuss emotional issues with a stranger.

Building links While they perceive one of the advantages of hospital-based follow-up as the ready access it provides them to specialist knowledge and investigations, they dislike the way that they often see a different team member each time they attend outpatient’s clinic. They report this lack of continuity in the follow-up phase as adding to their distress. They prefer instead to build relationships with the healthcare professionals they dealt with.

I believe advanced practice nurses are well-placed to contribute to the continuity of follow-up care for men on a prostate cancer pathway. As we begin a new year of urology nursing in 2015, it is timely to reflect on how expert nurses are employed to fully contribute to the continuity and quality of cancer follow-up. Where you practice, do nurses have access to the academic preparation, on-going specialised education, skills accreditation, practice audit and mentorship that you need to enable you and others to fulfil your potential within the multidisciplinary team?

Reference Cox, K. & Wilson, E (2003). Follow-up for people with cancer: nurse-led services and telephone interventions. Integrative literature reviews and meta-analyses. 43(1) 51-61.

By Sue Osborne
Urology Nurse Practitioner
Waitemata District Health Board Dept. of Urology Auckland (NZ)