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Follow-up by advance practice nurses improves care for patients with head, neck cancer
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The launch of an advance practice nurse outpatient follow-up clinic improved symptom management for high-risk patients with head and neck cancer following radiation therapy, according to findings from a study conducted at Cleveland Clinic.
This initiative led to fewer ED visits and hospital admissions, results showed.
Bridgett Harr
“These results are significant as they suggest more intensive follow up in high-risk head and neck patients can improve patient outcomes,” Bridgett Harr, CNP, of the department of radiation oncology at Cleveland Clinic, told HemOnc Today. “This intensive symptom management is an important role [advance practice nurses (APNs)] can fill in this and other patient groups by providing consistent, proactive management of symptoms during recovery from treatment. Our study suggests this will lead to improved patient experience, in addition to a reduction in cost to both the patient and health care system as a whole.”
Patients with head and neck cancer often undergo radiotherapy or chemoradiotherapy, and many experience debilitating side effects that require ED management or admission to the hospital. In 2014, an APN-led clinic was launched to focus on the acute rehabilitation of patients with head and neck cancer undergoing these therapies.
Harr and colleagues sought to evaluate the outcomes and incidence of adverse events among patients treated at an APN clinic compared with historical outcomes.
The analysis included data from 25 high-risk patients with head and neck cancer who received care post-treatment at an APN clinic and 24 patients who received standard follow-up care identified using a database. Clinic patients were seen 2 to 4 weeks after treatment and then every 2 to 4 weeks thereafter until their symptoms stabilized. Standard follow-up patients were seen on average between 4 to 6 weeks after treatment and then not again until 3 months post-treatment.
Patients were considered high risk if they had limited social support (35%), resided in a nursing home (16%), required multiple hydrations during treatment (18%), underwent stereotactic body re-irradiation (15%) and/or required a feeding tube (16%).
Ninety percent of patients had stage IV or recurrent cancer. Primary tumor sites included oropharynx (47%), oral cavity (16%), larynx/hypopharynx (12%) and other (25%).
All patients underwent stereotactic body radiation therapy or intensity-modulated radiation therapy. Fifty-five percent of the patients received chemoradiotherapy with either a cisplatin-based regimen (81%) or cetuximab (19%), and 45% of the patients received radiation therapy alone.
Patients in the APN clinic were seen almost twice as often as those in the standard follow-up group (median, 2 vs. 1.2 visits).
Eighteen patients experienced 26 adverse events that required either a visit to the ED or hospital admission. Six of those patients (33%) were seen in the APN clinic, whereas 12 patients (67%) were from the standard follow-up cohort.
“Not only is there greater patient satisfaction when being managed in an outpatient setting, it is more cost-effective to avoid emergency room or hospital admissions,” Harr said in a press release.
The benefits of the APN clinic appeared more substantial among patients who received radiation alone. Significantly fewer patients treated only with radiation who received their follow-up care at the APN clinic experienced an adverse event in the 90 days immediately after radiation compared with patients who received standard follow-up (60% vs. 16.7%; P = .01).
Researchers observed no difference between the arms for patients who underwent chemoradiotherapy because standard follow-up is also intensive, according to the researchers.
“This study illustrates an important role for APNs in radiation oncology,” Harr said. “APNs are in a unique position to provide more intensive follow-up care, allowing them to better manage the post-treatment symptoms of high-risk head and neck cancer patients.” – by Anthony SanFilippo
Harr B, et al. Abstract 3169.
Disclosure: HemOnc Today was unable to confirm the researchers’ relevant financial disclosures at the time of reporting.
Perspective
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Sagus Sampath, MD
The study by Harr and colleagues illustrates the importance of specialized follow-up care in patients receiving radiation therapy (RT) for head and neck cancer. Acute symptoms that develop during the 6 to 7 weeks of RT usually persist for an additional 1 to 2 months following treatment completion. These symptoms include mucositis-related pain and dysphagia, leading to dehydration, as well as neck desquamation. Timely management of these side effects can help mitigate their intensity and therefore minimize unplanned ED visits.Although the authors had specific inclusion criteria for “high-risk patients,” their findings will likely be applicable to the majority of patients receiving concurrent chemotherapy with RT. As with any retrospective study, imbalances in certain favorable patient characteristics — how many received RT alone in both groups — may have impacted their results. Also, the definition of “standard follow-up” is going to be very institution specific, and further details will likely be provided in the manuscript.
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