Page 38 Complete Your CE Test Online - Click Here In order for any of these options and choices to be available, the patient must have a frank discussion with the doctor about the proven benefits of the recommended treatment options and why one drug might be better than or equivalent to another. This is also an aspect of ongoing informed consent. When current financial barriers are identified, it can also help to refer the patient to the financial staff to find out about working with their insurance coverage. A medical social worker might be appropriate to refer the patient to other sources of help, such as Prescription Assistance Programs, local charity funding, and government programs for which they might qualify. People with health insurance nearly always have the right to make an appeal if coverage for an essential service is denied. Medical social workers or financial counselors at the facility can also help with this, and more information can be found online at http://www. Case study: Robert is a 62-year-old man with extensive-stage small cell lung cancer. He has had combination chemotherapy with carboplatin, etoposide, cyclophosphamide, doxorubicin and vincristine. He is back in the hospital with pneumonia three months after completing four cycles of chemotherapy. Scans have shown some progression of his disease, with larger metastases in his other lung. His doctor has now recommended a second-line treatment of IV paclitaxel weekly for eight doses after he goes home. When you talk with Robert about going home, he says that he does not think he wants this treatment and he is thinking of asking his doctor about “one of those new targeted pills I’ve heard so much about” from his lung cancer support group. He thinks it might produce a cure, and is hoping it will cost less than the IV treatment. You are concerned about this, and recommend that Robert talk with his doctor about the goals of treatment. You further explain that most people with extensive-stage small-cell lung cancer are treated to slow the growth of the cancer. When you come in again later, he and his wife are talking about taking out a second mortgage on the house to cover the cancer treatment he has already received and to help with future costs. You ask them if their finances are causing problems, and find out that he has learned his private health insurance plan counted some of his visits to specialists as “out of network.” Even for in-network care, copays have added up quickly. His illness is also causing him trouble at work and he is afraid he will lose his job and his health insurance. What do you do now? 1. Ask him if he has talked with his insurance administrator about his billing, and whether he has appealed the decision of his insurance company to withhold payment for his prescribed specialty care. 2. You explain that even though targeted drugs are helpful in non- small-cell lung cancer, most have not been shown to be as helpful in small-cell cancer, although research is still ongoing. You further mention that most of the targeted oral drugs are reimbursed in a different way than IV drugs, so that they often cost the patient more. This is also something he could discuss with his doctor. 3. Since you have already spoken with him about talking with his doctor about goals of treatment, and he is not asking more about that, do not bring it up again unless he has specific questions. 4. You ask if he has ever thought about clinical trials for people with extensive small-cell lung cancer in his situation, since some of the expenses might be covered by the trial administrators. This is something else he could bring up with his doctor. 5. Suggest that he discuss his health coverage and job situation with a medical social worker. Let the couple know that if he does quit or lose his job, he has a 60 days to enroll in a new health plan on the Health Insurance Marketplace, even if it does not happen during the annual open enrollment period. He can call 1-800-318-2596 or go online to to get started. This is called a Special Enrollment Period [274]. 6. All of the above. Depending on how much time you have, and how he responds to the discussion, answer six may be most appropriate. You are concerned that Robert does not understand that his prognosis is very limited, but you have already given him some information and suggested that he discuss this with his doctor. Now there is the additional issue that he is looking for less expensive treatments by asking for a treatment that not only is likely to cost him more, but is unlikely to accomplish what he hopes it might. A lot of people do not know that they can appeal an insurance plan’s decision. Most health insurance plans are required to review their decisions when asked, and in some cases the patient can even request an external review. It could be very useful for this patient to pursue an internal appeal, and if that doesn’t work, resort to an external appeal. More information can be found online at, if he searches “appeal a health plan decision.” The financial staff or medical social worker should be able to help too. Although some 60% of children with cancer are enrolled in clinical trials, fewer than 5% of adults are [18]. This is likely one of the reasons that cancer treatment has evolved more slowly in adult care. Health insurance companies in the past sometimes denied treatment coverage to people who were in clinical trials, but regulations have changed with the Affordable Care Act. Now health insurance plans largely do not put up barriers to participation in clinical trials. The difficulty is finding one for which the patient qualifies, since some exclude patients on certain medications or with co-morbidities. Patients can find out about clinical trials and possible matches using the Clinical Trials Matching Service from the American Cancer Society (see “Patient Resources”). Most people who have health insurance coverage at work can keep their health coverage even if they lose or must quit their jobs, through a program called COBRA. However, this tends to be a fairly costly option for most people. Another option for them might be the State Health Care Marketplace, which has an annual Open Enrollment Period near the end of each year during which people who do not qualify for other health coverage can sign up. But people who have changes in their life situation during the year that results in loss of health coverage (or if they gain an immediate family member through marriage, childbirth, or adoption) typically qualify for a Special Enrollment Period on the Marketplace. The patient must sign up within 60 days after their coverage is lost. However, if a person loses health coverage because they did not pay premiums, they do not qualify for a Special Enrollment Period [276]. If Robert loses his job and his spouse is employed in a workplace that offers family or dependent health plans to employees, he may be able to sign on to his spouse’s workplace policy. However, that option must be exercised even more quickly than the Marketplace option, as the special enrollment period is typically 30 days after loss of a health plan to sign onto a family member’s workplace insurance [279]. Finally, if Robert is concerned about his ability to do his job or concerned he will lose his job, it might be helpful for him to talk with his employer about Family and Medical Leave, so he can take time off for treatment. If side effects are a problem, the Americans With Disabilities Act may help him with some accommodation from his employer as long as he can do the essential duties of his job. If Robert waits too long while his cancer treatment is interfering with his work and is fired, he will lose access to benefits that he could have used if he had asked for help sooner. He does not have to share his diagnosis with his employer but he may need help from his doctor with legal paperwork. Posttreatment assessment, education, interventions: Survivorship There are differing definitions of “cancer survivor.” The National Cancer Center Network (NCCN) and some others define a cancer survivor as a person who has been diagnosed with cancer, for the rest of their lives [209]. But some people do not want to call themselves “survivors” until after treatment is over and if they have a good prognosis. The first part of this module focused on the diagnosis and treatment phases of survivorship. This section (like many survivorship plans) pertains mainly to the after-treatment phase of survivorship, especially that time in which nursing intervention and education is most needed. After treatment Patients often anticipate the end of their cancer treatment with a mixture of relief and dread. They are often happy that they do not have to get more cancer treatment, at least for now, but they usually understand that there is a risk of recurrence, or the possibility that the cancer is