“I would like to respectfully acknowledge the Traditional Owners of the land on which this event is taking place and pay my respect to their Elders both

past and present."

Identifying the Gaps and the Role of the Breast Care Nurse:

Can We Learn from the International Experience?

Margaret Barton-Burke, PhD, RN, FAANDirector, Nursing Research (and Innovation)

Memorial Sloan Kettering Cancer CenterNew York

Professor Emeritus, University of Missouri St. Louis

Adjunct Professor, QUT, Brisbane, AU

Good Morning

G’DAY

Bonjour

Jambo / Karibo

Salam Alaikum

Sawasdee ka

Magandang hapon

Hola

Special Thanks

Jean B. Sellers, RN, MSNONS SIG Coordinator, Nurse Navigation

Cynthia Cantril, RN, OCN, MPH & Sharon Francz Co-founders NCONN

Objectives

• Briefly review breast cancer

• Share aspects of my work with the Black Women Breast Cancer Survivors Project

• Discuss oncology nurse navigation within the context of care coordination

5/23/2016

Dissertation

• Breast Cancer Experiences: Women's Reflections Years After Diagnosis

• Literature review by dimensions (analytical scheme /quality of life guiding framework)– Physical– Psychological– Social– Economic– Spiritual & Existential

• Breast cancer as a disease condition• Breast cancer as a life experience

5/23/2016

An Incomplete Picture

The term black women is being used to include women of the African Diaspora; including those of African descent, Caribbean ancestry as well as descendents of United States slaves.

8

DEFINITION

5/23/2016

Black Women

Breast Cancer

Survivors

Project

Afrocentric

Research &

EBP Programs

Breast Cancer Current State

5/23/2016

Risk Factors• Significant risk factors include age, family

history, history of previous biopsies

• Hormone replacement therapy

• Diets high in saturated fat, alcohol intake

• Weight gain and obesity

• Link between increased breast density & increased risk for breast cancer (Bertrand et al., 2015

Breast Cancer Screening

• Mammograms help to detect breast cancer before it is clinically apparent

• Tomosynthesis (3-Dimensional (3-D) Mammography) uses high-resolution X-Ray images to create a 3-D image of breast

• High risk women should consider MRI screening

• Contrast-Enhanced Spectral Mammography (CESM) uses iodinated contrast injection to emphasize areas of suspicion, similar to MRI but with decreased cost

• Breast cancer survival is higher in woman who participate in regular screenings

Screening Use and the Disappearance of a Late-Stage

Breast Cancer Cluster

Mario Schootman, Ph.D.

Associate Professor of Medicine

Co-leader Prevention & Control program

Siteman Cancer Center at Washington University

December 15, 2008

14

15

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20041996

16

1996

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20041997

17

1997

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20041998

18

1998

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20041999

19

1999

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20042000

20

2000

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20042001

21

2001

Legend

Clusters obs/exp

Poisson 10% Pop. Circular Model

0.000

1.892

Missouri overall unadjusted late-stage (distant) breast cancer incidence for females aged 50 and older, 1996-20042003

22

2003

23

Screening Guidelines for Early DetectionControversy

Breast Cancer

• Breast cancer most common cancer in women & second largest cause cancer death

• Early diagnosis saves lives

• Self breast examinations (lack evidence), clinical exam, & mammograms

• Early detection & improved treatment increases survival rates for women with breast cancer

• Changes in treatment – Oral Anti-Cancer Treatments; Personalized/Precision Health Care; Costs

Discovery in Breast Cancer Unprecedented

• Researchers believe nearing conclusive findings on link between obesity, inflammation, & breast cancer risk

• Triple negative breast cancer or BRCA+ may find hope for better disease control with a new class of agents, PARP inhibitors

• Immunotherapy

• Vaccines

Clinical Trials

• Necessary to determine if treatments are effective

• Instrumental in increasing survival of women with breast cancer

• Ongoing trials in surgery, radiation &chemotherapy

• More About This Tomorrow

Black Women• Breast Cancer less frequently

than White women

• Mortality rate is higher

• Triple Negative Breast Cancer

• Make it current & hip – with a message

“Black women do not have to die from breast cancer”

1. Black Women & Breast Cancer: The Knowledge is Power Conference (300 x 6 = 1800)

2. Purple Tea (Survivors)

5/23/2016

5/23/2016

Can Nurse

Navigation

Help?

Patient Navigation

• Developed by Dr. Harold Freeman, (founder of Patient Navigation) in 1990 as a means to save lives by eliminating barriers to care

Barriers to Care

• Financial barriers, such as no health insurance

• Communication and information barriers

• Medical system barriers

• Fear, distrust, and emotional barriers

Freeman & Rodrigues, 2011

Principles of Patient Navigation

• Patient navigation promotes timely movement through healthcare continuum

• Patient navigation integrates fragmented healthcare system for patient

• Core function of patient navigation is elimination of barriers to timely care across all segments of healthcare continuum

• Patient navigation should be determined by level of skills necessary to navigate an individual

Freeman & Rodrigues, 2011

PATIENT NAVIGATION

Early Detection

Quality of Life

►Focus is on racial/ethnic minorities; medically underserved populations

► Integrate fragmented health care systems

►Elimination of barriers to care to ensure delivery of care

►Patient navigation may be delivered by a clinical or non-clinical lay patient navigator

Outreach Abnormal Results Diagnosis Treatment Rehabilitation

Education

Screening

Survivorship

Surveillance

(Freeman & Rodriguez, 2011; ONS, 2010)

Patient Navigation Across The Health Care Continuum

Prevention Diagnosis Treatment Post-Treatment Survival & Mortality

Patient Navigator Roles

Professional

• Oncology Nurse

• Social Worker

• Physician Assistant

• Advanced Practice Nurse

• Case Manager

• Patient Care Coordinator

Non-Professional

• Volunteer Lay Patient Navigator

• Patient Navigator

• Lay Health Advisors

• ACA exchange or market place navigator

• Community Health Worker

Wilcox & Bruce, 2010; Pedersen & Hack, 2010; Lorhan et al, 2013

ONS PromotesOncology Nurse Navigator

• 2009, Think Tank on patient navigation involving ONS, AOSW & National Association of Social Workers, a position paper on role of oncology nursing & social work in patient navigation is released

http://www.ons.org/publication/Positions/Navigation

• Paper noted navigation services can be delegated to trained non-professional and/or volunteers & should be supervised by nurses or social workers

• 2010, ONS Nurse Navigator SIG formed & 2015, over 2000 members

• 2012, ONS developed ONN Core Competencies outline knowledge & skills novice ONN should possess

• 2015, ONS position statement = OCN minimum certification for ONN

• ONS ONN SIG identified need for national education web based oncology nurse navigation program & certificate

http://www.ons.org/sites/default/files/ONNCompetencies_rev.pdf

First Textbook Oncology Nurse Navigation• July 2014, ONS publishes

first textbook that focuses on the role of the oncology nurse navigator

• Provides an in-depth review of the emerging specialty of oncology nurse navigation

• Includes concrete examples, tangible tools, national and community resources

ONN Professional Practice Framework

• Promotes key processes & relationships that influence role of ONN & desired outcome

• Identifies role of ONN in bi-dimensional framework: organization & patient

– Organization refers to healthcare system

– Patient corresponds to patient centered care & empowerment

• Examples of outcomes: patient satisfaction, improved interdisciplinary communication, patient retention & downstream revenues

Desimini et al, 2011; Fillion et al, 2013

Importance of Competencies

• Safe, effective & knowledgeable patient care is most important reason for nurse competencies

• Institute of Medicine (IOM,2003) defined professional competence as “the habitual & judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served.”

• IOM, 2010 addressed need to develop nurses within nursing programs, health care institutions & professional organizations.

CORE COMPETENCIES Patient Navigator Oncology Nurse Navigator

Professional Role General knowledge of disease, healthcarefacility, community

Clinical knowledge of disease process

Education General knowledge of health promotion, cancer prevention and how to address non-clinical barriers to care

Assess educational needs and clinical barriers to care of patient. Provides disease specific information & symptom mgmt.

Care Coordination Acts as a liaison for community resourcesAnd healthcare system

Ensure patient needs are met across all settings & facilitates the delivery of quality care and improved outcomes.

Communication Facilitates communication between ONN and patient

Facilitates communication with all members of the health care team; Provides psychosocial support

ONS Nurse Navigator Core Competencies, 2012; Gentry & Sellers, 2014

Focus on Care Coordination

• Advanced Practice Nurse

• CNS

• Patient Navigator

• Pivot Nurse (Canada)

• Coordinator

• Bone Marrow

• Stem Cell Transplant

• Case Manager

• Guided Care Nurse ($$$)

Oncology Care

Coordination

Summary

• Breast cancer discoveries unprecedented

• Unequal Treatments for parts of population

• Oncology nurse navigation may help

• Care coordination is a must

Questions

Not to know is bad; not to ask is worse(African Proverb)

"Be the change that you wish to see in the world.“ Mahatma Gandhi

Thank you

Merci

Asante Sana

Salamat