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Effectiveness of Nurse-Led Case Management in

Cancer Care: Systematic Review
Article in Clinical Nursing Research · May 2018
DOI: 10.1177/1054773818773285

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Clinical Nursing Research
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Review

Jee Young Joo, PhD, RN1

and Megan F. Liu, PhD, RN2

Abstract
Cancer survivors need accountable, patient-centered and lifelong care. Case
management has been shown effective at providing quality care and at
reducing both hospital access and health care costs. However, how effective
case management in cancer care is to date unclear. This systematic review
examines recent evidence of the effectiveness of nurse-led case
management in adults with cancer. The Cochrane processes and PRISMA
statements guided this systematic review. The methodological risk of bias
was assessed. From four electronic databases, nine experimental studies
published from 2008 to 2017 were retrieved. Synthesized results show
positive case management effectively improved patients’ quality of life and
significantly reduced hospital readmission rates. However, there were mixed
results of health care costs and other hospital access outcomes. There is
some evidence that nurse-led case management is effective in cancer care.
Further research applying rigorous design to large populations of cancer
patients is recommended.

Keywords
case management, cancer, quality of life, hospital access, systematic review

1Gachon University, Incheon, South Korea

2Taipei Medical University, Taiwan
Corresponding Author:
Megan F. Liu, School of Gerontology Health Management, College of Nursing, Taipei Medical
University, Taipei, Taiwan.
Email: fangliu@tmu.edu.tw
2 Clinical Nursing Research 00(0)

Introduction
Cancer is deadly and expensive, and requires a high level of care (Siegel,
Miller, & Jemal, 2015). It is estimated that 8.8 million people died due to cancer
in 2015; indeed, it is the second leading cause of death globally (World Health
Organization, 2017). Moreover, the total annual economic cost of can-cer is
approximately US$1.16 trillion (World Health Organization, 2017). Individuals
with cancer require extended inpatient and outpatient care by several health
professionals (Bleich et al., 2017; Strupp et al., 2018). However, during cancer
treatment, the care that patients receive has been uncoordinated and fragmented
due to the many health care providers patients see in multiple health care
settings (Strupp et al., 2018). This is a problem because many cancer patients
have high levels of physical dysfunction and psychological stress (Bleich et al.,
2017; Hsu, Chai, Lin, Wang, & Chen, 2017; Strupp et al., 2018). The stress also
challenges their quality of life (QoL) and raises their health care costs (Centers
for Disease Control and Prevention, 2016; Hsu et al., 2017). To provide
coordinated and continuous care to cancer survivors, case management (CM)
has been introduced to provide efficient and effec-tive cancer care (Hsu et al.,
2017; Strupp et al., 2018).
CM is defined as a “collaborative process of assessment, planning, facili-
tation, care coordination, evaluation, and advocacy for options and services to
meet an individual’s and family’s comprehensive health needs through
communication and available resources to promote quality, cost-effective
outcomes” (Case Management Society of America [CMSA], 2017). CM has
been shown to promote QoL, reduce health care costs, and provide patient-
centered and comprehensive care for a variety of chronic illnesses in hospi-tal-
based and community-based settings (Hsu et al., 2017; Joo & Huber, 2017).
Furthermore, several systematic reviews have found CM to effectively reduce
hospital access, increase QoL, and improve satisfaction with care in the care of
chronic illnesses (Huntley, Johnson, King, Morris, & Purdy, 2016; Joo & Liu,
2017; Stokes et al., 2015). Nevertheless, in these reviews, CM was studied with
high-risk populations, such as frail elderly individuals, or for usual chronic
illnesses such as hypertension, diabetes, or heart failure.
The concept of CM in cancer care should be discussed apart from care for
other chronic diseases because cancer care is integrative with palliative care and
associated with lifelong and end-of-life care (Hsu et al., 2017; National Cancer
Institute, 2016). Unfortunately, no recent reviews have systematically
synthesized studies of CM effectiveness in cancer care. Only a few studies have
surveyed cancer patients’ satisfaction with CM services (Chiang et al., 2018;
Hsu et al., 2017). And while an integrative review evaluated effective-ness of
CM with chronic illnesses, among its retrieved studies only two
Joo and Liu 3

targeted cancer (Joo & Huber, 2014). That review identified effectiveness of
CM in chronic disease care, but the overall results were mixed; therefore, the
evidence of CM effectiveness in cancer care is unclear. Finally, a systematic
review by Wulff, Thygesen, Søndergaard, and Vedsted (2008) analyzed CM
efficacy with cancer care but drew no conclusions because of the scarcity and
heterogeneity of outcomes of the included studies. While CM is a promising
tool for coordinating care (Hsu et al., 2017), more evidence is needed of its
effectiveness in cancer care. Therefore, this study seeks to identify recent
empirical evidence of CM effectiveness on improving cancer care.

Method
Aim
The aim of this systematic review was to identify and synthesize recent evi-
dence of CM effectiveness at optimizing care and reducing problems
associ-ated with cancer. To identify the most recent evidence, this
systematic review analyzed studies published within the last 10 years. The
research question was as follows:

Research Question 1: Has CM been effective in reducing patient out-

comes, hospital utilizations, and health care costs for adults who suffer
cancer?

Study Design
The study design was guided by the Cochrane Handbook for Systematic
Reviews of Interventions (version 5.1.0; Higgins & Green, 2011). Also, the
study reported according to the principles of the PRISMA Statement
(Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009) and PICO
(Patients, Intervention, Context, Outcome) Framework (Robinson,
Saldanha, & Mckoy, 2011).

Search Strategy
Four electronic bibliographic databases—CINAHL, PubMed, Web of Science,
and PsycINFO—were used to find empirical studies of CM pub-lished within
the last 10 years. As outlined by the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins & Green, 2011), MeSH terms and keywords
were identified for searching each electronic database for rel-evant studies. The
following keywords and MeSH terms were combined with
4 Clinical Nursing Research 00(0)

Boolean operators “and” or “or” with appropriate truncations: (cancer case

management) OR (case management) OR (nurse-led case management) OR
(palliative case management) AND (cancer) OR (cancer patient). Additional
search terms were (effectiveness) OR (impact) OR (outcomes). In addition,
combinations of specific types of cancer (lung cancer or liver cancer or
colorectal cancer or stomach cancer or breast cancer, etc.) were used. The
search was limited to studies published between 2008 and 2017, published
only in English, and with populations of adults. The initial search was con-
ducted in September 2017, and a confirmation search was completed in
October 2017.

Inclusion and Exclusion Criteria

Empirical and primary studies with experimental research designs were
included. The PICO (Patients, Intervention, Context, Outcome) format
adopted for this review included the following definitions:

•• Patients: Adults with all types of cancer

•• Intervention: CM for cancer
•• Comparison: Usual care
•• Outcomes: Changes in participants’ outcomes after receiving CM
interventions

Specific inclusion criteria for this systematic review included studies (a) that
used an experimental design; (b) that took place in hospital- or commu-nity-
based settings and used CM interventions aimed at management of can-cer; (c)
that had as participants adults (≥18 years) with any type of cancer;
(d) that included as outcomes psychobehavioral, hospital access, or health
care cost analysis; and (e) that were published in English in peer-reviewed
journals.
Excluded from this systematic review were studies (a) that were
literature reviews or qualitative studies, (b) that used mixed interventions,
and (c) that were primarily descriptions of future studies.

Study Selection Process

Figure 1 presents a PRISMA flowchart of the study screening and selection
process. From four electronic databases, a total of 715 articles were retrieved.
All articles were imported to a RefWorks database and duplicates were
removed. The remaining 323 articles were evaluated by title; 290 of these were
excluded. Thirty-three articles were then evaluated by abstract, of which
Joo and Liu 5

Figure 1. PRISMA flowchart of screening and selection process.

Note. CM = case management.

13 were identified for full-text review. Of these, four articles were excluded
based on the exclusion criteria of this review. Finally, nine empirical studies
were selected for the quality assessment. In this process, the first author
con-ducted the study selection and the second author reviewed and
confirmed the study selection process.

Quality Assessment
For quality appraisal, the Amsterdam–Maastricht Consensus List for Quality
Assessment (Furlan, Pennick, Bombardier, van Tulder, & Cochrane Back
Review Group, 2009) was used. This tool was developed to guide systematic
reviews in identifying studies’ methodological rigor and risk of bias using 12
6 Clinical Nursing Research 00(0)

criteria (Furlan et al., 2009). If a study qualified in a criterion, it scored 1;

otherwise, it scored zero. Thus, the range of this tool is from 0 to 12, and
higher scores mean a study has low risk of bias. If the score of a study was
equal to or above 6, it means that a study had sufficient methodological
qual-ity (Furlan et al., 2009). The first and second investigator scored each
retrieved study independently. After that, they met to resolve discrepancies.
Table 1 shows the results of the quality assessment. All the studies’ scores
ranged from 6 to 12; the studies that were not randomized controlled trials
(RCTs) scored from 6 to 7, and the three RCTs scored 10, 11, and 12 each.
The studies as a whole had moderate to high methodological rigor.

Data Extraction and Synthesis

Due to the heterogeneity of outcome measures, we were unable to conduct a
meta-analysis. Instead, we conducted a systematic synthesis of study results
(Higgins & Green, 2011). The following study information was tabulated:
aim, year, country, target population, sample size, setting, design, interven-
tion, variables, and major outcomes (Higgins & Green, 2011). Common
out-comes of the studies were extracted and synthesized into three domains.
The studies were summarized and synthesized by the first author
independently. The second author checked the table for accuracy.

Results
General Description of Included Studies
Table 2 presents general characteristics of the nine included studies (Bleich et
al., 2017; Chen, Chang, Tsou, Chen, & Pai, 2013; Hubbard, Gray, Ayansina,
Evans, & Kyle, 2013; Ozcelik, Fadiloglu, Karabulut, & Uyar, 2014; Scherz et
al., 2017; Seow et al., 2008; Wang, Piet, Kenworthy, & Dy, 2015; Wu et al.,
2014; Wulff, Vedsted, & Søndergaard, 2012). Table 3 presents an evidence
grid. Study authors were multidisciplinary, coming from fields such as public
health, nursing, and medicine. All nine studies had a control intervention as
usual care. Year of publication ranged from 2008 to 2017, but most studies were
published within the last 5 years (n = 7). The mean population age was 55.14
years old (range = 50.2-66.25 years). The total number of study partici-pants
was 9,601. The two studies that were published in the United States had
Medicare and Medicaid patients as participants. Types of cancer included
breast, colorectal, lungs, ovarian, prostate, and cervical cancer, among others.
Six of the studies included several types of cancer; three were targeted to
individuals with breast (n = 2) or colorectal cancer (n = 1). Sample sizes
 Table 1. Summary of Study Quality Assessment Using the Amsterdam–Maastricht Consensus List for Quality Assessment.

Hubbard, Ozcelik,
Gray, Fadiloglu, Wulff,
Bleich Chen, Chang, Ayansina, Karabulut, Scherz Seow Wang, Piet, Vedsted, and
et al. Tsou, Chen, Evans, and and Uyar et al. et al. Kenworthy, Wu et al. Søndergaard
Items (2017) and Pai (2013) Kyle (2013) (2014) (2017) (2008) and Dy (2015) (2014) (2012)

1. Was the method of randomization − − + − + − − − +

adequate?
2. Was the treatment allocation concealed? − − + − + − + − +
3. Was the patient blinded to the − − − − + − − − +
intervention?
4. Was the care provider blinded to the − − − − − − − − +
intervention?
5. Was the outcome assessor blinded to the − + + − + + + + +
intervention?
6. Was the dropout rate described and + + + + + − − + +
acceptable?
7. Were all randomized participants analyzed − − + − + − − − +
in the group to which they were allocated?
8. Are reports of the study free of suggestion + + + + + + + + +
of selective outcome reporting?
9. Were the groups similar at baseline + + + + + + + − +
regarding the most important prognostic
indicators?
10. Were co-interventions avoided or similar? + + + + + + + + +
11. Was the compliance acceptable in all + + + + + + + + +
groups?
12. Was the timing of the outcome assessment + + + + + + + + +
similar in all groups?
Total 6 7 10 6 11 6 7 6 12

Note. Range = 0–12 points; − = no, criterion was not met or not clearly stated; + = yes.
7
8 Clinical Nursing Research 00(0)

Table 2. Characteristics of Included Studies.

Characteristic Description Number of studies

Study design RCT 3
CBA 6
Nation of publication The United States 3
Germany, Taiwan, the United 1 each
Kingdom, Denmark, Turkey,
Switzerland
Total sample size <100 4
>100 5
Mean age of sample 50-60 7
60-70 2
Year of publication 2008-2012 2
2013-2017 7
Outcomes Psychological symptoma 5
Hospital utilizationsa 5
Health care costsa 2

Note. RCT = randomized controlled trial; CBA = controlled before-and-after study.

aDuplicated answer.

ranged from 18 to 7,445, and six studies reported power analysis for sam-
pling. All participants had been diagnosed with cancer for at least 1 year
and were in the middle of cancer therapy.
Three studies were RCTs. Due to the limited number of RCTs that met
the aim of this study, six quasi-experimental studies were included.
Although the randomization was not allocated, these studies sustained rigor
of research design and addressed possible risk of bias.

Characteristics of Nurse-Led Cancer CM Interventions

All nine studies conducted nurse-led CM as interventions for cancer care.
The aim of the interventions was to assess comprehensive health needs for
cancer care and to provide patient-centered, continuous, supportive, and pal-
liative care. All interventions were targeted to cancer patients diagnosed
with cancer prior to intervention and were led by nurses or nurse case
managers who specialized in oncology. The nurses led multidisciplinary
teams com-posed of health care professionals such as physicians and social
workers. The details of intervention dosage—type, duration, and breadth—
were somewhat heterogeneous; however, some components of standard CM
practice were congruent.
 Table 3. Evidence Grid.
Authors (year)/ Participants power Control CM intervention/setting/
country Purpose(s) Design analysis intervention duration Outcome measures (tool) Major findings

Bleich et al. To evaluate whether Quasi- Breast cancer patients Usual care The individual and continuous •• QoL (Short form 8 The tested CM model
(2017)/ CM was effective experimental recruited from two support of the patient Health Survey and improved in the IG’s Short
Germany in improving design acute hospitals (which provides the EORTC 11) form 8 Health Survey
health-related N = 244 patient’s personal •• Anxiety and physical component (p =
QoL and reducing IG: n = 126 resources) is performed depression (Hospital .040) at a 12-month follow-
the psychological CG: n = 118 by professional case Anxiety and up; however, no group
distress of breast Mean age: 55.7 years managers. Depression Scale) difference in the EORTC
cancer patients Yes Team: Nurse-led, 11 or Hospital Anxiety and
multidisciplinary Depression Scale.
Setting: From hospital-
initiated CM
Duration: 12 months
Chen et al. To evaluate the Quasi- Patients diagnosed with Usual care Hospital-based nurse- •• Unplanned The unplanned readmission
(2013)/Taiwan effectiveness of experimental lung, liver, breast, led cancer CM: case readmission rate rate caused by infection was
nurse-led CM in design colon, buccal, or managers’ face-to-face •• The rate of patient significantly decreased in the
improving care cervical cancers contact, consultations by continuing treatment IG compared with the CG
quality in cancer N = 1,200 phone (open 24 hr); case (1.5% vs. 4.7% in the CG, p
patients IG: n = 600 managers recommended = .002). The rate of patient
CG: n = 600 appropriate medical continuing treatment in
Mean age: 61.7 years resources, identified the institution significantly
Yes individual barriers and increased in the IG than the
needs, and provided CG (93.8% vs. 84.8%, in the
education and training CG, p < .001).
about disease care.
Team: Nurse-led,
multidisciplinary
Setting: Hospital-based
Duration: 12 months

(continued)
9
10

Table 3. (continued)
Authors (year)/ Participants power Control CM intervention/setting/
country Purpose(s) Design analysis intervention duration Outcome measures (tool) Major findings

Hubbard et al. To assess the RCT Women with breast Usual care CM services to assess •• Sick leave days After CM, the IG reported
(2013)/the feasibility and cancer individuals’ needs to enable •• QoL (Functional 53 fewer days of sick leave
United Kingdom acceptability of N = 18 work retention or return Assessment of over the first 6 months
a CM vocational IG: n = 7 through signposting or Cancer Therapy– postsurgery than those in
rehabilitation trial CG: n = 11 direct referral to a range Breast Cancer/Breast the CG, but the difference
of women with Mean age: 50.5 years of supportive services cancer subscale) was not statistically
breast cancer Yes according to need, •• Fatigue (The significant (p = .122; 95%
To inform the such as physiotherapy, Functional confidence interval = [−15.8,
development of a occupational therapy, Assessment of 122.0]). At 6 months,
larger study occupational health Chronic Illness QoL with the Functional
nurse, occupational Therapy Fatigue Assessment of Cancer
health doctor, counselor/ Scale) Therapy–Breast Cancer
psychological therapy, was higher in the IG than
or other complementary the CG, but not statistically
therapy significant (p = .333). The
Team: Nurse-led, QoL with the Breast Cancer
multidisciplinary Setting: subscale indicated significant
Community-based improvement for the IG
Duration: 6 months compared with the CG (p
= .020). No difference in
fatigue scores was found
between the IG and the CG.

(continued)
 Table 3. (continued)
Authors (year)/ Participants power Control CM intervention/setting/
country Purpose(s) Design analysis intervention duration Outcome measures (tool) Major findings

Ozcelik et al. To investigate the Quasi- Patient with advanced Usual care in CM services included •• Symptom control The level of decrease in
(2014)/Turkey improvement in experimental stage cancer, life the oncology consultation and follow- (Edmonton Symptom symptom severity in the
symptoms, QoL, design expectancy of department up, effective symptom Assessment System) IG patients was more
patient and family between 6 and 12 management, psychosocial •• QoL (European than in the CG (p < .000).
satisfaction with months stress management, social Organization for The satisfaction level of
care, and direct N = 44 support, care and training Research and patients and family in the
costs resulting from IG: n = 22 support, education, and Treatment Quality IG was higher than that
a palliative CM CG: n = 22 family counseling services of Life Questionnaire for conventional service in
model Mean age: 53.11 years Team: Nurse-led, C30) the CG (p < .05). The IG
Yes multidisciplinary •• Satisfaction levels showed better EORTC-30
Setting: Hospital-based •• Direct health costs symptom scores (p < .05).
Duration: 12 months •• Length of stay in No statistical difference
hospital was detected between the
IG and the CG regarding
the direct health costs and
the mean length of stay in
hospital (p > .05).
Scherz et al. To investigate the RCT Patients with Usual care CM by nurse case managers •• Health-related The change in QoL over 12
(2017)/ effect of CM on completion of a specializing in oncology QoL (Functional months was significantly
Switzerland QoL in early cancer curatively intended Team: Nurse-led, Assessment of greater in the IG than
survivors cancer treatment multidisciplinary Cancer Therapy) in the CG (p = .006).
(Chemotherapy, Setting: Hospital-based •• Self-efficacy The accordance of care
radiotherapy and/ Duration: 12 months (Jerusalem and increased by 0.20 (SE
or surgery) and Schwarzer = 0.14) in the IG and
expected questionnaire) decreased by 0.29 (SE =
Survival of at least •• Accordance of care 0.12) points in the CG (p =
1 year (Patient Assessment .009). Self-efficacy increased
N = 95 of Chronic Illness by 3.1 points (SE = 0.9) in
IG: n = 47 Care) the IG and by 0.7 (SE = 0.8)
CG: n = 48 points in the CG (p = .049).
Mean age: 50.2 years
Yes

(continued)
11
 Table 3. (continued)
12

Authors (year)/ Participants power Control CM intervention/setting/

country Purpose(s) Design analysis intervention duration Outcome measures (tool) Major findings

Seow et al. To evaluate a Controlled Patients are those with Usual care, A palliative care CM Hospital admissions The IG was 86% less likely to
(2008)/the palliative care CM before-and- active cancer from which program for patients facing Total costs for all have one or more hospital
United States pilot program for after study the beginning of consisted potentially life-threatening admissions admissions than the CG,
Medicaid cancer (CBAs) with diagnosis to hospice of physician cancer controlling for time since
patients in managed a retro- N = 89 care and Team: Nurse-led, referral, age, and gender (p
care spective IG: n = 69 support from multidisciplinary = .006). However, the mean
cohort CG: n = 20 the customer Setting: Hospital-based total costs for all admissions
analysis Mean age: 52 years service Duration: Not reported was not significantly different
No department between the IG (US$42,265)
of the and the CG (US$29,567) (p
managed = .277).
care
organization
without CM
or palliative
care
Wang et al. To evaluate a palliative Controlled Medicaid patients with Usual care A palliative care CM program •• Inpatient admission The IG had a lower inpatient
(2015)/the care CM program before-and- cancer delivered a level of care rate admission rate than the
United States for Medicaid cancer after study N = 186 that is supportive of •• ICU admission rate CG (56.8% vs. 74.1%; p =
patients in managed (CBAs) with IG: n = 132 patients to improve their •• Mean ICU days .03), lower ICU admission
care a retro- CG: n = 54 QoL and to contain health •• ED visit rate rate (12.9% vs. 24.1%; p =
spective Mean age: 50.8 years care costs •• Mean hospice days .06), longer mean hospice
cohort No Team: Nurse-led, •• Rate of persons with days (45.8 vs. 31.1 days; p =
analysis multidisciplinary death in hospital .01), and lower percentage
Setting: Hospital-based •• Hospice election rate of persons with death in
Duration: Not reported hospital (24.2% vs. 35.9%;
p = .04). No statistically
significant differences were
found in mean ICU days
(8.7 vs. 9.7 days; p = .32),
treat-and-release ED visit
rate (22.0% vs. 16.7%; p =
.42), or hospice election rate
(65.9% vs. 70.4%; p = .56)
between groups.

(continued)
 Table 3. (continued)
Authors (year)/ Participants power Control CM intervention/setting/
country Purpose(s) Design analysis intervention duration Outcome measures (tool) Major findings

Wu et al. (2014)/ To assess the impact Controlled Patients diagnosed with Usual care Oncology nurse-led •• Monthly cancer- Monthly cancer-related medical
the United of a CM program before-and- cancer telephonic CM program related medical costs costs during 6-month
States led by oncology after study N = 7,445 gave support to patients follow-up were lower by
nurses on cancer- (CBAs) with IG: n = 3,255 and their families and US$1,128 (9.8%) for the IG
related medical a retro- CG: n = 4,190 caregivers to reduce ED compared with the CG (p
costs and hospice spective Mean age: 56 years visits and hospitalizations = .002). Cost savings were
use cohort No Team: Oncology nurse-led, driven by lower inpatient
analysis multidisciplinary (57.8%) and chemotherapy
Setting: Hospital-based (32.2%) costs.
Duration: 6 months
Wulff et al. To analyze the RCT Colorectal cancer Usual care: No The manual-based CM •• Health-related There were no statistically
(2012)/ effectiveness of patients who were designated intervention: CM was QoL (European significant group differences
Denmark hospital-based CM to undergo further health conducted by nurse case Organization for on any of the health-related
in terms of patient- investigation or professional managers who undertook Research and QoL subscales (Global QoL,
reported outcomes treatment overlooked care pathway supervision, Treatment Quality Physical, Role, Emotional,
N = 280 the information dissemination of Life Questionnaire Cognitive, Social Function)
IG: n = 140 coordination to health professionals C30) at 8, 30, or 52 weeks.
CG: n = 140 of health and outreaching patient Patients allocated to CM, all
Mean age: 66.25 years services support. The nurse point estimates favored CM
Yes case manager regularly at Week 8 and 30; at Week
telephoned the patient 52, six of seven estimates
to assess his or her favored CM.
biopsychosocial status
and screen for barriers
to optimal care related
to coordination and
awareness of the care plan
Team: Nurse-led,
multidisciplinary
Setting: Hospital-based
Duration: 4 weeks

Note. CM = case management; IG = intervention group; CG = control group; RCT = randomized controlled trail; QoL = quality of life; EORTC = European
Organization for Research and Treatment of Cancer; CBA = controlled before-and-after study; ICU = intensive care unit; ED = emergency department.
13
14 Clinical Nursing Research 00(0)

Across the nine studies, CM interventions aimed to provide comprehen-

sive care through palliative care, supportive services, and regular follow-ups
with the goal of reducing fragmented and duplicated care (Bleich et al.,
2017; Chen et al., 2013; Hubbard et al., 2013). Patients in the usual care
groups received regular care services such as managed care and supports
from health care providers. In addition to regular CM services (CMSA,
2017), several studies provided hospice care (Seow et al., 2008; Wang et al.,
2015; Wu et al., 2014). To provide optimized care, some studies made nurse
case managers available for phone consultation at all hours (Chen et al.,
2013; Wu et al., 2014). Finally, Hubbard et al. (2013) added vocational
rehabilitation services to CM care for patients with breast cancer.
Because individuals with cancer need continuous nursing care for symp-
tom management (Wang et al., 2015), all of the studies began their interven-
tions in hospital-initiated CM programs and continued with community-
based follow-up care. At the beginning of the interventions, nurses
introduced the CM program to the participants. Then nurse managers
completed health assessments in regards to participants’ health.

Outcomes of Cancer CM
Outcomes from the retrieved studies were categorized into three domains:
psychological outcomes, hospital access outcomes, and health care costs.
Following are the specific results for each outcome from the studies. In the
studies, there was no statistical difference between the intervention and con-
trol groups at baseline.

Psychobehavioral outcomes. Five studies reported psychobehavioral

out-comes as a result of the CM interventions (Bleich et al., 2017; Hubbard
et al., 2013; Ozcelik et al., 2014; Scherz et al., 2017; Wulff et al., 2012).
The psychobehavioral outcomes in this review were health-related QoL,
psychological distress, self-efficacy, or fatigue. All measures were self-
reported by patients.

QoL. First, the studies investigated QoL using different self-reported QoL-
related scales. Most studies reported positive engagement results with the
CM interventions using Likert-type scales. To assess QoL, Hubbard et al.
(2013) used a self-reported scale: the Breast Cancer subscale (BCS). The
BCS assesses the experience of living with breast cancer, including symp-
toms such as anxiety, body image, and pain (range = 0-40; higher scores
indicate positive perception). At 6 months of follow-up, the intervention
group showed higher BCS scores than the usual care group (p = .020).
Joo and Liu 15

Bleich et al. (2017) measured QoL in the short- (at 6-month follow-up)
and long-term (at 12-month follow-up), using two different tools: the Short
Form 8 Health Survey (SF-8), to assess generic QoL, and the European
Organization for Research and Treatment of Cancer 11 (EORTC-11), to
assess cancer-specific QoL. The SF-8 has two domains: physical (reliability
= .90) and mental component summary (reliability = .85). At the 12-month
follow-up, there was no difference between the intervention and control
groups in the SF-8 mental component summary (p = .894); however, the
physical component summary showed significant difference between
groups (p = .040). At the 6-month follow-up, the intervention group showed
better results in EORTC-11 physical than the control (p = .014).
Wulff et al. (2012) used the EORTC-30, which the EORTC-11 is a short-
ened form of, to report QoL for colorectal cancer patients. It ranges from 0 to
100; a high score indicates better functioning. This study provided CM ser-vices
to the intervention group and investigated the EORCT-30 at baseline, 8, 30, and
52 weeks. There were no statistically significant differences between
groups. Ozcelik et al. (2014) used a Turkish version of the EORTC-30 to
assess the impact of CM intervention in QoL (Cronbach’s α ≥ .70). After
CM, the intervention group showed significant positive outcomes in
symptoms (p < .05) and in some of the functional scores (emotional, global
quality-of-life, role, and social; p < .005).
Finally, Scherz et al. (2017) investigated QoL using the Functional
Assessment of Cancer Therapy–General (FACT-G). This tool is for assessing
health-related QoL with cancer survivors (range = 0-108 points; higher scores
mean better controlled QoL). This study investigated QoL using FACT-G from
baseline to 12 months. Over that time, the trend of FACT-G showed a more
significant increase for the CM intervention group than the control (p =
.006). These reported results support that the nurse-led cancer CM interven-
tions positively affected QoL with cancer patients.

Other psychobehavioral outcomes. Fatigue, anxiety and depression,

self-effi-cacy, symptom control, and satisfaction with care were reported as
psycho-logical outcomes of CM interventions to cancer patients. Hubbard et
al. (2013) used the Functional Assessment of Chronic Illness Therapy
Fatigue Scale (FACIT-Fatigue) with breast cancer patients. FACIT-Fatigue
is a 13-item instrument that measures cancer-associated fatigue with a 5-
point Likert-type scale (range = 0-52; higher scores indicate better health
condi-tions). There was no difference between groups at 6 and 12 months.
Bleich et al. (2017) assessed anxiety (α = .80) and depression (α = .81) with
the German version of the Hospital Anxiety and Depression Scale (HADS-D).
Both the intervention and control groups showed alleviation with
16 Clinical Nursing Research 00(0)

anxiety and depression scores from baseline, but no group difference was
reported between groups at 6 or 12 months.
Self-efficacy was measured as an outcome of CM intervention by Scherz
et al. (2017). Compared with baseline scores, the intervention group showed
a significantly greater improvement in self-efficacy scores than the control
group over 12 months (p = .049).
Finally, Ozcelik et al. (2014) measured symptom control and satisfaction
with care. The CM intervention group showed significantly better symptom
control than the control group (p < .000). The intervention group’s satisfac-
tion with care was also significantly higher than the control group’s
satisfac-tion with usual care (p < .05).

Hospital Access Outcomes

Four studies reported hospital access outcomes of nurse-led CM interven-
tions (Chen et al., 2013; Ozcelik et al., 2014; Seow et al., 2008; Wang et al.,
2015). Access outcomes in this review included hospital readmissions,
length of hospital stay, or emergency department (ED) or intensive care unit
(ICU) utilization outcomes.

Hospital readmissions. Three studies reported unplanned readmissions to

hos-pitals (Chen et al., 2013; Seow et al., 2008; Wang et al., 2015). To
report hospital readmissions, all three studies calculated patients’ number of
admis-sions. Chen et al. (2013) compared the unplanned readmission rate
due to infection between groups and reported that the CM group showed
signifi-cantly lower rates than the control group of unplanned readmission
(1.5% vs. 4.7%; p = .02). Similarly, Seow et al. (2008) reported that the
odds of being admitted to the hospital were reduced in the intervention
group (p = .006). Finally, Wang et al. (2015) showed lower hospital
admission rates in the intervention group than in the control (p = .03).
Overall, cancer patients in CM programs had a statistically significant fewer
number of unplanned hos-pital admissions than the control group.

Other access outcomes. Some studies reported length of stay in hospital, ED

visits rates, or ICU admission rates. Ozcelik et al. (2014) compared the mean
length of stay in hospital between the CM intervention and control groups. The
intervention group spent fewer days in the hospital than the control group (9.4
vs. 13.9 days, respectively); however, the difference between groups was not
significant (p = .070). Wang et al. (2015) compared ICU admission rates and
the mean length of stay in the ICU. These results were conflicting: the
intervention group had significantly lower ICU admission rates than did the
Joo and Liu 17

control group (12.9% vs. 24.1%, respectively; p = .06); however, there were
no group differences in the mean ICU days (8.7 vs. 9.7 days in control
group; p = .32). This study also compared ED visit rates and reported that
there was no difference in ED visits rates between the intervention and
control groups (22.0% vs. 16.7%, respectively; p = .42).

Health Care Costs

Three studies reported on health care costs with nurse-led CM interventions
(Ozcelik et al., 2014; Seow et al., 2008; Wu et al., 2014). Ozcelik et al. (2014)
compared “direct health costs” between the CM-receiving intervention group
and the usual care group. Direct health costs are patients’ hospital expendi-
tures. After 12 months of CM intervention, the intervention group had lower
direct health costs than the control group; however, no statistically significant
group difference was detected (p = .760). Similarly, Seow et al. (2008) reported
the mean total costs for all hospital admissions but found no statisti-cally
significant group difference (p = .277). In contrast, Wu et al. (2014) reported
cost savings with CM intervention. In this study, monthly cancer-related
medical costs were analyzed. During 6 months of follow-up, the inter-vention
group showed 9.8% lower medical costs than the control group. This result was
statistically significant (p = .002).

Discussion
This review systematically synthesized experimental studies to identify the
effectiveness of nurse-led CM interventions for adults with various types of
cancer. The nine selected studies were published between 2008 and 2017.
Because only a limited number of RCTs met the aim of this review, we also
included controlled before-and-after experimental studies. However, all stud-ies
had CM intervention groups and control groups with usual treatment. Through
analysis and synthesis of the nine studies, three domains of out-comes were
identified: psychobehavioral, hospital access, and health care cost outcomes.
The outcomes and outcome measures were heterogeneous, so meta-analysis of
the study results could not be conducted. Nevertheless, the study results indicate
that patients with nurse-led CM interventions showed improvement in QoL and
significant reductions in unplanned hospital admis-sions. These review results
are consistent with other reviews studying CM effectiveness on complex
conditions (Joo & Liu, 2017; Latour et al., 2007). However, other outcomes of
CM interventions were somewhat mixed.
All nine studies implemented multidisciplinary care teams that were led by
nurses, conducting CM interventions composed of advocacy, educational,
18 Clinical Nursing Research 00(0)

follow-up, and palliative services. The nurse case managers were specialized in
oncology and offered direct care in hospitals and indirect care outside of
hospitals. As described in the Standard Practice of Case Management (CMSA,
2016), CM programs continuously follow up and advocate for patients’
concerns. Furthermore, they identified their patients’ care needs and offered
referral services to hospice or community services. Finally, they were available
24 hr a day by phone call. These kinds of comprehensive care ser-vices seem to
benefit participants’ physical and psychological conditions (Bleich et al., 2017;
Wang et al., 2015; Wu et al., 2014). These results are in line with other research
that shows CM to be effective when combined with telehealth strategies
(Gilberg, 2011; Joo & Huber, 2012).
A major outcome of the studies is that participants saw significant
improvement in QoL measures with CM. QoL includes emotional, physical,
cognitive, and social functions. Even though the five studies that reported
QoL outcomes used different tools for measuring QoL, the intervention
group consistently showed improvement in QoL compared with the usual
care groups. Other psychobehavioral outcomes that showed significant
improve-ment were self-efficacy, symptom control, and satisfaction with
care (Ozcelik et al., 2014; Scherz et al., 2017). The positive results were not
universal; however, fatigue, anxiety, and depression showed mixed results.
Although no differences between groups were intended, it may be that the
control group received higher quality care than usual care (Bleich et al.,
2017). Finally, all of these outcomes were self-reported by patients,
meaning they could be overestimated and may represent no real difference
between groups (Bleich et al., 2017; Hubbard et al., 2013).
Another successful outcome of CM interventions for cancer care was
hos-pital readmissions. Only three studies examined hospital readmissions,
but they all found statistically reduced rates of hospital readmissions.
Moreover, one study reported significant results in cutting ICU readmission
rates (Wang et al., 2015). Other access outcomes, however, such as length
of stay or ED visits, were limited. The positive readmission results in
particular are in accord with CM studies targeted to other diseases
(Alshabanat et al., 2017; Joo & Liu, 2017).
Three studies analyzed whether CM in cancer care reduced health care
costs. Two of these studies reported that intervention groups had lower
direct health costs and lower cancer-related medical costs than usual care
groups. However, the third study reported no effectiveness with CM. CM
has been recognized and shown cost-effective in the care of chronic illness
(Joo & Liu, 2017). More research is needed into CM’s effectiveness at
improving hospi-tal access outcomes and lowering health care costs to
ensure it is a successful model in cancer care.
Joo and Liu 19

All nine studies described to participants in detail how the CM interven-tions

would be conducted. However, only a few studies explicitly described to
participants how the intervention’s fidelity would be ensured. To be suc-cessful,
CM interventions must carry out correct dosage of services, how nurse case
managers deliver services to patients must be monitored, and nurse case
managers must be trained to follow the intervention protocol with skill and
ability (Sidani & Braden, 2011). Some studies did explain how they trained
nurse care managers with protocols for standardized interventions (Ozcelik et
al., 2014; Wulff et al., 2012). We therefore recommend that CM interventions
provide detailed intervention protocols for nurse case managers and describe the
degree of CM intervention dose in future studies.

Review Limitations
The findings of this review favor nurse-led CM interventions; however,
there are possible limitations. Too few RCTs were published in the last 10
years to assess the impact of CM in cancer care using patient outcome
studies. Thus, we have included only two RCTs; the rest were quasi-
experimental studies. A systematic review should primarily include RCTs to
minimize the method-ological risk of bias. It is also possible that the
included quasi-experimental studies overestimate the CM interventions’
effect. To their credit, the quasi-experimental studies included in this review
reported a rigorous methodology and objective data for their results.
This systematic review only included studies published in English. More
evidence of CM effectiveness in cancer care may be found in studies pub-
lished in other languages. In addition, the studies included here conducted
their interventions in seven different countries. Because different nations
have different health care systems, the results of this systematic review may
not be broadly applicable. Finally, the included studies conducted interven-
tions with a limited number of adults with cancer. It is therefore possible the
review’s results may not apply to all types of cancer or to individuals of all
ages.

Implications for Research, Nursing Practice, and Policy

The implications of this systematic review for research are that more rigor-ously
and variously designed studies of CM with cancer populations are needed. First,
the number of RCTs studying CM in cancer care was limited. To achieve an
evidence-base of CM’s effectiveness, randomized and rigorous research is
essential. Second, only three studies targeted a single type of can-cer. To know
the impact of CM on each type of cancer precisely, more
20 Clinical Nursing Research 00(0)

single-cancer research is required. Finally, studies are needed that describe

cancer patients’ experience with CM interventions. Therefore, we recom-
mend that researchers undertake qualitative studies into CM effectiveness
with cancer care.
Another research need is the development of tools that improve the mea-
surement of CM in cancer care. For instance, each of the studies in this
review used a different tool for measuring QoL as an outcome of CM.
Moreover, studies used self-reported outcome measures. Either could be
obscuring the true effectiveness of CM. Case in point, it was impossible to
conduct meta-analysis because of heterogeneous outcomes. To ensure
evidence of the true effectiveness of CM with cancer is identified, more
research to develop valid measurement tools is essential.
This review showed the pivotal roles of nurse case mangers on cancer
treatment. Nurse case managers in the selected studies provided accountable
and patient-centered care, beginning at the diagnosis of cancer. Through
nurse-led CM, patients received optimized, continuous, and comprehensive
care above the standard of usual treatment plans. For example, nurse case
mangers provided direct care, referrals, advocacy, and educational services
to patients (Bleich et al., 2017). These practices were connected to better
physi-cal and psychological outcomes. The results of this review should be
intro-duced to nursing practitioners and nursing managers.
The successful results of this review could further be used as a rationale by
health care leaders and policy makers for accepting CM as a core strategy in
cancer care. Patients with cancer are threatened in their QoL and experience
serious declines in their physical and psychological functions (Scherz et al.,
2017). CM with nurse case managers optimizes care and overcomes prob-lems
of fragmented care. Therefore, nursing researchers, nurse practitioners, and
policy makers should consider CM to further enhance cancer care.

Conclusion
This systematic review found that nurse-led CM interventions for cancer
treatment improve QoL and reduce hospital admissions. Moreover, the CM
interventions for cancer care provide comprehensive, continuous, patient-
centered, palliative, supportive, quality, and assertive care. Therefore, we
find evidence of nurse-led CM’s effectiveness in cancer care. However, as
some outcomes of CM in cancer care remain mixed, we recommend further
research into the intervention’s fidelity using rigorous measures. Such rig-
orous studies will ensure the trustworthiness of evidence-based CM in can-
cer care.
Joo and Liu 21

Author Contributions
The study was designed by J.Y.J. Data collection, analysis, and synthesis were per-
formed by J.Y.J. and M.F.L. Manuscript writing was done by J.Y.J. Critical
revisions for important intellectual content were provided by J.Y.J. and M.F.L. The
study was supervised by M.F.L.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This research was supported by the
National Research Foundation of Korea (NRF) grant (2018R1C1B5029635). The
authors wish to thank Gachon University for supporting this research.

ORCID iD
Jee Young Joo https://orcid.org/0000-0003-0450-6781

Supplemental Material
Supplementary material is available for this article online.

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Author Biographies
Jee Young Joo, PhD, RN, is an assistant professor in the College of Nursing at the
Gachon University, Incheon, Korea. She was at the University of Missouri–Saint
Louis previously. Her cognate area is case management with chronic illnesses.
Megan F. Liu, PhD, RN, is an assistant professor in the School of Gerontology
Health Management at Taipei Medical University, Taipei, Taiwan. Her cognate area
is qualitative studies with chronic illnesses.

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