	Linda A. Lee, MD, director of the Johns Hopkins Integrative Medicine & Digestive Center (JHIMDC) in Lutherville, Maryland, believes that an integrative approach to treating conditions and symptoms helps improve patients’ quality of life. At the Second Annual NCONN Conference, she described the origin of her interest in holistic treatment. 

	Several years ago, Lee, who is board-certified in internal medicine and gastroenterology, was primarily seeing patients with chronic problems and felt improperly equipped to help them. “I felt very limited in how I had been trained. I began to learn and reach out to other healthcare providers to find out what they brought to the table regarding how to help our patients achieve a better quality of life.” 

	Integrative medicine integrates the best scientific medicine with a broader understanding of the nature of illness, healing, and wellness. This practice makes use of all appropriate therapeutic approaches and evidence-based modalities to achieve optimal health and healing, Lee explained.

	She also pointed out that integrative medicine “doesn’t reject conventional medicine, but seeks to enhance it.”  Further, while Lee is a strong supporter of integrative medicine, she doesn’t uncritically embrace all alternative practices.

	Lee’s center in Maryland, JHIMDC, is a multidisciplinary clinic for patients. Along with using the best therapies available to treat a variety of medical conditions and symptoms, the staff incorporates nutrition and other healing modalities to improve symptoms and outcomes. Medical services include acupuncture and Chinese medicine, digestive health services, integrative psychotherapy, nutrition consultations, and therapeutic massage. 

	“When a person comes to our center, we spend a lot of time educating the patient. We want them to be an active participant in their healthcare,” Lee said. The emphasis is on an individualized approach that considers a patient’s beliefs, values, and concerns.

	Cancer patients frequently deal with chronic issues. For example, breast cancer patients can experience weight gain and loss, fatigue, menopausal symptoms, psychological distress, and lymphedema. Integrative medicine may help these patients, but finding evidential support for the nonstandard therapies can be challenging. 

	“There is evidence if you look for it,” Lee said. “It’s very hard to find evidence for integrative medicine therapies in our standard medical journals. While the medical literature is full of reports, it takes time to sift through, find, and weigh how reasonable [a therapy] is.”

	Lee highlighted a study by Walker et al (http://bit.ly/gz4Y45) published in the Journal of Clinical Oncology that examined acupuncture for vasomotor symptoms in 50 patients with breast cancer. Patients were randomized to either 12 weeks of acupuncture (n = 25) or venlafaxine (Effexor) (n = 25). The results showed that acupuncture was as effective as venlafaxine in reducing hot flashes. Patients receiving acupuncture also experienced no adverse effects (AEs), compared with 18 incidences of AEs in the venlafaxine group. Within 2 weeks of discontinuing drug therapy, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. 

	Integrative therapies are safe when used appropriately, Lee informed NCONN attendees. She specifically mentioned that acupuncture needles do not cause significant bleeding, even in patients with low platelet counts or at risk for increased bleeding, and modified therapeutic massage (oncology massage) can be done safely in patients with cancer who have undergone surgery. 

	Lee noted the importance of educating patients on integrative therapy use, particularly dietary supplements due to their popularity. “Eighty percent of cancer patients you’re seeing use dietary supplements. Cancer patients love dietary supplements,” Lee said. She then described situations when specific supplements should be avoided. 

	Patients should not use probiotics if they have a central line (a tube inserted in the patient to administer treatment) and should avoid antioxidants during radiation or some forms of chemotherapy, Lee advised. “If they’re actively getting radiation or chemotherapy, I tell patients taking antioxidants at this time it is probably not a good idea because theoretically it can counteract what radiation and chemotherapy do,” she said. 

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Linda A. Lee, MD, director of the Johns Hopkins Integrative Medicine & Digestive Center (JHIMDC) in Lutherville, Maryland, believes that an integrative approach to treating conditions and symptoms helps improve patients' quality of life.

Integrative Medicine and Cancer Treatment 

	Cancer centers and institutions are embracing the role of nurse navigation as part of the changing environment of oncology care. Unfortunately, formal reimbursement for nurse navigation services is lacking.

	At the Second Annual NCONN Conference, Matthew Farber, MA, director of provider economics and public policy for the Association of Community Cancer Centers, discussed methods for reimbursement.

	Currently, navigation is done essentially without reimbursement and how it is funded varies. Hospitals and cancer institutions are funding navigation from general operating budgets, charitable donations, and government and industry grants. Furthermore, hospitals and cancer centers participating in the National Cancer Institute Community Cancer Centers Program are using grant money for navigator programs. These institutions will be responsible for funding programs after the grant money expires. 

	A valid current procedural terminology (CPT) code is needed for formal reimbursement for nurse navigation. “Right now there is no set reimbursement code that you’re writing down or no set modifier that you add to a CPT code that identifies the work you’re doing,” explained Farber.

	CPT codes are assigned a relative value unit (RVU) to determine the amount of work associated with the code. RVUs are assigned by the America Medical Association’s RVS (Relative Value Scale) Update Committee (RUC). To get a new CPT code, an application needs to be submitted to the CPT Editorial Panel & Advisory Committee. Because codes are updated January 1 of each year, it takes a year to find out if a new code is granted. Certain criteria must be met for the committee to consider a new code. If the editorial panel approves the request, it then moves onto RUC for valuation.

	“For the application, the key is to demonstrate that the service is distinct and differs from other services already being offered,” Farber advised. “It’s important to be very clear on how this is a unique service.”

	Working with advocacy organizations is also prudent, as well as attending the CPT Editorial Panel & Advisory Committee meeting. “Attend the meeting when they’re talking about your application. This can be vital if they have questions [because] you can be the expert they turn to,” said Farber. 

	Cancer organizations have been instrumental in getting bills introduced to improve the delivery of cancer care. Farber cited 2 examples: the Assuring and Improving Cancer Treatment Education and Cancer Symptom Management Act of 2009 (HR 1927) and the Comprehensive Cancer Care Improvement Act of 2009 (HR 1844). Congressional action on these bills is unlikely this year, noted Farber. 

	“Nothing is really going to happen this year because everyone in Congress is tired of talking about healthcare. We just passed this massive healthcare reform bill so Congress wants to talk about something else or doesn’t want to spend any more money.”

	Although the newly passed Patient Protection and Affordable Care Act (section 3510) would extend patient navigator programs for 5 years at $4 million a year, Farber said it will not be continued next year because the money was not appropriated for it.

	If institutions want navigation legislation passed, they should find a champion in Congress to introduce the bill. Farber said much of the initial legwork falls on the group wanting the legislation and their ability to rally members to get involved.

	Efforts are under way to have private payers reimburse for navigation services. “You really have to promote how nurse navigation services and patient navigation services can promote quality of care for patients,” said Farber. “Also payers not only want to do this, but many want to show they’re promoting quality of care while keeping costs down.”

	One way of keeping costs down is bundled payments for episodic care. In order for nurse navigation services to be included in bundled payments, “You need to be vocal and communicate with these private payers and third-party payers that this is an integral part of oncology care and without this the patient wouldn’t have this good quality of care,” said Farber.

	In addition to provider advocacy organizations, patient advocacy organizations can benefit reimbursement efforts by mobilizing patients to talk about the importance of these resources—especially when speaking with Congress and government agencies. “Not only do your patients love you, but they will speak on your behalf and advocate for you,” Farber said.

	“There are opportunities to get reimbursed. It’s a long process and there are no guarantees. Don’t get discouraged if it doesn’t work out the way you want it,” said Farber. “I know there are a lot of people who support navigation. This is an integral part of cancer care and it’s only going to grow in the future.

Cancer centers and institutions are embracing the role of nurse navigation as part of the changing environment of oncology care.

Reimbursement for Nurse Navigation:  It Can Be Done 

	Monica Knoll is no stranger to cancer. Her sister is a breast cancer survivor and her father died from esophageal cancer. Still, she was not prepared for a breast cancer diagnosis in 2000. 

	“When I was diagnosed, I was at a loss for what to do. Once I heard the words ‘you have cancer,’ I felt like I was kicked in the stomach,” she told attendees at the Second Annual NCONN Conference. “I called my nurse ‘Sarge’ because she pushed me around and really told me what to do, which I needed because I was very much in denial.”

	Now 10 years later, Knoll is a 4-time cancer survivor with a mission. “Before my cancer, I think I was lost. I didn’t really have a passion for a career. I didn’t really have a big motivating factor in my life,” she said. “Once I started talking with other breast cancer patients, I found we were overwhelmed by the process. There are so many resources we didn’t know where to begin.”

	“Navigation was not even a word that was used when I was diagnosed. So many nurses didn’t have the tools they needed to provide for patients. Great resources existed, but there wasn’t a great way to disseminate them,” she said.

	Knoll wanted a way for cancer patients to get these necessary resources. “One of the components with cancer is getting organized. I felt that was missing in the cancer world because when I was diagnosed, there was no way of getting resources organized.”

	Taking her experiences and those of other patients with breast cancer and survivors, Knoll founded the nonprofit organization CANCER101—an information resource for cancer patients&mdash;in 2002. According to CANCER101’s Website, its mission is “to empower cancer patients and their caregivers to take control over their diagnoses from the moment they learn they have cancer, a recurrence, or metastases through 10 years of follow-up care. Having a plan of attack, the means to stay organized, and access to appropriate resources and information is half the battle to getting through a cancer diagnosis.” 

		Empower patients and caregivers to get organized and informed to fight their cancer

		Help healthcare professionals better manage their patients’ needs

		Educate patients about clinical trials and how to find them

		Ensure patients receive CANCER101’s resources when they need them most: when they learn they have cancer

		Provide complementary wellness support to help patients manage their side effects and emotional well-being

		Provide a unique social media and video campaign that offers nonmedical advice for patients, caregivers, medical professionals, and survivors

		Encourage survivors to educate family and friends about early detection and prevention

	Knoll, who serves as the organization’s executive director, explained that the program has a three-fold strategy. 

	The organization provides free CANCER101 Planners to participating National Cancer Institute (NCI) and Association of Community Cancer Centers across the country. Following the first appointment with an oncology specialist, patients receive Planners that include national resources, important questions to ask their healthcare team, a glossary of medical terminology, a section for tracking medical bills, insurance information, and more. The Planners also include information provided by NCI, the American Society of Clinical Oncology, and the Coalition of Cancer Cooperative Groups (CCCG). CANCER101 also partnered with NCI to develop cancer-specific information for patients with each tumor type.

	The Planner is designed as a tool to help nurse navigators manage their patients’ medical needs. “If the nurse navigator organizes the patient, the patient will be more likely to partner and take ownership of their health. If the patient takes ownership, they will allow the nurse navigator to help more patients,” explained Knoll.

	She recommended that nurse navigators put the Planners together in advance and include additional cancer information and an NCI booklet inside the folder. Nurse navigators also should ensure patients know how to use the Planner, encourage patients to use the Planner and take it with them to all appointments, and check periodically that patients are filling out the Planner correctly.

) complements the Planner. It offers a live calendar of national teleconferences, Webinars, annual conferences, and retreats. Many of the same resources found in the CANCER101 Planner are available on the Website. An online version of the Planner and a smartphone application are under development.

	In addition to CANCER101 resources, the Website provides external links to numerous cancer resources. When you click “National Cancer Resources” under “Get Informed” on the home page, you reach a CANCER101-compiled list of available Web resources covering a variety of cancer topics. Some of the specific topics include advocacy, drug information, employment issues, fertility, and financial help.

	Another valuable tool the site provides is the “Learn From Our Partners” section, which hosts cancer resources furnished by CANCER101’s strategic partners. The Profiler Tool provided by Nexcura helps patients make informed treatment decisions by giving them access to the latest clinical research relevant to their diagnosis. The CCCG “What Is a Clinical Trial” section offers a Q&A of pertinent clinical trial topics to help patients who are weighing participation in the research programs. The “Questions to Ask Your Doctor” page by Cancer.net facilitates open communication between patients and doctors, which will empower patients as they make crucial treatment decisions.   

	CANCER101 has launched a social media campaign that offers patients, caregivers, survivors, and healthcare professionals nonmedical advice to help make their lives easier using Facebook and Twitter.

	In concluding her presentation, Knoll stressed that CANCER101 and healthcare professionals are a team. “We look at you [nurses] as our customers. We provide these resources to you as well as the patients and want your feedback.”

Monica Knoll is no stranger to cancer. Her sister is a breast cancer survivor and her father died from esophageal cancer. Still, she was not prepared for a breast cancer diagnosis in 2000

By Eileen Koutnik-Fotopoulos

Articles

Integrative Medicine and Cancer Treatment

Reimbursement for Nurse Navigation: It Can Be Done

Tools to Help Patients Navigate Their Treatment Path