APRN-Led Clinics Enable Comprehensive Survivorship Care

A survivorship clinic allows APRNs to practice autonomously and highlights their strengths and skills, including assessing long-term toxicities, providing expert symptom management, coordinating with other disciplines, and making referrals as appropriate. Long-term toxicities from cancer treatment are disease- and treatment-specific and will be unique to each patient.

Case Study

Donna, a 58-year-old woman with a history of stage III colon cancer who underwent right hemicolectomy nine months ago and completed FOLFOX three months ago, presents to the APRN in the survivorship clinic. The patient reports persistent fatigue from treatment (5 on 0–10 scale) and has gained 15 lbs since completing treatment. She has not been exercising regularly. She also reports occasional stress fecal incontinence that has been present since surgery but seemed to get worse from diarrhea with chemotherapy. 

The APRN provides a comprehensive assessment and evaluates Donna for long-term toxicity. Bloodwork, including carcinoembryonic antigen (CEA), complete blood count, and comprehensive metabolic panel (CMP), are reviewed, and the APRN sees that CEA is within normal limits (1.1) and CMP is unremarkable except for a nonfasting glucose of 174 mg/dl. She orders a computed tomography scan prior to Donna’s next visit, as recommended by National Comprehensive Cancer Network guidelines (https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf), and a colonoscopy for one year from surgery and coordinates this with the gastrointestinal care team in the appropriate timeframe. Donna will also obtain fasting lab, hemoglobin A1C, and thyroid-stimulating hormone tests before she visits her primary care provider (PCP) in two weeks.

The APRN refers Donna to physical therapy for pelvic floor rehab for her occasional stool incontinence. She is motivated to return to her gym and plans to start with low-impact exercise twice weekly. The APRN also reminds Donna that she will be due for her annual mammogram prior to her next visit, so they order and schedule it. Finally, a nutritionist meets with Donna and reviews a diet that is higher in protein and fruits and vegetables and lower in carbohydrates. 

In this example, the APRN engages with the patient, collaborates with PCPs, and makes referrals as appropriate. She reviews a comprehensive survivorship care plan and provides a copy for the patient and PCP and also sends a copy of today’s progress report to the PCP. If issues are more complex with coordination between providers, a phone call may be appropriate.

Key Tools for Survivorship Clinics

APRNs are well suited for the complexity of this role and need to be knowledgeable about resources for survivors, such as those available from the National Coalition for Cancer Survivorship, American Society of Clinical Oncology, American Cancer Society, and LIVESTRONG. Survivors can also have many unmet financial needs, and a nurse navigator or social worker should be available to assist.

Knowledge of cancer-specific surveillance as outlined in the NCCN guidelines (https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf) is important. Some referrals that may be appropriate in a survivorship clinic may include smoking cessation, social work, nutrition consultation, or genetic counseling. APRNs should also be well versed on recommendations for specific immunizations for each patient. 

Regularly updating patients’ family history of cancer helps APRNs assess risk factors for a secondary malignancy. The overall cancer rate is increased in those with a history of cancer even without genetic susceptibilities. Collaboration with a genetic counseling team for patients with a genetic syndrome may be necessary to follow recommendations for surveillance guidelines. If secondary cancers occur, patients should be restaged and referred back to their medical oncologists. 

Survivorship Care Plans

The National Academy of Medicine recommended (http://georgiacore.org/articleImages/articlePDF_396.pdf) that patients with cancer and their primary care providers receive a written survivorship care plan at the end of active treatment that communicates what occurred during cancer treatment. The document should include a comprehensive care summary and a plan specifically outlining the responsibility of each provider in follow-up care.

APRNs can provide ownership over the creation and delivery of survivorship care plans. This includes carefully reviewing a patient’s history and chart for all treatments received across many disciplines and formalizing a follow-up plan for monitoring the patient for recurrence with recommendations provided for intervals for follow-up physicals, blood work, or imaging. Screening for secondary cancers and health promotion strategies is also necessary. Patient engagement is indispensable in survivorship, and patients may feel empowered when receiving their care plan to remain compliant with the team’s recommendations.