Cancer has been called many things, but “predictable” is not one of them. The elusive disease affects nearly every part of the body, arises from a variety of causes, and is capable of cellular mutations that frustrate providers battling it.
Similarly, there is no easy way to pin down the effects that cancer treatments may have on patients. Chemotherapy, for example, may work therapeutic wonders, but it is toxic weaponry that can cause pain, nausea, fatigue, fever, loss of appetite, and depression, among other often debilitating symptoms. Radiation and surgery also can have taxing effects.
If providers are slow to respond to cancer symptoms, problems can cascade into emergency department trips, hospitalizations, and missed therapy sessions, slowing or even derailing the prospects of recovery.
“If we can’t keep cancer patients on therapy, their chances of survival decrease,” said Adam Poust, PharmD, lead pharmacist with the University of Colorado Cancer Center’s Infusion Center.
Twin win. Poust is a member of a team that staffs the recently created CARE (Clinical Assessment & Rapid Evaluation) Clinic at the University of Colorado Cancer Center. The idea is to provide prompt stabilizing support for cancer patients struggling with symptoms when the Cancer Center’s clinic schedules are full.
That’s good for patients, of course, but the CARE Clinic also aims to relieve pressure on the routinely busy clinics and on the Emergency Department and inpatient units at University of Colorado Hospital.
“The CARE Clinic gives patients access to appropriate care without waiting,” said Sarah Eppers, RN, practice manager for the Infusion Center. “We don’t want them to wait. They are already struggling.”
The CARE Clinic, which uses two exam rooms in the Infusion Center, opened in February after a team that included Poust (see box) worked on developing it through the Institute for Healthcare Quality, Safety and Efficiency (IHQSE) certificate training program. Mary Jane LaRoche, MS, ANP-BC, AOCNS, ACHPN, a medical oncology nurse practitioner, initially saw patients two days a week. Today, the CARE Clinic is open five days a week from 9 a.m. to 5 p.m., and LaRoche shares the caseload with Whitney Herter, PA-C, a physician assistant.
“It’s been busier than we thought it would be,” Eppers said.
LaRoche stressed that each patient’s primary source of care remains his or her specialty oncology clinic. But if a lung cancer patient, say, is experiencing problems, and the clinic schedule is full, a clinic nurse can triage the patient and determine if it is appropriate to refer him or her to the CARE Clinic. There, LaRoche and Herter can perform a full assessment and work with the patient’s physician to order labs, X-rays, scans, and medications, if necessary.
“We’re an extension of the patient’s primary cancer clinic,” LaRoche said. “We close the communication loop.”
Focused treatment. The benefit to patients referred to the CARE Clinic is more a matter of expertise than of convenience, LaRoche added. For example, Neulasta, a drug used to boost white blood cell counts and decrease the risk of infection in chemotherapy patients, can cause bone pain.
A crowded clinic schedule might mean not only a time-consuming trip to the ED for a patient in that situation, but also a delay in getting pain relief, simply because an ED provider might not be familiar with the condition, the medication, and the symptoms. As Poust explained, cancer pain is often deep and generalized, much different than the pain caused by the acute injuries and illnesses that send most people to the ED.
“In the CARE Clinic, we can get patients started on medications that will manage their pain earlier,” LaRoche said.
The approach has been a boon to the Cancer Center and to the hospital as a whole, said Tom Purcell, MD, the hospital’s executive medical director of cancer services.
“During oncology care, issues come up all the time. Having the flexibility to be able to see patients very quickly on the same day and then being able to address the issues in the infusion center really allows us to provide comprehensive service,” Purcell wrote in an email. “Our goal is to manage symptoms as best as possible and keep patients out of the emergency department and the hospital. The CARE clinic really helps in accomplishing that goal.”
A second look. The difficulties of dealing not only with cancer but the side effects of treating it quickly became apparent to Kim Patmore, whose mother, Joan Zak, 83, was diagnosed with stage IIIA non-small cell lung cancer in late January. Patmore said Zak’s first chemo treatment at a Denver-area hospital “completely knocked her down” with pain for which providers hadn’t prepared her.
“We were caught off guard,” Patmore said. “We hadn’t talked about pain medication control and we had no one to contact.” Zak had four units of blood transfused over the next four weeks, part of a “downward spiral,” including kidney issues and atrial fibrillation, that Patmore attributes to the initial failure to control the pain.
Patmore contacted Fred Grover, MD, a cardiothoracic surgeon at UCH, with whom she serves on the board of the Iliff School of Theology. She requested from Grover a second opinion from the Cancer Center. Grover put Patmore in touch with his cardiothoracic surgery colleague John Mitchell, MD, for a full workup and second opinion. With a diagnosis established, Patmore and Zak met with radiation oncologist Tracy Schefter, MD, and medical oncologist Robert Doebele, MD, to plan the next treatment steps.
A week later, however, Zak experienced severe fatigue. Kristen Petrelli, FNP, a patient navigator with the Lung Cancer Multidisciplinary Clinic who was coordinating her care, connected Zak and Patmore with the CARE Clinic. Herter ordered fluids, giving Zak nearly immediate relief.
Herter also addressed Zak’s ongoing bowel, intestine, and kidney problems. The clinic drew blood, took a urine sample, and brought in nutritionists to help treat Zak’s debilitating diarrhea. The nutritionists ultimately prescribed a probiotic that helped her manage the diarrhea and maintain her fluid levels, a must for preparing for treatment.
Team approach. Herter also communicated with other providers – including Zak’s community urologist – to make sure everyone involved in the patient’s care was aware of what had been done.
“The care was very collaborative,” Patmore said. Herter helped to ensure that Zak’s various specialists consulted with one another instead of pursuing independent, and possibly counterproductive, paths of treatment, she added.
The CARE Clinic served as a bridge for a subsequent meeting at the hospital’s Lone Tree Health Center. Petrelli coordinated meetings with medical oncologist Eamon Berge, MD, and clinical pharmacist Colette McMillan, PharmD, and set up a tour of the facility. Berge and McMillan discussed the treatment program – a combination of radiation and possibly chemotherapy – as well as the possible side effects and ways to mitigate them, Patmore said.
Zak received two radiation treatments in mid-April. She experienced severe back pain that Schefter and Berge have helped to control, Patmore said.
In describing the care her mother received from the CARE Clinic, Patmore stated more than once her feeling that the providers “treated the whole patient.” The uncertainty prior to coming to the Cancer Center, Patmore added, took an emotional toll on her as well as on Zak.
“Before I felt I just wasn’t doing what I needed to do for my mom,” Patmore said. “I feel here that people have the time to answer your questions, and sometimes they realize you were in a fog the first time they told you. They just go back and explain again. The group understands we’re not medical people, and that has been such a relief. This has been a blessing in our lives.”