Display options
Share it on

J Adv Nurs. 2022 Jan;78(1):48-62. doi: 10.1111/jan.14962. Epub 2021 Jul 07.

Role of the nurse in the design, delivery, monitoring and coordination of cancer survivorship care plans: An integrative review.

Journal of advanced nursing

Nerea Elizondo Rodriguez, Leire Ambrosio, Virginia La Rosa-Salas, Marta Domingo-Osle, Cristina Garcia-Vivar

Affiliations

  1. Subdirectory of care, Hospital Complex of Navarra, University of Navarra, Pamplona, Spain.
  2. Faculty of Health Sciences, University of Southampton, Southampton, UK.
  3. Director Teaching Practice Unit, University of Navarra, Pamplona, Spain.
  4. Registered Nurse at University of Navarra Clinic and Lecturer at the Practical Teaching Unit, Faculty of Nursing, University of Navarra, Pamplona, Spain.
  5. Department of Health Sciences, Public University of Navarre, IdiSNA, Pamplona, Spain.

PMID: 34235775 DOI: 10.1111/jan.14962

Abstract

AIM: Survivorship care plans (SCPs) are recommended as a tool for the care of cancer survivors. SCPs have been implemented with a multidisciplinary approach; however, the specific role of nurses in the SCP is unknown. Our aim is to determine the role of nurses and their degree of participation in cancer SCPs.

DESIGN: Integrative review of the literature with systematic methodology.

DATA SOURCES: PubMed, CINAHL, PsycINFO, Web of Science, Cochrane and Cancerlit databases were reviewed. Articles published up to March 2021 were included.

REVIEW METHOD: Of the 2,638 publications identified, 22 studies met our inclusion criteria. Quality of included studies was assessed using Joanna Briggs Institute quality assessment tools.

RESULTS: The studies showed that nurses play a key role and participate in different phases of the SCP, including design, delivery, monitoring and coordination among different levels of care, with varying degrees of involvement and responsibility; design and delivery of the SCP are the phases with the highest nurse participation (18 out of 22 studies). The majority of SCPs are implemented in specialized, hospital-based care and focus on short-term cancer survivors, who are actively undergoing oncological treatments.

CONCLUSION: This review shows that nurses actively participate in the design, implementation and coordination of SCPs. However, SCPs focus on the acute survival and treatment phases, and there is a gap in their use in long-term cancer survivorship. This gap may be one reason the needs of long-term cancer survivors are not covered.

IMPACT: This review contributes to the current body of knowledge by addressing the role of nurses in cancer SCPs. We recommend the involvement of an advanced practice nurse as SCP coordinator to improve communication between cancer specialists and primary care providers and to promote continued care throughout the different phases of cancer survivorship, including long-term survival.

© 2021 John Wiley & Sons Ltd.

Keywords: care plan; nurse; oncology; participation; role; survivorship

References

  1. American Society of Clinical Oncology (2017). Cancer survivorship care plan. Alexandria. Retrieved from https://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdf - PubMed
  2. Boekhout, A. H., Maunsell, E., Pond, G. R., Julian, J. A., Coyle, D., Levine, M. N., & Grunfeld, E. (2015). A survivorship care plan for breast cancer survivors: Extended results of a randomized clinical trial. Journal of Cancer Survivorship, 9, 683-691. https://doi.org/10.1007/s11764-015-0443-1 - PubMed
  3. Brant, J., Blaseg, K., Aders, K., Oliver, D., Gray, E., & Dudley, W. (2016). Navigating the transition from cancer care to primary care: Assistance of a survivorship care plan. Oncology Nursing Forum, 43(6), 710-719. https://doi.org/10.1188/16.onf.710-719 - PubMed
  4. Bray, F., Jacques, F., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal of Clinicians, 68(6), 394-424. https://doi.org/10.3322/caac.21492 - PubMed
  5. Cavallar Oriol, B., & García-Vivar, C. (2019). Necesidades de los familiares en la etapa de larga supervivencia de cáncer [Needs of family members in the long-term cancer survivorship]. Enfermería Oncológica, 21(2), 42-51. https://doi.org/10.37395/seeo.2019.0006 - PubMed
  6. Clarke, A. L., Roscoe, J., Appleton, R., Parashar, D., Muthuswamy, R., Khan, O., Dale, J., & Nanton, V. (2020). Promoting integrated care in prostate cancer through online prostate cancer-specific holistic needs assessment: a feasibility study in primary care. Supportive Care in Cancer, 28(4), 1817-1827. https://doi.org/10.1007/s00520-019-04967-y - PubMed
  7. Colombani, F., Sibé, M., Kret, M., Quintard, B., Ravaud, A., & Saillour-Glénisson, F. (2019). EPOCK study protocol: A mixed-methods research program evaluating cancer care coordination nursing occupations in France as a complex intervention. BMC Health Services Research, 19(1), 1-16. https://doi.org/10.1186/s12913-019-4307-7 - PubMed
  8. Corcoran, S., Dunne, M., & McCabe, M. S. (2015). The role of advanced practice nurses in cancer survivorship care. Seminars Oncology Nursing, 31(4), 338-347. https://doi.org/10.1016/j.soncn.2015.08.009 - PubMed
  9. Corner, J. (2003). The role of nurse-led care in cancer management. Lancet Oncology, 4(10), 631-636. https://doi.org/10.1016/s1470-2045(03)01223-3 - PubMed
  10. Coyle, D., Grunfeld, E., Coyle, K., Pond, G., Julian, J. A., & Levine, M. N. (2014). Cost effectiveness of a survivorship care plan for breast cancer survivors. Journal of Oncology Practice, 10(2), e86-e92. https://doi.org/10.1200/jop.2013.001142 - PubMed
  11. De Leeuw, J., & Larsson, M. (2013). Nurse-led follow-up care for cancer patients: What is known and what is needed. Supportive Care Cancer, 21(9), 2643-2649. https://doi.org/10.1007/s00520-013-1892-6 - PubMed
  12. de Rooij, B. H., Ezendam, N. P. M., Nicolaije, K. A. H., Caroline Vos, M., Pijnenborg, J. M. A., Boll, D., Boss, E. A., Hermans, R. H. M., Engelhart, K. C. M., Haartsen, J. E., Pijlman, B. M., van Loon-Baelemans, I. E. A. M., Mertens, H. J. M. M., Nolting, W. E., van Beek, J. J., Roukema, J. A., Kruitwagen, R. F. P. M., & van de Poll-Franse, L. V. (2017). Effects of Survivorship Care Plans on patient reported outcomes in ovarian cancer during 2-year follow-up - The ROGY care trial. Gynecologic Oncology, 145, 319-328. https://doi.org/10.1016/j.ygyno.2017.02.041 - PubMed
  13. de Rooij, B. H., Ezendam, N. P. M., Vos, M. C., Pijnenborg, J. M. A., Boll, D., Kruitwagen, R. F. P. M., & van de Poll-Franse, L. V. (2019). Patients’ information coping styles influence the benefit of a survivorship care plan in the ROGY Care Trial: New insights for tailored delivery. Cancer, 125(5), 788-797. https://doi.org/10.1002/cncr.31844 - PubMed
  14. DeGuzman, P. B., Colliton, K., Nail, C. J., & Keim-Malpass, J. (2014). Survivorship care plans. Rural, low-income breast cancer survivor perspectives. Clinical Journal of Oncology Nursing, 21(6), 692-698. https://doi.org/10.1188/14.onf.447-448 - PubMed
  15. Ezendam, N. P. M., Nicolaije, K. A. H., Kruitwagen, R. F. P. M., Pijnenborg, J. M. A., Vos, M. C., Boll, D., van Bommel, M., & van de Poll-Franse, L. V. (2014). Survivorship care plans to inform the primary care physician: results from the ROGY care pragmatic cluster randomized controlled trial. Journal of Cancer Survivorship, 8, 595-602. https://doi.org/10.1007/s11764-014-0368-0 - PubMed
  16. Fenlon, D., & Foster, C. (2009). Care after cancer. Retrived from https://citeseerx.ist.psu.edu/viewdoc/download?doi = 10.1.1.734.7062&rep = rep1&type = pdf - PubMed
  17. Fuentes, A. C., Lambird, J. E., George, T. J., & Merry, J. M. (2017). Cancer survivor’s history and physical. Southern Medical Journal, 110, 37-44. https://doi.org/10.14423/SMJ.0000000000000585 - PubMed
  18. Ganz, P. A., & Hahn, E. E. (2008). Implementing a survivorship care plan for patients with breast cancer. Clinical Journal of Oncology Nursing, 12(3), 479-487. https://doi.org/10.1200/JCO.2007.14.2851 - PubMed
  19. Garcia-Vivar, C. (2005). Calidad de vida en supervivientes a largo plazo de cáncer de mama. Un área olvidada en la investigación enfermera. [Quality of life in long-term survivors of breast cancer. A missed area in nursing research]. Index De Enfermería, 14(50), 30-34. - PubMed
  20. Garcia-Vivar, C., Elizondo, N., & Ambrosio, L. (2019). Primary care nursing is essential to fully implement survivorship care plans for long-term cancer survivors and their families. Cancer Nursing, 42(3), 177-178. https://doi.org/10.1080/713685949 - PubMed
  21. Glaser, K. M., McDaniel, D. C., Hess, S. M., Flores, T. F., Rokitka, D. A., & Reid, M. E. (2019). Implementing an integrative survivorship program at a comprehensive cancer center: A multimodal approach to life after cancer. Journal of Alternative and Complementary Medicine, 25(S1), S106-S111. https://doi.org/10.1089/acm.2018.0383 - PubMed
  22. Grant, M., Economou, D., & Ferrell, B. R. (2010). Oncology nurse participation in survivorship care. Clinical Journal of Oncology Nursing, 14(6), 709-715. https://doi.org/10.1188/10.CJON.709-715 - PubMed
  23. Hawkins-Taylor, C., Carson, P., Anderson, D., Carlson, A., Kerkvliet, J., Cowan, J., Gaster, S., McClure, C., & Pugsley, L. (2019). Survivorship care plans: health actions taken and satisfaction after use. Oncology Nursing Forum, 46(5), 585-594. https://doi.org/10.1188/19.ONF.585-594 - PubMed
  24. Hewitt, M., Greenfield, S., & Stovall, E. (2005). From cancer patient to cancer survivor - lost in transition. (I. of and N. research council Medicine, Ed.). Washington D. C. https://doi.org/10.17226/11613 - PubMed
  25. Jacobs, L. A., & Shulman, L. N. (2017). Follow-up care of cancer survivors: challenges and solutions. The Lancet Oncology, 18(1), e19-e29. https://doi.org/10.1016/S1470-2045(16)30386-2 - PubMed
  26. Jefford, M., Aranda, S., Gough, K., Lotfi-Jam, K., Butow, P., Krishnasamy, M., Young, J., Phipps-Nelson, J. O., Russell, L., King, D., & Schofield, P. (2013). Evaluating a nurse-led survivorship care package (SurvivorCare) for bowel cancer survivors: Study protocol for a randomized controlled trial. Trials, 14, 1-9. https://doi.org/10.1186/1745-6215-14-260 - PubMed
  27. Jeppesen, M. M., Ezendam, N. P. M., Pijnenborg, J. M. A., Caroline Vos, M., Boll, D., Kruitwagen, R. F. P. M., Jensen, P. T., & van de Poll-Franse, L. V. (2018). The impact of the survivorship care plan on health care use: 2-year follow-up results of the ROGY care trial. Journal of Cancer Survivorship, 12, 18-27. https://doi.org/10.1007/s11764-017-0639-7 - PubMed
  28. Joanna Briggs Institute (2017). Critical Appraisal tools. Retrieved from https://joannabriggs.org/critical-appraisal-tools - PubMed
  29. Jost, S. G., Bonnell, M., Chacko, S. J., & Parkinson, D. L. (2010). Integrated primary nursing. Nursing Administration Quarterly, 34(3), 208-216. https://doi.org/10.1097/naq.0b013e3181e7032c - PubMed
  30. Lagergren, P., Schandl, A., Aaronson, N. K., Adami, H.-O., Lorenzo, F., Denis, L., Faithfull, S., Liu, L., Meunier, F., & Ulrich, C. (2019). Cancer survivorship: an integral part of Europe’s research agenda. Molecular Oncology, 13(3), 624-635. https://doi.org/10.1002/1878-0261.12428 - PubMed
  31. Lawn, S., Fallon-Ferguson, J., & Koczwara, B. (2017). Shared care involving cancer specialists and primary care providers - What do cancer survivors want? Health Expectations, 20(5), 1081-1087. https://doi.org/10.1111/hex.12551 - PubMed
  32. Levine, M. N., Maunsell, E., Grunfeld, E., Pond, G. R., Boekhout, A. H., Coyle, D., & Julian, J. A. (2015). A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial. Journal of Cancer Survivorship, 9(4), 683-691. https://doi.org/10.1007/s11764-015-0443-1 - PubMed
  33. Lewis, R., Neal, R. D., Williams, N. H., France, B., Wilkinson, C., Hendry, M., & Weller, D. (2009). Nurse-led vs. conventional physician-led follow-up for patients with cancer. Journal of Advanced Nursing, 65(4), 706-723. https://doi.org/10.1111/j.1365-2648.2008.04927.x - PubMed
  34. Maly, R. C., Liang, L.-J., Liu, Y., Griggs, J. J., & Ganz, P. A. (2017a). Randomized controlled trial of survivorship care plans among low-income, predominantly latina breast cancer survivors. Journal of Clinical Oncology, 35(16), 1814-1821. https://doi.org/10.1200/JCO.2016.68.9497 - PubMed
  35. Maly, R. C., Liang, L.-J., Liu, Y., Griggs, J. J., & Ganz, P. A. (2017b). Randomized controlled trial of survivorship care plans among low-income, predominantly latina breast cancer survivors. Journal of Clinical Oncology, 35(16), 1814-1821. https://doi.org/10.1200/JCO.2016.68.9497 - PubMed
  36. Mateo, A. M., & Garcia-Vivar, C. (2019). Modelos de atención sanitaria en la supervivencia del cáncer y gestión de cuidados enfermeros [Health care models in cancer survival and nursing care management]. Enfermería Oncológica, 21(1), 18-23. - PubMed
  37. Mayer, D., Deal, A., Crane, J., Chen, R., Asher, G., Hanson, L., Wheeler, S., Gerstel, A., Green, M., Birken, S., & Rosenstein, D. (2016). Using survivorship care plans to enhance communication and cancer care coordination: Results of a pilot study. Oncology Nursing Forum, 43(5), 636-645. https://doi.org/10.1188/16.onf.636-645 - PubMed
  38. Mayer, D. K., Gerstel, A., Walton, A. L., Triglianos, T., Sadiq, T. E., Hawkins, N. A., & Davies, J. M. (2014). Implementing survivorship care plans for colon cancer survivors. Oncology Nursing Forum, 41(3), 266-273. https://doi.org/10.1188/14.onf.266-273 - PubMed
  39. Minnesota Cancer Alliance (2013). Cancer Survivor Care Plan What’s Next?. Life After Cancer Treatment. - PubMed
  40. Miller, R. (2008). Implementing a survivorship care plan for patients with breast cancer. Clinical Journal of Oncology Nursing, 12(3), 479-487. https://doi.org/10.1200/JCO.2007.14.2851 - PubMed
  41. Monterosso, L., Platt, V., Bulsara, M., & Berg, M. (2019). Systematic review and meta-analysis of patient reported outcomes for nurse-led models of survivorship care for adult cancer patients. Cancer Treatment Review, 73, 62-72. https://doi.org/10.1016/j.ctrv.2018.12.007 - PubMed
  42. Nicolaije, K. A. H., Ezendam, N. P. M., Vos, M. C., Pijnenborg, J. M. A., Boll, D., Boss, E. A., Hermans, R. H. M., Engelhart, K. C. M., Haartsen, J. E., Pijlman, B. M., van Loon-Baelemans, I. E. A. M., Mertens, H. J. M. M., Nolting, W. E., van Beek, J. J., Roukema, J. A., Zijlstra, W. P., Kruitwagen, R. F. P. M., & van de Poll-Franse, L. V. (2015). Impact of an automatically generated cancer survivorship care plan on patient-reported outcomes in routine clinical practice: Longitudinal outcomes of a pragmatic, cluster randomized trial. Journal of Clinical Oncology, 33(31), 3550-3559. https://doi.org/10.1200/JCO.2014.60.3399 - PubMed
  43. Nicolaije, K. A. H., Ezendam, N. P. M., Vos, M. C., Pijnenborg, J. M. A., van de Poll-Franse, L. V., & Kruitwagen, R. F. P. M. (2013). Oncology providers’ evaluation of the use of an automatically generated cancer survivorship care plan: Longitudinal results from the ROGY Care trial. Journal of Cancer Survivorship, 8, 248-259. https://doi.org/10.1007/s11764-013-0327-1 - PubMed
  44. Nolte, L., Kinnane, N., Lai-Kwon, J., Gates, P., Shilkin, P., & Jefford, M. (2016). The impact of survivorship care planning on patients, general practitioners, and hospital-based staff. Cancer Nursing, 39(6), E26-E35. https://doi.org/10.1097/NCC.0000000000000329 - PubMed
  45. Poghosyan, L., Norful, A. A., Liu, J., & Friedberg, M. W. (2018). Nurse practitioner practice environments in primary care and quality of care for chronic diseases. Medical Care, 56(9), 791-797. https://doi.org/10.1097/MLR.0000000000000961 - PubMed
  46. Reb, A., Ruel, N., Fakih, M., Lai, L., Salgia, R., Ferrell, B., Sampath, S., Kim, J. Y., Raz, D. J., & Sun, V. (2017). Empowering survivors after colorectal and lung cancer treatment: Pilot study of a self-management survivorship care planning intervention. European Journal of Oncology Nursing, 29, 125-134. https://doi.org/10.1016/j.ejon.2017.06.003 - PubMed
  47. Rowland, J. H., Kent, E. E., Forsythe, L. P., Loge, J. H., Hjorth, L., Glaser, A., Mattioli, V., & Fosså, S. D. (2013). Cancer survivorship research in Europe and the United States: Where have we been, where are we going, and what can we learn from each other? Cancer, 119(SUPPL11), 2094-2108. https://doi.org/10.1002/cncr.28060 - PubMed
  48. Siegel, R. L., Miller, K. D., & Jemal, A. (2019). Cancer statistics, 2019. CA: A Cancer Journal for Clinicians, 69(1), 7-34. https://doi.org/10.3322/caac.21551 - PubMed
  49. Singh-Carlson, S., Wong, F., & Oshan, G. (2018). Evaluation of the delivery of survivorship care plans for South Asian female breast cancer survivors residing in Canada. Current Oncology, 25(4), 265-274. https://doi.org/10.1007/s00520-016-3209-z - PubMed
  50. Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C., & Wood, L. (2015). Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), 130-136. https://doi.org/10.1016/j.outlook.2014.08.004 - PubMed
  51. Sociedad Española de Oncología Médica SEOM (2011). Monográfico SEOM de largos supervivientes en cáncer [SEOM Monograph of long-term cancer survivors]. Retrieved from https://seom.org/seomcms/images/stories/recursos/infopublico/publicaciones/MONOGRAFICO_SEOM_LARGOS_SUPERVIVIENTES_I.pdf - PubMed
  52. Sprague, B. L., Dittus, K. L., Pace, C. M., Dulko, D., Pollack, L. A., Hawkins, N. A., & Geller, B. M. (2013). Patient satisfaction with breast and colorectal cancer survivorship care plans. Clinical Journal of Oncology Nursing, 17(3), 266-272. https://doi.org/10.1188/13.cjon.17-03ap - PubMed
  53. Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546-553. https://doi.org/10.1111/j.1365-2648.2005.03621.x - PubMed

MeSH terms

Publication Types