Preferences for Follow-up After Treatment for Lung Cancer

Karen Cox, PhD, BSc(Hons), RN, DipHE, DN, OncCert, DGCAP; Eleanor Wilson, MSc, BA(Hons), PeRt; Wesley Heath, RAN; Jacqueline Collier, PhD, MSc, BBc(Hons), RAN, PSycho; Linda Jones, BA, PGDip; Ian Johnston, MD, MB BChir, MA, BA, MRCP

Disclosures

Cancer Nurs. 2006;29(3):176-187. 

In This Article

Abstract and Introduction

Abstract

Pressure on lung cancer clinics is increasing with the "2-week wait" initiative. This initiative is one of the key targets set out in the National Health Service (NHS) Cancer Plan for the United Kingdom, whereby all patients presenting with symptoms which may be indicative of a cancer diagnosis will be seen by a consultant within 2 weeks of initial presentation at their primary care provider. This has resulted in busy clinics, with the potential for extended clinic waiting times and unmet needs for information and psychosocial support on the part of patients and families. There is increasing interest in the most appropriate mode of follow-up for patients with lung cancer who are under observation, many of whom have completed specific treatments. Such patients may benefit from specialist nurse review for symptom control and psychosocial support. Nurse-led clinics are safe and cost effective in the oncology and research-funded setting. This study aimed to assess the acceptability of nurse-led follow-up in a large general lung cancer clinic seeing approximately 250 new patients annually.

Over a 34-week period, there were 487 follow-up attendances and 94 (19.3%) of these were made by 72 patients deemed eligible for nurse-led follow-up. Sixty patients were approached and 54 (90%) agreed to participate in the study. A questionnaire containing vignette scenarios of nurse-led, telephone, GP-led, and standard (hospital, medical) follow-up was completed by 34/54 (63%) of eligible patients, 10/20 (50%) carers, 20/31 (65%) staff, and 11/38 (29%) GPs. Respondents rated acceptability of the scenarios on a range of issues on a scale of 1 to 5. Patients also completed the EORTC QLQ C30 and lung module questionnaire. Subsequent interviews were carried out with samples of these respondent groups.

Fatigue, dyspnea, cough, and pain were the most common general symptoms. Both standard and nurse-led follow-up scenarios were highly rated by patients and other respondents and both were highly significantly favored over GP follow-up, which was the least favored in all areas of the questionnaire. Telephone follow-up tended to elicit more polarized reactions, both positive and negative. In interviews, in relation to nurse-led follow-up, the importance of clear protocols, training, and easy access to medical review were highlighted.

Introduction

Lung cancer is the most common cause of cancer death in the UK. Men are more likely to be affected, although the number of women with lung cancer has been increasing.[1] The prognosis for the majority of patients with lung cancer is poor, and until more effective treatments are available, approaches to treatment and care must be focused on maximizing quality of life, improving symptoms, and ensuring service provision meets the needs of patients and their families.[2,3] One area receiving increasing attention is that of follow-up for patients who have completed treatment for their cancer or are under observation without anticancer treatment.

After treatment for cancer, most patients are offered some form of follow-up. The effectiveness and efficiency of oncological follow-up, however, is the subject of debate.[4,5] Important issues to be considered include prognosis, quality of life, and financial implications.[4] Little is known about the effects of routine follow-up on patients with cancer or about the value patients attach to follow-up.[6] Some studies suggest that routine follow-up is not an effective method of detecting cancer recurrence and that patients themselves are better catalysts for detecting recurrence by reporting new symptoms.[7] On the other hand, follow-up may have positive effects on feelings of security and may reduce physical and psychological distress.[8,9]

In the case of patients with lung cancer, there appears to be little in the way of established best practice guidelines with regard to follow-up. Virgo et al,[10] for example, suggest that follow-up in lung cancer varies widely and is influenced more by clinician preferences than evidence-based practice. Existing guidelines relate primarily to surveillance programmes for patients with non-small cell lung cancer who have undergone curative treatment.[11,12] For patients with disease recurrence or for whom treatment options are limited, there may well be benefits from close monitoring, symptom control, and support which follow-up can offer. However, follow-up by busy doctors in a crowded clinic may not be most appropriate for these types of patient. As an alternative, nurse-led follow-up is now arousing considerable interest. In the specialist and research oncology setting, studies have consistently found that nurse-led clinics are safe, effective, acceptable, and cost effective.[2,13,14,15,16]

Many clinical staff are now suggesting that alternative models of care provision for patients with lung cancer, who have completed their treatment, need to be explored. Patients who are prediagnosis or having treatment need to have medical assessment. However, if the clinical nurse specialist saw patients in the follow-up phase for symptom control and psychosocial support, this may both be beneficial for patients and potentially decrease clinic waiting times. Follow-up patients would have access to the additional assessment and support skills of the clinical nurse specialist which are more in line with their care needs at this time.

With the above in mind, service providers wanted to set up nurse-led follow-up in a regional cancer center in a large teaching hospital in the East Midlands, England. However, prior to introducing such a service, it was necessary to assess the acceptability of nurse-led follow-up in a busy clinical setting from the perspective of patients, relatives, and healthcare professionals.

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