Results from this study show that nurses can well perform follow-up of patients at home after upper gastrointestinal cancer surgery. Nurse-led follow-up had some small, statistically nonsignificant, positive effects on quality of life and satisfaction of patients and spouses. In addition, this follow-up strategy was most likely to be cost effective compared with standard follow-up.
As far as we are aware, no previous studies have reported about follow-up of cancer patients by home visits, although nurses have increasingly become involved in the care of patients with malignancies (Loftus and Weston, 2001
). Results from this study are in line with findings in other studies, in which nurse-led follow-up of patients undergoing pelvic radiotherapy (Faithfull et al, 2001
) or with lung cancer (Moore et al, 2002
) was also reported to be effective with regard to assessment of symptoms, patient satisfaction and costs.
For some disease-specific or generic quality-of-life scores, slightly more improvement was noted for the nurse-led than the standard follow-up group. We found no differences in quality-of-life scores over time in the two follow-up groups. In agreement with other studies, the largest improvement in quality of life was seen during the first months after surgery (Zieren et al, 1996
; De Boer et al, 2000
; Brooks et al, 2002
). It has previously been reported that some symptoms, such as early satiety, fatigue and diarrhoea, still persist in patients 2 years after oesophageal resection and without evidence of tumour recurrence (De Boer et al, 2000
; Fagevik Olsen et al, 2005
). Indeed, we found that nausea/vomiting, diarrhoea and fatigue were still present 13 months after surgery. These results confirm that a relatively extended period is required for patients to recover from oesophageal or gastric cancer surgery and to adjust to the new anatomical situation.
Assessment of patient satisfaction may provide information about the extent to which patients' needs and expectations are addressed (Bredart et al, 2005
). We found no differences in patient satisfaction between the nurse-led follow-up group and standard follow-up group, despite the fact that the duration of follow-up was longer in the nurse-led follow-up group than in the standard follow-up group (median: 43 vs
min). However, spouses in the nurse-led follow-up group were more satisfied with this new type of care compared with those of the standard follow-up group. Northouse et al (2000)
found that spouses more often reported emotional distress and experienced less social support than patients. Health professionals should include family caregivers in planned programs of care. In addition, they should support both patients and spouses, not only because both have legitimate needs for support, but also because role adjustment problems in spouses may negatively affect the long-term adjustment of patients (Northouse et al, 2000
). The results of our study support this.
If specific symptoms and medical problems occurred in the nurse-led follow-up group, patients were referred to the outpatient clinic for evaluation (n=21, 39%). We found no differences in occurrence of recurrent tumour growth and/or metastases, and in survival between both follow-up groups. This suggests that patients of the nurse-led follow-up group were adequately referred to a medical specialist for evaluation of symptoms and problems that occurred during follow-up, such as dysphagia or suspicion of recurrent malignancy. In the future, it may well be that curative treatment options for recurrent or metastatic disease will become available. If this is the case, a more active approach to detect recurrent or metastatic oesophageal cancer will most likely be part of the follow-up protocol of patients with resected oesophageal cancer.
Although the majority of patients were able to eat a normal diet or solid food with some difficulty, body weight of patients of the standard follow-up group deteriorated slightly (P=0.04), whereas body weight of patients of the nurse-led follow-up group remained stable. This can probably be explained by the fact that disease management, such as advice on food intake and diet, routinely was part of the follow-up strategy in patients of the nurse-led follow-up group and was probably less explicitly performed in the standard follow-up group.
It is remarkable that economic implications of involvement of nurses in the oncological practice have only been evaluated in a few studies (Wallace et al, 1999
; Helgesen et al, 2000
; Faithfull et al, 2001
; Basnyat et al, 2002
; Moore et al, 2002
; Niv and Niv, 2005
). We found that costs of intramural care were substantially lower in the nurse-led follow-up group, although not statistically significant. Nurse-led followed patients were less frequently admitted or visited the outpatient clinic, which translated in a reduced use of hospital-related medical services compared with the standard follow-up group. In addition, nurse-led follow-up may reconfigure care to make it more responsive to individual needs, and reduce the burden of unnecessary hospital visits and investigations for patients. Although total cost were not significantly different, acceptability curves showed that nurse-led follow-up of patients after oesophageal or gastric cardia cancer surgery was very likely a cost-effective strategy.
A limitation of this study is the limited sample size. The study was designed to test for a major difference in HRQOL (0.56 s.d., requiring >100 patients). The test was two-sided, allowing for doctors to be better or worse than the nurses. To more precisely investigate nurse-led follow-up of patients after upper gastrointestinal cancer surgery, further research is needed.
In conclusion, nurse-led follow-up at home does not adversely affect quality of life or satisfaction of patients compared with follow-up by clinicians at the outpatient clinic. Although not significant, some quality-of-life scores were in the advantage of the nurse-led follow-up group. In addition, this type of care is most likely to be more cost effective. We speculate that this type of follow-up could also be an attractive alternative to standard follow-up of patients with other types of cancer, particularly in patients in whom no curative treatment option is available for recurrent or metastastic malignancy, for example, pancreatic cancer. In addition, a nurse-led service at home may help to reduce waiting lists in hospitals and/or reduce the workload of physicians.