Specialized Cancer Care Roles: from Clinical Practice to Research and Beyond

Specialized roles undertaken by cancer nurses are not a new trend in clinical practice. It was as early as in the 70s that the need for such roles emerged and the need for additional education within the specific context of cancer begun to rise. 1Amir Z, Scully J, Borrill C. The professional role of breast cancer nurses in multi-disciplinary breast cancer care teams. Eur J Oncol Nurs 306–14.Google Scholar There are a number of different definitions of what constitutes a specialized cancer nurse, primarily due to the variations on the roles assumed in different countries. A specialist cancer nurse is expected to be educated to a degree level (or higher), have a formal training in cancer and to care for cancer patients as a specialized population, and across different cancer types and the entire cancer care continuum. 2Canadian Association of Nurses in Oncology (CANO) Roles in Oncology Nursing.Available from: http://wwwcano-acioca/rolesDate: 2016Date accessed: November 16, 2019Google Scholar According to the WHO, a cancer nurse has successfully completed specialist postqualification education in cancer nursing which builds on initial generalist nursing education, enabling the nurse to work in a specialized tile with individuals and families experiencing and/or affected by cancer. 3World Health Organization WHO European Strategy for Continuing Education for Nurses and Midwives. WHO Regional Office for Europe, Copenhagen2003Available from: http://wwweurowhoint/__data/assets/pdf_file/0016/102265/e81551pdfDate accessed: December 2, 2019Google Scholar The question that arises here is what were those reasons that contributed to the rise of this need? The development of cancer therapies as well as the changing face of cancer are the main reasons to be discussed. With regard to the evolution of cancer treatment, this includes the introduction of new effective but at the same time demanding and complex therapies (i.e., from the point of view of the health-care professional). With these new treatments, it became apparent that the nurses' role should also be adjusted to this highly specific process in order to be able to meet the specific requirements for appropriate, safe administration and monitoring of such treatments. To this end, the advanced nursing assessment prior the onset of such treatments as well as the monitoring of the patient throughout the duration of the therapy and well beyond safeguards against possible complications (e.g., treatment-related toxicities) and ensures that when such complications do occur, these are timely diagnosed and acted upon. 4Ciccolini K, Lucas AS, Weinstein A, Lacouture M. Advanced care provider and nursing approach to assessment and management of immunotherapy-related dermatologic adverse events. J Adv Pract Oncol 138–45.Google Scholar The treatment of cancer has also contributed to the changing face of cancer over time. Cancer has become a chronic disease where increased number of patients lives longer, receives their care in the ambulatory setting (e.g., home setting), and experiences better quality of life. 5Mooney K, Berry DL, Whisenant M, Sjoberg D. Improving cancer care through the patient experience: How to use patient-reported outcomes in clinical practice. Am Soc Clin Oncol Educ Book 695–704.Google Scholar This changing context is closely connected to the shift of the cancer nurse's role toward being more independent within the ambulatory context and within the hospital context where care is being delivered based on multidisciplinary and interdisciplinary frameworks. The value of such frameworks has been systematically reported in the literature, 6Soukup T, Lamb BW, Arora S, Darzi A, Sevdalis N, Green JS. Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: An overview and synthesis of the available literature. J Multidiscip Healthc 49–61.Google Scholar although some limitations were identified such as the presence of autocratic practice and hierarchical boundaries that can constitute a team becoming dysfunctional and participation stressful. 7Punshon G, Endacott R, Aslett P, Brocksom J, Fleure L, Howdle F, et al. The experiences of specialist nurses working within the uro-oncology multidisciplinary team in the United Kingdom. Clin Nurse Spec 210–8.Google Scholar Within such frameworks, the changing nurse's role includes the delivery of complex treatments, management of treatment-related adverse events, educating and supporting patients and their families (but also as informal caregivers helping to support this role), acting as an advocate for the patient, and being an integral part of the multidisciplinary and interdisciplinary teams. Within the hospital setting, over the years, cancer nurses assume specialized roles throughout the cancer care continuum and across cancer populations. 8McPhillips D, Evans R, Ryan D, Daneshvar C, Sarkar SA, Breen D. The role of a nurse specialist in a modern lung-cancer service. Br J Nurs S21–7.Google Scholar, 9Tarrant C, Sinfield P, Agarwal S, Baker R. Is seeing a specialist nurse associated with positive experiences of care.The role and value of specialist nurses in prostate cancer care?. BMC Health Serv Res 65.Google Scholar, 10Chapple A, Ziebland S, McPherson A. The specialist palliative care nurse: A qualitative study of the patients' perspective. Int J Nurs Stud 1011–22.Google Scholar An example of such roles is the nurse-led clinics in cancer care that prioritize the patient as the center of care, providing the opportunity to address the serious medical, functional, and psychosocial consequences of cancer and its treatments. In many contexts, nurse-led clinics evolved from primary care, where practice nurses set up clinics for patients with chronic diseases such as diabetes. The later expansion within GP (General Practitioner) practices included nurse practitioners/advanced nurse practitioners and other health professionals, where nurses performed highly specialized interventions. Overall, many of the current nurse-led clinics in oncology emphasize on routine follow-up after completion of adjuvant therapy; however, the reductions in routine medical follow-up influence this trend, leading to considerations of alternative methods of follow-up. 11Beaver K, Twomey M, Witham G, Foy S, Luker KA. Meeting the information needs of women with breast cancer: Piloting a nurse-led intervention. Eur J Oncol Nurs 378–90.Google Scholar A recent example is the setup of a nurse-led diagnostic/supportive follow-up clinic to improve capacity, while at the same time ensure high-quality care. By retrospectively reviewing the patient outcomes from the nurse-led clinic, the findings showed a shortened duration of the pathway, more efficient than the medical-led diagnostic clinics, while maintaining excellent patient experience. 12Kerr S, Mambwere M, Hardavella G. Nurse led lung cancer diagnostic/supportive follow up clinical different approach to optimise lung cancer pathway. Eur Respir J PA2074.Google Scholar Within this nurse-led context, the rapid expansion and development of nursing roles and responsibilities in oncology has also contributed to the onset of nurse-led chemotherapy clinics. 13Lennan E, Vidall C, Roe H, Jones P, Smith J, Farrell C. Best practice in nurse-led chemotherapy review: A position statement from the United Kingdom Oncology Nursing Society. Ecancermedicalscience 263.Google Scholar, 14Farrell C, Walshe C, Molassiotis A. Are nurse-led chemotherapy clinics really nurse-led.An ethnographic study?. Int J Nurs Stud 1–8.Google Scholar The extended and specialized roles that cancer nurses assume are also reflected in the relevant literature. A recent systematic review by Charalambous et al. 15Charalambous A, Wells M, Campbell P, Torrens C, Östlund U, Oldenmenger W, et al. A scoping review of trials of interventions led or delivered by cancer nurses. Int J Nurs Stud 36–43.Google Scholar aimed for the first time to capture these advanced roles that are assumed or led by cancer nurses across the cancer care continuum. Over 200 trials were included in the review referring to specialized interventions undertaken or led by cancer nurses from around the world. Although the number might seem high at first, according to the authors, this does not reflect the reality in the sense that many researchers poorly (or not at all) described the role of the carrier of the interventions resulting in many trials been excluded based on the inclusion criteria. Although in the review, it is reported that most of the interventions were nurse led, a number of interventions were also facilitated by cancer nurses within a wider team. This finding stresses the important role of specialist nurses within such multiprofessional teams, where advanced co-ordination roles are also assumed by cancer nurses. In terms of the actual interventions that cancer nurses undertake, there was a large variation including direct care, psychological, educational, cognitive-behavioral, assessment and monitoring, care management, and coordination. While the majority of the studies were undertaken during the treatment phase (i.e., the phase where patients' needs peak), the changing landscape of cancer will in the near future see much more involvement of cancer nurses in prevention (i.e., focus on preventive programs and screening) and survivorship (i.e., more patients are cured or live longer dealing with the delayed adverse events of treatment). Furthermore, the interventions were not limited to the hospital setting but rather extended across settings, cancer populations from diagnosis to survivorship and palliative care. 15Charalambous A, Wells M, Campbell P, Torrens C, Östlund U, Oldenmenger W, et al. A scoping review of trials of interventions led or delivered by cancer nurses. Int J Nurs Stud 36–43.Google Scholar The systematic review by Charalambous et al., 15Charalambous A, Wells M, Campbell P, Torrens C, Östlund U, Oldenmenger W, et al. A scoping review of trials of interventions led or delivered by cancer nurses. Int J Nurs Stud 36–43.Google Scholar alongside preceding studies on nurse-led interventions in various contexts, nurse-led clinics, and studies on specialized roles have all raised the necessity for cancer nurse specialists in the field. Furthermore, expert opinions and position papers have also emphasized on the importance of including specialist nurses at the core of multiprofessional teams in various cancer populations including colorectal, 16Beets G, Sebag-Montefiore D, Andritsch E, Arnold D, Beishon M, Crul M, et al. ECCO Essential requirements for quality cancer care: Colorectal cancer.A critical review. Crit Rev Oncol Hematol 81–93.Google Scholar melanoma, 17Wouters MW, Michielin O, Bastiaannet E, Beishon M, Catalano O, Del Marmol V, et al. ECCO essential requirements for quality cancer care: Melanoma. Crit Rev Oncol Hematol 164–78.Google Scholar breast, 18Mahony J, Masters H, Townsend J, Hagerty F, Fodero L, Scuteri J, et al. The impact of breast care nurses: An evaluation of the mcgrath foundation's breast care nurse initiative. Asia Pac J Oncol Nurs 28–34.Google Scholar prostate, 9Tarrant C, Sinfield P, Agarwal S, Baker R. Is seeing a specialist nurse associated with positive experiences of care.The role and value of specialist nurses in prostate cancer care?. BMC Health Serv Res 65.Google Scholar sarcoma, 19Andritsch E, Beishon M, Bielack S, Bonvalot S, Casali P, Crul M, et al. ECCO essential requirements for quality cancer care: Soft tissue sarcoma in adults and bone sarcoma.A critical review. Crit Rev Oncol Hematol 94–105.Google Scholar lung, 8McPhillips D, Evans R, Ryan D, Daneshvar C, Sarkar SA, Breen D. The role of a nurse specialist in a modern lung-cancer service. Br J Nurs S21–7.Google Scholar esophageal, and gastric cancer 20Allum W, Lordick F, Alsina M, Andritsch E, Ba-Ssalamah A, Beishon M, et al. ECCO essential requirements for quality cancer care: Oesophageal and gastric cancer. Crit Rev Oncol Hematol 179–93.Google Scholar just to name a few. The challenges remain, however, for achieving a universal recognition of cancer nursing specialty and its integration within the core of the multiprofessional teams. 21Kelly D, Charalambous A. Recognising the impact and future potential of cancer nursing: The RECaN project and beyond. Eur J Oncol Nurs PA1–PA2.Google Scholar Despite the fact that such advanced/specialized roles have been introduced in many countries, cancer care is still been provided by nonspecialized cancer nurses in a significant number of countries. An increased number of cancer nurses assume these specialized roles contributing to the optimization and safety of cancer care across cancer settings and cancer populations. 22Sharp L, Rannus K, Olofsson A, Kelly D, Oldenmenger WH. EONS RECaN group.Patient safety culture among European cancer nurses-An exploratory, cross-sectional survey comparing data from Estonia, Germany, Netherlands, and United Kingdom. J Adv Nurs 3535–43.Google Scholar With the benefits of such specialized roles expanding beyond the obvious of providing quality of care, 23Kousoulou M. , Suhonen R, Charalambous A.Associations of individualized nursing care and quality of oncology nursing care in patients diagnosed with cancer. Eur J Oncol Nurs 33–40.Google Scholar in the literature, there has been reported an increased patients' satisfaction through the better response to their needs, a more personalized approach to care, 24Charalambous A, Radwin L, Berg A, Sjovall K, Patiraki E, Lemonidou C, Katajisto J, Suhonen R. An international study of hospitalized cancer patients' health status, nursing care quality, perceived individuality in care and trust in nurses: A path analysis. Int J Nurs Stud 176–86.Google Scholar caring for the patient as a whole, and not merely emphasizing on the physical body just to report a few. In contrast, the provision of cancer care by nonspecialist nurses has been linked to poor quality of care often not only affecting the patients but also the nurses themselves who report high levels of distress due to their ill-preparedness to deal with such specialized cases. 25Gill F, Duffy A. Caring for cancer patients on non-specialist wards. Br J Nurs 761–7.Google Scholar Nil. There are no conflicts of interest.

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