More than ever before, oncology nurses are required to provide multifaceted care when it comes to managing patients with cancer. As the population of patients with cancer continues to age and cancer becomes more of a chronic condition, oncology nurses are seeing more patients who exhibit comorbidities during their cancer journey. Comorbidity complicates cancer care and requires nurses to recognize the importance of managing other diseases while treating the patient’s cancer.
According to the National Cancer Institute ([NCI], 2016), the top four cancers—lung, colorectal, breast, and prostate—have rates of comorbidity at 52.9%, 40.7%, 32.2%, and 30.5%, respectively. Patients with comorbid conditions often require a heightened level of coordination to manage their diseases effectively. Oncology nurses stand at the forefront of managing patient needs, especially with comorbid conditions.
Assessing Comorbidities in Patients
Many factors impact outcomes for patients with cancer, including age, race, and access to care. However, comorbid conditions present a unique set of challenges for healthcare providers. They can complicate traditional treatment regimens, while also impacting patients’ health, well-being, and quality of life in different ways. Assessing a secondary or tertiary illness in patients with cancer is one of the first steps when coordinating appropriate care.
“We often explain to folks that it’s very important to have other diagnoses managed, diagnosed, and maintained while they go through cancer treatment. We want to ensure that their health is at the best possible place, so that they can sustain treatment and not be as susceptible to toxicities,” ONS member Janine Overcash, PhD, GNP-BC, FAANP, director of the adult/geriatric nurse practitioner program at Ohio State University in Columbus, OH, says. “We talk about the importance of continuing care with primary care providers. A lot of patients—especially seniors—are focused on their oncology care and drop their other visits. Comorbidities add another level of complexity to cancer care in older adults.”
“The current single illness-focused care model isn’t always sufficient for the continuum care of individuals with cancer,” ONS member Horng-Shiuann Wu, RN, PhD, associate professor at the Goldfarb School of Nursing in St. Louis, MO, says. “Current oncology practice is disease-specific. When an individual is diagnosed with cancer, the care plan focuses on treating that cancer and managing its associated conditions—even though cancer patients often have other existing chronic illnesses.”
Overcash notes that assessing, screening, and identifying comorbidities is just the start. “Communication among providers is vital. Who is the patient seeing? How can we get the oncology records to that provider? How can we communicate our assessment findings and the toxicities that we may be seeing, so that the primary care provider knows? It takes time and a lot of coordination.”
Some comorbidities are more common in patients with cancer. “Hypertension, cardiovascular disease, and diabetes mellitus are common physical conditions,” Wu says. “Depression and anxiety are common psychological conditions.” She adds that comorbidities can vary depending on cancer type and patient populations.
The Challenges of Comorbidities in Aging Patient Populations
More than 60% of patients with cancer are diagnosed at 65 or older, and many suffer from existing conditions that complicate decisions during cancer treatment (Sogaard, Thomsen, Bossen, Sorensen, & Norgaard, 2013). In some cases, the presence of a comorbidity in adult patients aged 65 and older could double or triple their probability of death (NCI, 2016).
Managing older patient populations requires a unique skillset and an immense commitment to time and effort. “Treating geriatric patients with cancer is a robust endeavor,” Overcash says. “There are common comorbidities that exist within older populations, including issues of reduced independence, bone and joint pain, mobility issues, hypertension, and cardiac issues. This is what we see most often. With things like osteoarthritis, we look at how people function and what their predictors are for falls. They may need referrals for physical therapy, or we’ll contact their primary provider.”
Dementia, Overcash says, is a particularly challenging illness that can complicate cancer care. “Who’s managing it? Has it been diagnosed? Are there places of referral like memory disorder clinics where they can undergo further diagnoses? These are all very tough questions,” she says. “Not all communities have the resources needed to treat it.”
Without the proper resources to address certain comorbidities, patients run the risk of undertreating illnesses that could impact their overall outcomes. Oncology nurses are pivotal in assessing and addressing comorbidities through conversations and communication with patients and their primary providers.
Providing Individualized Care
When managing comorbidities in patients, it’s crucial to have a plan in place. “It’s important to really think about what your referral sources are,” Overcash says. “If you’re going to screen for comorbidities, you need to have referral plans for each of those and how you’re going to address them. A lot of infrastructure has to exist to make treating comorbidities effective.”
According to Wu, managing comorbidities in patients is not one-size-fits-all. “Individualized care planning is needed. It requires knowing a person’s health history, especially the existing non-cancer chronic illnesses,” she notes. “The oncology team needs to communicate and work closely with an individual’s primary healthcare providers. The individualized care planning must consider both cancer and non-cancer diseases. The continuum of care may consist of several stages and each stage has its priorities, with the focus on primary, secondary, and/or tertiary prevention for cancer and other chronic conditions.”
The oncology team needs to communicate and work closely with primary care providers to create individualized care planning that considers both cancer and noncancer diseases.
Working across disciplinary lines, speaking with other members of the healthcare team, and reaching out to family doctors are just a few ways to engage the healthcare community in addressing comorbidities.
“The entire oncology team, not only nurses, needs to be educated about how to manage comorbidities,” Wu says. “Educating patients about working with their primary care providers and developing plans for managing those illnesses during cancer treatment are vital. Patients need to be instructed to continue the treatment regimens for non-cancer health conditions, like how to manage their hypertension and/or diabetes during chemotherapy.”
“When you see a patient, you just want to fix everything at once,” Overcash says. “But you realize quickly that that’s not possible. When you’re providing care and screening for different issues like depression, falls, or malnutrition, you’ve got think about what the care plan looks like. What are you going to tackle first? What are the biggest issues? For nursing, it’s important to know what we can address today, how we can follow up on it, and how can we ensure that it’s working. From there, you can go to the next layer, so to speak, and address the next set of problems.”
For Overcash and Wu, managing comorbidities in patients with cancer is always a balancing act. Keeping open lines of communication between providers, providing referrals, and continuing follow-up with patients can go a long way to managing the complex care required for treatment. Oncology nurses are vital to ensuring that patients are managing their comorbidities to achieve the best outcomes possible.
National Cancer Institute. (2016). Annual report to the nation on the status of cancer, 1975–2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast or prostate cancer: Questions and answers. Retrieved from https://www.cancer.gov/news-events/press-releases/2013/ReportNationDec2013QandA#que12
Sogaard, M., Thomsen, R.W., Bossen, K.S., Sorensen, H.T., & Norgaard, M. (2013). The impact of comorbidity on cancer survival: A review. Clinical Epidemiology, 5(Suppl. 1), 3–29. doi:10.2147/CLEP.S47150