Optimizing the Care of Older Canadians with Cancer and their Families: A Statement Articulating the Position and Contribution of Canadian Oncology Nurses

CANO/ACIO POSITION STATEMENT

Position Summary

• The aging population presents a new reality for Canadian oncology nursing care. The variation and potential complexity of the needs of older adults with cancer and their families1 requires integrative, comprehensive, and tailored approaches to care.

• Canadian oncology nurses envision quality care for older adults with cancer and their families that honors strengths, promotes accessibility of care and optimal communication (in-person and virtually), supports treatment decision making processes, proactively assesses and addresses age-related concerns, involves effective interprofessional and interdisciplinary teamwork, and ensures active collaboration among community and cancer care providers.

• Oncology nursing practice is key to this quality care. Canadian oncology nurses notice patient and family concerns; advocate for the patient and family within and beyond health care teams; and act to optimize care by managing age-related needs, facilitating referrals, and coordinating care.

• To contribute fully to quality of care for older adults with cancer, Canadian oncology nurses require support and resources in clinical practice, leadership, education, policy, and research.

INTRODUCTION

Canadian oncology nurses face important challenges in providing care for older adults with cancer and their families. These challenges are often related to a misalignment between the healthcare system environment, processes, and resources and patient/family needs. This misalignment leads to challenges in care delivery, contributes to ethical dilemmas, and impacts treatment outcomes and healthcare costs.

Engagement from Canadian oncology nurses in clinical practice, leadership, policy, education, and research is necessary to address these concerns. In addition, these issues and concerns are not specific to oncology nursing care. Oncology nurses call on all nurses, in primary, community, and other acute areas of specialty care, to join them in optimizing care for this growing group of patients. Furthermore, Canadian oncology nurses recognize the need for regional variation in how recommendations are implemented, with specific attention to differences among provincial cancer care systems, urban and rural centers, as well as intersectional needs of diverse groups, particularly indigenous, immigrant groups, and people in precarious economic or living situations. The appendix provides background about cancer and aging in Canada, the Canadian context of cancer care, and the work that informed the development of this position statement.

VISION FOR QUALITY CARE

Canadian oncology nurses envision quality care for older adults with cancer and their families that:

• Honours the strengths and life experiences that older adults bring to their cancer experiences.

• Ensures accessibility of care and optimal communication for in-person and telehealth/virtual visits, with necessary accommodations available for those experiencing age-related health, functional, and social changes (e.g., mobility issues, hearing/vision/cognitive impairment, transportation issues).

• Supports processes of treatment decision making that ensure

  • ▪ provision of information not only about medical risks and benefits, but also about the requirements of the treatment trajectory and the potential impact of complications and side effects on day-to-day activities and those close to them; and

  • ▪ appropriate assessment of decision-making capacity.

• Proactively identifies and addresses age-related concerns that impact cancer care and treatment.

• Provides comprehensive assessment of patients’ health, functional, and social situation prior to treatment, to

  • ▪ inform appropriate treatment recommendations aligned with patients’ goals of care;

  • ▪ ensure patients and families receive appropriate information throughout the trajectory;

  • ▪ recognize unique challenges posed by various living situations, such as isolation or residential care; and

  • ▪ put necessary supports in place for older patients and their families through the cancer care continuum, from prevention and diagnosis, through treatment, and into survivorship and/or end-of-life care.

• Involves effective interprofessional and interdisciplinary teamwork, within and beyond cancer centres, to

  • ▪ optimize nurses’ contribution within the oncology care team and involvement in treatment decision making,

  • ▪ ensure effective and timely collaboration with allied health care professionals, and

  • ▪ facilitate access to geriatric expertise, if needed.

ACTION STATEMENTS

To contribute fully to quality of care for older adults with cancer, Canadian oncology nurses require support and resources in clinical practice, leadership, education, policy, and research.

Clinical Practice

• Increase awareness of aging and age-related issues, and available tools and resources to inform cancer care of older adults and their families, among point-of-care nurses, educators, and clinical leaders.

• Oncology nurses have the language, knowledge, tools, and resources to proactively identify, articulate, and address age-related concerns in their practice.

• Promote integration of validated geriatric screening and assessment tools into oncology nursing practice to support personalized care. For example, by providing simple clinical resources to facilitate screening and assessment of age-related concerns and guide appropriate intervention and referral.

• Tailor content and delivery of patient and family education to older patients and their families.

Leadership/Administration

• Ensure space and time to

  • ▪ conduct appropriate screening and assessment of age-related concerns prior to treatment, and

  • ▪ coordinate interprofessional and interdisciplinary management of identified concerns.

• Implement models of nursing care that promote early geriatric screening and assessment, knowing the older patient through the trajectory, and continuity of care (e.g., navigation, primary nursing, nurse-led clinics) to facilitate proactive management and understanding of changes in health/ functional status to inform ongoing treatment decision making.

• Encourage and support nursing specialization in geriatric oncology.

Education

• Provide specific training about aging and age-related concerns in cancer care, as well as the available tools and resources to identify and address these concerns, for all nurses working in oncology settings in

  • ▪ pre-licensure nursing education programs,

  • ▪ oncology nursing orientation, and

  • ▪ on-site clinical education.

• Integrate geriatric oncology into nursing and oncology nursing certification.

• Develop geriatric oncology post-licensure nursing continuing education programs and certificates.

• Develop specialized geriatric oncology nursing training programs and certification.

• Coordinate local, provincial, and national nursing and interprofessional education initiatives.

• Promote this work within Canadian Association of Schools of Nursing.

Policy

• Establish definition of standards of care and competencies for specialized geriatric oncology nurses, specialized oncology nurses, and all nurses providing care to older adults with cancer.

• Collaborate with other professions and organizations, such as the Canadian Partnership Against Cancer and the Canadian • Network on Aging and Cancer, to integrate geriatric oncology evidence into practice and address systemic ageism.

• Collaborate with Accreditation Canada to develop an accreditation tool to assess health systems accessibility to older adults with cancer.

• Develop and promote use of national measures that reflect outcomes of importance to older adults, such as functional status.

• Improve availability of community care for older adults with cancer and their families and strengthen collaboration between community and cancer care to

  • ▪ ensure timely access to needed supports for day-to-day activities and wellness checks during and after treatment;

  • ▪ optimize communication between community health/social care providers and cancer care providers; and

  • ▪ promote oncology knowledge, training, and resources among community health and social care providers.

• Ensure patient, family, and community care providers have access to information about resources to address age-related concerns as older adults start oncology treatment.

Research and Quality Improvement

• Support clinical research projects and quality improvement initiatives that include older adults, are tailored to their needs, and consider outcomes of importance to them.

• Ensure concepts and outcomes, such as quality of life, are appropriately defined for older adults.

• Promote inclusion of older adults in clinical trials.

• Promote research that provides understanding of the impact of oncology nursing interventions for older adults and their families, including nurse sensitive indicators.

• Support knowledge translation of emerging geriatric oncology evidence into practice.

Within CANO/ACIO, there is a strong commitment to addressing the needs and concerns of older Canadians with cancer by raising awareness, promoting education, and supporting the development of clinical resources.

APPENDIX

Background

In 2019, 61% of new cancer cases in Canada were expected to occur among people aged 65 years and older (Canadian Cancer Statistics Advisory Committee, 2019). The number of Canadians in this age group has nearly doubled in the past 20 years, and is expected to nearly double again in the next 20 years (Statistics Canada, 2019), with a corresponding increase in the number and proportion of older Canadians with cancer (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2015). There is no clear definition of an older adult, with suggested chronological age cut-offs ranging from 60 to 85 (Scotté et al., 2018). Thus, aging is better understood in terms of physical, functional, psychological, social, and existential changes that happen in different ways for different people (World Health Organization, 2015).

Geriatric oncology evidence and understanding have an important role to play in cancer care delivery when age-related changes impact cancer and cancer treatment (White & Cohen, 2006) and when cancer and cancer treatment affect experiences of aging (Hurria et al., 2016). However, despite requiring special consideration with tailored policies and approaches in cancer care, the aging population is often over-looked (World Health Organization, 2020). Age-based disparities in survival (Canadian Cancer Statistics Advisory Committee, 2019; Canadian Partnership Against Cancer, 2017); clear patterns of suboptimal treatment (Canadian Partnership Against Cancer, 2017); and unmet medical, informational, emotional, and physical needs (Puts et al., 2012; Tremblay et al., 2013, May 28–30; Williams et al., 2019) suggest that more work is necessary to optimize care for older Canadians.

In their Strategy for Cancer Control 2017–2022, the Canadian Partnership Against Cancer called for new initiatives that “address the needs of older people with cancer” to improve the quality of cancer care (Canadian Partnership Against Cancer, 2016, p. 34). They later highlighted the importance of ensuring that different populations receive services tailored to their healthcare needs (Canadian Partnership Against Cancer, 2018). Oncology nurses are uniquely positioned to identify and address concerns related to aging (Strohschein & Newton, 2018), but are under-prepared to meet growing demands (Bond et al., 2016). The Canadian Association of Nurses in Oncology (CANO/ACIO) Oncology & Aging Special Interest Group identified the need for a position statement concerning nursing care of older adults with cancer and those close to them to articulate common goals; promote integration of existing evidence into practice; and enable nurses to advocate for education, support, and resources.

Previous Position Statements

In 2007, the Oncology Nursing Society and the Geriatric Oncology Consortium published a joint position statement on cancer care for older adults, which updated their previous statement published in 2004 (Oncology Nursing Society & Geriatric Oncology Consortium, 2004, 2007). This statement identifies concerns related to the provision of cancer care for older adults and advocates for optimal care. However, the authors do not address challenges and potential contributions of nursing practice. In 2011, the Hartford Institute for Geriatric Nursing, together with specialty nursing associations, articulated a Global Vision for Care of Older Adults (Esterson et al., 2009; Mezey, 2009). This statement addresses nursing practice in caring for older adults but does not consider the unique context and challenges of cancer care.

As CANO/ACIO Oncology & Aging Special Interest Group members identified the need for a position statement on this topic, the International Society of Geriatric Oncology (SIOG) Nursing and Allied Health Interest Group saw this also as an international need. Therefore, the SIOG Nursing and Allied Health Interest Group, in collaboration with the CANO/ACIO Oncology & Aging Special Interest Group and the European Oncology Nursing Society, concurrently developed an international position statement (Puts et al., 2021). This Canadian position statement complements the International statement.

The international statement presents eight key points calling for oncology nurses’ active engagement in optimizing, and supporting, the care of older adults with cancer and their families (Puts et al., 2021). This Canadian statement supports this vision, articulating the quality of care called for by Canadian oncology nurses and highlighting key action points. The purpose of CANO/ ACIO’s Canadian statement is to articulate the current position of Canadian oncology nurses related to the care of older Canadians with cancer, recognizing the unique context of Canadian cancer care and considering the current situation of knowledge and practice in geriatric oncology in Canada. It includes a clear commitment from CANO/ACIO in addressing the needs and concerns of older Canadians with cancer.

Canadian Context of Cancer Care

Cancer care in Canada is provided within a universal, public health care system (Martin et al., 2018), with provincial/ territorial delivery of health services mandated by the Canada Health Act. As a result, there are 13 parallel cancer care programs in Canada, with territories providing many treatments and services in collaboration with neighboring provinces. National coordination of optimal cancer system performance is facilitated by the Canadian Partnership Against Cancer.

Canada is characterized by its large geography (almost 10 million km²) and a small population of approximately 38 million people (Statistics Canada, 2020). Geographical health disparities exist with Canada, with health outcomes generally improving from east to west, north to south, and rural to urban (Sutcliffe, 2011). For example, lung and colorectal cancer incidences are generally highest in the eastern provinces, Northwest Territories, and Nunavut, associated with increased modifiable risk factors, such as smoking and obesity, in these regions (Canadian Partnership Against Cancer, 2018). Canadian geography also contributes to important regional differences in the accessibility of cancer care and service delivery. The distribution of older adults also varies by province: Newfoundland has the highest proportion of people aged 65 years and older (22%) and Nunavut has the lowest (4%) (Statistics Canada, 2021).

Oncology nursing is supported nationally through CANO/ACIO, with oncology certification being offered through the Canadian Nurses Association. Entry-to-practice nursing education varies by province, including college, baccalaureate, and masters’ degree levels. Graduate nursing education is offered by universities in all provinces. Herein exist opportunities for optimizing care of older adults with cancer in clinical practice, leadership, policy, education, and research at local, regional, provincial, and national levels.

The Canadian Network on Aging and Cancer, established in 2016 (Puts et al., 2017), brings together Canadian clinicians, researchers, and educators with an interest in geriatric oncology, across disciplines and health professions. Currently, there are few established geriatric oncology clinics in Canada, currently existing only in Quebec and Ontario. In contrast, the United States and many European countries, such as France and Belgium, have actively worked to establish geriatric oncology clinics and networks (Puts et al., 2017). Although Canada is among high-income countries with the highest overall cancer survival for several common cancers, Canada falls behind other high-income countries in terms of absolute increase in survival for people aged 75 years and older for some of these cancers (Arnold et al., 2019). Most notably, survival of older Canadians with lung and colorectal cancers, the most common cancer diagnoses among older Canadians, is increasing more slowly in Canada than in other high-income countries (Arnold et al., 2019).

Equity is a priority within Canadian cancer care (Canadian Partnership Against Cancer, 2018, 2019). Canadian cancer care disparities are primarily considered with respect to socioeconomic status, rurality, ethnicity, and regional groups (Ahmed & Shahid, 2012; Canadian Partnership Against Cancer, 2019). This same attention must be given to disparities that affect older Canadians, the largest group within our cancer care system.

Position Statement Development

The need for a position statement concerning oncology nursing practice in the care of older adults with cancer and their families was first identified at the annual meeting of the CANO/ACIO Oncology & Aging Special Interest Group in October 2017. At this meeting, CANO/ACIO Oncology & Aging Special Interest Group members expressed the need for a document concerning oncology nursing care of older adults with cancer that could be used to articulate common goals; promote integration of existing evidence into practice; and enable nurses to advocate for education, support, and resources. Work towards position statement development began at a 2018 CANO/ACIO conference workshop, in which CANO/ACIO board members and conference attendees confirmed the importance and relevance of developing a position statement on this topic. Given the richness of the conversation and insight that occurred in this conference workshop, 12 additional roundtable sessions were conducted in English and French from March 2019 to February 2020 with nurses across Canada and a bilingual online survey was circulated (Strohschein et al., 2021).

Therefore, this position statement is informed by the perspectives of 170 nurses, 160 of whom are specialized in oncology, working across nine provinces in clinical practice, leadership/administration, policy, education, and research (Strohschein et al., 2021). A draft position statement was presented to CANO/ ACIO members during the 2020 virtual conference, as well as at meetings of the Oncology & Aging Special Interest Group, the Council of Special Interest Groups, and the Council of Chapters. We integrated the feedback that we received. In this way, this Canadian position statement represents the collective concern and current perspectives of these voices. It is a call to action.