MODULE 4
MANAGING COMMON HEALTH CONCERNS
Introduction
Hi and welcome to Module 4: Managing Common Health Concerns.
When you’re ready to begin, click the next button.
In this module
This module covers 6 main topics, they are: Impact of Cancer and its
Treatment- this is about common physical and psycho social effects of cancer
and its treatment; Assessing and Managing Supportive Care Needs- this is
about stratification and supportive care; Screening for Need and Information
Provision- this covers who to screen and what to include when screening;
Further Referral for Assessment and Intervention- this is about tools used to
assist knowing when to provide further referral; Early Intervention Tailored to
Need- this covers specific examples of health professional interventions for
survivors; and Referral for Specialised Services and Programs- this covers
when to refer and who to refer to.
Impact of cancer and its treatment
Whilst many cancer survivors experience high quality of life, many still
experience physical and/or psycho social effects of cancer and its treatment.
Some sequelae become evident during treatment, called Long Term Effects,
while others may not manifest for months or years following active therapy,
and these are called Late Effects. These effects can range in severity and
impact, from mild to severe, and extent of associated disability. Some effects
can also be potentially life threatening. It has been reported that at least 50%
of survivors experience some Late Effects of cancer treatment. The most
common problems in cancer survivors are depression, pain and fatigue.
Physical effects in cancer survivors include pain, musculoskeletal issues,
organ toxicities, fatigue, lack of stamina, urinary or bowel problems,
lymphedema, premature menopause, cognitive deficits and sexual
dysfunction. Physical changes is an ACSC information page covering these
issues. There are 3 main categories for effects of cancer and its treatment,
they are: Pulmonary Effects, Cognitive Effects and Cardiac Effects.
Pulmonary Effects include bleomycin induced pneumonitis, which is a dosedependent, reversible acute toxicity that may progress in pulmonary fibrosis.
Radiation pneumonitis is reported in 5-15% of lung cancer patients receiving
definitive external beam radiation therapy. A minority of individuals may
develop progressive pulmonary fibrosis. Late pulmonary complications
specific to haematopoietic stem cell transplantation patients who develop
interstitial pneumonitis, include idiopathic pneumonia syndrome and
bronchiolitis obliterans. Studies have reported than 17-75% of women
experienced cognitive deficit 6 months to 20 years after exposure to
chemotherapy to breast cancer. Whole brain radiation is associated with
delayed cognitive changes. It is difficult to determine the cause of cognitive
issues in the cancer survivor. Aging, depression, stress, cancer treatments, or
a combination of these factors have been associated. Cardiac effects may
manifest years after cancer treatment is completed. The estimated aggregate
incidence in radiation induced cardiac disease is 10-30% in 5 to 10 years,
although this may be improving with new techniques. Broad categories of
effects have been described, and these are: vascular disease, hypertension,
thrombosis and myocardial dysfunction. You can click each of these buttons
to see some more details about them.
Impact of cancer and it’s treatment continued
Cancer survivors are at increased risk of subsequent malignant neoplasms, or
second cancers, due to genetic susceptibilities (for example, cancer
syndromes), shared etiological exposures (for example, smoking and
environmental exposures), and mutagenic effects of cancer treatment.
Incidence of subsequent unrelated cancers ranges from 2% in survivors of
malignant lymphoma, to 30% in survivors of small cell lung cancer. A range of
psycho social effects are experienced by survivors. Cancer can have positive
effects for some individuals, including strengthened relationships, a sense of
gratitude or empowerment, or an increased appreciation for life. Psychological
distress experienced by survivors, is linked to concerns about fear of
recurrence or death, or to ongoing physical, social or practical problems
associated with the cancer diagnosis and its treatment. As many as 19% of
survivors meet the criteria for Post Traumatic Stress Disorder.
There are 2 links provided which are ACSC information pages- 1 on
Emotional Changes and 1 on Fear of Cancer Coming Back.
Practical and social problems of survivors include those issues surrounding
employment, finances and health and life insurance. There’s an ASCS
information page on finance, work and insurance also. There are evidence
summaries available for sexual dysfunction, fatigue, distress and adult cancer
pain.
Assessing and managing supportive care needs
Supportive Care screening, assessment and referral of cancer survivors in
Australia is an emerging area of practice. Tools specifically adapted to meet
the needs of cancer survivors are in development. The model presented is an
example of best practice Supportive Care. The practices of health services
should reflect evidence based practice, but be customised according to the
resources and expertise available within the multidisciplinary team, pathways
for referral and access to services.
Screening for need and information provision
All survivors should be routinely and periodically screened for Supportive
Care needs using a systematic, evidence based approach. Screening
involves the routine and systematic identification of potential Supportive Care
needs or risk factors, before the issue becomes a symptom. Key steps in
screening include: the person affected by cancer completes the screening
tool; following the completion of the tool, a discussion is held between the
person and the health clinician to identify the health priorities, evaluate their
impact on daily living and quality of life; and plan for further assessment and
referral as needed. Documentation is also a key step. Examples of validated
screening tools include: the distress thermometer and problem checklist, the
Peter Mac Supportive Needs Screening Tool and the Needs Assessment Tool
for Carers.
Screening activity
Describe the processes used for screening cancer survivors Supportive Care
needs in your health setting. Consider how effective these processes are in
identifying needs. Access the Supportive Cancer Care Victoria Supportive
Care Screening Tools Summary Guide to review the evidence underpinning
validated tools, such as the distress thermometer and problem checklist, the
Peter Mac Suupportive Needs Screening Tool and the Needs Assessment
Tool for Carers. Also in your response, consider if the screening processes in
your health setting are evidence based. A Supportive Care Needs Screening
Process Guide describes suggested methods for undertaking Supportive Care
screening. You can click the buttons for more information about each of these.
Further referral
If Supportive Care needs are identified as part of a screening process, a more
focused assessment of those needs or the sources of distress may be
appropriate. Through discussion of Supportive Care concerns, clinicians can
work collaboratively with cancer survivors to identify their existing resources
and capabilities for self-management, and identify a need for additional
supportive services. Person centred communication skills facilitate the
process of assessment and effective interviewing. A range of tools can be
used to guide this more focused assessment. Some examples are provided
on screen, including: tools to assess specific symptoms or concerns (such as
the Brief Pain Inventory, spirituality assessment and Bristol stool chart), tools
to diagnose specific mental health concerns (such as the hospital and anxiety
depression scale), promise measures. Grading scales for physical symptoms
are identified in the common terminology criteria for adverse offence. And
these provide a framework for a consistent assessment of need. The focused
assessment may indicate the need for further support and survivors may be
referred to other members of the multidisciplinary team. Specialist cancer
nurses with advanced skills in communication and available support
processes, such as clinical supervision, may be able to provide this level of
intervention.
Fewer than 10% of people are actually referred to psycho social help, despite
having needs identified. Reasons for the lack of follow up include
inappropriate timing of referrals, clinicians not knowing the Supportive Care
resources available, clinicians not asking about Supportive Care needs, and
clinicians not able to skillfully introduce the Supportive Care service.
Further referral activity 1
Identify a Supportive Care need common to survivors in your health service.
Outline the process to undertake a focused assessment of this need to
identify the etiology and intervention strategies. In your response, consider the
recommendations outlined by Supportive Cancer Care Victoria, in the post
screening discussion tool and the referral pathway classification guide.
Further referral activity 2
Identify the process for referral in your health setting, if a focused assessment
indicates the need for further support from a member of the MDT. Reflect on
the barriers and enablers you experience in referring cancer survivors.
In your response, consider these guidelines and tools developed by
Supportive Cancer Care Victoria. After you’ve finished your answer, click the
buttons to see some examples of recommendations to improve the process of
referral, and communication skills to encourage acceptance of a referral.
Early intervention tailored to need
Some cancer survivors will require cancer supportive care interventions,
which require the services of specialist cancer professionals. A combination of
activities, rather than any single intervention by itself, is also likely to be the
approach required. Supporting people to manage their illness may involve
education, development of new skills, preparing for a threatening procedure or
a brief counseling intervention. Central to all these components is
coordination of care, therapeutic communication and evaluation of the
effectiveness of care. There are 2 examples of this level of health professional
intervention. You can click each of the buttons to learn more about them.
Referral to specialty
Referrals to other health professionals or services are sometimes required to
provide specialised support or address more complex issues beyond the
capabilities of the multidisciplinary team. Referral may be indicated to meet a
need for specialist information or to help manage specifically identified risk
factors or needs such as persistent physical symptoms, people socially or
financially at risk, people with culturally and linguistically diverse or with
Aboriginal and Torres Strait Islander backgrounds, perceptions of
hopelessness and pre morbid mental health issues. Examples of specialised
services and programs include a lymphedema practitioner, continence
physiotherapists, sex therapists and psychiatrists. Clinicians may consider
referrals to the person’s General Practitioner to access services covered by
Medicare through the GP Mental Health Plan or Chronic and Complex Care
Plan.
Two links are provided. One to the Chronic Disease Management Medicare
Items and one to the Allied Health Services Under Medicare Fact Sheet.
On screen is the Cancer Council Victoria’s specialist referral advertisement.
Referral to specialty activity
Identify a Supportive Care need experienced by cancer survivors in your
health service, which requires specialist referral. Identify local health
professionals or services to meet survivors’ needs and outline the local
referral process to the health professional and/or service.
References 1
These 2 slides contain the list of references used to create this module.
Thanks for listening.