In this community outreach example, the daunting challenges of treatment, and the impact on quality of life, drive the questions, “How can we better serve these patients?” and “Is there anything we can do to prevent or detect head and neck cancers earlier?”
This case study demonstrates the unique and complex challenges patients with head and neck cancers face. It also provides individual and public health interventions to reduce the risk for this condition, and the available screenings to promote early detection.
A man, aged 62 years, received a diagnosis of left tonsillar cancer that was considered stage IV because of the size of the obstructing tumor. The patient had a mass in the left side of the neck for approximately 1 year, and it had recently begun to grow. He had a long beard, which hid the growing tumor. Additional case details included:
- Increasing tenderness on palpation, and some difficulty swallowing was reported
- The ear, nose, and throat (ENT) specialist detected a lesion on the left tonsil
- Biopsy results indicated squamous-cell carcinoma, and tested positive for human papillomavirus (HPV)
- The patient previously smoked for a long period, but no longer smokes
- History of drinking 4 to 5 beers daily was reported
- Pulmonary metastases were suspected on positron emission tomography scan; the patient refused biopsy
- The patient was overwhelmed with everything that had to be done before treatment could begin (eg, schedule dentist appointment, have a port placed, have a percutaneous endoscopic gastrostomy tube inserted, get referrals, and meet with speech pathologist and dietitian)
- The patient was no longer working; his wife worked, but they could not afford his copays
- The patient had Wellcare Senior Health insurance and coverage was not great, but he could not afford his wife’s insurance
- He did not want his wife to go into debt because of his health
- No dental coverage, and the bill to remove the loose teeth before radiation could begin was over $1800
- The patient was receiving largely palliative care and concurrent chemotherapy with radiation.
Defining Aim of Study
The nurse navigator and her team reflected on this patient’s challenges, and recognized the potential for community outreach activities to raise awareness and provide education about head and neck cancers, HPV vaccination recommendations, and HPV screening guidelines. In addition, increasing access to smoking cessation programs and implementing oral and dental screenings to aid in early detection of these cancers were identified as methods for reducing risk and improving outcomes of patients with head and neck cancers.
The quality improvement team determined that the aim of their project would be to conduct outreach activities and accomplish 3 goals: (1) reduce community members’ risk for head and neck cancers, (2) increase the rate of HPV vaccinations, and (3) increase access to screenings to aid in early detection of dental issues.
Next, the quality improvement team identified metrics that would allow them to address the project’s goals, define data collection points, and evaluate outcomes for the improvement project. These metrics included:
- Documentation of community events providing education about the HPV vaccine, numbers of patients impacted, and the number of people navigated to getting the vaccine
- Documentation of dental screenings, including the number of patients participating, the number of abnormal findings, and navigation to diagnosis, staging, and treatment
- Identification of access and barriers to care, whether patients have no insurance or are underinsured
- Adherence to screening and recommended follow-up
- Downstream revenue from referrals (eg, biopsy, computerized tomography [CT] scans)
- Tracking date of positive pathology to treatment time
- Documentation of the use of smoking cessation programs and outcomes
- Assessment of new patients with head and neck cancers to identify smokers, navigate them to smoking cessation, and assess quitting-related outcomes (ie, new patient packet screening tool)
- Assessment of new patients with head and neck cancers regarding alcohol use, documentation for counseling, and outcomes
- Tracking treatment compliance, and the number of missed appointments
- Tracking referrals to social workers, nutritionists, chaplains, transportation, and smoking cessation programs.
Tools and Resources
Some tools that were used to collect the relevant data for this project and are widely available to nurse and lay navigators include:
- Intake form for patients with head and neck cancers (Appendix 1) developed by the interdisciplinary team, including the nurse navigator, social workers, nutritionists, chaplains, and financial counselors
- Flow sheet (Appendix 2) for treating patients with head and neck cancers, and increasing coordination of care to assist with compliance issues
- Provide calendars to patients with scheduled appointments listed
- Letters to insurance companies (Appendix 3) to appeal for coverage of men’s HPV vaccinations
- Explore partnerships with local health departments, dentists
- Navigate patients to state-run smoking cessation programs
- National Comprehensive Cancer Network guidelines stating that patients with head and neck cancers should be tested for HPV1
- Print materials outlining the benefits of quitting tobacco use (Appendix 4)
- Educate primary care providers about risk factors, when to refer patients to an ENT specialist, and screening and prevention services available in your community
- Electronic medical records or spreadsheets for documentation
- Anatomic illustrations specific to a patient’s diagnosis found on medical illustration websites.
After completing this type of quality improvement project, the nurse navigator and her team can share their results and best practices within their institution and in the wider healthcare community, including:
- Sharing outcomes with hospital leadership
- Discussing follow-up projects for patients with head and neck cancers, or similar outreach projects for other cancer types at their hospital
- Sharing best practices with regional navigators
- Writing an abstract for a poster presentation at the Academy of Oncology Nurse & Patient Navigators (AONN+) Annual Conference
- Expanding outreach to disparate populations.
- National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN guidelines): Head and Neck Cancers. http://oralcancerfoundation.org/treatment/pdf/head-and-neck.pdf. Accessed December 18, 2015.