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Breast Cancer Navigation


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Sue Bowman, RN, OCN, CBCN, MSW …

Sue Bowman, RN, OCN, CBCN, MSW
Leesa Mattingly, RN, OCN

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  • 1. 5 Steps to Better Navigation: Breast Cancer Navigation Breakout Session
    Sue Bowman, RN, OCN, CBCN, MSW
    Breast Oncology Nurse Navigator
    Wellspan Health, York Cancer Center
  • 2. About the speaker…
    Breast oncology nurse for 16 years
    Breast cancer survivor for 18 years
    Breast cancer navigator for 9 years
    Developed successful survivor programs
    Published author
    Conducting nursing research in breast cancer survivorship
    Member of several breast oncology groups
    Certified in oncology and breast cancer care by ONS
    Enjoy being a navigator
  • 3. Breakout Session Topics
  • 4. What Is a Navigator ?
  • 5.
  • 6. Translation – We Are “Cat Herders”
    Cat Herding - Persuading a group of independently minded people to go in the same direction
  • 7. Dr. Harold Freeman
    “Navigators assure that individuals with cancer will receive timely diagnosis and treatment.”
  • 8. Dr. Allan GibofskyProfessor of Public Health Weill Cornell Medical College
    “Breast cancer is a complex disease causing disruption in the physical, social, psychological, and spiritual aspects of caring. It is the role of the navigator to pave the way for these individuals to access the necessary information that will make the journey less fearful and more understandable.”
  • 9. Barrier-Focused Definition
    Patient navigation is a barrier- focused intervention that has the following common characteristics:
    Provided for a defined period of time
    Has a start and end
    Targets the specific set of health services required
    Identifies barriers and reduces delays in accessing care
    Sara Koslosky
    Inova Health Breast Care Nurse
  • 10. Is a Standardized Navigator Definition a Practical Goal?
  • 11. Actual Value of a Navigator
    The true value of a successful navigator program is the ability to guide patients through the health system by removing barriers that prevent quality care.
  • 12. Critical Question #1
    How does a navigator develop this ability to guide patients around or through barriers?
  • 13. Critical Question #2
    How are barriers identified?
  • 14. Critical Question #3
    How does a navigator resolve barriers?
  • 15. The answer is…
    …something you have used your entire professional career
    The Nursing Process Theory
    Developed in 1961 by
    Ida Jean Orlando
    Ida Orlando
  • 16. The Focus of the Nursing Process
    The Patient
    Improve care by addressing the most pressing need first
    5-step process
  • 17. Things to Remember…
    This is a new process
    Use what you know works
    Nurses and other navigators can use Orlando’s Nursing Process Theory to resolve patient barriers – successfully
    Create your role and program to reflect your patients’ barriers
    Keep your role fluid
    Navigators have become important members of the oncology care team
    Navigation is a difficult task at best
    Nurse navigation is still developing
    Start small
    Be patient with yourself
  • 18. 5 Steps to Better Navigation:Using the Nursing Process
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  • 34. Key Point: Implementation is NOT only your responsibility. You are NOT a “Guardian Angel.” You are a facilitator. Your patient is responsible for doing what he or she is able to do. The goal is to complete recommended care, create a partnership, provide tools for growth, and support the healing process.
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  • 41. Applying the 5-Step Nursing Process Theory in Breast Cancer Navigation
    Case Study
  • 42. How to Prepare for an Effective Initial Contact
    • Receive referral
    • 43. Review medical record
    • 44. Gather appropriate resource materials
    • 45. Focus on rapport building
    • 46. Use an assessment tool
  • Assessment Tool
    A comprehensive intake form includes:
    Demographics & contact information
    Medical history & provider information
    Pathology results
    Existing support systems
    Medications & comorbidities
    Social roles & responsibilities
    Health maintenance routine
    List of possible referrals
    Worksheet format
  • 47. Elderly Case Study Mary: Physical Barriers
    78 years old, post menopausal
    Thoraco-lumbar stenosis
    Cataracts & bilateral hearing aides
    Thickness noted in left breast
    Invasive lobular carcinoma, ER+, PR-, HER-2 -, 4 cm., 3 positive nodes, 1 micro-mets
  • 48. Case StudyMary: Emotional Barriers
    Spouse in long term care post recent CVA
    Reluctant to ask for help
    One son 200 miles away
    Accustomed to being in control of
    her life experiences
  • 49. Case StudyMary: Support System Barriers
    No living siblings
    Spouse unavailable
    Son & family not local
    Attends Sunday church services
    Lives alone in family home
    Does not drive in “bad” weather or at night
    Limited circle of friends
  • 50. Case StudyMary: Knowledge Barriers
    Unaware of community resources, including cancer center
    Incomplete understanding of medication use
    Impending information overload
    No personal experience with breast cancer
    No known family history
    Unfamiliar with screening, treatment, disease, survivorship recommendations
    Unaware of impact of treatment and
    healing issues
  • 51. Case StudyMary: Financial Barriers
    Car is 15 years old
    Limited income
    Medicare & supplement health coverage
    Able to make ends meet at this time, no reserve
    Sporadic grocery shopping
    Ocassionally misses bill due dates
    12 year old dog requires frequent vet appts
    Home repair ignored
  • 52. Case StudyMary: Systemic Barriers
    Complex medical system
    Cottage industry of care
    Treatment may require an escort
    Provider communication relies on phone
    Treatment may require travel in poor weather or when dark
  • 53. Elderly Case StudyMary: Personal Strengths & Resources
    Uses her small circle of contacts well
    Willing to help herself
    Enjoys learning new things
    Reads and questions health care information
    Asks questions on behalf of her spouse
  • 54. Use the 5-Step Nursing Process Theory to Develop an Effective Strategy
    Nursing diagnosis
  • 55. Barrier Ball ActivityRemember the Nursing Process
    Catch a Barrier Ball
    Recruit people near to you to formulate a way to reduce that barrier
    Take 2 minutes to develop your plan (Write it down)
    Pick one person to come to the microphone, state barrier and how to reduce this barrier
  • 56. Transportation Barrier
  • 57. Possible Transportation Approaches
    Ask patient for her ideas.
    Public transportation programs
    Church groups
    Cancer center programs
    American Cancer Society
    Investigate hospital resources
    Establish a list of resources for navigator use
  • 58. Financial Barriers
  • 59. Possible Financial Approaches
    Ask her what help she needs first
    Refer to financial counselor, if available
    Contact local patient advocacy programs
    Refer to food and clothing banks
    Brainstorm with patient to find additional ways to economize
    Free Medicaid cell phone program
    Work with patient finance rep for available options
    Explore providers’ willingness to waive fees
    Pharmaceutical programs
    National patient advocate programs
    Establish a list of resources for your future use
    Be sensitive to privacy issues
  • 60. Healthcare Barriers
  • 61. Possible Complex Healthcare Approaches
    Offer to attend appointments for support, note taking, advocacy
    Explain steps before they happen
    Anticipate barriers
    Provide verbal and written information in increments
    Enlist help from PCP
    Be available for questions and concerns
    Collaboratively develop a way to be organized that matches her need
    Be prepared to repeat information and present it in different ways
    Establish a list of resources for your future use
  • 62. Psychosocial Barriers
  • 63. Possible Psychosocial Approaches
    Establish rapport and positive regard
    Explore adequate emotional support: counseling, medication
    Offer social work services
    Reinforce her strengths
    Explore her current relationship with her spouse
    Ask about provider gender preference
    Social Work 101: “Meet the patient where she is”
    Check your biases
  • 64. Remember the 5 Steps of the Nursing Process Theory for Better Navigation
    Gather information
    Use a tool
    Nursing diagnosis
    Identify individual and systemic barriers
    Collaborative process
    Baby steps; don’t expect perfection
    Focus on personal strengths
    Don’t promise what you can’t deliver
    Be patient
    “Assist” always; “do” only when your patient is unable
    Encourage independence
    Do YOU have a knowledge deficit relating to her specific barriers?
    Do YOU have a comprehensive understanding of women’s developmental stages?
    Evaluation never ends
    and results in continual reassessment
  • 65. The Multidisciplinary Navigation Team
  • 66. The Multidisciplinary Navigation Team
    Nurses cannot do this alone
    Remember the cat herders?
    Multidisciplinary services are indicated for an optimal breast cancer experience
    You already have a team of people available to provide these services
    Volunteer vs paid employees
    Virtual vs centrally located team
    You can create a team
  • 67. Interdependence:Making a Cheeseburger
    Independent Cheeseburgers
    Raise the cattle
    Butcher and grind the meat
    Bake the rolls
    Grow lettuce and tomato
    Make cheese & age it
    Grow trees, cut down, process for charcoal
    Time needed: years
    Interdependent Cheeseburgers
    Go to the grocery store
    Purchase hamburger, cheese, rolls, tomato, lettuce, charcoal, ketchup, mustard
    Return home & prepare
    Time needed: hours
  • 68. Team MembersNonclinical Patient Navigators
    They can:
    Access information
    Connect to support
    Encourage organization skill development
    Address cultural & language barriers
    They cannot:
    Provide medical information
    Give opinions about treatment
    Give opinions of healthcare providers
    Interfere with provider/patient relationship
  • 69. Team MembersFinancial Counselor
    Locate Medicare, Medicaid programs
    Organizational programs for support
    Pharmaceutical programs
    Guide to economize lifestyle
    Assist with applications for services
    May be able to organize fundraising
  • 70. Team MembersOncology Dietitians
    Counsel healthy nutrition through treatment
    Provide guidance for plant-based diet after treatment
    Provide nutritional supplements and reassurance
    Supply facts about alternative or unconventional diets
  • 71. Team MembersOncology Social Workers
    Logical, essential, and necessary
    Assist with disability, FMLA, Social Security, Medical Assistance
    Connect to appropriate resources
    Facilitate mental healthcare
    Provide crisis intervention
    Offer patient and family counseling
    Provide support groups
    Support other members of the navigation team
    Psychosocial education
  • 72. Team Members;Other Potential Members
    Research nurses
    Imaging personnel
    Radiation, surgical, medical oncology
    Complementary medicine providers
    Physical & occupational therapists
    Survivorship classes
    Support groups
    Community members
  • 73. The Puzzle of Assembling the Right Team Activity
    In 5 minutes:
    Find your color-coded puzzle piece
    Read your patient comment or list of team members
    Find the team member who matches your puzzle piece
    Decide how your team will address this barrier
    Can you add other resources or ideas?
    3 teams may come to the microphone to share their barrier and describe team members’ actions
  • 74. Focus on Psychosocial Assessment
  • 75. Focus on Psychosocial Assessment
    What is distress?
    Any emotional issue which affects a person’s ability to
    Cope with disease, treatment, survivorship
    Make informed decisions
    Follow recommended treatment
    Breast cancer is a holistic experience
    Distress is best managed by using the “onion analogy”
  • 76. Focus on Psychosocial Assessment
    Why is this important?
    33% of all patients experience significant emotional distress
    5% obtain help
    Breast cancer survivors: commonly experience distress which interferes with coping
    Psychosocial assessment will be required for cancer center accreditation
    Distress is one of the 3 most common barriers:
    Insurance & out-of-pocket expense
    Fear & emotions
  • 77. Barriers Are Risk Factors for Distress
    Low income
    Less education
    Young age
    Hispanic ethnicity
    Non-English speaking
    Treatment side effects
    Unstable support systems
    Preexisting mental illness
    Substance abuse
    Role confusion
    Endless number of perceived barriers
    ALL people have barriers
  • 78. Focus on Psychosocial Assessment in Navigation: American College of Surgeons Commission on Cancer
    Continuum of Care Services Standard 3.2
    Screening of all patients for distress & psychosocial health needs
    Provide referral, follow-up, and re-evaluation
    Minimum of 1 screening per patient
    Use of standardized tool
    General standards first published in 1930 to ensure quality cancer care
    New standards September 2011
    Voluntary accreditation includes patient care improvements & outcomes through a team approach
  • 79. Focus on Psychosocial Assessment in Navigation
    Institute of Medicine: Cancer Care for the Whole Patient
    Screen all patients
    Referral to appropriate psychosocial services
    Effective communication
    Identify barriers
    Design and implement a plan for care
    Coordinate care & support patients
    Reassess and adjust the plan of care
    National Comprehensive Cancer Network
    “Distress should be recognized, monitored, and documented, and treated promptly at all stages of the disease”
    Requires systemic follow-up
  • 80. Focus on Psychosocial Assessment
    The basics of the IOM, NCCN, and ACoS recommendations sound a lot like Orlando’s Nursing Process Theory
  • 81. Nurse Navigator Initial Contact
    Remember: Use the 5-step Nursing Process Theory
    Be alert to the fluid nature of the process
    Use an assessment tool and document your findings
    Collaborate with your patient to develop a care plan
    Mental illness or instability may be exacerbated with diagnosis
    Self-report, observation, medication list
    Further assessment is needed
    Communicate with physician
    Use the nursing process with frequent reassessment as tool for maintaining support
    Refer to appropriate psychosocial support
    Use recommendations from IOM, ACoS, NCCN to guide your plan
  • 82. Need for Assessment Is Evidence Based
    Will be required by ACoS CoC Standard 3.2 by 2015 for accreditation
    Research: Heilman & Lackey (1991), Kilpatrick et al (1998), Sanson et al (2000)
    High levels of unmet needs (barriers)
    Increase distress levels
    Decrease coping abilities
    Affect patient, family, caregivers, providers
    Complicate family support, hope, and a sense
    of the future
  • 83. Mitchell (2010) Identified 6 Tools for Measuring Distress in Cancer Patients
    Hospital Anxiety & Depression Scale
    Distress Thermometer
    Single verbal question
    Psychological Distress Inventory
    Combination Distress and Impact Thermometers
    Two verbal questions
    All tools comparable in accuracy
    Never a substitute for clinical assessment or management
    Choose a tool based on
  • 84. Distress Thermometer
    Easy to use
    20 seconds to complete
    Pencil & paper
    Scale 1-10
    High specificity and sensitivity
    Provides specific areas of potential barrier for assessment
  • 85. Conference Stress Gauge Activity
    Find your Conference Stress Gauge
    Take 1 minute to complete this tool
    Share comments with the person next to you
    Did this tool evaluate your current stress level accurately?
    Could you use the NCCN Distress Thermometer for your patients?
  • 86. Best Practices in Navigation and Survivorship
  • 87. What Are “Best Practices”?
    Best Practices are generally accepted, informally standardized techniques, methods or processes that have proven themselves over time to accomplish given tasks
    Often based on common sense when no firm guidelines exist
    Best practices continue to evolve as change occurs
  • 88. Why Are Best Practices Valuable?
    Used to maintain quality
    Used as an alternative to mandated, legislated standards
    Based on self-assessment
    Changeable and flexible
    Important aspect of accreditation standards
  • 89. The key in adopting a best practice is being able to tailor it to your own organization’s needs
  • 90. Current Best Practice Resources
    Design of Six Sigma (DFSS)
    Business model for redesigning existing
    or new processes
    Prioritizes customer (patient) needs
    Formulates specifications
    Integrates them into a program
    Aligns customer (patient) needs with
    provider services
  • 91. Current Best Practice Resources
    Association of Community Cancer Centers Patient Navigation Tool Kit (ACCC)
    Assessment tools
  • 92. Current Best Practice Resources
    American College of Surgeons Commission on Cancer Standard Drafts
    3.1 Patient Navigation
    3.2 Psychosocial Distress Screening
    3.3 Survivorship Care Plan
  • 93. Current Best Practice Resources
    Published navigation research or literature review articles
    Professional organizations
    Regional best practice
    Classic best practice
    Orlando’s 5-step nursing process theory
  • 94. Survivor Care Plans as a Best Practice
    The number of survivors is rising
    The number of medical oncologists is not
    Primary care physicians may be responsible for cancer surveillance
    Changes in breast cancer treatment occur often
    Coordination of care is imperative
  • 95. Survivor Care Plans
    What are they?
    Useable documentation of treatment completed and plan for future
    Comprehensive record of diagnosis and treatment
    Patient-friendly and valuable to providers
    Includes treating providers & contact information
    Includes treatment identification, dose, duration, effects
    Includes services used
    Includes guidance for recovery and survivorship
    Includes surveillance recommendations, health maintenance
    Lifestyle changes
  • 96. National Community Cancer Centers Program (NCCCP) Survivor Care Plan
    Four methods of care plan development
    Cancer registry populates treatment summary
    Nurse Practitioner led survivorship program using software for care plan
    Survivorship Navigator completing treatment summary
    Use online care plans such as:
    Survivor care plans will be required for ACoS CoC Accreditation 2015
  • 97. Successful Survivorship Program Initiation and Support
  • 98. Why Are Survivor Programs Important for Your Navigation Program?
    Increasing number of cancer survivors requiring continuing care
    Better treatment
    Better follow-up
    Better science
    Better delivery
    Better professional education
    New phase in the cancer trajectory: Survivorship
    Longer life
    Patient demand
    Extension of traditional treatment
    Primary care physicians may not be familiar with late effects of diagnosis or treatment
  • 99. What Survivor Programs Are Right for Your Navigation Program?
    Use the 5-step Nursing Process
    Assess: Find out what is needed
    Focus group
    Interview patients & providers
    Nursing Diagnosis: Define needs in terms of patient barriers
    Lack of adherence to hormonal therapy
    Poor appointment follow-up
    Fear about leaving active treatment
  • 100. What Survivor Programs Are Right for Your Navigation Program?
    Plan: Develop an interactive, engaging way to educate patients, meeting the needs expressed
    Adult learning styles
    Program providers, resources
    Scope of practice
    Specific goals
    Team involvement
    Implement: Time to practice
    Try out your program ideas with an open mind
    Know that some components will be successful, some will need revision
    Build resource list
  • 101. What Survivor Programs Are Right for Your Navigation Program?
    Evaluate: Look at your successes and failures
    Keep a list of what went well and what didn’t
    Develop a way to prove effectiveness of your program
    Readjust your program to enhance effectiveness
    Process is the key word
    Programs are never finished; open to change
    Make it fun for you and the people you serve
    Ideas are limited only to your imagination and creativity
  • 102. Prescription for Living:Beyond Breast Cancer
    An 8-session interactive class for women who have been diagnosed and treated for breast cancer
    Women’s Intervention Nutrition Study, Chlebowski (2006)
    Physical activity
    Stress reduction
    Taught by oncology dietitians, nurse navigator
    Guest speakers include physician, navigation team members, community leaders
    In place for 4 years
    Adjustments made to reflect patient need
  • 103. Prescription for Living: Beyond Breast Cancer
    Focus group
    Surveyed providers and patients
    Secured support for referral from providers
    Engaged pharmaceutical reps for funding
    Applied for grants
    Nursing diagnosis:
    Asked providers what barriers patients encountered most often after treatment
    Distilled that list to teachable vignettes, linking them with current research findings and recommendations
  • 104. Prescription for Living: Beyond Breast Cancer
    Reviewed adult learning preferences
    Organized topics
    Requested speaker commitment
    Outlined course
    Compiled supporting information
    Developed Power Points
    Considered learning experience to include many modalities
    Purchased tools & books
    Calorie King
    ACS Healthy Eating
    Contacted related organizations for patient handouts
    Calcium Supplements
    Vaginal lubricant
    Lymphedema ID wristbands
  • 105. Prescription for Living: Beyond Breast Cancer
    Offered first class in September 2007
    Two times: afternoon and evening
    Spring and fall classes
    90-minutes class
    Provided instruction, demonstration, homework, and food tasting
    Secured funding
    Pre- and post-class evaluation for participants
    Evaluations per funding agreement
    Feedback from providers
    Feedback from speakers
    Reassessment and program change
  • 106. Orlando’s Nursing Process Theory Is a Valuable Tool in Navigation Programs
    Effective navigation is the nursing process
    Know it and use it
    The answer to navigation process development and success has been with us all along
  • 107. For questions or comments:
    With thanks and appreciation to:
    David Bowman - presentation development
    Tom Bowman - support and editing
    York Cancer Center for supervision and encouragement
  • 108. Breast Cancer NavigationChallenges Facing the Younger Breast Cancer Patient
    Leesa Mattingly, RN, OCN
    Breast Health Navigator
    Norton Cancer Institute
  • 109. Norton Healthcare and The Norton Cancer Institute
    Norton Healthcare is the largest provider of healthcare in Louisville, Kentucky, and the surrounding region with 5 acute care hospitals
    Norton Cancer Institute is the only National Cancer Institute Community Cancer Center Program (NCCCP) in Kentucky
    The goal of the Norton Cancer Institute is to create a community-based cancer center network to support research, increase access to care, and increase quality of care
  • 110. Norton Cancer InstituteResource Centers
    The Norton Cancer Institute currently has 3 resource centers throughout the community for anyone touched by cancer
    These centers are staffed Monday-Friday,
    8:00 AM-4:30 PM, with Oncology Certified Nurses
    Many of the services are offered at no cost to anyone in the community with a cancer diagnosis, caregiver, or family member
  • 111. Community Resources
  • Navigation Program
    3 Breast Health Navigators
    1 Thoracic Navigator
    1 Neuro Navigator
    1 GI Cancer Navigator
    1 Hepatic Arterial Navigator
    4 Oncology Navigators
  • 122. What Is a Nurse Navigator?
    An Oncology Certified Nurse who oversees the educational, emotional, and social needs of the patients and family members from point of suspicious finding through diagnosis, treatment, and into survivorship
    Nurse navigators are specially trained to offer the latest information on prevention, early detection of cancer treatment options, and recovery concerns
  • 123. Norton Cancer Institute Breast Health Services
    The multidisciplinary team includes:
    Board Certified Breast Surgeons
    Board Certified Reconstructive Surgeons
    Medical and Radiation Oncologists
    Genetic Counselors
    Lymphedema Specialists
    Oncology Certified Nurses
    Nurse Navigators
    Behavioral Oncologists
    Licensed Dietitians
    Social Workers
    Complementary Therapists
  • 124. Referrals
    Physician referrals
    Inpatient and outpatient
    Surgery schedule
    Community outreach/screenings
    Reputation in the community
  • 125. Facts About Breast Cancer
    Young women under age 45 can and do develop breast cancer. In the United States, about 10% of all breast cancer occurs in women under age 45
    24,000 women in the United States under age 45 are expected to be diagnosed with breast cancer this year (including in situ breast cancer)
    More than 3000 will die
    Breast cancer is the leading cause of cancer deaths in women under age 40
  • 126. History of the Young Survivors Support Group
    In September 2006, a young women (M.S.) in our community was diagnosed with breast cancer at age 31
    M.S. shared her story with the news media and her journey was also followed by our local paper
    M.S. focused on “wanting to help other young women like myself”
  • 127. What Makes This Support Group Different?
    Women aged 40 and younger when first diagnosed with breast cancer
    Social networking
    Survivors willing to mentor a newly diagnosed woman, caregiver, or spouse
    Family events
    Young Survivors Coalition Annual Conference
  • 128. How Is It Funded?
    Local football game
  • 129. Case Study 1: J.H.
    J.H. was a 22-year-old college student when in 2008 she found a lump while performing breast self-examination (BSE)
    Biopsy showed a G3 IDC of the right breast. ER-/PR+ Her-2/neu-
    She and her mother arrived from the surgeon’s office for our first meeting together
  • 130. Assessment of Barriers/J.H.
    Physician appointments
    Body image
    Anxiety, fear, stress
  • 131. Education
    Type of cancer, grade, prognostics
    Prophylactic mastectomy
    Sentinel node biopsy
    J.H. opted for a right mastectomy with left prophylactic mastectomy and immediate reconstruction with tissue expanders (TEs). Right sentinel node biopsy removed 6 nodes, all negative
  • 132. MD Appointments
    • Medical Oncologist - Chemotherapy
    • 133. Dose-dense doxorubicin and cyclophosphamide times 4 cycles followed by docetaxel times 4 cycles
    • 134. No hormone suppression
    • 135. Reconstructive Surgeon
    • 136. Immediate reconstruction with TEs
    • 137. Fertility Specialist
    • 138. No egg harvesting
    • 139. Genetics
    • 140. Mother negative for breast cancer, maternal grandmother with breast cancer at age 65
    • 141. Father was adopted
    • 142. Negative for BRCA I and II mutation
  • Finances
    College student living at home with parents
    Covered by her father’s insurance
    Leave of absence from school
    Parents voiced some financial concerns
  • 143. Body Image
    Bilateral mastectomy
    ̵̵ Hair loss/wig, LGFB program
    ̵̵ Weight gain/dietitian, exercise and yoga
  • 144. Autonomy
    J.H. is an adult of legal age living with her parents
    Building trust
  • 145. Emotional Issues
    Anxiety, fear, stress
    Young Survivors Support Group
    Behavioral oncology
    Massage therapy
  • 146. Case Study 2: A.L.
    • In February 2009, A.L. found a lump in her right breast while performing BSE. This was 10 days after her 27th birthday and 8 months after her mother’s diagnosis with breast cancer
    • 147. Biopsy showed IDC of the right breast. ER+/PR-Her-2/neu-
    • 148. Married with no children. Works as a medical assistant in a physician’s office
    • 149. Family history includes grandmother, mother (diagnosed at age 61), and several aunts with breast cancer
  • Assessment of Barriers/A.L.
    Physician appointments
    Body image
    Anxiety, fear, stress, guilt, anger
  • 150. Education
    Type of cancer, grade, prognostics
    Prophylactic mastectomy
    Sentinel node biopsy
    A.L. opted for right mastectomy with prophylactic left mastectomy and immediate reconstruction with TEs. Sentinel node biopsy removed 10 nodes, all negative
  • 151. MD Appointments
    Medical Oncologist - Chemotherapy
    Cyclophosphamide and docetaxel times 6 cycles
    Oral antihormone agent
    Reconstructive Surgeon
    Immediate reconstruction with TEs
    Fertility Specialist
    Egg harvesting
    Negative for BRCA I and II mutation
  • 152. Finances
    A.L. had to continue working during treatment. Fertility procedure was not covered by insurance
    Med Assist
    Co-Pay Relief
    Fertile Hope
    Transportation Assistance
  • 153. Body Image
    Bilateral mastectomy
    Hair loss/wig, LGFB program
    Weight gain/exercise and yoga
    Hormone suppression
    Decreased libido/behavioral oncology
  • 154. Emotional Concerns
    Anxiety, fear, guilt, stress, anger
    Young Survivors Support Group
    Behavioral oncology
    Massage therapy
    Delay in pregnancy
  • 155. J.H. and A.L. Today
    J.H. has completed treatment phase. She works part- time and attends college
    A.L. has finished her chemotherapy treatment and breast reconstruction. She remains on an oral antihormonal medication. She is working full-time as a medical assistant in a physician’s office. A.L. is anxious to end treatment totally, so that she can pursue her lifelong dream of becoming a mother
  • 156. Quotes from a Young Survivor
    “I joined the Young Survivors group and looked forward to the fellowship. I had other women who made me feel like what I was going through was normal, that I wasn’t alone.”
    “As a young woman, I feel the dynamics of cancer affect us differently than that of the middle-aged population. Young Survivors have done a great job advocating for women diagnosed with breast cancer at a young age.”
  • 157. “EGGS FOR EGGS”
    an employee of Internal Medicine and Pediatrics,
    has just been diagnosed with breast cancer.
    Within 3 weeks, she will be undergoing a double mastectomy.
    As if that wasn’t bad enough,
    Alicia is 27 years old.
    The chemotherapy will more than likely make it impossible
    For her to ever be a Mommy.
    She was hoping to go through an Egg Harvesting procedure
    Before her surgery,
    but it will cost $12,000.
    These ribbons were created out of love,
    in hopes that we could help offset the costs.
    Show your support,
    and take a ribbon out of one of these special eggs.
    We ask that you leave behind a pledge of support.
    Whether it’s $1…
    or $100…
    We thank you for helping us
    help Alicia
    To fulfill what she ultimately wants…
    To Be a Mom…
  • 158.
  • 159. References
    Facts about breast cancer, retrieved August 8, 2011, from
    Norton Healthcare, retrieved August 8, 2011, from