Oncology Nurse Navigation in the Care of Breast Cancer

Introduction

A breast cancer diagnosis can be highly stressful and traumatic, not only for the patient but also for their family and support systems. The experience of moving through the breast cancer continuum from diagnosis to treatment and beyond is a complex process that can be alleviated by the guidance and support of an Oncology Nurse Navigator (ONN). An ONN is defined by the Oncology Nursing Society (ONS) as “a professional RN with oncology-specific clinical knowledge who offers individualized assistance to patients, families, and caregivers to help overcome healthcare system barriers.” The ONN works to help overcome healthcare system barriers and facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all phases of the cancer experience. Using the nursing process, the ONN provides education and resources to cancer patients to better facilitate informed decision making and timely access to care. This chapter will focus on oncology nurse navigation in breast cancer care.

History of Patient Navigation

In 1989, the American Cancer Society (ACS) published the Report to the Nation on Cancer in the Poor , which summarized a series of national hearings that looked at patient access and barriers to care for those who live in poverty. The report found that poor Americans face significant barriers to obtaining cancer care. Those who live in poverty received substandard healthcare that they had difficulty paying for and were made to “endure assaults on their personal dignity when seeking treatment for cancer.” The report identified that cancer education programs were often “culturally insensitive and irrelevant.” Then president of the ACS, Dr. Harold Freeman, subsequently developed the first patient navigator program to address the elimination of barriers to care in Harlem in 1990. Freeman recognized that cancer care for poor, underinsured, and uninsured people faced unique barriers to care, which led to the development of a patient navigation program for the underserved. From this, Freeman was able to prove that cancer survival rates can improve with increased screening and reducing barriers to healthcare for cancer patients. Initially this navigation program was focused on breast cancer patients and staffed by lay community case workers. They worked to facilitate access by addressing financial barriers, such as no health insurance, as well as communication, information, and medical system barriers. Over time the scope of patient navigation has expanded beyond just breast cancer and across the entire healthcare continuum including prevention, detection, diagnosis, treatment, and survivorship to the end of life.

In 2005, the Patient Navigator and Chronic Disease Prevention Act added Section 340a of the Public Health Service Act (PHSA) that encouraged the development of programs to improve health outcomes for patients with cancer and other chronic diseases, with the goal of improved access to high-quality coordinated care. In 2012, the American College of Surgeons Commission on Cancer created a new standard addressing patient navigation to be implemented by 2015 for cancer programs seeking accreditation.

Program Accreditation

Healthcare accreditation validates that a cancer program meets or exceeds a set of quality and care standards set by an “accrediting” body of experts. Many accrediting bodies require that the cancer program have a navigation program in place. The National Cancer Institute defines a standard of care as “treatment that is accepted by medical experts as a proper treatment for a certain type of disease and that is widely used by healthcare professionals.” In breast cancer care, the standards that define and measure quality of care involve multiple organizations but are largely driven by the National Comprehensive Cancer Network (NCCN), the National Accreditation Program for Breast Centers (NAPBC) offered by the American College of Surgeons, and the American Society of Clinical Oncology (ASCO). NAPBC represents a consortium of national, professional organizations dedicated to the quality of care of patients with diseases of the breast. In 2018, NAPBC published navigation standard 2.2, which states that, “A patient navigation process is in place to guide the patient with a breast abnormality through provider and referred services. The patient navigation process includes consistent care coordination throughout the continuum of care and an assessment of the physical, psychological, and social needs of the patient. The anticipated results are enhanced patient outcomes, increased satisfaction, and reduced costs of care. Patient navigation is provided by a professional (for example, nurse, social worker) who has documented training to provide individualized assistance to breast disease patients, families, and caregivers at risk. If patient navigation is provided by a lay navigator, then he or she is required to have documented patient navigation training.”

In 2021, ASCO developed Oncology Medical Home (OMH) standards, which provide a comprehensive road map for oncology practices to deliver high-quality, evidence-based cancer care including access to equitable, comprehensive, and coordinated team-based care including a process for patient navigation.

Defining the Oncology Nurse Navigator Role

Patient navigation can be performed by different types of professionals, including trained lay personnel, social workers, advanced practitioners, as well as nurses. Table 3.1 outlines the different navigation roles. There is variability in workflow by institution, but typically the ONN is one of the first points of contact for a newly diagnosed patient, often from the radiology department after the patient has an abnormal mammogram. The ONN completes a nursing assessment to identify the patient’s unique, individualized needs. They offer emotional support, advocate for patients and their loved ones, provide continuity of care, address psychosocial needs, provide education, and assess barriers to care.