1. Nutrition Department, Peter MacCallum Cancer Centre, Victoria.
2. Nutrition and Dietetics, Princess Alexandra Hospital, Queensland.
3. Nutrition Department, Fremantle Hospital, Western Australia.
Increasing numbers of cancer patients are receiving radiotherapy treatment in regional areas, in addition to those requiring long-term local follow-up on treatment completion at metropolitan centres. Dietitians in rural and remote areas are by necessity required to practise a broad range of nutritional interventions. A limited knowledge of specialist cancer nutritional management, particularly for head and neck and upper gastrointestinal cancer, can arise from lack of exposure to a cancer caseload, limited access to professional development and recruitment and retention issues. Mentoring and professional support has been demonstrated to improve confidence, facilitate skill development and build professional networks. Mentoring and professional support programs in head and neck and upper gastrointestinal cancer across various states in Australia assist regional dietitians and other health professionals in improving care for regional cancer patients through support in delivering a high quality and sustainable service.
Between 2003 and 2007 a total of 174,714 cases of cancer were diagnosed in regional and remote areas of Australia.1 Cancer patients living in rural and remote areas are known to have poorer outcomes than those in metropolitan areas.2 The mortality rate for all cancers combined for people living in remote and very remote areas of Australia over the five years from 2003 to 2007 was higher than for people living in more urbanised areas.1Numerous authors have discussed the disparities in treatment outcomes between metropolitan and regional areas.2-4 A multitude of reasons have been proposed to explain this disparity, including stage of cancer at presentation, socioeconomic disadvantage, indigenous status, treatment disparities and the comparatively small cancer caseloads of regional clinicians.2,3 Initiatives such as the National Radiotherapy Single Machine Unit trial have stemmed from the need to decentralise cancer services and provide access to treatment closer to home for patients living in regional areas.5 The impact of the trial was to redistribute radiotherapy services from metropolitan areas through an increase in the number of patients receiving radiotherapy at regional centres.5 The increasing numbers of cancer patients receiving medical treatment in regional centres, in addition to those requiring long-term follow-up care upon completion of treatment at metropolitan sites, highlights the importance of evidence-based supportive care and allied health services to be provided alongside medical care.
Dietitians in rural and remote settings are required to provide a broad range of patient care for all patients with cancer, often without having the opportunity to gain specialist experience. Exposure to cancer caseloads may be limited, particularly in relation to rare or complex cases which tend to be treated in metropolitan centres.4,6 Some authors recommend the establishment of regional cancer centres of excellence, with multidisciplinary care and support and educational services with links to metropolitan sites for mentoring and continuing professional development to address this issue.4,7 Dietitians in metropolitan cancer centres have a professional responsibility to provide support and mentoring for rural and remote colleagues.
In addition to the generalist nature of rural dietetics practice, a number of factors may contribute toward a limited knowledge of cancer nutrition in rural and remote areas. These include minimal exposure to oncology cases during undergraduate clinical placements and limited access to professional development, as well as recruitment or retention issues. Difficulty in recruiting and retaining staff in rural and remote areas can lead to high staff turnover and loss of knowledge and experience, highlighting the importance of ongoing and sustainable mentoring and professional support.
Mentoring and professional support models in cancer nutrition trialled in Australia have focused on nutritional management of patients with head and neck or upper gastrointestinal cancers. These tumour types were chosen due to the impact of the tumour and the treatment on nutritional status. The prevalence of malnutrition prior to head and neck surgery ranges from 20-67% and prior to chemoradiation can be as high as 50% of patients.8-10
Nutritional intake may be further compromised during treatment secondary to anatomical changes following surgery and from the acute toxicities of chemoradiation, including mucositis, xerostomia and dysgeusia, with up to 57% of patients requiring enteral feeding during treatment.11 The literature reports patients with tumours of the upper gastrointestinal tract experience similar nutritional concerns. Up to 69% of patients with oesophageal cancer experience weight loss with mean weight loss between 13 and 16% of body weight.12 A recent study demonstrated 75% of gastrointestinal cancer patients experience loss of weight during chemoradiation.13 Following the completion of treatment, acute toxicities can take months to resolve.14,15 Evidence-based guidelines for the nutritional management of patients receiving radiotherapy recommend a minimum six month follow-up for patients who require enteral feeding during radiotherapy.16 Follow-up should ideally occur close to home.
In complex cases there can be long-term consequences for nutrition, with one study demonstrating a gastrostomy tube dependency rate in head and neck cancer patients of 19% at 12 months following completion of chemoradiation.17 Throughout Australia, most head and neck and upper gastrointestinal cancer patients receive treatment in a few tertiary centres, often travelling vast geographical distances and returning home to receive community follow-up. The post treatment period is when rural dietitians are most likely to come across these patients during long-term follow-up care of complex cases discharged from metropolitan centres. Close links with metropolitan colleagues are vital to ensure continuation of optimal patient care.
The literature describes numerous benefits to mentees from mentoring, including improved confidence, skill development, enhanced professional support networks and improved recruitment and retention of staff.18-20 Valued qualities of a mentor are reported as experience and knowledge in the practice area and traits such as a friendly and positive personality.21 While traditional mentoring has involved a one to one relationship, new models of mentoring are emerging in the form of peer and group mentoring, with demonstrated effectiveness.22 Several strategies to provide mentoring and professional support to rural and remote dietitians have been employed across various states, although all have used a component of group based mentoring due to the numbers of dietitians involved. These programs have used concepts from mentoring models and adapted them to the specific professional support needs of the group, with most containing a multidisciplinary element. Strategies used have included the employment of experienced oncology dietitians as mentors or facilitators, workshops, interactive videoconferences and shadowing/observation of clinical practice.
A partnership between Western and Central Melbourne Integrated Cancer Service and Loddon Mallee Integrated Cancer Service was formed in 2010, to undertake a project funded by the Victorian Government to improve care for regional cancer patients through support and mentoring of regional health professionals. The project built upon a previous Commonwealth funded mentoring project. It aimed to provide a model of support for regional dietitians and speech pathologists through training and mentoring, at both a general cancer level and the development of specialist skills in head and neck and upper gastrointestinal (GI) cancer management. The project was undertaken in three stages. The first stage consisted of a learning needs survey distributed to dietitians, speech pathologists and nurses in the Loddon Mallee region. The survey enabled regional clinicians to identify their learning needs from a list of areas in the management of head and neck and upper GI cancer, as well as their level of confidence in management of specific discipline related issues in these tumour groups.
A project dietitian from Peter MacCallum Cancer Centre and a project speech pathologist from St Vincent’s Hospital, Melbourne, were employed for the second stage of the project, developing and delivering education and training to the regional clinicians. This included two day workshops attended by 15 dietitians, 10 speech pathologists and six nurses. The workshop content was based largely on the learning needs identified in the needs survey. Following the workshops, six dietitians and two speech pathologists participated in shadowing visits which involved regional clinicians visiting one of the metropolitan hospitals to consolidate skills learnt during the workshops and observe and participate in patient management. Site visits were also conducted by the project clinicians, upon request, to visit clinicians in their regional setting to consolidate skills in a local setting with local patients. Resource packs containing theory on evidence-based nutrition, speech and swallowing management of head and neck and upper GI cancer, references and resources, case studies, referral pathways and discharge proforma’s between regional and metropolitan centres, and patient education material, were developed by the project clinicians and disseminated to the workshop participants. The content was informed by feedback from participants during a brainstorming session at the workshops, the workshop evaluation and any unmet learning needs from the needs survey.
The final stage was the development of a sustainable model of mentoring and support to maintain and build on the knowledge, skills and confidence in nutrition, speech and swallowing management of head and neck and upper GI cancer in the Loddon Mallee region. A key element of the sustainability plan was the establishment of regional lead clinician roles in the disciplines of dietetics and speech pathology, with responsibility for updating the resource packs annually and facilitating ongoing professional development opportunities in the region with support from the metropolitan clinicians.
Evaluation following the workshops indicated all participants had an increased knowledge of head and neck and upper GI cancer management. Final evaluation at project completion demonstrated educational needs had reduced and confidence had increased.
An opportunity to address the professional development needs of health practitioners working with the long-term and complex needs of patients with head and neck cancer came through the Cancer Care Workforce Learning and Development Initiative. This employed four 0.5FTE Workforce Development Officers commencing in 2009, with positions funded until June 2011. Each Workforce Development Officer has a statewide clinical portfolio focused around the key allied health areas documented in the Queensland Statewide Cancer Treatment Services Plan 2008-17. Within each clinical portfolio area, the brief was to look at new ways of learning and to develop mentoring type programs modelled on the Pharmacy Mentoring Program at Princess Alexandra Hospital (2006-07). In May-June 2009, the Head and Neck Cancer Mentoring Program was piloted as a structured five week mentoring program for staff working in both metropolitan and rural/remote areas.
Fifty participants from allied health, oral health, nursing and medical streams provided individual learning objectives, a learning contract and demonstrated manager support. Funding was available for an experienced speech pathologist and dietitian to develop the content and deliver the program. A specialist dentist also delivered a videoconference attended by an additional 51 oral health staff.
The program incorporated five two-hour interactive videoconferences. Content was tailored to mirror participants’ learning objectives and focused on the problems experienced by head and neck cancer patients that are often addressed by allied health staff. Participants were encouraged to share individual case studies and experiences with the group. Phase I evaluation included participant and line manager email surveys and focus groups. It was identified that the coordinated approach contributed to the program’s success.
The very popular pilot program resulted in further funding for July 2009 – June 2010. The program was renamed Head and Neck Cancer Peer Support Program to reflect the diverse needs of participants. The 91 participants linked in from 19 videoconference sites, ranging from tertiary hospitals to community health centres and more remote areas.
Modifications to the format included videoconferences every two months with different times to accommodate staff shifts, some sessions more in-depth and discipline specific, and a continued focus on case studies and active participation. Telephone/email mentoring by a dentist, speech pathologist or dietitian was also available. Sixteen clinical observership visits were provided to multidisciplinary clinics held at Princess Alexandra Hospital and Royal Brisbane and Women’s Hospital. A face-to-face workshop was also held at the 2010 Advancing Key Initiatives in Cancer Care forum in Brisbane. Positive feedback from the Phase II evaluation in June 2010, led to continued funding to the program for another year. An online community of practice forum is currently being developed.
This program is an example of a successful interprofessional education program for health professionals working in cancer care. Participants have reported an increased understanding of the roles of other disciplines, as well as improved referral processes. It demonstrates a strong perceived need among professionals for professional support in this area and highlights how technology can assist networking and information sharing for clinicians despite geographical distance.
In Western Australia, the Head and Neck Cancer Education Roadshow was developed and taken out to all seven rural regions of WA. Roadshow team members included a cancer nurse coordinator, speech pathologist, dietitian, dentist and doctor (radiation oncologist or surgeon, with a link to the rural area). Commencing in November 2009, the team, with the support of the Western Australian Cancer and Palliative Care Network and the Western Australian Clinical Oncology Group, aimed to visit each of the rural regions of WA over a 14 month period, equating to approximately one show every two months.
The aim of the roadshow was to increase knowledge and skills of health professionals in the management of head and neck cancer. This included all facets of management, including detection, referral to specialised multidisciplinary clinics, treatment involved and associated side-effects (including management) and post-treatment rehabilitation. Additionally, the roadshow aimed to break down the barriers between urban and rural health professionals.
To cover the aims of the roadshow, two sessions were conducted in each region. An evening show aimed at all health professionals provided an overall picture of the head and neck cancer patient and the multidisciplinary team, including detection of the cancer, treatment of the cancer, dental management, side-effects and post-treatment rehabilitation. Each team member presented a snapshot of their role, demonstrating how the team worked together. The emphasis of the first session was on signs, symptoms, treatment and referral pathways. The second session targeted supportive care workers, building on the overview from the evening session. It provided practical information on the management of dysphagia, nutrition, symptom management and laryngectomy care. Case studies and real-life patient presentations were used to give practical and useful information.
Attendance at the roadshows varied with the size of each region. Input from rural cancer nurse coordinators has been crucial in ensuring good attendance from all health professionals. On assessment of attendees after the first three shows, the greatest proportion of attendees was from dental health and nursing (24% and 23% respectively). Remaining attendees were fairly evenly split between general practitioners (8%), speech pathologists (11%) and dietitians (8%).
Feedback was obtained from participants through the use of a questionnaire (completed at the end of each session). Feedback has been collated from the first three roadshows. The responses were positive with the majority of attendees agreeing that they would make changes to their practice. Comments from participants included: “Increased awareness of specialised multidisciplinary clinics”; “Better understanding of the treatment pathway prior to seeing rural clinician”; “Understanding the role of each profession in managing head and neck cancer patients”; and “More aware of the pathways to get advice and help for patients”. Comments provide a strong indication that the aims of the roadshow were achieved. In addition, the presenting team has been able to reflect on their practice and improve handover procedures to their rural counterparts.
Dietitians and other health professionals in rural and remote areas have demonstrated their willingness to participate in professional development and mentoring programs provided by metropolitan colleagues. These programs have been designed to increase confidence and skills in head and neck and upper GI cancer management and provide valuable networking opportunities. Positive outcomes have included improved understanding of multidisciplinary roles, improved referral processes and increased awareness of the availability of support from metropolitan colleagues. These programs have potential for broader application to other health disciplines and tumour groups and should be assessed for longer term impact on patient outcomes.
Victorian project: Loddon Mallee and Western Central Melbourne Integrated Cancer Services partnership project governance group, in particular project speech pathologist Belinda Gray. Queensland project: Cancer Care Workforce Learning and Development Initiative, Kelli Hancock, Belinda Morey, Dr Michael ‘Pat’ Jackman, Alana Fraser. Western Australia: Western Australian Cancer and Palliative Care Network, in particular project speech pathologist Vivian Tai and cancer nurse coordinator Rachel Jenkin. Dr Claire Palermo for her expertise and advice on mentoring and review of the manuscript.
8. Capuano G, Gentile PC, Bianciardi F, Tosti M, Palladino A, Di Palma M. Prevalence and influence of malnutrition on quality of life and performance status in patients with locally advanced head and neck cancer before treatment. Support Care Cancer. 2010;18(4):433-437.
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