Transcript Cancer Care Training: A Multidisciplinary Approach to Pain

Cancer Care Training:
A Multidisciplinary
Approach to Managing Pain
and Palliative Care In Rural
Primary Care
Program Partners
Mary Ann Burg, LCSW, PhD
Community Health & Family Medicine
Kendra Siler-Marsiglio, PhD
Director
Dawn Grinenko, MD
Community Health & Family Medicine
Merry Jennifer Markham, MD
Adult Medical Director, UF Cancer Survivor
Program
Gail Adorno, LCSW, MSW
Social Worker, UF Cancer Survivor Program
Susan Fleming
Cancer Program Administrator
Why this training, why now?
– Growing numbers of cancer survivors require
cancer follow-up care and comprehensive health
care
– Need to increase access for patients to these
services in their home communities
– Need to increase capacity and skills of rural
providers to care for persons with cancer histories
National Cancer Survival Rates
FIGURE 2-2 Five-year relative survival rates. SOURCE: NCI (2004c).
Cancer Incidence and Mortality in Rural North Florida
Rate of New Cancers 2002-2006
Rate of Cancer Deaths 2002-2006
Counties with mortality rates higher than state average:
Baker , Clay , Dixie, Hamilton, Levy, Madison, Marion, Putnam,
Suwannee, Taylor, Union. Putnam County has experienced a
RISING trend in cancer mortality:
Cancer Survivors By Site of Cancer
People With A Cancer History Are Everywhere
You Look…
Today’s Training Goals:
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Discuss the role of the multidisciplinary
primary care team in cancer care;
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Define cancer-related palliative care
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Review best practices for screening and
treating palliative care needs of rural
patients with cancer histories in primary care
settings
What is the Cancer Experience?
• Treatment, and then
what?
• Fragmented care
• Body changes &
unexpected symptoms
• Emotional rollercoaster
• Role changes
• Family stress
• Financial stress
Life “Before and After” Cancer
The Cancer Experience Can Also Be…
A new beginning:
•“post traumatic growth”
• improved wellness behavior
• improved health knowledge
• A cycle of new medical
problems
• Cancer recurrences
• The beginning of the end
Patients Need Comprehensive Cancer Care:
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Anti-cancer therapy
Supportive care
Palliative care
End-of-life care
Bereavement care
Comprehensive cancer care is ALL care that occurs after a
patient is diagnosed with cancer
Comprehensive Cancer Care Model
Palliative Care
Hospice Care
Palliative Care Is…
“Patient and family-centered care that focuses upon
effective management of pain and other distressing
symptoms, while incorporating psychosocial and
spiritual care according to patient/family needs,
values, beliefs and culture(s).
The goal of palliative care is to prevent and relieve
suffering and support the best quality of life for
patients and their families, regardless of the stage of
disease or need for other therapies.”
NCCN Practice Guidelines in Oncology – v.1.2010
Palliative Care Is Also…
• Relevant to any type of cancer
• Important at all stages of cancer care
• Care that can be combined with therapies aimed
at remitting or curing cancer, or it may be the
total focus of care
• Multidisciplinary: members of a palliative care
team may include professionals from medicine,
nursing, social work, chaplaincy, nutrition,
rehabilitation, pharmacy and other professional
disciplines
Caring for the Patient With A Cancer History in a
Primary Care Setting
• Assessment and treatment of acute and
chronic health problems
• Health promotion
• Cancer screening
PALLIATIVE
CARE
USUAL
CARE
• Intervention for consequences of cancer
and its treatment
• Coordination of care between specialists
and negotiation of care
• Assisting patients through care transitions
(including hospice care)
Primary Care Is An Essential Site for Palliative Care
Primary
Care
Cancer treatment
Cancer follow-up Care
Primary
Care
Cancer recurrence
End-of-life care
Primary
Care
Primary
Care
The Primary Care Team: Taking
Multiple Roles In Caring for Persons With Cancer
Front
Office
Social
Worker/
Nurse
Provider
Pharmacist
Initiate a cancer
care medical record
Cancer- sensitive
communication
Screen for cancer
related symptoms
Screen for palliative
care needs
Help coordinate
care
Encourage family
participation in
care
Assisting in care
transitions
PLAY VIDEO: INTAKE SPECIALIST & OFFICE STAFF
PLAY VIDEO: INTAKE SPECIALIST & OFFICE STAFF
Best Practices 1:
Welcoming the New Patient With a Cancer History
• Acknowledgment of the cancer history & its relevance
• Welcoming patient to their “medical home”
• Assisting patient in information gathering
• Assisting patient in communication with providers
Consider Health Literacy
“Health literacy is the degree to which individuals have the
capacity to obtain, process, and understand basic health
information and services needed to make appropriate health
decisions".
• Low health literacy impacts cancer incidence, mortality, and quality
of life:
– Cancer screening information may be ineffective; as a result, patients
may be diagnosed at a later stage.
– Treatment options may not be fully understood; therefore, some
patients may not receive treatments that best meet their needs.
– Informed consent documents may be too complex for many patients
and consequently, patients may make suboptimal decisions about
accepting or rejecting interventions.
(Merriman, Betty, CA: A Cancer Journal for
Physicians, May/June 2002)
Patients With Low Health Literacy May Have
Difficulty With…
•Locating providers and services
•Filling out complex health forms
•Sharing their medical history with providers
•Interpreting test results
•Knowing the connection between risky behaviors and health
•Managing chronic health conditions
•Understanding directions on prescription labels
PLAY VIDEO: NURSE
PLAY VIDEO: NURSE
The New Patient Medical History Interview:
Cancer-related Components
1. Type of cancer /stage of diagnosis/current status
2. Cancer treatments/dates/places/dosages
3. Treatment-related side-effects
4. Patient’s beliefs about their cancer and aftermath
Possible Cancer Trajectories
• Live cancer free for many years
• Live long cancer free, but die rapidly of late
recurrence
• Live cancer free (first cancer), but develop
second primary cancer
• Live with intermittent periods of active disease
• Live with persistent disease
• Live after expected death
Welch-McCaffrey et al., 1989
Definition of Cancer Stage
• Stage of cancer
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Extent that cancer has spread
Correlated with prognosis
Stages I, II, III, and IV
Varies by cancer type
• “Early stage” (stage I and II): mostly curable
• “Locally advanced” (stage III): sometimes curable
• “Metastatic” (stage IV): rarely curable
Types of Cancer Treatments
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Surgery
Radiation therapy
Chemotherapy
Immunotherapy
Hormone therapy
Treatment type varies by type and stage of cancer
Late and Long-term Effects of Cancer
• Late effects refer specifically to unrecognized toxicities that
are absent or subclinical at the end of therapy and become
manifest later with the unmasking of hitherto unseen injury
because of any of the following factors: developmental
processes, the failure of compensatory mechanisms with the
passage of time, or organ senescence.
• Long-term effects refer to any side effects or complications of
treatment for which a cancer patient must compensate; also
know as persistent effects, they begin during treatment and
continue beyond the end of treatment. Late effects, in
contrast, appear months to years after the completion of
treatment.
SOURCE: Aziz and Rowland (2003).
Common Cancer Effects Can Be Helped With
Palliative Care Approaches in the Primary Care
Setting
Including:
• Pain
• Fatigue
• Anxiety/depression
• Sexual side effects
PLAY VIDEO: PROVIDER
PLAY VIDEO: PROVIDER
Pain & Palliative Care Assessment Tools
• FACT-G (B, C, M, P) Functional Assessment of Cancer
Therapy
– http://www.facit.org/about/overview_website.aspx
• Patient Comfort Assessment Guide
– www.partnersagainstpain.com
• Distress Management Screening Tool
– www.nccn.org
Possible Complaints by Type of Cancer History
GENERAL
Pain, fatigue, sleep problems, swelling, weight loss,
appetite problems, urinary or bowel problems,
sexual dysfunction, shortness of breath
Breast
Colorectal
Lymphedema, hot flashes
Appetite, bowel problems, diarrhea, swelling,
weight loss
Urinary problems, rectal bleeding, sexual
dysfunction, hot flashes
Pain, cough, shortness of breath
Prostate
Lung
Patients With Cancer Histories May Have More
Functional Limitations
SOURCE: Hewitt et al. (2003).
Best Practices 2:
Responding to Cancer-related Symptoms In
Primary Care
• Prioritize symptoms and negotiate care plan with patient
• Set goals with patient to recover optimal level of
functioning and quality of life
• Encourage patient, family and caregiver participation in
care
Responding To Pain Complaints In Patients With
Cancer Histories
Main considerations:
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Type of pain
Assessment of pain and functioning
Steps of analgesic management
Side-effects of pain management
Non-pharmacological pain
management
Common Types of Cancer Pain
• Somatic pain
• Visceral pain
• Neuropathic pain
Treatment induced chronic pain syndromes
Breast cancer
Intercostobrachial neuralgia
Phantom breast pain
Pain related to implants/reconstruction
Peripheral neuropathy
Osteoporotic vertebral compression fractures
Radiation induced plexopathy
Head & Neck
Postcervical lymph node dissection pain syndrome
Accessory nerve damage
Jaw ostonecrosis
Shoulder pain
Lung
Post-thoracotomy pain syndrome
Chronic “chest tightness”
Genitourinary
Pelvic pain syndrome
Osteoporosis
Vertebral compression fractures
Levy M, Chwistek M, Mehta RS. Management of chronic pain in cancer survivors. Cancer J 2008;14:401409
Guidelines for Responding to Pain in the Primary
Care Setting
• Promptly evaluate pain to rule out recurrence or new
cancer or other medical problem (x-ray, bone scan,
imagery?)
• Treat first with analgesics and non-pharmacologic
therapies
• Refer intractable pain back to oncologist or pain
specialist for narcotics and other approaches
Steps of Analgesic Pain Management
Common symptoms
Type of pain
Co-analgesic medications
Focal/incident pain
Somatic
NSAIDs
Dull, poorly localized Visceral
Sharp, shooting,
stabbing, burning
Localized to neural
dermatome or distal
extremities
Neuropathic
Tricyclic antidepressants
Desipramine
Nortriptyline
Levy M, Chwistek M, Mehta RS. Management of chronic pain in cancer survivors. Cancer J 2008;14:401409
Common Side-Effects of Pain Management
• Constipation from narcotics
• Somnolence
• Gastrointestinal problems (e.g., dyspepsia or gastritis
from NSAIDS)
Consider Non-pharmacologic Modalities
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Physical therapy
Acupuncture
Hypnosis
Mindfulness-based stress reduction
Cognitive behavior therapy
Guided imagery
Massage
Frequent Use of Complementary Therapies After
Cancer
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Relaxation techniques (44%)
Spiritual forms of healing (42%)
Nutritional supplements (40%)
Meditation (15%)
Massage (11%)
Support groups (10%)
•Gansler T, Kaw C, Crammer C, Smith T. A population-based study of prevalence of
complementary methods use by cancer survivors. Cancer 2008;113:1048-57.
Special Considerations In Pain Management In the
Primary Care Setting
• Even if you don’t prescribe narcotics in your practice,
cancer patients may be taking them under the care
of a pain specialist or oncologist
• There is a real stigma of addiction among patients
and families which can be a barrier to pain control
• Patients may be reluctant to take adequate pain
medications because they fear being over-medicated
and less cognitively sharp
Best Practices 3:
Pain Management In Palliative Care
• Consider patient’s ability to function in usual activities
and how to improve it
• Consider “double effect” approach to pain and multiple
symptoms (e.g., treating anxiety first)
• Negotiate goals of care and treatment priorities with
patient and family
• Coordinate team approach to care
Patient and Family Education About Pain
Palliation
• Relief of pain is important; there is no benefit to
suffering with pain.
• There are many options to treating pain.
• When narcotic drugs are used appropriately to treat
pain, addiction is rarely a problem.
• Communication with doctors and nurses about your
pain is critical.
• Pain can be helped with non-pharmacologic
therapies
Review:
Goals of Primary Care Provider With Patients with Cancer
Histories
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Comprehensive cancer-related history
Surveillance for cancer spread, recurrence
Assessment of medical and psychosocial
effects of cancer
Health promotion
Palliative care intervention for
consequences of cancer and its treatment
Coordination of care between specialists
and negotiation of care
Assisting patients through care transitions
(including hospice care)
PLAY VIDEO: SOCIAL WORKER
PLAY VIDEO: SOCIAL WORKER
Psychological Impacts of Surviving Cancer
• Fear
• Feelings of isolation
• Ambivalence about completing treatment
• Coping with permanent disabilities
• Realization of lost opportunities
• Unanticipated depression when recovery is supposed to be a “good
thing”
• Anxiety associated with checkups
• New meaning to life (“Post-traumatic growth”)
Psycho- Social lmpacts of Cancer
Risk Factors for Psychological Distress in
Survivors
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Unexpected symptoms
No discussion of cancer within the family
Family problems
Low social support
Pain and/or fatigue
Co-morbidity
Impaired professional work
Previous psychiatric problems
*Massie MJ. Prevalence of Depression in Patients With Cancer. J Natl Cancer Inst Monogr 2004;32:57–71.
Components of Palliative Psychosocial Care for
Patients With Cancer Histories
• Know risk factors for psychosocial distress
• Assess psychosocial problems
• Provide supportive counseling
• Connect patients with appropriate services
• Coordinate psychosocial and biomedical care
• Engage family and caregivers in care
Interventions for Psychological Distress
– Relaxation therapy
• Progressive relaxation, Guided imagery, meditation, yoga
– Psycho-education
• Providing information through print, audiovision or chat rooms
increases knowledge about cancer and reduces uncertainty
– Supportive-expressive therapies
• Group therapy, Art therapies
– Cognitive-behavioral therapy
• Changing maladaptive thoughts and behaviors
– Family therapy/Couples counseling
Jacobsen PB, Jim HS. Psychosocial interventions for anxiety and depression in adult cancer patients: achievements and
Challenges. CA Cancer J Clin 2008;58:214-230.
Comprehensive Cancer Care Includes End-of-Life Care
Palliative Care
Hospice Care
Hospice Care Goals:
• Safe and comfortable dying
• Self-determined life closure
• Effective grieving
Levels of Hospice Care
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Routine care
General inpatient care
Continuous care
Respite care
Hospice Core services
• Interdisciplinary care
– Chaplaincy, nursing, medical social services,
counseling, volunteers
– Hospice medical director
– Primary care physician
– Palliative care physician (consultation)
• Bereavement counseling
• Medical equipment, supplies
• Medications and therapies related to the terminal
diagnosis
Review:
Role of the Primary Care Team
With Patients with Cancer Histories
• Communicate with and support the patient
• Assist patient and family retrieve and comprehend medical
information
• Assess for AND respond to psychosocial problems
• Be aware of therapeutic options
• Have knowledge of community resources and covered
services
• Address ongoing health maintenance needs
• Assist in care coordination
• Maintain regular contact
• Be available
Brotzman GL, Robertson RG. Role of the primary care physician after the diagnosis of cancer.
Prim Care. 1998;25:401–6
Cancer Supportive Care Resources
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Local resources
State resources
National resources
Complementary and alternative care resources
COMPREHENSIVE
CANCER CARE FOR
THE RURAL PRIMARY
CARE PATIENT:
IT TAKES A TEAM!
PLAY VIDEO THROUGH END