Exploring the Nurse's Role in Oncology Care
October 17, 2022
By Kristin Baird Rattini
At nearly every step of treatment at Dana-Farber, you will find a nurse. They are the face of the Institutute's relationship-based care model.
"We believe that the relationship between the nurses and their patients and loved ones is therapeutic itself, in addition to the treatments we provide them," says Anne Gross, PhD, RN, NEA-BC, FAAN, senior vice president for Nursing and Patient Care Services and Chief Nursing Officer. "It is a very important piece of our approach to caring for patients with cancer."
It's a relationship that starts from the first day at Dana-Farber, often with a nurse navigator, and continues throughout the patient's time at the Institute. Through regular visits, infusions, clinical trials, and everything in between, one constant is the steady care of a dedicated group of highly expert, compassionate nurses, who guide patients and families throughout the trajectory of their care. They have earned Dana-Farber the Magnet designation for excellence in nursing practice since 2005.
While each of the four nursing specialty roles at Dana-Farber — nurse navigator, nurse practitioner, infusion nurse, and research nurse — plays a distinct role, the nurses all work closely together as a cohesive, coordinated team that accompanies each patient through his or her cancer journey.
Nurse navigators are the primary nursing contact for patients at Dana-Farber. They're a North Star that orients patients through the constellation of providers, appointments, services, and symptoms. They're usually the first person to welcome a new patient and the first person whom patients contact with any and all questions that arise.
"One of the exciting parts of being a nurse navigator is that we do so many things to support the patients and the care team however they need, so we need to have a wide variety of skills," says Claudia Howe, BSN, RN, oncology nurse navigator in gynecologic oncology.
On a typical day, Howe might review a new patient's medical history to ensure their chart is well detailed for their first provider visit. She might suggest interventions for patients with treatment-related side effects, such as constipation or nausea. She might check with a patient to ensure that they know how to take a new medication properly. Or assist in arranging home care, hospice care, and COVID-19 testing. And she might consult with the patient's care team to determine whether something can be treated at home or requires a visit to Dana-Farber.
Above all, "nurse navigators alleviate a lot of stress and concern," Howe says. If a patient is worried about a symptom or sees a test result they don't understand, a nurse navigator will be the first to respond. "We usually can get back to them rapidly," Howe says. "Even if it's just to say, 'I heard your question and we're checking with the doctor,' that is a great stress reliever for the patient to know that they have been heard. It's so rewarding to be able to allay their concerns and support the care team so that everyone is working with the patient's best care in mind."
Nurse practitioners (NPs) are advanced-practice nurses who have earned a master's degree or doctoral degree in nursing practice. They work collaboratively with doctors to diagnose and treat illness, perform physical exams, discuss results, and formulate plans of care. They educate patients on their diagnosis and treatment and work with them on prevention and health management.
"We're able to comprehensively bring everything together for our patients," says Kim Noonan, NP, Dana-Farber's chief nurse practitioner. "You feel like you can really make a difference in so many ways."
"As nurses and providers, we nurse practitioners have a holistic view of being able to care for our patients," says Elahe Salehi, DNP, ANP-BC, breast oncology nurse practitioner and director of Advance Practice Nursing at Dana-Farber. "We get to know our patients in a very intimate way, and that is so gratifying."
Helping Patients in Cooling Cap Study
Through her holistic approach to care, Salehi addresses an important issue: hair loss and self-image. "About 8% of female cancer patients turn down chemotherapy because they don't want to lose their hair," she says.
In the first nurse-led therapeutic study at Dana-Farber, Salehi is currently conducting a clinical study of cooling caps, which are designed to reduce hair loss by applying cold temperatures to the scalp to constrict blood vessels and minimize the effects of cytostatic agents on hair follicles.
Salehi had participated in an earlier small pilot study of cooling caps, which showed promise. She used that data as a springboard to design a study that covers new ground by targeting a patient population for which there's limited data about scalp cooling: patients with metastatic breast cancer who are on one of three treatment regimens that have not yet been examined (treatments include sacituzumab govitecan, trastuzumab deruxtecan, and eribulin).
"I want to make sure we give everyone the chance (to use cooling caps), not just early-stage patients," Salehi says. "The trajectory of breast cancer treatment has changed positively; they are more effective and therefore, patients are living longer."
The study is evaluating not only the degree of hair preservation, but also the impact of scalp cooling on participants' quality of life. "I'm seeing good results," Salehi says. "I can see scalp cooling become a standard of care for our patients."
Nearly 40% of Dana-Farber's NPs have earned additional certification in an advanced specialty, which expands the knowledge that they bring to each patient. Susanne Menon, MSN, WHNP, OCN, ACHPN, a nurse practitioner in gynecologic oncology, has earned three advanced specialties — in oncology, women's health, and hospice/palliative care — to better serve her patients.
"By doing my work in the clinic, it allows our physicians to have time for staying on top of the newest research and for me to do what I do well: symptom management," Menon says. "I love to figure out what's causing someone's discomfort and how I can make it better."
For many patients, the infusion room is where they spend most of their time at Dana-Farber. Infusion nurses not only administer chemotherapy, immunotherapy, and other medications, but also provide support and company for patients and their loved ones during what can be long sessions together.
"There is such a variety of protocols that we administer to our patients," says Stephanie Benoit, RN, an infusion nurse at Dana-Farber for 19 years. "We're learning about new drugs every day. We're seeing a lot of different treatments that are easier to tolerate, that are given by pill instead of IV, and that are keeping patients alive a lot longer."
Some patients come for relatively short appointments, for fluids, injections, oral medicines, and pain and symptom management. Others come for chemotherapy, delivered through special pumps over a fixed amount of time in the infusion chair or in smaller pumps that patients take home. It's what Benoit calls "high-tech, high-touch care."
"It's a blessing to help these patients," Benoit says. "We get to know them, to hear stories about their children and grandchildren. Sometimes it's just about being someone they can feel safe with and cry with. Sometimes they'll rush in after traveling for hours and we'll spend some time to help them relax before treatment. Sometimes it's a new patient who is scared and anxious about how the infusion will work. It's a privilege to help these patients understand what's going on and help them through their journey."
"I feel like I have the best job, because I get the best of all worlds," says Stephanie Morrissey, BSN, RN, a research nurse in gynecologic oncology who has worked at Dana-Farber for 32 years. "I have constant patient contact. I am an integral member of the team, working with nurse practitioners, nurse navigators, infusion nurses and providers. I sit in on all patient visits and study appointments. I can utilize both my assessment and teaching skills and serve as a resource for protocol-related questions."
As a research nurse, Morrissey has two important roles. First and foremost is as an advocate for her patients, caring for their physical, psychological, and social needs. The second is as a resource for the clinical trial protocol itself, which must be followed precisely to provide the kind of data that can lead to new standards of care and save lives. When a protocol treatment she has worked on receives Food and Drug Administration (FDA) approval, "it is such an honor," Morrissey says. "I am so lucky to witness the whole process. I feel like I am part of Dana-Farber history."
Research nurses are paired with a specific oncologist, whose patients become "their" patients. "We are so fortunate to have an incredibly talented and dedicated team of research nurses, many of whom have worked in our departments for decades," says Erica Mayer, MD, MPH, director of Breast Cancer Clinical Research and a medical oncologist in breast oncology. "They have an exquisite understanding of cancer research and how clinical trials help to push our field forward."
Margaret "Peg" Campbell, BSN, RN, a research nurse in breast oncology, has seen first-hand how the field has advanced. "My position has grown by leaps and bounds," Campbell says. "There have been tremendous advances in care. Patients are living longer, and you develop a close bond with them as you're on that journey with them."
Campbell was the recipient of the CURE 2022 Extraordinary Healer Award, a national recognition that honors nurses in the cancer community who strive to go above and beyond their call of duty.
The accolades confirm what Dana-Farber's patients already know: That the nurses they see at every step of their journey are an integral part of their cancer care, and their expertise and compassion provide a place where each patient feels heard, held, and well cared for.
In Studying Drug Reactions, 'Nurses Do Make a Difference'
In her quest to relieve her patients' discomfort, nurse practitioner Susanne Menon, MSN, WHNP, OCN, ACHPN, sometimes encountered patients suffering hypersensitivity reactions to taxanes, a common category of chemotherapy drugs. These reactions — which include flushing, itching, shortness of breath, pain, and nausea — require immediate attention and management from nurses.
"The reaction can be traumatic for patients and cause anxiety for future infusion treatments," Menon says.
Data showed that 19% of patients on taxanes at Dana-Farber had experienced reactions over the previous two years. Most were referred to the allergy department for a desensitization protocol, but the waiting list for that treatment ranged up to 12 weeks. Menon teamed up with Donna-Marie Lynch, FNP-BC, an allergy nurse practitioner at Brigham and Women's Hospital, to undertake an evidence-based practice project to see if a three-step titration of taxanes would reduce the rate of hypersensitive reactions in patients. (Titration involves initiating a medication at a slower rate and gradually increasing it toward the maximum rate of infusion.)
Their third partner and co-principal investigator on the study, Terri Jabaley, RN, PhD, of Dana-Farber's Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, guided Menon and Lynch through the existing literature, which confirmed that titration could be an effective approach. In all, 99 patients received titration. They were compared to 123 previous patients who did not receive titration. The rate of hypersensitivity decreased from 19% to 7%; 6% of those were mild reactions.
"We significantly reduced the rate of reactions in our patients," Menon says. They're now evaluating how to make titration a sustainable practice throughout Dana-Farber.
"This is one of the most exciting things that has ever happened in my career. The project was run completely by nurses, driven by the desire to make things better for our patients. It shows that nurses do make a difference."