Nurse-led telephone follow-up in ovarian cancer: a psychosocial perspective
Commentary by Ms Kathryn Nattress
The article:
Cox A., Bull E., Cockle-Hearne J., et al. Nurse-led telephone follow-up in ovarian cancer: a psychosocial perspective. European Journal of Oncology Nursing 2008;12(5):412-7.
The reviewer:
Ms Kathryn Nattress is a Clinical Nurse Consultant-Gynaecological Cancer at the Sydney Cancer Centre.
Summary
Abbreviations
GP (General Practitioner)
Study Design
The aim of this pilot study was to assess a nurse-led telephone intervention for the follow-up of ovarian cancer patients. The intervention had a holistic approach to patient wellbeing including the detection of recurrent disease and the identification and management of physical and psychological morbidity. This article addresses the psychosocial elements of the intervention and looks at the following questions:
- Which areas of psychosocial wellbeing did women with ovarian cancer discuss with the nurse during telephone follow-up?
- How satisfied were these women with telephone follow-up?
- What are the benefits of telephone follow-up from a patient perspective?
Eligibility criteria of the intervention included women with stage II-IV stable disease, who had completed initial cancer treatment. Women received 20 minute follow-up telephone calls every 3 months over the 10 month intervention period. Prior to each appointment a clinic letter and blood test form to be used at the participant’s local medical practice for CA125 testing were sent. Nurses’ contact details were available if women needed to discuss anything between appointments. After the follow-up phone call, nurses sent letters detailing the next appointment and contact information were sent to the women and their GP.
The telephone follow-up focused on two areas. Firstly, detection of recurrent disease, including discussion of results and implications from the recent blood test and discussion and assessment of symptoms, with immediate referral back to medical care if necessary. The second area focused on providing tailored information, practical advice and coping strategies in physical, psychosocial and social domains.
Evaluation of the intervention was measured using the FACT-Ovarian and Satisfaction and Experience of follow-up questionnaires.
Findings
Of the 77 women eligible for the study there were 52 women who received telephone follow-up, from these women 46 completed pre and post data collection. Eighteen of the 46 participants were under the age of 60 years with the remaining 28 aged 60 years and over. Forty-nine percent of the sample had stage I/II ovarian cancer while 51% had stage III/IV.
Participants had good quality of life pre-intervention. There were few changes between pre and post questionnaire scores for physical wellbeing, social/family wellbeing and functional wellbeing. However, there was significant improvement in emotional wellbeing (p=0.016), with reduced emotional problems post telephone follow-up. All women had the opportunity during their telephone appointment to discuss their psychological and social wellbeing. Thirty-three women were recorded as having discussed issues regarding psychological wellbeing; 42% discussed feelings of anxiety or depression and 33% discussed fear of disease recurrence. Thirty-nine women discussed issues related to social wellbeing; 56% discussed their family, 51% discussed work and/or finances and 41% discussed sexual intimacy.
Participants were asked in the questionnaires of satisfaction and experience with follow-up to rate on a scale of 1 to 10 (1 being ‘dreadful’ and 10 ‘excellent’) the support they received during telephone follow-up. The mean score was 8.24, and for the 44 women who provided their preference for method of follow-up, 73% preferred telephone in comparison to 18% for doctor/consultant appointments. Women were also asked “what has been particularly good about your follow-up care?” Forty three advantages were identified, with the two most common being the relationship and discussions between the women and the nurse, and the convenience of telephone follow-up appointments.
Conclusion
The authors concluded that this pilot study suggests that nurse-led telephone follow-up offers an acceptable opportunity for psychosocial support for women with ovarian cancer. The results have directed the design of a randomised controlled trial comparing telephone follow-up and traditional clinic based follow-up care in ovarian cancer.
Commentary
What does this article add to existing clinical evidence in this area?
Utilising an innovative intervention this article discusses two current and often contentious issues in cancer management, follow-up and nurse-led care.
Traditionally women with ovarian cancer have undergone long term follow-up with hospital doctors. Clinical practice guidelines for the management of women with epithelial ovarian cancer state that ‘Follow-up is designed to provide appropriate medical review to support the physical and emotional needs of women following treatment’ (p127).1 Ensuring that psychosocial issues are adequately addressed in follow-up requires a paradigm shift from the medical model of detection of recurrent disease to a more comprehensive and holistic approach such as the one described in the article.
Interest in nurse-led follow-up of patients has been generated due to its potential as a cost effective way of addressing the increasing pressure on follow up services. Furthermore it has been suggested that quality of care might be improved because nurses may attend to broader aspects of the health care experience. In traditional clinical follow-up, evidence exists that there is little time to meet information and psychosocial needs of patients.2 Indeed the literature suggests that nurse-led follow-up for patients with cancer meets their needs for psychological support and information.3 Such hypotheses are supported by this article, as nurse-led follow-up identified significant psychosocial issues within the sample; 19% of the women were referred for counselling and 17% were referred to social services. Of particular significance is that almost a third of women felt able to discuss issues of sexual intimacy, an aspect of care that is frequently neglected.
Whether nurse-led telephone follow-up is acceptable to patients must be considered. In this study the majority of women who participated expressed a preference for nurse-led telephone follow-up, citing the main advantages as the relationship and discussions between the patient and nurse and the convenience of having follow-up appointments by phone. Although no explanation was given by the authors as to why almost a third of eligible women refused or were unsuitable to participate, one could speculate that some lacked confidence in the follow-up model described. The limited evidence currently available regarding patient perspective of routine follow-up is conflicting. A questionnaire considered the views of 96 women who had been treated for gynaecological cancer. Over 90% of those surveyed thought that follow-up should be provided by a hospital doctor.4 A qualitative study of women with breast cancer reported that more than half of those surveyed would prefer their follow-up care to be provided by specialist nurses as they were more supportive and had the necessary time, skills and knowledge.5
How adequate was the methodology used in addressing the aims of this study?
A limitation of the methodology was that the intervention was provided by a specialist nurse with considerable clinical experience and one must consider whether the intervention is transferable and indeed whether it was the involvement of a specialist nurse rather than the intervention that produced the identified benefits. A survey of 70 women with gynaecological cancer reported similar results, finding that women who had support from a specialist nurse experienced a clinically significant reduction in levels of psychological distress six months from diagnosis.6 A further limitation of the methodology is that a significant number of eligible women did not participate in the study and a further number withdrew thus the results are only reported from 60% of possible participants with potential implications for the findings.
Overall median quality of life scores were high and relatively stable, although the 6-point change between pre and post-intervention could represent a clinically relevant finding. The only domain that women reported significant improvement in was emotional wellbeing, though this may be due to emotional adaptation over time and not entirely due to the intervention.
What are the implications of this study for clinical practice in Australia?
Regular review in the acute hospital setting remains standard follow-up care, a practice which puts significant strain on financial and workforce resources. There is a need to explore alternative approaches of follow-up which ensure an equivalent quality of surveillance whilst addressing broader aspects of the healthcare experience. The telephone intervention described in this study encourages a proactive approach to cancer management, incorporating a holistic approach with traditional clinic based follow-up care. Rural patients in particular would benefit from such a model, allowing them to receive comprehensive care in a convenient and inexpensive manner.
References
- The Australian Cancer Network and National Breast Cancer Centre. Clinical practice guidelines for the management of women with epithelial ovarian cancer. 2004, National Breast Cancer Centre, Camperdown. NSW.
- Beaver K & Luker K (2005) ‘Follow up in breast cancer clinics: reassuring for patients rather than detecting recurrence’, Psycho-oncology, 14(2): 94-101.
- Cox K & Wilson E (2003) ‘Follow-up for people with cancer: nurse-led services and telephone interventions’, Journal of Advanced Nursing, 43(1): 51-61.
- Kew F, Galaal K, Manderville H & Verleye L (2007) ‘Professionals’ and patients’ views of routine follow up: a questionnaire survey’, International Journal of Gynecologic Cancer, 17: 557-560.
- Pennery E & Mallett J (2000) ‘A preliminary study of patients’ perceptions of routine follow-up after treatment for breast cancer’, European Journal of Oncology Nursing, 4: 138-145.
- Booth K, Beaver K, Kitchener H, O’Neill J & Farrell C (2005) ‘Women’s experiences of information, psychological distress and worry after treatment for gynaecological cancer’, Patient Education and Counselling, 56: 225-232.
Editor: Ms Alison Pearce, Program Manager, National Breast and Ovarian Cancer Centre.
Editorial Committee: Prof Michael Friedlander – Medical Oncologist, Prof Neville Hacker – Gynaecological Oncologist, Dr Gillian Mitchell – Medical Oncologist, Dr Deborah Neesham – Gynaecological Oncologist, Ms Georgie Richter – Gynaecological Nurse.
Disclaimer
Clinical Update - Ovarian Cancer is produced by the National Breast and Ovarian Cancer Centre (NBOCC) and is intended to provide health professionals with timely expert commentary on new research in ovarian cancer. Commentaries included in Clinical Update - Ovarian Cancer do not replace recommendations included in NBOCC clinical practice guidelines.
Information contained in Clinical Update - Ovarian Cancer is not intended to be used as substitute for an independent health professional's advice. The NBOCC does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information contained in Clinical Update - Ovarian Cancer. The NBOCC develops material based on the best available evidence however cannot guarantee and assumes no legal liability or responsibility for the currency or completeness of the information.