Nurse-led follow-up of patients after oesophageal or gastric cardia cancer surgery: a randomised trial. Br J Cancer. 2009;100:70-76. [PMID: 19066612 DOI: 10.1038/sj.bjc.6604811]

Long-term impact of aerodigestive symptoms on adults with oesophageal cancer: A qualitative study

PURPOSE

The impact of long-term aerodigestive symptoms following oesophageal cancer surgery is still not well understood. This study aimed to qualitatively understand the long-term impact of aerodigestive symptoms on quality of life in adults post-oesophagectomy.

METHOD

Participants who received curative transhiatal/transthoracic surgery for oesophageal cancer in Ireland's National Oesophageal Cancer Centre were invited to attend semi-structured interviews. Surgery had to be completed at least 12 months prior. Reflexive thematic analysis was conducted.

RESULT

Forty participants were interviewed individually face-to-face. Four key themes were identified: (a) isolation, reflecting the reported solitude experienced by oesophageal cancer survivors when attempting to manage their ongoing aerodigestive symptoms; (b) fear, including fear of choking and fear that dysphagia symptoms may indicate recurrence of oesophageal cancer; (c) altered work capacity, caused by ongoing aerodigestive symptoms; and (d) avoidance of social situations involving food, due to the pain, discomfort, and embarrassment caused by these symptoms.

CONCLUSION

Oesophageal cancer treatment can be lifesaving, however, such medical interventions can result in distressing physiological aerodigestive symptoms throughout survivorship, which can significantly impact quality of life. Our findings indicate a need for greater community support to manage aerodigestive symptoms and reduce the impact these have on quality of life.

Interdisciplinary interventions that improve patient-reported outcomes in perioperative cancer care: A systematic review of randomized control trials

INTRODUCTION

Interdisciplinary teams are often leveraged to improve quality of cancer care in the perioperative period. We aimed to identify the team structures and processes in interdisciplinary interventions that improve perioperative patient-reported outcomes for patients with cancer.

METHODS

We searched PubMed, EMBASE, and CINAHL for randomized control trials published at any time and screened 7,195 articles. To be included in our review, studies needed to report patient-reported outcomes, have interventions that occur in the perioperative period, include surgical cancer treatment, and include at least one non physician intervention clinical team member: advanced practice providers, including nurse practitioners and physician assistants, clinical nurse specialists, and registered nurses. We narratively synthesized intervention components, specifically roles assumed by intervention clinical team members and interdisciplinary team processes, to compare interventions that improved patient-reported outcomes, based on minimal clinically important difference and statistical significance.

RESULTS

We included 34 studies with a total of 4,722 participants, of which 31 reported a clinically meaningful improvement in at least one patient-reported outcome. No included studies had an overall high risk of bias. The common clinical team member roles featured patient education regarding diagnosis, treatment, coping, and pain/symptom management as well as postoperative follow up regarding problems after surgery, resource dissemination, and care planning. Other intervention components included six or more months of continuous clinical team member contact with the patient and involvement of the patient's caregiver.

CONCLUSIONS

Future interventions might prioritize supporting clinical team members roles to include patient education, caregiver engagement, and clinical follow-up.

[Nutritional supportive care in the course of patients with esophagogastric cancers]

Supportive care plays a central role in the management of patients with esophagogastric cancers, at all disease stages. Malnutrition has a high prevalence in this population, reaching up to 60 % of the patients. Sarcopenia and cachexia are also common. These complications have negative impact on functional abilities, quality of life and overall survival. They impair anti-tumor treatments effectiveness and increase their toxicity. Early detection and management are needed, before reaching advanced stages, which are refractory to therapeutic interventions. Specific nutritional support is recommended, relying on different nutritional support tools (dietetic counseling, oral supplements, artificial nutrition), depending on the clinical situation. When artificial nutrition is recommended, enteral nutrition (nasogastric tube, gastrostomy or jejunostomy) should be preferred. When enteral nutrition is impossible or insufficient, parenteral nutrition could be necessary. For patients with advanced esophagogastric cancers, digestive prostheses and decompressive radiation therapy may have a symptomatic benefit on dysphagia. Adapted physical activity is also recommended at all stages of cancer care and ongoing clinical trials will help to specify its modalities and to optimize its place in the therapeutic strategy. Finally, psychosocial support could be useful. A combined approach of these different interventions on the nutritional, physical and psychological aspects is beneficial for patients with esophagogastric cancers. This multimodal and multidisciplinary approach applies to both the early stages of the disease, with prehabilitation and/or rehabilitation to reduce perioperative morbidity and mortality and the advanced stages, with a benefit on survival and quality of life, in parallel with anti-tumor treatments.

Oncological surgery follow-up and quality of life: meta-analysis

BACKGROUND

Previous trials found that more intensive postoperative surveillance schedules did not improve survival. Oncological follow-up also provides an opportunity to address psychological issues (for example anxiety, depression, and fear of recurrence). This systematic review assessed the impact of a less intensive surveillance strategy on health-related quality of life (HRQoL), emotional well-being, and patient satisfaction.

METHODS

A systematic search was conducted in PubMed/MEDLINE, Embase, Web of Science, Cochrane database, PsycINFO, and Google Scholar to identify studies comparing different follow-up strategies after oncological surgery and their effect on HRQoL and patient satisfaction, published before 4 May 2022. A meta-analysis was conducted on the most relevant European Organisation for Research and Treatment of Cancer QLQ-C30 and Hospital Anxiety and Depression Scale subscales.

RESULTS

Thirty-five studies were identified, focusing on melanoma (4), colorectal (10), breast (7), prostate (4), upper gastrointestinal (4), gynaecological (3), lung (2), and head and neck (1) cancers. Twenty-two studies were considered to have a low risk of bias, of which 14 showed no significant difference in HRQoL between follow-up approaches. Five studies with a low risk of bias showed improved HRQoL or emotional well-being with a less intensive follow-up approach and three with an intensive approach. Meta-analysis of HRQoL outcomes revealed no negative effects for patients receiving less intensive follow-up.

CONCLUSION

Low-intensity follow-up does not diminish HRQoL, emotional well-being, or patient satisfaction.

Follow-up strategy and survival for five common cancers: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the effectiveness of intensive follow-up after curative intent treatment for five common solid tumours, in terms of survival and treatment of recurrences.

METHODS

A systematic literature search was conducted, identifying comparative studies on follow-up for colorectal, lung, breast, upper gastro-intestinal and prostate cancer. Outcomes of interest were overall survival (OS), cancer specific survival (CSS), and treatment of recurrences. Random effects meta-analyses were conducted, with particular focus on studies at low risk of bias.

RESULTS

Fourteen out of 63 studies were considered to be at low risk of bias (8 colorectal, 4 breast, 0 lung, 1 upper gastro-intestinal, 1 prostate). These studies showed no significant impact of intensive follow-up on OS (hazard ratio, 95% confidence interval) for colorectal (0.99; 0.92-1.06), breast 1.06 (0.92-1.23), upper gastro-intestinal (0.78; 0.51-1.19) and prostate cancer (1.00; 0.86-1.16). No impact on CSS (hazard ratio, 95% confidence interval) was found for colorectal cancer (0.94; 0.77-1.16). CSS was not reported for other cancer types. Intensive follow-up increased the rate of curative treatment (relative risk; 95% confidence interval) for colorectal cancer recurrences (1.30; 1.05-1.61), but not for upper gastro-intestinal cancer recurrences (0.92; 0.47-1.81). For the other cancer types, no data on treatment of recurrences was available in low risk studies.

CONCLUSION

For colorectal and breast cancer, high quality studies do not suggest an impact of intensive follow-up strategies on survival. Colorectal cancer recurrences are more often treated locally after intensive follow-up. For other cancer types evaluated, limited high quality research on follow-up is available.

Risk Stratification and Cancer Follow-Up: Towards More Personalized Post-Treatment Care in Canada

After treatment, cancer survivors require ongoing, comprehensive care to improve quality of life, reduce disability, limit complications, and restore function. In Canada and internationally, follow-up care continues to be delivered most often by oncologists in institution-based settings. There is extensive evidence to demonstrate that this model of care does not work well for many survivors or our cancer systems. Randomized controlled trials have clearly demonstrated that alternate approaches to follow-up care are equivalent to oncologist-led follow-up in terms of patient outcomes, such as recurrence, survival, and quality of life in a number of common cancers. In this paper, we discuss the state of follow-up care for survivors of prevalent cancers and the need for more personalized models of follow-up. Indeed, there is no one-size-fits-all solution to post-treatment follow-up care, and more personalized approaches to follow-up that are based on individual risks and needs after cancer treatment are warranted. Canada lags behind when it comes to personalizing follow-up care for cancer survivors. There are many reasons for this, including difficulty in determining who is best served by different follow-up pathways, a paucity of evidence-informed self-management education and supports for most survivors, poorly developed IT solutions and systems, and uneven coordination of care. Using implementation science theories, approaches, and methods may help in addressing these challenges and delineating what might work best in particular settings and circumstances.

The effectiveness of telephone and Internet-based supportive care for patients with esophageal cancer on enhanced recovery after surgery in China: A randomized controlled trial

Objective

The aim of this study was to establish a nurse-led supportive care program based on telephone and Internet support and evaluate its efficacy in comparison with conventional care on enhanced recovery after surgery.

Methods

The study was designed as an open-label, randomized controlled trial to value the efficacy of a nurse-led supportive care program in comparison with conventional care. A convenience sampling method was employed to recruit patients with esophageal cancer in a tertiary Grade A cancer center in Beijing from November 2018 to January 2019. Patients were assigned randomly (1:1) to one of the two groups (intervention group vs control group) via a web randomization system. The control group received conventional care. Patients from the intervention group received conventional care and one-on-one phone calls from nurses following their discharge assessments and education about nutrition and symptoms. Nurses also set up a WeChat group, which they invited patients to join in before discharge for better communication during follow-up. Statistical testing, including nutritional status, quality of life, the helpfulness of the follow-up service, and the patients’ satisfaction with their care, was conducted 6 months after discharge to assess for differences between the two groups. The independent sample t, chi-squared, and Mann–Whitney tests were used to compare between the experiences of the intervention and control groups. The Spearman correlation analysis was used for the analysis of correlation of the nutritional index and quality of life.

Results

Finally, 168 patients were included in the study, with 86 patients in the intervention group and 82 in the control group. Significant differences between the intervention and control groups were found in the nutrition risk screening 2002 and simple diet self-assessment tool scores. The changes in blood albumin, prealbumin, and transferrin were also statistically significant. All (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) QLQ-C30 results of the intervention group were better than those of the control group. A significant positive correlation of the simple diet self-assessment tool (the higher, the better) and the scores for total health/quality of life were detected (r ​= ​0.214, P ​= ​0.005). A significant negative correlation of the nutrition risk screening 2002 (the lower, the better) and the scores of total health/quality of life was detected (r ​= ​−0.446, P ​= ​0.000). The patients’ scores on the helpfulness of the follow-up service and their satisfaction with it were both significantly higher in the intervention group than in the control group.

Conclusions

This study highlighted the important role of nurse-led supportive care based on telephone and Internet-based support for patients after enhanced recovery after surgery. The supportive care improved patients’ nutritional status, elevated their quality of life, and improved their satisfaction with the care provided to them.

Early experience with a nutrition and survivorship clinic in esophageal cancer

Improved cure rates in esophageal cancer care have increased focus on health-related quality of life (HRQL) in survivorship. To optimize recovery after esophagectomy, particularly nutritional well-being, a personalized multidisciplinary survivorship clinic was established at this center. Assessments at 6 and 12 months postoperatively include validated European Organization for the Research and Treatment of Cancer (EORTC) symptom and health-related quality of life (HRQL) questionnaires, functional status review, anthropometry, and biochemical screening for micronutrient deficiencies. 75 patients, at a mean age of 63 years, 84% male, 85% with adenocarcinoma, and 73% receiving multimodal therapy were included. Mean preoperative body mass index (BMI) was 27.5 (4.3) kg m -2. 6- and 12-month assessments were completed by 66 (88%) and 37 (93%) recurrence-free patients, respectively. Mean body weight loss at 6 months was 8.5 ± 6.6% and at 12 months 8.8 ± 7.3%. Of the 12-month cohort, micronutrient deficiency was present in 27 (79.4%) preoperatively and 29 (80.6%) after 1 year (P = 0.727), most commonly iron deficiency (preoperative: 16 [43.2%] and postoperative: 17 [45.9%] patients, P = 0.100). 26 (70.3%) of these patients also had clinically significant dumping syndrome persisting to 12 months after surgery. We describe a novel follow-up support structure for esophageal cancer patients in the first year of survivorship. This may serve as an exemplar model with parallel application across oncological care.

Design of the PROstate cancer follow-up care in Secondary and Primary hEalth Care study (PROSPEC): a randomized controlled trial to evaluate the effectiveness of primary care-based follow-up of localized prostate cancer survivors

BACKGROUND

In its 2006 report, From cancer patient to cancer survivor: lost in transition, the U.S. Institute of Medicine raised the need for a more coordinated and comprehensive care model for cancer survivors. Given the ever increasing number of cancer survivors, in general, and prostate cancer survivors, in particular, there is a need for a more sustainable model of follow-up care. Currently, patients who have completed primary treatment for localized prostate cancer are often included in a specialist-based follow-up care program. General practitioners already play a key role in providing continuous and comprehensive health care. Studies in breast and colorectal cancer suggest that general practitioners could also consider to provide survivorship care in prostate cancer. However, empirical data are needed to determine whether follow-up care of localized prostate cancer survivors by the general practitioner is a feasible alternative.

METHODS

This multicenter, randomized, non-inferiority study will compare specialist-based (usual care) versus general practitioner-based (intervention) follow-up care of prostate cancer survivors who have completed primary treatment (prostatectomy or radiotherapy) for localized prostate cancer. Patients are being recruited from hospitals in the Netherlands, and randomly (1:1) allocated to specialist-based (N = 195) or general practitioner-based (N = 195) follow-up care. This trial will evaluate the effectiveness of primary care-based follow-up, in comparison to usual care, in terms of adherence to the prostate cancer surveillance guideline for the timing and frequency of prostate-specific antigen assessments, the time from a biochemical recurrence to retreatment decision-making, the management of treatment-related side effects, health-related quality of life, prostate cancer-related anxiety, continuity of care, and cost-effectiveness. The outcome measures will be assessed at randomization (≤6 months after treatment), and 12, 18, and 24 months after treatment.

DISCUSSION

This multicenter, prospective, randomized study will provide empirical evidence regarding the (cost-) effectiveness of specialist-based follow-up care compared to general practitioner-based follow-up care for localized prostate cancer survivors.

TRIAL REGISTRATION

Netherlands Trial Registry, Trial NL7068 (NTR7266). Prospectively registered on 11 June 2018.

Follow-up strategies following completion of primary cancer treatment in adult cancer survivors

BACKGROUND

Most cancer survivors receive follow-up care after completion of treatment with the primary aim of detecting recurrence. Traditional follow-up consisting of fixed visits to a cancer specialist for examinations and tests are expensive and may be burdensome for the patient. Follow-up strategies involving non-specialist care providers, different intensity of procedures, or addition of survivorship care packages have been developed and tested, however their effectiveness remains unclear.

OBJECTIVES

The objective of this review is to compare the effect of different follow-up strategies in adult cancer survivors, following completion of primary cancer treatment, on the primary outcomes of overall survival and time to detection of recurrence. Secondary outcomes are health-related quality of life, anxiety (including fear of recurrence), depression and cost.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases and two trials registries on 11 December 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised trials comparing different follow-up strategies for adult cancer survivors following completion of curatively-intended primary cancer treatment, which included at least one of the outcomes listed above. We compared the effectiveness of: 1) non-specialist-led follow-up (i.e. general practitioner (GP)-led, nurse-led, patient-initiated or shared care) versus specialist-led follow-up; 2) less intensive versus more intensive follow-up (based on clinical visits, examinations and diagnostic procedures) and 3) follow-up integrating additional care components relevant for detection of recurrence (e.g. patient symptom education or monitoring, or survivorship care plans) versus usual care.

DATA COLLECTION AND ANALYSIS

We used the standard methodological guidelines by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC). We assessed the certainty of the evidence using the GRADE approach. For each comparison, we present synthesised findings for overall survival and time to detection of recurrence as hazard ratios (HR) and for health-related quality of life, anxiety and depression as mean differences (MD), with 95% confidence intervals (CI). When meta-analysis was not possible, we reported the results from individual studies. For survival and recurrence, we used meta-regression analysis where possible to investigate whether the effects varied with regards to cancer site, publication year and study quality.

MAIN RESULTS

We included 53 trials involving 20,832 participants across 12 cancer sites and 15 countries, mainly in Europe, North America and Australia. All the studies were carried out in either a hospital or general practice setting. Seventeen studies compared non-specialist-led follow-up with specialist-led follow-up, 24 studies compared intensity of follow-up and 12 studies compared patient symptom education or monitoring, or survivorship care plans with usual care. Risk of bias was generally low or unclear in most of the studies, with a higher risk of bias in the smaller trials. Non-specialist-led follow-up compared with specialist-led follow-up It is uncertain how this strategy affects overall survival (HR 1.21, 95% CI 0.68 to 2.15; 2 studies; 603 participants), time to detection of recurrence (4 studies, 1691 participants) or cost (8 studies, 1756 participants) because the certainty of the evidence is very low. Non-specialist- versus specialist-led follow up may make little or no difference to health-related quality of life at 12 months (MD 1.06, 95% CI -1.83 to 3.95; 4 studies; 605 participants; low-certainty evidence); and probably makes little or no difference to anxiety at 12 months (MD -0.03, 95% CI -0.73 to 0.67; 5 studies; 1266 participants; moderate-certainty evidence). We are more certain that it has little or no effect on depression at 12 months (MD 0.03, 95% CI -0.35 to 0.42; 5 studies; 1266 participants; high-certainty evidence). Less intensive follow-up compared with more intensive follow-up Less intensive versus more intensive follow-up may make little or no difference to overall survival (HR 1.05, 95% CI 0.96 to 1.14; 13 studies; 10,726 participants; low-certainty evidence) and probably increases time to detection of recurrence (HR 0.85, 95% CI 0.79 to 0.92; 12 studies; 11,276 participants; moderate-certainty evidence). Meta-regression analysis showed little or no difference in the intervention effects by cancer site, publication year or study quality. It is uncertain whether this strategy has an effect on health-related quality of life (3 studies, 2742 participants), anxiety (1 study, 180 participants) or cost (6 studies, 1412 participants) because the certainty of evidence is very low. None of the studies reported on depression. Follow-up strategies integrating additional patient symptom education or monitoring, or survivorship care plans compared with usual care: None of the studies reported on overall survival or time to detection of recurrence. It is uncertain whether this strategy makes a difference to health-related quality of life (12 studies, 2846 participants), anxiety (1 study, 470 participants), depression (8 studies, 2351 participants) or cost (1 studies, 408 participants), as the certainty of evidence is very low.

AUTHORS' CONCLUSIONS

Evidence regarding the effectiveness of the different follow-up strategies varies substantially. Less intensive follow-up may make little or no difference to overall survival but probably delays detection of recurrence. However, as we did not analyse the two outcomes together, we cannot make direct conclusions about the effect of interventions on survival after detection of recurrence. The effects of non-specialist-led follow-up on survival and detection of recurrence, and how intensity of follow-up affects health-related quality of life, anxiety and depression, are uncertain. There was little evidence for the effects of follow-up integrating additional patient symptom education/monitoring and survivorship care plans.

Advanced Practice Providers and Survivorship Care: They Can Deliver

INTRODUCTION

As the number of cancer survivors grows, new models of survivorship care are being implemented, but there is limited evaluation to date. This retrospective review assesses the concordance of care provided to adult-onset cancer survivors by advanced practice providers (nurse practitioners and physician assistants) with Institute of Medicine guidelines for survivorship care.

METHODS

Records from three survivorship clinics at a single institution were reviewed for frequency of recurrence surveillance, screening for second cancers, symptom management (physical, psychological), health promotion education (alcohol, tobacco, cholesterol, and bone density screenings; diet/exercise discussion), care coordination, and provision of care plan. Data were characterized using descriptive statistics.

RESULTS

Over 2 years, 9,052 unique survivorship visits occurred; 210 breast, 208 prostate, and 204 colorectal visits were randomly selected for review. All patients with breast cancer underwent surveillance for recurrence; 99% were screened for new cancers. Discussion of health promotion activities ranged from 83% to 100%; 91% of patients were reviewed for physical symptoms, and 93% were reviewed for psychological symptoms. All patients with prostate cancer underwent recurrence surveillance; 97% were screened for new primaries. Health promotion activities ranged from 70% to 97%, and symptoms were discussed in 89% of visits. All patients with colorectal cancer underwent a surveillance colonoscopy for recurrence; 97% had a carcinoembryonic antigen test. Among women, 97% had mammograms, and 96% had a Papanicolaou test; 83% of men had a prostate-specific antigen test. Health promotion activities ranged from 69% to 100%, and symptoms were discussed in 93% to 97% of visits.

CONCLUSIONS

Findings suggest that advanced practice providers can provide survivorship care in accordance with Institute of Medicine standards, which provide a normative standard. This assessment is an important step in evaluating survivorship outcomes.

Long-Term Survivorship Care After Cancer Treatment - Summary of a 2017 National Cancer Policy Forum Workshop

The National Cancer Policy Forum of the National Academies of Sciences, Engineering and Medicine sponsored a workshop on July 24 and 25, 2017 on Long-Term Survivorship after Cancer Treatment. The workshop brought together diverse stakeholders (patients, advocates, academicians, clinicians, research funders, and policymakers) to review progress and ongoing challenges since the Institute of Medicine (IOM)'s seminal report on the subject of adult cancer survivors published in 2006. This commentary profiles the content of the meeting sessions and concludes with recommendations that stem from the workshop discussions. Although there has been progress over the past decade, many of the recommendations from the 2006 report have not been fully implemented. Obstacles related to the routine delivery of standardized physical and psychosocial care services to cancer survivors are substantial, with important gaps in care for patients and caregivers. Innovative care models for cancer survivors have emerged, and changes in accreditation requirements such as the Commission on Cancer's (CoC) requirement for survivorship care planning have put cancer survivorship on the radar. The Center for Medicare & Medicaid Innovation's Oncology Care Model (OCM), which requires psychosocial services and the creation of survivorship care plans for its beneficiary participants, has placed increased emphasis on this service. The OCM, in conjunction with the CoC requirement, is encouraging electronic health record vendors to incorporate survivorship care planning functionality into updated versions of their products. As new models of care emerge, coordination and communication among survivors and their clinicians will be required to implement patient- and community-centered strategies.

Nurse-led interventions on quality of life for patients with cancer: A meta-analysis

BACKGROUND

To compare the quality of life outcome between nurse-led and non-nurse-led interventions for patients with cancer using a meta-analysis.

METHODS

A systematic literature review was performed by searching randomized controlled trials about nurse-led interventions in PubMed, EMBASE, and Cochrane Library databases until June 2017. Pooled summary estimates for quality of life outcome was calculated as standardized mean difference (SMD) either on a fixed- or random-effect model via Stata 13.0 software.

RESULTS

Seven literatures involving 1110 patients (554 in the nurse-led group and 556 in the control group) were included. Pooled analysis showed there were no differences in the global quality of life, cognitive, emotional, role, social and physical functions, appetite loss, diarrhea, and dyspnea scales of Quality of Life Questionnaire C30 version 3.0 core (QLQ-C30) questionnaires between the nurse-led and control groups. However, the nurse-led management program significantly decreased the occurrence of constipation (SMD = -0.36, 95% CI = -0.71 to -0.00; P = .001) and insomnia (SMD = -0.33, 95% CI = -0.99 to 0.32; P = .011) and reduced the financial difficulty (SMD = -0.34, 95% CI = -0.65 to -0.03; P = .033) for patients with cancer.

CONCLUSION

The nurse-led disease management strategy seemed to be effective to improve constipation, insomnia, and financial impacts for patients with cancer in quality of life assessment.

The costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs: A systematic review of international evidence

BACKGROUND

Patients with palliative care needs do not access specialist palliative care services according to their needs. Clinical Nurse Specialists working across a variety of fields are playing an increasingly important role in the care of such patients, but there is limited knowledge of the extent to which their interventions are cost-effective.

OBJECTIVES

To present results from a systematic review of the international evidence on the costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs, defined as seriously ill patients and those with advanced disease or frailty who are unlikely to be cured, recover or stabilize.

DESIGN

Systematic review following PRISMA methodology.

DATA SOURCES

Medline, Embase, CINAHL and Cochrane Library up to 2015. Studies focusing on the outcomes of Clinical Nurse Specialist interventions for patients with palliative care needs, and including at least one economic outcome, were considered. The quality of studies was assessed using tools from the Joanna Briggs Institute.

RESULTS

A total of 79 papers were included: 37 randomized controlled trials, 22 quasi-experimental studies, 7 service evaluations and other studies, and 13 economic analyses. The studies included a wide variety of interventions including clinical, support and education, as well as care coordination activities. The quality of the studies varied greatly.

CONCLUSION

Clinical Nurse Specialist interventions may be effective in reducing specific resource use such as hospitalizations/re-hospitalizations/admissions, length of stay and health care costs. There is mixed evidence regarding their cost-effectiveness. Future studies should ensure that Clinical Nurse Specialists' roles and activities are clearly described and evaluated.

Evaluation of a specialized oncology nursing supportive care intervention in newly diagnosed breast and colorectal cancer patients following surgery: a cluster randomized trial

BACKGROUND

Better coordination of supportive services during the early phases of cancer care has been proposed to improve the care experience of patients. We conducted a randomized trial to test a community-based nurse-led coordination of care intervention in cancer patients.

METHODS

Surgical practices were cluster randomized to a control group involving usual care practices or a standardized nursing intervention consisting of an in-person supportive care assessment with ongoing support to meet identified needs, including linkage to community services. Newly diagnosed breast and colorectal cancer patients within 7 days of cancer surgery were eligible. The primary outcome was the patient-reported outcome (PRO) of continuity of care (CCCQ) measured at 3 weeks. Secondary outcomes included unmet supportive care needs (SCNS), quality of life (EORTC QLQ-C30), health resource utilization, and level of uncertainty with care trajectory (MUIS) at 3 and/or 8 weeks.

RESULTS

A total of 121 breast and 72 colorectal patients were randomized through 28 surgical practices. There was a small improvement in the informational domain of continuity of care (difference 0.29 p = 0.05) and a trend to less emergency room use (15.8 vs 7.1%) (p = 0.07). There were no significant differences between groups on unmet need, quality of life, or uncertainty.

CONCLUSION

We did not find substantial gaps in the PROs measured immediately following surgery for breast and colorectal cancer patients. The results of this study support a more targeted approach based on need and inform future research focused on improving navigation during the initial phases of cancer treatment. ClinicalTrials.gov Identifier: NCT00182234. SONICS-Effectiveness of Specialist Oncology Nursing.

Oesophageal cancer

Oesophageal cancer is the sixth most common cause of cancer-related death worldwide and is therefore a major global health challenge. The two major subtypes of oesophageal cancer are oesophageal squamous cell carcinoma (OSCC) and oesophageal adenocarcinoma (OAC), which are epidemiologically and biologically distinct. OSCC accounts for 90% of all cases of oesophageal cancer globally and is highly prevalent in the East, East Africa and South America. OAC is more common in developed countries than in developing countries. Preneoplastic lesions are identifiable for both OSCC and OAC; these are frequently amenable to endoscopic ablative therapies. Most patients with oesophageal cancer require extensive treatment, including chemotherapy, chemoradiotherapy and/or surgical resection. Patients with advanced or metastatic oesophageal cancer are treated with palliative chemotherapy; those who are human epidermal growth factor receptor 2 (HER2)-positive may also benefit from trastuzumab treatment. Immuno-oncology therapies have also shown promising early results in OSCC and OAC. In this Primer, we review state-of-the-art knowledge on the biology and treatment of oesophageal cancer, including screening, endoscopic ablative therapies and emerging molecular targets, and we discuss best practices in chemotherapy, chemoradiotherapy, surgery and the maintenance of patient quality of life.

Toward improved survivorship: supportive care needs of esophageal cancer patients, a literature review

The growing prevalence of esophageal cancer survivors represent a population typified by an extensive treatment regime, significant postsurgical long-term effects, and a dismal prognosis. Despite this, little is known of the supportive care needs of this patient group and the extent to which these are being met in practice. This review provides a synthesis of the research evidence to date; emphasizing opportunities for clinical application and setting a future agenda with research priorities. A literature search was performed using Medline/Embase, PsycINFO, and Web of Science. Search headings used included; [esophagus] or [esopohageal] or [upper gastrointestinal] or [upper GI] AND [cancer] or [carcinoma] or [squamous cell] AND [supportive care] or [survivorship] or [psychological] or [emotional] or [information] or [social] or [communication] or [spiritual] or [health-related-quality-of-life] or [HRQL] or [qualitative] or [patient narrative] or [clinical nurse specialist] or [CNS]. Related articles in English were reviewed, with additional articles harvested from reference sections. Esophageal cancer survivors report significant late-term effects posttreatment, encompassing sustained impairment in most areas of health-related quality of life. With a necessitated change in eating behavior, survivors find it particularly challenging to adjust to a new social identity and as a cancer population report high levels of psychological morbidity. Although the determinants of psychological morbidity are largely unknown, illness representations may be a key contributor. Several multidisciplinary supportive care interventions have been developed with promising results. The research summarized in this paper provides valuable insight into the psychosocial well-being of the esophageal cancer survivor. However, knowledge gaps remain, alongside a dearth of applied examples in meeting supportive care need.

The effect of a nurse led telephone supportive care programme on patients' quality of life, received information and health care contacts after oesophageal cancer surgery-A six month RCT-follow-up study

BACKGROUND

Following oesophagectomy, a major surgical procedure, it is known that patients suffer from severely reduced quality of life and have an unmet need for postoperative support. Still, there is a lack of research testing interventions aiming to enhance the patients' life situation after this surgical procedure.

AIM

The aim of the study was to evaluate the effect of a nurse led telephone supportive care programme on quality of life (QOL), received information and the number of healthcare contacts compared to conventional care following oesophageal resection for cancer.

METHOD

The study was designed as a randomized controlled trial (RCT) aiming to test the effect of a nurse led telephone supportive care program compared to conventional care. Patient assessments were conducted at discharge, 2 weeks, 2, 4 and 6 months after discharge and comprised evaluation of QOL, received information and the number of health care contacts. Statistical testing were conducted with repeated measurements analysis of variance to test if there were differences between the groups during follow-up.

RESULT

The results show that the intervention group was significantly more satisfied with received information for items concerning the information they received about things to do to help yourself, written information and for the global information score. The control group scored significantly higher on the item regarding wishing to receive more information and wish to receive less information. No effect of the intervention was shown on QOL or number of health care contacts.

CONCLUSION

Proactive nurse-led telephone follow-up has a significant positive impact on the patients' experience of received information. This is likely to have a positive effect on their ability to cope with a life that may include remaining side effects and adverse symptoms for a long time after surgery.

Economic evaluations of follow-up strategies for cancer survivors: a systematic review and quality appraisal of the literature

The aim of this study was to review and critically assess the health economics literature on post-treatment follow-up for adult cancer survivors. A systematic search was performed using PubMed, EMBASE and the Cochrane Library. The Consolidated Health Economic Evaluation Reporting Standards checklist was adopted to assess the quality of the included studies. Thirty-nine articles met the eligibility criteria. Around two thirds of the studies addressed the most common cancers (i.e., breast, colorectal, cervical and lung); 21 were based on a single clinical study, while the rest were modeling papers. All types of economic evaluations were represented other than cost-benefit analysis. The overall quality was generally high with an average proportion of 74% of checklist criteria fulfilled. The cost-effectiveness results supported the current trend towards less intensive, primary care-based and risk-adapted follow-up schemes.

Remote surveillance after colorectal cancer surgery: an effective alternative to standard clinic-based follow-up

AIM

Most colorectal cancer recurrences are asymptomatic and are detected through routine postoperative clinic surveillance programmes with associated investigations. However, attendance at these clinics has a financial cost and may be associated with an increase in patient anxiety and dissatisfaction. The results of a remote follow-up system developed for selected patients are reported.

METHOD

A remote surveillance programme has been in place in our institution for over 9 years. Patients having elective and emergency treatment for colorectal cancer were enrolled. The timeliness of the investigation, detection of local recurrence and distant metastases and overall 5-year survival rates were determined. A cost review and patient satisfaction survey were performed.

RESULTS

The programme was suitable for over 900 patients who had received surgery for colorectal cancer between 2004 and 2012, representing some 50% of the total number of patients treated in this period. Of these, 811 (90%) had investigations carried out on time. Five-year survival rates were comparable with national data. Cost-minimization analysis demonstrated a financial saving of 63% and a 75% reduction in clinic appointments. High levels of overall patient satisfaction (97%) were noted with the programme.

CONCLUSION

A remote surveillance system after colorectal cancer surgery is a safe and cost-effective alternative to traditional clinic-based follow up and has high patient satisfaction.

A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial

PURPOSE

Prevailing wisdom suggests that implementation of a survivorship care plan (SCP) will address deficits in survivorship care planning and delivery for cancer patients. Here, we present 24-month results of a randomized clinical trial on health service and patient-reported outcomes among breast cancer patients transferred to their primary care physician for follow-up care. The 24-month assessments represent the long-term benefit and sustainability of the implantation of a SCP.

METHODS

In all, 408 patients with early-stage breast cancer were randomized to the SCP or control group. Patient self-completed questionnaires, supplemented with telephone interviews, during the 24-month study period assessed health service and patient-reported outcomes. The primary outcome was cancer-specific distress. Secondary outcomes included health-related quality of life, patient satisfaction, continuity and coordination of care, and health service outcomes such as adherence to guidelines.

RESULTS

Over the course of 24 months, there were no differences between both groups in health service and patient-reported outcomes. Women from Quebec compared to those from Western Canada (p < 0.001), women within 2 years of completion of primary treatment compared to a longer period (p = 0.013), and those with a higher SF-36 mental component score compared to a lower score (p = 0.044) were positively associated with adherence to guidelines.

CONCLUSION

The implementation of a SCP in the transition of survivorship care from cancer center to primary care did not contribute to improved health service or patient-reported outcomes in this study population. Therefore, additional research is needed before widespread implementation of a SCP in clinical practice.

IMPLICATIONS OF CANCER SURVIVORS

The transition of survivorship care from cancer center to the primary care setting showed no negative effect on health service and patient-reported outcomes.

Costs and effects of new professional roles: Evidence from a literature review

One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.

Patterns of surveillance following curative intent therapy for gastroesophageal cancer

PURPOSE

Our aims were to examine surveillance strategies after curative treatment of early gastroesophageal (GE) cancer and to evaluate the impact of different approaches on outcomes.

METHODS

A total of 292 patients with non-metastatic GE cancer who were referred to the BC Cancer Agency from 2001 to 2010 for curative intent treatment were analyzed. Surveillance practices were classified into the following: cohort 1 (discharge to general practitioner), cohort 2 (follow-up by oncologist with clinical assessments), cohort 3 (specialist follow-up with laboratory investigations), and cohort 4 (specialist follow-up with imaging or endoscopy). Outcomes were compared across cohorts using Kaplan-Meier methods and Cox regression.

RESULTS

In total, median age was 63 years and 76 % were men. Eighty-nine (30%), 18 (6%), 32 (11%), and 152 (53%) patients were classified into cohorts 1 to 4, respectively. Patients with primary lesions involving the distal esophagus were more likely to undergo intensive surveillance which involved imaging studies and endoscopic procedures (p = 0.001). Individuals affected by specific histological subtypes, such as squamous cell carcinoma and the signet cell variant, and those whose disease were managed with definitive chemoradiotherapy without surgery were also more inclined to receive intensive follow-up (p = 0.008 and p = 0.001, respectively) There were no significant differences in overall (p = 0.34) or relapse-free survival (p = 0.59) among the different surveillance strategies, even after adjusting for measured prognostic factors.

CONCLUSION

In this population-based analysis, outcomes of GE cancer were comparable irrespective of surveillance strategy. Intensive follow-up with routine imaging and endoscopy may not be justified given the financial implications of these costly investigations.

Quality of life measurements as an indicator for timing of support after oesophagectomy for cancer: a prospective study

Background

Oesophagectomy is a major procedure with known side effects and reduced postoperative quality of life (QOL). It has been shown that support of patients in their new life situation is often lacking. Knowledge about how QOL changes over time is fundamental for addressing patient needs and for determining the optimal timing of supportive care. The aim of this study was to identify QOL changes over time as well as factors that may impact patient QOL during the first year after oesophagectomy for cancer.

Methods

Patients operated on for adenocarcinoma or squamous cell cancer of the oesophagus were included in this study. Seventy-nine patients completed the European Organisation for Research and Treatment of Cancer QOL questionnaires (QLQ-C30 and QLQ-OES18) before and 2, 4, 6, 9, and 12 months after surgery. A general linear model with repeated measurement analysis of variance was used for statistical testing.

Results

There was a significant QOL nadir at 2 months compared to 12 months after surgery (QLQ-C30 function scales p < 0.001, symptom scales p < 0.001, QLQ-OES18 scales p < 0.001). Treatment with proton-pump inhibitors was associated with enhanced QOL according to QLQ-C30 symptom scales (p = 0.003) and OES-18 scales (p = 0.015), but age, gender and American Society of Anaesthesiologists classification did not significantly impact QOL.

Conclusions

Patient QOL is severely hampered the first year after oesophagectomy for cancer, with a nadir at 2 months after surgery. Treatment with proton-pump inhibitors improved patient responses to symptom scales. Evidence of severely affected QOL after surgery indicates that these patients need support at an early stage after surgery. These results can be used by healthcare professionals to develop a postoperative supportive-care programme that is timed and better optimised to meet patient needs. Trial registration: EudraCT database 2009-009997-28.

Nursing interventions after radical gastrectomy

AIM: To investigate the clinical effects of nursing interventions after radical gastronomy.

METHODS: Ninety patients treated at Shaoxing People's Hospital from June 2013 to June 2014 were divided into either an intervention group or a control group. The control group received routine nursing, while the intervention group received targeted nursing interventions on the basis of routine nursing. Clinical effects were compared for the two groups.

RESULTS: The times to first flatus, defecation, return of bowel sounds time, and meal were significantly shorter in the intervention group than in the control group (P < 0.05). The incidence of postoperative complications was significantly lower in the intervention group than in the control group (6.7% vs 20.0%, P < 0.05).

CONCLUSION: Targeted nursing interventions after radical gastrectomy can improve gastrointestinal function and reduce postoperative complications.

Nurse-led follow-up at home vs. conventional medical outpatient clinic follow-up in patients with incurable upper gastrointestinal cancer: a randomized study

CONTEXT

Upper gastrointestinal cancer is associated with a poor prognosis. The multidimensional problems of incurable patients require close monitoring and frequent support, which cannot sufficiently be provided during conventional one to two month follow-up visits to the outpatient clinic.

OBJECTIVES

To compare nurse-led follow-up at home with conventional medical follow-up in the outpatient clinic for patients with incurable primary or recurrent esophageal, pancreatic, or hepatobiliary cancer.

METHODS

Patients were randomized to nurse-led follow-up at home or conventional medical follow-up in the outpatient clinic. Outcome parameters were quality of life (QoL), patient satisfaction, and health care consumption, measured by different questionnaires at one and a half and four months after randomization. As well, cost analyses were done for both follow-up strategies in the first four months.

RESULTS

In total, 138 patients were randomized, of which 66 (48%) were evaluable. At baseline, both groups were similar with respect to clinical and sociodemographic characteristics and health-related QoL. Patients in the nurse-led follow-up group were significantly more satisfied with the visits, whereas QoL and health care consumption within the first four months were comparable between the two groups. Nurse-led follow-up was less expensive than conventional medical follow-up. However, the total costs for the first four months of follow-up in this study were higher in the nurse-led follow-up group because of a higher frequency of visits.

CONCLUSION

The results suggest that conventional medical follow-up is interchangeable with nurse-led follow-up. A cost utility study is necessary to determine the preferred frequency and duration of the home visits.

Risk-based health care, the cancer survivor, the oncologist, and the primary care physician

Cancer survivors face substantial risks for morbidity, reduced quality of life, and premature mortality related to the cancer itself and/or the interventions undertaken to control cancer. Risk-based care that involves a personalized systematic plan of periodic screening, surveillance, and prevention relevant to the cancer experience is recommended to address the comprehensive health needs of the growing population of cancer survivors. Risk-based care and coordination between oncology and primary care providers have been identified as important metrics of quality cancer survivorship care. Various models of survivorship care, treatment summaries, and survivorship care plans have been promoted as methods to facilitate communication among providers across care transitions and improve survivor access to quality survivorship care. However, research supporting the feasibility of implementing these practices and their effectiveness in enhancing health outcomes is limited. This article reviews key concepts underpinning clinical and research initiatives endeavoring to improve access to quality care among long-term survivors and summarizes results of intervention studies implementing these elements in transitioning survivors from oncology to primary care providers for long-term follow-up care.

Patterns of symptoms following surgery for esophageal cancer

PURPOSE/OBJECTIVE

To explore patterns of symptoms before and after surgery for cancer of the esophagus.

DESIGN

Longitudinal, descriptive study.

SETTING

An urban comprehensive cancer center in the northeastern United States.

SAMPLE

218 patients with cancer of the esophagus undergoing esophagectomy.

METHODS

Symptoms were assessed by self-report before surgery, at the first postoperative visit, and at 6 and 12 months postsurgery.

MAIN RESEARCH VARIABLES

Symptoms and demographic and clinical variables, including stage, treatment, gender, and comorbidities.

FINDINGS

Patients with esophageal cancer reported numerous symptoms before and after esophagectomy. Several patterns of symptoms were identified. General cancer symptoms (e.g., pain, cough, shortness of breath, weight loss) were reported as worse after surgery but recovered to baseline by one year. A second pattern of esophageal-specific symptoms (feeling full too quickly, feeling bloated, nausea, and diarrhea) worsened after surgery and did not recover to baseline by one year. Reflux was the only symptom that did not worsen after surgery but did worsen significantly during the first year of recovery.

CONCLUSIONS

Patients with esophageal cancer experienced multiple prolonged symptoms following surgical treatment for their disease. General cancer symptoms resolved by one year post-treatment, whereas esophageal-specific symptoms worsened after surgery and did not recover to baseline.

IMPLICATIONS FOR NURSING

Identification of symptom patterns preoperatively and during recovery can assist nurses in developing intervention protocols to minimize long-term complications for patients with esophageal cancer.

KNOWLEDGE TRANSLATION

Patients with esophageal cancer are at risk for multiple prolonged symptoms following surgery. Symptom assessment should occur often after surgery and include a broad range of symptoms.

Recent developments in esophageal adenocarcinoma

Answer questions and earn CME/CNE Esophageal adenocarcinoma (EAC) is characterized by 6 striking features: increasing incidence, male predominance, lack of preventive measures, opportunities for early detection, demanding surgical therapy and care, and poor prognosis. Reasons for its rapidly increasing incidence include the rising prevalence of gastroesophageal reflux and obesity, combined with the decreasing prevalence of Helicobacter pylori infection. The strong male predominance remains unexplained, but hormonal influence might play an important role. Future prevention might include the treatment of reflux or obesity or chemoprevention with nonsteroidal antiinflammatory drugs or statins, but no evidence-based preventive measures are currently available. Likely future developments include endoscopic screening of better defined high-risk groups for EAC. Individuals with Barrett esophagus might benefit from surveillance, at least those with dysplasia, but screening and surveillance strategies need careful evaluation to be feasible and cost-effective. The surgery for EAC is more extensive than virtually any other standard procedure, and postoperative survival, health-related quality of life, and nutrition need to be improved (eg, by improved treatment, better decision-making, and more individually tailored follow-up). Promising clinical developments include increased survival after preoperative chemoradiotherapy, the potentially reduced impact on health-related quality of life after minimally invasive surgery, and the new endoscopic therapies for dysplastic Barrett esophagus or early EAC. The overall survival rates are improving slightly, but poor prognosis remains a challenge.

Effects of a self-care education program on quality of life after surgery in patients with esophageal cancer

In recent years, the number of quality-of-life (QOL) studies on patients with esophageal cancer has increased; however, the number of studies related to the effects of self-care education programs on QOL of these patients is scarce. This article reports on the effects of a self-care education program on QOL for patients with esophageal cancer in Babol, Iran. The quasi-experimental study had a convenience sample of 105 patients with esophageal cancer referred to oncology centers in Babol City. A quasi-random allocation technique was used to divide the sample into experimental (n = 55) and control (n = 50) groups. Appropriate instruments were used to measure QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30 and Quality of Life Questionnaire-Oesophageal 18). Questionnaires were completed by the respondents before and 3 months after implementing the educational program that consisted of group discussion, lectures, and pamphlets. There was no significant difference between QOL mean score of both groups before the intervention; however, after implementing the educational program, the QOL significantly improved in the experimental group (p = .001), whereas QOL decreased in the controls. We conclude that self-care education programs have positive effects on the QOL of patients with esophageal cancer. Planning and implementing such self-care education programs, when patients are under treatment, can help them improve their QOL.

Nurse or surgeon follow-up after rectal cancer: a randomized trial

AIM

Follow-up programmes consume a large amount of resources with less time for the surgeon to take on new patients. The aim of this randomized study was to compare patient satisfaction, resource utilization and medical safety in patients curatively operated for rectal cancer who were followed up by either a surgeon or a nurse.

METHOD

The nurse was trained by the colorectal surgeon before the start of the study. Curatively operated patients were asked to give their consent to participate. Randomization was performed by the stoma therapist. After each consultation, the patient completed a questionnaire.

RESULTS

A total of 110 patients (58 men) age 68 (range 41-87) years were included between 2002 and 2005. Only three patients refused participation. Patient satisfaction was high according to the Visual Analogue Scale (VAS): 9.4 for the surgeon and 9.5 for the nurse (NS). Consultation time was longer for the nurse: 24 vs 15 min (P = 0.001), with more blood samples being taken (29%vs 7%, P = 0.002). Radiological investigations exceeding the routine were made in 11%vs 4% (NS) cases. Surgical assistance was needed in 13 of 182 consultations with the nurse [mean 6 (1-15) min, total 75 min]. Distant metastases were detected in seven patients in the surgeon group and eight in the nurse group (P = 0.953). Total costs of follow-up did not differ.

CONCLUSION

Patient satisfaction was equally high for the specialist nurse as for the colorectal surgeon. On only a few occasions was surgical assistance necessary and total costs for the follow-up showed no difference. Medical safety appeared uncompromised. Nurse-led follow-up is encouraged.

Cost comparison study of two different follow-up protocols after surgery for oesophageal cancer

BACKGROUND AND AIM

Costs of follow-up strategies in patients after surgery for oesophageal cancer have not been evaluated. We therefore randomised 109 patients to standard outpatient clinic follow-up by a surgeon (n=55) or home visits by a specialist nurse (n=54) and compared costs between these two strategies.

METHOD

Cost comparisons included comprehensive data on hospital costs, diagnostic interventions and extramural care. Detailed information on health care consumption was obtained from a case record form at 6 weeks, and 3, 6, 9 and 12 months after randomisation.

RESULTS

Total medical costs were lower for nurse-led follow-up (euro 2592 versus euro 3798) than standard follow-up, although this difference was not statistically significant (p=0.11). This advantage in the nurse-led follow-up group was mainly due to lower costs for follow-up visits (euro 234 versus euro 503; p<0.001), and a trend towards lower costs for total intramural care (euro 1477 versus euro 2277; p=0.19).

CONCLUSION

Nurse-led follow-up of patients after oesophageal cancer surgery is likely to be cost effective and may even generate cost savings. The results of this study further support a specific role of nurses in the medical care of patients with malignant diseases.