Oncology Nurses Play Pivotal Role in Survivor Follow-Up Care

Michelle Mollica, PhD, MPH, RN, OCN

Oncology nurses can serve as the key to ensure that cancer survivors receive the follow-up care they need, according to Michelle Mollica, PhD, MPH, RN, OCN.

Mollica, who is a senior advisor in the NCI Office of Cancer Survivorship and is consequently responsible for developing, supporting, and promoting research efforts focused on cancer survivorship, presented on individualized survivorship care plans at the 47th Annual Oncology Nursing Society Congress. During the meeting, she sat down with Oncology Nursing News® to discuss what nurses should know about survivorship care plans.

“Something I cannot stress enough is the importance of the oncology nurse in assessing the specific needs of cancer survivors and that [this] needs to happen early,” Mollica said. “Listen and be aware of what patients and survivors need from the point of diagnosis all the way through because those needs might change.”

Oncology Nursing News®: Could you discuss the basic framework of an effective survivorship care plan?

Mollica: A survivorship care plan is a tool that is meant to guide patients and survivors, as well as health care providers, for the necessary survivorship care. Ideally, the plan should have a summary of cancer history, pertinent health history, as well as treatment summaries, and a follow-up plan for what should occur in the future for that survivor. It should be tailored to the needs of the survivor, and their cancer type and treatment history.

How might care for a childhood cancer survivor differ from that of an adult or even an elderly patient?

Individuals who are diagnosed with cancer as children are at high risk for late- and long-term effects—symptoms that occur well after their treatment has ended. There is a real need to monitor for those impacts, especially things like cardiotoxicity and other symptoms, well after their treatment has ended.

That is different from an older adult who often is dealing with lots of other comorbid conditions: they might have diabetes or have other health issues that are in essence competing with their follow-up care for cancer. It is up to the older adult to coordinate their care in a way with their providers that makes the most sense based on their needs.

What are the challenges in caring for different populations, specifically rural cancer survivors?

Rural cancer survivors often have issues engaging and accessing survivorship care; they are less likely to receive a survivorship care plan or have a survivorship care discussion with their oncologist. They often have challenges engaging back with their primary care provider after their treatment has ended or knowing what types of treatment follow-up care they need.

Oncology nurses play a key role in sort of bridging that gap. They can help survivors know what's ahead, know how to access those resources, and [guide them through] supported self-management—[teaching] when to call if they have symptoms or issues that they think they may need to get checked out. The oncology nurse is key to both assessing the needs of survivors and educating patients, particularly for vulnerable populations like rural cancer survivors.

Which factors do you consider when determining a patient's level of risk?

Many professional organizations have recommended risk-based survivorship care, which means that survivorship care is tailored based on the needs of the survivor. That can include an assessment of factors that include risk for recurrence risk for second cancers, their likelihood for late- and long-term effects, and how many other comorbid conditions they have. It can also be based on things like level of social support: do they have someone to take them to their follow-up care visits? It is important to [consider these risks] and tailor the care based on these factors.

What are some challenges that can be linked to primary care coordination? How might a nurse help overcome those barriers?

Primary care providers are dealing with so many things daily. Seeing cancer survivors is just a small part of their day, although we have a growing number of survivors that are being seen in primary care. When survivors are transitioned back to primary care, either during or after treatment, it is essential that primary care providers know what type of care is needed and how to deliver that care for the survivor. I would say there are lots of challenges to doing that.

Engaging with primary care and having access to a primary care provider is always a challenge. In addition, primary care providers often need to be educated on the impact of new therapies like biotherapies and targeted therapies—these may have another host of symptoms that survivors need to worry about, as well as staying up with guidelines for cancer survivors.

Oncology nurses can help survivors navigate those challenges. They can help educate patients and what they should bring to their primary care provider. They can also make contact with the primary care provider and in many cases, advanced practice oncology nurse practitioners are actually providing that survivorship care and bridging that gap.

How can patients be proactive in helping to manage their care plans or even coordinating with their care team to individualize it?

It is important for patients to know what questions need to be asked and to ask as many questions as early and often as possible. That includes: what type of care do I need to receive? What is this going to look like for me as I transition either off treatment, or in these periods where I might not be treated? Who should I see and when, and making sure that that's all included in their survivorship care plan and using that as a tool to navigate their care?

Patients also need to be empowered to reach out if they experience any symptom that they aren't familiar with or is new to them. This is because, often, symptoms emerge that we might not be aware of between visits, and they need to know to reach out to their provider and ask questions.