The development and implementation of the After Cancer Treatment Transition (ACTT) Program for survivors of cancer.

Background: The After Cancer Treatment Transition (ACTT) program at Women's College Hospital (Toronto) is a transitional follow-up program for patients, their families, and healthcare providers to address the broad range of post-cancer treatment and survivorship needs. This publication describes the systematic development and implementation of the ACTT program, with a focus on the advanced practice nursing (APN) role. Program Development: ACTT development required the collaboration of an APN, a general practitioner in oncology (GPO), and an inter-professional team. ACTT developers proposed a clinic structure in an ambulatory setting, linking healthcare professionals to provide post-treatment follow-up and ongoing survivorship care. Post-treatment guidelines were developed based on expert oncologist consensus, cancer site group input, and evidence-informed guidelines or best practice recommendations. Program Implementation: Initial challenges and concerns were rooted in the requirements that post-cancer treatment care was maintained and survivor needs were addressed. Cancer site groups and the inter-professional teams provided continuous feedback on processes and protocols. ACTT established a standard approach to transition patients safely and effectively out of tertiary care and, ultimately, to primary care. Current ACTT Program: ACTT delivers comprehensive posttreatment and survivorship care through close collaboration between the GPO and APN. Both roles specialize in managing late or persistent effects, cancer surveillance and prevention, and addressing psychosocial needs prior to discharge to primary care. The survivorship care plan provided by ACTT is an informative tool for both patient and primary care provider to continue post-treatment follow-ups. Future Directions: Next steps for ACTT include expanding to other cancer specialties, exploring new ways to deliver care, optimizing the transition of care, and conducting comprehensive evaluations of patient reported outcomes.

Guiding the Clinical Nurse Specialist role in oncology within Princess Margaret Cancer Centre.

In 2019, the Canadian Nurses Association (CNA) published the Advanced Practice Nursing: A Pan-Canadian Framework, defining and highlighting the competencies of the clinical nurse specialist role (CNS). In response to the CNA publication, the CNS Community of Practice (CoP) at Princess Margaret Cancer Centre (PM) reviewed how the oncology CNS roles at PM aligned with the CNA competencies. The primary goal was to utilize the CNA (2019) document to guide the development of a PM CNS role-clarity document and new-hire CNS pathway to assist the onboarding process for new CNS hires at PM. The secondary goal was to raise awareness of the diverse CNS oncology roles at a local and national level through developing, implementing, and disseminating the PM CNS role-clarity document and new-hire CNS pathway.

Impact of an Inter-Professional Clinic on Pancreatic Cancer Outcomes: A Retrospective Cohort Study.

Background: Pancreatic ductal adenocarcinoma (PDAC) presents significant challenges in diagnosis, staging, and appropriate treatment. Furthermore, patients with PDAC often experience complex symptomatology and psychosocial implications that require multi-disciplinary and inter-professional supportive care management from health professionals. Despite these hurdles, the implementation of inter-professional clinic approaches showed promise in enhancing clinical outcomes. To assess the effectiveness of such an approach, we examined the impact of the Wallace McCain Centre for Pancreatic Cancer (WMCPC), an inter-professional clinic for patients with PDAC at the Princess Margaret Cancer Centre (PM). Methods: This retrospective cohort study included all patients diagnosed with PDAC who were seen at the PM before (July 2012-June 2014) and after (July 2014-June 2016) the establishment of the WMCPC. Standard therapies such as surgery, chemotherapy, and radiation therapy remained consistent across both time periods. The cohorts were compared in terms of survival rates, disease stage, referral patterns, time to treatment, symptoms, and the proportion of patients assessed and supported by nursing and allied health professionals. Results: A total of 993 patients were included in the review, comprising 482 patients pre-WMCPC and 511 patients post-WMCPC. In the multivariate analysis, adjusting for ECOG (Eastern Cooperative Oncology Group) and stage, it was found that post-WMCPC patients experienced longer median overall survival (mOS, HR 0.84, 95% CI 0.72-0.98, p = 0.023). Furthermore, the time from referral to initial consultation date decreased significantly from 13.4 to 8.8 days in the post-WMCPC cohort (p < 0.001), along with a reduction in the time from the first clinic appointment to biopsy (14 vs. 8 days, p = 0.022). Additionally, patient-reported well-being scores showed improvement in the post-WMCPC cohort (p = 0.02), and these patients were more frequently attended to by nursing and allied health professionals (p < 0.001). Conclusions: The implementation of an inter-professional clinic for patients diagnosed with PDAC led to improvements in overall survival, patient-reported well-being, time to initial assessment visit and pathological diagnosis, and symptom management. These findings advocate for the adoption of an inter-professional clinic model in the treatment of patients with PDAC.

Nurses' experiences caring for patients and families dealing with malignant bowel obstruction.

Malignant bowel obstruction (MBO) is a well-recognised complication of advanced abdominal and pelvic cancers. Often surgical intervention is not feasible, resulting in complex symptoms and an unpredictable course. Although symptom management is a crucial part of nursing care, psychosocial and emotional issues frequently emerge for patients and families. This qualitative study explored the perspectives of nurses from a palliative care unit, in-patient acute care oncology units, ambulatory cancer setting, and the community on their experiences of caring for patients with MBO and their families. Six individual interviews and two focus groups were conducted. Eight overarching messages were identified related to nurses' experiences. Highlights include aspects of patients' and families' emotional distress, and the nurse-patient relationship in relieving suffering. Nurses have an important and privileged role that involves identifying MBO signs and symptoms, having knowledge of treatment and symptom management options, and helping patients transition from a curative to a palliative philosophy of care.

Development of a psychoeducational intervention for people affected by pancreatic cancer.

BACKGROUND: Pancreatic cancer has one of the highest mortality rates of any malignancy, placing a substantial burden on patients and families with high unmet informational and supportive care needs. Nevertheless, access to psychosocial and palliative care services for the individuals affected is limited. There is a need for standardized approaches to facilitate adjustment and to improve knowledge about the disease and its anticipated impact. In this intervention-development paper guided by implementation science principles, we report the rationale, methods, and processes employed in developing an interdisciplinary group psychoeducational intervention for people affected by pancreatic cancer. The acceptability and feasibility of implementation will be evaluated as a part of a subsequent feasibility study. METHODS: The Schofield and Chambers framework for designing sustainable self-management interventions in cancer care informed the development of the intervention content and format. The Consolidated Framework for Implementation Research served as an overarching guide of the implementation process, including the development phase and the formative evaluation plan of implementation. RESULTS: A representative team of stakeholders collaboratively developed and tailored the intervention content and format with attention to the principles of implementation science, including available resourcing. The final intervention prototype was designed as a single group-session led by an interdisciplinary clinical team with expertise in caring for patients with pancreatic cancer and their families and in addressing nutrition guidelines, disease and symptom management, communication with family and health care providers, family impact of cancer, preparing for the future, and palliative and supportive care services. CONCLUSIONS: The present paper describes the development of a group psychoeducational intervention to address the informational and supportive care needs of people affected by pancreatic cancer. Consideration of implementation science during intervention development efforts can optimize uptake and sustainability in the clinical setting. Our approach may be utilized as a framework for the design and implementation of similar initiatives to support people affected by diseases with limited prognoses.

Introducing a patient-focused care map in colorectal surgery: a pilot qualitative study of patients' and surgical oncology nurses' experiences.

Care maps for patient care have been around for many years. Key stakeholders at our institution developed and implemented a care map for patients undergoing surgery for colorectal cancer. The purpose of this descriptive, qualitative pilot study was twofold. First was to understand the lived experience of patients being cared for under a newly-implemented care map utilizing patient diaries and interviews. The second goal was to describe the experiences of surgical oncology nurses caring for these patients using a focus group technique. The results of our small study indicated that patients appreciated having a document that outlines daily activities and goals, and were anxious to get home, but were disappointed in the discharge planning process. Nurses were positive about the care map overall, but felt they could have contributed more in the development and planning stages of the care map. Overall, the implementation of our patient-centred care map was a success.

Exploration of Families' Experiences Caring for Loved Ones With Advanced Ovarian Cancer.

Ovarian cancer is challenging, both physically and psychologically, because of the advanced nature of the disease at diagnosis, adverse effects of the disease and treatment, and impact on roles and responsibilities. The family plays an integral role in promoting and maintaining the health of family caregivers, as well as providing physical and emotional support. The purpose of this study was to explore the experience of family caregivers caring for their loved ones with advanced ovarian cancer. Thirteen family caregivers were interviewed. The analysis of the data revealed 4 significant challenges that characterized the caregiving experience over time: confronting the initial diagnosis, dealing with fluctuations in physical status, confronting a turning point, and facing decline and death. Woven throughout these challenges, family caregivers routinely described difficulties in accessing information and navigating the health care system, which caused them added concern and frustration.

Genomics-Driven Precision Medicine for Advanced Pancreatic Cancer: Early Results from the COMPASS Trial.

Purpose: To perform real-time whole genome sequencing (WGS) and RNA sequencing (RNASeq) of advanced pancreatic ductal adenocarcinoma (PDAC) to identify predictive mutational and transcriptional features for better treatment selection.Experimental Design: Patients with advanced PDAC were prospectively recruited prior to first-line combination chemotherapy. Fresh tumor tissue was acquired by image-guided percutaneous core biopsy for WGS and RNASeq. Laser capture microdissection was performed for all cases. Primary endpoint was feasibility to report WGS results prior to first disease assessment CT scan at 8 weeks. The main secondary endpoint was discovery of patient subsets with predictive mutational and transcriptional signatures.Results: Sixty-three patients underwent a tumor biopsy between December 2015 and June 2017. WGS and RNASeq were successful in 62 (98%) and 60 (95%), respectively. Genomic results were reported at a median of 35 days (range, 19-52 days) from biopsy, meeting the primary feasibility endpoint. Objective responses to first-line chemotherapy were significantly better in patients with the classical PDAC RNA subtype compared with those with the basal-like subtype (P = 0.004). The best progression-free survival was observed in those with classical subtype treated with m-FOLFIRINOX. GATA6 expression in tumor measured by RNA in situ hybridization was found to be a robust surrogate biomarker for differentiating classical and basal-like PDAC subtypes. Potentially actionable genetic alterations were found in 30% of patients.Conclusions: Prospective genomic profiling of advanced PDAC is feasible, and our early data indicate that chemotherapy response differs among patients with different genomic/transcriptomic subtypes. Clin Cancer Res; 24(6); 1344-54. ©2017 AACR.

Building comfort with ambiguity in nursing practice.

Current nursing literature recognizes the need to honor the concept of ambiguity. Nurses experience uncertainty with handling or honoring complexity and ambiguity when confronted with times of struggle. Traditional models of care fall short as patients and families define their expectations of the healthcare system. Nurses bear witness to the discomfort caused by the unknown in their daily practice. They are challenged to address their feelings, unsure of what to anticipate, what to say, or how to respond to their patients. Uncertainty diminishes the opportunity for meaningful dialogue between nurses and other people. Nurses attempting to ease the discomfort of ambiguity by providing patients or families with reassurance, offering advice on how to fix problems, or avoiding talking about situations often express dissatisfaction. Nurses should be invited to explore ambiguity and seek understanding through dialogue and nursing knowledge. Encouraging nurses to define the meaningfulness in nursing practice that embraces human science theory will help relieve some of the ambiguity that exists in current practice. This article will explore the concept of ambiguity, highlight how nursing theory based on human science can support practice, and propose recommendations for practice.

Self-determination and information seeking in end-stage cancer.

When patients learn that their cancer has recurred after primary treatments or is no longer responding to therapy and no alternative treatment options exist, their motivation to carry on living may be impacted greatly. Using the Self-Determination Theory, this article's reflective analysis explores the unique situation of a woman with end-stage cancer and her continuous motivation to seek information about her illness. Information was gathered during clinical observations and informal conversations. The analysis showed how the patient sought information about her illness, how she manifested motivation, and how the hospital's social environment influenced her behavior. To understand the experience of being confronted with a terminal illness, the following issues are identified: expansion of awareness, life-facing knowledge contradictions, being open-minded and an active explorer of information sources, medical truth, and professional attitudes toward patients' informational needs. Nurses must understand patients' reasons for self-determination when facing illness uncertainty. Reflecting on such situations will strengthen nursing practice.