Access provided by
London Metropolitan University
Find out about a complex specialty with many disciplines and cutting-edge treatments to learn about
I am an associate breast cancer clinical nurse specialist (CNS), specialising in ovarian function suppression (OFS) and herceptin-based therapies. I have been in the band 6 role for seven months. I have always wanted to be an oncology CNS, so when this job came up covering maternity leave for a breast cancer CNS, I jumped at the opportunity. I was interviewed and thrilled to be appointed to the role.
Cancer Nursing Practice. 22, 5, 12-13. doi: 10.7748/cnp.22.5.12.s5
Published: 04 September 2023
What does your role involve?
My team and I are the first point of contact for all patients with HER2-positive breast cancer (roughly one in five of all breast cancer cases) undergoing herceptin-based therapies, and breast patients undergoing OFS treatment. The focus is patient-centred and we provide holistic support.
Herceptin is given as neoadjuvant therapy (before surgery) and adjuvantly in conjunction with chemotherapy, radiotherapy and surgery. Herceptin-based drugs such as trastuzumab (herceptin), trastuzumab emtansine (Kadcyla) or trastuzumab and pertuzumab interact with the HER2 protein, blocking its effects.
We also provide treatment after neoadjuvant/adjuvant chemotherapy for up to a year. This involves troubleshooting toxicities, managing the treatment pathway, carrying out echocardiograms and clinics, and being patients’ main point of contact.
We start OFS patients on suppression treatment with luteinizing hormone-releasing hormone analogues such as goserelin (Zoladex) and antioestrogens or aromatase inhibitors and manage them for up to five years. Managing a patient through chemically induced menopause involves reducing treatment toxicities and ensuring they are well supported. If the patient needs a referral or intervention from a specialty, we arrange it. The width and breadth of queries and problems we solve are enormous; no day is the same. I also work with GPs and review blood test results to ensure that the suppression is maintained.
What attracted you to the role and what qualifications did you need?
Having previously worked on a medical oncology ward and in acute oncology management, I knew I only saw a small part of a patient’s journey.
The opportunity to support and manage a patient’s treatment for a longer duration was appealing, and HER2 and OFS are fascinating because both services are essentially a niche within a niche. Knowing about cancer pathways and treatment is an advantage, and any extra training or courses complement an application – I completed a master’s module in acute oncology.
The specialty is so complex, there are so many disciplines and treatments, and the treatment can be cutting edge. You often need every skillset a nurse has. I encourage anyone to try it, as I cannot recall a day when I have not felt a sense of achievement.
What were your expectations from the job, and how does the reality compare?
Going into a specialty is daunting. I knew I would be expected to know a lot, not just about breast cancer, but the treatment pathways and toxicities.
The sheer scope of the service means it is incredible what you learn about. I never thought I would learn about cardiology [HER2 patients require regular cardiac monitoring], become accustomed to reading pathology reports or know a lot about the menopause.
When I was a nursing student, a mentor told me never to try to answer a question I didn’t know the answer to. Instead, tell the patient you will find out and get back to them promptly when you know. This has become my mantra.
I was unprepared for how forward-thinking it is to be in a nurse-led service and how the team problem-solves and finds the best way to do things that benefit patients. This extends to being up to date with the latest relevant trials data to ensure that we are delivering evidence-based nursing and helping to inform patient choice.
When the toxicities of continuing with treatment begin to outweigh the benefits, it is important to have difficult conversations with patients, showing empathy. These conversations need to be sensitive because patients sometimes feel they have failed if they cease treatment; they haven’t.
Being a CNS embodies the ‘therapeutic nurse’ in that you build a relationship of trust with a patient over months and years, where they rely on you to resolve their issues. A cancer diagnosis can be terrifying so people need to trust the service and the CNS when answering difficult questions.
What has been your highlight?
I have cherished getting to know patients and being with them the whole way through treatment – the highs and the lows.
What has been the biggest challenge?
Our services are nurse-led, so although the consultants are on hand should we need their input, clinical decision-making about treatment changes is usually ours. This can be daunting. Although rationalising and justifying clinical decision-making is important, so is acknowledging when to get input from a peer or the medical team.
I have learned how broad multidisciplinary discussions can be when resolving patient issues.
What lessons have you learned and what advice would you give to a new starter?
Always listen to the patient. So many issues or problems arise if something is misconstrued or misinterpreted, so communication must be clear.
Consider how cancer can affect a person’s mental health. Many patients struggle with treatment ending as well as the beginning, so knowing when to intervene or suggest where they can seek input is essential. When I started in this role, I did a lot of research into the information and support available to patients to tailor what advice I give my patients.
Embrace the wisdom of your co-workers. The nurses I work with are so knowledgeable. It is humbling sometimes how much they know about obscure issues. Self-learning is incredibly important but learning from those around you makes you a better practitioner in the long run.
Reach out to other specialties if you have a specific knowledge gap; people are generally generous if you come to them asking to learn things that will benefit patients.
Put the patient at the centre of every decision you make. Remember, you are their advocate. Never leave them in the dark when it comes to reasoning and decision-making.
1. Don’t try to learn everything at once; it is impossible. Instead, ask if there is any information or literature you can read about the treatments you will be giving and familiarise yourself with the main points before you start
2. Be interested in and well-read in your disease group. Try to understand the patient experience, the relevant cancer pathways, general treatment and long-term follow-up policies
3. Introduce yourself to the team before you start. This will give you a chance to ask questions you might not have thought of during the interview
4. Go into the role with an open mind and be prepared to learn. Your colleagues will have a wealth of information to point you in the right direction. This could be identifying learning needs or courses for you to attend
5. Put the patient at the centre of what you do. You can learn a lot from the patient as they have first-hand experience of the treatments
What are your future goals?
I love my role and team and hope to stay in OFS and HER2. I want to work in a clinical specialty I have a passion for. I am looking for a permanent band 7 CNS position. In addition, I want to complete a full oncology-based master’s degree and non-medical prescribing qualification.
I am interested in a similar job – what should I do?
If you have a passion, follow it, because a passionate nurse who loves what they do can only ever benefit patients. Many oncology CNSs start their careers on the oncology medical/surgical/clinical wards or chemotherapy units as it gives you a broad experience of disease types and treatments. From there, you can find what interests you and get the relevant experience that can lead to a CNS post in that disease group.
If you are not in oncology, many jobs can be done with transferable skills. Allocating time to learn about jobs or disease specialties will benefit you and your CV, but also reach out to specialists for advice before you apply so you can have a fuller picture of what the job entails.
Another thing to consider is where you will work. Always do your due diligence on the trust. Where I work there is a culture of investing in nurse education. I have benefited from this and would not be in this role today if they had not. Find a supportive workplace where you can imagine having a fulfilling future.
Breast Cancer Now (2023) How Do I Know if My Breast Cancer Is HER2 Positive or HER2 Negative?
Cancer Research UK (2021) Trastuzumab.
NHS (2023) Trastuzumab (Herceptin). www.nhs.uk/medicines/trastuzumab-herceptin
This is an abridged version of an article at rcni.com/cns-cancer-care