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Transforming patient lives through a nurse-led Herceptin clinic

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A nurse-led Adjuvant Herceptin Clinic at the Christie Hospital Foundation Trust in Manchester has completely transformed the care of countless patients with breast cancer. Nurse clinician in clinical oncology, Helen Mitchell, spoke to Vivienne Cohen about the service’s innovations since it opened just over a year ago.

Herceptin is one of a new group of cancer drugs called monoclonal antibodies. It works by interfering with one of the ways in which breast cancer cells divide and grow. In the UK, Herceptin is used mainly to treat women with breast cancer. It may be used in the early stages to increase the chances of a cure or in advanced stages to help control the disease when the breast cancer has come back.

Herceptin is given by an infusion through a cannula inserted into a vein.
Adjuvants are agents that modify the effect of other agents (much like a catalyst) while having few, if any direct effects when given themselves.

The new clinic has allowed patients to lead less disruptive lives, as Herceptin treatment is started in the clinic and is then continued at the patient’s home, via the home care treatment service, HealthCare at Home.

Since it opened in December 2006, nurses at the Adjuvant Herceptin Clinic have treated over 180 patients.

‘Under the old treatment system’, said Helen, ‘Adjuvant Herceptin treatments were co-ordinated by a pharmacist.’

She explains that at that time, patients remained under the care of their consultant teams. ‘Responsibility for giving the patient information regarding Herceptin, taking consent for treatment, prescribing treatment and requesting cardiac assessments was with the consultant or team member who saw the patient in the general clinic’, she says.

Under the old system, all 18 treatments and cardiac assessments were requested at the start of treatment. Delays in patients receiving treatments and interpretation of cardiac assessments were often delayed as patients were frequently seen in clinics either before assessments took place or at inappropriate intervals.

‘Timings of scans and treatments were difficult to co-ordinate’, says Helen.

The new service is completely co-ordinated by two nurse clinicians: Helen and Carle Farrell, a nurse clinician in medical oncology, as well as two breast care nurses, Vicky Lau and Victoria Cooper, who are both breast nurse specialists.

‘Consultants refer directly to the team prior to patients needing to start their adjuvant treatment’, says Helen.

‘All patients are then seen in the adjuvant Herceptin clinic for a full explanation regarding rationale for their treatment and the treatment plan for Herceptin.

‘Information is given regarding the action of the drug, clinical trials which have led to its use, how cardiac assessments will be scheduled and results interpreted, and when follow-up appointments will be given,’ she says.

All patients receive verbal and written information and contact details for the team. A breast care nurse requests a baseline ECG and the results are reviewed by the nurse clinician prior to the patient’s first appointment.

Helen says that consent is taken at the assessment visit and arrangements made for the patient to receive their first two treatments at three-weekly intervals in the hospital. She says: ‘Cycles 3 to 18 of the treatment are given via HealthCare at Home in the patient's own home.

‘Repeat echocardiograms are requested every 12 weeks and patients are seen in clinic one week later and assessed by the nurse clinician.

‘At this visit the patient’s cardiac assessment results are discussed and a clinical examination, including a cardiac assessment, is performed, as well as a review of the patient’s symptoms.

‘If the patient is well with no cause for concern in terms of their cardiac assessment, the nurse clinician prescribes a further four cycles of Herceptin,’ she explains.

The assessment process is continued in the same manner at 12-weekly intervals until completion of treatment. Helen adds that patients are reviewed by the nurse clinician for the entire 12-month treatment period and says that surgical follow-up at the general hospital clinic continues as scheduled to ensure that patients continue to have regular mammography assessments if required.

Finally, she says: ‘After 12 months, or if treatment is discontinued earlier, patients are then returned to the care of the referring consultant.’

Helen stresses that the consultants are very supportive of the new clinic, but says that there were some initial difficulties to overcome.

She says: ‘Difficulties were encountered in attempting to gain consensus regarding the development of a treatment protocol. There were disagreements among the consultants regarding, for example, concomitant treatment with taxanes and radiotherapy.

‘But finally,’ she says, ‘agreement was reached with individual consultants regarding their requirements and these were integrated into the protocol.

‘It was agreed that the HERA study algorithm for the management of cardiac toxicity would be used as a guide, although individual consultants are conferred with for patients who are causing concern regarding cardiac toxicity or when recurrence is suspected.’

For more information about the Herceptin clinic, contact

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