EONS Magazine Summer 2016

N U R S I N G

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T H E

H E A R T

O F

P A T I E N T

C A R E

Summer 2016

Cancer care

for older patients Cancer and ageing: screening and assessing older patients

Improving oncology nurses’ knowledge of geriatrics

Needs of family caregivers of an older person with cancer

Cindy Kenis

Peggy Burhenn

Petra Stolz-Baskett

Contents Editor-in-Chief: Helen Oswald Executive Editor: Clair Watts Art Editor: Jason Harris Production Editor: Jim Boumelha

Summer 2016

EDITORIAL

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Geriatric Oncology – Etienne Brain and Cindy Kenis, SIOG

Medical Editor: Catherine Miller Editorial Assistant: Rudi Briké EONS Secretariat: haysmacintyre, 26 Red Lion Square London, WC1R 4AG, UK Phone: +32 (0)2 779 99 23 Fax: +32 (0)2 779 99 37 e-mail: eons.secretariat@cancernurse.eu Website: www.cancernurse.eu EONS acknowledges Novartis and Hoffmann-La Roche for their continued support of the Society

LATEST NEWS

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Oldest nursing department marks 60 years

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Masterclass – We can and we WILL eat the elephant!

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EONS’ first research workshop for PhD students,

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A Spanish nurse on working in the UK

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Migrants and refugees – a challenge for Austrian oncology

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‘Cancer and Cancer Care’ – a review

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Recognising the value of cancer nursing – EONS leads the way

as sustaining members.

Print run: 1000 copies.

FEATURES

Electronic version accessible to 23,000 EONS members.

12 Cancer and ageing: screening and assessing older persons with cancer

Design and production:

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Improving oncology nurses’ knowledge of geriatrics

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Polypharmacy: evaluation of medication management

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Four nurses on developing cancer care for older patients

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Needs of family caregivers in geriatric cancer

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Research priorities for geriatric oncology nursing

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EONS 10 – What’s in store in Dublin this autumn?

© 2016 HarrisDPI. www.harrisdpi.com Printed by: Richline Graphics Ltd. www.richline.co.uk Cover Illustration: Jason Harris Disclaimer The views expressed herein are those of the authors and do not necessarily reflect the views of the European Oncology Nursing Society. The agency/ company represented in advertisements is solely responsible for the accuracy of information presented in that advertisement.

The European Oncology Nursing Society (EONS)

does not accept responsibility for the accuracy of any translated materials contained within this edition of the EONS Magazine.

© 2016 European Oncology Nursing Society

Author profiles and references can be found for this edition of the magazine at www.cancernurse.eu/magazine

EDITORIAL

Cancer care for older patients Etienne Brain, SIOG President

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Guest Editorial - Etienne Brain (SIOG President) and Cindy Kenis (SIOG Nursing & Allied Health Professional Interest Group Chair)

e are delighted to have the opportunity to partner with EONS for this special issue of the EONS magazine.

The International Society of Geriatric Oncology (or Société Internationale d’Oncogériatrie, hence the acronym SIOG) is a multidisciplinary society dedicated to foster the development of health professionals in the field of geriatric oncology in order to optimise treatment of older adults with cancer.

Founded in 2000, SIOG includes physicians in the fields of oncology and geriatrics, and allied health professionals, and has members in more than 40 countries around the world. SIOG promotes its efforts through three strategic directions: ●● EDUCATION via the dissemination of knowledge, the integration of geriatric oncology in the curricula for medical and nursing education, and addressing the shortage of health professionals specialising in geriatric oncology ●● CLINICAL PRACTICE via the integration of geriatric evaluation into oncology decision-making and guidelines, the improvement of the quality of prevention, diagnosis, treatment and follow-up of older patients ●● RESEARCH via the development, the testing and the dissemination of easy screening tools, the creation of a clear and operational definition of vulnerability/frailty applicable to oncology, advocating for the increase of the relevance of clinical trials designed for older patients and the promotion of a multidisciplinary, basic/translational research on the interface of aging and cancer.

Because the major risk for cancer is age, and with the ageing population of the world, a major epidemiologic

challenge is before us. The mobilisation and the education of all health professionals is essential, including nurses, who are at the core of older patient care.

In the first part of the magazine, you will be able to catch up on all the latest EONS news. Then, in the first feature article, you can gain an insight into the importance of appropriate geriatric screening and assessment of older patients with cancer. We then take a look at research opportunities within the field of geriatric oncology. The next article describes the impact of polypharmacy in older patients with cancer in which medication adherence is a specific point of interest for nurses and allied health professionals. We continue with the examination of the needs of informal caregivers in the care of older patients with cancer and we put the education of nurses into perspective. We also focus on the experiences of nurses in the field who spend their daily oncology practice with older patients.

We hope these articles help you identify useful actions to guide your daily practice and convince you of the need to work hand in hand in order to improve the care of older patients, when providing evidence-based geriatric oncology remains a challenge in Europe and beyond. Promoting multidisciplinary practice is the only way to go and we would stress how important your involvement as nurses is for tomorrow, starting today! Visit our website (www.siog.org) for more information, including an overview of the activity of the SIOG nursing and allied health interest group. Plus, the next SIOG annual meeting will be held in Milan, from 17-19 November, and there will be a specific meeting for nurses the day before. Please note the date and join us!

The 2016 summer edition of EONS Magazine is the result of a collaboration between the European Oncology Nursing Society (EONS) and the International Society of Geriatric Oncology (SIOG).

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Pioneering academic centre marks 60 years EONS President Professor Daniel Kelly recently attended a celebration at Edinburgh University to mark the 60th anniversary of Europe’s longest-standing university nursing department. This was also the first UK

department to host a Professor of Nursing.

Danny joined former nursing graduates and University staff to celebrate how Edinburgh has helped transform the profession. (See picture, left.)

Dr Sheila Rodgers, Head of Nursing Studies, said: “When Edinburgh nursing students entered the wards in the early 1960s they blazed a trail in a profession that until then had not seen nurses educated in a university setting.”

“Nursing was run in a military fashion. No one asked questions about what they were asked to do. They did as they were told.”

“The degree nurses were encouraged to question what they saw and look for how things could be done better. They were pioneers of the profession. Today all nurses in Scotland require a degree.”

Nursing Studies at Edinburgh has maintained a vital role in the profession.

It continues to undertake ground-breaking research and prepare future leaders through a sustained programme of quality teaching and clinical experience.

Danny said: “The nursing degree at Edinburgh was unique in bringing nursing into the centre of British universities.

I was delighted to take part in these celebrations as one of the graduates of this degree in the 1980s. I was also pleased to be invited to meet Princess Anne when she visited the Department in April to mark 60 years of Nursing Studies at Edinburgh University.”

EONS will be holding its Board Meeting at Edinburgh University in August to help mark this important year for nursing.

EONS welcomes Iveta Nohavova as a new Projects Manager Here, Iveta tells us about her forthcoming work with EONS: I was appointed as a part-time EONS Project Manager earlier this year.

You may also know me from the EONS Research Working Group of which I have been a member since December 2012. I am an oncology nurse by profession, currently also working on two international projects in various capacities. My role in the “Eastern Europe Nurses - Centre of Excellence for Tobacco Control” project is as a co-manager and nurse leader. I am also a research consultant on the EU’s Horizon2020 project called “Tobacco cessation within TB programmes - A ‘real world’ solution for

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countries with dual burden of disease”.

My main responsibility as an EONS Project Manager is to assist with two start-up educational projects, as well as any other necessary education-related activities.

The first project is the EONS TITAN Course Update, which is lead by EONS Past President, Erik van Muilekom.

The TITAN course was last updated in 2008. Currently, we are in the process of confirming committed funding and forming a task group consisting of field experts on anaemia, neutropenia and thrombocytopenia side effects. The planned start for the TITAN Update is October 2016.

The second project is phase III of the Prostate Cancer Education Project (PrEP)

which aims to develop an innovative education module(s) to provide education and support to prostate cancer nurses addressing identified patient needs. Again, Erik van Muilekom will lead this project with EONS Board Member Andreas Charalambous as co-chair. We are now at the stage of securing adequate financial resources while looking for prostate cancer experts to form a task group. The anticipated start is later this year.

I am also helping with an EONS Core Curriculum Update, which is lead by EONS President Elect Lena Sharp. This work is expected to be completed in March 2017.

I usually work on Tuesdays and Thursdays and can be reached at projects@ cancernurse.eu. Do get in touch if you want to know more about any of these projects.

LATEST NEWS

We can and we WILL eat the elephant!

Lena Sharp reports on the 2016 oncology nursing masterclass

For the 9th time, EONS arranged another successful Masterclass in Oncology Nursing this spring, in collaboration with ESO (European School of Oncology). Again, it took place at the beautiful Wolfsberg Conference Centre outside Zurich, Switzerland, and was headed up by facilitators Lena Sharp, Birgitte Grube, Anita Margulies and Cristina Lacerda.

From a record number of 106 applications, 27 nurses from 15 countries were chosen to participate. This year we had a more integrated programme, mixing nurses and physicians to a greater extent to focus more on inter-professional learning.

A selection of other comments from the participants ●● The best professional experience ever! ●● It was an amazing experience that will continue inspiring me. ●● The Masterclass is the perfect environment to learn, with the right people to

motivate us. ●● After this experience, I am a better person and a better nurse! ●● If sometimes I have doubts about nursing development, after this week I am

certain of the potential of cancer nursing in Europe! ●● We will help each other to change practice! ●● I feel more motivated to continue career development!

Masterclass in Oncology Nursing 2016

We continued with the successful workshops in communication skills from previous years, led by Andrew Hoy and Anne Arber in collaboration with professional actors, but also added new joint sessions, such as cancer and physical activities, by nursing professor Yvonne Wengström.

Among the new topics in the nursing programme were compassion fatigue, clinical leadership and nutrition. We also focused more on immunotherapy for nurses and worked more intensely with clinical case discussions, problem-based and peer-learning. EONS Past-President Erik van Muilekom and President Danny Kelly joined us for part

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of the week to share their expertise.

In the final closing sessions, the nurses summed up the event and looked back on their expectations and goals for the week.

Many of the participants were inspired by new knowledge and insights but also new friendships with colleagues across Europe. One of them, Sara Parreira, said: “EONS Masterclass is all about knowing.

Not only about oncology nursing but also about our colleagues and their practices all over Europe. I got to know new and different nursing projects and practices, some of which I am trying to introduce in my department. I was encouraged to reflect, to respect our differences and to enhance cancer nursing. It was a special and unique opportunity.”

During the week, we came back to the important but difficult issue of changing practice in busy clinical environments. We

discussed how to be successful and how to manage challenging obstacles, or put another way: ‘How do you eat an elephant? In small pieces!’ and, as one nurse concluded, ‘YES! We can eat the elephant and we will!’

EONS and ESO took the opportunity to give a special thanks to Anita Margulies (pictured right), this year’s senior advisor, who has arranged more Masterclasses than anyone: Thank you for all the hard work, enthusiasm, knowledge sharing and great advice, Anita!

We will miss you so much next year!

In 2017, we will celebrate the 10th EONSESO Masterclass in Oncology nursing. The

Anita Margulies and Danny Kelly

event will be moving to Germany and run from 25-30 March. So, please make a note in your calendar! Call for applications will appear on the EONS website, in the newsletter and on social media.

Merel van Klinken, from the Netherlands, shares her experience I was selected to present my clinical case at the EONS Masterclass in Switzerland. Terrified as I was, I introduced Mrs. R to the group of nurses from across Europe that were attending the course.

Mrs R was a 51-year-old female, married with two children (and a dog) when she was diagnosed with breast cancer.

She received multiple lines of treatment, starting with surgery and followed by chemotherapy, radiotherapy and then immunotherapy. She was then admitted to hospital with pain due to bone metastasis.

During her admission, she received multiple rounds of radiotherapy for which she had to be sedated because of the considerable pain she was experiencing.

The second fraction of radiotherapy had to be performed in an older machine, because she couldn’t be moved from the bed onto a table.

The nurses working with Mrs R questioned the need and benefit of the treatment.

Our questions were about whether or

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not the right amount of radiotherapy was given for her metastases, as well as the timing. We thought Mrs R was not going to survive the time needed for the radiotherapy to be effective. The situation of Mrs R was complicated by a severe pseudomonas infection in the wound on her back. Dressings needed changing at least twice a day, which was very painful, sometimes impossible. The wound also caused a non-optimal pain relief. Physicians preferred an epidural, but didn’t want Mrs R to die of sepsis.

Mrs R just wanted to go home to see her family and her dog, but this was not possible due to her condition. I was able to arrange for the dog to come to the hospital, where Mrs R said goodbye. Not long after, she had to be sedated and she died with her family around her.

Discussion arose in the group after the case presentation, helpfully structured

by Lena Sharp. One of the tips I received from the group was to invoke a meeting where these patients are discussed after death. When I started my new job

at the palliative team in my hospital I introduced this. Now we regularly have multidisciplinary meetings where we discuss patients in retrospect. This allows us to learn from the perspective of other disciplines and enhances learning efficiency for future cases.

I also talked about this with other nurses in the hospital and more and more of them have taken the initiative to set up a multidisciplinary meeting outside of the ones already there, and not only in retrospect.

As scared as I was to present the case, it was inspiring to do it. In fact, the whole week was very inspiring and the organisation was excellent. I’ve learned so much, most of all from the other nurses and hearing about the healthcare systems in their countries. It was so nice to see so many likeminded and enthusiastic people. This week was very valuable to me as an oncology nurse, but also to me as a person. Once again, it was stressed that we can change healthcare and improve it.

EONS’ first Research Workshop for PhD students blazes a trail at Scotland’s University of Stirling Two of those attending, Maria Cable and Kicki Olausson, tell us how it was for them.

Maria Cable, UK For the very first time, EONS created a unique opportunity for 20 cancer nurses from across Europe undertaking PhD studies to gather at the University of Stirling in May this year.

Nurses from Italy, Greece, Iceland, Turkey, Ireland, UK, Netherlands, Portugal and Sweden attended and it was a wonderful opportunity to share the fascinating array of cancer-related topics that are being researched.

All participants were at very different stages in their studies and approaching them in very different ways. The value of focussed time with the expertise of the three cancer nursing professors who facilitated the event – Mary Wells, Professor of Cancer Nursing Research & Practice at the Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, EONS President Daniel Kelly of Cardiff University, and Professor Elisabeth Patiraki of University of Athens – was remarkable and palpable from all attendees.

Constructive and insightful discussions on topics around methodological approaches, ethics and achieving impact, amongst other PhD-specific issues, took place. All delegates felt that at the end of the event they had found some much-needed comradeship and

revitalisation to help them navigate their PhD journey in the pursuit of enhanced cancer nursing care, the goal that underpinned all their research. A new community of European Cancer Research Nurses has been created with mutual respect and commitment to the various research landscapes we work in across Europe.

All participants expressed their gratitude to EONS and the facilitators. They acknowledged the benefit of the opportunity to come together, which helped reduce the burden of isolation often felt by PhD nurses who often navigate practice alongside their PhD studies. For some delegates, the event helped them find their very important ‘a-ha’ moment, which was a joy to share.

We were reminded of the value of time to think, reflect, nurture ourselves and discuss our issues with experts. We are grateful for this unique opportunity. Thank you EONS! Kristina Olausson, Sweden “A few words from a non-native English speaking nurse: If you hesitate to participate at an EONS workshop due to language barriers or concerns regarding your language skills – don’t! When 20 oncology nurses are put

together in a workshop we are all very supportive, and this is reflected in the friendly environment at EONS workshops. Try it!”

OTHER COMMENTS FROM PARTICIPANTS INCLUDED: “It was a great experience for me, thank you for giving me this opportunity!”

“Had a fantastic trip to beautiful Stirling University – a big ‘a-ha’ moment & met an inspiring group of nurses! Thank you!”

“Would I do it again? Of course! Had a great time with my European colleagues! Inspired and energized.”

“Thank you for bringing together another vibrant community of EU cancer nurses.”

“The workshop was fantastic, a very worthwhile experience…”

“Thank you for this, I thoroughly enjoyed the workshop.”

“It was FANTASTIC! We had an amazing time, I learned so much.” *The event had plenty of coverage on social media. There’s a Storify from the workshop (https://storify.com/cancernurseEU/eons-research-workshop-2016) and reflections at http://bit.ly/29riOFS, plus you can check out the hashtag #eonsphd2016.

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‘The best adventure ever!’

A Spanish nurse working in the UK tells a tale of two countries Celia Diez de los Rios de la Serna is an advanced Nurse Practitioner in medical oncology at the University Hospital Southampton NHS Foundation Trust.

When I finished my nursing degree in Madrid, I never imagined I would one day make Southampton my home.

Nurses in Spain have a very good, intense training. During that period, they assess the patients and help with their care and treatment. They get involved in everything: their hygiene, dressings, medication, cannulation, discharge, teaching, end of life... When they finish their degree they are independent, able to perform a wide number of techniques.

Both England and Spain have a public and a private sector and, in both, newly qualified nurses prefer to work in the public sector as the range of learning opportunities is wider.

In Madrid, in order to work in a public hospital, the nurses enrol on a list where they earn points when they do training and/or work.

The hospitals call the first number regardless of that person’s previous experience or preferences. Every three years, nurses can take an exam to get a permanent contract in a hospital. However, that didn’t happen from the time I finished university (2007) until 2014, so I never had a permanent contract.

As a starting point, this can be quite good: you work in very different sectors and that allows you to grow and to try different specialities. This was a positive experience until I worked in an oncology and haematology day unit where I realised oncology nursing was my passion. When the economic problems started in Spain and, as a consequence,

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public hospitals had fewer contracts, I started thinking about other options, as I did want to continue to work solely in oncology.

That is when I applied to Southampton General Hospital. And I made the right choice!

Nursing in the UK is different. In essence, a nurse is a nurse regardless of the country, but I suffered from an initial cultural shock at the beginning. For example, I had never seen a commode before coming and now, years later, I’m not really sure how a hospital works without them. The patient-nurse ratio is better in England than in Spain and is actually something they are constantly looking at here. The support and learning opportunities are endless. I started as a supernumerary and, after that, it took me some time before I could give oral medication, more to give IV medication and even more to give chemotherapy. These and other techniques were common practice for me in Spain, but going slowly helped me to build my confidence.

As a staff nurse, I felt more supported and less independent than in Spain. Eight months later I was given an amazing opportunity to develop a new service. The hospital, in partnership with Macmillan, designed a job that included study for a Master in Advanced Clinical Practice, for which I applied and was successful: a dream job.

There are no Advanced Nurse Practitioners in Spain. While there, nurses were trying to approve nurse prescribing with a lack of

support from the doctors, I was being trained with the support of the senior doctors to be an independent prescriber. I started an amazing job where I could give good care to my patients, help my colleagues and embrace a new challenge.

If nurses had more support and credibility in Spain, I would never have left. There are many things I have learned that I would like to bring to Spain, and there are many other things that I try to bring to the UK from Spain. From both countries I have learned to be what I am at the moment, and I hope my experience will help other nurses from both countries and other services to improve. My bosses have always been open to changing practice based on evidence.

Patients frequently ask where I come from (because of my accent and very long surname!) but I cannot remember a single time when I have not felt welcomed by them. I regularly receive good feedback about Spain and Spanish nurses. Quite frequently, people tell me that they think coming to England to work was something brave. I think it was the best adventure ever but, at the same time, it is sad to think I could not go back home to do the amazing work I do here. While the nursing degree is better in Spain, the multidisciplinary work, and the career development opportunities for nurses, including myself, that we have in England, are still very far from being implemented in Spain.

LATEST NEWS

Migrants and refugees – a (new) challenge in Austrian oncology?

Christine Schneider-Worliczek, of the Austrian Association of Hematology / Oncology Nurses Society (AHOP), looks at how the healthcare system is attempting to meet the challenges presented by newcomers to the country.

The so-called “Gastarbeiter” (guest-workers) started to come to Austria in the 1960s when the government invited them to work here, to build up the country. Many followed, mainly from Turkey and the former Yugoslavia. In 2014, Romania and Bulgaria joined the EU which opened the Austrian employment market for them too. Additionally, refugees from the East started to arrive in our country in the summer of 2015. Due to these migration flows a wide diversity of cultures has developed in Austria. Every fifth person living in Austria has a migration background, in big cities the percentage is even higher. Therefore, there is an increasing need for multilingual and intercultural medical treatment in health care.

Research has revealed a variety of difficulties: migrants, mainly with former-Yugoslavian or Turkish backgrounds, hesitate to use cancer screenings. Men of those origins on average smoke twice as much as Austrian men.

Women from countries with strong patriarchal structures are often not encouraged to learn German. They also consult a GP less often than others.

Thus, migration itself is not a health risk, but the socio-economic and psychosocial context can be.

How much do we know about this issue? In an Interview, Dr. Elena Jirovsky from the ethno-medicine institute of the University of Vienna confirms that there is no research in the field of “migration and oncology”.

A variety of approaches Interviews with colleagues from nine university or general hospitals in Austria revealed the following: All hospitals use professional interpreters for a pre-treatment discussion if necessary. All hospitals use family-members for the “dailylife” communication on the ward.

Five hospitals use so-called amateur interpreters: hospital employees (they can be non-medical staff) who have another mother-tongue than German or who have foreign language skills.

Two hospitals have multi-language information on the oncology ward and two hospitals use telephone interpreters on ward and one even uses professional video interpreters in the outpatients department.

Furthermore, we have a variety of online dictionaries, hospital phrasebooks, translated information about treatments and pictograms (e.g. for hand disinfection). There is even a little booklet explaining gestures –

which can vary in different cultures.

However, all these means are either not always available or do not provide sufficient specific information concerning treatment and side-effect management in oncology. Problems arise when more complicated medical facts need to be communicated, or when you need the patient’s compliance.

Another challenge is how to deal with the emotional burden a cancer diagnosis brings for the patients as well as their relatives. Different cultures have different ways of dealing with pain, emotions and distress. Often it is not the patients themselves who do not “understand”: I remember more than one case where family members with a migration background wanted to bring cooked food to the ward for their relatives. It was nearly impossible for them to accept that during high-dose chemotherapy and reduced immune system it is not allowed to bring food in from outside, as this was their way to express empathy and support.

My colleagues agree that while we are more or less familiar with the culture of people from the Balkan countries, we are going to face huge challenges with cultures coming from the Eastern/Arabic regions in terms of language and cultural differences.

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‘Cancer and Cancer Care’ Bringing the care of the cancer patient to life EONS Board Member, Andreas Charalambous, reviews a book on cancer care with a psychosocial emphasis that might be just the perfect read to take you up to this autumn’s EONS 10 Congress in Dublin this autumn, with the 18th Congress of the International Psycho Oncology Society (IPOS).

Cancer and Cancer Care provides a comprehensive, holistic perspective on many aspects of cancer and cancer care. The emphasis is on the psychosocial aspects of cancer that often receive less attention than the biophysical challenges faced by patients.

The book starts by placing cancer into context by use of statistics, presenting the attitudes of healthcare professionals towards cancer itself and emphasising the discrepancies encountered when patients are affected by cancer at different times of their lifespan.

(The literature used to support this chapter, and others, is heavily UK based and would benefit from a wider European and International perspective however.)

Subsequent chapters look at cancer risk, screening, detection and diagnosis and the challenges faced by professionals in successfully communicating risk and screening information, and performing accurate detection and diagnosis. The book goes

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on to deal with the biology of cancer and tumour pathology. (These two chapters would be better placed following the first chapter.) The remaining chapters deal with specialised areas such as treatment options, psychosocial care, complementary alternative therapies and survivorship.

Overall, the structure of the book lends itself well to the study of different aspects of caring for a person with cancer for a wide audience such as students, educators, and clinicians from various healthcare disciplines involved in cancer care.

A criticism of the book would be that certain important areas seem to have been left out. For example, Chapter 25: ‘The use of complementary and alternative therapies in cancer care’, seems oddly to focus on complementary and alternative medicine (CAM) used in cancer survivorship, with the contribution of these Andreas modalities to the Charalambous supportive care of

EONS and the UK’s EU referendum The European Oncology Nursing Society (EONS) is disappointed that the United Kingdom (UK) has chosen to vote to leave the European Union (EU). However, we would like to reassure all our members across Europe that we remain a pan-European organisation dedicated to the support and development of cancer nurses. The vote will not change that. We will continue to work in partnership to develop and promote excellence in cancer nursing practice through education, research, leadership and support to cancer nurses across Europe. The EONS Board remains strongly committed to working as a European collective. EONS will not be constrained by national politics and we will continue to grow as the Society representing cancer nurses across Europe.

If you have any questions we invite you to share those with us by sending them to: eons.secretariat@ cancernurse.eu EONS President, Daniel Kelly

the patients (following diagnosis and the active treatment phases) not discussed.

The chapter would benefit from a wider perspective on CAM modalities.

All in all though, the book’s use of reflective activities and vivid stories in the form of case studies, helps bring the care of the cancer patient to life. Well-chosen recommendations for further reading are also provided and the author’s enthusiasm for the topic is obvious throughout.

Cancer and Cancer Care by Debbie Wyatt and Nicholas Hulbert-Williams is published by Sage Publications Ltd, 1 May 2015.

LATEST NEWS

Recognising the value of cancer nursing – EONS leads the way EONS has been offered the opportunity to lead on a major European oncology nursing project that aims to make a real difference to oncology nursing and ultimately to patient care.

The joint ECCO project, entitled ‘Recognising the value of cancer nursing’, was announced at last autumn’s ECCO Congress. It will be delivered over three years and ultimately the ambition will be to increase the recognition of oncology nursing across Europe, using a variety of different methods including research, education, clinical leadership, nursing strategy, advocacy, and policy development.

EONS President Professor Daniel Kelly will lead a three-stage process, working closely with EONS’ National Societies and working groups, the EONS Board and the Onco-policy community. EONS will also ensure that the voice of patients and families is included.

Danny said: “This is a great opportunity for oncology nursing in Europe and EONS is in a unique position to make a real impact. One of EONS’ key strategic aims is ‘To strengthen EONS’ political voice and impact across Europe’ so, over the next three years, this new project, co-sponsored and jointly delivered with ECCO, will allow us to focus on this important goal.

“To gain recognition, we need to show the value of nursing to patients and we have chosen to do this by first examining the published evidence and research base. We also need to show the benefits of having excellent educational opportunities and career structures, as well as the scope for role development and innovation that will benefit patients.

“This exciting project is already underway and we look forward to working together to make sure we influence politicians, health ministers and those who have the authority to change the way oncology nursing is valued.”

If you have experience of systematic reviews and would like to be involved, or wish to learn more, please let us know at eons.secretariat@cancernurse.eu. Further details will be placed on the EONS website over the coming months at www. cancernurse.eu/advocacy/oncopolicy.html

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Cancer and ageing: screening and assessing older persons with cancer The increase in cancer incidence with advanced age requires new initiatives in evaluation and treatment. A more holistic approach centred on geriatric screening and assessment is essential in daily oncology practice.

Cindy Kenis

O

ver 60% of all cancers are diagnosed in patients older than 65 years in Europe and the USA. This is expected to rise to 70% within the next 30 years.1,2 About two thirds of cancer deaths are within this age group.3 The management of older patients with cancer has become a major public health concern as a result of the ageing of the world population and the steady increase in cancer incidence with advanced age. The specific characteristics and complex needs of this group of patients require new initiatives to improve the quality of care. This is particularly true as more survivors of cancer live to experience cancer as a chronic disease. The care of older patients with cancer therefore constitutes an important part of the daily clinical practice for oncologists, haematologists, radiation-oncologists, as well as nurses, other professional healthcare workers and family physicians.

Treatment decisions Although the number of older patients with cancer is steadily increasing, there is not enough

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information available about the best treatment options, since this group is under-represented in clinical trials.4 Few data exist regarding the risks and benefits of different cancer treatments in the older population, and there are few guidelines that specifically address their evaluation and treatment. The heterogeneity in the ageing process further contributes to the complexity of treatment decisions. Older patients are less likely to receive all types of standard cancer treatments compared to younger individuals.5-9 Possible reasons include concerns regarding increased toxicity, competing causes of morbidity and mortality, ageism, financial constraints, lack of access to care, and the personal preference of the physician or the patient. This may make under- or overtreatment more likely which may influence both the risk of treatment toxicity and survival.10,11 Since chronological age alone represents the ageing process poorly, a systematic and evidence-based way of assessing older persons with cancer is needed in order to guide oncologic treatment decisions.12 A Comprehensive Geriatric Assessment (CGA) can fill this gap.

CANCER CARE FOR OLDER PATIENTS

Comprehensive geriatric assessment in the older population with cancer This method comprises five consecutive steps and is the main principle of modern geriatric medicine:14 1. Identify patients who can benefit from CGA. 2.

Assess these patients.

3.

Develop recommendations for geriatric interventions based on the problems detected by CGA.

4.

Implement these recommendations in a care plan.

5.

Provide follow-up and adjust the care plan with repeated CGA.

Comprehensive geriatric assessment as standard of care Instead of focusing on the cancer diagnosis only, older persons need a more holistic approach that focuses on a combination of medical, social, functional, cognitive, mental and nutritional needs.

Performing a comprehensive geriatric assessment (CGA) is therefore recommended.

CGA is defined as a ‘multidimensional, interdisciplinary diagnostic process comprising five consecutive steps (see box above) focusing on determining an older person’s medical, psychosocial and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up’.13 Since the mid-1990s, treating physicians, in particular oncologists and geriatricians, have tried to integrate the CGA-based approach into daily clinical oncology practice. Since its implementation, CGA in oncology has mainly focused on screening and assessment – the first two steps of the CGA – the term ‘geriatric assessment’ (GA) is, therefore, preferred for this approach in older patients with cancer.15

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Older persons need a more holistic approach that focuses on a combination of medical, social, functional, cognitive, mental and nutritional needs.

Geriatric assessment as a two-step approach The main geriatric domains to be assessed in GA are functional status, fatigue, comorbidity, cognition, mental health, social support, nutrition and geriatric syndromes, e.g. dementia, delirium, falls, incontinence, osteoporosis or spontaneous fractures, neglect or abuse, failure to thrive, constipation, polypharmacy, pressure ulcers, and sarcopenia.15 Various measuring instruments are available to investigate these domains, and the superiority of one instrument over another has not been proven. The choice of a measuring instrument might rely on local preferences and resources available.15,16 The drawbacks of GA include the amount of time it takes for professional healthcare teams. The lack of staff trained to perform GA, even in large academic hospitals and poor financial rewards for performing a GA by health insurance systems are additional barriers. In order to focus on the most vulnerable patients, there is an increasing interest in the use of shorter screening tools to detect older persons who would benefit the most from further GA, which may provide a better insight into the patients’ general health and individual probability of survival, and allow targeted interventions.

Screening tools might also have prognostic/ predictive value for important outcome measures such as treatment-related toxicity, functional decline and overall survival. The tool used should be simple and take only a few minutes, while GA may take much longer. High sensitivity and high negative predictive value are the most important characteristics for screening tools in order to identify all patients at risk of adverse outcomes. In addition, a high specificity is of interest in order to limit the number of patients who unnecessarily undergo GA.17 Commonly used screening tools in the care of older patients with cancer include G8,18-20 the Flemish version of the Triage Risk Screening Tool (fTRST)19,21,22 and Vulnerable Elders Survey-13 (VES-13).23 In general, consensus guidelines from the European Organisation for Research and Treatment of Cancer (EORTC) and the International Society of Geriatric Oncology (SIOG) consider the two-step approach as a reasonable strategy.17 This approach starts with the systematic implementation of

14

geriatric screening in all patients aged 70 years or older, followed by GA if the screening indicates a potential geriatric problem. The recommendation to perform this geriatric screening and assessment from the age of 70 is based on evidence that the incidence of geriatric problems increases the most after the age of 70 in older patients with cancer.24 Geriatric screening and assessment in daily practice There are several reasons to implement a systematic geriatric screening and assessment in the care of older patients with cancer.15,25,26 They can reveal previously unknown geriatric problems in a large proportion of patients, and alter cancer treatment decisions, either by decreasing or increasing treatment intensity. Geriatric screening and assessment are important for comprehensive and individualised care planning. The most important step is the use of the additional knowledge gathered to set up targeted interventions, e.g. involvement of a dietician or social worker or referral to the geriatric day clinic. Several studies show that geriatric screening and assessment can predict treatment-related toxicity, functional decline or decrease in quality of life. It is important for the healthcare team to know if there is an increased risk of treatment-related toxicity, as this would allow for use of prophylactic measures to decrease this risk, e.g. growth factors, adapted dosing or regimen, or even avoidance of therapy. Finally, most aspects of GA, e.g. cognition, nutrition, functional status, comorbidity, have been shown to be important predictive factors for diminished overall survival. Geriatric screening and assessment can give an approximation of overall survival and life expectancy, which is crucial information in shared decision-making for Koen Milisen cancer treatment.

CANCER CARE FOR OLDER PATIENTS

From left to right: Johan Flamaing (geriatrician), Hans Wildiers (medical oncologist), Katleen Fagard (geriatrician), Cindy Kenis, Britt Leys (no longer in the team) and Jean-Pierre Lobelle (consultant in statistics). Another member of the team, Koen Milisen, is pictured below, left.

International Society of Geriatric Oncology guidelines The International Society of Geriatric Oncology (SIOG) was founded in 2000 and is a multidisciplinary society, including physicians in the fields of oncology and geriatric medicine, nurses and other allied health professionals (www.siog.org).

Its goal is to foster the development of healthcare teams in the field of geriatric oncology in order to optimise treatment and care of older patients with cancer. There are three strategic directions: education, clinical practice and research. Since 2014, SIOG has a specific interest group for nursing and allied health professionals which reaches out to all nurses and allied healthcare teams that deal with older patients with patients.

SIOG guidelines on geriatric screening tools17 and geriatric assessment,15 as well as a recent paper from the Nursing & Allied Health Interest Group,27 yield the most relevant advice to healthcare teams on implementing a systematic geriatric screening and assessment in daily oncology practice.

Recommendations for nurses and healthcare teams Healthcare teams need to be watchful for age-related/geriatric aspects in oncology. Geriatric screening and assessment detects many problems related to all geriatric domains, predicts survival and toxicity and influences treatment decisions..

However, the implementation of geriatric screening and assessment and the integration of geriatric recommendations and interventions, remain a real challenge in daily oncology practice, in which healthcare teams can play a crucial role.

“It is better to do some kind of imperfect geriatric screening and assessment than to do no screening and assessment at all‌â€?

Cindy Kenis is a geriatric oncology nurse at University Hospitals, Leuven, Belgium. She is also chair of the SIOG Nursing and Allied Health Interest Group.

Details of the references cited in this article can be accessed at www.cancernurse.eu/magazine

15

Improving oncology nurses’ knowledge of geriatrics Educating nurses to care for older adults with cancer is a relatively new field. Programmes being rolled out to educate US oncology nurses in geriatrics have already resulted in significant improvements in their knowledge base.

Peggy S. Burhenn

Cancer is primarily a disease of the older person, with the majority of new cancer cases occurring in people over the age of 65. However, in the US only 1% of nurses are gerontology certified.1 Certification is a measure of commitment to the science of gerontology and of excellence in the field. There is little attention paid to gerontology education for nurses after graduating and obtaining their licence. About one third of Bachelor of Science in Nursing programmes in the US have stand-alone content about gerontology in their nursing programmes.2 It is more common to integrate gerontology into “adult-gerontology” course work. There has been debate about which approached is preferred. According to the Institute of Medicine report in 2008, healthcare professionals are not prepared to care for the influx of older adults who are requiring healthcare.3 Creating programmes to educate nurses Oncology nurses understand oncology well and typically the care for older adults in oncology usually does not differ significantly from the care of other adults in actual practice. At City of Hope, in Cal-

16

ifornia, the gap in gerontology education for nurses is well recognised and a programme to educate oncology nurses in geriatrics was created. Five years ago the centre had one geriatrician, who was also an oncologist, but did not have nurses focused on the care of older adults.

The first step was to hire a gerontology-oncology Clinical Nurse Specialist (CNS) to create a programme to educate nurses. Recreating educational materials is time-consuming, and with resources available to educate nurses in geriatrics, existing geriatric education materials were used and tailored to the oncology population. The materials used were from the Nurses Improving Care for Healthsystem Elders (NICHE),4 which provided many educational materials, including a programme for registered nurses called the Geriatric Resource Nurse (GRN) curriculum. The Oncology Nursing Society (ONS) also had a four-hour lecture programme called “Care of the Older Adult with Cancer,” which was used for training. Nursing staff were surveyed before and after implementing this education on geriatrics, and a significant improvement in nurses’ knowledge was found post-education.5 It was also found that nurses

requested more education on gerontology and more geriatric-specific resources.6 To build on this work, a team from City of Hope Medical Center, California, USA, was awarded a National Institutes of Health grant to educate oncology nurses in geriatrics. This helped develop a programme which focuses on teaching oncology nurses key domains of geriatric assessment and geriatric care, with the goal to improve care of older adults.

The key domains covered include: physiological changes in ageing, comorbidity, functional changes, cognition and mental status, nutrition, social support, polypharmacy, and geriatric syndromes. There will also be a focus on developing a plan for the participants to implement goals when they return from the conference, in addition to a discussion about impacting change and advocating for older adults.

SHUTTERSTOCK

Nationally-recognised faculty, who are experts in geriatric care, will teach this course and the first of four annual courses took place in July 2016.

Incorporating geriatric assessment into daily practice A key aspect of education that is taught to oncology nurses includes a comprehensive geriatric assessment (CGA). The International Society of Geriatric Oncology (SIOG) Nurses and Allied Health Interest Group published an article examining the domains of the geriatric assessment and how they apply to nursing practice.7 This article describes the domains of social support, comorbidities, functional status, cognition, depression, nutrition, fatigue, polypharmacy, geriatric syndromes and quality of life, and provides suggestions for assessment crite-

ria in each domain and practical advice for integrating and intervening when a patient has a need in a specific area. It could serve as a starting point for organisations that are looking to integrate geriatric assessment into oncology care. At City of Hope, this work has been adapted into an abbreviated checklist of screening questions or brief assessments to allow nurses to identify problem areas for older adults that might not be recognised in a typical history and physical (See Table 1).

This abbreviated tool has not been validated in the clinical setting. However, it serves as a way to bring evidence-based practice to the bedside and for nurses to organise their care while incorporating the components of a geriatric assessment into daily practice. Further evaluation would be carried out during its use with older adults with cancer.

The field of geriatric oncology education is relatively new and evolving.

Existing geriatric-specific materials will continue to be of great help and can be modified to meet the needs of oncology care. The materials available at the previously mentioned NICHE were used by our organisation to create a unique programme. NICHE provides an online curriculum for nurses in geriatric care called the GRN programmes which are conducted biannually. There are 20 GRN online modules and nurses are asked to complete three to four each month. After completion of the assigned modules, the group meets to review the material and discuss how to apply it to older adults with cancer. The course typically requires six months to complete, and graduation from the programme includes a ceremony with the distribution of GRN pins that

17

Table 1. Condensed geriatric assessment screening Domain

Assessment method

Finding needing intervention

Intervention

Caregiver/ social support

Do you have someone to help you at home if you were confined to bed?

Negative response

Discussion regarding support system and needs Local community resources Social work referral

Comorbidities

List of comorbidities Does this impact your daily activities?

Comorbidities that might impact treatment If impacting ADL/IADL

PT/OT referral as appropriate Review with PCP share plan of care and treatment summary

Function

TUG, IADL, ADL Falls in the last 6 months Baseline and repeat

TUG≥13 seconds8 or IADL/ADL dysfunction Any falls

Exercise Home safety evaluation PT/OT

Cognition

Mini-COG9 Evaluate for decision making capacity Baseline and repeat

Abnormal

Referrals as needed to geriatrician, neurology or psychiatry Home safety evaluation

Depression

Have you felt sad or depressed in the last few weeks? Do you have little interest in doing things?

Positive response

Discuss past coping skills Social worker or psychologist as indicated

Nutrition

Weight Appetite

Weight loss ≥ 5% BMI <22 Poor appetite Vitamin D, B-12, Albumin

Education for increasing protein and calories MNA10 for further evaluation Nutritional consult

Polypharmacy

Brown bag med review Med reconciliation Beers list review

Drug interactions PIM

Rationale discontinuation, if possible Review med instructions and adherence Review with PCP or MD/NP

Geriatric syndromes

Are you sleeping well?

Do you have trouble with incontinence of bladder?

Do you have any sores on your skin?

SPICES11 review

Positive responses

Education on non-pharm sleep measures Education on urinary control or referral to urology or uro-gyn or PT for exercises Evaluate skin lesions education on pressure and skin tear injury or referral to wound care if indicated

ADL: activities of daily living; BMI: body mass index; IADL: instrumental activities of daily living; MNA: mini nutritional assessment; NP: nurse practitioner; PCP: primary care provider; PIM: potentially inappropriate medications; PT/OT: physical therapy/occupational therapy; SPICES is an overall assessment tool for older adults; TUG: timed up and go.

identify that the nurse has completed the programme. Quarterly educational meetings are held for any nurse who has previously completed the course, with different educational topics at each meeting, to keep nurses up to date.

Nurses at the centre are encouraged to become certified in their area of specialty –oncology or advanced oncology certification, or an oncology specialty area, such

18

as paediatrics, breast care, or blood and marrow transplant. They are also encouraged to be dually certified in another area, such as gerontology. This certification is available from the American Nurses’ Credentialing Center. In order to achieve that goal, a Gerontology Certification Course is being developed and will be offered for the first time this year.

All the efforts to support increasing the

knowledge base of nurses in geriatric care have an end goal to also improve the care of older adults with cancer.

Peggy Burhenn is a Clinical Nurse Specialist in geriatric oncology. She is Professional Practice Leader for Geriatric Oncology at City of Hope Medical Center, California, USA. Details of the references cited in this article can be accessed at www.cancernurse.eu/magazine

CANCER CARE FOR OLDER PATIENTS

Polypharmacy: evaluation of medication management The use of multiple medications and inappropriate medications can severely compromise cancer management plans. In view of the risks involved, specific guidelines are urgently needed to regulate the management of polypharmacy in older adults with cancer.

Ginah Nightingale

Polypharmacy is a significant public health problem that disproportionately affects older adults, particularly those with multiple comorbid conditions.

It is commonly defined as concurrent use of five or more medications, including prescription, non-prescription and complementary and herbal supplements.1-3 Polypharmacy can also be defined by the use of potentially inappropriate medications (PIM), which are associated with an increased risk of adverse drug effects in older adults. Bushardt et al.4 suggested that there are 24 distinct definitions of polypharmacy, ranging from unnecessary or inappropriate medication use to excessive numbers of medications.

While the use of many medications may be good practice for the treatment of some chronic medical conditions, the addition of cancer-related therapy to existing polypharmacy is problematic. The multiple layers of specialists, primary care, and allied health professionals in the continuum of care makes this population particularly prone to errors attributed to medication changes, complex regimens, and incomplete information handoff between providers. This means there may be an increased risk for adverse drug events, drug-drug interactions, non-adherence and in some cases of hospitalisation

and increased healthcare utilisation.5-11 The National Comprehensive Cancer Network (NCCN) Older Adult Oncology Guidelines recommend a thorough evaluation for polypharmacy and potentially inappropriate medications.12 (Patients should also be asked about herbal medications.) The prevalence of polypharmacy in the ambulatory older adult oncology population ranges from 48 to 80%, and of potentially inappropriate medication from 8 to 51%.13-17 This variability may be attributed to the methodology, e.g. self-reports, medical records extraction, pharmacist assessment, screening tools and terms for defining polypharmacy and inappropriate medications.

Identifying and categorising potentially inappropriate medications is also complex: there are medications lacking evidence-based indications, those with treatment risks that outweigh benefits, those significantly associated with adverse drug reactions, or those that may potentially interact with other medications or diseases.18 The most current, evidence-based, validated criteria and screening tools to capture potentially inappropriate medications include the 2015 Beers criteria, the Screening Tool of Older Person’s Prescriptions (STOPP) and the Medication Appropriateness Index.19-23

Polypharmacy and potentially inappropriate medication use warrant substantial concern among oncology healthcare teams, because of the perils associated with their use in this vulnerable population – such as increased risk of falls and/or fractures and cognitive impairment – all of which can lead to compromised cancer management plans.

How do we address these issues? The ‘brown bag’ method is highly recommended and involves the patient bringing all medicines into the clinic for a provider to review.

In addition, the clinician can assess patients’ ability to read medication label directions, self-administer and manage medications in an organised manner. However, currently, there is not a consensus or specific guideline on the management of polypharmacy in older adults with cancer. Well-designed, inter-professional studies that measure patient-reported outcomes and quality improvement are needed to evaluate medication management interventions in this complex and vulnerable population.

Ginah Nightingale is an Assistant Professor in the Department of Pharmacy Practice at Thomas Jefferson University, Philadelphia, USA. Details of the references cited in this article can be accessed at www.cancernurse.eu/magazine

19

Four nurses talk about their role in developing the care older patients with cancer receive BREAKING DOWN THE BARRIERS – THE ROLE OF THE GERIATRIC ONCOLOGY NURSE Allison Loucks and Rana Jin

Older adults with cancer are often over-treated or under-treated with cancer therapy, putting them at high risk for adverse events and negative outcomes. To enhance the cancer care older adults receive, the geriatric oncology demonstration project team at Princess Margaret Cancer Centre in Toronto, Canada, launched the new older adults with cancer clinic (OACC) in July 2015. The first year of our demonstration project aims to provide a comprehensive geriatric assessment (CGA) for vulnerable older adults with a genitourinary (GU) cancer, to decrease toxicity and increase tolerance to cancer therapy by (a) providing the treating oncologist with recommendations for individualised cancer treatment based on the CGA findings for patients without an established treatment plan, and (b) establishing an enhanced supportive care plan for high risk older adults with cancer for patients at any point in their cancer journey. Other project goals are (c) to evaluate the utilisation and performance of vulnerable elders survey (VES-13) frailty screening tool in identifying high-risk vulnerable older adults; (d) to conduct a needs assessment of the oncology nurses and physicians in the GU disease site, and (e) to build capacity in providing geriatric care

20

adults with cancer in the GU cancer disease site, we design and deliver geriatric oncology educational programmes to meet the identified learning needs of the GU oncology nurses and provide ongoing clinical support.

The geriatric oncology nurse plays a pivotal role in optimising the health of vulnerable older adults with cancer.

Geriatric oncology nurses can positively impact the cancer care plan for older adults by providing ongoing symptom management, medication titration, accessing community resources when needed, collaborating with patients’ oncology care teams, and coordinating care through close telephone assessment and monitoring. Providing close telephone follow-up increases accessibility to care for vulnerable older adults, who often have poor social support, decreased mobility, and transportation issues. Geriatric oncology nurses are attuned to the barriers older adults are faced with when attempting to navigate and access complex health systems on their own. These barriers to care are broken down through the assistance, support, and advocacy of the geriatric oncology nurse.

By incorporating frailty screening and specialised geriatric assessment in our cancer centre, the geriatric oncology demonstration project is changing current structural barriers and allowing for greater access to specialised care for vulnerable older adults with cancer.

Allison Loucks and Rana Jin

within the GU disease site, by providing education and support.

Our interdisciplinary team consists of one geriatric oncologist, two parttime geriatric oncology advance practice nurses, and a part-time social worker. To meet our identified evaluation outcomes for the first year, Rana Jin and I shared the nursing responsibilities of case finding, triaging referrals, contacting appropriate patients, clinic bookings and organisation; telephone assessment (i.e. intake).

We also conducted the CGA assessment in the clinic along with the geriatric oncologist, Dr Shabbir Alibhai.

Our day-to-day work as project leaders consists in gathering project data to analyse trends and identify risks to the success of the project, which enables our team to make adjustments to our approaches and process along the way, and to ensure project goals are met. In order to build capacity in caring for older

Allison Loucks and Rana Jin are nurses in Geriatric Oncology at Princess Margaret Cancer Centre in Toronto, Canada

CANCER CARE FOR OLDER PATIENTS

HOLISTIC CARE FOR OLDER PATIENTS WITH CANCER

Ramona Moor

Ramona Moor

As a nurse, my clinical function is geriatric oncology care coordinator in the Cliniques Universitaires Saint-Luc in Brussels, Belgium. Geriatric oncology is a clinical activity aimed at optimising care of older patients with cancer. It is the result of an active collaboration between oncologists, geriatricians, general practitioners and all other professional healthcare workers involved in the assessment of the patient, and in the conduct of his or her treatment. Some older patients have a robust health status and can benefit from standard cancer treatment. But other older patients present geriatric problems such as functional decline, malnutrition, cognitive impairment, falls, pain, fatigue, which have to be detected in order to propose a tailored cancer treatment and a personalised geriatric care plan. I am the reference person for this new approach of holistic care in older patients with cancer.

Most of the time, I meet the patients after a phone call or email from the oncologist or from the patient’s oncology care coordinator. I give an appointment or I join the patient directly after the visit to the cancer specialist. Firstly, I complete the G8 screening tool with the patient. If the result is normal (score > 14/17), the patient has no geriatric risk profile. If the result is less or equal to 14/17, I immediately proceed with a standardised geriatric assessment.

The geriatric assessment we use includes: ●● Demographic and social support data ●● Katz index, Lawton scale, a fall questionnaire – timed up and go, to assess functional status ●● Visual analogue scales to assess pain and fatigue ●● Questions about sleeping, vision, hearing,

chronic wounds, recent hospitalisations, perception of health and quality of life ●● Mini-mental state examination to assess cognitive status ●● Geriatric depression scale to assess emotional status ●● Mini-nutritional assessment to assess nutritional status ●● Zarit-burden scale to assess the burden to the family member(s) ●● Charlson comorbidity index ●● A questionnaire about polypharmacy.

It takes roughly 45 minutes to complete all the questionnaires with the patient (and his or her family). At the end of the interview, I give a short feedback to the patient about the detected geriatric problems and available resources. I inform the patient that we will establish a personalised care plan taking into account the detected frailties.

For each patient with a geriatric assessment, I prepare a report including: ●● a summary of the medical history of the patient ●● the proposed oncological treatment ●● the results of the geriatric screening and assessment.

Based on this report, I present the case

of each patient at our weekly multidisciplinary geriatric oncology meeting in the presence of our dedicated geriatrician, oncologist and pharmacist. The aim of this meeting is to write the personalised geriatric oncology care plan, which includes an opinion on the proposed oncological treatment and the recommended geriatric interventions. This document appears in the electronic medical file of the patient, and is sent to the oncologist and to the general practitioner.

Following on from the previous steps, I actively coordinate the implementation of the proposed patient’s care plan. I put the patient in contact with every necessary professional healthcare worker, e.g. physiotherapist, dietician, social worker, psychologist, etc. Finally, around three months after the multidisciplinary geriatric oncology consultation, I do a short follow-up assessment of the patient by phone or based on the medical file.

The data about our patients is collected in order to perform a scientific analysis.

Next to my clinical function, I also have research and teaching activities related to care for older patients with cancer.

21

“CARING IS THE ESSENCE OF NURSING” Cindy Kelly

Being a geriatric oncology nurse practitioner has been a tremendous positive experience for me. Not only do I feel like I am growing professionally, but more importantly, I believe that this vocation is creating conditions to help me expand personally and spiritually. I have been offered this position to work on a research team led

by Dr Arti Hurria, an internationally recognised leader in geriatric oncology, to improve the care of older oncologic patients at The City of Hope in Duarte, California, USA. Her research focuses on improving the care of older adults with cancer, and one of many studies she is actively researching is advancing screening and treatment for older patients with cancer.

My involvement in this particular nurse-led study is to see if, by obtaining a thorough geriatric assessment prior to the initiation of chemotherapy, we can improve outcomes of the patients that receive the nurse-led and other interdisciplinary interventions while they receive their chemotherapy. The interventions range from offering the services of a geriatric oncology nurse practitioner to follow up to assess for toxicities, and to counsel on sleep, hygiene, fatigue, pain management and psychosocial and spiritual concerns.

Additional interventions include physical and occupational therapy, supportive care consultation, social work, nutritional consultation, urinary consultation, advance directive planning and pharmacy review, and also to ensure greater collaboration with the patient’s primary care physician and their oncologist. Our goal is to decrease chemotherapy-related toxicities and hospital and emergency admissions, to improve quality of life while receiving chemotherapy and to obtain advance directives.

There is a constant flux of new information that I feel I need to know – not only in oncology, but in the optimal management of older patients. Working with older adults that also have a cancer diagnosis can be

22

Monica Trent, Daisy Rivera and Cindy Kelly

challenging. The process of ageing itself can present vulnerabilities, but then there is the burden of the cancer diagnosis that magnifies the vulnerabilities of this population. If there is one quality that I feel is essential to performing this work, it is sensitivity. This is needed to be empathic to the losses and changes that can be experienced during this time. I feel that the core role of being a geriatric oncology nurse practitioner is to care. Caring is the essence of nursing. To care requires the knowledge of what is the optimal course of action for what is happening at that moment. Knowledge comes in many dimensions, from understanding the current practice guidelines to being able Cindy with a patient

to trust one’s intuition. It is paying exquisite attention to our patients’ speech, body and family, and my body and mind. It means to truly listen and to have the openness to be with uncomfortable situations. Knowledge means being certified as a gerontology nurse (I am actively working towards this), and it also means being aware and compassionate as I communicate with others.

One of the unexpected skills that I have had to learn in this position is the ability to be diplomatic with my interactions and responses with the physicians, the healthcare team (nurses, therapists, social workers, dietitians and schedulers) and the patients and their families. My role as a geriatric oncology nurse practitioner can be viewed as a consultant by the medical oncology team that we are working with. So in this role, my position is to make recommendations and provide guidance on best practice. It has helped me to become more pliant in the manner that I interact with others. I would like to think that it helps me to see what is the best course of action for the patient, the primary oncology team and our research team.

I am grateful for this role. For the majority of the time that I interact with patients, I feel more relaxed, because I am usually seeing patients while they receive chemotherapy. There is not the demand of having to get them out of the room so that the next patient can be seen. I work at the same medical facility as Betty Ferrell and Peggy Burhenn – this is good karma! I have learned that the power of an interdisciplinary team can make a difference in our patients’ lives. I also see that everyone that I meet is teaching and helping me. (It may not be in the manner that I expect, but there is a connection that is helping us both to understand the life we have been given.)

This population has many needs and concerns and it is with this energy of kindness, compassion and expertise by each of the disciplines that makes this work.

Nursing is one of the forces that honours the processes of living amidst the realities of sickness and ageing.

CANCER CARE FOR OLDER PATIENTS

Needs of family caregivers of an older person with cancer

Caregivers of older cancer patients have specific needs that may go unnoticed. Their role in monitoring and dealing with treatment-related issues at home often impacts negatively on their quality of life.

The increasing number of older adults living into their 70s and over, combined with the shift for most cancer treatments to take place in the ambulatory setting, is leading to new challenges for oncology nurses in practice, education and research.1,2 Older adult cancer patients have unique care needs. Many rely on support from an informal family caregiver whilst undergoing ambulatory cancer treatment, or they may even be caring for an older spouse themselves.3 However, family caregivers are often only viewed as a resource, complementing the role of oncology healthcare providers, by monitoring and managing disease and treatment-related issues

Petra Stolz-Baskett

at home. Caregiversâ&#x20AC;&#x2122; quality of life may be negatively affected by patientsâ&#x20AC;&#x2122; symptom burden, and their needs might go unnoticed if not assessed within a structured family-focused care process.

Impact of cancer caregiving on family caregivers Research in the field of cancer caregivers has provided many insights over the past two decades, supporting the observation that caregiversâ&#x20AC;&#x2122; health is often negatively impacted by caregiving demands, and that

they suffer from moderate to high burden, including financial strain and compromised quality of life.4 Akin to the research undertaken in medical oncology, caregivers of older cancer patients are under-represented in these studies and their specific experiences and needs are not examined sufficiently. Some areas of described impact, though, are similar in the geriatric oncology setting, e.g. the moderate to high level of burden and unmet needs experienced.5 Factors identified that contributed to these outcomes in the geriatric oncology caregiver group include: characteristics of caregivers and person with cancer, e.g. number of comorbidities; psycho-emotional factors, including distress

23

and appraisal/coping; social factors, such as finance and family dynamics; physical and spiritual health; amount/type of caregiving tasks engaged in; as well as caregiver burden and level of unmet needs.5 Family caregiver needs Evidence about the specific needs and experiences of caregivers of older people with cancer who undergo ambulatory cancer treatment is limited. The author carried out an investigation as part of her doctoral study which found that caregivers report moderate levels of burden, mostly related to changes in their daily schedule, but also related to their own health. Additionally, some evidence is emerging to show that spiritual wellbeing is a significant contributor to the quality of life of family caregivers of older people with cancer.6 Furthermore, caregivers of older people with cancer have an array of unmet infor-

Petra Stolz-Baskett

mational and healthcare needs. Female caregivers had significantly more moderate/high unmet needs compared with male caregivers. No difference was found, however, in the number of moderate/high unmet needs between spouse/partner and other caregivers.7 Next to age- and gender-related associations, it is likely that caregiver needs are also dependant on the cultural and healthcare setting, with

a comparison between three samples of caregivers from Australia, the United Kingdom and Switzerland portraying considerable differences in the top 10 unmet needs reported (Table 1).

In summary, oncology nurses are encouraged to use a patient-centred, family-focused care approach in their assessments and care planning in the geriatric oncology setting. Doing this, the specialist oncology nurse must address questions around caregiving demands and caregiver burden, including spiritual wellbeing, in their needs assessment of the family caregiver supporting the older person with cancer at home.

Petra Stolz-Baskett is Speciality Clinical Nurse Oncology at Nelson Marlborough Health, New Zealand, and a Doctoral Student at King’s College London, United Kingdom.

Details of the references cited in this article can be accessed at www.cancernurse.eu/magazine

Table 1. Top 10 moderate/high unmet needs reported using Supportive Care Needs Survey – Partner & Caregiver Instrument “What was your level of need for help with ...”

Switzerland7 (n = 86)

Australia8

n

%

rank

Complaints regarding care addressed

29

35

Concerns about recurrence

29

35

1

18.6

Receiving best medical care for the patient

28

33

7

14.7

Fears about patient deterioration

28

33

8

14.3

Discussing concerns with doctor

28

33

13.4

Assuring doctor coordinated care

27

32

13.3

Information on alternative therapies

26

31

7.5

Information on prognosis

25

30

13.5

Information on decision making

25

30

5

15.1

Reducing stress for patient

24

29

2

18.1

Being involved in patient care

24

29

24

United Kingdom9 %

rank

%

9.9

1

48

7

31

3

38

13.0

THE EUROPEAN ONCOLOGY NURSING SOCIETY PRESENTS:

EONS

1

IN PARTNERSHIP WITH:

Two days of specialist cancer nursing educational workshops, scientific news, and networking opportunities at the Dublin Aviva stadium. For more information visit: www.eonsdublin2016.com

BALANCING HEALTH CARE NEEDS IN A CHANGING CONTEXT

Research priorities for geriatric oncology nursing Schroder Sattar, Samar Toubasi and Martine Puts

Older adults have been severely under-represented in clinical cancer research but, with the rapid increase in older cancer survivors, geriatric oncology nurses are well-placed to lead this research. Martine Puts, Assistant Professor at Lawrence S. Bloomberg Faculty of Nursing, Toronto, Canada, and PhDs Schroder Sattar and Samar Toubasi, examine the issues.

W

ith the increasing ageing of the population around the world there will be a significant increase in the number of older adults affected by cancer. Due to the physiological ageing process, older adults have unique needs. Older adults with cancer have often more than one disease which makes their care more complex. Nurses working with older adults with cancer need to have an understanding of both oncology nursing care as well as gerontological and geriatric nursing principles, to understand their needs and provide high-quality care. Nurses working

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with older adults with cancer need to understand how ageing can impact treatment tolerability and safety, how to manage their symptoms in the context of multiple conditions, how to improve or maintain quality of life and functional status and how to provide psychosocial support to older adults and their caregivers. Although geriatric oncology as a field grew significantly between the late 1990s and early 2000s, and while in some countries geriatric oncology is recognised, with special training programmes to develop this expertise in physicians, geriatric oncology nursing has been growing as well over the same period,

SHUTTERSTOCK

CANCER CARE FOR OLDER PATIENTS

but has not made the same progress.

Despite efforts to make improvements, older adults remain severely under-represented in clinical oncology trials, and that has not changed much over the past decade, which affects the evidence base for the care provided to them. Geriatric oncology nursing research priorities have been identified since the early 1990s.

The first published research priorities identified by oncology nurses focused on understanding the impact of cancer outcomes such as functional status and their psychological well-being. Since the 1990s there have been important studies conducted to strengthen the geriatric oncology nursing evidence-base. The first longitudinal study conducted by Given et al.1 clearly demonstrated that cancer treatment had a negative impact on functional status over time. But there was also an important study to show how essential highquality nursing care can be to improving patients’ outcomes. McCorkle et al.,2 in a randomised controlled trial, demonstrated that a home care intervention by advanced practice nurses after discharge improved survival. There have also been studies focusing on improving symptom management by nurses via in-person or telephone and other methods.3-5 The early geriatric oncology nursing research was mainly conducted in the US, but more recently geriatric oncology nursing research has been conducted in other parts of the world. A lot of current research in geriatric oncology has been focused on showing the feasibility and benefits of implementing some form of geriatric screening or geriatric assessment for older adults with cancer. Kenis et al.6 carried out a prospective study with 1967 patients who were screened using the G-8 geriatric screening tool and received a geriatric assessment if they had abnormal scores. The study showed that over 50% of patients had geriatric problems that were not known by the oncology team and 25% of them received geriatric interventions before starting treatment.

Treatment decision-making experiences With advancing age, the decline in physiologic function associated with increased frailty could influence risks and benefits of treatment. Evidence shows under-treatment in older patients, linked to age and comorbidities. This disparity is particularly obvious in those with declining health, suggesting challenges in identifying and recommending optimal treatment for this population. Moreover, although screening for frailty and functional status is critical for estimating the morbidity and mortality resulting from cancer and its treatment, and it is recommended that comorbidity and frailty should be considered in the treatment decisionmaking process (TDMP), there is no evidence this is

carried out in clinical practice. Furthermore, little is known with regard to the cancer treatment decisionmaking process in older adults. A previous systematic review conducted by the authors showed very few studies have focused on exploring treatment decisionmaking experiences in older adults, particularly in the ‘oldest old’. A longitudinal, multi-perspective study to better understand the decision-making from the viewpoint of older patients, their family members, family physicians, and cancer specialist, is currently being conducted by the authors. Items being explored include the influence of factors such as comorbidity, frailty, and functional status on chemotherapy treatment decision in the metastatic setting, and patients’ satisfaction with the decision-making process and with the amount of support provided.7 Geriatric assessment Older adults are a heterogeneous population in their health and functioning; chronologic age alone is insufficient to predict benefit from cancer treatment.

It is therefore imperative to perform a thorough assessment to determine their biological age. A comprehensive geriatric assessment (CGA) can help determine whether the expected benefits of the cancer treatment outweigh the associated toxicity. Developed initially in the 1980s and recently tailored specifically for cancer patients, the CGA is a multidimensional assessment that encompasses activities of daily living (ADL), instrumental activities of daily living (IADL), mobility, strength, energy, nutrition, functional status, physical activity, mood and cognitive behaviour. This holistic approach can help detect the presence of frailty, recognise the impact of comorbidities, and identify the patient’s treatment preferences. A CGA can help detect functional and psychosocial concerns in older cancer patients and inform tailored interventions to prevent or defer adverse outcomes, as well as maintain or improve the functional status and well-being of this population.

Since a full CGA in the clinical setting could be timeconsuming and is not required in all older patients, a more efficient two-step screening process can be used to screen those who are frail/vulnerable. For instance, a frailty measurement tool such as the G-8 or VES13 (which assesses for frailty based on weight loss, mobility, and cognitive function) can be used to identify those who would benefit from the CGA. Those who score above or below the pre-set frailty cut-off level will then be offered a full CGA. As forerunners in conducting frailty screening and CGA in older cancer patients, nurses in the geriatric oncology setting are well-positioned to lead CGA research. Research priorities includes the holistic

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approach of the CGA, as well as the best way to incorporate patientsâ&#x20AC;&#x2122; preferences with the objective measures obtained from the CGA in order to ensure optimal treatment. Research is also needed to examine whether implementation of interventions based on CGA findings will improve patient outcomes.

A team of researchers based in Toronto, Canada, are conducting a parallel single-blind randomised controlled trial to explore the impact of a CGA performed by a multidisciplinary geriatric team, followed by an integrated care plan, with the goal of optimising outcomes in older patients with advanced breast, gastrointestinal, or genitourinary cancer, who are starting first-line chemotherapy. This will be among the first randomised controlled trials of CGA conducted in the geriatric oncology context to examine feasibility and to make available estimates of impact and patient-reported outcome that can in turn inform the design of a phase III trial.

Patient engagement in research Older adults, in particular those who are frail and those with comorbidities, are severely under-represented in clinical cancer research. To increase and improve patient engagement in research with the goal of improving cancer care for this population, the authors are conducting a study to examine how older cancer patients and their caregivers can be engaged in research, as well as to understand their priorities for future research projects. This 12-month project utilises public meetings and focus groups to engage older adults and their caregivers in discussion about research, research priorities, and the support they will need in becoming a research team member. Participants who express interest in getting involved in future research projects will be contacted when appropriate projects are established.

Impact of falls on cancer treatment Falls are a major health issue among older adults. About one-third of this population sustain a fall each year.

Falls are the leading cause of nursing home placement and fracture. Falls may be of added concern due to the cancer disease processes and various cancer treatments.

Research shows that delay in treatment could negatively affect prognosis and outcome. Since cancer incidence increases with age, how falls can potentially affect cancer treatment will be an important question to ponder. A recent systematic review of research literature was conducted to investigate how falls can affect treatment in this population.8 A cross-sectional study examining the impact of cancer treatment will be conducted with older adults receiving chemotherapy or radiotherapy who reported a fall in the past 12 months.

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Nurses working with older adults with cancer need to have an understanding of both oncology nursing care as well as gerontological and geriatric nursing principles Medication adherence With about 25% of chemotherapy and targeted therapies currently being delivered orally, adherence to cancer treatment has become increasingly important, as it can have significant implications for health outcomes and quality of life. The gradual transition from intravenous therapy to oral therapy in recent years leads to a shift of responsibility toward patients and their caregivers.

Geriatric oncology nurses are well-positioned to target this research priority. Evidence shows that strategies such as motivational interviews and cognitive behavioural interventions help promote adherence.

Therefore, in addition to designing intervention studies utilising these strategies to improve adherence, geriatric oncology nurses can also use research to investigate the usability of CGA in uncovering system factors, e.g. lack of care coordination, that influence adherence. Undertaking studies that translate findings from research on chronic disease management to the oncology setting can also promote treatment adherence in developing countries.

Cancer survivorship The ageing of the population and advancement in cancer detection and treatment have resulted in a rapid increase in the number of older cancer survivors.

However, there is a paucity of robust evidence to inform the development of tailored interventions for this population. Research in the form of longitudinal studies to explore the late and long-term effects of cancer and cancer-treatment is thus one of the priorities in geriatric oncology research. Workforce studies to understand the education required in gerontology and oncology to meet the needs of this growing population are also called for, as well as inquiries to examine the incorporation of CGA and survivorship care plans to enable smooth transition from active treatment to survivorship.

Martine Puts is Assistant Professor at Lawrence S. Bloomberg Faculty of Nursing, Toronto. Schroder Sattar is a PhD candidate and Samar Toubasi a PhD student there. Details of references cited in this article can be accessed at www.cancernurse.eu/magazine

SIOPE Society Day 27th January 2017 RAI Congress Centre Amsterdam the Netherlands Credit Attilio Rossetti photographer, Italy

A Unique Event for all those working for a Better Future for Children and Adolescents with Cancer On the first day of the European Cancer Congress (ECCO2017) SIOPE will present a highly innovative 1-day programme for its community of childhood cancer professionals

SIOP SIOP Europe

the European Society for Paediatric Oncology

Discover more:

www.siope.eu

Avenue E. Mounier 83 - 1200 Brussels, Belgium E-mail: office@siope.eu

AD SIOPE SOCIETY DAY.indd 1

30/05/16 12:18

EONS 10 Mary Wells tells us what’s in store at our Congress in Dublin this autumn Plans are well ahead for our autumn congress and we look forward to seeing lots of EONS nurses at the state-of-the-art Aviva Stadium in the beautiful Irish capital city of Dublin on 17-18 October. IT’S TIME FOR YOU TO REGISTER!

T

he Scientific Committee have worked very hard to put together a high quality programme for this exciting twoday event on a theme of “Balancing Healthcare Needs in a Changing Context”. We are fortunate that the conference will take place in the same venue as the International Psycho-Oncology Society (IPOS) conference, which means that EONS nurses will also have access to some of the specialist IPOS academy sessions on offer.

Our hosts, the Irish Association of Nurses in Oncology (IANO), will join EONS to welcome delegates to the conference on the morning of Monday 17 October. We will then hear from our distinguished plenary speaker Meinir Krishnasamy, who is Professor of Cancer Nursing Translational Research at the Department of Nursing, University of Melbourne, Australia.

Mei is well known to many EONS nurses as she previously worked in the UK, and we are really delighted that she will be joining us in Dublin to discuss the place of cancer nurses in delivering value-based healthcare within a context of increasing demand.

On the first day of the conference, our delegates will be able to choose from a fantastic range of topics, including joint sessions with the European Society for Blood and Marrow Transplantation and the European School of Oncology, as well as proffered paper sessions on Survivorship, Clinical Leadership, Symptoms and Palliative Care. Invited speakers from Ireland, Scandinavia, Netherlands,

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Greece, Cyprus, UK and North America will tell us about different approaches to supporting families, providing care in the community, addressing inequalities, and promoting a good death, as well as communicating more effectively within clinical teams. Our workshop on Day 1 will provide an opportunity to discuss a key objective for EONS and ECCO over the next few years: gaining recognition for and advancing roles in cancer nursing. Delegates will have plenty of time to review over 150 posters from all over Europe, and attend satellite symposia. We also hope that everyone will attend our networking evening and enjoy some refreshments!

Day 2 starts with the all-important EONS General Meeting over breakfast. After that, delegates will be able to choose from the Irish Association for Nurses in Oncology special session, or a morning on Cancer Survivorship with Professor Yvonne Wengstrom and speakers from the National Cancer Research Institute Psychosocial Oncology and Survivorship Group in the UK. Alternatively delegates will be able to hear the latest on complementary therapies or attend a practical workshop on managing psychological distress in cancer patients, led

by Professor Nick Hulbert-Williams, from the University of Chester, UK. The morning also presents an opportunity to hear about innovations in patient reported outcomes, psychological health and wellbeing and new developments and roles in cancer nursing.

EONS 10

Aviva stadium

We also plan to host a networking event for PhD students, following the very successful workshop held at the University of Stirling in May. Our final afternoon will include a multi-national ISNCC/ONS/ EONS joint session on building cancer nursing through national societies. We are really excited that we will hear from leaders in Ireland, UK, Slovenia and Australia as well as from the Presidents of ISNCC and ONS. This promises to be a great event!

Other highlights of the day include an important session on symptom management, and proffered papers covering a range of psychosocial care issues.

At the end of Day 2, we will celebrate the achievements of oncology nurses through our awards session, with presentations from 2013 Research Grant winner Dr Gianluca Catania and from Clinical Travel Grant and Research Travel Grant winners in 2015. The Novice Dissemination Award will also be presented in this session. Closing remarks will be given by our President, Professor Daniel Kelly, who will no doubt challenge us to leave the conference inspired and with renewed energy to address the needs of patients and their families and to work more effectively with fellow health care professionals within the ever changing context of cancer care. Find out more at http:// eonsdublin2016.com/ Mary Wells is Professor of Cancer Nursing Research & Practice at the Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU), University of Stirling and Chair of the EONS Research Working Group.

*REGISTER NOW AT http://eonsdublin2016.com/register-now/ 31

Advance Programme eccocongress.org/info

FROM EVIDENCE TO PRACTICE IN MULTIDISCIPLINARY CANCER CARE ECCO2017 is a unique, clinically oriented, multidisciplinary annual Congress with a strong educational focus.

25 Aug 2016

Abstract Submission Deadline

27 Aug 2016

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28 Nov 2016

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7 Dec 2016

Late-breaking Abstract Submission Deadline

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