Health and well-being events for supporting patients after melanoma treatment
Intended for healthcare professionals
Evidence and practice    

Health and well-being events for supporting patients after melanoma treatment

Claire Lusted Advanced nurse practitioner, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, England

Why you should read this article:
  • To understand the importance of post-treatment self-management interventions for patients with melanoma

  • To enhance your knowledge of the benefits, issues and barriers in relation to health and well-being events

  • To find information on organising a local health and well-being event for patients with melanoma

The incidence of melanoma is increasing, and with the advent of new treatments people with the condition are living longer. In the UK, cancer policies recommend that every patient receives a personalised care package that includes access to a post-treatment health and well-being event. Such events aim to provide patients with the information and resources they need for effective self-care. At the author’s trust, a local service evaluation showed that the provision of information to patients with melanoma at the end of treatment was variable and that patients did not have access to a health and well-being event.

This article explores some of the literature and guidance on end-of-treatment self-management interventions, with a focus on health and well-being events. The author considers whether a health and well-being event may be an effective way of providing information and advice to melanoma survivors and provides an example of the content and format of such an event.

Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1834

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

claire.lusted@gstt.nhs.uk

Conflict of interest

None declared

Lusted C (2023) Health and well-being events for supporting patients after melanoma treatment. Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1834

Published online: 09 February 2023

In the UK, around 2.5 million people are living with and beyond cancer and this number is predicted to rise to 4 million by 2030 (Macmillan Cancer Support 2021). Melanoma is the fifth most common cancer in the UK, with 16,700 people diagnosed annually (Cancer Research UK 2023). In England, melanoma is the second and third most common cancer in men and women aged 15-44 years, respectively (Melanoma Focus 2023). In contrast with most other cancer types, melanoma occurs relatively frequently at a younger age (Melanoma Focus 2023). Five-year survival rates in patients with melanoma have increased from 46% 40 years ago to 90% today due to earlier detection and improved treatment (Cancer Research UK 2023).

These increases in survival rates have presented the NHS with the challenge of meeting the needs of a growing population of patients living with the long-term effects of cancer and cancer treatment alongside comorbidities and the effects of ageing (Healthcare Improvement Scotland 2017, NHS England and NHS Improvement 2020). Cancer survivors have been shown to have a reduced quality of life compared with the general population (Macmillan Cancer Support 2019) and are more likely to be admitted to hospital than people who have not had cancer (Department of Health and Social Care 2013).

Cancer follow-up models tend to focus on detecting disease recurrence. Such medical-led follow-up models have been found to be inadequate and patients with different types of cancer have reported unmet physical, psychosocial and financial needs (Dickinson et al 2014, Macmillan Cancer Support 2015, Alfano et al 2019). A systematic review of the use of technology to deliver cancer follow-up found that the models used were financially unsustainable because of the increasing number of patients (Dickinson et al 2014). It is widely accepted that the NHS needs to change its focus from acute, medical-led care towards holistic, personalised approaches (NHS 2019). Supported self-management interventions for patients after cancer treatment, including health and well-being events, form an integral part of this transformation (Macmillan Cancer Support 2014, Barbieri et al 2018).

To address the long-term needs of patients living with and beyond cancer and reduce the financial burden on the NHS, policies and strategies for cancer services have, over the past decade, focused on improving survivorship care (NHS England 2016). Many of these policies and strategies recommend that patients have access to a personalised care package – a series of interventions which, when delivered together, can improve patient outcomes (Welsh Government 2012, Macmillan Cancer Support 2014, Scottish Government 2016, Department of Health 2022). A personalised care package includes a holistic needs assessment, an end-of-treatment summary, a GP cancer care review and access to a health and well-being event. It is intended to provide patients with interventions tailored to their needs and assist them to take an active role in their care (Macmillan Cancer Support 2023).

Local evaluation of service provision for patients with melanoma

The author of this article works at a large London cancer centre where post-treatment follow-up for patients with melanoma features regular review by oncologists or dermatologists. A local evaluation of service provision for these patients conducted at the end of 2021 found that care in some areas required improvement. The evaluation found that the clinical nurse specialist team focused on care at the time of diagnosis – through the completion of holistic needs assessments and the provision of information and psychological support – but that the provision of information at the end of treatment was variable and that patients did not have access to a health and well-being event. Additionally, the 2020 National Cancer Patient Experience Survey (NCPES) (2021) showed that the trust’s skin cancer services scored lower than the national average in several areas related to patient information and support.

The findings from the local service evaluation and the results of the 2020 NCPES prompted the author to explore the literature on supported self-management interventions at the end of melanoma treatment, including health and well-being events, with the aim of determining whether a health and well-being event could be an effective way of improving support for melanoma survivors. This article describes the author’s findings and reflections on:

  • Survivorship care for patients with melanoma.

  • Health and well-being events.

  • Implementing a local health and well-being event.

Survivorship care for patients with melanoma

Despite the increased focus on survivorship in cancer care in general, there has been little research on survivorship in patients with melanoma, partly because survival rates for this type of cancer used to be low (Oliveria et al 2007, Wiley 2021). Medical studies of follow-up care for patients with melanoma have focused on detecting disease recurrence, while non-medical research has focused on the psychosocial effects of the condition and the associated supportive care needs of patients, rather than on the methods of survivorship care delivery (Trotter et al 2013).

Stamataki et al (2015), who explored the effects of a melanoma diagnosis on patients and their supportive care needs in a sample of 15 patients, noted that little is known about the specific needs of patients with melanoma from their own perspective. Four main themes emerged from Stamataki et al’s (2015) study:

  • Emotional effects of a melanoma diagnosis on patients due to body image changes, fear of the sun and uncertainty about the future.

  • Effects of a melanoma diagnosis on relationships, some patients needing more support than others from family and colleagues.

  • Functional effects of a melanoma diagnosis on patients due to ongoing symptoms such as pain and lymphoedema.

  • Health system and information needs of patients with melanoma, specifically in relation to the clarity, quality and timing of information received from healthcare professionals.

Tan et al (2014), who conducted a qualitative assessment of the psychosocial effects of the condition, coping and adjustment in 19 high-risk melanoma patients and 14 carers, had identified similar care needs to Stamataki et al (2015) and proposed group-based interventions as an effective means of supporting patients and delivering follow-up care.

UK and US guidelines on melanoma care and follow-up (Healthcare Improvement Scotland 2017, American Cancer Society 2020, National Institute for Health and Care Excellence 2022) recommend that patients receive personalised holistic care, but there is little mention of how such care should be delivered (Wiley 2021). Furthermore, guidelines tend to focus on the role of the skin cancer specialist nurse at the time of diagnosis and on medical-led follow-up in the post-treatment period (Melanoma Taskforce 2015).

Although there is evidence of the benefits of the use of personalised care and supported self-management interventions at the end of cancer treatment, the literature focuses on their use in patients with more common cancers – such as breast cancer, prostate cancer and colorectal cancer – and in patients with cancers such as head and neck cancer where a multidisciplinary approach to follow-up is well established (Cuthbert et al 2019). The needs of patients with melanoma differ from those of patients with other types of cancer, notably in relation to age at presentation, skin surveillance and sun exposure and safety, so it is crucial that these factors are considered in any end-of-treatment support intervention aimed at this population.

Key points

  • Research into survivorship care for patients with melanoma is limited

  • The needs of patients with melanoma differ from those of patients with other types of cancer, notably in relation to age, skin surveillance and sun exposure

  • Cancer follow-up models tend to focus on detecting recurrence but a more holistic and personalised approach is needed

  • Health and well-being events aim to provide patients with information and resources to self-manage their care after cancer treatment has ended

  • Health and well-being events need to be supported by the wider multidisciplinary cancer team and sustainably funded

Health and well-being events

Aim and format

A health and well-being event is a group intervention which aims to ensure that patients are supported during the transition from the end of cancer treatment to their ‘new normal’ by providing them with the information and resources they need to self-manage their care effectively. It is ‘a supportive event to help prepare people with cancer, their carers and family for the transition through their cancer journey’ (Macmillan Cancer Support 2018). Health and well-being events bring together a range of service providers from the healthcare, social care, community and voluntary sectors. They can be delivered in different formats according to local need. For example, they can be organised for a small, local group of patients or for a larger group of patients from a wider geographical area. They may be generic events for patients with different types of cancers or focus on specific cancer types.

Benefits and issues

Offering health and well-being events supports a shift in focus from a one-size-fits-all approach, whereby all patients attend a standardised consultation and receive the same information, to an approach where follow-up care is patient-centred and where each individual’s clinical, psychosocial and practical needs are assessed and managed effectively (Macmillan Cancer Support 2014).

Evidence suggests that ‘informed’ patients – that is, patients who have been given, and have been supported to use, information about their condition and its treatment so that they are able to make ‘informed’ decisions about their care – can manage their condition and changes in their health status more effectively than ‘uninformed’ patients, make less use of NHS services and have fewer unplanned admissions to hospital. Additionally, the provision of information, and of support to use that information, can help people to regain a sense of control over their lives (NHS Improvement 2017).

NHS England and NHS Improvement (2020) have produced a handbook for local healthcare organisations on how to implement ‘personalised stratified follow-up pathways’ for people with cancer at the end of treatment. These pathways focus on supporting health and well-being, for example through the provision of information on signs and symptoms of recurrence, telephone advice and support, regular surveillance and personalised care and support planning. The aim is to improve the self-detection of recurrence, encourage healthier lifestyles and reduce demand for unplanned care. This in turn could reduce the financial burden on the NHS associated with cancer survivorship (Dickinson et al 2014).

Some authors, however, have questioned the effectiveness of group interventions. It has been suggested that group interventions do not always result in cost savings compared with individual interventions, that large groups may negate the delivery of personalised care and that the content of group interventions may not be applicable to all attendees, who may vary in age, understanding, literacy and language (Biggs et al 2020). Furthermore, many supported self-management interventions such as health and well-being events are funded by charities such as Macmillan Cancer Care (Macmillan Cancer Support 2014) but such funding is often provided for a fixed period only, which raises the question of the sustainability of these interventions.

Barriers to implementation

Despite evidence of the benefits of supported self-management interventions such as health and well-being events at the end of cancer treatment, there remains a reluctance within the NHS to provide such interventions (Williamson et al 2020, Rimmer and Sharp 2021). At the time of writing there is no specific national tariff in the NHS in England for health and well-being events, so these are generally commissioned locally, which can result in regional inequalities (Macmillan Cancer Support 2018). Additionally, Macmillan Cancer Support (2015) has suggested that ‘senior stakeholders’ are reluctant to ‘buy into’ health and well-being events because their delivery requires substantial investment in staff training, time and material resources. Meanwhile, high staff turnover and staff shortages within multidisciplinary cancer teams mean that the leadership and skill mix required to provide high-quality interventions is often lacking (Biggs et al 2020).

Limitations of the literature

Studies into the use of health and well-being events for patients with cancer are lacking. This could be due in part to the challenges associated with researching group interventions. Many studies of self-management interventions have a small sample size and methodology limitations. Few studies have used objective measures to assess patient outcomes, which may have hindered the translation of interventions into clinical practice (Cuthbert et al 2019). This is supported by Rimmer and Sharp (2021), who argued that although research has identified that there is a need for self-management interventions, it remains unclear whether they are effective without evaluation in routine practice. There is also a lack of cost-effectiveness data. Some studies of health and well-being education programmes did not conduct a health economic evaluation and some reports on cost-effectiveness have been inconclusive (Aubin and Egan 2018).

Effects of the pandemic

Much of the research on supported self-management interventions has been undertaken before the coronavirus disease 2019 (COVID-19) pandemic, when interventions were mostly delivered face-to-face. Since the start of the pandemic, cancer services have undergone profound changes and the effects of these changes on melanoma cancer care and survivorship care are not yet fully known (Raza et al 2022). Many face-to-face post-treatment interventions were cancelled during the pandemic, since they were deemed non-essential. Some evidence suggests that this reduction in face-to face activity, alongside shielding, has had a detrimental effect on patients’ anxiety levels (Koczwara 2020). NHS funding, priorities and service delivery have altered significantly since the start of the pandemic, so pre-pandemic literature on supported self-management interventions should be interpreted with caution since it may not reflect the current needs of patients or the clinical and financial priorities of the NHS. COVID-19 has also limited the amount of research undertaken over the past two years.

Implementing a local health and well-being event

While there is evidence of the benefits of supported self-management interventions such as health and well-being events for patients with cancer, there is little research on such interventions for patients with melanoma (Cuthbert et al 2019). However, the author of this article believes that implementing a local health and well-being event for patients with melanoma at her trust’s skin cancer services would contribute to addressing the gap in care identified by the 2021 local service evaluation and the 2020 NCPES (2021) findings described above.

To implement a local health and well-being event would require engagement from a range of stakeholders, including the medical oncology team and commissioners. The engagement of the wider cancer multidisciplinary team would be essential, first to facilitate a cultural shift from the medical model of cancer follow-up to a more holistic approach to end-of-treatment care, and second to design and implement the event. Obtaining funding from commissioners would require the development and presentation of a business plan, which could include an evaluation of the role of local and national charities in supporting health and well-being events financially and organisationally. Consideration would have to be given to training those who would be involved in the event as well as to providing enough staff to deliver the event so as to ensure quality and sustainability. Finally, any new service should be considered in the context of post-COVID-19 priorities to ensure that limited resources are directed to those with the greatest need and that organisations provide services that have been shown to deliver optimal outcomes for patients.

A local health and well-being event for patients with melanoma could be delivered as a full-day or half-day standalone event or as a series of short workshops. The standalone event or series of workshops could be delivered face-to-face in a suitable venue, online via a videoconferencing platform, or in a hybrid mode to suit patients’ needs and preferences. The development, organisation and delivery of the event would require support and input from the wider multidisciplinary cancer team including nurses, doctors, physiotherapists, occupational therapists, Macmillan support workers and third-sector partners.

Such a health and well-being event would aim to:

  • Provide information and advice on health and well-being to support attendees to self-manage their care effectively in the post-treatment period.

  • Signpost attendees to clinical and non-clinical resources such as local and national charities.

  • Support interactions between attendees.

  • Table 1 shows an example of the content of a face-to-face health and well-being event for patients with melanoma.

Table 1.

Example of the content of a face-to-face health and well-being event for patients with melanoma

Type of contentEssential contentPossible additional content
Mode of deliveryInformation and advice delivered by members of the wider multidisciplinary cancer team to large or small groups of patients, followed by question-and-answer sessions and supplemented by written information packsExhibition stands hosted by local service providers, charities and/or third-sector partners
Topics
  • Healthy diet and nutrition, including vitamin D supplementation

  • Sun exposure and safety

  • How to manage fatigue

  • How to undertake a lymph node assessment and skin check

  • How to manage lymphoedema

  • Emotional health, relationships, sexuality, body image

  • Physical activity

  • Returning to work, finances

  • Relaxation and complementary therapy taster sessions

  • Advice on state benefit entitlements

  • Advice on finances and insurance

  • Information on hospice services

  • Information on how to access help from local and national support groups and charities

Conclusion

Survival rates in patients with melanoma have increased in recent years, which means a growing number of people are living with the long-term effects of melanoma and its treatment. It is crucial, therefore, that their care extends beyond diagnosis and melanoma treatment to the delivery of personalised supported self-management interventions. There is indirect evidence that health and well-being events could be an effective means of providing patients with the information and support they need to effectively self-manage their care in the post-treatment period. With appropriate and sustainable funding, and with the support of commissioners and the wider multidisciplinary cancer team, health and well-being events could assist in addressing gaps in end-of-treatment care of patients with melanoma and improve their long-term outcomes.

References

  1. Alfano CM, Mayer DK, Bhatia S et al (2019) Implementing personalized pathways for follow-up care in the United States: Proceedings from an American Cancer Society–American Society of Clinical Oncology Summit. Journal of Clinical Oncology. 69, 234-247. doi: 10.3322/caac.21558
  2. American Cancer Society (2020) Living as a Melanoma Skin Cancer Survivor. http://www.cancer.org/cancer/melanoma-skin-cancer/after-treatment/follow-up.html (Last accessed: 20 January 2023.)
  3. Aubin M, Egan E (2018) Designing an education programme to improve quality of life for cancer survivors: a systematic review. British Journal of Nursing. 27, 17, s18-s23. doi: 10.12968/bjon.2018.27.17.S18
  4. Barbieri M, Richardson G, Paisley S (2018) The cost-effectiveness of follow-up strategies after cancer treatment: a systematic literature review. British Medical Bulletin. 126, 1, 86-100. doi: 10.1093/bmb/ldy011
  5. Biggs K, Hind D, Gossage-Worrall R et al (2020) Challenges in the design, planning and implementation of trials evaluating group interventions. Trials. 21, 116. doi: 10.1186/s13063-019-3807-4
  6. Burns RM, Wolstenholme J, Shinkins B et al (2017) Including health economic analysis in pilot studies: lessons learned from a cost-utility analysis within the PROSPECTIV pilot study. Global and Regional Health Technology Assessment. 4, 1, grhta-5000269. doi: 10.5301/grhta.5000269
  7. Cancer Research UK (2023) Melanoma Skin Cancer Statistics. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/melanoma-skin-cancer (Last accessed: 20 January 2023.)
  8. Cuthbert CA, Farragher JF, Hemmelgarn BR et al (2019) Self-management interventions for cancer survivors: a systematic review and evaluation of intervention content and theories. Psych-oncology. 28, 11, 2119-2140. doi: 10.1002/pon.5215
  9. Department of Health (2022) A Cancer Strategy for Northern Ireland 2022-2032. http://www.health-ni.gov.uk/sites/default/files/publications/health/doh-cancer-strategy-march-2022.pdf (Last accessed: 20 January 2023.)
  10. Department of Health and Social Care (2013) Living with and Beyond Cancer: Taking Action to Improve Outcomes. http://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/181054/9333-TSO-2900664-NCSI_Report_FINAL.pdf (Last accessed: 20 January 2023.)
  11. Dickinson R, Hall S, Sinclair JE et al (2014) Using technology to deliver cancer follow-up: a systemic review. BMC Cancer. 14, 1, 1-16. doi: 10.1186/1471-2407-14-311
  12. Healthcare Improvement Scotland (2017) SIGN 146: Cutaneous Melanoma. A National Clinical Guideline. http://www.sign.ac.uk/media/1082/sign146.pdf (Last accessed: 20 January 2023.)
  13. Koczwara B (2020) Cancer survivorship care at the time of the COVID-19 pandemic. Medical Journal of Australia. 3, 213, 107-108. doi: 105694/mja2.50684
  14. Macmillan Cancer Support (2014) Health and Wellbeing Clinics and Events. http://www.macmillan.org.uk/documents/aboutus/health_professionals/recoverypackage/healthandwellbeingclinics.pdf (Last accessed: 20 January 2023.)
  15. Macmillan Cancer Support (2015) The Burden of Cancer and Other Long-Term Health Conditions. http://www.macmillan.org.uk/documents/press/cancerandotherlong-termconditions.pdf (Last accessed: 20 January 2023.)
  16. Macmillan Cancer Support (2018) Health and Wellbeing Events: How to Guide. http://be.macmillan.org.uk/Downloads/ResourcesForHSCPs/MAC16500HWBEGuideWeb.pdf (Last accessed: 20 January 2023.)
  17. Macmillan Cancer Support (2019) Health Inequalities: Time to Talk. http://www.macmillan.org.uk/assets/health-inequalities-paper-april-2019.pdf (Last accessed: 20 January 2023.)
  18. Macmillan Cancer Support (2021) Treatment Summary: How-To Guide. http://be.macmillan.org.uk/Downloads/CancerInformation/ResourcesForHSCP/MAC16788Treatment-SummaryGuideWEB.pdf (Last accessed: 20 January 2023.)
  19. Macmillan Cancer Support (2023) Personalised Care for People Living with Cancer. http://www.macmillan.org.uk/healthcare-professionals/innovation-in-cancer-care/personalised-care (Last accessed: 20 January 2023.)
  20. Melanoma Focus (2023) What is Melanoma. http://melanomafocus.org/about-melanoma/what-is-melanoma (Last accessed: 16 January 2023.)
  21. Melanoma Taskforce (2015) Quality in Melanoma Care: A Best Practice Pathway. http://bdng.org.uk/wp-content/uploads/2017/02/LOW_RES_FINAL_QUALITY_IN_MELANOMA_CARE_A_BEST_PRACTICE_PATHWAY.pdf (Last accessed: 20 January 2023.)
  22. National Cancer Patient Experience Survey (2021) Cancer Patient Experience Survey 2020 Results: Guy’s and St Thomas’ NHS Foundation Trust. http://www.ncpes.uk/wp-content/uploads/2021/11/CPES-2020-Trust-Guys-and-St-Thomas-NHS-foundation-Trust-RJ1.pdf (Last accessed: 20 January 2023.)
  23. NHS (2019) The NHS Long Term Plan. http://www.longtermplan.nhs.uk/publication/nhs-long-term-plan (Last accessed: 20 January 2023.)
  24. NHS England (2016) Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020. One Year On 2015-16. http://www.england.nhs.uk/wp-content/uploads/2016/10/cancer-one-year-on.pdf (Last accessed: 20 January 2023.)
  25. NHS England and NHS Improvement (2020) Living With or Beyond Cancer: Implementing Personalised Stratified Follow Up Pathways: A Handbook for Local Health and Care Systems. http://www.england.nhs.uk/wp-content/uploads/2020/04/cancer-stratified-follow-up-handbook-v1-march-2020.pdf (Last accessed: 20 January 2023.)
  26. NHS Improvement (2017) Innovation to Implementation: Stratified Pathways of Care for People Living With or Beyond Cancer: A ‘How to Guide’. http://www.england.nhs.uk/wp-content/uploads/2016/04/stratified-pathways-update.pdf (Last accessed: 20 January 2023.)
  27. National Institute for Health and Care Excellence (2022) Skin Cancer. Quality standard No. 130. NICE, London.
  28. Oliveria SA, Hay JL, Geller AC et al (2007) Melanoma survivorship: research opportunities. Cancer Survivorship. 1, 1, 87-97. doi: 10.1007/s11764-007-0009-y
  29. Raza SA, Cannon D, Nuttall G et al (2022) Exploring the implications of the first COVID-19 lockdown on patients with melanoma: a national survey. Clinical and Experimental Dermatology. 47, 1, 114-116. doi: 10.1111/ced.14840
  30. Rimmer B, Sharp L (2021) Implementation of self-management interventions in cancer survivors: why are we not there yet? Journal of cancer Education. 36, 6, 1355-1358. doi: 10.1007/s13187-021-02021-2
  31. Stamataki, Z, Brunton L, Lorigan P et al (2015) Assessing the impact of diagnosis and the related supportive care needs in patients with cutaneous melanoma. Supportive Care in Cancer. 23, 3, 779-789. doi: 10.1007/s00520-014-2414-x
  32. Tan JD, Butow PN, Boyle FM et al (2014) A qualitative assessment of psychosocial impact, coping and adjustment in high-risk melanoma patients and caregivers. Melanoma Research. 24, 3, 252-260. doi: 10.1097/CMR.0000000000000059
  33. Trotter SC, Sroa N, Winkelmann RR et al (2013) A global review of melanoma follow-up guidelines. Journal of Clinical and Aesthetic Dermatology. 6, 9, 18.
  34. Welsh Government (2012) Together For Health – Cancer Delivery Plan: A Delivery Plan up to 2016 for NHS Wales and its Partners. http://www.iccp-portal.org/system/files/plans/120613cancerplanen.pdf (Last accessed: 20 January 2023.)
  35. Wiley K (2021) Nursing Considerations for Melanoma Survivorship Care. http://voice.ons.org/news-and-views/nursing-considerations-for-melanoma-survivorship-care (Last accessed: 20 January 2023.)
  36. Williamson S, Beaver K, Langton S (2020) Exploring health care professionals views on alternative approaches to cancer follow-up and barriers and facilitators to implementation of a recovery package. European Journal of Oncology Nursing. 46, 101759. doi: 10.1016/j.ejon.2020.101759

Share this page

Related articles

Increasing awareness of survivors’ needs
More people in the UK are surviving cancer, but the...

Survey evaluates quality of patient information at end of treatment
A patient experience survey was undertaken by the South West...

Community choir enhances coping skills and quality of life
This article explores the development of the Tenovus Sing...

Chronic pain in breast cancer survivors
The 20-year relative survival rate for women diagnosed with...

Services for women with metastatic breast cancer in the US
This article describes the experience of a nurse on an...