Gastrointestinal Cancer Gastrointestinal Cancer NavigationNavigation

Coralyn Martinez, MSN, RN, OCNThe Lacks Cancer Center Nicole Messier, BSN, RNVermont Cancer Center

Gastrointestinal (GI) Cancer Navigation

Coralyn Martinez MSN, RN, OCNThe Lacks Cancer Center Saint Mary’s Health Care Grand Rapids, MI

Nicole Messier BSN, RNVermont Cancer CenterFletcher Allen Health CareBurlington, VT

ObjectivesObjectives

• Create strategies for the identification and removal of specific barriers to efficient and effective patient care in gastrointestinal (GI) cancer navigation

• Discuss the roles of various types of GI navigators and the ways in which they improve patient care

• Evaluate best practices regarding GI navigation and survivorship care

• Understand the processes for implementing and sustaining a successful GI cancer navigation program

• Assess methods for managing the psychosocial needs of patients and caregivers

Fletcher Allen OverviewFletcher Allen Overview

• 6700+ employees

• Regional referral center for 1 million; Vermont and northern New York

• Academic medical center in affiliation with the University of Vermont

Fletcher Allen Fletcher Allen Upper GI Multidisciplinary Cancer ClinicUpper GI Multidisciplinary Cancer Clinic

• Initiated in January 2007 • Dedicated UGI Nurse Navigator• Patient navigator from American Cancer Society (2009)• Cancer Patient Support Program (nutritionist, clinical

psychologists, social worker)• Surgeons, medical oncologists, radiation oncologists,

gastroenterologists, pathologist, radiologist, nurses, fellows, residents, students

• Second, fourth, and fifth Mondays with pre-clinic conference from 7:30 to 8:30 AM (films, path, and clinical presentation reviewed)

• Patients then seen in clinic by all appropriate specialists

The Lacks Cancer CenterThe Lacks Cancer Center

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The Lacks Cancer CenterThe Lacks Cancer Center

• National Cancer Institute Community Cancer Centers Program (NCCCP) site

• West Michigan’s only dedicated cancer center• Community teaching hospital • Member of Trinity Health • Focus on minimally invasive surgery• Multidisciplinary clinics available for all solid

tumors

Lacks Cancer Center Lacks Cancer Center GI Multidisciplinary ClinicGI Multidisciplinary Clinic

• Initiated in 2009• Dedicated GI Nurse Navigator• Cancer Resource Specialist (CRS) (MSW)• Oncology Certified Dietitian• Surgical oncologist, medical oncologist, radiation

oncologist, interventional radiologist, pathologist, financial consultant, CRS, palliative care, genetics counselor, nurses, residents, research coordinators

• Meets weekly every Friday morning• Tumor Board/treatment planning conference prior to

clinic• Patient seen by all “appropriate” disciplines

Poll the AudiencePoll the Audience

• What type of navigator are you?– Nurse– Social Worker– Lay Person– Other

• What is the primary setting in which you work?– Hospital– Clinic– Other

• Do you navigate additional cancer types?

Nurse Navigation:Nurse Navigation:Major Impacts on Patient CareMajor Impacts on Patient Care

• Efficiency of diagnostic evaluation• Expediency of treatment initiation• Increased access to clinical trials• Improved patient satisfaction• Enhanced communication with referring

physicians

Keys to Successful NavigationKeys to Successful Navigation• Clarification of role• Strong referral base• Communication• Quality guidelines (National Comprehensive

Cancer Network)• Tracking of metrics/QA projects

– Database• Tumor Board/treatment planning conferences• Teamwork

– Buy-in, commitment, and flexibility of key players

• Survivorship programs

Nurse Navigator

Multidisciplinary Team ApproachMultidisciplinary Team Approach

MedicalOncologyMedical

Oncology

SurgicalOncologySurgical

OncologyRadiationOncologyRadiationOncology

Survivor

Network

Pathology

Clinical

Research

Familial Cancer

Program

Financial

Counseling Prevention Program

Cancer Education

Specialty

Physicians

Nutrition

Services

Palliative Care and

Integrative

Medicine

Social

Services

Radiology

Nurse Navigator

Navigation TypesNavigation Types

• Diagnostic• Treatment• Survivorship• Patient versus nurse• All in one• Outpatient versus inpatient

GI NavigatorsGI Navigators• What type of Navigator are you? • What types of GI cancers do you navigator?• Who makes up your GI MDC team?• What are the goals or objectives of the MDC in your hospital?• Where do you get your referrals from?• What is your case load? What defines your case load?• What are the goals or objectives of the MDC in your hospital?• How do you document? (EMR/Navigation Software)• What are your favorite resources for patients/ yourself?• Keys to success?• How are you measuring your accomplishments? • Do you measure the quality of the care delivered?

The GI MDC TeamThe GI MDC Team

• Surgical Oncologists• Radiation Oncologists• Medical Oncologists• Gastroenterologists• Radiologist• Interventional Radiologist• Pathologist• Nurse Navigator

• Patient Navigator• Clinical Psychologist• Nutritionist• Social Worker• Financial Consultant• Research Coordinators• Palliative Care• Genetic Counselor

Goals of GI MDC Goals of GI MDC

• Provide high-quality multidisciplinary patient care:− Patients see a radiation oncologist, surgical

oncologist, medical oncologist, nurse navigator, nutritionist, and cancer patient support specialists in a single visit

− Staging and treatment according to best practice standards (NCCN guidelines)

Goals of GI MDC Goals of GI MDC

• Deliver efficient patient care and increase patient satisfaction:− Every effort to complete all necessary diagnostic

testing made prior to the patient’s first MDC clinic visit

− Provide both patients and their physicians with a clear treatment plan at the conclusion of their clinic visit

− Patients will be seen in days, instead of weeks of being referred to the clinic

Getting into the System…Getting into the System…

• GI referral − Abnormal finding on imaging and/or EGD/EUS

• Primary care physician (PCP) referral− Abnormal finding on imaging

• Self-referral• Medical Oncology• Radiologists• Pathology

• Where do you get referrals from?– PCP– GI– Oncology– Radiology– Pathology

Poll the AudiencePoll the Audience

• When do you start navigating patients?– Abnormal finding– Confirmed cancer diagnosis– With treatment initiation

• How long do you navigate your patients?– Through workup and diagnosis– Through treatment– Into survivorship

• What is your case load?

Initial InterviewInitial Interview

• Introduction of Nurse Navigator• Thorough intake • Education – clarification of diagnosis

– Pamphlets/booklets– Websites– Answer their questions

• Appointment!!– Explain MDC

MDC AppointmentMDC Appointment

• Patient and support person(s):– Meet with each specialist individually– Information about diagnosis and treatment– Reinforcement of education/current knowledge– Questions– Plan: Next steps

Case DiscussionCase Discussion• 73-year-old man, P.L.

– Medical history: diabetes, hypertension, chronic obstructive pulmonary disease, asthma

– Social history: borderline mental retardation (independent with exception of management of his medications and finances), lives alone, no family in area, attends the VNA Adult Day Program Monday-Friday 8 AM to 5 PM, transportation provided by the Special Services Transportation Agency (SSTA)

• Primary contact/support person is Heather, the RN at the Adult Day Program

Continued…Continued…

• Heather sets up an appointment for P.L. to see his PCP on 6/9/11 after noticing that he is “choking” and “coughing” when eating solids, once requiring the Heimlich maneuver

• 50-lb weight loss noted over past year, although most loss is attributed to hospitalization for dehydration and hypoglycemia secondary to infection with the norovirus in late 2010. Was admitted to rehab for several months due to significant weakness and inability to perform activities of daily living

Continued…Continued…• PCP refers P.L. to GI for EGD, done on 6/13/11

– Mass in middle third of esophagus identified– Path c/w poorly differentiated squamous cell cancer

• Referral to GI MDC by GI– Met with patient in endoscopy – GI unwilling to discharge patient home due to

• No caregiver at home to monitor patient post-anesthesia• SSTA to transport patient home

– Phone call to Heather to see if VNA could provide a home visit to assess patient that evening

Continued…Continued…• Due to social situation/patient anxiety, staging CT was

bypassed in favor of a PET/CT to reduce number of tests/visits– H&P, CBC, and chemistry profile– EGD– CT chest/abdomen with IV and oral contrast– PET scan if no evidence of M1 disease– EUS if no evidence of M1 disease, with FNA if indicated

• PET/CT performed on 6/21/11– Avid FDG uptake in the esophageal mass and in an 8-mm

para-esophageal LN

Continued…Continued…

• EUS 6/24/11– 7-cm esophageal mass, invading the adventitia

(T3)– Lymph nodes around the mass seemed to be

involved, with 1 to 2 nodes greater than 1 cm (N1)– Clinically staged as T3 N1 M0 (stage III)

Continued…Continued…

• GI MDC 6/27/11– Evaluated by medical, radiation, and surgical

oncology– Role of chemo versus chemoradiation versus

palliation of symptoms discussed• Not an ideal candidate for surgery, role of surgery to be

determined

– Treatment with chemoradiation recommended– Initiated weekly paclitaxel/carboplatin with

radiation on 7/18/11

Continued…Continued…

• P.L. also meets with…– Jessica, ACS Patient Navigator– Jennifer, Nutritionist– Julia, Psychologist

Lower GI-Colon Cancer Work-UpLower GI-Colon Cancer Work-Up

• Case Study E.H. – 53-year-old male – Presented with anemia– Abdominal CT scan reveled umbilical hernia and

multiple liver lesions – Liver lesions were thought to be cysts and

cavernous hemangioma– Ultrasound reading didn’t agree– Colonoscopy revealed mass at hepatic flexure

Colon Cancer Work-Up (cont.)Colon Cancer Work-Up (cont.)

• You are the Nurse Navigator referred to work with the patient

• What would you recommend the physicians order next?

• NCCN guidelines

• CEA• CT of Pelvis and Chest• PET• Why??• To assess liver lesions

Colon Cancer Work-Up (cont.)Colon Cancer Work-Up (cont.)

• Sent to surgery without further evaluation of liver lesions

• Liver was palpated in surgery and described as normal

• Patient unhappy with his care, came to The Lacks Cancer Center

• Proper work-up completed• Liver lesions positive on PET

• Chemotherapy followed by liver resection

Colon Cancer Follow-Up Care Colon Cancer Follow-Up Care Case StudyCase Study

• Case Study P.I.– 65-year-old male – Screening colonoscopy found colon cancer– Right hemicolectomy – T2, N0, M0 – Stage I

Colon Cancer Follow-Up (cont.)Colon Cancer Follow-Up (cont.)

• What should his surveillance consist of?• Surveillance with CEA and CT scans• Rise in CEA and liver lesion seen on CT scan• Liver biopsy order• Biopsy canceled by radiologist, because it was

a “hemagioma”

Colon Cancer Follow-Up (cont.)Colon Cancer Follow-Up (cont.)

• Repeat scan ordered by oncologist• Liver lesion seen once again• Biopsied – + adenocarcinoma • PET scan – 2 lesions in liver • Referred to Nurse Navigator• Referred to surgical oncology• Liver resection followed by chemotherapy

Long-Term Colon Cancer Long-Term Colon Cancer SurveillanceSurveillance

• What should it include?– CEA– CT

• C/A/P or A/P

ResourcesResources

• National Comprehensive Cancer Network (NCCN) guidelines (for work-up, diagnosis, staging, and treatment) – NCCN.org

• American Cancer Society – Cancer.org• National Cancer Institute (NCI) – Cancer.gov• Pancreatic Cancer Action Network (PanCAN)• The Lustgarten Foundation for Pancreatic Cancer• Mycoloncancercaoch.org• AJCC staging manual • AONN.org

• What are your favorite resources?

Take-Home Points/ConclusionTake-Home Points/Conclusion

• Develop a consistent process • Provide clear communication to patients and

providers• Be alert to red flags

– Eliminate barriers– Improve timely service

• Use quality standards and guidelines • Measure your success!

Questions to PonderQuestions to Ponder

• What do you like best about being a navigator?

• What do you like least about being a navigator?

• Is there anything you would change about your current navigation role or program?