Digital Repository Doctoral Projects Fall 2021 A Breast Cancer Transition Pathway for the Huntsman Cancer Institute Kristina Bennett Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Bennett, K. (2021) A Breast Cancer Transition Pathway for the Huntsman Cancer Institute. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. A Breast Cancer Transition Pathway for the Huntsman Cancer Institute by Kristina Bennett A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director 1 Running head: SURVIVORSHIP AND BREAST CANCER Breast Cancer Transition Pathway for the Huntsman Cancer Institute Project Paper Kristina Bennett Weber State University 2 SURVIVORSHIP AND BREAST CANCER Acknowledgment Thank you to Dr. Cindy Matsen, who shared her passion with me on breast cancer survivorship, who mentored me to achieve my goals, and who never gave up even during a pandemic. To Dr. Mary Anne Reynold, who encouraged me to pursue my passion in survivorship care and helped me develop my project. To Dr. Jessica Bartlett for her countless hours of editing and assisting me in perfecting my project. To my DNP colleagues who consistently uplifted and encouraged my efforts. My family and especially my husband, who made dinner, drove carpools and managed life at home while pursuing my dreams of becoming a DNP. 3 SURVIVORSHIP AND BREAST CANCER Abstract Breast cancer (BC) is the most common non-cutaneous malignancy in females and represents 4 in 10 women cancer survivors in America. Many evidence-based clinical guidelines exist for BC diagnosis and treatment, but few guidelines address after-cancer care. Complications of BC treatments include depression, anxiety, cognitive dysfunction, pain, sleep disorders, sexual function problems, infections, immobility, and fatigue. These complex problems have short-term and long-term effects on the BC survivor. Gaps in treatment among long-term BC survivors include resources to enhance life quality, tactics to reduce stress, and transition to survivorship care. The Huntsman Cancer Institute (HCI) Survivorship Team created a BC transition pathway and assessment document to guide long-term BC survivors to after-cancer resources. The pathway used evidence-based strategies, including clinical practice guidelines, validated evaluation tools, and professional recommendations. This Doctor of Nursing Project aimed to direct long-term BC survivors to after-cancer resources and improve communication and documentation between HCI providers and BC survivors. Seven out of nineteen (37%) BC survivors filled out the transition pathway assessment document. The BC transition pathway program improved documentation and communication between the patient and the provider, addressed the significant long-term needs of BC survivors, confirmed the necessity for a survivorship clinic. This project advanced nursing practice at HCI by providing patient-centered survivorship care plans to transition long-term BC survivors to appropriate after-cancer resources. Keywords: breast cancer, survivor, survivorship, transition of care, quality of life 4 SURVIVORSHIP AND BREAST CANCER Breast Cancer Transition Pathway for the Huntsman Cancer Institute Introduction Breast cancer (BC) is the most common non-cutaneous form of cancer in women in the US (Runowics et al., 2016). Currently, there are no standardized follow-up models of care for patients who are long-term cancer survivors. As of January 1, 2019, there were 3,861,520 BC survivors in the United States and approximately 26,643 BC survivors in Utah (American Cancer Society, 2020). By 2020, BC will cost Americans an estimated 20.5 billion dollars a year, and the cost will rise by 2% annually (Mariotto et al., 2011). This paper reviews the literature on cancer survivorship, focusing on BC survivorship, and indicates how a breast cancer (BC) transition pathway program facilitated providers at the Huntsman Cancer Institute (HCI) to address follow-up care for BC survivors. Gap At HCI, BC survivors continue to increase due to early detection and advanced treatment practices. Many of these patients prefer to stay in the HCI system even after the usual five years of follow-up, leading to an overcrowded clinic 3A. A BC transition pathway guided long-term BC survivors to after-cancer resources outside clinic 3A. The BC transition pathway included an assessment document that addressed unique survivorship issues such as depression, anxiety, pain, sleep disorders, sexual function problems, immobility, and fatigue. The BC transition pathway guided the cancer survivor to follow-up care at the Huntsman Survivorship Clinic, a primary care clinic, or continue care at the HCI clinic 3A. Hence, this literature review provided the foundation and evidence to develop a BC transition pathway to offer long-term survivor care to decrease overcrowding at HCI clinic 3A. Improvement Plan 5 SURVIVORSHIP AND BREAST CANCER A BC transition pathway program was developed to assist providers at HCI clinic 3A to transition BC survivors to after-cancer resources. Before this quality improvement project, HCI underutilized a survivorship care plan to transition BC survivors to after-cancer care. The survivorship team introduced the transition pathway program to transition long-term BC survivors to follow-up resources. Breast cancer transition pathway assessment document. A BC transition pathway assessment document was developed to evaluate long-term BC survivors' unique needs and preferences for follow-up care. The transition pathway document addressed unique survivorship issues of body image, psychosocial well-being, physical well-being, distress, and sexual health. The BC survivor was given the BC transition pathway document to fill out while waiting to see the provider. The transition pathway document evaluated the BC survivor's quality of life and provided follow-up options for survivorship care. The transition pathway document incorporated the validated Minnesota Cancer Alliance After Cancer Tool to assess the BC survivor's concerns. (Minnesota Cancer Alliance, 2020). Review of the Literature Search methods This literature search was performed using Google Scholar and the Stewart Library databases CINAHL, PubMed, and MEDLINE. Studies were chosen based on study type, keywords, and year published. Eligible studies were published between 2005-2020. The search terms included: survivorship, BC, cancer survivorship, BC survivorship, survivorship care plan, survivorship care model, individualized care plan, patient-centered care plan, transition of care, treatment, breast-conserving surgery, mastectomy, overall survival, quality of life, communication, mobility, pain, stress reduction, physical exercise, survivorship tool, distress 6 SURVIVORSHIP AND BREAST CANCER tool, depression tool, Distress Thermometer, pain tool, assessment tool, breast questionnaire, PROMIS, PROMIS Global-10, clinical practice guidelines, random controlled trial, expert panel, systematic review, and meta-analysis. Cancer Survivorship In 2020, 16.9 million people had a history of cancer in America (American Cancer Society, 2020). A person with a history of cancer, after active treatment, is a cancer survivor through the remainder of their life. According to the Institute of Medicine (IOM) (2005), cancer treatments can cause physical, spiritual, psychological, social, and long-term effects on a cancer survivor. Cancer survivorship care is the surveillance and health promotion of the cancer survivor. Breast Cancer Survivorship. In 2019, there were an estimated 271,270 new BC cases in America, and an estimated 42,260 people died from BC alone (American Cancer Society, 2020). Survival is likely after BC treatment, with a 5-year survival rate of almost 90% (Runowics et al., 2016). Although the survival rate is high, the very nature of treatment modalities of surgery, chemotherapy, radiation, and long-term hormone-blocking medications can cause depression, anxiety, cognitive dysfunction, pain, sleep disorders, sexual function problems, infections, immobility, and fatigue. These complex problems have short-term and long-term effects on the BC survivor. In addition to these problems, BC survivors can experience chemotherapy-induced peripheral neuropathy, cognitive issues, lymphedema, hormonal imbalances, radiation side effects, and body image issues. Complexities of Breast Cancer Survivorship. Currently, the National Comprehensive Cancer Network has excellent guidelines for breast cancer treatment and follow-up for the first five years (National Comprehensive Cancer Network, 2017). But there are no standardized 7 SURVIVORSHIP AND BREAST CANCER follow-up models of care for patients who are long-term BC survivors. In 2005, the Institute of Medicine (IOM) emphasized the lack of comprehensive treatment for cancer survivors and issued proposals to improve survivorship practice (Institute of Medicine [IOM], 2005). Gaps in treatment among BC survivors include resources to enhance life quality, strategies to reduce stress, survivorship care plans, and follow-up care resources (Runowicz et al., 2016). McCabe et al. (2013) found that a significant barrier to standardizing survivorship care is the diverse cancer types, the survivor age spectrum, and the evolving treatment modalities. Further, access to high-quality survivorship care is influenced by socioeconomic status, insurance coverage, race, general health before diagnosis, and the survivor's values and beliefs. Consequences of Breast Cancer Survivorship. Cancer survivors experience unique survivorship issues such as depression, anxiety, pain, sleep disorders, sexual function problems, immobility, and fatigue (Runowicz et al., 2015). These symptoms may be short-term or long-term, depending on the cancer survivor. The cancer survivors' quality of life is disrupted due to cancer treatment's adverse outcomes, both physical and emotional. Providers and organizations must assess and transition BC survivors to survivorship care to fill the gap in survivorship care. Transition Pathway Progam According to the American Society of Clinical Oncology (ASCO) (2021), a long-term plan for follow-up care is essential for cancer survivors. ASCO recommends that oncology providers develop a customized survivorship care plan with a written follow-up plan to guide the cancer patient to post-cancer life. A transition pathway assessment document is a written plan to monitor the late effects of cancer treatments and a resource to guide the patients to follow-up treatment options. The European Society for Medical Oncology (2017) also recommends a 8 SURVIVORSHIP AND BREAST CANCER written plan to evaluate the long-term effects of cancer treatments and establish follow-up resources for cancer patients. Validated Tools A transition pathway assessment document can include validated tools like PROMIS, Distress Thermometer (DT), and the Minnesota Cancer Alliance Cancer Survivorship Care Plan to evaluate BC survivor needs. PROMIS. The Patient-reported Outcomes Measurement Information System (PROMIS) is a validated tool used to measure the quality of life of BC survivors. PROMIS was launched by the National Institute of Health, in 2004, as a collaborative approach to measure patient-reported outcomes (PRO) that are standardized and shared across disease states (Seneviratne et al., 2019). A short-form of PROMIS called PROMIS Global-10 is used to decrease interruption in workflow. According to Code Technology (2020), PROMIS Global-10 is a free, validated, sensitive, easy to use, and reliable tool. The PROMIS Global-10 consists of 10 items that assess physical health, mental health, social health, pain, fatigue, and perceived quality of life. Summary scores from the PROMIS Global-10 are categorized as a Global Physical Health (GPH) score and a Global Mental Health Score (GMH). The GPH and GMH provide clinicians with a quick summary of the patient's health and mental status. A recent qualitative study by Krohe et al. (2019) found that PROMIS has content validity in the BC population. This study found that 90 % of subjects demonstrated understanding of the content, and 70% provided useful PROMIS responses. Longitudinal research by Shalet et al. (2016) found that the PROMIS tool is sensitive to significant physical function changes across six different chronic health conditions. A retrospective study by Seneviratne et al. (2016) found that PROs like the PROMIS Global-10 easily integrate into clinical workflow. Krohe et al. 9 SURVIVORSHIP AND BREAST CANCER (2019) also found that PRO questionnaires like PROMIS are valuable tools that give insight into the patient perspective and experience. Distress screening. Since 2015, distress screening has been mandated for accreditation for cancer centers in the US (Ehlers et al., 2019). Ehlers et al. (2019) found that distress screening is an essential piece of BC survivorship. Approximately 25-50% of cancer patients indicate significant levels of stress. Researchers have developed and validated many distress screening tools in the last decade, such as the Distress Thermometer (DT), the Hospital Anxiety and Depression Scale, and the Patient Health Questionnaire. This study found that these tools effectively detect stress levels, and clinical staff reports positive perceptions of the screening procedure. The National Comprehensive Cancer Network (NCCN) defines distress as a multifactorial unpleasant emotional experience that may interfere with life's daily activities (Cormio et al., 2019). Distress may interfere with the quality of life and leads to syndromes like anxiety and depression. According to Cormio et al. (2019), Distress Thermometer is a reliable and valid tool to assess distress in patients. This study found that Distress Thermometer use allows providers to identify patients with specific psychosocial distress characteristics to improve the patients' therapeutic outcomes. Similarly, Hegel et al. (2008) found that the Distress Thermometer scores were significantly higher for depressed persons. Likewise, a study by McFarland et al. (2018) found that the Distress Thermometer represents an efficient means of capturing physical distress symptoms for the BC population. Minnesota Cancer Alliance Cancer Survivorship Care Plan. Another helpful tool to provide patient-centered care is the Minnesota Cancer Alliance Cancer Survivorship Care Plan (Minnesota Cancer Alliance, 2020). The transition pathway document includes the Minnesota 10 SURVIVORSHIP AND BREAST CANCER Cancer Alliance Survivorship Care Plan to assess the BC survivor's concerns. In the after-treatment section of the care plan, personal matters consist of relationship concerns, financial issues, nutrition, emotional support, health changes, and fear of recurrence. This assessment tool is used to develop individualized Survivorship Care Plans (SCP). Individualized Survivorship Care Plan The literature exhibited evidence for individualized SCP strategies, which include 1) survivor engagement, 2) survivor preferences, 3) exemplar models of care, and 4) adherence to the American Cancer Society (ACS)/American Society of Clinical Oncology (ASCO) BC Survivorship Care Guidelines. Survivor Engagement. According to the Nursing Alliance for Quality Care (NAQC), patient engagement is critical for patients to make well-informed decisions and to take action to support those decisions (Sofaer & Schumann, 2013). Patient-centered care relies on the full engagement of patients and their families in shared-decision making and is the stated goal of many quality improvement projects. Patients are the best source of information about their health, values, and preferences. An involved patient has more positive care outcomes, increased trust with the provider, and a higher chance of sharing information with clinicians (Finkelman, 2018). A BC transition pathway assessment document engages survivors in their survivorship care and can improve survivor outcomes. Survivor Preferences. A survivorship care model should be individualized and based on survivor preferences. Weaver et al. (2019) evaluated patient preferences for survivorship care among recently treated BC survivors. Survivors had comparable choices for SCPs, discussion topics, and components of survivorship care. BC survivors reported 1) monitoring for recurrence, 11 SURVIVORSHIP AND BREAST CANCER 2) getting additional treatment, 3) assessing side effects, and 4) recognizing late effects as essential details for follow-up care discussions as crucial aspects of an SCP. Exemplar Models. Another effective strategy for individualizing an SCP is looking to other models of care. Stanford Medicine developed the 4R-Model to empower patients to engage in their care (Stanford Medicine, 2020). The 4R-Model encourages cancer survivors to be more involved in planning and implementing their SCP. The 4R-model focuses on the Right Information/Right Patient/Right Care/Right Time to help manage care sequence and facilitate teamwork between the patient, family, and provider. Stout et al. (2012) developed a Prospective Surveillance Model (PSM) to provide a framework to guide individual rehabilitation for BC survivors. The expert panel found that ongoing assessment after disease treatment is essential for BC survivors' individual needs. The aims of the PSM are: 1) promote surveillance for physical impairments and functional limitations associated with BC survivors, 2) provide education to reduce the risk of adverse events related to functional and physical limitations, 3) introduce exercise and rehabilitation strategies, and 4) promote and support physical activity and weight management. The Prospective Surveillance Model is an excellent example of individualized care for BC survivors. A patient-centered SCP follows the ASC/ASCO BC Survivorship Care Guidelines. Runowicz et al. (2015) developed the ACS/ASCO BC Survivorship Care Guideline based on research and consensus expert opinion. The clinical practice guideline proposes five essential areas of survivorship: 1) observation for BC recurrence, 2) monitoring for second primary cancers, 3) assessment and organization of physical and psychosocial lasting side effects of BC and treatment, 4) health advancement, and 5) care management and practice suggestions. An 12 SURVIVORSHIP AND BREAST CANCER individualized SCP should adhere to the ACS/ASCO clinical practice guidelines' evidence-based recommendations. Measures to Improve Quality of Life This literature review also indicates that a patient-centered SCP should include measures to improve the quality of life of BC survivors (Cardoso et al., 2019). The evidence supports those adjunct therapies of 1) physical exercise, 2) stress relief tactics, and 3) communication are beneficial for BC survivors. Physical exercise. Recent studies show that physical exercise improves the quality of life for BC survivors. For example, Falcetta et al. (2018) found that physical activity significantly improved early-stage BC survivors' quality of life. Similarly, Cordoso et al. (2019) found that lifestyle factors such as exercise can have functional and psychological benefits in addition to local and systemic treatments. Also, McNeely et al. (2006) discovered that activity is an effective intervention to improve life quality, cardiorespiratory fitness, physical functioning, and fatigue symptoms in BC survivors. Stress relief tactics. An integral component of an SCP is reducing stress for BC survivors. Lengacher et al. (2016) performed a randomized controlled trial to evaluate mindfulness-based stress reduction (MBSR) effectiveness for BC survivors. Psychological factors included stress, anxiety, depression, fear of recurrence, and physical signs, including pain and fatigue. The MBSR group demonstrated clinically significant mental and physical symptoms improvement compared to the usual care group. Another way to reduce stress for BC survivors is access to a survivorship clinic. In 2019 Chasen et al. evaluated the impact of a BC survivor clinic on BC survivors. A systematic chart review found that survivors had a statistically significant decline in distress after at least one visit 13 SURVIVORSHIP AND BREAST CANCER to the BC survivor clinic. Survivors also showed a statistically significant reduction in nausea, pain, depression, tiredness, anxiety, shortness of breath, and drowsiness. Communication. Communication is a vital aspect of a BC survivorship care model, and BC has a considerable effect on the sexuality of a BC survivor. Reese et al. (2015) examined provider and survivor experiences and preferences related to conversations about BC-related sexual concerns. Common themes in the study included: 1) survivor communication actions; 2) provider communication behaviors; 3) survivor communication barriers; 4) provider communication barriers; 5) communication implementors; 6) contextual factors; 7) communication favorites. As a result, a conceptual model was developed to promote survivor/provider communication about sexual concerns. Theoretical Framework Model The DNP student used Juran's Trilogy Model to develop a quality improvement project for HCI. Using Juran's Trilogy Model, a DNP student developed a project plan that identified the customer, determined the customer's desires, and developed a product or service to address the customer's needs (Finkelman, 2018). This process, known as quality planning, identified the customer as the providers at the HCI clinic 3A. The needs of the clinicians include issues with the transition of BC patients to survivorship care. During the planning phase, the DNP student met with stakeholders such as the providers, nurses, and patients and developed a plan to transition patients from the HCI clinic 3A to a survivorship clinic or primary care physician. Next, the DNP student began the quality improvement phase. The DNP student developed a BC transition pathway program to optimize survivors' survivorship care (Finkelman, 2018). The BC transition pathway addressed BC survivors' unique survivorship issues and guided patients to after-cancer treatment options. The BC transition pathway led the clinician to 14 SURVIVORSHIP AND BREAST CANCER evaluate patient distress, pain, quality of life, fatigue, sexual health, and other long-term survivorship issues. The clinician also used the BC transition pathway to discuss where the patient wanted to receive survivorship care. Lastly, the DNP student evaluated and mainstreamed the quality improvement project. In this last stage, the effectiveness and sustainability of the transition were assessed. The BC transition pathway program aimed to assist providers in guiding long-term BC survivors to survivorship care. Project Implementation Expected Outcomes and Goals The project's outcomes were 1) to complete a needs assessment and stakeholder plan, 2) develop a BC transition pathway program, 3) implement with a single provider, and 4) gather and analyze data. First, the DNP student completed a needs assessment and collaborated with stakeholders to develop a plan. Next, the DNP student developed an evidence-based BC transition pathway assessment document to transition BC survivors to follow-up resources. The BC transition pathway assessment document evaluated a BC survivor's needs and preferences regarding long-term survivorship care. Next, the project was implemented with one provider with a goal to implement with multiple providers. Finally, the DNP student gathered and analyzed the data. Data was measured by examining the rate of patients who completed a transition pathway assessment document. The goals for this project are 1) 80% of eligible patients to complete the transition document, 2) improve communication and documentation between the patient and provider, 3) guide BC patients to follow-up care, and 4) identify long-term effects of cancer treatments. 15 SURVIVORSHIP AND BREAST CANCER Setting HCI is the official cancer center of Utah and is the only comprehensive cancer center in the Mountain West (National Cancer Institute, 2020). HCI hosts more than 142,000 cancer survivors annually. Cancer is the leading cause of death in Utah, and 10,950 new cases are diagnosed annually. The HCI clinic 3A offers care to BC patients and hosted 19,172 visits in 2019 (E. Olsen, personal communication, July 20, 2020). Population The primary population are the providers at the HCI clinic 3A. Twenty-four providers range from eighteen medical doctors, one physician's assistant, and five nurse practitioners. The secondary population is the BC patients at HCI clinic 3A. The providers host 250 to 3,800 BC patients per year, and BC patients over five years from diagnosis accounted for 14.64% of the breast clinic visits in 2019 (E. Olsen, personal communication, July 20, 2020). Both the providers and the BC patients are affected by the flow and capacity of the breast clinic 3A. Project Issues The DNP student assessed the available resources for the project. Resources include champions of the project, the availability of a survivorship clinic, paper for the BC transition pathway assessment document, funding for the resources, time to complete and review the transition pathway document, and the existing survivorship care plan. Champions and other supportive factors are crucial to the success of a BC transition pathway program. Throughout the project, Dr. Cindy Matsen agreed to mentor the DNP student with her assistant Alexis Daily. Emily Olsen, Chanteel Ballard, and Brighton Loveday helped gather information about the setting and population for the project. 16 SURVIVORSHIP AND BREAST CANCER At the beginning of the project, resources such as a stand-alone survivorship clinic were cut due to funding issues from Covid-19. Recently, HCI has established a survivorship clinic for providers to transition long-term BC survivors. BC survivors now have three options for follow-up care; 1) survivorship clinic, 2) primary care provider, and 3) continue care at clinic 3A with a medical oncology nurse practitioner. Resources of paper, printing ink and time management facilitated the success of the quality improvement project. The funding for paper and printing ink was inexpensive and provided by clinic 3A. Time management was maintained by the brevity of the transition pathway and facilitated by Dr. Matsen's nurse. Obstacles to this project included communication barriers, follow-through, and multiple clinic settings. Due to Covid-19, communication was limited to emails, and the DNP did not work at the facility, which limited access to ensure implementation status. Additionally, implementation was hindered by forgetfulness and disruption of flow at different clinic settings. Project Implementation Plan Project Plan. A BC transition pathway program was developed to evaluate BC survivors' unique needs and preferences to improve the patients' transition to follow-up care. Eligible long-term BC survivors were identified at each clinic. Eligible patients were given the BC transition pathway assessment document to fill out while waiting to see the provider. The transition pathway document evaluated the BC survivor's quality of life and provided follow-up options for survivorship care. The transition pathway assessment document incorporated the validated Minnesota Cancer Alliance After Cancer Tool to assess the BC survivor's concerns. Problems include pain, anxiety, fatigue, sexual worries, body image, sleep, mobility, and cancer recurrence 17 SURVIVORSHIP AND BREAST CANCER anxiety (Minnesota Cancer Alliance, 2020). This project assisted providers at the breast clinic at HCI in transitioning BC survivors to long-term survivorship care. Implementation Plan. From September 2019 to October 2020, the DNP student researched breast cancer survivorship and evaluated survivorship care at the HCI clinic 3A. Next, the DNP student developed a quality improvement project to improve survivorship care at the HCI clinic 3A. Then the DNP student gained approval for the project in October of 2020 (see Appendix A). From January 2021 to April 2021, the DNP student and the survivorship team at HCI researched and developed a BC transition pathway assessment document (see Appendix B). From May 2021 to July 2021, the project was implemented. Project implementation began by printing the BC transition pathway assessment documents. Next, Dr. Matsen's nurse reviewed the weekly schedule to plan which patients would receive the BC transition pathway document. Then, at the transition visit, the transition pathway document was given to BC survivors who qualified as survivors (three to five years from diagnosis). Next, Dr. Matsen assisted the patient with filling out the transition pathway document based on patient preferences. Finally, the BC transition pathway ensured that survivorship patients transitioned to survivorship care. Dr. Matsen plans to introduce the BC transition pathway program to other providers at the next treatment planning conference in October 2021. Dr. Matsen used the BC transition pathway program for three months, and then the DNP student began the evaluation phase of the project. Evaluation Methods. The Survivorship Team created a BC transition pathway to direct BC survivors to after-cancer resources. The patient and provider used the pathway program to develop an individualized care plan for BC survivors. The goals for this project are 1) 80% of 18 SURVIVORSHIP AND BREAST CANCER eligible patients to complete the transition assessment document, 2) improve communication and documentation between the patient and provider, 3) guide BC patients to follow-up care, and 4) identify long-term effects of cancer treatments. Evaluation and Data Analysis Evaluation Evaluation and analysis of the quality improvement project were done by quantitative and qualitative data analysis, and data were extracted and summarized from the BC transition pathway assessment documents and a post-project survey. Evaluation of the BC transition pathway began in August 2021. Quantitative data was gathered using a spreadsheet divided into weeks (see Table 1). At the beginning of the project, the DNP student provided a spreadsheet and a dropbox for the completed forms. Each week the spreadsheet was marked to represent total qualified patients versus the total number of patients who filled out the transition pathway assessment document. The DNP student analyzed how many patients used the pathway during the allotted period. The DNP student collaborated with the Survivorship Team every few weeks to ensure the project's progression. The qualitative data were analyzed using descriptive statistics. Project Results The study population included breast cancer survivors three to five years post-cancer diagnosis, and nineteen prospective patients met inclusion criteria. During a three-month implementation period, seven out of nineteen (37%) eligible patients filled out the transition pathway assessment document (see Table 1). Descriptive results from a qualitative survey include 1) the BC transition pathway program improved communication and documentation between the provider and the patient, 2) guided BC patients to follow-up care, 3) identified long- 19 SURVIVORSHIP AND BREAST CANCER term effects of cancer treatments, and 4) revealed a need for a survivorship clinic (Appendix C). The success of this project has led to the future goal of integrating the BC transition pathway program into the electronic medical record. Table 1 Discussion, Conclusions, and Recommendations Discussion The project results of 37% completion rate are lower than expected due to communication errors, champion follow-through, and the complexity of two clinic settings. The DNP student communicated with the Survivorship Team every one to three weeks regarding the project. The DNP student was assured that the project was going well throughout the project. Based on the project results, the DNP student should have communicated weekly. Additionally, the DNP student did not work at HCI and did not have adequate access to the project site to ensure complete implementation. The project results were also affected by the compliance of the survivorship team. Implementation of the transition pathway program was sometimes overlooked, and the nurse explained that the transition pathway was not implemented when she was out of town. Excluding the results from the two weeks that the nurse was out of town increases the completion rate from 37% to 47% (see Table 1). Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total % Total Patients 2 1 2 3 2 0 1 2 0 2 0 1 1 2 19 Total Forms 2 1 1 1 1 0 0 0 0 0 0 0 1 0 7 37 Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total % Total Patients 2 1 2 3 2 0 1 0 0 1 1 2 15 Total Forms 2 1 1 1 1 0 0 0 0 0 1 0 7 47 Nurse in town BC Transition Sheet Results 20 SURVIVORSHIP AND BREAST CANCER Finally, clinic 3A has expanded to a Sugarhouse office. The nurse felt it was challenging to use the transition pathway in two separate offices. She had a significant responsibility to bring the pathway documents from office to office. Although the completion rates are lower than expected, this quality improvement project was successful. The BC transition pathway program improved communication and documentation between the provider and the patient, guided BC patients to follow-up care, identified long-term effects of cancer treatments, and revealed a need for a survivorship clinic. The success of this project has led to the future goal of integrating the BC transition pathway into the electronic medical record. Sustainability. Despite the low completion rate, Dr. Cindy Matsen would like to continue to use the BC transition pathway program. The plan is to move the BC transition pathway to the EMR to improve utilization across the multidisciplinary team. Dr. Matsen also plans to introduce the transition pathway to other providers once the schedulers are trained about the survivorship clinic orders and schedule. Implications to Healthcare A BC transition pathway program answers the Institute of Medicine's petition to improve after-cancer care for cancer survivors (IOM, 2005). A BC transition pathway advanced nursing practice by establishing an exemplar of patient-centered survivorship resources to transition BC survivors to appropriate after-cancer care. A BC transition pathway addresses the significant long-term needs of BC survivors, improves documentation and communication between the patient and the provider, and confirms the necessity for a survivorship clinic. The BC transition pathway also identified the significant long-term effects of cancer of pain, anxiety, fatigue, sexual worries, body image, sleep, mobility, and cancer recurrence anxiety. This project 21 SURVIVORSHIP AND BREAST CANCER provided a pathway to assist providers at the breast clinic at HCI to transition BC survivors to survivorship care. Recommendations According to the American Society of Clinical Oncology (2021), BC survivors require long-term surveillance, risk assessment, and preventative services. A BC transition pathway was used at HCI to transition BC survivors to after-cancer resources. The quality improvement project recommendations are to advance the transition pathway to the EMR and to utilize the transition pathway by Dr. Matsen and other physicians. Conclusion At HCI, long-term BC survivors continue to increase due to early detection and advanced treatment practices. BC survivors experience unique survivorship issues such as depression, anxiety, pain, sleep disorders, sexual function problems, immobility, and fatigue. A BC transition pathway program successfully transitioned long-term BC survivors to after-cancer resources, improved documentation and communication between the provider and patient, and confirmed the need for a survivorship clinic. This Doctor of Nursing practice project indicates that BC survivors need personalized long-term follow-up care after completing cancer treatments. This literature review defines cancer survivorship, focusing on breast cancer survivorship, and maintains that the standard of practice for breast cancer survivors is adequate after-cancer care. Evidence from the literature supports using a BC transition pathway, validated evaluation tools, and individualized survivorship care plans. The literature also exhibits evidence that care plans should include measures to improve the quality of life. 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This letter serves as an official notification to proceed with the implementation and evaluation of your project. If you have further questions, please contact your Project Faculty Lead. Sincerely, Dr. Jessica Bartlett 29 SURVIVORSHIP AND BREAST CANCER Appendix B Service Line or Department 2000 Circle of Hope, Room 0000 Salt Lake City, UT 84112 801-555-5555 Cancer survivorship is a distinct stage of cancer care, and patients who reach three to five years from diagnosis are known as cancer survivors. At the Huntsman Cancer Institute, cancer survivors will transition to survivorship care. At the transition visit, the patient and healthcare provider will develop a plan to meet the cancer survivor's physical and psychosocial needs. The plan will include where the patient will receive follow-up treatment and resources for long-term cancer-related issues. The patient will transition to the Huntsman Survivorship Clinic, the Medical Oncology Clinic, or back to their primary care provider for survivorship care. Long-term Issues ☐ Pain ☐ Emotional support ☐ Hormone changes ☐ Low energy/fatigue ☐ Sexual Concerns ☐ Fertility ☐ Body Image ☐ Anxiety/depression ☐ Heart problems ☐ Appetite changes ☐ Weight loss/gain ☐ Breathing problems ☐ Memory changes ☐ Sleep problems ☐ Dental concerns ☐ Mobility ☐ Hearing changes ☐ Urinary problems ☐ Swollen arms or legs (lymphedema) ☐ Headaches ☐ Skin changes ☐ Numbness of hands or feet ☐ Financial ☐ Other Follow-up clinic Phone Number How often ☐ Huntsman Survivorship Clinic ☐ Survivorship Care from the Medical Oncology Clinic ☐ PCP 30 SURVIVORSHIP AND BREAST CANCER Appendix C