Nurse-led care
Personal view
The role of nurse-led care in cancer
management
Jessica Corner
Extending nurses’ roles and responsibilities so that they may take
on some functions of doctors is widely advocated to assist with
shortages of medical staff, improve service provision, and to
reduce costs. In cancer care in particular, use of specialist
nurses to help meet targets for faster diagnosis and treatment is
seen as essential. However, there has been little detailed
investigation of the consequences, effectiveness, or
acceptability of doctor–nurse substitution across health care, or
more specifically in cancer services. In this article, I review the
evidence for nurse-led care in cancer.
Lancet Oncol 2003: 4: 631–36
Across all aspects of health care the roles of health
professionals are being redefined. Boundaries between the
various professions are becoming blurred and new roles
for health-care workers are being introduced. Now, rigid
demarcations between the responsibilities of individual
health professions are actively discouraged and policy
makers are starting to advocate a more fluid approach to the
delivery of health care.1 The imperatives for these
changes are numerous; cost and efficiency are important
factors, as are workforce issues. There are too few doctors,
increasing pressures to reduce working hours of junior
doctors, and a continuous need to rapidly improve cancer
services while not overburdening the already stretched
medical staff. The drive to prioritise the quality of patients’
health-care experiences over professional goals is also a
central concern in contemporary health policy. Extending
the role and responsibilities of nurses so that they may
substitute for doctors has been suggested as a solution to
these problems.2
Internationally however, the situation is not a uniform
one. For some time, North American health care has used
nurses trained as physician’s assistants to do many of the
functions of doctors.3–4 In some European countries
where there are higher numbers of doctors per head of the
population than in the UK, the impetus for change has not
yet developed and there is still resistance to extension of
nursing roles. So, what evidence exists to support the
introduction of doctor–nurse substitution or nurse-led care
in the context of cancer services? And in what ways might
such nurses be trained to take on some of the functions
traditionally done by doctors?
Arguments for nurse-led services
People who support the use of nurses in doctors’ roles
generally argue that greater efficiency may be achieved.3
Because nurses are paid less than doctors, nurse-led services
could be cheaper. Furthermore, it has been suggested that
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Figure 1. Extending the role of nurses may improve cancer care.
quality of care might be improved because nurses may
attend to broader aspects of the health-care experience,
rather than concentrating solely on treating disease.
However, it is unclear whether nurse-led services are
acceptable to patients who may feel more confident with
advice or treatment given by a doctor. In general, nurses
are keen to take on more responsibility and, in turn,
anticipate greater recognition for their contribution to
health care. However, they are reluctant to take on additional
tasks if this is simply to reduce doctors’ workload.
The extent to which nurse-led care initiatives may
reduce the costs of health care has been examined in a few
studies, although information remains limited. Cumulative
evidence from the USA for the past 20 years3 shows
that nurses have delivered cost-effective care that can be
substituted for doctors’ services in many situations and
that nurses are also providing new services in areas of
need. Length of hospital stay, rates of re-admission,
emergency department visits, and number of prescriptions
have been reported to be lower with nurse-led care than
with conventional care (figure 2). Quality of life and
symptom management are also thought to be improved. A
UK-based systematic review5 of evidence for the cost-
effectiveness of nurse–doctor substitution is more reticent
however. This study implies that between 30% and 70% of
tasks currently undertaken by doctors could be done by
nurses. However, the cost savings achieved from a shift
such as this are difficult to determine. One problem is the
difficulty of
JC is Professor of Cancer and Palliative Care at the School of Nursing
and Midwifery, University of Southampton, UK.
Correspondence: Prof J Corner, University of Southampton,
Highfield, Southampton, SO17 1BJ, UK. Tel: +44 (0)23 8059 7979.
Fax: +44 (0)23 8059 7820. Email: J.L.Corner@soton.ac.uk
1
 Personal view Nurse-led

unit was
calculating potential costs of salary increases for nurses
who would inevitably require pay changes to match their
higher status. The review also highlighted the fact that few
UK- based studies have investigated these issues.

Evidence for the effectiveness of nurse-led

services
Hobbs and Murray6 state that evidence for the effectiveness
of nurse-led care is conflicting. They argue that few
rigorous investigations have been done or reported, and
there are no guidelines for how the complex effects that
may result from diversification of nursing initiatives might
be assessed. Of the randomised controlled trials that have
been completed, few show differences in outcomes for
patients treated by nurses and those treated by
conventional doctor-led care. However there are some
notable exceptions. For example, a study of nurse-led care
for patients with heart failure, where predischarge education
preceded home visits from nurses, showed significant
reductions in re-admission rates and improved quality of
life for patients receiving nursing care.7 A study of nurse-led
anticoagulation service revealed that nurse-led care was at
least as effective as doctor-led care and did not cause cost
increases.8 One conclusion from such studies is that a
positive effect on care is more likely when nurse roles
are focused on delivering clinical and specialised care,
rather than more generic coordination responsibilities.6
Investigations into the usefulness of nurse-led services
in various health-care settings tend to distinguish between
medical functions (which are narrowly defined and
generally consist of technical tasks) and broad-range
roles, where several new responsibilities are assumed. For
example, Dowling and colleagues did a study comparing
two different nurse-practitioner roles.9 In one group nurses
were partially substituted for junior doctors, taking on some of
their routine responsibilities; professional nursing work was
explicitly excluded in this scenario. The second model put
nurses in a neonatal unit where they completely took over
the clinical work of a neonatal senior house officer, but
retained an advanced nursing role and joint management
accountability to medical and nursing directors. Data from
the study led to the conclusion that when the scope of new
roles includes expansion of nursing and considerable clinical
discretion—as in the latter model—there are long-term
benefits such as improved quality of care and reduction in
workload for junior doctors. The short-term costs in
establishing such roles are high however. By contrast, if the
scope of the nurses job is limited and there are no nursing
duties and little clinical autonomy—as in the first model—
there may be short-term benefits, but the overall effect on
junior doctors may be slight and there is a risk of
fragmentation of care. These results suggest that
developments in nurse-led care may be divided into two
parts: a restricted-delegation model and a more
comprehensive advanced-practitioner model.
Studies of nurse-led in-patient units have produced
conflicting results.10–13 A recently reported UK study that
compared a nurse-led intermediate-care unit in London
with a hospital,14 reported equivocal cost and quality-
of-life outcomes for nurse and doctor care. The nursing

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 Nurse-led care
Personal view

established to facilitate the transition from acute hospital

care to the community. Nursing was seen as the
predominant active therapy and therefore nurses had the
authority to admit and discharge patients. There was no
routine involvement from consultant-led hospital
medicine; medical care (when required) was supplied by a
doctor acting as a general practitioner who was employed
on a session-by-session basis. 177 patients were
randomised to either care in the nurse-led unit, or to
standard care on a consultant-led acute ward. No
significant differences in outcomes between the two types
of care were found; indeed, costs were significantly higher
for patients who had nurse-led care due to longer stays. The
study suggests that cost and patient outcomes are not
automatically gained through the introduction of nurse-led
models of care. It should therefore be concluded that the
dynamic effects on service provision of new models of
care are complex and require more detailed study.
Research to date encompassing all aspects of health care
seems inconclusive; however, only few studies have been
done. There are few full economic analyses of nurse-led
services and these do not seem to support large cost savings.
In situations where the goals of nurse-led initiatives were
to improve quality of care, this outcome was not always
achieved.

Studies of nurse-led care in

cancer management
In cancer services in particular there is a desire to improve
the roles of nurses. New roles have been established—for
instance specialist nurses trained to deal with common
cancers—and aspects of current service provision are
now

Figure 2. Patients receiving nurse-led care may have fewer visits

to emergency departments.

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 Personal view
under question. Specific issues include: how can earlier
diagnosis can be achieved? And, how can patients enter
the treatment system more quickly? But the value of
follow-up after cancer treatment has also come under
scrutiny. Some people suggest that the resources invested
in long-term surveillance might be put to better use
elsewhere.15
To improve cancer services in the UK, targets have
been set for the achievement of shorter waiting times and
earlier diagnosis; the expected result is that cancers will be
detected at an earlier stage.16 Meeting these targets will
stretch existing services considerably. Treatment delivery is
also being reviewed. Surgical treatment requires less time in
hospital, so efforts are being directed at promoting early
discharge and administering other cancer treatments in an
outpatient basis or at home, for instance with the help of
continuous infusion devices for chemotherapy. The
management of advanced disease and care of the dying is
increasingly supported around a model of home-based
care; patients have only intermittent admissions or contact
with the treatment team. In all these settings, nurses are
playing an increasingly important role in the delivery of
treatment and support. However, little thought has been
given to how nursing roles, many of which are new, might
be best used to improve the quality and effectiveness of
care. The need to
Studies evaluating nurse-led care in cancer services
Ref Study design
21 Patient satisfaction survey of 119 women and
audit of fine needle aspirations of breast
comparing performance of doctors
and nurse specialists
22 Randomised controlled trial of 210 women
diagnosed with breast cancer, outcome of an advanced practice nurse who took No major cost savings variables: quality of life,
psychological
well-being and costs
23,24 Randomised controlled trial of 554 terminally
patients with cancer. Outcome variables:
physical symptoms, psychiatric problems, use
of and satisfaction with services and carers’
25 Randomised controlled trial of 166 patients with
cancer. Outcome variables: symptom
mood, current concerns, and social
dependency
26,27 Randomised controlled trial of 203 patients with
lung cancer. Outcome variables: quality of life,
patient satisfaction, general practioner
satisfaction, survival costs
28 Semi-structured interview study of 71 patients
prospective review of consultations and
waiting times
29 Randomised controlled trial of 56 patients
receiving radiotherapy. Outcome variables:
side-effects and anxiety
30 Audit of consultation times and effectiveness
radiotherapy for central nervous system
31 Randomised controlled trial of 115 men
undergoing pelvic radiotherapy for prostate
cancer. Outcome measures: quality of life,
symptoms of radiotherapy toxicity,
satisfaction with care, costs
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Nurse-led
develop new nursing roles has raised several important
questions.17 How can new nursing roles be evaluated in
cancer settings? What evidence exists for the effectiveness of
nurse–doctor substitution? Are nurse-led services acceptable
to patients? And, how might these changes be implemented?
Nurses have already been used to develop cancer care
packages in several situations including: early discharge after
breast surgery; home-based chemotherapy for patients with
colorectal cancer; and breast cancer diagnosis clinics. In the
context of early detection and rapid diagnosis, studies
indicate that nurse practitioners are competent at detecting
suspicious skin lesions for dermatological follow-up, once
they have been adequately trained.18 The effectiveness of
nurse endoscopists has also been extensively studied.19–20
These investigations suggest that nurses are successfully
doing tasks traditionally done by doctors and are capable of
taking on new areas of patient management. The roles that
have been looked at closely largely fall within a restricted-
delegation model, rather than the comprehensive advanced-
practitioner model advocated by Dowling and colleagues.9
Clinical trials of nurse-led cancer services
A handful of randomised controlled trials of nurse-led care
in which nurses take on an advanced-nursing role in cancer
Model of nurse-led care Main findings
Nurse-led breast cancer diagnostic clinic High satisfaction with care, nurses produced
lower proportion of inadequate samples lesions
Standard medical care with additional input No major cost benefits newly
responsibility for coordination of care and
support or women compared with standard
medical care only
Care individually coordinated by a nurse Little differences in outcomes for patients, ill
vs standard care costs of care lower for nurse coordinated
care
Nurse specialist led home care, vs Doctor-led care patients deteriorated more lung
standard home care, vs doctor-led quickly and showed greater social distress,
outpatient based care dependency, nurse specialist-led care
patients had fewer hospital admissions
Post-treatment nurse-led follow up versus Higher satisfaction rates and higher
doctor-led follow-up for patients with lung proportion of home deaths with nurse-led
cancer care, no differences in quality-of-life
outcomes or costs
Nurse-led radiotherapy review clinic vs Nursing consultations longer but resulted in and
doctor-led clinic shorter waiting times
Nurse-led consultations vs doctor-led Lower anxiety in patients receiving nurse-led
care with additional general health education care
information vs doctor-led care alone
Nurse-led phone clinic for patients following Nurse-led care equally effective and resulted of care
in 30% saving in medical time
tumours vs standard doctor-led care
Nurse-led care with open access clinics and Greater satisfaction with care from nurse-led
telephone follow-up vs standard care. Costs were lower for nurse-led care.
doctor-led care No differences in quality of life or symptoms
 Nurse-led care
care have been done.22–27,29,31 In addition, there have been
some descriptive and evaluative studies of nurse-led care
initiatives.21,28,30 From these studies (table 1), evidence about
the effectiveness of these initiatives is beginning to emerge,
but the challenges of establishing new advanced-nursing
roles and practices are also becoming clear.
In the context of breast cancer services, one study reports
high satisfaction among women attending a nurse-led
diagnosis clinic, although there was no comparison group
for conclusive results to be determined. An audit of fine-
needle aspirations of breast lesions taken in this clinic
revealed a lower proportion of inadequate samples from
nurses than those taken by other team members.21 A
randomised controlled trial22 of advanced nursing care in
addition to medical care compared with medical care alone
for women with breast cancer failed to show substantial
benefits for women, although uncertainty was lower
among the women receiving nursing care. Furthermore, no
cost savings were shown. However, problems with the
study methods mean it is difficult to draw firm conclusions.
Several randomised controlled trials of nurse-led follow-up
for women who have completed breast cancer treatment are
ongoing; these projects are evaluating different models of
post-treatment monitoring and support.
Addington-Hall and co-workers have reported a trial of
care coordinators for terminally ill patients with cancer.23,24 In
this study, patients who were allocated to the coordinated
care group received the assistance of two nurse co-
ordinators whose role was to assure that care met the specific
needs of the patient and their family. The measured
outcomes were: presence and severity of physical
symptoms; use of and satisfaction with services; and
carers’ problems. Few differences were reported between the
patients receiving nurse coordinated care and those who did
not, and it was concluded that the service made little, if any,
difference to care received. However, costs were
significantly lower for those receiving nurse-coordinated
care; this result was quantified in terms of fewer days spent
in hospital and fewer nurse home visits. The nurses’ ability
to obtain services on behalf of patients was entirely
dependent on goodwill since they had no direct budgetary
control. Furthermore, the nurses employed may not have
the skills required for a “service brokerage” model of care.
This study seems to reflect the view that nurse-led care
does not necessarily mean better care. Successful outcomes
depend on the particular model of service developed, the
authority given to the new nursing role, and the personal skills
and resources of the individual nurse. New roles
established against a background of resistance and few
resources are unlikely to offer benefits to patients.
Two studies in nurse-led care for patients with lung
cancer have been done. An early study25 of a nurse-led home-
care service compared patients who were allocated to three
different care models: advanced cancer nurse practitioners
who offered support to patients at home; standard
community care; and, physician-led conventional care.
Patients were interviewed and were asked to complete a
number of standard tests every 6 weeks during a 6-month
period. For all patients, symptom distress increased over
time, but for those receiving conventional doctor-led care
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Personal view
this occurred sooner and to a greater degree than in the
two groups receiving home-based care. Social dependency
was also considerably greater in the doctor-led care group;
however, these patients consistently had improved
perceptions of their health compared with the two home-
care groups. So, what additional benefit did the advanced
cancer nurse practitioners offer over standard community
care? Interestingly, the group receiving advanced nurse-
practitioner care had fewer hospital admissions, and
shorter hospital stays (although the latter was not
statistically significant) than either of the other two models
of care.
I have recently completed a trial with colleagues,26,27
which sought to develop and evaluate nurse-led follow-up
for patients with lung cancer. We did extensive preparatory
work before implementing the nurse-led care model and
launching a clinical trial of the service. The follow-up
service was audited to investigate the nature of work
undertaken by doctors and the problems and needs of
patients attending follow-up. We observed that follow-up
consultations with doctors tended to focus on patients’
physical problems; there was little discussion about their
concerns or about how they were coping more generally.
Our research pointed to several inadequacies in the existing
model of follow-up: it was lacking in coordination; the
interval between visits to hospital seemed haphazard;
and, patients were often seeing numerous different
individuals about their problems. Only half the patients
seemed to have been referred to a palliative- care service
despite the fact that 75% died within 36 weeks of entering
follow-up. The new model of care we devised was not
simply an experiment in doctor–nurse substitution, instead
it was designed to be a vehicle for improving the service
provided to patients with lung cancer. The model of care
was developed as a more supportive, flexible, and
accessible model than the existing one. Disease
surveillance was considered important, but since this was
commonly identified through clinical symptoms reported
by patients, rather than through investigations that are
part of a follow- up protocol, the nurse-specialist-led model
of care placed less emphasis on routine investigations and
these were only ordered if there appeared to be an
identifiable need. Emphasis was instead placed on
encouraging patients to report symptoms, offering
assistance with alleviating symptoms and on addressing
psychological and social needs. Patients had a detailed first
assessment, and thereafter were followed up by telephone
monthly, patients then were offered an “open-access”
clinic and ready access to the nurse-specialists via a
message pager. The approach was tested during a pilot
study and subsequently evaluated in a clinical trial.
Acceptability of nurse-led care was high, 75% of eligible
patients agreed to participate in the trial, and of those who
refused, only 16% did so because they preferred to see a
doctor. There were no differences in survival between
the two groups and nurses were as effective in detecting
disease progression, indeed there was some evidence that
nurses detected this sooner than occurred for those
receiving doctor-led care. There were few differences in
quality-of-life outcomes between doctor-led care and
5
 Personal view Nurse-led

nurse-led care, and no differences in costs, although patients

were significantly more satisfied with nurse-led care.

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 Nurse-led care
Personal view
higher than with conventional doctor-led models of care.
Four studies,28–31 two of which used full However, the reasons for this increased satisfaction warrant
randomised controlled designs, have been reported in the investigation
context of radiotherapy care. In one study30 of
follow-up post- radiotherapy treatment for patients with
tumours in the central nervous system was transferred to a
nurse-led ‘phone clinic’ with a 30% saving of medical time as
a result, the method of follow-up was deemed equally
effective, releasing medical time for more complex cases.
A second study29 investigated the effect of weekly
structured nursing consultations on anxiety, severity of
side-effects and the use of self-care strategies. Patients
were randomly allocated to three groups: usual care,
additional general health information, and weekly
individual nursing consultations with an expert
practitioner. During 6 weeks of follow-up, patients
receiving nursing consultations had consistently lower
anxiety scores than patients in either of the other two
groups. There were no differences in side-effects experienced
or the ability to self-care between the groups.
The other studies have examined the potential for
nurses to manage the care of patients undergoing
radiotherapy treatment. This involves monitoring for side-
effects of treatment, checking that the correct dose of
radiotherapy is being administered, and assisting patients
with symptoms or other problems. A non-randomised
study28 of a nurse-led radiotherapy review clinic has been
reported, which compared outcomes for patients attending
nursing consultations with those who saw a doctor.
Although the nursing consultations lasted longer, shorter
waiting times were achieved. Few of the nurse
consultations required the additional input of a doctor and
half of those that did were for a prescription. None of the
patients in the study indicated a preference for seeing a
doctor.
Faithfull and colleagues’31 randomised controlled trial set
out to establish whether nurse-led follow up improved
patients’ morbidity and satisfaction with care in men
treated with radical pelvic radiotherapy for bladder and
prostate cancer. The nurse-led care commenced at the
start of radio- therapy and continued for 12 weeks when
patients returned to medical care. The specialist nurse
provided information and answered questions on healthy
eating, radiotherapy, and how to manage urinary symptoms
during radiotherapy at an initial contact. Thereafter,
patients could attend a nurse-led clinic for further help as
required, and telephone contact was maintained with the
patient to check the patients’ health status. Those men
who received nurse-led care were significantly more
satisfied with their care at 12 weeks. There were also
significant cost-benefits with a reduction in costs of 31% for
nurse-led care compared with medically-led care. Only six
of 131 (5%) men approached to participate in the study did
not wish to receive nurse-led care.
From these studies it is possible to conclude that in
cancer settings some substantial studies have been done using
robust trial methodology to examine the effectiveness of
nurse-led care, delivered by advanced nurse practitioners.
The studies suggest that use of nurses is effective and safe,
and that nurse-led care is acceptable to most patients.
Satisfaction with nurse-led care is high, indeed is seems to be

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 Personal view Nurse-led

patient should be reviewed. Thus, the nurse-led care in this

because it may relate to a greater attention to service system was felt to improve multiprofessional working by
organisation and a more person-centred model of care, providing a filter
rather than to particular characteristics of nurses. Costs,
when compared, have been similar or lower than for
conventional care. Unlike in other settings, in cancer
services where nurses have been given advanced-nursing
roles it seems that nurse-led care is not more costly. In
comparisions like these, it is important to take the type of
care model into account. In previous studies these have
largely been out- patient or community settings and the
nurses involved were highly trained and had years of
experience in working with cancer. Therefore, these
nurses are more akin to consultant nurses than to the
junior or untrained nursing assistants that staffed the
nurse-led intermediate-care unit studied by Richardson
and colleagues.14 Costs and benefits of nurse-led care and
the dynamic and long-term effects on service use warrant
further detailed investigation.

Difficulties in developing nurse-led services

Some studies have examined the practical difficulties
involved with developing nurse-led care services. In
particular, training and supervision of nurses in roles
where they take on considerable responsibility and
aspects of delegated medical practice need close
attention. There are carefully structured systems for team
working in medical practice and supervision of decisions
about patients’ treatment. Nurses who take on extra
responsibility for patients will not automatically be accorded
the same amount of supervision. Questions such as which
aspects of nurses’ practice should be supervised, and how
this can be done while maintaining supervision and
management by senior nurses, need to be resolved as
new models of care are developed. Nurses report feeling
burdened by new responsibilities that their previous
nursing training has not prepared them for, and these
feeling can be stressful.26 Studies have also reported
considerable resistance by both nursing and medical
colleagues to new ways of working. Securing resources
and facilities such as clinic space, or protocols to enable
ordering of tests and investigations is also a problem.32,27,33
Nurses working in acute hospital settings in the UK continue
to be limited by legal constraints since although nurses
may now prescribe, this does not extend to many of the
treatments used in cancer management and means that
nurses may not take full responsibility for making
decisions about patient care. The status of nurses in
relation to tasks traditionally done by doctors needs to be
addressed and may require further changes in legislation if
the full potential for interchange between professional roles
is to be achieved.
In developing cancer services there has been a
commitment to multiprofessional teamwork; however,
doctor–nurse substitution may run counter to this
philosophy if nurse-led care is interpreted to be “nurse alone”
care. One of the benefits which was perceived to be
particularly important by patients in the study of nurse-led
care in follow-up of patients with lung cancer,26 was the
ready access to doctors should the patients feel they
wanted a medical consultation, or if the nurses felt the

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 Nurse-led care
Search strategy and selection criteria
Papers cited in this review were identified using searches of
PubMed, CINAHL, EMBASE, and Cancerlit databases. The
search terms “nurse-led care”, “nurse practitioner”, “nurse
specialist”, “advanced nursing practice/practitioner”, and “cancer”
were used. Additional papers were identified by searching
reference lists from retrieved papers. The ‘grey literature’ was also
sought. Papers selected in relation to nurse-led care in cancer
services were studies of nursing roles where nurses were given
significant responsibility for the care of patients, and substituted
for doctors in a particular setting, rather than offering care that was
supplemental to medical care. Nurse-led care was thus
differentiated from care by a more conventionally used nurse
specialist.
for those in most need and facilitating rapid access to medical
care should this be required. It is likely that many, but not
all, functions in health care, can be performed
interchangeably by doctors or nurses without loss of
quality or jeopardising patient outcomes. The key is to
identify those functions that are best performed by doctors,
nurses, or others, and in what circumstances. However, this
goal will require further study.
Conclusion
Health-care delivery, if viewed as an activity that may be
delivered by interchangeably by various professionals, may
lead to the development of a more flexible and fluid
workforce and to more satisfying working relationships
between different professionals groups as a result of the
opportunity to share perspectives on patient care and
treatment. Improving the status of nurses and their
relationships with medical colleagues has been identified as
an imperative for maintaining the nursing workforce in
future.34 If carefully planned and managed, nurse-led models
of care may lead to better services for patients. Studies
that have been done in the context of cancer services suggest
that nurses can take a lead role in patient management
through interdisciplinary teamwork without detriment to
the well being of the patient. There may also be other
benefits, but these are not automatic and cannot be
assumed. Investment in developing professional roles,
services or individuals, rather than simply in initiatives will
produce the best results. Further detailed study is needed
so that the complex dynamics at play may be elaborated
further.
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