Kathleen Shannon Dorcy, PhD, RN, FAAN (left)

nurse, Rose Nankinga, in Uganda in January 2018.

From her start washing laundry at a nursing home to her most recent work to improve nurse education in Uganda, Kathleen Shannon Dorcy, PhD, RN, FAAN, has felt she was called to make a difference in world health.

As director of clinical nursing research, education, and practice at the Seattle Cancer Care Alliance (SCCA), and a staff scientist at Fred Hutchinson Cancer Research Center, she mentors many nurses and expands nurse education around the world. She has been a part of moving research to bedside care and believes that nurses make important contributions to improving cancer care.

“The suffering caused by the burden of cancer cannot be underestimated,” she says. “The work we do in nursing, especially oncology, has to be a sense of envisioning better, working as a team to get there.”

This vision has driven Shannon Dorcy throughout her work in clinical care nursing, and she shares that vision with other nurses locally and globally.

After high school, Shannon Dorcy briefly joined a Dominican convent. The Dominicans believe in working with people to search for their personal truths. “The Dominicans believe truth, ‘veritas,’ is always being revealed,” she says.

Within 2 years, Shannon Dorcy left the convent, feeling her search for truth and her calling were better found in education and nursing. As a licensed practical nurse, she worked in a nursing home where she always found a way to connect with the patients through something that was important to them. Soon she was back in school earning a bachelor’s degree in nursing. Afterward, she worked in orthopedics and pediatrics, then pursued her master’s degree in nursing at the University of Washington while working in a research position in pediatric oncology at Fred Hutchinson Cancer Center.

“I had not wanted to be in cancer care,” she says. “I thought it would be too sad.” But her experiences caring for people with cancer changed her mind. “I was captivated by families and children and the people I came in contact with,” she adds.

Shannon Dorcy cared for a 3-year-old girl named Kelly with severe graft-versus-host disease after a bone marrow transplant who had come to Seattle to receive an experi¬mental treatment. Kelly responded well to the treatment, and within a few months, her treatment was approved by the FDA. Kelly was able to go home to Michigan just in time for Christmas and continue to receive the new treatment. “I felt great joy at seeing clinical research move from concept to care and bring a good outcome to a child and her family,” Shannon Dorcy says.

She has continued working at Fred Hutchinson and the SCCA. She has enrolled patients in clinical trials, worked on exciting advances in cancer care, and continued learning. In 2015, she earned her doctorate studying hope and how it influences people to enroll in clinical trials. She has also worked on early research into immunotherapy, targeted therapies, and monoclonal antibodies.

Through decades of experience in clinical research and patient care, Shannon Dorcy has a lot to share with other nurses. She’s committed to improving the profession and supporting nurses in finding their own callings.

“As nurses, we can become weary because of so many pressures,” she says. “How to be a nurse, how to keep up with outstanding scientific development, how to handle the heartbreak as illness takes babies or parents or grandparents. We need to build a sense of connection for ourselves as nurses.”

At SCCA, Shannon Dorcy focuses on empowering nurses to think differently and work with each other as well as other layers of their organizations. She encour¬ages nurses to always ask questions and seek ways to do things better and finds it rewarding to watch the nurses in her organization take the lead. One example is when a protocol was developed to implement a scalp cooling program at SCCA; the nurses were instrumental in bringing that service to patients.

In addition to mentoring nurses, fellows, and students, Shannon Dorcy represents SCCA as part of a community effort called Career Work$ Medical, which prepares participants for careers in the healthcare industry. Seattle is notoriously expensive, and it can be difficult for young people to attend school or get entry-level jobs that will become careers.

“We try to reach young people who are disenfran¬chised and help them find employment across the region,” Shannon says.

Kathleen Shannon Dorcy, PhD, RN, FAAN, (top right corner) with Seattle Cancer Care Alliance colleague Arlyce Coumar, RN, OCN (bottom left), and students in the continuing education course they taught in Uganda.

SCCA’s tagline is “better together,” which extends beyond Seattle to building up cancer care and the nursing field around the world. Shannon Dorcy has also spread her knowledge outside the United States, working with institutions at which SCCA has existing affiliate networks for physicians and researchers to develop stronger programs for nursing outreach. She has taught classes in Guam to help nurses gain oncology certification. Most recently, Shannon and others taught more than 100 nurses at the Uganda Cancer Institute; these nurses stay connected to SCCA and to each other with streaming courses.

“There’s a sense of greatness, not only in the individual, but also in community access,” Shannon says about her work. “The best care happens when everyone comes together.”

Last year, Shannon Dorcy’s lifetime of service to nursing was recognized when she was inducted as a fellow in the American Academy of Nursing. She is excited about the added level of exposure and influence that being a fellow allows her.

“It means I have the power to touch other people across the country, to bring in new ideas and continue scientific exploration,” she says. “I can be part of policy setting and advocate for equitable funding for underresourced areas nationally and globally.”

Articles

How Kathleen Shannon Dorcy, PhD, RN, FAAN, became a leading voice in oncology nursing.

Pursuing a Calling: From Convent to Cancer Care

 is an increasingly common concern for cancer survivors, affecting their treatment, recovery, quality of life, functional abilities, and long-term survival. About 31% of cancer survivors are obese,

 and that percentage has been steadily increasing for more than 2 decades, with no signs of slowing. Underserved populations, which tend to be minorities and those in rural areas, face a disproportionate burden, with higher rates of cancer and higher mortality. These populations also tend to have higher rates of obesity, creating a challenging environment for providers to address unmet needs and encourage lifestyle modifications.

Karen Meneses, PhD, RN, FAAN, professor and associate dean for research at the University of Alabama at Birmingham (UAB) School of Nursing, studies the intersection of obesity, cancer, and underserved populations. She said about 40% to 60% of the population around her is overweight or obese.

Despite efforts by leading health organizations and individual institutions, there’s still no standard approach to weight management and nutrition for cancer survivors. Nurses are poised to be advocates for patients, incite change, and spur individuals to action.

Research in breast cancer survivors found a 41% increase in all-cause mortality among obese women compared with those of a normal weight.

According to Wendy Demark-Wahnefried, PhD, RD, who studies weight management and patients with cancer and works with Meneses in underserved populations, second cancers represent the fastest-growing cancer diagnoses in the country. Though obesity may not necessarily be identified as the direct cause of death in second cancers, she says, it does increase mortality from comorbidities such as heart disease and diabetes. “We also know that individuals with diabetes have diminished physical functioning,” Demark-Wahnefried, who is professor and Webb Endowed Chair of Nutrition Sciences and associate director, UAB Comprehensive Cancer Center, added.

Meneses said many of the patients she works with are breast cancer survivors who were overweight or obese before their diagnosis. “With the food culture in the South and a preferred self-image that skews toward being a little larger, many of these women struggle through treatment and put on more weight,” she said. Many of her patients come from rural, underserved communities, presenting unique challenges to tackling obesity throughout treatment.

In the United States, about 21% of cancer survivors live in rural areas, where people tend to be poorer, have less access to community programs, and have higher education gaps than those living in urban areas. Low-income minority populations also have higher rates of obesity.

Whether from lacking money or living in food deserts, many underserved populations simply don’t have access to healthy foods. They have more convenient fast-food chains than quality restaurants. And some people are unaware of how to make the most of what they do have available. For instance, urban populations may have more grocery stores or food banks they can learn to use appropriately, while rural areas may be more able to grow their own produce and have access to community gardens or farmers markets.

. “In underserved populations, [people] have access to fast foods, junk food, and grocery stores. Patients tend to put others before themselves and buy food that is convenient or cheaper.”

Smith is currently field medical director in GU Oncology at Pfizer and works periodically at the University of Chicago Medicine as an oncology nurse navigator. She has worked with underserved populations throughout much of her career.

When much of the population is obese, many people don’t see themselves as overweight or obese. They’re concerned about the perceptions of their family and friends if they lose weight. They also may not get the support they need when their loved ones aren’t trying to lose weight or maintain healthy weights themselves.

“Some patients we see worry that if they lose weight, their friends and family would worry too much about what is wrong because families think cancer is associated with massive weight loss,” Meneses said.

Meneses and Smith emphasized that food is deeply personal for many people, representing kinship and community. Someone gets sick? You take food to them. Family or church gathering? Everyone brings food. Cultural traditions can make it hard for patients to follow healthier eating patterns when social functions make it easy to overeat.

Preparation methods get passed down through generations. Frying tends to be cheaper and easier than other methods of cooking. It’s also how many people whom Smith has met were raised to eat. “People cook like Mama used to cook,” she said.

“It’s the only way they know how, and even the kids know how to use the deep fryer to prepare meals when Mom or Dad can’t.”

Pro Tips for Advising Patients about Weight Loss

Karen Meneses, PhD, RN, FAAN, suggests giving survivors who are obese or at risk simple strategies to reduce their weight:

Recommend that they follow free workout videos on YouTube for 15 or 30 minutes of physical activity daily

Teach them about small changes to cooking habits

Suggest better choices at fast-food restaurants

Share healthy recipes that feature affordable ingredients

Suggest they eat more fruits and vegetables

Trust between patients and their providers affects whether those patients will be willing to accept messages about the need to address obesity. Meneses has found challenges in helping Hispanic women, who in her experience tend to defer to their husbands’ opinions and have different family dynamics. With this population, a nurse or a dietitian may need to engage a woman’s husband and other family members to explain why weight loss is important and how it contributes to recovery and survival.

Smith finds that in Chicago, African American patients are sometimes wary of accepting messages from medical staff who don’t look like them. “Patients don’t always feel they can trust the information they are being told because they can’t relate specifically to some of the individuals sharing that information with them,” she said. Smith, who is also African American, makes a point to connect with her patients, sharing her own or her family’s struggles to build trust and inspire change.

“Although nursing is the most trusted profession, it’s still hard to find diversity,” she said. “It’s important to have conversations and relate to patients personally.”

Obesity leads to a host of problems for cancer survivors, but the good news is, there’s a lot that patients can do to reduce their risks. Obesity is the second-leading preventable cause of cancer, and lifestyle modifications do make a difference.

In one study, cancer survivors who had more physical activity had a 37% lower risk of dying from cancer than those who were less active. In another, weight management interventions improved metabolic health and decreased inflammation. Weight loss of just 3% to 5% lowers the risk of diabetes and cardiovascular disease.

 Knowing that interventions work, nurses next need to figure out how to spur patients to take action.

Nurses are in a role to inspire change in their patients and organizations. Financial limitations may make accessing supportive services difficult for some survivors. But many communities around the country have coordinated outreach programs. And exercise and healthy eating can be affordable; individuals just need motivation more than anything.

“Establishing principles of self-management and empowerment are where we have to go,” Meneses said. “More burden is being placed on the survivor and family.”

The first thing nurses can do is simply deliver the message about food, weight, and exercise in culturally relevant ways, and do it early. “The easiest way to intervene is at the point of diagnosis,” Demark-Wahnefried said. “Tell people that some treatments increase the chance of becoming overweight or obese.”

The American Society of Clinical Oncology (ASCO) and other groups recommend talking about weight management, including diet and exercise, with patients, starting with the basics and not assuming patients know the risks of being overweight.

A 2017 ASCO opinion survey found that only 31% of Americans realized that obesity was a risk factor for cancer.

Nurses can begin the conversation by showing the patient a body mass index chart and explaining the benefits to obese people of losing even 3% of their body weight. Educating survivors on the importance of building and maintaining muscle to lessen weight gain could halt some preventable consequences.

Delivering the message to underserved populations can be challenging. “We have to introduce changes in diet and physical activity slowly and repeat the message,” Meneses said. That’s why it’s all the more important to start at diagnosis.

Emphasize what they can control, Smith said. They can control what they eat, how they prepare meals, and how much they move around. Encourage them to use what they have at home for exercise, such as canned goods as weights or videos on their smartphones.

Meneses, Demark-Wahnefried, and Smith all emphasized the importance of nurses’ modeling positive behaviors and maintaining healthy weights. “Delivering a message about weight can be uncomfortable and harder if you’re insecure about your own weight,” Demark-Wahnefried said. “But I’ve seen a new generation of nurses becoming more health conscious and leaner.”

“I was overweight a few years ago,” Smith said. “I didn’t want to repeat my family history, so I changed my habits.” She’s now able to share that journey with patients as well.

Addressing obesity and cancer is complicated and multifaceted. Results from research have shown that providers have gaps in their knowledge of nutrition and physical activity recommendations, making it harder to deliver these messages.

 Not to mention the time involved in talking about health and following up, along with cancer and survivorship care. Nurses don’t have to do it alone. Registered dietitians and nutritionists have deep knowledge of food and health. Refer patients to these experts, and tell the dietitians about a patient’s care plan. Is a patient on a medication that will likely cause weight gain? Is the patient at risk of losing muscle mass that could cause weight gain? Working together will give patients the best information and strategies for self-management.

Despite more recognition of the problem of obesity, coordinated, national efforts are lacking. Meneses and her team at UAB have worked on community programs that have seen success, focusing mostly on empowering patients and educating them on ways to improve self-management skills, including:

Overweight survivors in rural and minority populations need nurses on their side.

Obesity, Cancer, and the Underserved

"The goal of prehabilitation is to prevent [patients] from getting to the point of needing reconditioning," says Lillie Shockney, RN, MAS, ONN-CG.

Today, a cancer diagnosis does not mean a patient’s life is over, but it does mean things may get more difficult for that individual. Despite knowing that many patients with cancer will survive the disease, much of the medical focus is still on the acute-care phase and less on what comes before or after.

Prehabilitation is a growing service in many cancer centers that helps patients prepare for acute care and long-term survivorship. It enables the care team to consider what will change in patients’ lives because of treatment and how the team can help them face those changes.

Nurses and nurse navigators play a significant role in advocating for prehabilitation and other services that can help preserve patients’ quality of life.

Prehabilitation is an evidence-based process that occurs in the time between diagnosis and the start of acute care. The goal is to prepare a patient with cancer as much as possible, in whatever ways necessary, for surgery, chemotherapy, or radiation. This process may include physical, social, emotional, or environmental interventions.

Julie Silver, MD, associate chair for strategic initiatives in the Department of Physical Medicine and Rehabilitation at Harvard Medical School, is credited as the founder of prehabilitation. She established the Survivorship Training and Rehabilitation (STAR) Program in 2009, partly because of her own experiences with breast cancer in 2003, and advocates for more adoption of metricsdriven prehab programs.

In a 2013 interview with NPR, Silver shared with listeners that she wished she had been more prepared for what was to come during her own illness and had known what she could have done to help ensure the best possible outcomes. She noted that when she did exercise testing after breast cancer treatment, her results indicated she was in her 60s. She was 38 at the time.

“I had aged 3 decades in a matter of months through cancer treatment.”

 The STAR model includes 5 components to prepare patients for cancer treatment: smoking cessation, general exercise, targeted exercise, nutrition, and stress reduction.

 Interventions in the model are time-based and thoroughly documented to track effectiveness.

Lillie Shockney, RN, MAS, ONN-CG, director of cancer survivorship programs at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, is another strong advocate for prehabilitation. She estimates that more than half of cancer centers in the United States have some form of prehabilitation program. With increased awareness, she hopes that more programs can be added—or, at least, that more patients can be referred to services.

“Rather than waiting for a patient to become physically debilitated by cancer treatment and then be reconditioned, the goal of prehabilitation is to prevent them from getting to the point of needing reconditioning,” she said. Shockney noted that prehab at Johns Hopkins is divided into two categories. The first is referrals to the appropriate prehabilitation services, whether physical therapy, occupational therapy, or at-home exercises to increase the patient’s strength or to learn important exercises before treatment. The second is steps taken to safeguard patients’ life goals.

The second category involves taking the time to understand what’s important to the patient. For example, one of Shockney’s patients loved playing the piano and dreamed of becoming a concert pianist, but her proposed treatment could have caused peripheral neuropathy, potentially ending her dream. As her navigator, Shockney intervened to ask for a different chemotherapy. Understanding such life goals helps nurses work with the care team to prepare patients to maintain functioning or choose other treatment options.

Exercises or physical activity of some kind are common components of prehabilitation. For example, physical therapy can be used to help reduce or prevent lymphedema.

“Part of recovery means being physically fit before treatment starts,” Shockney said. “In the case of lymphedema, beginning arm exercises and learning do’s and don’ts before surgery is a better way to prevent it. Without this preparation, [the patient] may already have done some things that raise her risk of getting lymphedema before she enters rehabilitation. That can be prevented.”

Like Silver, Shockney became an advocate because of her own experiences with a breast cancer diagnosis 26 years ago. After undergoing her first mastectomy, the cancer then was diagnosed in her other breast, ultimately leading to a second mastectomy. For medical reasons, Shockney wasn't able to do reconstruction until 10 years after her second mastectomy when she decided to undergo deep inferior epigastric perforator (DIEP) flap reconstruction, which would transplant belly fat to her chest. Because she knew that having more core strength would help her recover faster, Shockney began physical therapy 6 weeks before the surgery, with the goal of shortening her time in the hospital.

“Back then, most patients who had this surgery stayed in the hospital 4 to 5 days,” she said. “I was the first to go home at 3 days. Now the average stay is 3 nights. People go home on day 4, in part because they are starting prehab to strengthen their core before surgery.”

Prehabilitation may also teach someone to use an incentive spirometer or do exercises to prevent blood clots. This allows patients to immediately begin their recovery after treatment, rather than waiting to be taught or having a steep learning curve after surgery.

Nurses and nurse navigators are on the frontline of patient care. They’re the ones learning what matters most to patients and advocating for their values. Alene Nitzky, PhD, RN, OCN, an oncology nurse, personal trainer, and author of the book 

Navigating the C: A Nurse Charts the Course for Cancer Survivorship Care

, is also an advocate for prehabilitation and preparing for cancer treatment in general. She founded Cancer Harbors, a center in Colorado that focuses solely on survivorship care after acute treatment. The patients she sees may have struggles or limitations they will deal with for years after they’ve gone into remission.

“I work with people after treatment, and I find that they don’t get the information they’re going to need before they go through treatment,” she said. “There’s physical preparation, but also emotional, social, mental, and environmental.”

That’s why she advocates for preparation by patients, doctors, nurses, and others. This includes staying or becoming more physically fit and healthier overall, entering a prehabilitation program to get prepared for a specific treatment, or getting resources in place to handle the disruptions cancer will cause to daily life.

“The better condition your body is in before you go into any kind of treatment, the better off you’ll be,” she said. “You’ll tolerate treatment better, heal faster, and recover better.”

Nurses can help patients get referrals and find services. Nitzky and Shockney both pointed out that, although there are exceptions, most patients don’t need to rush into treatment. Many people can wait a few weeks for prehab recommendations and to start them before treatment begins. “Time is something the medical community doesn’t explain very well,” Nitzky said. “Generally, people have time to absorb information, get a second opinion, and start prehab.”

Nurses can request that patients be referred to physical, speech, or occupational therapies or to other interventions that may prepare them to undergo treatment. Nurses are the key advocates for getting patients into prehab. They can identify patients and refer them to the proper services by asking the right questions, such as: • What are this patient’s activities of daily living? • Will the patient be able to do those activities independently after treatment? • What resources will the patient need after treatment? • What are the patient’s goals and interests? • Can the proposed treatment impair the patient’s ability to do those things? • Is there an alternative treatment? • What is the patient’s baseline health functioning? • Is there an intervention the patient can do in advance to reduce the chances of impairment? • What strengthening or lifestyle interventions would help the patient better tolerate treatment?

Nurses and nurse navigators are the most likely team members to be asking these questions. They know the patients personally, understand their daily activities, and know what parts of the patients’ bodies will be disrupted by treatment. “Doctors aren’t making the referrals, and patients don’t know to ask for them,” Nitzky said. “There’s where nurses can help.”

Early research finds that prehabilitation may improve patients’ physical and psychological outcomes. Providers need to determine a patient’s baseline physical function at the time of diagnosis and then extrapolate the possible burdens treatment may add. For example, if a patient loves to compete in 5Ks and has radiation scheduled, focus on exercises to help him maintain some level of physical activity during treatment. If a patient stocks shelves as part of her work duties before undergoing a mastectomy, it is important that she strengthen her upper body and begin preventing lymphedema before surgery. Choosing interventions known to address potential limitations from treatment may reduce complications, length of stay, readmissions, and severity of impairments, according to research published by Silver.

There’s not a lot of formal research specifically on the cost savings from prehabilitation programs. Cost is a concern for providers and patients, but because interventions are evidence-based, insurance coverage hasn’t been a problem. Prehabilitation doesn’t have a specific billing code, but each individual service is usually covered. For example, it’s well known that patients need to stop smoking, so smoking cessation is included in cancer care.

Nutrition is also a common intervention in most programs because it’s understood that specific eating habits need to change, especially in patients with particular cancer types. Patients have a certain number of covered rehabilitation sessions that can be used before treatment rather than after. Plus, some interventions, like walking or a general increase in physical activity, can be done by patients at home for free. And studies have found that walking programs reduce fatigue for people undergoing radiation.

Many cancer centers offer services to prepare patients for treatment; however, formal research on the outcomes of prehabilitation are still limited. Silver’s STAR Program is time-based, evidence-based, and has measurable goals, so she and others involved with STAR are actively working to contribute to the growing body of research about prehabilitation.

The growth of formal programs that document prehabilitation interventions and outcomes will also help add to the research in this arena. In today’s metrics-driven healthcare environment, implementing these interventions and documenting them will be key to increasing adoption and payment.

Shockney points out that even without formal evidence, prehabilitation is just common sense. “For prehab, a lightbulb went off and we said, ‘Why are we allowing patients to become physically deconditioned when we can maintain physical activity during treatment?’” she said. “I’m not sure why it took so long, but it did.”

Whether a cancer center has a formal prehab program or not, nurses are still poised to suggest referrals to these types of services for patients who would benefit the most.

Gotbaum R. Cancer rehab begins to bridge a gap to reach patients. National Public Radio. npr.org/sections/health-shots/2013/02/18/172099043/cancer-rehab-begins-to-bridge-a-gap-to-reach-patients. Published February 18, 2013. Accessed March 6, 2018. 2.

Silver J. Cancer prehabilitation: important lessons from a best practices model.

2015;8(2). jhoponline.com/ton-issue-archive/2015-issues/march-vol-8-no-2/16357-cancer-prehabilitation-important-lessons-from-a-best-practices-model. Accessed March 6, 2018.

Silver J. Cancer prehabilitation and its role in improving health outcomes and reducing health care costs. 

. 2015;31(1):13-30. doi: 1016/j.soncn.2014.11.003.

Cancer prehabilitation can combat potential limitations and preventable adverse effects.

Tricia Chaney

Articles

Pursuing a Calling: From Convent to Cancer Care

Obesity, Cancer, and the Underserved

An Ounce of Prevention: Cancer Prehabilitation