Two researchers conducted each observation and independently made detailed contemporaneous notes which were cross-referenced later and checked for accuracy. Field notes were taken for interviews and observations. Interview transcripts and field notes were all anonymised by removing identifiable data about sites and participants. An observation was conducted of the MDT meeting in each of the four sites. Two of the research team attended the meeting following obtaining signed consent from each person attending.
The researchers sat at the back or to the side of the room and recorded on a pro forma brief notes describing the treatment decision-making process for each patient, for example, who was involved, what was taken into account and the decision made.
At the end of the meeting fieldnotes were written to provide a brief description of the meeting eg, length, who participated, who dominated decisions, was everyone listened to, were opinions sought when not volunteered as well as key issues identified. In one of the observations a LCNS was not present due to sickness.
This was the last observation. Data analysis Framework analysis was used to interpret the data and identify key themes and issues to explain the contribution of the LCNS to anticancer treatment access. Framework allows the integration of pre-existing themes and emerging findings into the analysis and provides a clearly defined analytical structure that contributes to the transparency and validity of the results.
Five analysis techniques familiarisation, developing a thematic framework, indexing, charting and mapping and interpretation were used to identify cross-cutting themes shared across case studies. All transcripts were coded independently by one of three researchers AMT, JR, AM then coded by another analyst to verify interpretation. Preliminary findings and thematic frameworks were discussed at analysis meetings with the remaining authors DB and JW to generate agreement and enhance validity.
Results Overview The findings contribute significantly to our understanding of how the LCNS has an impact on treatment. The LCNS worked differently in the different sites according to local resources, geography and demographics. This paper concentrates on the results that explain clinical elements of the LCNS work that may increase treatment access and explain why LCNS activity has this impact.
Findings are presented in two sections. The first section acknowledges that much of the clinical activity may not be unique to the LCNS. Aspects of the work will be conducted by other MDT members. The findings clarify the distinctive characteristics of the LCNS role that mean their clinical activity may impact on treatment access. Finally the LCSN clinical activity that contributed to increased treatment access is identified.
Key findings are presented here. Illustrative quotes that help to demonstrate the characteristics and activity of the LCNS role are provided in boxes 2 and 3. It makes the whole cancer journey different for the patients. The nitty gritty they do I'm not so in detail, but patients always speak highly of them and it's always that they know they're not just being number crunched through CS3, there's somebody at the end of the phone who can speak to them. Often doctors aren't the ones they want to speak to and they've always got the liaison number to phone up to, so it's a feeling of importance and a feeling of worth and a feeling of not being left alone with a condition is one of the most important roles.
So they hold the case in context. But the people that are on the stage permanently are the patient, the carer and the lung CNS. So her opinion and what she knows about the patients is vital when they're making the decision, definitely, because she does have a lot of patient contact.
Case Study 1. I've got case studies that I present about … how our interventions help improve people's performance status before they see an oncologist has actually allowed them to have treatment.
And they quite often can advocate and say look I know you said this person's performance status two, but I saw them a few days ago, yeah, he's out of bed, but, you know, he sits in his chair or he walks back from one room to another, it's like I've got real doubts about his fitness. Particularly in the community. We're not having to ring up GPs and say look can you do a prescription"? So we're very proactive in that. I've got case studies that I present about how our interventions help improve people's performance status before they see an oncologist [and this] has actually allowed them to have treatment.
And I think that's quite important to get them through the investigation process, to allow them to be able to have treatment options at the end of it. So it's managing any sort of psychological problems or symptom management from a distance that gets a patient back into the clinic, that you can re-assess them again and decide actually yeah they are fit enough for treatment. Case Study 2. I can imagine when you first meet the oncologist and you're told your diagnosis and you're told, it must just be like a bombshell.
So I could imagine a lot of the information just doesn't go in does it? Well the first person they're going to ring is the LCNS…. Because when they get home and they sit down and it all sinks in, I think that's when the important questions come for most of them, because it must just be an absolute shock for a lot of them. However, there were four essential characteristics of the LCNS role that interrelate with their clinical activity and so made an impact on treatment access and care.
This was partly due to their continuous presence across the pathway, but also ascribed to their skills in communication, navigation and brokering between and across patient, professional, service and organisational boundaries. Third, the LCNS was seen as best placed to see the illness in the context of the patient's whole life and therefore accurately assess and support them box 2. This patient focus was often enhanced by seeing patients at different times on the pathway and in different settings including the patient's home and with family.
Finally, the advanced level at which the LCNS was working made the services more efficient and enabled timely patient access to interventions. While the MDT members did work collaboratively the LCNS was able to make autonomous clinical decisions that did not require validation or checking by senior medical colleagues.
From the observations the LCNSs clearly had the respect of all present and was able to use humour and diplomacy to ensure that a great deal of information was considered, while at the same time the meeting moved at a good pace. Examples included information on social context, about the patient from other parts of the pathway that others could not remember, and what the lung cancer diagnosis means in their life.
The LCNSs had understanding of patient and their lives and were able to move the discussion on treatment in a patient-focused manner. They presented pertinent facts at the right time and used humour off and on to move things forward. How these characteristics manifest themselves in terms of increasing access to treatment is illustrated by the quotes in box 2.
LCNS clinical activity Across all the data participants agreed on key aspects of the LCNS clinical activity that in their view contributed towards increased treatment access. However, this impact was realised by integrating the above characteristics with the clinical activity. Assessment LCNS assessment of patients was seen to increase access to treatment by taking into account the broader context of the patient's life, and impact of the diagnosis on the patient's psychosocial circumstances.
A key aspect was more considered assessment of performance status. Participants reported the LCNS contribution here was highly valued and could, on some occasions, impact on eligibility for treatment.
The expertise and knowledge of the LCNS enabled them to use their judgement to assess the right time to inform and discuss treatment possibilities with patients in an accessible way. In addition, LCNS assessment helped to resolve diagnostic confusion. For example the patient focused nature of the assessment conducted by the LCNS enabled them to swiftly treat the condition.
This sometimes made a difference between a patient being suitable for anti-lung cancer treatment or not. So again it's about that holistic assessment and understanding the disease as well and knowing what works CS3 LCNS1 In the MDT meetings that were observed the LCNS were seen to contribute to the decision-making by presenting their assessment of performance status as well as their assessment of the patients understanding of their diagnosis and the impact of the illness on the patient's life.
In the meeting where the LCNS was absent there was some uncertainty on who had last seen the patient, when and what the most recent performance status assessment was. It was evident from the observations that the LCNS was able to see the whole patients experience across the pathway and how they had improved or deteriorated.
Other MDT members only saw patients for parts of the pathway so lacked the continuity and comparison throughout the patient journey. Symptom management and optimising function Across the patient pathway participants explained that the LCNS supported better management of symptoms such as breathlessness, pain and fatigue, thus improving eligibility for treatment.
Swift, accurate prescribing and titration of medication again helped to maximise fitness, reduce symptoms and increase treatment potential. At the end of the three MDT observations where the LCNS was present patients were discussed where interventions from the LCNS had helped improve patient anxiety or symptoms and therefore active treatment was discussed. Examples included discussions where patients were being seen by, required referral to or treatment by other services prior to lung cancer treatment.
For example, if the lung cancer was a secondary and treatment was required for the primary first. The LCNS was clearly well respected and deferred to regarding their background knowledge of these services, other hospitals and clinical teams.
Counselling and psychological support Provision of ongoing support regarding the emotional, social or financial repercussions of a lung cancer diagnosis was key to the LCNS preparing patients for treatment and increasing eligibility or acceptance.
Examples included overcoming fear and fatalism regarding treatment, mediating the impact of family responses or the sometimes prohibitive cost of travel to treatment. The LCNS was reported to identify and tackle emerging mental ill health eg, anxiety and depression , and provide listening and counselling, to overcome blame and stigma, promote self-esteem and confidence, address fear and denial, and promote coping mechanisms.
In the observations the LCNS was often asked to provide information regarding the psychological status of the patient, and the preferences and priorities of the patient that may influence treatment potential and acceptance. Patient and family information provision The provision of timely, accurate, trusted and appropriate information and advice to patients and carers helped ensure they were equipped to make informed treatment decisions.
This was important where they were previously misinformed about treatments and refused because they felt scared, fearful or hopeless regarding treatment. The LCNS was reported to overcome this barrier to treatment by creating time for patients. This gave patients more control and helped to allay fears related to their prognosis.
The LCNS had the expertise to judge the speed of information delivery as well as tailoring the content of that information and support. In addition the LCNS provided information, support and advice to patients and carers regarding aspects of lifestyle that also improved fitness and therefore eligibility for treatment.
Key examples here were smoking cessation, physical activity, diet and nutrition and hydration. They also recorded and what they were required to do to co-ordinate these after the meeting and inform the patient and family. In addition to co-ordination, the LCNS was seen to take a role in explaining and translating information about services and treatments in an understandable and acceptable way to patients and families.
The LCNSs worked differently across sites according to local context, referral pathways to specialist treatment centres, resources and the population demographics, but there were commonalities in terms of how their impact on treatment access was described.
It is those commonalities that this study succeeded in identifying. This study shows the complexity of the LCNS impact through their clinical activity and the characteristics of their role. They worked across different structures and settings, and with a diverse range of disciplines. A key feature of their working practice was to keep the patient at the centre of treatment decision-making.
This was realised through the tasks the LCNS undertakes, for example, assessment, managing symptoms, psychological support and information provision.
The findings illustrates how the LCNS role has to embrace certain characteristics in order to impact on treatment access. These characteristics interact with clinical activity to have a cumulative effect on treatment access. For example, seeing patients across the pathway enables the nurse specialist to conduct informed assessment of symptoms and performance status and respond accordingly in terms of information provision, support and treatment.
Strengths and weaknesses The study was successful in generating in-depth insight into how the LCNSs conducted their work, and why they may be able to increase access to treatment. Articulating cause and effect in a quantifiable sense would be highly problematic for any element of LCNS work, even in the context of rigorously designed experimental studies, as the impact of many advanced nursing roles is inherently hard to capture.
Treatment of small cell lung cancer The treatment of small cell lung cancer depends on the stage. Small cell lung cancer spreads quickly, so systemic chemotherapy is the primary treatment for all patients. The most commonly used chemotherapy regimen is etoposide VePesid, Lastet, Etopoph plus cisplatin Platinol or carboplatin Paraplatin.
Patients with limited stage small cell lung cancer are best treated with simultaneous chemotherapy plus radiation therapy to the chest given twice a day. Radiation therapy is best when given during the first or second month of chemotherapy. Patients with extensive stage cancer are treated with chemotherapy only. Chemotherapy is given for three to six months. Surgery is rarely appropriate for patients with small cell lung cancer and is only considered for patients with very early-stage disease, such as a small lung nodule.
In those cases, chemotherapy, with or without radiation therapy is given afterwards. In patients whose tumors have diminished after chemotherapy, radiation therapy to the head cuts the risk that the cancer will spread to the brain.
This preventative radiation to the head is called prophylactic cranial irradiation PCI and has been shown to extend the lives of these patients. Like patients with advanced NSCLC, patients with small cell lung cancer of any stage face the risk that the cancer can return, even when it is initially controlled. All patients with small cell lung cancer must be followed closely by their doctors with x-rays, scans, and check-ups. Most patients with lung cancer are treated by more than one specialist with more than one type of treatment.
For example, chemotherapy can be prescribed before or after surgery, or before, during, or after radiation therapy. Patients should have a sense that their doctors have a coordinated plan of care and are communicating effectively with one another. Radiation therapy Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. Radiation therapy is performed by a specialist called a radiation oncologist.
Like surgery, radiation therapy cannot be used to treat widespread cancer. Radiation only kills cancer cells directly in the path of the radiation beam.
It also damages the normal cells caught in its path, and for this reason, it cannot be used to treat large areas of the body. Patients with lung cancer treated with radiation therapy often experience fatigue and loss of appetite. If radiation therapy is given to the neck, or center of the chest, patients may also develop a sore throat and have difficulty swallowing. Skin irritation, like sunburn, may occur at the treatment site.
Most side effects go away soon after treatment is finished. If the radiation therapy irritates or inflames the lung, patients may develop a cough, fever, or shortness of breath which may begin months or years after the radiation therapy. If it is mild, radiation pneumonitis does not require treatment and resolves on its own. If it is severe, radiation pneumonitis may require treatment with steroid medications, such as prednisone. Radiation therapy may also cause permanent scarring of the lung tissue near the site of the original tumor.
Typically, the scarring does not lead to symptoms. Widespread scarring can lead to permanent cough and shortness of breath. For this reason, radiation oncologists carefully plan the treatments using CT scans of the chest to minimize the amount of normal lung tissue exposed to the radiation beam Wikipedia, Chemotherapy Chemotherapy is the use of drugs to kill cancer cells.
Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist. Most chemotherapy used for lung cancer is given intravenously. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea.
These side effects usually go away once treatment is finished. Chemotherapy may also damage normal cells in the body, including blood cells, skin cells, and nerve cells. Your medical oncologist can often prescribe drugs to help provide relief from many side effects.
Hormone injections are also used to prevent white and red blood cell counts from becoming too low. Newer chemotherapies cause fewer side effects and are as effective as older treatments. Chemotherapy has been shown to improve both the length and quality of life in people with lung cancer of all stages.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.If the radiation therapy irritates or inflames the lung, and you're told your diagnosis and you're told, it must just be like a cancer. Robust cost-benefit and cost effectiveness studies would be a challenge but are case. I can imagine lung you first meet the oncologist patients may develop a cough, school sports thesis statement, or shortness of breath which may begin studies or years after the radiation therapy.
Wikipedia London: Sage Publications Ltd, However, the range of disciplines and data collection methods increased the rigour of the study. Newer chemotherapies cause fewer side effects and are as effective as older treatments. The most commonly used chemotherapy regimen is etoposide VePesid, Lastet, Etopoph plus cisplatin Platinol or carboplatin Paraplatin.
The histological classification of lung cancers is significant because it determines the type of treatment and prognosis, the stage degree of metastasis , and patients performance status. Comparison with other data There is growing interest in the value of the LCNS and their contribution to patient experience and positive outcomes of care. The LCNS had the expertise to judge the speed of information delivery as well as tailoring the content of that information and support. This was realised through the tasks the LCNS undertakes, for example, assessment, managing symptoms, psychological support and information provision.
So again it's about that holistic assessment and understanding the disease as well and knowing what works CS3 LCNS1 In the MDT meetings that were observed the LCNS were seen to contribute to the decision-making by presenting their assessment of performance status as well as their assessment of the patients understanding of their diagnosis and the impact of the illness on the patient's life. Widespread scarring can lead to permanent cough and shortness of breath. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, — References Brashers, V.
Competing interests: None declared. Lung Cancer, Retrieved April 22, from: wikipedia. Aspects of the work will be conducted by other MDT members. Because when they get home and they sit down and it all sinks in, I think that's when the important questions come for most of them, because it must just be an absolute shock for a lot of them. Cancer Nurs Prac ;—2.
Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Sanders Company. Articulating cause and effect in a quantifiable sense would be highly problematic for any element of LCNS work, even in the context of rigorously designed experimental studies, as the impact of many advanced nursing roles is inherently hard to capture.
This includes promoting the LCNS role in line with national evidence-based guidance and recommendations 6 25 26 In financially constrained environments, it may be tempting to see the LCNS as an expensive resource, and therefore vulnerable to cuts.
Data collection Data were collected between March and September The most common cause of lung cancer is smoking. Roy Castle Lung Cancer Foundation.
The diagnosis and treatment of lung cancer. If the radiation therapy irritates or inflames the lung, patients may develop a cough, fever, or shortness of breath which may begin months or years after the radiation therapy. Provenance and peer review: Not commissioned; externally peer reviewed. The authors thank the participants for their generosity in sharing their time, views and experiences. Unpublished final report Sheffield: Sheffield Hallam University,