Oncology Nurse Advisor January/February 2015 by Haymarket Media

ONCOLOGY NURSE ADVISOR â&#x20AC;˘ JANUARY/FEBRUARY 2015

January/February 2015

www.OncologyNurseAdvisor.com A F O R U M F O R P H YS I C I A N A S S I S TA N T S

PATIENT NAVIGATION

FEATURE

Evolving roles for oncology nurses: Biospecimen collection

FEATURE

Quantifying mental disorders in patients with cancer

FEATURE

Rationalizing your survivorship program

A crucial role in creating a better path for patients with cancer This emerging role is poised to change the face of oncology care and improve overall patient outcomes.

FEATURE

Mobile support helps younger breast cancer survivors

ISSUES IN CANCER SURVIVORSHIP

Mistletoe is making headlines as a cancer treatment

REFLECTIONS

Managing obesity should be part of cancer care VOLUME 6, NUMBER 1

ASK A PHARMACIST

Importance of sequence when giving premeds with paclitaxel

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Oncology Nurse Advisor (ISSN 2154-350X), January/February 2015, Volume 6, Number 1. Published 6 times annually by Haymarket Media Inc, 114 West 26th Street, 4th Floor, New York, NY 10001. Oncology Nurse Advisor is available for single copy purchases at the following rates. Price per copy: USA $20; Foreign $30. To order call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

EDITORIAL BOARD Ann J. Brady, MSN, RN-BC Huntington Cancer Center Pasadena, California Jia Conway, DNP, FNP-BC, AOCNP, NP-C Cancer Care Associates of York York, Pennsylvania Marianne Davies, DNP, ACNP, AOCNP Smilow Cancer Center @ Yale New Haven New Haven, Connecticut Frank dela Rama, RN, MS, AOCNS Palo Alto Medical Foundation Palo Alto, California Donald R. Fleming, MD Cancer Care Center, Davis Memorial Hospital Elkins, West Virginia Susanne Menon, NP, OCN Center for Gynecologic Oncology Massachusetts General Hospital Cancer Center Boston, Massachusetts Leah A. Scaramuzzo, MSN, RN-BC, AOCN Billings Clinic, Inpatient Cancer Care Billings, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 1

CONTENTS

January/February 2015

IN THE NEWS • Oncology-palliative care partnership improves hospital outcomes for cancer patients • Treatment-resistant NSCLC responds to investigational drug • Life expectancy still not used to determine aggressiveness of prostate cancer treatment … and more

ONCOLOGY NURSE ADVISOR FORUM • Vaginal lubricant options for women with HR+ cancer • Reducing side effects of everolimus administration • Managing oral side effects of irinotecan therapy … and more

NAVIGATOR NOTES Oncology navigators: A crucial part of a cancer patient’s path

Karyl Blaseg, RN, MSN, OCN

FEATURES Evolving roles for oncology nurses: Biospecimen collection Bryant Furlow

Quantifying mental disorders in patients with cancer Kathy Boltz, PhD

Navigation and survivorship: Rationalizing your program Mike Darud

43 FIND US ON

Mobile support helps younger breast cancer survivors Bette Weinstein Kaplan

Continues on page 4

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CONTENTS

Have a question? Our panel of oncology clinicians is available to answer your questions. Submit questions to editor.ona@HaymarketMedia.com.

January/February 2015

Answer the ONA poll question 33

STAT CONSULT Netupitant/palonosetron (Akynzeo)

RADIATION & YOUR PATIENT How genomic correlates are predictive of radiotoxicity Bryant Furlow

ONA asks… Answer our poll question and compare your opinions with those of your colleagues on key nursing issues at OncologyNurseAdvisor.com Subscribe to ONA newsletters Stay current with daily news reports and special series from key oncology conferences on our Web site, sign up for our e-newsletters at OncologyNurseAdvisor.com/subscribe.

COMMUNICATION CHALLENGES Patient education in subtitles Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Mistletoe: The holiday plant is making headlines as an alternative cancer treatment

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THE TOTAL PATIENT A social enterprise serves as a working model for the future of palliative care

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FROM CANCERCARE Understanding the male patient with cancer William Goeren, MSW, LCSW-R

REFLECTIONS Managing obesity should be part of cancer care Donald R. Fleming, MD

ASK A PHARMACIST Importance of sequence when giving premeds with paclitaxel Lisa A. Thompson, PharmD, BCOP

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IN THE NEWS Oncology-palliative care partnership improves hospital outcomes for cancer patients

Facility experience impacts patient outcomes in radiation for head and neck cancer When it comes to specialized cancer surgery, the more experienced the surgeon, the better the outcome is generally true. The same might hold true for radiation therapy used to treat head and neck cancer, according to a new study. The study compared survival and Mask and target in other outcomes in 470 patients treated radiotherapy with radiation therapy at 101 treatment centers through a clinical trial held from 2002 to 2005. The trial was sponsored by the National Cancer Institute and organized by the Radiation Therapy Oncology Group

(RTOG). It was conducted by researchers at The Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital in Columbus. Radiation therapy for head and neck cancer requires complex treatment planning that can vary considerably between institutions and physicians. In addition, significant short-term and long-term side effects can occur that require management by a carefully coordinated multidisciplinary care team. National Comprehensive Cancer Network (NCCN) guidelines recommend that head and neck cancer patients receive treatment at experienced centers, but whether provider experience affects outcomes was previously unknown. The research team used participation in previous RTOG head and neck cancer clinical trials as a surrogate for experience. They identified 88 low-accruing centers that

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A new collaborative model in cancer care reduced the rates at which patients were sent to intensive care or readmitted to the hospital after discharge. In the new treatment model, medical oncologists and palliative care physicians partnered in a co-rounding format at Duke University Hospital’s solid tumor unit in Durham, North Carolina. The Duke model fostered collaboration and communication between the specialists, who met several times a day to discuss patient care. “The integration of palliative care, as a necessary and essential component of cancer care, is one that has been increasingly endorsed,” said lead author Richard Riedel, MD, medical director of Duke University Hospital’s solid tumor inpatient service. “The benefits of palliative care have been shown in the outpatient and consultative settings, but we didn’t know its impact on daily inpatient care. Now, we have successfully partnered with our palliative care colleagues to bring their unique skill sets and expertise directly to our admitted patients, and have shown it to be beneficial.” After the model was implemented at Duke in 2011, the analysis showed, there was a 23% decrease in the number of patients readmitted to the hospital within a week of discharge. Patient transfers to the intensive care unit also decreased by 15%, and patients were discharged from the hospital approximately 8 hours sooner, on average. During the same time, hospice referrals increased by 17%. The findings emphasize the value of implementing palliative medicine soon after a cancer diagnosis rather than waiting until later in the disease’s progression. The new approach allows patients earlier opportunities to discuss their care goals and quality of life, which is becoming a central issue among health policy leaders. Researchers hope to pursue several leads from this initial study, including an in-depth cost-benefit analysis.

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Treatment-resistant NSCLC responds to investigational oral drug ASP8273, an oral drug under investigation in a phase 1 clinical trial in Japan, caused tumor shrinkage in patients, according to the researchers. This drug is a way of treating non-small cell lung cancer (NSCLC) that has both the epidermal growth factor receptor (EGFR) Advanced stage and T790M mutations. NSCLC Twenty-four Japanese patients have enrolled so far to receive 1 of 6 doses (25, 50, 100, 200, 400, and 600 mg) once a day. An additional seven patients have been enrolled into a second group to evaluate doses of 100 mg, 200 mg, and 400 mg a day (a dose escalation study). The researchers plan to enroll a total of 124 patients. Cancer had progressed in all the patients after prior treatment with EGFR TKI therapy, and most of them had the T790M mutation. “Preliminary results from this study show a high overall response rate of 78%, with tumors shrinking in seven out of nine patients who had both the EGFR and T790M mutations. While the number of patients is still small, this response is comparable with two other drugs in development that target EGFR, CO-1689 and AZ-9291, but ASP8273 has fewer safety concerns than these drugs,” said Haruyasu Murakami, MD, of the Shizuoka Cancer Center in Japan.

Benefits of T cell therapy for children with relapsed leukemia are ongoing An innovative cell therapy designed to treat a highly aggressive form of acute lymphoblastic leukemia (ALL) continues to show highly promising results in children treated in a pilot study. At 1 month after treatment, 92% of the 39 children receiving bioengineered T Human T cell on a cells had no evidence of cancer, with dendritic cell this complete response persisting in some cases for more than 2 years. The personalized cell therapy reprograms a patient’s immune system and offers the potential of long-term success. “As we continue to follow children in this study, we see exciting results for patients who have exhausted their other treatment options,” said study leader Stephan A. Grupp, MD, PhD, a pediatric oncologist at The Children’s Hospital of Philadelphia and a professor of Pediatrics at the Perelman School of Medicine of the University of Pennsylvania. A relatively new approach in cancer treatment, bioengineered T cells function as cancer hunters, killing the leukemia cells that normally evade regular T cell surveillance.

Patients with ovarian cancer may benefit from pelvic radiotherapy Pelvic radiotherapy (RT) may help treat a rare form of ovarian cancer that can recur in women after surgery and chemotherapy. These findings were published in International Journal of Gynecological Cancer. The study evaluated 56 patients with ovarian clear cell adenocarcinoma (CCA), an aggressive form of ovarian cancer that is more likely to be resistant to chemotherapy and to have a poorer prognosis than other forms of this disease. All but one patient in the study received chemotherapy for a median of six cycles. Six patients received pelvic RT and 50 did not. Ovarian cancer initially recurred in the pelvis of 25% of patients while nearly 11% had disease recurrence outside of the pelvis. Rates of recurrence were 28%, 39%, and 43% at 3-, 5-, and 8-year follow-up points, respectively. The study demonstrated a trend toward a reduction in the incidence of tumor recurrence in patients who had received pelvic RT. In the News continues on page 8

LEFT: © SCOTT CAMAZINE / PHOTOTAKE; RIGHT: © DAVID SCHARF / SCIENCE SOURCE

enrolled an average of four patients yearly to the trials (less experienced), and 13 high-accruing centers that enrolled an average of 65 patients annually (more experienced). Next, the researchers compared outcomes based on whether patients were treated at the high-accruing or low-accruing centers. They found that 5-year local recurrence rates were higher among patients treated at less experienced centers versus more experienced centers (36% vs 21%). The radiation therapy plan was more likely to deviate from protocol at less experienced centers (18% vs 6%). Treatment at lowaccruing centers was associated with a 91% increased risk of death and an 89% increase in progression or death when compared with high-accruing centers. Institutional elements not assessed by the study that can also influence outcomes included use of a tumor board, the number of colleagues and their years of practice, and ancillary services such as speech and swallowing therapy, diet and nutrition support, and specialized nursing.

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IN THE NEWS Life expectancy still not used to determine aggressiveness of prostate cancer treatment National guidelines recommend that men with low- and intermediate-risk prostate cancer and life expectancies of less than 10 years should not be treated with radiation or surgery, since they are unlikely to live long enough to benefit from treatment. But researchFrontal view of ers found that men were being treated prostate cancer aggressively anyway, with little regard for their quality of life, said the study’s first author Timothy Daskivich, MD, of the University of California Los Angeles. Researchers sampled 96,032 men ages 66 years and older with early stage prostate cancer diagnosed during 1991 to 2007 from the Surveillance, Epidemiology, and End Results (SEER) Medicare database. They calculated life expectancy using the patient’s age and other medical conditions at diagnosis and then determined treatment patterns in those men whose life expectancies were less than 10 years. The research team found that men, ages 66 to 69 years, with life expectancies of less than 10 years based on their health status were treated aggressively with radiation, surgery, or brachytherapy 68% of the time. In men with life expectancies of less than 10 years, those ages 70 to 74 years underwent aggressive treatment 69% of the time; those ages 75 to 79 years, 57% of the time; and men 80 years and older were treated aggressively 24% of the time.

Rociletinib produces response in treatmentresistant advanced NSCLC A new drug, rociletinib (CO-1686), targets not only common cancer-causing genetic mutations in patients with non-small cell lung cancer (NSCLC), but also a form of the mutation that causes resistance to treatment. In addition, the drug has shown promising results in patients, in a phase I/II clinical trial. Approximately 10% to 15% of white and 30% to 35% of Asian patients with NSCLC have a mutation in the epidermal growth factor receptor (EGFR), which can be successfully targeted with tyrosine kinase inhibitors (TKI), such as erlotinib, gefitinib, and afatinib. However, these patients eventually develop resistance to TKI therapy. A further EGFR mutation called T790M accounts for 60% of this acquired resistance. No currently approved therapies target T790M.

“Rociletinib (CO-1686) is a new and potent oral EGFR inhibitor designed to selectively target both the initial activating EGFR mutations as well as the T790M resistance mutation. This compound spares wild-type EGFR and this means that it causes far fewer toxic side effects than other EGFR inhibitors,” said Professor Jean-Charles Soria, MD, PhD, chairman of the Drug Development Department at Gustave Roussy Cancer campus, France. Soria explained that rociletinib may benefit patients as a first-, second-, or later-line treatment, and it has a reduced toxicity profile compared to current EGFR inhibitor therapies that cause acne-like skin rashes and paronychia. The data from the rociletinib clinical trials suggest success in targeting and overcoming resistance to EGFR inhibitors, reported Soria.

Combination therapy effective for patients with higher-risk MDS/AML A phase II study investigating the potential of azacitidine and lenalidomide demonstrated that the two therapies in combination may be an effective frontline treatment regimen for patients with higher-risk forms of myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Myelodysplastic syndrome is a type of cancer in which the bone marrow does not make enough healthy blood cells, resulting in abnormal (blast) cells in the blood and/or bone marrow. Acute myeloid leukemia is the most common acute leukemia affecting adults, incidence of which increases with age. The study, led by Guillermo Garcia-Manero, MD, professor of leukemia at The University of Texas MD Anderson Cancer Center in Houston, shed new light on effective dosage schedule and amounts for the drugs. The research team evaluated the administration of azacitidine and lenalidomide on days 6 to 10 of a 28-day cycle of treatment. The combination therapy appeared to be effective in patients presenting with as high as 30% blast cells. “The responses were rapid with a median of two cycles for the drugs to be effective. Treatment with this dosage and schedule was well tolerated,” reported the researchers.

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ONCOLOGY NURSE ADVISOR FORUM QUESTIONS & ANSWERS

Our Consultants Ann J. Brady, MSN, RN-BC, symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

Jia R. Conway, DNP, CRNP, FNP-C, AOCNP, oncology nurse practitioner at Cancer Care Associates of York in York, Pennsylvania. Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/ PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS, clinical pharmacist specialist, Clear Lake Regional Medical Center, Webster, Texas Donald R. Fleming, MD, hematologist/oncologist, Cancer Care Center, Davis Memorial Hospital, Elkins, West Virginia. Kerstin L. Lappen, RN, MS, ACNS, ACHPN, clinical nurse specialist, palliative care consult service, Abbott Northwestern Hospital, Allina Health System, Minneapolis, Minnesota. K. Lynne Quinn, RN, MSN, CRNP, AOCNP, director of oncology, Bryn Mawr Hospital and Bryn Mawr Health Center, Bryn Mawr, Pennsylvania.

Lisa A. Thompson, PharmD, BCOP, clinical pharmacy specialist in oncology, Kaiser Permanente, Colorado

Rosemarie A. Tucci, RN, MSN, AOCN, manager for oncology research & data services, Lankenau Hospital, Wynnewood, Pennsylvania

VAGINAL LUBRICANT OPTIONS FOR WOMEN WITH HR+ CANCER I have a patient who is asking about alternatives to vaginal lubricants. She is hormone-receptor positive (HR+), and commercially available creams have estrogen in them. What can I suggest to her? —name withheld on request Vaginal dryness due to atrophy is a common complaint in postmenopausal women, often resulting in itching, irritation, and painful intercourse. Estrogen therapy is often the recommended treatment; however, for women with contraindications to hormone therapy, safe and effective alternatives to estrogen therapy are available. Symptoms of vaginal dryness can be managed by regular use of a vaginal moisturizer with supplemental use of vaginal lubricants for sexual activity. Vaginal moisturizers are water-based, nonhormonal gels designed for regular use (two or three times per week) to maintain or replenish vaginal moisture. Examples of over-thecounter brands are Replens and Vagisil Feminine Moisturizer. In addition to regular use of a moisturizer, a vaginal lubricant used immediately prior to sexual activity can increase comfort. There are many over-the-counter products available, including Astroglide and KY Jelly, which are water-soluble. There are also many oil-based and silicone-based agents on the market, which may last longer and provide more effective relief during intercourse. Orally administered or locally applied vitamin E in daily doses of 100-600 IU has been found to increase vaginal lubrication, along with coconut oil, which contains caprylic acid to help stave off yeast infections. It should be noted, however, that oil-based lubricants may break down the latex in condoms and diaphragms. For women who have painful intercourse that is not easily relieved with moisturizers and lubricants, the use of graduated vaginal dilators may be helpful in reestablishing elasticity to the vaginal tissue over time. Vaginal dilator use can be taught to women by a clinician or pelvic physical therapist. In women with estrogen-dependent cancers and severely symptomatic vaginal atrophy that fails to respond to nonhormonal options, vaginal estrogen replacement may be considered, but this should always be discussed with your oncologist. And always see your doctor with any complaint of abnormal vaginal bleeding, abnormal vaginal discharge or odor, or new/concerning lesions. —Susanne Menon, NP, OCN

REDUCING SIDE EFFECTS OF EVEROLIMUS ADMINISTRATION Patients taking everolimus (Afinitor) are instructed to wrap the pills in food or coat them with honey, butter, or cream cheese so the pill doesn’t touch their tongue or mouth before swallowing. This technique is reported to reduce the chance of developing mucositis and stomatitis. Is this true? Have the pills been reformulated so as not to leave the residue on the tongue

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ONCOLOGY NURSE ADVISOR FORUM The sequence of various chemotherapy drugs in general does not matter, as the half life of each drug will make it impossible to determine what drug is at what level at any particular time, based on patient pharmacodynamics. that increases mouth sores? Are there other tips nurses can share with patients on how to avoid oral therapy-related side effects? —Jeanette Robinson, RN, BSN, OCN Everolimus targets the mammalian target of rapamycin pathway (mTOR). This classification of drugs is associated with several epidermal toxicities, including skin rash, oral ulcerations, stomatitis, and mucositis. These side effects develop at the cellular level following metabolism of the drug. Stomatitis/oral mucositis occurs in approximately 38% of patients (range 44%-78%). The formulation of everolimus has not changed. It is produced as a dry tablet or the tablet may be dissolved in oral suspension. Everolimus may be taken with food or on an empty stomach. However, food (particularly a high-fat meal) delays the absorption of the everolimus, causing variability in drug concentrations in the blood; therefore, patients need to be consistent in taking it either with food or without food. Patients should avoid use of oral rinses that include alcohol, hydrogen peroxide, iodine, or thyme. Nurses and providers should complete a medication review with all patients as several prescription medications and supplements may interact with everolimus causing a delay in absorption and excretion. This may contribute to worsening side effects. —Marianne Davies, DNP, ACNP, AOCNP

MANAGING ORAL SIDE EFFECTS OF IRINOTECAN THERAPY Many of our patients who are receiving irinotecan for colon or pancreatic cancer via FOLFIRI or FOLFIRINOX are experiencing thick tongue. Although the effect occurs in both settings, it happens more often with FOLFIRINOX. We usually give atropine 0.5 mg IV as a premed, but many patients still have this effect during infusion. We wondered if the IV atropine contributes to the thick tongue, dysarthria. Is there a rationale to give another dose, add lorazepam or Benadryl to help minimize it, or is it more effective to use atropine 0.5 mg SQ? —Sherry Looker, RN, BSN, OCN Thick tongue sensation is likely related to the effects of oxaliplatin (Eloxatin); however, co-administration of irinotecan (Camptosar) and atropine may contribute to the symptom. Oxaliplatin can

cause acute reversible sensory neuropathies that include dry mouth, dysarthria, and an abnormal tongue sensation. This sensation has been reported by more than 50% of patients who receive oxaliplatin in combination with 5-fluorouracil/leucovorin. Irinotecan can cause swelling in the mouth, although it is a rare side effect. Irinotecan is also associated with cholinergic syndrome that may include side effects of hypersalivation and abdominal cramping. The risk of cholinergic syndrome is increased when irinotecan is administered with oxaliplatin. Because of these unpleasant side effects, many practitioners prophylactically administer atropine as a premedication. Atropine sulfate injection is an anticholinergic agent and muscarinic antagonist. It can cause excessive xerostomia (dryness of the mouth), thirst, and difficulty swallowing. Patients may report a sensation of feeling as though their tongue is thick. These side effects are decreased when atropine is administered subcutaneously. Administration of an additional dose of atropine is not likely to improve symptoms. Lorazepam may be used to decrease the anxiety associated with the sensations of thick tongue and dysarthria. —Marianne Davies, DNP, ACNP, AOCNP

IMPORTANCE OF SEQUENCE IN CHEMOTHERAPY ADMINISTRATION Is sequencing important when administering chemotherapy on the same day? —Kathy Kerley, RN, OCN I think the best or correct order for drug administration is very difficult to answer. Administering chemotherapy apart from neutrophil growth factors is well known, and unless desired as a radiation sensitizer, avoid the use of chemotherapy during radiation. But the sequence of various chemotherapy drugs in general does not matter, as the half life of each drug will make it impossible to determine what drug is at what level at any particular time, based on individual patient pharmacodynamics. However, there are certain principles one can follow. For example, when administering a taxane in combination with a platinum, the taxane should always be given first. This is because myelosuppression has been observed in patients who received the platinum before the taxane. In published reports on various chemotherapy regimens, the original research articles may state the order in which the agents were administered, but this

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is rare. So basically, do not worry about order of chemotherapy drugs. —Donald R. Fleming, MD

IMPACT OF VITAMINS, SUPPLEMENTS, AND DIET ON CANCER TREATMENT-RELATED HAIR LOSS Many of our patients ask about supplements or medications for hair loss during and after treatment. Some have anecdotally reported good results with either biotin or a hair/skin/nail vitamin. What are your thoughts and recommendations? —Jennifer Grap, MSN, CRNP Can vitamins or supplements grow hair? The hair thinning or loss from cancer therapy differs from generalized loss, so this is a question that oncology nurses are frequently asked. Given the vast number of vitamins, supplements, and plant extracts claiming to grow hair, you would think that this would no longer be an issue. While there are a handful of studies showing that some exotic plant extracts, such as Asiasari radix extract, Citrullus colocynthis schrad extract, Polygonum multiflorum extract, Thuja orientalis extract, Eclipta alba extract, and Cuscuta reflexa Roxb extract, may assist in hair growth, most of those studies were done on specially bred mice—none of them were performed on people in an appropriate, independent study. So, while the results may be good for the mice, it is unclear if it is an answer. When it comes to vitamins and supplements for hair growth, if your patients are not seriously vitamin deficient (and most are not), there are no studies showing any vitamin or mix of vitamins and supplements can change a single thinning hair. If they are truly vitamin deficient, it is important to find out which vitamin or vitamins are lacking, because hair loss would probably be the least of their problems. For example, biotin, a form of B vitamin, is often present in hair-growth supplements. But, if patients were truly biotin deficient, they would be too sick to get to the store. Blood tests can show if patients are low in vitamin D, zinc, or iron, all of which are related to hair growth as well as to other important fundamental bodily functions related to overall health. Getting these nutrients back within the normal range definitely can make a difference in well-being, and possibly can help increase the density of hair. Other vitamins and supplements that show up in claimed hairgrowing products include vitamin C, omega-3 and omega-6 fatty

acids, amino acids, B vitamins, vitamin A, and vitamin E. All of these are basic ingredients in most vitamin supplements (including prenatal vitamins, which many swear by to help their hair grow). So a general vitamin may be the answer. Can diet affect hair growth? As is true for every part of a person’s body, a healthy diet can go a long way toward making hair, nails, and skin look beautiful. That said, there is no research showing a specific diet or group of foods will help grow hair. You’ll read about lentils, walnuts, salmon, and even poultry as being a few of the dietary answers for hair growth, but it is really about a healthy diet. One interesting aspect of diet: Because hair is mostly protein (in this case, a protein known as keratin), it is a good, though unproven, assumption that there is a need for protein in the diet to grow hair. A protein deficiency can cause hair loss, as can malnutrition from excessive dieting or the eating disorder anorexia, but these are related to serious protein deficiency, and affect only a small percentage of the population. However, patients with cancer do sometimes decrease protein intake during treatment secondary to taste changes and/or the treatments themselves. —Rosemarie A. Tucci, RN, MSN, AOCN

POLYPHENOLS IN GREEN TEA MAY INTERFERE WITH BORTEZOMIB THERAPY What is the mechanism or rationale for why a patient on bortezomib (Velcade) therapy should avoid green tea? — Connie P. Gazmen, MS, RN, OCN Green tea interferes with the proteasome inhibitor activity of bortezomib, effectively blocking the drug’s antineoplastic effect on cancerous cells. In patient management, concurrent use of green tea extract and other green tea products should be avoided during treatment. In addition, clinicians should assess the benefits versus risk of therapy if the decision is made to initiate therapy. —Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS

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One interesting aspect of diet: Because hair is mostly protein (in this case, a protein known as keratin), it is a good, though unproven, assumption that there is a need for protein in the diet to grow hair. www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 11

Take a bite out of G-CSF acquisition costs* GRANIX is another option in short-acting G-CSF therapy TM

» GRANIX demonstrated a 71% reduction in duration of severe neutropenia (DSN) vs placebo1 – GRANIX significantly reduced DSN when compared to placebo (1.1 days vs 3.8 days; p<0.001)1 – Efficacy was evaluated in a multinational, multicenter, randomized, controlled, Phase III study of chemotherapy-naïve patients with high-risk breast cancer receiving doxorubicin (60 mg/m2 IV bolus)/docetaxel (75 mg/m2)1 *Based on wholesale acquisition cost (WAC) of all short-acting G-CSF products as of November 11, 2013. WAC represents published catalogue or list prices and may not represent actual transactional prices. Please contact your supplier for actual prices.

» Safety was evaluated in 3 Phase III clinical trials1

Indication

Important Safety Information (continued)

» GRANIX (tbo-filgrastim) Injection is a leukocyte growth factor indicated for reduction

» Use in patients with sickle cell disease: Severe and sometimes fatal sickle cell crises can occur

in the duration of severe neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

in patients with sickle cell disease receiving hG-CSFs. Consider the potential risks and benefits prior to the administration of GRANIX in patients with sickle cell disease. Discontinue GRANIX in patients undergoing a sickle cell crisis.

» Potential for tumor growth stimulatory effects on malignant cells: The granulocyte colony-

Important Safety Information » Splenic rupture: Splenic rupture, including fatal cases, can occur following the administration of human granulocyte colony-stimulating factors (hG-CSFs). Discontinue GRANIX and evaluate for an enlarged spleen or splenic rupture in patients who report upper abdominal or shoulder pain after receiving GRANIX.

» Acute respiratory distress syndrome (ARDS): ARDS can occur in patients receiving hG-CSFs. Evaluate patients who develop fever and lung infiltrates or respiratory distress after receiving GRANIX, for ARDS. Discontinue GRANIX in patients with ARDS.

» Allergic reactions: Serious allergic reactions, including anaphylaxis, can occur in patients receiving hG-CSFs. Reactions can occur on initial exposure. Permanently discontinue GRANIX in patients with serious allergic reactions. Do not administer GRANIX to patients with a history of serious allergic reactions to filgrastim or pegfilgrastim.

stimulating factor (G-CSF) receptor, through which GRANIX acts, has been found on tumor cell lines. The possibility that GRANIX acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, diseases for which GRANIX is not approved, cannot be excluded.

» Most common treatment-emergent adverse reaction: The most common treatment-emergent adverse reaction that occurred in patients treated with GRANIX at the recommended dose with an incidence of at least 1% or greater and two times more frequent than in the placebo group was bone pain. Please see brief summary of Full Prescribing Information on adjacent page. For more information, visit GRANIXhcp.com. Reference: 1. GRANIX TM (tbo-filgrastim) Injection Prescribing Information. North Wales, PA: Teva Pharmaceuticals; 2013.

Take a bite out of G-CSF acquisition costs* GRANIX is another option in short-acting G-CSF therapy TM

» Safety was evaluated in 3 Phase III clinical trials1

Indication

Important Safety Information (continued)

» GRANIX (tbo-filgrastim) Injection is a leukocyte growth factor indicated for reduction

» Use in patients with sickle cell disease: Severe and sometimes fatal sickle cell crises can occur

in the duration of severe neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

» Potential for tumor growth stimulatory effects on malignant cells: The granulocyte colony-

BRIEF SUMMARY OF PRESCRIBING INFORMATION FOR GRANIX™ (tbo-filgrastim) Injection, for subcutaneous use SEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE GRANIX is indicated to reduce the duration of severe neutropenia in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. 4 CONTRAINDICATIONS None. 5 WARNINGS AND PRECAUTIONS 5.1 Splenic Rupture Splenic rupture, including fatal cases, can occur following administration of human granulocyte colony-stimulating factors. In patients who report upper abdominal or shoulder pain after receiving GRANIX, discontinue GRANIX and evaluate for an enlarged spleen or splenic rupture. 5.2 Acute Respiratory Distress Syndrome (ARDS) Acute respiratory distress syndrome (ARDS) can occur in patients receiving human granulocyte colony-stimulating factors. Evaluate patients who develop fever and lung infiltrates or respiratory distress after receiving GRANIX, for ARDS. Discontinue GRANIX in patients with ARDS. 5.3 Allergic Reactions Serious allergic reactions including anaphylaxis can occur in patients receiving human granulocyte colony-stimulating factors. Reactions can occur on initial exposure. The administration of antihistamines‚ steroids‚ bronchodilators‚ and/or epinephrine may reduce the severity of the reactions. Permanently discontinue GRANIX in patients with serious allergic reactions. Do not administer GRANIX to patients with a history of serious allergic reactions to filgrastim or pegfilgrastim. 5.4 Use in Patients with Sickle Cell Disease Severe and sometimes fatal sickle cell crises can occur in patients with sickle cell disease receiving human granulocyte colony-stimulating factors. Consider the potential risks and benefits prior to the administration of human granulocyte colony-stimulating factors in patients with sickle cell disease. Discontinue GRANIX in patients undergoing a sickle cell crisis. 5.5 Potential for Tumor Growth Stimulatory Effects on Malignant Cells The granulocyte colony-stimulating factor (G-CSF) receptor through which GRANIX acts has been found on tumor cell lines. The possibility that GRANIX acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, diseases for which GRANIX is not approved, cannot be excluded. 6 ADVERSE REACTIONS The following potential serious adverse reactions are discussed in greater detail in other sections of the labeling: • Splenic Rupture [see Warnings and Precautions (5.1)] • Acute Respiratory Distress Syndrome [see Warnings and Precautions (5.2)] • Serious Allergic Reactions [see Warnings and Precautions (5.3)] • Use in Patients with Sickle Cell Disease [see Warnings and Precautions (5.4)] • Potential for Tumor Growth Stimulatory Effects on Malignant Cells [see Warnings and Precautions (5.5)] The most common treatment-emergent adverse reaction that occurred at an incidence of at least 1% or greater in patients treated with GRANIX at the recommended dose and was numerically two times more frequent than in the placebo group was bone pain. 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. GRANIX clinical trials safety data are based upon the results of three randomized clinical trials in patients receiving myeloablative chemotherapy for breast cancer (N=348), lung cancer (N=240) and non-Hodgkin’s lymphoma (N=92). In the breast cancer study, 99% of patients were female, the median age was 50 years, and 86% of patients were Caucasian. In the lung cancer study, 80% of patients were male, the median age was 58 years, and 95% of patients were Caucasian. In the non-Hodgkin’s lymphoma study, 52% of patients were male, the median age was 55 years, and 88% of patients were Caucasian. In all three studies a placebo (Cycle 1 of the breast cancer study only) or a non-US-approved filgrastim product were used as controls. Both GRANIX and the non-US-approved filgrastim product were administered at 5 mcg/kg subcutaneously once daily beginning one day after chemotherapy for at least five days and continued to a maximum of 14 days or until an ANC of ≥10,000 x 106/L after nadir was reached.

Bone pain was the most frequent treatment-emergent adverse reaction that occurred in at least 1% or greater in patients treated with GRANIX at the recommended dose and was numerically two times more frequent than in the placebo group. The overall incidence of bone pain in Cycle 1 of treatment was 3.4% (3.4% GRANIX, 1.4% placebo, 7.5% non-US-approved filgrastim product). Leukocytosis In clinical studies, leukocytosis (WBC counts > 100,000 x 106/L) was observed in less than 1% patients with non-myeloid malignancies receiving GRANIX. No complications attributable to leukocytosis were reported in clinical studies. 6.2 Immunogenicity As with all therapeutic proteins, there is a potential for immunogenicity. The incidence of antibody development in patients receiving GRANIX has not been adequately determined. 7 DRUG INTERACTIONS No formal drug interaction studies between GRANIX and other drugs have been performed. Drugs which may potentiate the release of neutrophils‚ such as lithium‚ should be used with caution. Increased hematopoietic activity of the bone marrow in response to growth factor therapy has been associated with transient positive bone imaging changes. This should be considered when interpreting bone-imaging results. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C There are no adequate and well-controlled studies of GRANIX in pregnant women. In an embryofetal developmental study, treatment of pregnant rabbits with tbo-filgrastim resulted in adverse embryofetal findings, including increased spontaneous abortion and fetal malformations at a maternally toxic dose. GRANIX should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In the embryofetal developmental study, pregnant rabbits were administered subcutaneous doses of tbo-filgrastim during the period of organogenesis at 1, 10 and 100 mcg/kg/day. Increased abortions were evident in rabbits treated with tbo-filgrastim at 100 mcg/kg/day. This dose was maternally toxic as demonstrated by reduced body weight. Other embryofetal findings at this dose level consisted of post-implantation loss‚ decrease in mean live litter size and fetal weight, and fetal malformations such as malformed hindlimbs and cleft palate. The dose of 100 mcg/kg/day corresponds to a systemic exposure (AUC0-24) of approximately 50-90 times the exposures observed in patients treated with the clinical tbo-filgrastim dose of 5 mcg/kg/day. 8.3 Nursing Mothers It is not known whether tbo-filgrastim is secreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when GRANIX is administered to a nursing woman. Other recombinant G-CSF products are poorly secreted in breast milk and G-CSF is not orally absorbed by neonates. 8.4 Pediatric Use The safety and effectiveness of GRANIX in pediatric patients have not been established. 8.5 Geriatric Use Among 677 cancer patients enrolled in clinical trials of GRANIX, a total of 111 patients were 65 years of age and older. No overall differences in safety or effectiveness were observed between patients age 65 and older and younger patients. 8.6 Renal Impairment The safety and efficacy of GRANIX have not been studied in patients with moderate or severe renal impairment. No dose adjustment is recommended for patients with mild renal impairment. 8.7 Hepatic Impairment The safety and efficacy of GRANIX have not been studied in patients with hepatic impairment. 10 OVERDOSAGE No case of overdose has been reported. ©2013 Cephalon, Inc., a wholly owned subsidiary of Teva Pharmaceutical Industries Ltd. All rights reserved. GRANIX is a trademark of Teva Pharmaceutical Industries Ltd. Manufactured by: Distributed by: Sicor Biotech UAB Teva Pharmaceuticals USA, Inc. Vilnius, Lithuania North Wales, PA 19454 U.S. License No. 1803 Product of Israel GRX-40189 January 2014 This brief summary is based on TBO-003 GRANIX full Prescribing Information.

NAVIGATOR NOTES

he founding of patient navigation is commonly attributed to Harold P. Freeman, MD, and his concerns of health care disparities, in particular, correlations between poverty, culture, social injustice, and disease outcomes.1 In 1990, Freeman created the first navigation program in Harlem, New York, which consisted of outreach community education and access to free mammography screening for low-income women paired with trained navigators who assisted women in traversing the health care system, eliminating barriers to care, and thereby improving the timeliness of care between abnormal finding, diagnostic resolution, and treatment initiation.2 Throughout the two decades following these pioneering efforts, oncology care continues to be transformed through the widespread adoption and expansion of patient navigation programs along with a continued focus on eliminating health care disparities and improving the patient experience.

Oncology navigators: A crucial part of a cancer patient’s path Karyl Blaseg, RN, MSN, OCN

IMPORTANCE OF PATIENT NAVIGATION

Oncology care has become increasingly complex as preventive care, early detection screening approaches, and oncology treatments continue to evolve. Understanding and navigating cancer care delivery system structures, interfaces, and inner workings can be challenging and problematic for even the most savvy of health care consumers. As such, patient navigators are increasingly recognized as an essential component of comprehensive cancer care serving as the lynchpin for facilitating a coordinated and seamless experience for cancer patients and their families. While specific responsibilities of oncology patient navigators vary based on unique program needs, common fundamentals among navigation roles are found, such as a focus on the identification

and resolution of barriers to care, coordination of efficient evidence-based and patient-centered care, facilitating open communication and smooth transitions between the multidisciplinary team, and the provision of anticipatory guidance, education, and emotional support. Significant contributions are documented throughout the oncology literature to demonstrate the impact navigation programs are making to

improve not only clinical outcomes but also the overall patient experience. Wells and colleagues conducted a review and qualitative synthesis of 16 oncology patient navigation research articles published through October 2007.3 Paskett, Harrop, and Wells provided an update to this synthesis by summarizing new oncology patient navigation findings published November 2007 through July 2010.4 Some general themes among program outcomes include improvements in access to screening, time to diagnostic resolution and treatment initiation, patient and provider satisfaction, avoidable health care costs, and access to community resources. WHAT’S IN A NAME/TITLE? One challenge currently surrounding patient navigation pertains to the various titles, required qualifications, and subsequent role definitions that exist. A few examples of role titles often closely associated with that of a patient navigator include care coordinator, case manager, and patient liaison. While distinct differences are found between navigators and each of these examples, common responsibilities and interventions tend to center around enhancing timely access to care and minimizing health care barriers. Building on the original navigation definition set forth by C-Change, the Oncology Nursing Society (ONS), the Association of Oncology Social Work (AOSW), and the National Association of Social Workers (NASW) collaboratively issued a joint position statement defining navigation as “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience.”5 Continues on page 16

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 15

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NAVIGATOR NOTES GROWTH AND EVOLUTION OF PATIENT NAVIGATION

Cantril and Haylock summarized the historical achievements that have paved the way for the development and advancement of oncology patient navigation.6 While identified milestones date as far back as the 1971 National Cancer Act, the majority of accomplishments have occurred since the signing of the 2005 Patient Navigation and Chronic Disease Act and subsequent allocation of competitive funding to create sustainable navigation models. In addition, numerous professional organizations have recognized and endorsed efforts to advance the field of oncology navigation including C-Change, the Academy of Oncology Nurse and Patient Navigators (AONN+), the Association of Community Cancer Centers (ACCC), ONS, AOSW, NASW, and the American College of Surgeons (ACoS) Commission on Cancer (CoC). In fact, new patient-centered standards from ACoS have been phased in that now require CoC-accredited programs to provide access to patient navigation services as a mechanism to minimize system barriers and improve access to care. This impacts more than

New standards from ACoS require access to patient navigation services. 1,500 cancer programs that provide care to more than 70% of patients with newly diagnosed cancer.7 The navigation standard specifies processes must be defined and established based on a community needs assessment and identified health care disparities. Thereafter, navigation services are evaluated, documented, and reported annually to the organization’s

cancer committee with subsequent program modifications and enhancements to meet additional needs identified.8 LEARNING GAPS FOR PATIENT NAVIGATORS

Navigators are expected to have current knowledge of standard and emerging treatment options as well as available community and supportive resources so they can appropriately guide and offer interventions based on patient-specific needs. For example, as advances are made in the field of personalized medicine, navigators need current information on the use of biomarkers and how these guide treatment decisions so they can educate and support patients in discussions related to treatment options. Furthermore, navigators need to be well-versed in side effect management as they are often the first to be contacted when a patient experiences treatment toxicities. Then, there are survivorship issues navigators can assist in clarifying, such as late- and longterm effects of treatment, surveillance schedules, and appropriate follow-up care. One learning gap frequently expressed by both navigators and program administrators is the desire to establish and measure meaningful program outcomes. Developing such metrics not only documents program successes, but also provides direction for quality improvements and process enhancements contributing to overall program sustainability. These learning gaps demonstrate the importance of targeted education for oncology navigators. Evaluations from the 2014 NCONN Annual Conference indicate navigators prefer attending live conferences as their means for learning. In response to this feedback, Haymarket Media developed the Oncology Nurse Advisor Navigation Summit: Bringing Navigation to the Forefront, which will be held June 26-28, 2015, in Denver, Colorado. Its intent is to provide quality education for oncology patient

navigators. This fast-paced conference will consist of information-packed sessions, along with access to a range of exhibitors. More information on the ONA Navigation Summit can be found at www.OncologyNurseAdvisor.com/ navsummit. ■ Karyl Blaseg is interim director of the Billings Clinic Cancer Center, Billings, Montana. REFERENCES 1. Freeman HP. A model patient navigation program. Oncol Issues. 2004;19(5):44-46. 2. Freeman HP, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117(15 suppl):3539-3542. doi:10.1002/cncr.26262. 3. Wells KJ, Battaglia TA, Dudley DJ, et al; Patient Navigation Research Program. Patient navigation: state of the art or is it science? Cancer. 2008;113(8):1999-2010. doi:10.1002/cncr.23815. 4. Paskett ED, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;61(4):237-249. doi:10.3322/ caac.20111. 5. Oncology Nursing Society; Association of Oncology Social Work; National Association of Social Workers. Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers joint position on the role of oncology nursing and oncology social work in patient navigation. Oncol Nurs Forum. 2010;37(3):251-252. http://ons.metapress. com/content/f2830241m137mg1m/fulltext.pdf. Accessed January 14, 2015. 6. Cantril C, Haylock PJ. Patient navigation in the oncology care setting. Semin Oncol Nurs. 2013;29(2):76-90. doi:10.1016/j.soncn.2013.02.003. 7. About CoC accreditation. American College of Surgeons Web site. https://www.facs.org/ quality-programs/cancer/accredited/about. Accessed January 14, 2015. 8. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. v1.2.1. Chicago, IL: American College of Surgeons; 2012. https:// www.facs.org/~/media/files/quality%20programs/cancer/coc/programstandards2012.ashx. Accessed January 14, 2015.

16 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

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navigation

SUMMIT Register Guidance. Support. Knowledge.

Bringing Navigation to the Forefront June 26-28, 2015 Hyatt Regency Denver Denver, Colorado OncologyNurseAdvisor.com/navsummit

This activity is jointly provided by Global Education Group and Oncology Nurse Advisor. NURSING CREDIT DESIGNATION: Global Education Group is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA. This educational activity for 13.5 contact hours is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity. SOCIAL WORK CONTINUING EDUCATION: National Association of Social Workers This program has been submitted and is pending approval by the National Association of Social Workers for continuing education contact hours. For information about the accreditation of this program, please contact Global at 303-395-1782 or inquire@globaleducationgroup.com.

ONA NavSum_register_ad_F_r1.indd 1

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Oncology Nurse Advisor will host the first annual Navigation Summit from June 26-28, 2015 in Denver, Colorado. The Summit will address the overwhelming need for information specifically geared toward the oncology navigation profession.

BE ONE OF THE FIRST 75 REGISTRANTS and receive a FREE copy of ONS’s newly published Oncology Nurse Navigation book (a $91.00 value). It’s edited by Karyl Blaseg, RN, MSN, OCN, Interim Director at the Billings Clinic Cancer Center and ONA Navigation Summit Advisory Board Member and Speaker.

1/26/15 3:57 PM

FEATURE | Biospecimen collection

Evolving roles for oncology nurses: Biospecimen collection Personalized medicine is changing oncology nursing. This primer explains best practices for collecting and preparing biospecimens used to guide therapy. BRYANT FURLOW

he personalized oncology revolution hinges importantly on determining and monitoring tumor and patient genetics and molecular biomarkers that can guide targeted therapy. The oncology nurse is frequently responsible for collecting, preparing, and often, managing, the biospecimens needed for these analyses. As molecular tests have proliferated, the “complexity, required knowledge, and expectations of the oncology nurse have changed dramatically over the past decade,” says Sharon Kaufman, MS, a research protocol specialist at the Mayo Clinic Cancer Center in Rochester, Minnesota. “Many cancers are caused, at least in part, by several different genetic mutations along several different metabolic pathways,” Kaufman and coauthors noted in a recent review on oncology biospecimen collection and processing.1 These mutations and their gene products can be inhibited by targeted molecular therapies, at least temporarily.1 A goal of personalized oncology is to develop such targeted therapies and deploy them strategically against tumors with specific vulnerabilities. Toward that end, and to develop better risk-stratification tools, myriad prognostic biomarkers derived from blood and tumor tissue exist and are under development.1,2 Educating patients about the purpose of these tests, and collecting and preparing biospecimens with which to perform them, frequently fall within the responsibilities of the oncology nurse. “Oncology nurses used to monitor vital signs and administer chemotherapy,” Kaufman tells

18 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

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FEATURE | Biospecimen collection Oncology Nurse Advisor. “Now, they [also] need to be experts in collecting and processing blood and tissue; dissecting clinical trial protocols to determine the details of collecting and processing; helping guide patients through their treatment options, clinical trial options; and then monitoring vital signs and administering chemotherapy.” Oncology nurses must familiarize themselves with biomarker analyses relevant to their patients, biospecimen collection techniques for biomarker analysis, and not least, institutional policies, standard operating procedures, and laboratory manual guidance.

Tissue sample preparation may need to follow precisely specified procedures for specific biomarker analyses. Increasingly, effective treatment planning and monitoring require detailed insight into the tumor’s molecular biology and genomics. Circulating tumor cells can now be captured and isolated for genetic analysis and determination of a tumor’s suitability for targeted therapies, a process sometimes called liquid biopsy.3 “A few decades ago, a drop of blood was used to determine blood type, biopsies were believed to enhance the likelihood of metastases, and nursing assessment for a person believed to have cancer was limited to palpation and examination of [radiographs],” noted Kaufman and coauthors.1 Those ideas have changed. Today, that drop of blood provides much more information; it essentially opens a window into a person’s genetic makeup and risk profile. Biopsy specimens can be subtyped not just by histology, but tumor genetics and epigenetics for targeted therapy and stored for future research use as well. Nurses are expected to coordinate the correct collection of blood and tissue; mediate the overlapping needs of the clinical and research teams; then navigate patients through a maze of information systems that will help them understand risk, diagnosis, and treatment data at an individualized level.1 BLOOD COLLECTION Collection tubes are typically 10 mL; coagulation tubes, used to collect samples for coagulation determination, are typically 4 mL.1 “There is some good news here,” says Kaufman. “Advances in the tests and assays themselves have allowed smaller and smaller volumes for testing, into the range of

nanograms.” That should translate to smaller and smaller blood volumes in the coming years. Written protocols or lab manuals should be reviewed prior to a blood draw for specific requirements associated with a given test. Given the rapid accumulation of new biomarkers and tests, the updating of lab manuals represents a conundrum, cautions Kaufman. “Typically, the lab manual does not require IRB [Institutional Review Board/Human Subjects Review Committee] review and can be changed relatively easily,” she notes. “That’s fine when administrative details need to be updated. However, if something in the lab manual changes that affects the protocol or budget—volume of blood, ultrasound guidance for a biopsy—then it should be subject to review.” Depending on the intended analysis, the blood collection tubes will contain anticoagulants or preservatives, as indicated by color-coded caps.1 Red tube caps typically indicate no additives, such as those used for identifying antibodies, immune proteins, or lipids; whole-blood coagulation tubes have light blue caps; lavender or royal blue caps contain clot-preventing EDTA for complete blood counts and DNA extraction for genetic mutation analysis; gray-capped tubes contain sodium fluoride to preserve glucose and allow electrolyte analysis; and green-capped tubes contain heparin to prevent clotting for rapid blood chemistry labs.1 Yellow/ purple (bicolored tiger-striped) tube caps usually represent collection tubes for circulating tumor cell (liquid biopsy) analyses of cancer genomes and genetic mutations.1 Close attention to collected volumes is necessary, particularly as a collection tube’s expiration date approaches and tube vacuums grow weaker, resulting in incomplete filling.1 Blood collection supplies should be organized and reviewed before placing the tourniquet, Kaufman and coauthors emphasize.1 “(T)he longer the tourniquet is in place, the higher the risk of hemoconcentration of nonfilterable elements such as proteins in the blood,” they explain.1 “If the blood must be drawn from the same arm as an intravenous access site, then the tourniquet must be placed several inches above the site and only tight enough to restrict superficial venous flow. Tourniquets should not be left in place longer than 2 minutes before being loosened.” Once filled, blood collection tubes are completely inverted gently and repeatedly, typically five to 10 times. One inversion involves turning the tube completely upside-down (180˚) and back to cap-end-up1 (Table 1). If the protocol calls for clot formation within the tube, the tube is left at room temperature for a minimum of 30 minutes.1 Processing collected blood samples may also include centrifuge spinning at specific speeds and durations to precisely

20 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

fractionate the sample into readily visible layers, with red blood cells at the bottom, above which will be found white blood cells and plasma on the top, respectively.1 Carefully following written protocols’ specific guidance on centrifuge timing and speed is crucially important to avoid degrading the blood sample, as incorrect timing can leave blood components inadequately separated or damage blood cells.1 After a sample is centrifuged, the layers are collected with a pipette into separate tubes for subsequent analysis. Naturally, each sample must be carefully documented.

TABLE 1. Tube handling for blood collections1 Tube/syringe order of draw

Number of inversions

Plain syringe

None

Royal blue (plain metal)

Special coag (screw cap)

3-4

Blue

3-4

Black

3-4

CAI (SST)

TISSUE COLLECTION

Gold (calcium & other SST)

Tissue biopsy processing for analysis is evolving, with a trend away from the once-common formalin-fixed paraffin embedded (FFPE) preservation of biopsy tissue for future analysis to flash-freezing freshly harvested samples in liquid nitrogen and storage at –80˚C. Biopsy tissue samples should not exceed 0.5-cm dimensions, and regardless of whether preservatives are used, both preservation and freezing must occur rapidly.1 “Paraffin-embedded tissue seems to be of lesser quality, particularly where extraction of DNA and/or RNA is concerned, requiring a level of skill on the part of the lab personnel that is rare,” Kaufman explains. Fine-needle collection of tumor tissue and cells is also common.1 The timing of postcollection processing for preservation is key, and all equipment must be ready before collection begins.1 When collecting samples from resected surgical specimens, the time from when blood flow to the tissue is clamped off to the time of flash freezing or immersion in formalin should be minimal.1 Frequently, particularly when a patient is participating in a clinical trial, tissue sample preparation may need to follow precisely specified procedures for specific biomarker analyses. “I don’t believe that any of the collection and processing techniques are particularly difficult,” Kaufman says. “The challenge is doing it all within the protocol-specified time frames, which are all different. It’s more and more common that these details are so specific that they cannot be written into the protocol. A lab manual is then required.” For example, collecting tissue during a colonoscopy or bronchoscopy is a matter of being in the room, explaining to the clinician performing the procedure as to what to collect and from where, then accepting the tissue sample provided. “If there are eight pieces of tissues, they’ll likely come in rapid-fire succession,” Kaufman explains. “Some will have to be put into cryo-vials and immediately placed into liquid nitrogen. Some will be put into a container with formalin. For the latter, the protocol will specify how long the tissue

Red

RST

Green

8-10

Mint green

8-10

Royal blue (EDTA metal)

8-10

Purple

8-10

Pink

8-10

Black/tan tiger (sequenom)

8-10

Cellsave (purple/yellow)

8-10

Gray

8-10

Yellow

8-10

Pyruvate (screw cap)

Shake vigorously 10 times

QTB tubes (3)

Immediately after filling tubes, shake 10 times just firmly enough to coat tubes

PAXgene (RNA)

Lithium heparin syringe

Mix the sample horizontally for 30 seconds and then invert several times

KEY: CAI, free ionized calcium; EDTA, ethylene diamine tetra acetate; RNA, ribonucleic acid; SST, serum separation tubes.

has to be in formalin before it’s embedded in paraffin.” If paraffin blocks cannot be used, then slides are made from the paraffin block. “The nurse will have to navigate the institutional policies, arrange for paraffin embedding, and arrange for cutting slides, usually in a histology lab.” All cancer clinics should have written standard operating practices (SOPs) for these procedures. Even in clinics that do not participate in clinical trials, blood and tissue samples need to be collected for assays and gene sequencing that will likely guide the course of treatment for many patients with cancer, explained Kaufman. Continues on page 22

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 21

FEATURE | Biospecimen collection THE FUTURE With the increasing emphasis on biomarkers in treatment planning and monitoring and as biospecimen collection become more voluminous, many cancer centers may consider employing biospecimen resource managers. To date, many institutions tend to expect their oncology nurses to take on that role or have assigned others to become specialists/managers for biospecimen collecting.

Many institutions tend to expect its oncology nurses to take on the role of manager for biospecimen collection. “However, there’s more involved than just assigning a person to manage the biospecimens,” Kaufman cautions. Quite a bit of infrastructure is also required, including laboratory facilities, freezers, storage—and policy for accessing clinical archives for research, the approvals required, and biospecimens and biosafety review committees. Understanding cancer at the molecular-genetic level will lead to detailed diagnoses and precise treatment planning, Kaufman and coauthors predict.1 “Among the emerging responsibilities of the oncology nurse is helping patients to take control of their disease and treatment. Once again, the oncology nurse will need to be a navigator,” Kaufman

explains—a role that is itself undergoing a transformation in the era of personalized oncology care. “The role of navigator has changed from helping the patient navigate the possibilities for cancer treatment, to helping the patient navigate ethics, genetics, prevention options, family history, and costs.” One often-neglected facet of personalized oncology is the availability to individual patients of independent wholegenome sequencing with a single blood draw, at a cost of approximately $1,000. “This provides the patient with a huge amount of information but very little context and no truly reliable interpretation,” Kaufman warns. One of the emerging roles of the oncology nurse will be to help patients evaluate their probable risks based on genetic, lifestyle, and other factors. “The science is changing very quickly,” Kaufman notes. “Oncology nurses have always had to participate in continuing education. It now more critical than ever.” ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Neumann RM, Garvey C, Kaufman S. Biospecimen collection, processing, and analysis: new challenges for oncology nurses. Semin Oncol Nurs. 2014;30(2):117-123. doi:10.1016/j.soncn.2014.03.005 2. Richmond ES, Dunn D. Biomarkers: an overview for oncology nurses. Semin Oncol Nurs. 2012;28(2):87-92. doi:10.1016/j.soncn.2012.03.002 3. Furlow B. Circulating tumor cells: the coming era of ‘liquid biopsies.’ Cancer Therapy Advisor. http://www.cancertherapyadvisor.com/ circulating-tumor-cells-the-coming-era-of-liquid-biopsies/article/355315/. Published June 11, 2014. Accessed December 5, 2014.

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FEATURE | Mental health challenge

Quantifying mental disorders in patients with cancer Researchers in Germany interviewed more than 2,000 patients with cancer to gather epidemiologic data on mental health of patients with cancer. KATHY BOLTZ, PhD

igh levels of psychological distress are known to exist among patients with cancer. In this study, German researchers sought to provide realistic estimates of psychosocial distress in patients with cancer by providing reliable epidemiologic data.1 It is the largest to date that uses a fully standardized, diagnostic face-to-face interview to assess the mental and emotional health of patients with cancer. More than 2,100 patients were interviewed at inpatient and outpatient care centers to determine how many patients with cancer experienced a clinically meaningful level of mental or emotional distress that meets strict diagnostic criteria. The mental disorders investigated included anxiety, depressive disorders, and adjustment disorders during the previous 4 weeks. One or more mental disorders were diagnosed in 32% of the cancer patients.1 Anxiety disorders (11.5%) and mood disorders (6.5%) were the most prevalent. The highest 4-week prevalence occurred in patients with breast cancer (42%).1 The prevalence of these disorders varied by cancer type. Prevalence was higher among patients with breast cancer (42%), head and neck cancer (41%), and malignant melanoma (39%).1 It was lowest in patients with prostate cancer (22%), stomach cancers (21%), and pancreatic cancer (20%).1 At least one clinically meaningful mental health issue was experienced by 32% of

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FEATURE | Mental health challenge patients, whereas prevalence of mental health issues in the general population is 18% to 20%.1 A mood disorder, such as major depression, occurred in 6.5% of the patients interviewed. An anxiety disorder was experienced by 11.5% of patients during the 4-week period prior to the interview. This is slightly higher than the 9% seen in the general population.1 An adjustment disorder was diagnosed in 11% of the patients, meaning a predominantly mixed anxiety-depressive syndrome that persisted for at least 4 weeks in response to a significant life event, such as a cancer diagnosis.1 Adjustment disorders are seldom assessed in the general population, and this rate is likely to have significantly contributed to the prevalence rate of mental disorders in this population of patients with cancer. These fi ndings can likely be generalized to the United States, explained lead author Anja Mehnert, PhD, a professor of psychosocial oncology at the University of Leipzig in Germany.1 She stated that the prevalence of mental health diagnoses is similar between the two countries. EMPOWERING ONCOLOGY NURSES TO AID PATIENTS

“Nurses are uniquely positioned to assist in the screening for mental disorders (eg, anxiety, depression) and overall distress. They get to know our patients well, and sometimes even better than the treating oncologist. They are essential partners in the care of patients with cancer, throughout the cancer journey,” said Don S. Dizon, MD, an expert from the American Society for Clinical Oncology in an interview with Oncology Nurse Advisor. Dizon explained that this study used a standardized questionnaire to determine the incidence of mental disorders. He stated that routine clinical practice could adopt such questionnaires, including the Beck Depression Inventory, the Hospitalized Anxiety and Depression Scale, or even the National Comprehensive Cancer Network (NCCN) Distress Thermometer. “In addition, all clinicians can watch for signs of distress in our patients, whether it be obvious (excessive sadness, frequent bouts of crying, seeming anxious at visits) or subtle (withdrawn, fighting with loved ones, changes in

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outlook or persona). And never forget that there is much to be learned about our patients, solely with observation,” he added. Study findings showed patients with breast cancer had a higher prevalence of mood disorders than patients whose conditions had less optimistic prognoses, including pancreatic,

Nurses need to acknowledge their patients’ emotions, and let patients know that their distress is not only real but common. esophageal, and stomach cancers. “This issue alone warrants further evaluation to better understand why this difference was found,” Dizon said. Dizon also urged further research to understand how a patient’s mood and psychological health changes throughout the cancer journey. “Further understanding of times when patients may be at more distress than others would be useful,” he said. Nurses need to acknowledge their patients’ emotions. Dizon stated that nurses can let patients know that their distress is not only real but common, as this study indicated. When an oncology nurse feels that a patient needs help through psycho-oncologic interventions, Dizon said, “Getting these patients the help they need requires multidisciplinary collaboration, which might include social work or even specialty psychologic or psychiatric referrals. Nurses should feel empowered to bring these issues up with the treating team, all done to ensure our patients get referred to the services they may need.” ■ Kathy Boltz is a medical writer based in Phoenix, Arizona. REFERENCES 1. Mehnert A, Brähler E, Faller H, et al. Four-week prevalence of mental disorders in patients with cancer across major tumor entities. J Clin Oncol. 2014;32(31):3540-3546. doi:10.1200/JCO.2014.56.0086.

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FEATURE | Rationalizing program costs

Navigation and survivorship: Rationalizing program costs The cost of nonbillable nursing hours needed for these programs may hinder compliance. The right technology can link treatment silos and lower this cost. MIKE DARUD

ost cancer care providers are familiar with the report From Cancer Patient to Cancer Survivor: Lost in Transition, released in 2005 by the Institute of Medicine (IOM). Almost a decade old now, the report detailed shortfalls in the cancer care system undermining the transition of patients from treatment to survivorship. Recommendations from the report include practical items such as providing a survivorship care plan to each patient as well as addressing system-wide issues such as coordination of care across diverse communities and improved access to care.1 In September 2013, the IOM delivered a new report, which concluded that the cancer care delivery system was in a crisis. 2 The report, Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis, described a system that was not patientcentered, accessible, evidence-based, or well-coordinated.2 Interesting to note is that, in the 8 years between the reports, the number of cancer survivors cited increased by 4 million people, with the 2013 report quoting 14 million survivors. So a cancer system that has not seemed to improve in 8 years is increasingly burdened with a growing population of survivors. The health care system has undergone many changes in the last few years as politicians and decision makers try to make the system less expensive, more efficient, and able to address some of the identified needs for quality care. The

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 25

FEATURE | Rationalizing program costs Patient Protection and Affordable Care Act is the most prominent of these measures. The impact of these changes, which mainly focus on technology and reimbursement, have met with mixed results so far, as the well-publicized political battles rage on. NEW ROLES FOR NURSES Patient-centric care is designed to meet the needs of the patient and their family by supporting their active involvement in treatment decision-making. The introduction of nurse navigators to the mainstream of health care has impacted both the patient experience as well as care coordination.3 The role of the nurse navigator fits nicely into

Survivorship nurses have skills to deal with survivor issues but need support at the hospital level to provide this service. the IOM model for delivering quality care by providing a well-trained professional whose main focus is to guide the patient through the complexity of diagnosis and treatment. The navigator becomes the support person for the patient both emotionally and clinically. The navigator can operate outside of the usual treatment silos in cancer care, overlapping the areas of diagnosis, treatment (surgery, chemotherapy, and radiation therapy), and perhaps even survivorship. An effective navigator should be able to help eliminate problems associated with poor care coordination, duplication of care, and accessibility. But a navigation program has to be supported at the hospital level, as it is unlikely to be owned by one of the traditional treatment silos. From this perspective, the value of a navigator has to be seen in the coordinating role they play, as navigation is not a billable service that can be seen to pay for itself in traditional fee-for-service models. Survivorship programs suffer from this same ownership issue. Patients receive treatments from each of the treatment specialties, but none specifically take ownership for the patients when they leave the treatment phase. The primary care physician is expected to fill this role, but often they do not have the knowledge to deal with treatment-related side effects. Survivorship nurses have skills to deal with survivor issues but need support at the hospital level to provide this valuable service.

CHANGING THE REIMBURSEMENT MODEL In the 2013 IOM report, alternate care models such as accountable care organizations (ACOs), oncology-centered medical homes, and bundled payments, which reimburse for medical care based on quality measures rather than fee-for-service, are recommended.2 These models can be considered supportive of the roles of navigators and survivorship nurses as they shift the payment system from fees for medical procedures to fees for overall patient outcomes and quality care. The supportive roles of navigators and survivorship nurses mesh with these care models, as many of the services they provide are not billable procedures but add to the quality of care the patient receives. The Centers for Medicare and Medicaid Services (CMS) is supporting this change in reimbursement by providing options for those providers willing to switch their approach to care for Medicare patients.4 Although some providers worked with CMS’ Pioneer program to trial the ACO model, not all of them continued with the program. Of the 32 Pioneer ACO participants, nine left the program after the first year. On average, the Pioneers were able to slow cost increases, but only 13 participants were able to lower costs sufficiently to generate savings to CMS for which they would then be eligible to share. Two Pioneers actually spent more money than expected and were required to reimburse CMS approximately $4 million. Views on the success of the Pioneer program are mixed and often politically charged.5-9 Regardless of the perceived success or failure of ACOs, getting every provider to switch to one of these new models of reimbursement is not likely to happen. Whether it be simple inertia or fear of losing money—as some Pioneer ACOs did—some care providers will not change. TECHNOLOGY: A SOLUTION, A BAND-AID, OR A PROBLEM?

Technology is often touted as the solution to any given problem. Health care is no different with the push by CMS for adoption of electronic health record (EHR) technology through the Meaningful Use programs.10 CMS lists the benefits of the Meaningful Use programs as improving quality, engaging patients, and improving care coordination.11 The barriers of cost and operational integration as well as skepticism about the clinical value have been cited as reasons for the slow adoption of EHR technology.12 However, EHR implementation is occurring at double the rate of 2009 through the CMS’ Meaningful Use programs.13 As this adoption process is still in its early stages, several technology issues still confound the goals of the 2013 IOM report. Interoperability and exchange of information between EHR systems are significant

26 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

SURVIVORSHIP CARE BUNDLED INTO ONE EFFICIENT WORKFLOW Karen is a survivorship nurse. The facility where she works provides her with a dedicated software tool, Equicare CS, to help her prepare patients for life after cancer treatment. The tool allows Karen to manage her patient cases as well as meet each patient’s individualized needs. Using Equicare CS, Karen is able to • • • • • •

Check a schedule of patients that she is actively managing in her Survivorship program Provide an automatically generated comprehensive treatment summary for each patient Assign a nationally recognized schedule of follow-up tasks appropriate for that patient Provide education materials on the short- and long-term side effects of cancer treatment Assign quality of life questionnaires that will evaluate patient condition now and in the future Set up automatic reminders for the patient for all appointments and follow-up tasks.

As all these tasks can be performed with one comprehensive technology tool, Karen can do this in minutes, rather than hours.

issues. This is a particular challenge during transitions of care where the patient moves from one provider or institution to another.13 Information has to be transferred between providers, and solutions for this are rudimentary. The survivorship care plan remains an important part of delivering patient-centered care. The provision of a care plan for a patient who has finished cancer treatment demonstrates the challenges that still encumber providing patient-centered care. The survivorship care plan generally contains the summary of any treatment the patient has received as well as other important information such as • Diagnosis and staging, as well as biomarkers and specific tissue information; • Recommended follow-up activities and surveillance; • Education on short-term and long-term side effects, as well as symptoms of recurrence; and • A plan for addressing a patient’s psychosocial needs. However, getting all this information into one package to deliver to the patient remains a significant challenge for oncology nurses. The American College of Surgeons Commission on Cancer (CoC) surveyed 1,390 of its member programs in the summer of 2013. Only 40% of the CoC programs felt that they were able to meet Continuum of Care Service Standard 3.3, which requires the institution to deliver a care summary and follow-up plan for each patient. Of the three Continuum of Care standards, the other two being patient navigation process and psychosocial distress screening, this standard was indicated as the hardest to meet due to the time required to prepare a meaningful summary and lack of reimbursement for the task.14 The time-consuming nature of creating the care plan is surprising given that most of this information exists

within the array of electronic medical records that health care providers use. The trick, obviously, is in the ability to link multiple systems and pull the pertinent information into one package in a format that is useful to the patient. An oncology nurse may be doing most of this task today, accessing multiple EHRs, reading and summarizing information from unstructured text fields, and arranging it in a Word document for the patient. Doing a good job of this is time consuming, inefficient, and nonbillable. Technical challenges in information exchange may improve through the Meaningful Use programs. However, implementing interface solutions between the silos of information residing in hospital EHRs may entail some cost, which cost-conscious hospitals may not be willing to pay. Technology may eventually reduce the time needed to create a survivorship care plan, but the task is still just one of many oncology nurses complete to fully support a survivorship patient. Dedicated IT tools are needed to help the oncology nurse work efficiently. CURRENTLY AVAILABLE SOLUTIONS

Improvements in the areas of navigation and survivorship, with the assistance of technology, may achieve the goals of the IOM without creating a political minefield. An argument can be made that even in today’s health care environment, there is sufficient business incentive to justify the cost of navigation and survivorship programs. By applying current CPT codes to survivorship followup guidelines from the National Comprehensive Cancer Network (NCCN), a business case can be made that actively managing patients, using dedicated care coordination software, can be a profitable addition to a health care

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FEATURE | Rationalizing program costs network. Efficiencies gained through better coordination of care across a multidisciplinary continuum within a hospital network would enhance the diagnostic and treatment capacity of the facility. The cost of operating the survivorship program for a typical mix of patients (30% breast, 15% lung, 20% prostate, and the remainder a mix of other diseases) in a facility seeing 1,500 patients per year with modest referral growth (2%) can be recovered with this type of efficiency. The basis for this business case comes from several avenues: patient retention, operational efficiency, and efficient resource allocation. Patient retention Active navigation and survivorship programs engage patients and provide for a seamless transition into the services offered by the hospital. From a strictly business aspect, navigators will be referring patients to services within their own hospital network. Meaningful encounters with the patient could also encourage the patient to stay within the hospital network, as the experience with the navigator can build brand loyalty for hospital services. In addition, barriers to care, such as financial and psychosocial needs that may inf luence patient attendance at medical appointments, can be addressed by these programs. Operational efficiency Just like physicians with paper charts, navigator and survivorship tools of the past have included paper calendars and Excel spreadsheets. True productivity gains can be made using electronic tools to manage patient schedules, coordinate tasks, and gather patient health information. In addition, evaluation of activity using data captured within an electronic system can lead to incremental improvement of operations. Efficient resource allocation With dedicated navigation and survivorship programs, nurses and nurse practitioners can carry out the bulk of routine patient interactions, involving the physician as needed. Physicians are able to focus on tasks such as new patient consults and planning treatment delivery. The use of these physician extenders can help maintain a high level of care as the predicted shortage of oncologists becomes evident in the coming years.15 While able to make the case for navigation and survivorship on the business side, the corollary, happily, is improved patient care. Engaging the patient with a navigator program has the benefit of providing guidance at a challenging time for most patients. The period of diagnosis and transition to treatment can be a distressing time. Having a nurse navigator to assist the patient through these transitions is recognized by the American College of Surgeons in their accreditation standards and has been shown to increase patient satisfaction with care.3,16,17

Survivorship programs also provide emotional support to patients. Many patients experience difficulty as they leave the treatment care team they have had for many months. The survivorship nurse is able to provide some context to the follow-up tasks needed as well as be a connection to the oncology team during the transition period to life after cancer. TECHNOLOGY AS A CHANGE AGENT Nurse navigators and survivorship nurses have valuable roles in care coordination. Like any care provider, they need tools that allow them to effectively manage their patients. Traditional EHRs often do not support the workflow and documentation needs of specialty support roles such as nurse navigators and survivorship nurses. These providers coordinate and document their daily activities in generic systems that may not be efficient or support their activities. Manual solutions are not an option. No doubt, robust technology is needed. Coordinating care for patients in a growing survivorship program will require tools that track follow-up care tasks, help clinicians manage their time, and engage patients in their own care. Technology companies are doing their best to create tools to help care providers. Information exchange standards such as Health Level 7 (HL7) and interconnectivity between EHR systems should become more commonplace and widely available. Stage 2 of Meaningful Use pushes organizations to exchange information between systems and use the information that has been exchanged. While the focus here has been on navigation and survivorship in cancer care, the business case easily models out for managing other chronic conditions within a hospital

[Navigators and survivorship nurses] can generate sufficient activity within the hospital network to offset expenses. network. Cardiac care, hypertension, and diabetes are all examples of chronic diseases that could be served by navigation and coordinated follow-up, or survivorship. Electronic tools that coordinate care and summarize treatment information from various treatment silos can be used to manage follow-up tasks necessary for patients with more than one chronic disease. CMS seems to partially recognize

28 ONCOLOGY NURSE ADVISOR â&#x20AC;˘ JANUARY/FEBRUARY 2015 â&#x20AC;˘ www.OncologyNurseAdvisor.com

the value in this as they have begun providing reimbursement for providers who manage the care for patients with two or more chronic conditions.

7. Capeless M. Evaluating the first-year development of Pioneer ACO Model. EHR Intelligence Web site. http://ehrintelligence. com/2013/08/08/evaluating-the-first-year-development-of-pioneeraco-model/. Date August 8, 2013. Accessed January 21, 2015.

CONCLUSION The IOM has provided insight into the difficulties in providing efficient and coordinated care in cancer treatment delivery. Although CMS has tinkered with the reimbursement model in an attempt to promote change, their actions may not be sufficient to initiate widespread acceptance. A different approach may be to see the value in coordinated care within the existing structure of the health care environment. Nurse navigators and survivorship nurses, using electronic tools, can manage the care of patients outside of the traditional treatment silos. From a business perspective, these care providers can generate sufficient activity within the hospital network to offset expenses, and ultimately generate revenue. Electronic tools that exchange information and make coordinating care more efficient are necessary to support these care providers in delivering meaningful services to the ever-increasing number of cancer survivors. ■

8. Bunis D. Pioneer Accountable Care Organization first-year results include savings and losses. The Commonwealth Fund. http://www. commonwealthfund.org/publications/newsletters/washington-healthpolicy-in-review/2013/jul/july-22-2013/pioneer-aco-first-year-results. Date July 16, 2013. Accessed January 21, 2015. 9. Goldsmith J. Pioneer ACO’s disappointing first year. The Health Care Blog Web site. http://thehealthcareblog.com/blog/2013/08/16/pioneeracos-disappointing-first-year/. Published August 16, 2013. Accessed January 21, 2015. 10. An introduction to the Medicaid EHR Incentive Program for eligible professionals. Washington, DC: Center for Medicare and Medicaid Services; 2014. https://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/Downloads/EHR_Medicaid_Guide_ Remediated_2012.pdf. Accessed January 21, 2015. 11. Meaningful Use definition and objectives. HealthIT.gov Web site. http://www.healthit.gov/providers-professionals/meaningful-usedefinition-objectives. Accessed January 21, 2015. 12. Greenspun H, Coughlin S, Stanley EL. Physician Adoption of Health Information Technology: Implications for medical practice leaders

Mike Darud is senior clinical analyst for Equicare Health, an industry leader in providing care coordination software for survivorship and navigation, based in Vancouver, British Columbia, Canada.

and business partners. Washington, DC: Deloitte Center for Health Solutions; 2013. http://www2.deloitte.com/content/dam/Deloitte/ us/Documents/life-sciences-health-care/us-lshc-physicianadoption-10012014.pdf. Accessed January 21, 2015.

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13. The Office of the National Coordinator for Health Information

1. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer

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Survivor: Lost in Transition. Washington, DC: The National Academies

Update on the Adoption of Health Information Technology and

Press; 2006.

Related Efforts to Facilitate the Electronic Use and Exchange of

2. Levit LA, Balogh EP, Nass SJ, Ganz PA, eds. Delivering High-Quality Cancer

Health Information: A Report to Congress. Washington, DC: Office

Care: Charting a New Course for a System in Crisis. Washington, DC: The

of the National Coordinator for Health Information Technology

National Academies Press; 2013.

(ONC); June 2013. http://www.healthit.gov/sites/default/files/

3. Wagner EH, Ludman EJ, Aiello Bowles EJ, et al. Nurse navigators in early cancer care: a randomized, controlled trial. J Clin Oncol. 2014;32(1):12-18. 4. The Affordable Care Act: Helping providers help patients. A menu of

rtc_adoption_of_healthit_and_relatedefforts.pdf. Accessed January 21, 2015. 14. Rosenthal ET. Deadline for survivorship care plan compliance being

options for improving care. http://www.cms.gov/Medicare/Medicare-

rethought. Oncology Times. 2014;36(13):1,14-16. http://journals.lww.com/

Fee-for-Service-Payment/ACO/Downloads/ACO-Menu-Of-Options.pdf.

oncology-times/Fulltext/2014/07100/Deadline_for_Survivorship_Care_

Accessed January 21, 2015.

Plan_Compliance.4.aspx. Accessed January 21, 2015.

5. Patel K, Lieberman S. Taking stock of initial year one results for Pioneer ACOs. HealthAffairs Blog Web site. http://healthaffairs.org/

15. Yang W, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an

blog/2013/07/25/taking-stock-of-initial-year-one-results-for-

aging, better-insured population will result in shortage. J Onc Prac.

pioneer-acos/. Published July 25, 2013. Accessed January 21, 2015.

2014;10(1):39-45.

6. Press release: Pioneer Accountable Care Organizations succeed in improving care, lowering costs [press release]. CMS.gov Web site. http://www.cms.gov/Newsroom/MediaReleaseDatabase/PressReleases/2013-Press-Releases-Items/2013-07-16.html. July 16, 2013. Accessed January 21, 2015.

16. American College of Surgeons. Cancer Program Standards 2012 Version 1.2.1: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2014. 17. Lee T, Ko I, Lee I, et al. Effects of nurse navigators on health outcomes of cancer patients. Cancer Nurs. 2011;34(5):376-384.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 29

FEATURE | Survivorship support

Mobile support helps younger breast cancer survivors A new digital program using a Web site and social media aims to meet the unique support needs of women younger than 40 years with breast cancer. BETTE WEINSTEIN KAPLAN

urviving cancer is difficult at any age, but a diagnosis of breast cancer brings unique concerns for a young woman. She might be a student intent on finishing her college education, or a recent graduate embarking on a new career, or perhaps she is a new mother raising active young children. One young woman with breast cancer might even fit into all three categories. In addition to the fact that the disease and its treatment can be painful, difficult, and time consuming, the breast cancer that targets younger people is often an aggressive disease. How do these young women cope? Dealing with breast cancer will soon be easier for the young survivor with this disease thanks to the Centers for Disease Control and Prevention (CDC), which recently authorized funding of $2.2 million for the creation of the Gulf States Young Breast Cancer Survivors Network. The Gulf States Young Breast Cancer Survivors Network, a new coalition composed of health facilities in Alabama, Louisiana, and Mississippi, will provide the support these patients need. Its partners include the University of Alabama at Birmingham School of Nursing, the Louisiana Cancer Prevention and Control Programs at the Louisiana State University (LSU) Health New Orleans School of Public Health, and the University of Mississippi Medical Center. A fourth center, the Mary Bird Perkins Cancer Center of Louisiana, which developed the

30 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

successful SurviveDat program 3 years ago, will be part of the coalition as well.1 A MULTIMEDIA PROGRAM Working together, the three medical centers will create a web site and social media presence designed to provide online support and resources to young breast cancer survivors. The Mary Bird Perkins Cancer Center will provide expertise and technical support for this multistate and multimedia initiative. Donna Williams, DrPH, who is the director of LSU Health New Orleans School of Public Health’s Cancer Prevention and Control Programs, will lead the coalition. Williams explains that the goal of this program is to enable the young breast cancer survivor to identify what she needs to improve her quality of life, whether it is medical care or supportive services. After the young survivor has identified what will help her progress, the next step is to be her own best advocate. To that end, the coalition will teach these women how to use social media. “Messages on social media will address family history and genetic risks, psychosocial health and support, reproductive health and fertility, family support, health monitoring, and evidence-based preventive lifestyle behaviors such as maintaining a healthy weight, reducing tobacco use, and excessive alcohol use,” explained Williams.1 A large number of young women with breast cancer live in the three states served by the coalition facilities. Among states with breast cancer deaths for women younger than 50 years, Mississippi ranks second, Alabama is fourth, and Louisiana ranks fifth.1 Furthermore, although the incidence of breast cancer among black women is lower overall than among white women, it is higher in black women younger than 45 years. Black women comprised 40% of the cases of breast cancer diagnosed in young women in Louisiana, Mississippi, and Alabama from 2007 to 2011.1 This population will derive great benefit from the program. Although they live in parts of the participating states that are rural and have a low-income demographic that discourages traveling to in-person support groups, the women who live in those areas will be able to take advantage

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of these resources when they are made available online. This is because a large number of them have smartphones. According to the Pew Research Center, almost 60% of black women have smartphones, a number that is significantly higher than the number of white women who do. Pew notes that smartphone use among all young women is high.1-3 The new project’s web site and social media will list a variety of national, state, and local resources for young breast cancer survivors. These will range from educational and

The goal of the program is to help the young breast cancer survivor identify what she needs to improve her quality of life. technical information on breast cancer to more mundane yet practical advice on matters such as what are the best local sources for wigs, or who offers lessons on the technique of applying makeup to compensate for the effects of chemotherapy. There will also be videos and plenty of opportunities for these survivors to share their stories and offer personalized advice. Family members, caregivers, and even providers will have their own resources in the Network as well. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. SurviveDat. http://www.survivedat.org. Accessed December 16, 2014. 2. Cell phone and smartphone ownership demographics. Pew Research Internet Project Web site. http://www.pewinternet.org/data-trend/ mobile/cell-phone-and-smartphone-ownership-demographics/. Accessed December 16, 2014. 3. The Mobile Consumer: A global snapshot February 2013. Slideshare Web site. http://www.slideshare.net/duckofdoom/mobile-consumer report2013-17748641?related=1. Accessed December 16, 2014.

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Drug type

• Oral fixed combination of palonosetron and netupitant ——Palonosetron prevents nausea and vomiting during acute phase ——Netupitant prevents nausea and vomiting during both acute and delayed phase after cancer chemotherapy Indications

• Prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of cancer chemotherapy, including, but not limited to, highly emetogenic chemotherapy Mechanisms of action

• Netupitant is a substance P/neurokinin 1 (NK1) receptor antagonist and palonosetron is a serotonin-3 (5-HT3) receptor antagonist • Cancer chemotherapy produces nausea and vomiting by stimulating the release of serotonin, which then activates 5-HT3 receptors located on vagal afferents to initiate the vomiting reflex • The development of acute emesis is known to depend on serotonin, and its 5-HT3 receptors have been demonstrated to selectively stimulate the emetic response • Delayed emesis has been largely associated with the activation of NK1 receptors by substance P Dosage and administration

• Fixed dosage: netupitant 300 mg/palonosetron 0.5 mg capsule

• Administration with highly emetogenic chemotherapy, including cisplatin-based chemotherapy ——One capsule approximately 1 hour prior to start of chemotherapy with dexamethasone 12 mg given 30 minutes prior to chemotherapy on day 1 and 8 mg orally once daily on days 2-4 • Administration with anthracyclines and cyclophosphamide-based chemotherapy and chemotherapy not considered highly emetogenic ——One capsule approximately 1 hour prior to start of chemotherapy with dexamethasone 12 mg given 30 minutes prior to chemotherapy on day 1 • Take with or without food Specific populations

• Pregnancy ——Pregnancy Category C ——Not recommended unless potential benefit justifies potential risk to fetus • Nursing mothers ——Not established ——Decision should be made whether to discontinue nursing or to discontinue the drug • Pediatric ——Not established • Geriatric ——Use caution when dosing elderly patients as they have greater frequency of decreased hepatic, renal, or cardiac function and concomitant disease or other drug therapy Continues on page 34

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STAT CONSULT • Renal impairment — Avoid use in patients with severe renal impairment or ESRD • Hepatic impairment — Avoid use in patients with severe hepatic impairment Warnings/Precautions

• Hypersensitivity — Hypersensitivity reactions, including anaphylaxis, have been reported with or without known hypersensitivity to other 5-HT3 receptor antagonists • Serotonin syndrome — Monitor patients for mental status changes, autonomic instability, neuromuscular symptoms, seizures, with or without gastrointestinal symptoms — Monitor for emergence of serotonin syndrome, particularly when used concomitantly with other serotonergic drugs — If symptoms occur, discontinue Akynzeo and initiate supportive treatment Adverse effects

• Most common adverse reactions (≥3% of patients) — Asthenia — Constipation — Dyspepsia — Erythema — Fatigue — Headache Drug interactions

• Coadministration with CYP3A4 substrates — Combination may increase levels of CYP3A4 substrates (eg, dexamethasone, benzodiazepines, chemotherapeutic agents, oral contraceptives) • Coadministration with CYP3A4 inducers — Strong CYP3A4 inducer can decrease efficacy by substantially reducing plasma concentrations of netupitant component — Avoid concomitant use in patients who chronically use a strong CYP3A4 inducer (eg, rifampin) — Coadministration with CYP3A4 inhibitors

FIND US ON

— Concomitant use with a strong CYP3A4 inhibitor (eg, ketoconazole) can significantly increase systemic exposure to netupitant component — No dosage adjustment necessary for single-dose administration of Akynzeo • Coadministration with serotonergic drugs — Serotonin syndrome has been described following concomitant use with 5-HT3 receptor antagonists and other serotonergic drugs (eg, serotonin norepinephrine reuptake inhibitors [SNRIs], selective serotonin reuptake inhibitors [SSRIs], dextromethorphan, fentanyl, linezolid, tramadol) What to tell your patient

• You should tell your nurse or doctor if you have had an allergic reaction to palonosetron or any medication for nausea and vomiting. • You should tell your nurse or doctor if you have liver problems. • You should tell your nurse or doctor if you are pregnant or plan to become pregnant. • You should tell your nurse or doctor if you are breastfeeding or plan to breastfeed. • You should tell your nurse or doctor all the medications you are taking, including nonprescription, dietary supplements, and herbal medicines. • Take one capsule by mouth, approximately 1 hour before receiving your chemotherapy • You may take this medication with or without food. • This medication may cause side effects, including — Allergic reactions — Serotonin syndrome • The most common side effects of this medication are — Constipation — Fatigue — Headache — Skin redness — Upset stomach — Weakness Prepared by Jason Hoffman, PharmD, RPh.

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RADIATION & YOUR PATIENT

How genomic correlates are predictive of radiotoxicity Bryant Furlow After more than a decade of work, genomic correlates of radiotoxicity have now been identified, and the research infrastructure is in place to identify more loci predictive of a patient’s risk of experiencing radiation-associated adverse effects. The long-sought goal of risk-stratification prognostic biomarkers for personalized radiotherapy planning, is finally within sight.

adiotherapy, a key treatment modality for cancer, is administered to half of cancer patients around the world.1 However, its tumoreradicating potential is frequently limited by toxicities associated with irradiation of patients’ healthy, normal tissues. Major advances in conformal and intensitymodulated radiotherapy have sought to reduce irradiation of nontarget tissue, but

acute radiotoxicities and late radiation effects remain a significant treatment challenge.1 Personalizing radiotherapy planning through risk stratification, by identifying which patients have increased intrinsic healthy-tissue radiosensitivity, and who are therefore more likely to suffer from radiotoxicities, has therefore long been seen as a Holy Grail of radiobiology.2 Now, after more than a decade of research, that Holy Grail might finally be within sight, thanks to international research collaborations, says radiogenomics pioneer Barry S. Rosenstein, PhD, at the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai, New York, New York. “We have made a great deal of progress in the past couple of years, and I am now cautiously optimistic this work will translate into the clinic in the near future,” Rosenstein says. The field’s primary goal is to develop “a genomic assay in which the results of a simple and rapid blood test will predict with a high level of accuracy the likelihood that a particular cancer patient will develop complications from treatment with radiotherapy,” Rosenstein explains. Such a test will help cancer treatment teams and patients make optimal treatment decisions. Because radiotherapy tolerance doses are based on the most radiosensitive segment of the patient population, the ability to identify those patients before treatment should allow development of separate, risk-stratified guidelines that would protect them while allowing dose-escalated radiotherapy regimens for other patients.1 “For people predicted to suffer complications from treatment with radiation, then possibly a strictly surgical option would be most appropriate, or the use of modified radiation dose parameters,” Rosenstein explains. “For prostate cancer

patients, possibly active surveillance may represent the best option. Alternatively, for those patients predicted to be at low risk for developing injuries from radiation, possibly a more aggressive form of radiotherapy using a higher dose could be considered, which may improve the chance for a cure of their cancer.” Better understanding of the molecular pathways involved in healthy tissue radiotoxicities is another goal of radiogenomics.1 New insights into those pathways might facilitate the development of novel radioprotective agents and possibly even novel combination-modality therapies. Radiogenomics researchers like Rosenstein are now convinced that what was once black-boxed as a patient’s bad luck is really in large measure a reflection of inherited risks of adverse effects from radiation. An estimated 80% to 90% of variation in patients’ tissue responses to irradiation are due to patient-specific factors, primarily associated with inherited single nucleotide polymorphisms (SNPs) of common versions of genes.3,4 Even controlling for differences in dose, delivery modality, patient demography, and clinical factors, “adverse effects show a large degree of interpatient variability in incidence and severity, suggesting that genetics plays a role,” Rosenstein and his colleagues have argued.1 The search for those genes was slow going for years, with little success confirming roles for numerous candidate radiotoxicity-associated SNPs that had been the focus of the preliminary small studies based on existing understandings of the etiology of radiation-induced injuries.5 This initial search for radiotoxicityassociated SNPs was largely unsuccessful because it was too restrictive, biologically speaking, to identify prognostic biomarkers, since it depended largely on our very limited understanding of the molecular pathways responsible for the

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 35

RADIATION & YOUR PATIENT development of normal tissue damage resulting from radiation exposure.3,4,6 Radiogenomics research has therefore shifted to collaborative genome-wide association studies (GWASs), in which a chip is used to screen the DNA from each patient, often for more than a million SNPs across the genome.6-8 Toward that end, the National Cancer Institutefunded Radiogenomics Consortium (RGC) was established in 2009 and now consists of 188 investigators working at 110 institutions in 26 countries. Thanks to RGC’s promulgation of collaborative research, and an 18-item checklist for reporting radiogenomics study findings, data from cohort studies around the world can now be readily pooled for meta-analysis, increasing statistical power to identify biomarkers that will form the basis of an instrument to predict which patients are most likely to suffer from injuries resulting from radiotherapy.1,6

"Adverse effects show a large degree of interpatient variability." GWAS work has already yielded unexpected, but biologically plausible reported associations with radiotoxicity.5 There are now six tentatively confirmed genetic loci associated with radiotoxicities.3,4 Published GWAS findings indicate that the risk of radiotherapy-associated erectile dysfunction among men with prostate cancer has been tied to a SNP in the follicular stimulating hormone (FSH) receptor gene and SNPs associated with the 17-beta-hydroxysteroid dehydrogenase II gene (HSD17B2), which is involved in

androgen and estrogen metabolism5; rectal incontinence appears to be associated with SNPs near the KCND3 gene for cellular ion channels involved in smooth muscle contraction.5,8 “None of these SNPs were located in genes involved in radiobiology in a narrow sense and they were certainly not located in any of the ‘usual suspects’ investigated (previously) as part of candidate-gene studies,” notes Christian Nicolaj Andreassen, of the Department of Experimental Clinical Oncology at Aarhus University Hospital in Denmark.5 “Instead, they were involved in physiological phenomena that may interact with various types of normal tissue toxicity.” Another GWAS found that among patients treated with external-beam radiotherapy for prostate cancer, SNPs in the TANC1 gene are prognostic of overall late radiotoxicity—a finding that was replicated with cohorts from the United States and United Kingdom.7 TANC1 is involved in muscle tissue regeneration and these recent findings suggest that it also influences late radiotherapy effects.7 The RGC is collaborating with the OncoArray consortium network to genotype SNPs from 400,000 DNA samples from patients with prostate, breast, lung, colorectal, or ovarian cancer.3,4 The European Union-funded prospective REQUITE study is following comorbidity and radiotoxicity outcomes for 5,300 patients with prostate, breast, and lung cancers undergoing radiotherapy.3,4,9 Meanwhile, Andreassen encourages other radiation oncology teams around the world to prepare to include their patients as validation cohorts for SNP associations detected in GWASs.5 “Whenever a patient is entered into a radiotherapy trial, bank a blood sample,” Andreassen urges. “Be prepared to take part in the future of radiogenomics!” ■

REFERENCES 1. Kerns SL, Ostrer H, Rosenstein BS. Radiogenomics: using genetics to identify cancer patients at risk for development of adverse effects following radiotherapy. Cancer Discov. 2014;4(2):155-165. doi:10.1158/2159-8290.CD-13-0197. 2. Andreassen CN. Searching for genetic determinants of normal tissue radiosensitivity— are we on the right track? Radiother Oncol. 2010;97(1):1-8. 3. Kerns SL, L West CM, Andreassen CN, et al. Radiogenomics: the search for genetic predictors of radiotherapy response. Future Oncol. 2014;10(15):2391-2406. doi:10.2217/ fon.14.173. 4. Kerns SL, de Ruysscher D, Andreassen CN, et al. STROGAR - STrengthening the Reporting of Genetic Association studies in Radiogenomics. Radiother Oncol. 2014;110(1):182-188. doi:10.1016/j. radonc.2013.07.011. 5. Andreassen CN. The future has begun in radiogenomics! Radiother Oncol. 2014;111(2):165-167. doi:10.1016/j. radonc.2014.04.006. 6. Rosenstein BS, West CM, Bentzen SM, et al; Radiogenomics Consortium. Radiogenomics: radiobiology enters the era of big data and team science. Int J Radiation Oncol Biol Phys. 2014;89(4):709-713. 7. Fachel L, Gómez-Caamaño A, Barnett GC, et al. A three-stage genome-wide association study identifies a susceptibility locus for late radiotherapy toxicity at 2q24.1. Nature Genet. 2014;46(8):891-894. doi:10.1038/ng.3020. 8. Barnett GC, Thompson D, Fachal L, et al. A genome wide association study (GWAS) providing evidence of an association between common genetic variants and late radiotherapy toxicity. Radiother Oncol. 2014;111(2):178-185. 9. West C, Azria D, Chang-Claude J, et al. The REQUITE Project: Validating predictive models and biomarkers of radiotherapy toxicity to reduce side-effects and improve quality of life in cancer survivors. Clin Oncol (R Coll

Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.

Radiol). 2014;26(12):739-742. doi:10.1016/j. clon.2014.09.008.

36 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

Patient education in subtitles

Ann J. Brady, MSN, RN-BC

Recently, I had a patient experience where I learned firsthand how challenging editing content into subtitles can be.

here is a small theater in my town that shows independent and foreign films. A few weeks ago my husband and I made an evening of it and went to a foreign film. It was quite some time since I’d seen a film with subtitles. Even if a movie interests me, the idea of subtitles is often enough to dissuade me from going. I worry that I will miss something while I’m busy reading the subtitles. It is difficult to focus on the lines and on the action taking place on the screen. Then, there will be a long dialogue between two characters and yet only a couple of lines will appear so I am left to wonder if the subtitles are accurate. Maybe, to keep from interrupting the flow of the story, some of the words are left out. But which ones? How do I know if something important is missing? Since I’m relying on the subtitles, I am left hoping I get the full story. Translating via subtitles is an interesting process. Recently, I had a patient experience where I learned firsthand how challenging editing content into subtitles can be.

CASE “Tell me about the symptoms you are having.” This is how I usually start an assessment. I ask the patient to describe any symptoms they are experiencing. Even when another member of the health care team has alerted me to an issue, I prefer to have the patient tell me what is going on directly. But with this patient, it was more complicated. This was a new communication challenge for me. My patient, Fred, and his wife, Sally, are both deaf. Fred reads lips but does not vocalize, while Sally reads lips, and although she speaks, it is with a flat intonation that is a bit difficult to understand. Fred was partway through his radiation therapy. He had pain from bone metastases and was also experiencing ongoing nausea. The strategy for assessing his symptoms was not problematic, but communication about it presented some interestingly complex challenges. The greater Los Angeles area, where I work, is home to the most languages spoken in homes, with one study saying as many as 135 languages are spoken in this area alone. The 10 most common languages spoken in the United States are English, Spanish, French, Chinese, German, Tagalog, Vietnamese, Korean, Italian, and Russian. Within the department where I work, eight of those languages are represented among my co-workers, which gives me the opportunity for a co-worker to translate. In addition, we have access to a phone language line. I have had enough experience using a translator to appreciate how patient teaching is affected by the process of translation. With all of these resources, I am always confident I will be able to communicate with my patients or their family. Continues on page 38

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COMMUNICATION CHALLENGES

It wasn’t just my communication with Fred and Sally that improved. I found myself slowing down with other patients.

Fred and Sally sat in the conference room and faced me. Although they could read lips, to do so I had to face each one directly, which was impossible to do. We quickly established that it made sense to write down all of my questions and instructions. The first barrier was my penmanship! I like to joke that I was meant to be a physician as a way of explaining my lousy handwriting. For me to write legibly enough for Fred and Sally to read, I had to slow down and write carefully. That was an adjustment in itself, as I cannot write as quickly as my mind thinks. An interesting dynamic quickly emerged: the written word does not include inflection or intonation. The modulation of a word or phrase that I might use to emphasize a point was missing. I had to rely on the sentences I put down on the paper. I discovered how much I depend on sound to convey information and what a big part of how I teach patients was impacted by the spoken word. It made me think of the movie with subtitles. I had more to say than I could write, so I had to distill everything down to as few words as possible, while trying to ensure the content was precise. But was I leaving anything out? It was slow going. That was another thing I realized. There is an immediacy to saying something, then watching as the other person hears what you say and responds. I was forced to be cryptic, but did not want to sacrifice meaning in the process. My first question was the same one I always use, “Tell me about the symptoms you are having.” Fred pointed

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to his lower back, where he is receiving his XRT, and wrote, “It hurts.” “What words would you use to describe it?” I wrote. I made a list: achy, shooting, crampy, burning, deep. He pointed to the words achy and deep and wrote, “Sometimes bad, sometimes very bad.” We made our way through the rest of the assessment in the same methodical manner. It took longer than usual since there was no shorthand. I asked Fred about his nausea and he bent over and held his stomach. Physical gestures were still important! Several times the three of us laughed as I bungled my way through and had to reword or rewrite my questions. DISCUSSION Over the years I have developed almost a script of questions I use to assess symptoms as well as language I use to educate patients. When I am focused on assessment, I can hear when their answer includes a change in inflection; I hear if the patient puts stress on a certain word, and the subtext of what they are saying becomes apparent or may signal me to ask for clarification. But when all I had to go on was the written word, I had to repeat myself and ask for confirmation before I continued. I met with Fred and Sally several times and became more adept with each encounter. But it wasn’t just my communication with Fred and Sally that improved. I found myself slowing down with other patients, and checking that what I said was clear to them. I listened to myself and made adjustments. I started to change my established script. Communication is a constant challenge. Choosing the right words to make the right point is a challenge with or without a language barrier. Fred and Sally smiled and nodded to me when I last went over instructions with them. Those two gestures were an unspoken affirmation, and one I was glad to have. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

38 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP

Mistletoe: The holiday plant is making headlines as an alternative cancer treatment Bette Weinstein Kaplan

istletoe’s big season may have just ended, but its role as an anticancer agent could be just getting started. An oncologist at Johns Hopkins successfully treated a patient who had advanced colon cancer with an extract of the seasonal botanical, sparking interest in the plant’s anticancer properties. The Smithsonian Institution describes mistletoe as a semiparasitic plant in the order of flowering plants known as Santalales. There are approximately 1,300 species that grow mostly in temperate or tropical areas throughout the world. The two types that are commonly sold during the Christmas season are Phoradendron serotinum, the North American mistletoe, and Viscum album, the European variety.1 Scientists are interested in the latter type for medical applications. THERAPEUTIC USE Europe and Asia Although mistletoe

is poisonous when ingested, doctors outside the United States have been processing it into an injectable extract to treat patients with cancer for a number of years; and with increasingly positive results.2 In fact, German physicians recently published a paper demonstrating how treatment with mistletoe apparently led to the complete regression of an adenoma in the colon of a 78-year-old man who had refused

chemotherapy for a cancer relapse 5 years after surgery.3 United States Physicians in the United States, however, have not been so eager to use the substance, and the

The effectiveness of mistletoe could lie in its ability to boost the immune system. National Institutes of Health (NIH) discourages its use outside of clinical trials, despite citing some success. According to the National Center for Complementary and Alternative Medicine (NCCAM) Clearinghouse: “Laboratory studies have found that mistletoe kills cancer cells and stimulates the immune system. “The use of mistletoe to treat cancer has been studied in Europe in more than 30 clinical trials. Although improvements in survival or quality of life have been reported, almost all of the trials had major weaknesses in their design that raise doubts about the f indings. For example, many of the studies had a small number of participants or did not have a control group.”4

Studies from Europe have shown benefits for patients with cancer of the colon, breast, pancreas, and even for those with melanoma, but the results of treating other types of cancer with mistletoe have not been so positive. Now, researchers at Johns Hopkins will study mistletoe as a cancer treatment thanks to one patient’s success story, her openminded oncologist, and his colleague, a physician specializing in alternative and complementary medicine. SOMETHING WORKED

In 2008, Luis Diaz, MD, an associate professor of oncology at the Johns Hopkins School of Medicine, treated Ivelisse Page, a 37-year-old woman with stage IV cancer of the colon. Despite resection of 15 inches of colon and 28 lymph nodes, the cancer progressed to her liver. After a second surgery in which 20% of her liver was removed, Peter Hinderberger, MD, a physician on Page’s health care team, suggested trying mistletoe. A specialist in using complementary therapies, Hinderberger had seen patients respond favorably to injections of the substance. Diaz, also the director of translational medicine at the Ludwig Center for Cancer Genetics and Therapeutics at the Johns Hopkins Kimmel Cancer Center, reviewed the literature on mistletoe studies from Europe, and decided to initiate the therapy. He noted, “… as

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ISSUES IN CANCER SURVIVORSHIP

soon as she went on it, she started feeling better. That’s a universal feature I’ve seen in all patients who get mistletoe.”5 Whether it was the surgery, diet and exercise, or the mistletoe therapy, Page has been free of cancer since her liver surgery.6 She and her husband formed a nonprofit organization, Believe Big, to bring the mistletoe extract from Europe, where it is manufactured, to the United States for clinical trials. They also hope to use their organization to connect cancer patients with doctors who use nonconventional therapies.6 Channing Paller, MD, is principal investigator for the Johns Hopkins research on the use of mistletoe in cancer. An assistant professor of oncology at the School of Medicine, she theorizes that the effectiveness of mistletoe could lie in its apparent ability to boost the immune system and increase patients’ tolerance of traditional chemotherapy. That would mean that patients could receive higher doses of chemotherapy, enhancing the effect but with fewer consequences.

LIVE CONFERENCE COVERAGE

Germany and other countries have approved prescribing mistletoe for palliation, but not for chemotherapy.7 Studies have shown the plant’s derivatives have led to enhanced quality of life, concentration, and mood. Patients on chemotherapy report that they have more energy, and they experience less nausea and discomfort while taking mistletoe. Researchers in the United States are hoping to achieve similar positive effects while proving the extract’s anticancer activity. ■

3. von Schoen-Angerer T, Goyert A, Vagedes J, et al. Disappearance of an advanced adenomatous colon polyp after intratumoural injection with Viscum album (European mistletoe) extract: a case report. J Gastrointestin Liver Dis. 2014;23(4):449-452. 4. European mistletoe. Side effects and cautions. NIH National Center for Complementary and Alternative Medicine (NCCAM) Web site. http://nccam.nih.gov/health/ mistletoe#cautions. Accessed January 7, 2015. 5. Sugarman J. Are mistletoe extract injections the next big thing in cancer therapy? Johns

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

Hopkins Magazine. http://hub.jhu.edu/ magazine/2014/spring/mistletoe-therapycancer. Published Spring 2014. Accessed

REFERENCES 1. Mistletoe facts from a Smithsonian Botanist. Smithsonian Science Web site. http:// smithsonianscience.org/2011/12/mistletoefacts-from-a-smithsonian-botanist/. Accessed January 7, 2015. 2. Wrotek S, Skawiński R, Kozak W. Immuno-

January 7, 2015 6. Ivelisse’s Story. Believe Big Web site. http:// www.believebig.org/WhoWeAre.html. January 7, 2015. 7. Handwerk B. Medical mistletoe: Can the holiday plant really fight cancer? Smithsonian.com Web site. http://www.

stimulatory properties of mistletoe

smithsonianmag.com/science-nature/

extracts and their application in oncology

medical-mistletoe-can-holiday-plant-really-

[in Polish]. Postepy Hig Med Dosw (Online).

fight-cancer-180953551/?no-ist. Published

2014;68:1216-1224.

December 8, 2014. Accessed January 7, 2015.

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THE TOTAL PATIENT

A social enterprise serves as a working model for the future of palliative care Bette Weinstein Kaplan

n innovative model for palliative care is taking shape, and with financial support from a modern-day funding initiative: crowdfunding. Palliative medicine practitioner Michael Fratkin, MD, conceived the idea for ResolutionCare, a social enterprise. Fratkin’s goal is to combine nonprofit and professional organizations that share the same mission, ensuring that soulful and capable care is available to everyone everywhere as life approaches completion.1 Fratkin turned to the Indiegogo international platform to raise the funds needed to support his enterprise. The campaign was wildly successful, with contributions totaling more than $37,000 over his $100,000 goal by the end of the campaign.2 CHANGING THE FIELD WITH TECHNOLOGY

ResolutionCare is out to change the delivery of palliative care medicine. Fratkin and his team utilize modern technology to distribute care to a broad patient population, in their homes. If a team member cannot make a house call in person, they arrive in patients’ homes via teleconference. Not just for one consultation either, but on an ongoing basis as long as is necessary. ResolutionCare’s palliative care team members are physicians, nurse practitioners, social workers,

community health workers, and chaplains. They work closely with the patient’s own clinicians to gain insight about the patient and to provide their expertise and support. This team does not replace the treatment team, but enhances it, providing expertise in such fields as oncology, pain management, nephrology, and dialysis. The hope is that by working this way, with the doctors and nurses who are familiar to the patient and in the comfort and familiarity of the patient’s home environment, the patient’s quality of life is also enhanced. Of course, palliative care is most effective when brought into the continuum of care early. The ResolutionCare model assures that patients receive palliation in their own homes before hospice comes in. Patients do not experience the stress of hospitalizations and there are no unnecessary costs in time or money. Patients determine what medical care they receive, which can be seriously empowering, especially at the end of life. PROJECT ECHO ResolutionCare also addresses the need to educate health care providers about palliative care and help them enhance their basic palliative care skills. Fratkin’s enterprise partnered with Project ECHO from the University of New Mexico (UNM) School of Medicine to accomplish this goal.

Project ECHO provides a hub-andspokes model of professional medical education throughout the United States. An academic institution serves as the hub, and primary care clinicians in the community are the spokes.3 Project ECHO provides many levels of expertise to its partners throughout the United States and the world. The goal is to bring medical expertise to the patient, minimizing the need for sick patients to travel to their health care providers. To this end, the project holds weekly teleECHO clinics, similar to grand rounds but by teleconfer-

TeleECHO clinics give providers the opportunity to gain input from experts. ence, where primary care providers present cases from their own communities to primary care clinicians in other communities and to mentoring academicians at the hub. These clinics give the local providers the opportunity to discuss recent developments in their patient cases and to gain input from experts on what the next steps in treatment should be. Continues on page 42

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 41

THE TOTAL PATIENT Among ECHO’s other projects, the program provides expertise in holistic and multidisciplinary pain management to the United States Armed Forces. Formal educational lectures with case-based learning are offered to medical providers at military treatment facilities worldwide.

that expert palliative care reaches patients in need, in their own homes, no matter how far away patients are from the advanced care available in medical academia. ■

Web site. http://resolutioncare.com/. Accessed January 14, 2015. 2. ResolutionCare: care and guidance before hospice. Indiegogo Web site. https://www.indiegogo.com/ projects/resolutioncare-care-and-

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

guidance-before-hospice. Accessed January 14, 2015. 3. Project ECHO: a revolution in medical

A HUMAN EXPERIENCE Fratkin says, “Dying is not a medical experience; it is a human experience.”1 ResolutionCare can ensure

REFERENCES

education and care delivery. UNM School

1. Bringing capable and compassionate

of medicine Project ECHO Web site.

care to everyone everywhere as life

http://echo.unm.edu/. Accessed

approaches completion. ResolutionCare

January 14, 2015.

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42 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

he words “you have cancer” are life altering. Responses to this news vary, but there are also commonalities. As an oncology social worker who has counseled many men, both individually and in group settings, I have found that men often—at least initially—cope with a cancer diagnosis by retreating, some by shutting down emotionally. They may withhold or suppress their feelings, refrain from seeking emotional assistance, and isolate themselves from loved ones, family, and friends, who are often frustrated in attempts to provide support. Many men retreat further into their work or sports, and others, into a lonely exile. A common and primary component to this suppression and isolation is that many men, on receiving a diagnosis, grapple with a change in, or a loss of, their sense of identity, rejecting the notion of needing or wanting solace and support from others. Cancer and the effects of treatment can compromise their ability to fulfill certain roles, such as a financial provider, husband, intimate partner, or hands-on parent or grandparent, leaving them asking the question, “If I cannot perform these duties, then who am I now?” One of my patients, Laurence, joined a face-to-face CancerCare support group for men with cancer, after a prostate cancer diagnosis and undergoing a prostatectomy. Initially, Laurence was withdrawn, depressed, overwhelmed, and burdened with a great deal of confusion and regret over the quality-of-life-altering effects of his prostate cancer treatment choices.

Understanding the male patient with cancer William Goeren, MSW, LCSW-R

Over the next several months, I watched as Laurence listened intently as the other male group members shared their cancer journeys. He began to identify with the other members’ struggles and triumphs, and slowly started sharing his own powerful and poignant story. The other men provided a safe and secure atmosphere for Laurence to challenge his wall of defended and suppressed feelings. With the support of the other men in the group, he began to trust others, and also himself.

These walls slowly began to come down, tentatively at first, as he allowed himself to open up, become more vulnerable, engaged, and involved with other people. By finding his voice, Laurence was able to discuss and cope with his new reality, to take risks in connecting and asking for support, and to confidently step back out into the world. I am proud to say that the same man who was once afraid to speak in a group of eight recently shared his personal experience at a national cancer symposium, profoundly moving hundreds of attendees. When looking back on his time in the support group, Laurence feels that an emotional weight has been lifted. “The group as a whole has become like a unified support system where anything goes—any question, any topic, any fear,” he says. “It’s about surviving our lives and it’s been very helpful. I’ve witnessed that many men are like clams and they hide. It is very important for me to be aware of my feelings and use them to see and interpret my life.” No one should face a cancer diagnosis alone, although some do whether out of circumstances or other concerns, such as fearing rejection or being a burden to friends or family. As Laurence experienced, talking with others who are facing similar feelings and challenges can be very helpful. Wanting to establish a caring community is a wonderful way to find support from other people going through a similar experience while at the same time reducing isolation. A support

Men often—at least initially—cope with a cancer diagnosis by retreating, some by shutting down emotionally. www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 43

FROM

FROM group may offer patients a safe space to connect with others and to receive and offer support. If a group setting is not right for certain patients, speaking one-onone with an oncology social worker can help develop strategies for coping with some of the more complex emotions and concerns they may be experiencing. Encourage patients to resist the urge to retreat—there’s help available, and it can change the course of their future. Caregivers and family may feel especially confused by the patient’s tendency to shut down or isolate. Just as the patient is trying to deal with the diagnosis and treatment and the concerns that go along with it, so, too, is the family. In fact, as is often stated, the experience of being a caregiver is as stressful as being the patient, although the caregivers stressors are different. There may be a heightened

sense of anxiety surrounding how to best help and how to communicate. Much has been written about the need to remain positive for the person with cancer, and family members are often concerned that if they express negative thoughts or concerns, it will make the illness worse.

One suggestion is to encourage patients to set aside time for a family meeting. Resources are available for family members coping with a loved one who has retreated emotionally, including the booklets Coping with Cancer: Tools to Help You Live and Caregiving for Your Loved One With

Cancer. The fact sheet, “What Can I Say to a Newly Diagnosed Loved One?” may also help patients’ family members talk with you about your diagnosis. Another good resource is The Breast Cancer Companion (New York: Avon Books; 1993) by Kathy LaTour; several chapters deal with opening communication. One suggestion is also to encourage patients to set aside time to have a family meeting and allow each member an opportunity to talk about their concerns. For example, family members might meet to read aloud letters they have written about their own fears and emotions, as a way to begin the discussion. For more information about fi nding support, and for other helpful resources, visit www.cancercare.org. ■ William Goeren is director of Clinical Programs at CancerCare.

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Read the article on OncologyNurseAdvisor.com, then follow the link to the posttest. Pain management in patients receiving palliative care - expires June 15, 2015 Lung cancer: Guidelines, new drugs improve outcomes - expires October 15, 2015 Vertobroplasty is effective for managing myelomatous VCFs - expires December 15, 2015 Understanding current and emerging therapies for HNC - expires December 31, 2015 How the immune system is unleashed to fight cancer - expires August 31, 2015 Using guideline adherence to manage CINV effectively - expires October 31, 2015 Breast cancer and pregnancy: An overlapping of two disciplines - expires December 31, 2015

LOOK FOR A BRAND NEW CONTINUING EDUCATION ACTIVITY IN FEBRUARY! 44 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

Write for ONA! Oncology Nurse Advisor offers clinical updates and evidence-based guidance to the oncology nurse community and includes regular coverage of topics such as the safe handling and administration of chemotherapy drugs, side effect management, new developments in specific cancers, palliative care, communication with patients and family, and cancer survivorship. We welcome contributions from readers in the following categories: Oncology Nurse Advisor Forum: Answers to clinical questions and advice for clinical problems. Readers may submit questions and requests for advice that are 50 to 100 words long. The author should include full name and degrees, name of institution or practice, and city and state. Feature article: Oncology Nurse Advisor welcomes feature articles on the administration and handling of chemotherapy drugs; side-effect management; communication with patients, families, and colleagues; whatâ&#x20AC;&#x2122;s new in the treatment of specific cancers or cancer-related conditions; survivorship issues; patient navigation; and other topics of interest to oncology nurses. Manuscripts should be 1200 to 2000 words long and should include a brief reference list. Reflections: These are brief, reflective essays on a topic related to oncology practice or narratives recounting a meaningful experience with a patient. Manuscripts should be 800 to 1200 words long. Case Study: This department focuses on clinical cases of interest to oncology nurses. Manuscripts should be written in the standard case-followed-by-discussion format and should be 1500 to 2000 words long. A brief reference list may accompany the discussion section. Please include a list of 3 to 5 take-home points (teaching points) for the reader. The PDF template in our Author Guidelines is an easy, step-by-step guide for writing up your Case Study. Ask a Pharmacist: In this department, our oncology pharmacist answers readersâ&#x20AC;&#x2122; drug-related questions. Questions should be 50 to 100 words. The author should include full name and degrees, name of institution or practice, and city and state. See our author guidelines, available at www.OncologyNurseAdvisor.com, for more details.

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REFLECTIONS

ÂŠ THINKSTOCK

besity is at an epidemic level in the United States, as well as globally. More than twothirds of American adults are overweight or obese. It contributes to avoidable and premature deaths from the top two killers: cardiovascular disease and cancer.1 People who are overweight or obese have a higher risk of other serious health conditions, including type 2 diabetes and high blood pressure. The most recent statistics reported by the US National Institutes of Health (NIH) is that approximately two-thirds of adults age 20 years or older are overweight or obese, with a body mass index (BMI) greater than 25, and nearly one-third have a BMI greater than 30.1,2 Less than one-third of Americans are at a healthy weight with a BMI of 18.5 to 24.9. In 1995, the economic cost of overweight and obesity in the United States alone was estimated to be $117 billion per year. Obesity is a risk factor for several types of cancer. Although a higher weight may not necessarily directly cause cancer, maintaining a healthy weight is associated with a lower risk of many chronic diseases, including cancer. Factors that cause people to become overweight or obese include genetic, hormonal, environmental, emotional, and cultural factors; however, the main causes are controllable. Scientists and physicians have been trying to understand weight gain and cancer risk. Several studies have explored why being overweight or obese may increase cancer risk and growth.3 People who are obese have

Managing obesity should be part of cancer care Donald R. Fleming, MD

more fat tissue that can produce hormones such as insulin, testosterone, and estrogen, which may cause cancer cells to grow.3 Fat cells also produce many other chemical messengers that affect how the body works. The fat cells are active, producing hormones and proteins that are released into the bloodstream and carried throughout

the body. These chemical messengers can increase the risk of several different cancers. Most recent investigations have focused on excess insulin. The hormone insulin is a very important part of how the body uses energy from food. Overweight or obese people have much more insulin in their bodies. How this leads to cancer is not clear, but high insulin levels are a common feature of many cancers. Even how the fat is distributed has been shown to correlate with the risk of certain cancers. Too much fat carried around the belly can do more damage. This so-called apple shape is linked to colorectal, kidney, esophageal, pancreatic, breast, and uterine cancers.1,3 Oncologists have not typically been involved in weight reduction management, which is not by any fault of their own as weight loss instruction has not been integrated into medical school, residency, and fellowship programs. For now, oncologists should start by talking to cancer patients and survivors about calculating body mass index and assessing weight status, and how the role of healthy eating and exercise can reduce fatigue, improve body image, and lower incidence of recurrent cancer.3,4 Most studies suggest that obesity and a cancer diagnosis may be linked to increased recurrence and mortality. Obesity can also affect the appropriate dosing of cancer therapy and increase the risks of treatment-related side effects, as much as it may reduce the efficacy. Calculating optimal chemobiotherapy doses is very diff icult

Most studies suggest that obesity and a cancer diagnosis may be linked to increased recurrence and mortality. 46 ONCOLOGY NURSE ADVISOR â&#x20AC;˘ JANUARY/FEBRUARY 2015 â&#x20AC;˘ www.OncologyNurseAdvisor.com

when the patient has an excessive amount of body fat per body mass. In addition, past studies have demonstrated that activity included in a healthier lifestyle post cancer diagnosis helps reduce the chances of both breast and colorectal cancer spread and recurrence, to the same degree as adjuvant chemotherapy.4,5 Also, it’s free! In order to promote long-ter m behavior change, it’s important for oncologists to partner with other members of the cancer care team, including primary care physicians and other professionals such as dietitians and physical therapists. Oncologists should also attempt to model and promote healthy lifestyles in the community.

As with smoking, obesity is a controllable risk for cancer. Many resources are available to help people maintain a healthy weight, including doctors and dietitians. Talk with your patients about developing an appropriate weight control plan for them. ■

2. Ballard-Barbash R, Berrigan D, Potischman N, Dowling E. Obesity and cancer epidemiology. In: Berger NA, ed. Cancer and Energy Balance, Epidemiology and Overview. New York, NY: Springer; 2010. 3. Roberts DL, Dive C, Renehan AG. Biological mechanisms linking obesity and cancer risk: new perspectives. Annu Rev Med.

Donald Fleming is an oncologist/hematologist at the Cancer Care Center, Davis Medical Center, Elkins, West Virginia.

2010;61:301-316. 4. Demark-Wahnefried W, Platz EA, Ligibel JA, et al. The role of obesity in cancer survival and recurrence. Cancer Epidemiol Biomarkers

REFERENCES 1. Polednak AP. Estimating the number of

Prev. 2012;21(8):1244-1259. 5. Schmid D, Leitzmann MF. Association

U.S. incident cancers attributable to

between physical activity and mortality

obesity and the impact on temporal

among breast cancer and colorectal

trends in incidence rates for obesity-

cancer survivors: a systematic review and

related cancers. Cancer Detect Prev.

meta-analysis. Ann Oncol. 2014;25(7):

2008;32(3):190-199.

1293-1311.

Do you have a story you want to share? Oncology Nurse Advisor welcomes narrative essays from oncology nurses for Reflections, our narrative medicine blog. Write 800 to 1,200 words about a patient or life experience that was meaningful to you or a perspective on oncology patient care, and email the manuscript to editor.ona@haymarketmedia.com.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2015 • ONCOLOGY NURSE ADVISOR 47

ASK A PHARMACIST

Importance of sequence when giving premeds with paclitaxel

In what sequence should you administer premedications prior to paclitaxel: Should the antihistamine be given first or the steroid? Does it matter? —Name withheld on request

Premedications are administered prior to paclitaxel (Taxol), as well as some other chemotherapy agents, to reduce the incidence and severity of infusionrelated reactions. The paclitaxel premedication regimen consists of an antihistamine (eg, diphenhydramine), a corticosteroid (eg, dexamethasone),

Lisa A. Thompson, PharmD, BCOP Clinical Pharmacy Specialist in Oncology Kaiser Permanente, Colorado

and an H 2 receptor antagonist (eg, famotidine). Early studies of paclitaxel demonstrated high rates of hypersensitivity reactions. The mechanism through which paclitaxel produces hypersensitivity reactions is not well characterized, and may be due to the Cremophor EL present in traditional paclitaxel products. A premedication regimen was developed to reduce the severity and incidence of these reactions. Originally, the antihistamine and corticosteroid were administered 12 hours and 6 hours prior to paclitaxel administration. As some patients may have difficulty adhering to this schedule, intravenous regimens have also been studied. These regimens, in which the antihistamine, corticosteroid, and H2 receptor antagonist are administered intravenously 30 to 60 minutes prior to paclitaxel, have been shown to be similarly effective compared to the oral regimens. Administering premedications within the appropriate time frame is important for efficacy; so long as the medications are administered within this time frame, the exact order of administration is flexible and should be done in accordance with your local standard of practice. ■

ASK A PHARMACIST

Conceptual illustration of a stimulated site of pain (ball of barbed wire)

Managing peripheral neuropathy related to vincristine Has any medicine or supplement been shown to help lessen severity of peripheral neuropathy related to vincristine? Glutamine or gabapentin has not been successful in our experience. —Carrie L Lewis, RN, MSN, CPNP, CPON

neuropathy include higher doses of vincristine, larger cumulative doses of vincristine, the presence of baseline neuropathy, and some drug-drug interactions. Patients experiencing peripheral neuropathy due to vincristine may experience pain, tingling, numbness, and reduced sensation in the hands and feet. Management of peripheral neuropathy may depend on the severity of symptoms and the patient’s treatment course. Patients with clinically significant neuropathy during vincristine therapy should be monitored closely and considered for a dose-reduction or vincristine discontinuation. Improvement or resolution of neuropathy may take up to 2 years, and some patients may experience a worsening of their neuropathy symptoms after vincristine is discontinued. Unfortunately, some patients may have ongoing neuropathy even after this time. Treatment options for vincristine and other chemotherapy-induced peripheral neuropathy include tricyclic antidepressants (eg, amitriptyline [Elavil]), anticonvulsants (eg, carbamazepine [Tegretol]), gabapentin (Neurontin), pregabalin (Lyrica), and serotoninnorepinephrine reuptake inhibitors (eg, duloxetine [Cymbalta]). Some supplements, such as glutamine and pyridoxine, have also been studied in the prevention of peripheral neuropathy. Although multiple agents have been studied to treat chemotherapy-induced peripheral neuropathy, no agents have consistently shown a benefit in randomized phase 3 clinical trials. Opioids

Vincristine (Oncovin) is used in the treatment of a variety of cancers, including some leukemias and lymphomas. Rates of peripheral neuropathy with vincristine vary between regimens and patient populations, and have been reported in 35% to 45% of patients in some studies. Risk factors for development of peripheral

or other analgesics may be required to control pain symptoms in patients whose pain is not managed. Early detection of vincristine-induced peripheral neuropathy with appropriate adjustment of a patient’s vincristine therapy is critical to reduce the risk of long-term neuropathy symptoms after treatment. Patients with persistent symptoms should be referred to a neurologist for a thorough work-up and consideration of alternate therapies. Working with an occupational therapist may also be helpful to restore lost function due to neuropathy. TIP FOR PATIENTS National Drug Take-Back Day: April 26, 2014

Spring 2014 DEA Drug Take Back Day events will be held on Saturday, April 26, from 10 AM to 2 PM. These events are a great way for patients to dispose of expired or unwanted medications, including controlled substances such as pain medications. Since beginning in 2010, these events have disposed of more than 1,733 tons of prescription medications. For more information, including collection sites in your area, please visit www.deadiversion.usdoj.gov/ drug_disposal/takeback/ after April 1st. For information on how to advise patients regarding other ways to dispose of nonchemotherapy medications, please visit www.oncologynurseadvisor.com/ educating-patients-about-the-properdisposal-of-old-drugs/article/168850/. ■

ONCOLOGY Lisa A. Thompson, PharmD, BCOP NURSE AD VISOR FO RUM Clinical Pharmacy Specialist in Oncology Kaiser Permanente, Colorado

Our Con 52 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2014 • www.OncologyNurseAdvisor.com sult ants

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Would a patien CTIVE NAVIGAT ION TOOLS als, or both? t navigation tool be FOR PATI Web-based ENTS Which mem resources, introduce the ber of the printed mater treatment resource to team is the ithe patient ideal perso and when? n to — Robert Ideally, a patien Mark Baldr Jia R. Conwa t navigation idge y, easily under NP-C, oncolog DNP, FNP-BC, stand the inform tool is easy for the patien practitioner y nurse t and have at at Cancer Care least one device ation provided. Many patiento use, and the patient Associates of can resources are with which York in York, ts are savvy Pennsylvania. helpful. Other to access the Intern et users Internet; to-date each advantages includ time the patien e the resource therefore, web-based day, 7 days t refers is more to it; a week; and Abimbola a greater selectio the resource is usually availalikely to be upFarinde, Pharm some web-b MS, BCPP, ased D, n of ble 24 hours CGP, LCDC, a status and wheretools are designed specifi resources may be availa PM/ PRC, FASCP, ble. In additio FACA, FNAP, cally for naviga patients are ARSPharmS, Rsci, n, also allows for tors for monit clinical pharma creating end-o along the continuum of specialist, Clear oring patien cist patient and t Medical Center, Lake Regional their primary f-treatment documentati care. This method usuall Webster, Texas on that care physicians. y caring for the patient (now This tool then can be shared with the survivor) to to do lifetim allows all who correctly order e monit Donald R. might be oring. Fleming, MD, needed follow Printed mater hematologist/o up studies, etc, Cancer Care ncologist, to the patien ials, however, have a few Center, Davis t and easily review advantages Memorial Hospita as well. They information ed in person l, Elkins, is confusing West Virginia can be . Patients can . to them the patient is show their nurseshanded referring to reliabl and ask questions, and which administrati nurses can be e inform ve work to Kerstin L. maintain the ation. Disadvantages includ more confident Lappen, RN, supply up-toMS, supply of mater ACNS, ACHPN e the increased date. , clinical nurse ials, as well The ideal time specialist, palliativ as keeping to introduce service, Abbott e care consult the session with a patient naviga the patient’s Hospital, Allina Northwestern tion tool is at nurse. can Health the first be reviewed, Then, at each System, Minneapolis, updated, and Minnesota. subsequent visit, patient-education many aspect the navigation s of cancer care, adjusted to the patien tool t’s information effective one. an needs. As with For many patien approach tailored to the K. Lynne Quinn, printed mater patient’s ts, a combination CRNP, AOCNP RN, MSN, ials of both Web- needs is the most them to naviga would provide the inform oncology, Bryn , director of based resour te their cancer ation they need ces and Bryn Mawr Mawr Hospital and journey. —Th in a format Health Center, Bryn Mawr, that enables e Editors Pennsylvania. SOME POR T OF NURSINGMAINTENANCE IS OUTSIDE PRAC TICE THE SCOP Is it within Lisa A. Thomp E a nurse’s scope order? I am BCOP, clinical son, PharmD, getting mixe of practice to flip a port pharmacy specialist in literature that d responses oncology, Kaiser from collea over with a physician’s either suppo Permanente, Colorado gues, and canno Edwards, RN, rts or refute s nurse BSN, OCN t find s performing this task. —Jen any nifer This is a contro Rosemarie versial questi A. being said howev on, as AOCN, manag Tucci, RN, MSN, er, Oncology nursing practice can differ research & data er for oncology Nursing Societ from state to services, state. y’s standards Lankenau Hospita for caring for That l, Wynnewood, vascular Pennsylvania DO

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Let us answer your questions! E-mail us at editor.ona@ haymarketmedia.com with your general questions for our expert Advisor Forum and your drug-related questions for Ask a Pharmacist!

48 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2015 • www.OncologyNurseAdvisor.com

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