ONA January/February 2016 by Haymarket Media

ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016

www.OncologyNurseAdvisor.com

January/February 2016

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

FEATURE

LUNG CANCER Primary Site, Therapy Time Influence Radiation Palliation

FEATURE

Enabling the Connection With One’s Spiritual Identity

THE TOTAL PATIENT

Experiences, Dreams, and Visions: Easing Patients With Cancer Toward End of Life

Incidental Findings: A Program for Following Pulmonary Nodules This program is designed to investigate pulmonary nodules (red) found on thoracic imaging outside of the oncologic setting.

FROM CANCERCARE

Yoga Provides Mental, Emotional, and Physical Benefits

COMMUNICATION CHALLENGES

Pain: Listen for What Is Not Said

VOLUME 7, NUMBER 1

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PUBLISHING STAFF Editor Joyce Pagán editor.ona@haymarketmedia.com Senior digital content editor Rick Maffei Oncology writer Jason Hoffman, PharmD, RPh Contributing writer Bette Weinstein Kaplan Group art director, Haymarket Medical Jennifer Dvoretz

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Oncology Nurse Advisor (ISSN 2154-350X), January/February 2016, Volume 7, Number 1. P ublished 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 Jiajoyce R. Conway, DNP, CRNP, AOCNP 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 2016 • ONCOLOGY NURSE ADVISOR 1

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CONTENTS

January/February 2016

IN THE NEWS • Symptom Count Is Diagnostic for Lymphedema • Olanzapine Improves Control of CINV in the Prevention and Rescue Setting • No Therapies Post Ibrutinib Appear Effective for Mantle Cell Lymphoma … and more

ONCOLOGY NURSE ADVISOR FORUM • Managing TSH Levels After Total Thyroidectomy • Handling Closed System Device-Incompatible Chemotherapy Agents • FOLFIRINOX Regimen Sequence • My Perspective on Being an Oncology Nurse

NAVIGATOR NOTES Survivorship: The Transition Back to Primary Care

Joyce Pagán

43 22

FEATURES Inconclusive: The Pulmonary Nodules You Need to Follow Rosemarie A. Tucci, RN, MSN, AOCN; K. Lynne Quinn, RN, MSN, CRNP, AOCNP

Primary Site, Therapy Duration Influence Radiation Palliation Bette Weinstein Kaplan

47 FIND US ON

Enabling the Connection With One’s Spiritual Identity Elizabeth Ezra, LCSW, OSW-C

Continues on page 8

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STAT CONSULT Trifluridine/Tipiracil (Lonsurf) Trifluridine/tipiracil is a combination inhibitor drug indicated for the treatment of patients with metastatic colorectal cancer previously treated with chemotherapies and/or biologic therapies.

CONTENTS

January/February 2016

This fact sheet defines computed tomography (CT), explains its use in cancer detection, and answers questions regarding radiation exposure from CT use.

STAT CONSULT Cobimetinib (Cotellic)

RADIATION & YOUR PATIENT Novel Therapy Controls Late Effects in HL Survivors Bryant Furlow

COMMUNICATION CHALLENGES Pain: Listen for What Is Not Said Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Novel Research Investigates the Impact of Therapy Dogs on Children With Cancer Bette Weinstein Kaplan

THE TOTAL PATIENT Experiences, Dreams, and Visions: Easing Patients With Cancer Toward End of Life Bette Weinstein Kaplan

FROM CANCERCARE Yoga Provides Mental, Emotional, and Physical Benefits Ashley Chookazian, LMSW

PATIENT EDUCATION: FACT SHEET Computed Tomography (CT) Scans and Cancer

ASK A PHARMACIST Understanding Drug Naming Nomenclature

VIDEO: LUNG CANCER Immunotherapy for Lung Cancer Designed for patients and caregivers, this 45-minute webinar discusses current immunotherapy treatment options for patients with lung cancer, and how close we are to making these treatments available to more patients.

PUBLISHERS’ ALLIANCE: DOVEPRESS Managing Breast Cancer in Younger Women: Challenges and Solutions This research examines the unique challenges faced by younger patients with breast cancer, such as the tendency for a more aggressive biology and consequently a poor prognosis, as well as related fertility and psychosocial issues. Breast Cancer: Targets and Therapy

PUBLISHERS’ ALLIANCE: LIBERTAS ACADEMICA Eribulin in the Management of Advanced Breast Cancer: Implications of Current Research Findings This research examines previous recent research on the therapeutic effects and adversities of eribulin monotherapy and eribulin-based combination therapy for breast cancer treatment. Breast Cancer: Basic and Clinical Research

Lisa A. Thompson, PharmD, BCOP

Lead the way for your nurse navigator program by attending the 2016 ONA Navigation Summit

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8 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016 • www.OncologyNurseAdvisor.com

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IN THE NEWS Symptom Count Is Diagnostic for Lymphedema A count of symptoms may be a cost-effective initial screening tool for lymphedema, according to a study published

in Breast Cancer: Targets and Therapy. In this study, researchers from the New York University College of Nursing (NYUCN) examined the validity, sensitivity, and specificity of various symptoms indicative of breast cancer-related lymphedema. They also determined the best cutoff points for diagnosing lymphedema and risk of lymphedema in breast cancer survivors. Lymphedema has a latency of months to years before its overt swelling occurs. During this latency, changes in the affected limb cannot be detected with objective measures; the persistence of other symptoms is the only clinical clue. Therefore, self-reporting plays an important role in early detection. The NYUCN researchers collected data from 60 healthy female adults, 42 breast cancer survivors with previously diagnosed lymphedema, and 148 breast cancer survivors at risk of developing lymphedema. The risks of developing lymphedema were more than 5 times higher in women who reported arm heaviness, arm firmness, increased arm temperature, tightness, limited arm movement, tingling, and arm aching; and more than 4 times higher in women who reported limited finger movement, limited elbow movement, and limited wrist movement, compared with women who did not have these symptoms. Pain in the affected arm indicated the risk was nearly twice that of women who did not experience pain in the affected arm. Presence of 3 symptoms distinguished breast cancer survivors with lymphedema from healthy women with a sensitivity of 94% and a specificity of 97%, and presence of 9 symptoms distinguished at-risk survivors from survivors with lymphedema with a sensitivity of 64% and a specificity of 80%. The researchers encourage using symptom count in the absence of objective measurements to detect latent-stage lymphedema in breast cancer survivors.

CT Colonography and FIT Yield Different Participation and Detection Rates Computed tomography (CT) colonography with reduced preparation had increased participation compared with full cathartic preparation CT colonography, and detection rates were approximately 3 times higher for CT colonography compared with 3-dimensional CT the fecal immunochemical test (FIT). colonography These findings were published in the Journal of the National Cancer Institute. The study sought to address the question of what is the ideal screening method

for colorectal cancer (CRC), the third most diagnosed cancer in the world. The research team reviewed data from a single-center, randomized, controlled screening trial in Florence, Italy. The trial included 16 087 patient participants age 54 to 65 years in 4 parallel groups: biennial fecal immunochemical test for 3 rounds, reduced-preparation CT colonography, full cathartic-preparation CT colonography, and optical colonoscopy. Participation was different across the 4 screening methods (50.4% for first-round FIT, 28.1% for reduced-preparation CT colonography, 25.2% for full-preparation CT colonography, and 14.8% for optical colonoscopy), but detection rates of advanced neoplasia were different only between FIT and CT

TOP: © SPL / SCIENCE SOURCE; BOTTOM: © SCOTT CAMAZINE / SCIENCE SOURCE

Read more at http://bit.ly/20bSfFr

Benefits of Regular Mammography Extend to Women Older Than 75 Years Both black and white women age 75 to 84 years who underwent annual mammography had lower 10-year breast cancer mortality than corresponding women who underwent biennial or no/irregular mammographies according to findings published Annual screens help in the American Journal of Medicine. older women Researchers used Surveillance, Epidemiology, and End Results (SEER) data linked to Medicare administrative claims to identify screening mammography use from 1995 to 2009 of 64 384 non-Hispanic women (4886 black and 59 498 white). Three mutually exclusive categories were defined: no or irregular mammography; biennial mammography; and annual mammography. The researchers looked at data from non-Hispanic, white, or black women and also measured socioeconomic status. The study findings showed that white women who had died tended to be older, have later-stage disease at diagnosis, received chemotherapy, and were of a higher socioeconomic status. White women who died were less likely to have undergone surgery or radiation therapy. Similar characteristics were seen in black women as in white women. Risk of disease-specific mortality at 5 years or 10 years was consistently lower in those women age 69 to 84 years who underwent regular annual screening mammography

during the 4 years immediately preceding their breast cancer diagnosis compared with women who underwent no or irregular screening, regardless of race. The 10-year risks were more than 3 times higher among white women and more than 2 times higher among black women age 69 to 84 years with no or irregular screening compared with those who underwent annual screening. Read more at http://bit.ly/1Q3vpe9.

No Therapies Post Ibrutinib Appear Effective for Mantle Cell Lymphoma Although ibrutinib has unprecedented clinical activity in mantle cell lymphoma, primary and acquired resistance to ibrutinib is common, and the ideal management and outcomes of patients that experience ibrutinib failure remains unclear. Outcomes poor after Therefore, researchers sought to ibrutinib resistance conduct a retrospective cohort study of all patients with mantle cell lymphoma that experienced disease progression while receiving ibrutinib therapy from 15 international sites. For the study, researchers included 114 patients and analyzed their medical records for clinical characteristics, pathological and radiological data, and therapies used prior to and after ibrutinib. Results showed that median overall survival following ibrutinib therapy was 2.9 months (95% CI: 1.6-4.9). Researchers found that of the 104 evaluable patients, 73 had undergone subsequent treatment an average of 9 days after stopping ibrutinib. Those patients had a median overall survival of 5.8 months (95% CI: 3.7-10.4). The study demonstrated no association between subsequent treatment with bendamustine, cytarabine, or lenalidomide and overall survival. Furthermore, investigators observed poor clinical outcomes in the majority of patients with primary or secondary ibrutinib resistance. Read more at http://bit.ly/1n18xSQ.

For full news stories visit OncologyNurseAdvisor.com

LEFT: © THINKSTOCK ; RIGHT: © BSIP / SCIENCE SOURCE

disease vary depending on the person’s smoking status; therefore, the researchers stratified their data by smoking status. After a mean follow-up time of 6.7 years, 2124 women developed breast cancer. Among all women, the risk of breast cancer was 14% higher in those with periodontal disease. Among women who quit smoking within the past 20 years, those with periodontal disease had a 36% higher risk of developing breast cancer. Women who were smokers at the time of the study had a 32% higher risk if they had periodontal disease, but the association was not statistically significant. Among those who had never smoked and those who had quit more than 20 years ago, the risk of developing breast cancer was increased 6% and 8%, respectively, if they had periodontal disease.

12 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016 • www.OncologyNurseAdvisor.com

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

Jiajoyce R. Conway, DNP, FNP-C, AOCNP, NP-C, 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.

QUESTIONS & ANSWERS MANAGING TSH LEVELS AFTER TOTAL THYROIDECTOMY How should thyroid-stimulating hormone (TSH) be managed so its levels can be maintained within the normal range after total thyroidectomy for cancer of the papillary thyroid? Despite monthly monitoring of T3, my patient experienced hypo/hyperthyroidism three times in a year. What would be the ideal TSH level for these patients? Should we monitor for other biomarkers? —Name withheld on request Suppression of thyroid-stimulating hormone (TSH) after thyroidectomy for low-risk cancer can increase the risk of osteoporosis in women without cutting back on cancer recurrence, according to some reports.1 TSH suppression was defined as a median level of 0.4 mU/L or less. According to a retrospective study, those women who were found to suppress their TSH levels had a more than three-fold increased risk of osteoporosis than those whose levels were not suppressed.1 TSH is known to help stimulate tumor growth, invasion, angiogenesis, and thyroglobulin secretion in postoperative patients who are placed on thyroid hormone, which is approximately 1 mg/lb dose. For those who are considered to be low-risk patients, the recommendation is to maintain the serum TSH level just below the lower limit of the normal range, 0.1 to 0.4 mU/mL.2 In high-risk patients, the dosage is adjusted to maintain a serum TSH level of less than 0.1 mU/mL, and this has been reported to improve tumor free survival. The goal of the therapeutic efforts should focus on avoiding harm in the aftermath of the total thyroidectomy for cancer of the papillary thyroid.2 —Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS REFERENCES 1. Fiore K. TSH suppression: More harm than good after cancer surgery? Medpage Today Web site. 2015. http://www.medpagetoday.com/MeetingCoverage/ATA/42381. Accessed September 2, 2015. 2. Endocrine surgery: Long-term follow-up of thyroid cancer. Weill Cornell Medical College Web site. http://www.cornellsurgery.org/pro/services/endocrine/thyroid-follow-up.html. Accessed September 2, 2015.

HANDLING CLOSED SYSTEM DEVICE-INCOMPATIBLE CHEMOTHERAPY AGENTS What is the recommended best practice for preventing accidental exposure/ leaks when administering chemotherapy drugs that are incompatible or have unknown compatibility with the closed system device (CSD) utilized by the facility (eg, bendamustine is incompatible with most CSDs)? —Name withheld on request

DO YOU HAVE A QUESTION FOR OUR CONSULTANTS? Send it to editor.ona@haymarketmedia.com.

14 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016 • www.OncologyNurseAdvisor.com

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Frustrating and aggravating it can be, but I don’t know many nurses who choose this field of care—and it is a choice, especially if you stay in it for any length of time—who think to do anything else. National Institute for Occupational Safety and Health (NIOSH) recommends using CSDs when transferring hazardous drugs from primary packing such as vials to dosing equipment. The NIOSH proposed Vapor Containment Performance Protocol for closedtransfer devices is a useful assessment tool or guideline to evaluate containment efficacy of CSDs without creating potential exposures. Agents must be primed separately via a separate line with normal saline under an approved chemotherapy hood, and infused separately via free-flowing line. Alternative compatible syringes, vials and devices that have been tested and approved must be substituted. The stability and half-life of the medications should be taken into consideration when dealing with infusion times and methods. Specific guidelines vary by institutions, and no general guidelines relative to the type of replacement devices have been established. —Jiajoyce Conway, DNP, FNP-C, AOCNP, NP-C

FOLFIRINOX REGIMEN SEQUENCE What is the correct sequence for infusing FOLFIRINOX? —Helen Yung, BSN FOLFIRINOX regimen involves four drugs: oxaliplatin (Eloxatin, generics), leucovorin (Fusilev, generics), irinotecan (Camptosar, generics), and fluorouracil. The regimen sequence is as follows: Day 1 • Oxaliplatin 85 mg/m2 IV over 2 hours (total dose/cycle, 85 mg/m2) • Leucovorin 400 mg/m2 IV over 2 hours (total dose/cycle, 400 mg/m2) • Irinotecan 180 mg/m2 IV over 90 minutes (total dose/cycle, 180 mg/m2) • Fluorouracil 400 mg/m2 IV bolus; followed by 2,400 mg/m2 IV continuous infusion (CI) over 46 hours beginning on Day 1 (total dose/cycle [bolus and CI], 2,800 mg/m2) Repeat this cycle every 14 days until disease progression or unacceptable toxicity. Recommended course is 12 cycles. —Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS

MY PERSPECTIVE ON BEING AN ONCOLOGY NURSE How would you describe being an oncology nurse? —Name withheld on request

Oncology nursing is a dynamic career full of incredible learning experiences in an ever-evolving field; one that allows me to use the full breadth of my nursing knowledge, from clinical skills to therapeutic communication to research and teaching. But so much more than that, caring for patients with serious life-limiting illness has taught me what is truly important in my own life, how to focus on the here and now, and how to be thankful for every day. And that’s a lesson I don’t mind relearning. —Susanne Menon, NP, OCN, ACHPN Nursing in general is a nurturing and caring profession. But Oncology Nursing is so much more—yes, I capitalized the O and N intentionally! Working in cancer care has given me opportunities to share and learn from patients and families like never before. The bonding that can take place in caring for loved ones is unlike anything else I have seen, except for the wonderment of a new mother’s eyes when she sees her child for the first time. Frustrating and aggravating it can be, but I don’t know many nurses who choose this field of care—and it is a choice, especially if you stay in it for any length of time—who think to do anything else. Challenging but rewarding. Never boring. —Rosemarie A. Tucci, RN, MSN, AOCN As an oncology nurse, I treasure that we are able to use our past experiences with many patients/families in order to help the newly diagnosed and their families through a very difficult and new situation to them. Plus, our clinical expertise (on chemo, diagnostic tests, genetics, etc.) is often used to educate, as well as alleviate physical and psychosocial side effects of cancer treatment. On the flip side, I enjoy working with a lot of smart people (oncologists, radiologists, physical therapists, social workers, fellow nurses) who all are dedicated to the fight against cancer. Our collective goal is really quality of life for our patients/families. Finally, when networking with oncology nurses from all over, it’s great to connect with people that are passionate about quality cancer care, often sharing very similar stories of the ups and downs of onc nursing. —Frank dela Rama, RN, MS, AOCNS Oncology nursing is the most rewarding specialty field of nursing. Although it is physically, mentally, and emotionally challenging,

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2016 • ONCOLOGY NURSE ADVISOR 15

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From health promotion, to symptom management, to end-of-life care, we are able to make a difference not only in patients’ lives, but their families. I can never imagine working in something other than oncology. Advisor Forum Continued from page 15

it enables you to truly practice, teach, and mentor holistic care. From health promotion, to symptom management, to end of life care, we are able to make a difference not only in patients’ lives, but their families. I can never imagine working in something other than oncology, and I’m proud to be part of this amazing profession. —Leah A. Scaramuzzo, MSN, RN-BC, AOCN When describing how I view being an Oncology Nurse, one word comes to my mind, and that is humble. The path of disease that we cross within the discipline of oncology—cancer—is disruptive, and intrusive, and shows up in the midst of everyday life. I have had the privilege to take care of some of the most wonderful people whose lives have been disrupted by cancer. As they journey towards survivorship, I am humbled by their strength, courage, and perseverance in life. The opportunity to serve these men and women is a privilege and honor, it gives me the opportunity to

encourage them on their journey of hope and survivorship, and celebrate the gift of life. Either through touch, supportive care, or just being there, all that I do makes a difference from the greatest to the least. —Jiajoyce R. Conway, DNP, CRNP, AOCNP A nurse contemplating the wonders and drawbacks of a career in oncology nursing submitted this question to the Oncology Nurse Advisor Forum. We posed the question first to our editorial board for their perspective on being an oncology nurse; now we’d like to hear your thoughts on what your career means to you. Send us your thoughts, in approximately 150 words or less, to editor.ONA@ HaymarketMedia.com with the subject line “being an oncology nurse.” —The Editors

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NAVIGATOR NOTES

dvances in cancer care have resulted in an increasing number of survivors of many types of cancers. A new challenge for oncology clinicians is to help their colleagues in primary care and other specialties care for patients with long-term and late effects years after completing their cancer treatments. The nurse navigator is a key part of that team. They are poised to help patients return to nononcology clinicians with a plan for managing their health care as cancer survivors, yet keep their connections with their oncology team for continued monitoring for recurrent disease and new cancers. The American Society of Clinical Oncologists collaborated with the A mer ican Academy of Fa m i ly Physicians and the American College of Physicians on the 2016 Cancer Survivorship Symposium. Here is a synopsis of some of the news from their inaugural event. Improved adherence Nurse-navigated treatment summaries and survivorship care plans (TSSCPs) may improve adherence to first treatment recommendations and follow-up appointment attendance in medically underserved patients with breast cancer; however, time to treatment may not improve. In this study, researchers in the Division of Nursing Research and Education at City of Hope in Duarte, California, sought to evaluate the benefits of a nurse-navigated, culturally and linguistically responsive TSSCP for underserved patients with breast cancer. Adherence to treatment and follow-up

Survivorship: The Transition Back to Primary Care Joyce Pagán

in 26 patients who received TSSCPs was compared with 38 patients who did not receive TSSCPs. All patients had Medicaid insurance and 47% were racial and/or ethnic minorities. Patients were educated and assisted by a trained nurse in the use and

completion of the TSSCP at their first clinic visit. Nurse-navigated TSSCPs were then completed at each subsequent visit through 12 months of follow-up. Adherence to first treatment recommendations was 96% in the TSSCP arm vs 79% in the non-TSSCP group (P=.07). Furthermore, 88% of patients in the TSSCP arm and 73% of patients in the non-TSSCP arm adhered to all follow-up visits (P=.31). Seamless transition to adult care An established transition plan with a shared nurse navigator minimized anxiety experienced by patients who are survivors of childhood cancers transitioning from pediatric care to adult care. Although the importance of transitioning survivors of childhood cancers from pediatric care to adult care is acknowledged in the literature, barriers such as patient and provider anxiety, complexity of the health care system, and lack of knowledge regarding late effects impede smooth transfers to adult care. A work group of clinicians at Children’s Mercy (CM) and the University of Kansas Cancer Center (KUCC) collaborated to design a program that would reduce these barriers. The group met and reviewed models and delivery of survivorship care over 2 years to determine best practices. They identified use of a shared nurse navigator as an essential component of a seamless patient transition, and launched the Survivorship Transition Clinic (STC) at KUCC in July 2014. In this program, the nurse navigator’s support begins as the patient’s transition starts at CM. The same nurse navigator works with the patient to initiate adult

Nurse-navigated TSSCPs improve adherence to first treatment recommendations and follow-up appointment attendance. 20 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016 • www.OncologyNurseAdvisor.com

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survivorship care at KUCC STC. The nurse navigator provides treatment summaries and patient education, and orchestrates the survivorship referral services for the patient. Since the program launch, 16 of 16 survivors successfully transitioned from pediatric to adult survivorship care. Patient satisfaction surveys reflected a positive response to the program. Patients expressed relief that they had a familiar person to help them connect with their new health care team. Working with a nurse with whom they had an established relationship provided continuity of care throughout the transition. In addition, communications between the pediatric care team, adult primary care clinicians, and the subspecialists involved in the patients’ care were improved.

recommendations for further care, personalized breast cancer treatment summaries, and a list of resources such as patient support groups. The patients who received the survivorship care intervention also received a 1-hour counseling session with the survivorship care nurse. The session included role-play that coached the women on how to ask their physicians to implement the survivorship care recommendations.

Patient outcomes were significantly improved with survivorship plans.

Benefits of personalized care plans

A randomized, controlled clinical trial demonstrated that patient outcomes were significantly improved with survivorship care plans. Survivor health outcomes are affected by survivors’ breast cancer knowledge, confidence in interacting with physicians, and having a usual source of health care (eg, primary care physician). In this study, 212 low-income women with stage 0-III breast cancer were randomized to receive a survivorship care intervention or usual care. The intervention group completed a questionnaire assessing their needs and concerns, such as hot flashes, memory problems, weight gain, and sexual dysfunction, they then received recommendations on further care. The personalized survivorship care plans were drafted by a survivorship care nurse and provided to both the patient and their physicians of record (oncologist, surgeon, primary care physician). The plans included

At 12 months, adherence to the survivorship care recommendations was approximately 9.5% greater among the patients in the intervention group, compared with the patients in the usual care group (60.6% vs 51.1%). Health outcomes can ultimately be improved through increasing patient self-efficacy in interacting with physicians, breast cancer knowledge, and ensuring a usual source of care. Follow-up among AYA survivors of Hodgkin lymphoma Within the first

year posttreatment, more than half (52%) of Hodgkin lymphoma survivors did not receive all recommended care. However, 96% had had their recommended oncology visits and 70% had had the recommended laboratory tests within the first 5 years. Although standard treatments of chemotherapy and radiation for Hodgkin lymphoma are very effective and most patients survive past 5 years, survivors remain at high risk for long-term and

late effects of treatment, such as heart and thyroid problems, lung disease, second cancers, infertility, and psychosocial problems. The onset of late effects varies, with complications in some cases emerging as late as 10 years after treatment. This study assessed adherence to the National Comprehensive Cancer Network (NCCN) posttreatment guidelines. The study included 354 survivors of Hodgkin lymphoma whose disease was diagnosed at age 15 years to 39 years. The average length of followup was 6 years. The commonly lacking services were psychosocial counseling and appropriate vaccines. Patients whose disease was diagnosed in more recent years (2006 to 2010) were more likely to adhere to the recommended posttreatment care than were those whose disease was diagnosed between 2000 and 2005. Imaging to screen for recurrences and new cancers was both overused and underused. Two-thirds of survivors underwent a recommended CT scan in the first 12 months posttreatment; however, nearly half also received nonrecommended CT scans in year 2. In addition, a third of survivors underwent nonrecommended surveillance PET scans. Clinical indications for these tests were not determined. Persistent CIPN symptoms Among women cancer survivors, 45% still experience symptoms of chemotherapyinduced peripheral neuropathy (CIPN) years after they had completed their cancer treatment. Peripheral neuropathy is a relatively common side effect of specific types of chemotherapy, affecting an estimated 57% to 83% of patients during or after their treatment. Chemotherapy drugs known to injure peripheral nerves Continued on page 42

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2016 • ONCOLOGY NURSE ADVISOR 21

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FEATURE | Pulmonary Nodule Program

Inconclusive: The Pulmonary Nodules You Need to Follow Focused on early detection, this health care system’s program seeks to follow up all lung nodules seen on thoracic imaging studies throughout its facilities.

Color-enhanced axial CT showing several lung nodules (red).

ROSEMARIE A. TUCCI, RN, MSN, AOCN; K. LYNNE QUINN, RN, MSN, CRNP, AOCNP

ulmonary nodules may be identified through calcium CT scoring scans, radiographs for surgery clearance, abdominal CT scans, or secondary to an accident to the thorax requiring radiographs. The cardiologist, general surgeon, or emergency physician may refer the patient back to the PCP rather than to a pulmonologist. But will this land on the top of the referral pile? Are PCPs aware of the standards for 2-year follow-up? An inconclusive pulmonary nodule program can navigate patients whose nodule is not identified within the continuum of cancer care to either benign disease or an early diagnosis of cancer, based on Fleischner criteria.1 Programs that identify pulmonary nodules in high-risk patients are a priority with the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI), as evidenced by the changes in clinical research grants from CCOP to NCORP with an emphasis on prevention studies. But how should health care systems manage those patients whose nodules were identified on radiographs or scans in cases where a primary care physician (PCP) or pulmonologist was not involved? How many of these patients are missed at an early stage and are not picked up until the nodule is a cancer? Many hospitals are creating lung-screening programs for high-risk persons, and some cancer programs are establishing lung nodule clinics to address this specific issue. This article reviews

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the program developed for the Main Line Health regional health system in Lankenau, Pennsylvania, area. FROM A PILOT TO A SYSTEM-WIDE PROGRAM Our Pulmonary Nodule Program started as a pilot project at Lankenau Medical Center, the teaching institution in a regional health system that consists of 4 acute-care hospitals. Therefore, physician awareness and education was crucial in that we needed to work with not only attending physicians, but residents and fellows in a multitude of specialty areas as well. Creating a pilot program at 1 hospital was challenging; expanding it across an entire health care system required cooperation from multiple interdisciplinary teams. We found the keys to a successful program are to educate physician groups on appropriate referrals and follow-up, to keep tabs on patients’ follow-up needs, and to maintain communications with all involved. Issues of sharing information related to the patient with multiple electronic medical records (EMRs) or paper charts, however, are an ongoing work in process.

The goal of this program is to catch lung cancer earlier in its transition (stage I-II) vs the current timeline (stage III or IV). Multiple tumor board discussions regarding cancer cases with a notation of pulmonary nodules brought up the question of who was responsible for following up these nodules, regardless of the cancer diagnosis. For example, a patient with a known colorectal cancer is found to have a 4 mm nodule in the right upper lobe (RUL). GI knows about the nodule, but has someone put in for a pulmonary consult or called the nurse navigator to follow up the finding? When these types of cases became increasingly evident, marketing tools were created to promote the Pulmonary Nodule Program to other clinical staffs. The tools were designed to remind all clinicians of the program and encourage referral when nodules were seen in the course of treating the patient. Appropriate utilization of a nurse navigator who works with the care team reduces outward migration of care as well as early diagnosis of pulmonary cancers, which can lead to an improved quality of life for our patients. Oncology nurses are

in a unique position to manage the nontraditional patient, from determining that a nodule exists to designation of a benign or malignant outcome. The support of the Cancer Committee at each hospital, along with that of senior administration, made expanding the program from a pilot at 1 hospital to a full-fledged program across 4 acute-care hospitals within a regional health care system easier. Clinician education and identification of appropriate referrals is an ongoing need; however, the nurse navigator attends 1 to 2 tumor board meetings at each hospital each month, so knowledge of the program is continuing to grow and referrals are being made increasingly quicker. HOW THE PROGRAM SHOULD WORK A key element of ensuring early diagnosis of lung cancer is timely access to care; specifically, reducing the time from abnormal finding to treatment, if necessary. Often lung nodules are identified during diagnostic CT scans conducted for an unrelated condition. When completing a report for a referring physician, the radiologist sends a copy of the report of abnormal findings to the nurse navigator, who reviews the report with a pulmonary physician. The appropriate follow-up is then recommended. The nurse navigator then contacts the patient’s primary care physician and offers to follow up the patient within the pulmonary nodule program, if the physician wishes. Unless the primary care physician indicates a preference for a specific pulmonologist or other hospital/system, the patient will be seen as soon as possible (in 1 to 2 weeks). A pulmonologist runs the program, with a multidisciplinary team that evaluates patients, referring all patients with a malignancy to the lung cancer program. This process significantly reduces time from nodule identification to appropriate treatment while also driving patient volume to the cancer program. HOW IT MIGHT HAVE TO WORK

Some radiology department clinicians feel uncomfortable sending these reports directly to the nurse navigator, citing HIPAA regulations as well as possible Stark Law violations. If this is the case, the nurse navigator must wait for the ordering physician to direct the patient to the program, either by making the referral call themself or by having the patient/family call the program. This step increases the need to educate primary care and specialty physicians. Sometimes, the doctor will call the pulmonary department directly, and they place the patient into the Pulmonary Nodule Program for ongoing follow-up. Continued on page 24

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FEATURE | Pulmonary nodule program

Reminder Serves as an Effective Marketing Tool In the course of treating a patient, clinical staff may see a nodule on a patient’s imaging study and note it in the chart. But has a pulmonary consult been requested? Or the nurse navigator called? Our handout serves to remind clinical staffs within our health system to refer patients as needed. Simple wording, as in this example, makes a very effective marketing tool.

For referring physicians If you refer a patient to the Pulmonary Nodule Program at [XXX Medical Center], you can expect your patient to be seen in less than 10 working days—most often he or she can undergo a diagnostic procedure within a week. Our medical team will communicate all diagnostic plans and findings with you, and provide any additional work-up if needed. We will also provide ongoing radiographic follow-up, if indicated, for nodules not amenable to tissue diagnosis. Once a diagnosis is obtained, we will handle any referrals to specialists that may be needed; we serve as a single entry point into [XXX Medical Center].

Why choose us? Fast, accurate assessments

The Pulmonary Nodule Program at [XXX Medical Center] is committed to providing patients with the most accurate, rapid assessment of nodules and lesions. High-risk patients can typically expect to see a physician within 2 weeks of having a nodule identified. Physicians will provide a clear explanation of the best course of action for diagnoses and treatment. And once that is decided, patients’ diagnoses are determined with not only the best equipment available, but by the multidisciplinary pulmonary clinic team at [XXX Medical Center]. Advanced diagnostics Early, accurate diagnosis is the best way to end worries or begin a course of treatment. In the Pulmonary Nodule Program at [XXX Medical Center], we use the most precise, least invasive tools to diagnose nodules.

Regardless of which way the patient enters the program, the following points then need to occur. • The multidisciplinary team orders the appropriate diagnostic test following the Fleischner guidelines for the patient’s lung condition (eg, pulmonary nodule, pleural effusion, interstitial lung disease). • Patient is scheduled for a consult within 1 to 2 weeks. • All patients with lung nodules or masses meet with the pulmonary team to discuss biopsy options and determine resulting course of treatment as needed. Nurse navigators also have a critical role to play in streamlining patients’ access to care. Three tactics for proactively pulling patients into the thoracic program include leverage radiology data, keep an eye on the calendar, and network with pathology. Leverage radiology data The nurse navigator receives reports of abnormal findings from the Radiology Department weekly, if permissible. The nurse navigator can check with

the hospital’s legal department on whether this is allowable. If the nurse navigator cannot proceed without a formal referral, primary care physicians, emergency department physicians, hospitalists, internal medicine physicians, residents, and fellows, as well as any other clinicians who may be a member of the patient’s nononcology health care team, should be educated on how and why to contact the Pulmonary Nodule Program for appropriate patient follow-up. The nurse navigator then directly follows up with the primary care physician for any patients who meet the criteria for treatment in the thoracic center. Diagnostic work-up is streamlined, as navigators may not require a physician’s approval for every test if the program’s multidisciplinary team has established guidelines for proceeding ( Table 1). If no guidelines are established, the nurse navigator continues to work with the ordering physician to ensure appropriate actions take place in a timely manner. Keep an eye on the calendar Pulmonary Nodule Program nurse navigators may have access to the pulmonary and

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thoracic surgery calendar. If they do not, frequent and open communication with the Pulmonology and Thoracic Surgery office staff is key to ensuring appropriate and timely follow-up. Network with Pathology Department Pathology reports may be printed directly in nurse navigator’s office. The nurse navigator reviews the reports, identifies those with positive thoracic findings, and alerts the pulmonologist. The nurse navigator then reaches out to treatment physicians of those patients. Effective and efficient communication between physicians and nurse navigators is paramount to streamlining patient care, particularly during the diagnostic phase of patient care. All too often, patients experience significant delays because the diagnostic tests needed to determine their treatment plan require physician approval. As this health care system is COC accredited, we utilized the development of this program to meet programmatic metrics for ongoing accreditation. We created metrics for the program using the SMART methodology, and these metrics are currently being collected2: • Development of marketing tools for the program; • Collection of data regarding total number of patients in the program, number of cancers detected, and stage of cancer at detection; • Timely appointments with pulmonologist postinitial incidental identification of pulmonary nodule (within 5 to 10 working days). SUMMARY Pulmonary Nodule Programs are being developed to identify and follow abnormalities in persons that may or may not be cancerous at the time of diagnosis. However, some may lead to cancer as time progresses. The goal of this program is to catch lung cancer earlier in its transition (stage I-II) vs the current timeline (usually stage III or IV). Utilizing an oncology nurse as navigator gives credence to the program that we are being proactive about early detection of lung cancer. In addition, oncology knowledge can be applied to review of imaging studies and setup of necessary patient appointments. As oncology nurses, all of us know of cases in which a lung nodule looks benign but

ON THE

WEB

MAJOR RECOMMENDATIONS FOR LUNG NODULE FOLLOW-UP You can see this comprehensive chart in the online version of this article, or use this quick link: http://bit.ly/1Pn4Sdc.

TABLE 1. Diagnostic Work-up for Pulmonary Nodule Chest CT • Chest computed tomography (CT) ordered not more than 45 days prior to Pulmonary Nodule Program office visit • If previous imaging was only positron emission tomography (PET)/CT, order a separate chest CT per the following – IV contrast (if the patient’s blood urea nitrogen/creatinine is within normal limits) – Coronal and sagittal reconstructions PET/CT • If insurance will not pay for PET/CT without a tissue diagnosis of cancer – Review case and CT scan – Determine which option is most appropriate ■■

Percutaneous biopsy by interventional radiography

■■

Surgical biopsy

■■

Proceed without a PET/CT

Pulmonary function test • Within last 6 months

the patient’s previous medical history indicates that may not be the case. An appointment with a pulmonologist may be more of a priority for these patients than for other patients. Beyond what NCI and CDC believe to be important, quality patient care requires all of us to maintain routine screening and observation with appropriate intervention for any person in whom cancer is more than a normal-risk possibility. High-risk persons with pulmonary nodules will need follow-up scans for a minimum of 2 years to determine whether those nodules are benign or transitioning to cancer. A program in which nurse navigators with an oncology background work with a multidisciplinary pulmonary team is the best approach to providing our patients with the new standards of care. ■ Rosemarie Tucci is program coordinator for the MLH Lung Nodule Program at Main Line Health, in Lankenau, Pennsylvania. Lynne Quinn is the oncology director at Bryn Mawr Hospital, Main Line Health, in Bryn Mawr, Pennsylvania, and administrator of the Lung Cancer System Working Group for MLH. REFERENCES 1. MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: A statement from the Fleischner Society. Radiology. 2005;237(2):395-400. 2. Boise State University. Performance Management – Creating Smart Objectives: Participant Guide. April 24, 2007. http://www.falmouthinstitute.com/files/GV018/SMARTgoals.pdf. Accessed January 19, 2016.

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FEATURE | Management of Bone Metastasis

Primary Site, Therapy Duration Influence Radiation Palliation In a review of the Dutch Bone Metastasis Study results, palliative radiation therapy reduced pain and improved quality of life for select patients. BETTE WEINSTEIN KAPLAN

Sclerotic lesions (purple) in the spine of a man with metastatic prostate cancer

ncologists often turn to radiation therapy to treat painful bone metastasis, but how effective is it? Is the treatment reflected in the patient’s quality of life (QOL)? In a recent paper, investigators reviewed the Dutch Bone Metastasis Study for answers. They theorized that a reduction in pain would mean an improvement in QOL. They also sought to identify which patients were most likely to benefit from the radiation therapy palliation.1

DUTCH BONE METASTASIS STUDY The controlled Dutch Bone Metastasis Study evaluated 1157 patients who experienced painful bone metastases, from 1996 to 1998.2 Seventeen radiation therapy facilities throughout The Netherlands participated in the study. The clinics randomized patients to treatment schedules of 1 fraction of 8 Gy (the current gold standard for treatment) or 6 fractions of 24 Gy.1 Patients rated their pain, QOL, and overall health weekly for 12 weeks, then monthly for 2 years, until they died, or the study reached its endpoint. The goal of treatment was a reduction in the patients’ pain, and to that end, approximately 75% of patients across both regimens achieved relief.2 Although the original study did not consider tumor site, for this analysis the investigators grouped patients according to the location of their primary tumors. Thus, the 956 patients were divided into three groups: breast cancer, prostate cancer, and lung cancer.1 26 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016 • www.OncologyNurseAdvisor.com

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A NEW ANGLE ON THE FINDINGS No significant difference was seen in the response rate between the 2 treatment regimens. However, patient response rates changed over time. When the study began, 96% to 97% of patients responded to the treatment. After 6 weeks, the response rate was 73% to 75% of patients, and at the end of the 12 weeks, patient response rate had decreased to 61%.2 Baseline pain scores were comparable in the responding and nonresponding patients; however, other factors were different between the 2 study arms. When these researchers analyzed response rates in relation to cancer location, their findings show patients with prostate cancer responded significantly better than those with lung cancer. In fact, more of the patients who did not respond well to the radiation therapy had lung cancer and visceral metastases.

Patients who had prostate or breast cancer reported a better quality of life than those who had lung cancer. The responsive group was in better physical condition and less likely to have been on a systemic cancer treatment prior to radiation therapy. They were also younger. Mean age of those who responded well to the therapy was 64 years; mean age of those who did not respond to therapy was 67 years. Patients who responded well to the radiation treatment lived significantly longer than those who did not. Median survival was 35 weeks for the entire cohort, 16 weeks for the nonresponders, and 45 weeks for the responders. When the study closed, 67% of the responding patients had died whereas 87% of the nonresponding patients had died.1

Those patients who demonstrated a good response to the study’s radiation therapy regimen reported better QOL, especially during the first 3 months of treatment. Patients who had prostate or breast cancer reported a better QOL than those who had lung cancer. A number of factors related to QOL improved in the patients who responded well to the radiation therapy. For example, psychological and physical symptom distress scores improved in the responders; these scores declined in the nonresponders. In addition, activity-level impairment in the patients who responded remained stable, whereas it deteriorated among nonresponders. These differences worsened over time, becoming clinically relevant. CONCLUSION On multivariate analysis, these researchers found several baseline predictors for pain response: primary tumor in the prostate or breast, absence of visceral metastases, younger age, and use of opioids for analgesia. Which patients will experience improved QOL could not be accurately predicted, the investigators noted. However, 76% of the Dutch Bone Metastasis Study participants responded to the palliative radiation regimens, reporting reduced pain and improved QOL; therefore the researchers conclude that radiation therapy should be offered to all patients with painful bone metastases.1 ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Westhoff PG, de Graeff A, Monninkhof EM, et al; Dutch Bone Metastasis Study Group. Quality of life in relation to pain response to radiation therapy for painful bone metastases. Int J Radiat Oncol Biol Phys. 2015;93(3):694-701. 2. van der Linden YM, Lok JJ, Steenland E, et al. Single fraction radiotherapy is efficacious: A further analysis of the Dutch Bone Metastasis Study controlling for the influence of retreatment. Int J Radiat Oncol Biol Phys 2004;59(2):528-537.

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!

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FEATURE | Spiritual Care

Enabling the Connection With One’s Spiritual Identity Spirituality is an important part of patient care, but it is a challenging topic to broach. This guide helps nurses chart a course for this essential conversation. ELIZABETH EZRA, LCSW, OSW-C

s the efficacy of mind-body interventions in patients facing cancer is better appreciated by health care professionals, so should the importance of providing spiritual care as an integral component of patient care. The spiritual needs of patients, caregivers, and those who are posttreatment must be met along with their physical and emotional needs. The spiritual aspect of care helps to restore hope amidst the challenges that come with a cancer diagnosis. Clinician education that explores spiritual care practices, spirituality, and spiritual well-being is an essential component of comprehensive patient care. This type of education can lessen apprehension about spiritual care and foster a sense of openness in the patient-clinician relationship. Understanding diverse spiritual care practices increases clinician competence in the care provided. Including spiritual care in the medical care of people affected by cancer helps them feel that all aspects of their health are being appropriately addressed.

INTRODUCING SPIRITUALITY INTO CARE Spirituality can be difficult to define and, therefore, difficult to explore with people who have been affected by cancer. One’s spiritual identity, like one’s cultural identity, is a fluid quality, ever-changing, and distinctly personal. Some clinicians hesitate to broach the topic, leaving this essential support issue unexplored. Although bringing spirituality into the conversation is not easy, it is essential, as patients are 28 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2016 • www.OncologyNurseAdvisor.com

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FEATURE | Spiritual Care dealing with very existential issues. What is the meaning of life? How is the meaning different now? How can you find meaning in life when affected by cancer? A sense of meaning, purpose, and connection beyond oneself can enhance one’s quality of life. Numerous studies conducted over decades have shown that people with cancer have less anxiety, depression, and pain when they feel spiritually connected.

This is when we hear about regrets and spiritual pain, as well as the often-surprising upsides of a cancer diagnosis. Nourishing your patient’s spiritual voice in the face of a serious diagnosis will help them find meaning, untapped strengths, and needed connections. As clinicians, we are charged with helping patients learn to take care of their spiritual side as we encourage them to use all their strengths to effectively manage their diagnosis and the changes it demands. The goal is to initiate the conversation and to breathe life into the exploration of spirituality. EXPLORING SPIRITUAL IDENTITY

One’s sense of spirit is entwined in everything we do. Spiritual identity is challenged at the time of diagnosis or illness because of the strain on one’s established coping skills and the existential questions it brings up. When we talk to our patients about their cancer story, inevitably death or the fear of death comes into the room. Talking about death without talking about the meaning of life is challenging; even more challenging is to talk about meaning without talking about spirituality. This natural progression gives us a generous platform from which to explore how the patient is making connections with others, with nature, with a higher power, and with themselves. This is when we hear about regrets and spiritual pain, as well as the inspiration and, sometimes, the often-surprising upsides of a cancer diagnosis.

FIND US ON

Exploring spiritual identity helps us explain how spirituality leads one to find meaning and connection. People find this inspirational and grounding in many ways, and hopefully at this point, physical and psychological healing has begun. Helping patients formalize and put their thoughts into words has a powerful and regenerative affect. The goal is to increase the attention given to this important aspect of our patient’s lives. INITIATING THE CONVERSATION A strong therapeutic relationship is essential when broaching difficult subjects. The therapeutic relationship needs an atmosphere of trust, respect, and openness to grow. Clinicians should offer a meditative attitude using patience, gentleness, and compassion to foster this atmosphere. However, there can be obstacles and challenges to getting the conversation started. Questions that can help open the conversation include those that encourage reflecting on the moments in life that have special meaning. When have you witnessed or experienced truly remarkable human compassion? When have you experienced waves of hope? Or, simply, what do you do to soothe yourself ? There are many entrees into this profound dialogue. The words chosen do not lessen the importance of finding access to a patient’s spiritual side. THE SPIRITUAL SELF

Clinicians should be aware of their own feelings about spirituality and spiritual identity. What comes to mind when you think about spiritual identity? Do you hear your own spiritual language? Which beliefs give you meaning? What rituals keep you grounded? What nourishes you and gives you hope? Is this part of your self-care regime? Self-care and nourishing one’s soul are an essential part of the work we do every day interacting with clients and their families as they face illness and death. We often neglect ourselves and do not listen to our own advice. The more we understand the necessity of this practice for ourselves, the better prepared we are to guide others in this important intersection of life. ■ Elizabeth Ezra is Pancreatic Cancer Program Coordinator at CancerCare.

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STAT CONSULT Cobimetinib (Cotellic) Drug Type

• Kinase inhibitor Indications

• Treatment of patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation, in combination with vemurafenib

Mechanisms of Action

• Cobimetinib is a reversible inhibitor of MEK1 and MEK2 • MEK proteins are involved in the ERK signaling pathway, which promotes cellular proliferation • BRAF V600E and V600K mutations activate the BRAF pathway, which also includes MEK1 and MEK2 Dosage and Administration

• 60 mg orally once daily on days 1 to 21 of each 28-day cycle • Continue 28-day cycles until disease progression or unacceptable toxicity • Take cobimetinib with or without food Dosage Adjustments

• First dose reduction: 40 mg orally once daily • Second dose reduction: 20 mg orally once daily • Subsequent modification: Permanently discontinue cobimetinib if unable to tolerate 20 mg dose • Hemorrhage — Grade 3 ■ Withhold drug for up to 4 weeks » If improved to grade 0 or 1, resume at next lower dose » If not improved within 4 weeks, permanently discontinue — Grade 4 ■ Permanently discontinue • Dermatologic reactions — Grade 2 (intolerable), 3, or 4 ■ Withhold or reduce dose • Photosensitivity

— Grade 2 (intolerable), 3, or 4 ■ Withhold drug for up to 4 weeks » If improved to grade 0 or 1, resume at next lower dose » If not improved within 4 weeks, permanently discontinue • Cardiomyopathy — Asymptomatic, absolute decrease in left ventricular ejection fraction (LVEF) from baseline of >10% and less than institutional lower limit of normal (LLN) ■ Withhold drug for 2 weeks; repeat LVEF ■ Resume at next lower dose if all of the following are present: » LVEF ≥LLN » Absolute decrease from baseline LVEF ≤10% ■ Permanently discontinue if any of the following are present: » LVEF <LLN » Absolute decrease from baseline LVEF >10% — Symptomatic LVEF decrease from baseline ■ Withhold drug for up to 4 weeks; repeat LVEF ■ Resume at next lower dose if all of the following are present: » Symptoms resolve » LVEF is ≥LLN » Absolute decrease from baseline LVEF ≤10% ■ Permanently discontinue if any of the following are present: » Symptoms persist » LVEF <LLN » Absolute decrease from baseline LVEF >10% Continued on page 32

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STAT CONSULT • Serous retinopathy or retinal vein occlusion ——Serous retinopathy ■■ Withhold cobimetinib for up to 4 weeks »» If improved to grade 0 or 1, resume at next lower dose »» If not improved to grade 0 or 1 within 4 weeks, permanently discontinue ——Retinal vein occlusion »» Permanently discontinue • Rhabdomyolysis and CPK elevations ——Grade 4 CPK elevation or any CPK elevation and myalgia ■■ Withhold cobimetinib for up to 4 weeks »» If improved to grade 3 or lower, resume at next lower dose »» If not improved within 4 weeks, permanently discontinue • Other ——Grade 2 (intolerable) adverse reactions or any grade 3 adverse reactions ■■ Withhold cobimetinib for up to 4 weeks »» If improved to grade 0 or 1, resume at next lower dose level »» If not improved within 4 weeks, permanently discontinue ——First occurrence of any grade 4 adverse reaction ■■ Withhold cobimetinib until adverse reaction improves to grade 0 or 1, then »» Resume at next lower dose, or »» Permanently discontinue ——Recurrent grade 4 adverse reaction ■■ Permanently discontinue cobimetinib • Dose modification for concurrent CYP3A4 inhibitors ——Do not use strong or moderate CYP3A4 inhibitors with cobimetinib ——If concurrent short-term (≤14 days) use of moderate CYP3A4 inhibitors is unavoidable in patients taking cobimetinib 60 mg, reduce cobimetinib dose to 20 mg ■■ After discontinuation of moderate CYP3A4 inhibitor, resume cobimetinib 60 mg dose ——Use an alternative to a strong or moderate CYP3A4 inhibitor in patients taking a reduced dose of cobimetinib Specific Populations

• Pregnancy ——Cobimetinib can cause harm to the fetus when administered to a pregnant woman, based on its mechanism of action

• Nursing mothers ——Because of the potential for serious adverse reactions in a breastfed infant, advise a nursing mother not to breastfeed during treatment and for 2 weeks after final dose • Pediatric ——Not established • Geriatric ——Not established • Renal impairment ——Dose adjustment not recommended for mild to moderate renal impairment ——A recommended dose has not been established for patients with severe renal impairment • Hepatic impairment ——No dose adjustment is recommended for patients with mild hepatic impairment • Patients of reproductive potential ——Advise females to use effective contraception during treatment and for 2 weeks after final dose Boxed Warnings/Contraindications

• None Cautions

• New primary malignancies (cutaneous and noncutaneous) ——Monitor patients for new malignancies prior to initiating therapy, while on therapy, and for up to 6 months after last dose of cobimetinib • Hemorrhage ——Major hemorrhagic events can occur with cobimetinib ——Monitor for signs and symptoms of bleeding ——Withhold cobimetinib for grade 3 hemorrhagic events ■■ If improved to grade 0 or 1 within 4 weeks, resume at a lower dose level ——Discontinue for grade 4 hemorrhagic events and any grade 3 hemorrhagic events that do not improve • Cardiomyopathy ——Risk of cardiomyopathy is increased in patients receiving cobimetinib with vemurafenib compared with vemurafenib as a single agent ——Safety of cobimetinib has not been established in patients with decreased LVEF ——Evaluate for LVEF before treatment, after 1 month of treatment, then every 3 months thereafter during treatment • Serous retinopathy and retinal vein occlusion ——Perform an ophthalmologic evaluation at regular intervals and for any visual disturbances

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——If serous retinopathy is diagnosed, interrupt cobimetinib until visual symptoms improve ■■ Manage serous retinopathy with treatment interruption, dose reduction, or with treatment discontinuation ——If retinal vein occlusion is diagnosed, permanently discontinue cobimetinib • Hepatotoxicity ——Monitor liver function via laboratory testing before initiating cobimetinib and monthly during treatment, or more frequently as clinically indicated ——Manage grade 3 or 4 liver function abnormalities with dose interruption, reduction, or discontinuation • Rhabdomyolysis ——Monitor CPK periodically and as clinically indicated for signs and symptoms of rhabdomyolysis (eg, dark, reddish urine; muscle weakness) ——Depending on the severity of symptoms or CPK elevation, dose interruption or discontinuation of cobimetinib may be necessary • Severe dermatologic reactions ——Monitor for severe rashes ——Interrupt, reduce, or discontinue cobimetinib as indicated • Severe photosensitivity ——Advise patients to avoid sun exposure, wear protective clothing, and use a broad-spectrum ultraviolet (UV) A/UV B sunscreen and lip balm when outdoors ——Manage intolerable grade 2 or greater photosensitivity with dose modifications • Embryo-fetal toxicity ——Cobimetinib can cause harm to the fetus ——Advise females of reproductive potential to use effective contraception during treatment and for 2 weeks following the final dose • Most common adverse reactions (≥20% of patients) ——Diarrhea ——Nausea ——Photosensitivity reaction ——Pyrexia ——Vomiting • Most common grade 3-4 abnormalities in laboratory test results (≥5%) ——Hyponatremia ——Hypophosphatemia ——Increased alkaline phosphatase ——Increased ALT ——Increased AST ——Increased CPK

——Increased GGT ——Lymphopenia Drug Interactions

• Coadministration with strong or moderate CYP3A4 inhibitors ——Coadministration with strong CYP3A4 inhibitor (eg, itraconazole) increased cobimetinib systemic exposure by 6.7-fold ——Avoid concurrent use with strong or moderate CYP3A4 inhibitors ——If concurrent short-term (≤14 days) use of moderate CYP3A4 inhibitors (including certain antibiotics [eg, erythromycin, ciprofloxacin]) is unavoidable for patients taking cobimetinib 60 mg, reduce dose to 20 mg ■■ After discontinuation of a moderate CYP3A4 inhibitor, resume cobimetinib at the previous dose ——Use an alternative to a strong or moderate CYP3A4 inhibitor in patients taking cobimetinib 40 mg or 20 mg daily (reduced dose) ——Coadministration with a strong CYP3A4 inducer may decrease cobimetinib systemic exposure by more than 80% and reduce its efficacy ——Avoid concurrent with strong or moderate CYP3A4 inducers (eg, carbamazepine, efavirenz, phenytoin, rifampin, and St. John’s Wort) What to Tell Your Patient

• Cobimetinib is a prescription medicine used with vemurafenib to treat melanoma, a type of skin cancer, with a certain abnormality in the BRAF gene that has spread to other parts of the body or cannot be surgically removed • Tell your doctor or nurse if you ——Have any previous or current skin problems other than melanoma ——Have any medical conditions and/or are taking any medications that increase your risk of bleeding ——Have any heart, eye, liver, or muscle problems ——Have any other medical conditions ——Are pregnant or plan to become pregnant ——Are breastfeeding or plan to breastfeed • Take cobimetinib exactly as instructed by your nurse or doctor • Take cobimetinib 1 time each day with or without food for 21 days, followed by a 7-day rest period • If you miss a dose, skip the missed dose, and take the next dose as scheduled Continued on page 34

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STAT CONSULT • Cobimetinib should be stored at room temperature • While taking cobimetinib, you should avoid sun exposure ——Use lip balm and a broad-spectrum sunscreen • Cobimetinib may cause serious side effects, including the following: ——Increased risk of skin cancers ■■ Check your skin regularly and tell your nurse or doctor right away if you notice any changes in your skin ■■ Your nurse or doctor will check your skin before you start taking cobimetinib, every 2 months while you are taking cobimetinib, and for up to 6 months after you stop taking cobimetinib. ——Increased risk of bleeding ■■ Tell your nurse or doctor right away if you experience abdominal pain, blood in urine, dizziness, headache, red or black stools, unusual vaginal bleeding, or weakness ——Heart problems ■■ You will need to undergo testing to monitor your heart’s ability to pump blood before you start taking cobimetinib and during your treatment. ■■ Tell your nurse or doctor if you experience fatigue, increased heart rate, persistent cough or wheezing, shortness of breath, and/or swelling of your ankles and feet ——Rash ■■ Tell you nurse or doctor if you experience a rash that covers a large area of your body, blisters, or peeling skin ——Eye problems ■■ Tell your nurse or doctor if you experience blurred, distorted, or partly missing vision; halos; or any other vision changes ——Abnormal liver function or liver injury ■■ Tell your nurse or doctor if your skin or the white of your eyes turns yellow; you have dark or brown

urine; you experience nausea or vomiting, fatigue, or loss of appetite ——Photosensitivity ■■ Tell your nurse or doctor if you experience red, painful, itchy skin; sun rash; skin irritation; bumps or tiny papules; or thickened, dry, wrinkled skin ——Increased levels of certain enzymes in the blood ■■ Tell your nurse or doctor if you experience muscle aches; muscle spasms and weakness; or dark, reddish urine • The most common side effects of cobimetinib include: ——Diarrhea ——Fever ——Nausea ——Sunburn or sun sensitivity ——Vomiting • The most common changes in blood test results include: ——Decreased lymphocytes (white blood cells) ——Decreased phosphate, sodium, or potassium ——Elevated GGT, ALT, or AST (liver enzymes) ——Elevated CPK (muscle enzyme) ——Elevated alkaline phosphatase (liver or bone enzyme) • Females who can become pregnant should use an effective method of birth control during treatment and for at least 2 weeks after stopping cobimetinib ——Talk to your nurse or doctor about birth control methods that may be right for you ——Tell your nurse or doctor right away if you become pregnant or think you are pregnant while taking cobimetinib • Do not breastfeed during treatment with cobimetinib and for 2 weeks after your last dose ——Talk to your nurse or doctor about the best way to feed your baby during this time Prepared by Jason Hoffman, PharmD, RPh.

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RADIATION & YOUR PATIENT

Light micrograph of liver tissue affected by Hodgkin lymphoma

Novel Therapy Controls Late Effects in HL Survivors Bryant Furlow Radiotherapy is a highly effective modality for the local control of Hodgkin lymphoma and is commonly included in combinedmodality treatment regimens. Concerns about late effects—particularly for children, and adolescents and young adults (AYA)—have fueled advances in radiotherapeutic planning and delivery, including the recent development of involved site radiotherapy (ISRT). This review introduces ISRT and its emerging role in Hodgkin lymphoma management.

adiotherapy is frequently identified as the “most effective single modality” for local control of most types of lymphomas, and its role in lymphoma treatment (typically as part

of a combined-modality approach) has been called “one of the great successes in modern cancer treatment.”1 For decades, early stage classical Hodgkin lymphoma has been treated with combined chemotherapy followed by consolidative radiotherapy, but primary radiotherapy is also used for these patients.2 The risk of long-term radiation toxicities and late effects such as secondary malignancies—particularly in patients treated as children or AYAs—has been a source of controversy.1-4 The role of consolidative radiotherapy has been seriously challenged in early stage favorable classical Hodgkin lymphoma among adolescents and adults, for example.2 In pediatrics and in young adults, clinicians should remember that with the use of consolidative radiotherapy, “the late effects to normal organs may follow many years thereafter,” notes Carol Portlock, MD, of the Memorial Sloan Kettering Cancer Center in New York.2 Patients (or caregivers) should be educated to understand benefits and the long-term risks of the treatment regimen. There are no firm guidelines for organ-specific toxicities or late effects and their management for lymphoma radiotherapy, notes Portlock.2 Controversially, in some cases, concerns about late radiation effects have even led to the omission of radiotherapy in AYA patients with Hodgkin lymphoma.5 One 2015 analysis of data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) registry, found a significant decline in radiotherapy for AYA Hodgkin lymphoma between 1995 and 2010.5 The 5-year survival rate among AYA patients who underwent radiotherapy as part of treatment was superior to that of patients who did not

undergo radiotherapy (97.7% vs 96.4% for 2003-2010; P=.02), the authors of that study reported.5 The cumulative risk of second malignancies among these patients at 150 months was nearly identical among AYA patients with Hodgkin lymphoma who underwent radiotherapy and those who did not (3% and 3.3%, respectively; P=.87, not significant).5 However, the risk of death without secondary malignancy was significantly higher among AYA patients for whom radiotherapy was omitted (8.8%) than for those who underwent radiotherapy (5.7%; P=.0009), prompting the study authors to conclude that “omission of radiotherapy for early classical Hodgkin lymphoma in AYA may increase mortality without reduction in secondary malignancies.”5 Nevertheless, minimizing the incidence of late radiation effects remains an important goal—one that has fueled innovations in Hodgkin lymphoma

Minimizing the incidence of late effects remains an important goal. treatment and radiotherapy generally, integrating advanced anatomic and functional (eg, PET/CT) imaging for 3-dimensional treatment planning, with advanced radiotherapy-delivery approaches such as 3dCRT and IMRT. Extended-field and early involvedfield radiotherapy strategies that irradiated larger volumes that included lymph node stations have similarly been rethought, and smaller-volume radiotherapy targets are now widely preferred, to include lymph nodes only

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RADIATION & YOUR PATIENT when there is detectable involvement (such as can be detected with contrast-enhanced computed tomography imaging).3 This involved-node radiotherapy (INRT) is extremely conformal, but depends on the availability of optimal imaging, which is not always available.3 That has led to the development of an alternative, more conservative concept: involved-site radiotherapy (ISRT), which is intended for use when field-planning information is incomplete or suboptimal, allowing smaller tumor volume irradiation and hence, a lower risk of radiation acute and late toxicities and sequelae.1-4 The Inter national Lymphoma Radiation Oncology Group (ILROG) has recently issued guidelines describing ISRT for the treatment of Hodgkin lymphoma in children and adults, albeit emphasizing that ISRT has not yet been validated.3,4 In primary radiotherapy for Hodgkin lymphoma, the clinical target volumes are larger than is the case with consolidation radiotherapy, which is more tightly contoured.2 ISRT planning is based on prechemotherapy imagingbased treatment volumes, and accommodates patient respiratory movement (typically with an additional 1.5 to 2 cm superior-inferior margin).2 Tumor histology (eg, classical Hodgkin lymphoma vs. nodular lymphocyte predominance Hodgkin lymphoma) is addressed with radiation dose.2 Deep-inspiration breath-hold (DIBH) is a simple technique that can reduce the risk of late radiation effects involving

FIND US ON

mediastinal tissues and organs, because it pulls the mediastinal mass up and away from the heart and lungs, Portlock notes, citing evidence that this strategy reduces long-term risks for myocardial infarction, secondary cancers, and mortality.2 When IMRT is employed, tight ISRT margins are less likely to result in a radiotherapy geographic miss, Portlock notes.2 “As radiotherapy fields are modified with ISRT, it is critically important that the efficacy of postchemotherapy consolidative RT be continually examined,” she adds.2 “The new fields may not always be substantially smaller than

“This will become even more relevant as new chemotherapy regimens are introduced, utilizing new drugs such as brentuximab vedotin,” she predicts.2 ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Specht L, Yahalom J. The concept and evolution of involved site radiation therapy for lymphoma. Int J Clin Oncol. 2015;20(5):849854. doi:10.1007/s10147-015-0753-y. 2. Portlock CS. Involved site radiation therapy for the treatment of early-stage Hodgkin lymphoma in adolescents and young adults. J Clin Oncol Adolesc Young Adults. 2015;5:97-

DIBH is a simple technique that can reduce risks of late radiation effects.

102. doi:10.2147/COAYA.S70370. 3. Specht L, Yahalom J, Illidge T, et al. Modern radiation therapy for Hodgkin lymphoma: field and dose guidelines from the International Lymphoma Radiation Oncology Group (ILROG). Int J Radiat Oncol Biol Phys. 2014;89(4):854-862. doi:10.1016/j. ijrobp.2013.05.005. 4. Hodgson DC, Dieckmann K, Terezakis

the prior involved-field [approach], particularly in the typically bulky mediastinal mass. This is because neither ISRT nor INRT reduce the field size with chemotherapy improvement, but rather, closely conform the field to the prechemotherapy treatment imaging,” she cautions.2 “For the future,” she concludes, “clinical trials will need to examine further the value of ISRT, of DIBH, but more importantly, the role of adjunctive radiotherapy treating only the postchemotherapy volume.”

S, Costine L; International Lymphoma Radiation Oncology Group. Implementation of contemporary radiation therapy planning concepts for pediatric Hodgkin lymphoma: guidelines from the International Lymphoma Radiation Oncology Group. Pract Radiat Oncol. 2015;5(2):85-92. doi:10.1016/j. prro.2014.05.003. 5. Xavier AC, Costa LJ. Changes in the use of radiation therapy for early classical Hodgkin lymphoma in adolescents and young adults: implications for survival and second malignancies. Leuk Lymphoma. 2015;56(8):23392349. doi:10.3109/10428194.983097.

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COMMUNICATION CHALLENGES

Pain: Listen for What Is Not Said

Ann J. Brady, MSN, RN-BC

Beneath it all were huge concerns on his part about what taking pain medication meant to him.

ow do you handle pain management with a patient who admits to severe pain but continues to refuse pain medications? What language do you use to assess pain? Does your pain assessment include a patient’s personal barriers to taking opioids? How often do you revisit those barriers in conversations about pain management? One of my sons and I have an ongoing debate about which phone app for providing driving directions is better. I like the one that came on my phone while he prefers one he downloaded and that he insists is easier to use. Each time we drive to a new location we resume our good-natured debate. But regardless of which app we use, they both share 2 fundamental features: a starting point and an ending point. CASE Mr Brown was a large man. He was possibly my biggest patient ever. His pain was large, too. And beneath it all were huge concerns

on his part about what taking pain medication meant to him. He had head and neck cancer and was receiving radiation following a surgical resection. He had toughed his way through his surgery and recovery and was determined to tough it out as he went through radiation. Before he started treatment, our team explained how challenging it would be; throat pain and swelling, dry mouth, and skin desquamation were expected adverse effects. Our goal was to get him through his treatment. But he had a different destination in mind. Of course, he wanted to complete his treatment and he hoped for a good outcome, but his goal was to arrive at the end of therapy having taken as little pain medication as possible. The start of radiation therapy is easiest. The first few treatments have few or no adverse effects, which can lull patients into believing their symptoms will not be as bad as anticipated. It can trick them into thinking they can get by without pain medication, which perfectly aligned with Mr Brown’s personal plan. He was scheduled for 30 treatments and made it through the first several treatments with minimal adverse effects. It wasn’t until about the tenth fraction that he agreed to consider taking medication for breakthrough pain (BTP). His willingness to take the medication was actually more submission to than agreement with our plan. He took the paper prescription in his hand but waved it at me trying his best to smile, “I’ll get it filled but only because you say I should. I’ll only take it if I absolutely have to.” It was the closest we had gotten to an admission that his pain was increasing. Continued on page 38

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COMMUNICATION CHALLENGES

There are many tools for assessing pain. But with Mr Brown, it was not an issue of measuring his pain.

By the time he reached the halfway point in treatment he was beyond miserable. He was taking Extra-Strength Tylenol around the clock and finally decided he needed something stronger to control his discomfort. He started to take the BTP medications regularly, though it was with a great deal of reluctance. I kept encouraging him to take the pain medications more frequently, reminding him that our strategy was to take “the lowest effective dose” and explaining repeatedly that the word effective was more important than the word lowest. Though he was taking the medication regularly, I believed he was undermedicated based on his wincing when he spoke and on his dysphagia and odynophagia. However, it was progress of sorts that he took anything, and I continued to chip away at his resistance. Once he started taking the BTP medication, he established a regimen of 4 to 5 doses per day. We offered him a fentanyl patch to address his baseline pain. I went through the strategy of long-acting and short-acting pain medication and he nodded as he listened to my explanation. He took the new prescription and said the same thing he said when we gave him the previous prescription: “I’ll fill it, but I am only going to use it if I have to.” When he came in for his treatment 3 days later, he told me, “I finally put the patch on yesterday. You were right, I feel better.” Which made me feel better. But there was more to it. “Let me tell you a story,” he said. As a college freshman, he

JOIN THE CONVERSATION • Does your pain assessment include a patient’s personal barriers to taking opioids? • How often do you revisit those barriers in conversations about pain management?

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Go to http:bit.ly/1OVNPua for the online version of this article and join your colleagues in a discussion on the challenges of managing pain when the patient has personal barriers to taking opioids.

experienced a severe bout of pneumonia with a hacking cough that made it difficult to sleep. He was prescribed codeine, which helped with the cough. He ended up taking it for several weeks. When his pneumonia cleared and his coughing improved, he stopped the codeine abruptly. “That’s when it got really bad for me.” He described 4 to 5 days of withdrawal-like symptoms. He concluded that he had become addicted to it. Even worse, he was certain he was an addict and any further exposure to opioids would reveal that. With the onset of radiation therapy and subsequent discomfort, he agreed to take the pain medication only when his pain exceeded his anxiety about addiction. Before he was given the prescription for BTP medication, I discussed with him the difference between addiction, dependence, and tolerance. I had reviewed with him that our goal was to get through the treatment and to use the pain medication to facilitate that. But I had missed something critical. I had nudged him along the path, and indeed he had listened to me when I explained what addiction looked like compared with what we were doing, but he had not shared his story about codeine until later, afraid perhaps to reveal a past he believed meant something different than what it did. DISCUSSION There are many tools for assessing pain. But with Mr Brown, it was not an issue of measuring his pain. Good assessment and even good education were only going to get me where I wanted to be if we first understood our starting point. “Tell me more about your concerns with taking pain medication.” I had included that question in my initial assessment, and he had explained some of his concerns, but it wasn’t until later that he shared his experience taking codeine. Assessment includes more than the starting and ending point. Going back to the idea of an app for driving directions, some of the apps include another feature: they take into consideration traffic and weather conditions, both of which can change as you drive. For

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COMMUNICATION CHALLENGES

I needed to hear his story in order to integrate it into my teaching.

Mr Brown, his past experience influenced his willingness to take pain medication even though his pain was high. I needed to tweak my pain assessment “app.” Successful navigation needs to include those other conditions that may impede progress. Mr Brown had a big story. I needed to hear his story in order to integrate it into my teaching. There is an old nursing adage: “tincture of time.” For Mr. Brown, a certain amount of time needed to pass before he was ready to tell his story. Understanding his past

experience with codeine and his incorrect interpretation of its meaning helped me adjust my patient teaching. Pain assessment is an ongoing assessment that changes and adjusts to the circumstances. Mr Brown continued to undermedicate, which was what fit for him, yet he did come to understand his own barriers. As did I. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

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ISSUES IN CANCER SURVIVORSHIP

Novel Research Investigates the Impact of Therapy Dogs on Children With Cancer Bette Weinstein Kaplan

et therapy is frequently employed in many cancer centers, hospitals, and nursing homes. Although staff and patients report that such interactions provide benefit in these settings, there is little rigorous scientific evidence to substantiate that effect. Small studies have assessed interactions between therapy dogs and adult patients, but no studies have been conducted with large sample sizes, validated instruments, and control groups to evaluate the impact that therapy dogs have on children with cancer, according to Amy McCullough, PhD, national director of Humane Research and Therapy for the American Humane Association. McCullough hopes new research will correct that. In a recent presentation at the American Academy of Pediatrics (AAP) National Conference & Exhibition, she described how the American Humane Association with the sponsorship of Zoetis, the animal health company, undertook an ambitious study to look at the science behind the therapy dog modality.1 She emphasized that while survivorship of childhood cancer has increased over the past 40 years, quality of life for patients and their families is still concerning. The nationwide multi-institutional project was designed to measure the psychosocial effects of such animal-assisted interventions (AAIs). The investigators wanted to know specifically if

therapy dogs have positive effects on the stress and anxiety experienced by children with cancer. They also wondered whether interactions with dogs could alleviate the anxiety that parents experienced from having an ill child.

The researchers are looking forward to analyzing final data by early 2017. Lastly, the researchers wanted to determine how dogs react to the intense visits, including any distress they may experience. TREATMENT AND CONTROL GROUPS

Since the project began in 2014, 70 patients and their families and more than 30 therapy dog-handler teams have enrolled across the 5 study sites. Patients are selected at random to receive either standard-of-care treatment required by each child’s diagnosis or standard-of-care plus regular 15to 20-minute visits from a registered therapy dog and handler in the outpatient clinic or inpatient unit. Children are enrolled in the study just after they receive a diagnosis, which is usually

the time when they and their parents are the most anxious and confused. Typically a nurse or a child life specialist is the data-collection point person, as he or she gets to know the families and discuss their participation in the study. If the patient and parents agree, they then enroll in the program. Children and parents who do not enroll become the control group. They can enjoy visits with regularly scheduled therapy dogs along with other patients in the hospital, but they do not participate in a set weekly appointment and a guaranteed “dose” of interacting with the same dog. McCullough reports that nearly all patients who have been approached have participated in the study. RATING SCALES Both patient groups participate for 4 months. At designated intervals they complete behavioral and psychosocial rating scales, such as the PedsQL: Measurement Model for the Pediatric Quality of Life Inventory and the StateTrait Anxiety Inventory (STAI). 2,3 Children have their blood pressure and pulse measured at the beginning and end of each session. EVALUATING THE DOG Evaluations are also conducted of the dogs participating in the program. As part of each session a staff member videotapes the canine therapists so that

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ISSUES IN CANCER SURVIVORSHIP their behavior can be rated weekly on handler self-reports and on AAI behavior-specific ethograms. Samples of canine saliva are obtained to assess cortisol as a gauge of the dogs’ stress levels during each session, and the sample is compared to each dog’s average baseline cortisol measurement. The dogs’ behavior in the session and temperament are also assessed by each handler. Since their visits are with the same dog each week, the patients bond to the dogs and act as though they own them. The handlers play an important role also, becoming a source of support for the parents as well as the children. They discuss the dog’s activities during the week since their last visit. A handler might even buy the dog a collar in the color of the child’s favorite sports team as a show of support. All team members are dedicated to supporting the family. MANY POSITIVE REACTIONS

McCullough reported that the investigators see positive reactions from the staff during each session. Video demonstrates

Navigator Notes Continued from page 21

include bortezomib, platinums, taxanes, thalidomide, and vinca alkaloids. This study found that CIPN was associated with worse physical functioning, poorer mobility, and a nearly 2-fold higher risk of falls. Rehabilitation and fall prevention interventions should be tailored to persons with CIPN. The study analyzed 678 women cancer survivors, including 462 who self-reported symptoms of CIPN. The study participants had a mean age of 62 years and were approximately 6 years past their cancer diagnosis. In comparisons between the 2 groups, those with neuropathy had significantly

nurses and physicians interacting with the dogs, in addition to the children and their parents. The children talk about the dogs instead of their procedures. If children are upset in the clinic, the dogs help calm them. The dogs also help to distract patients from procedures that may be unpleasant or painful. Some hospitals keep a jar of dog treats at the nurses’ station, indicating that dogs are welcome and reinforcing that the therapy dog intervention has a positive impact on nursing staff as well. The researchers are looking forward to analyzing final data by early 2017. They are hopeful outcomes will continue to show with scientific rigor that young cancer patients experience positive results from interacting with therapy dogs. ■

ON THE

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Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. McCullough A, Jenkins M, Ruehrdanz A. The effects of animal-assisted interventions (AAIs) for pediatric oncology patients, their parents, and therapy dogs at five hospital sites. Presentation at: American Academy of Pediatrics National Conference & Exhibition; October 24-27, 2015; Washington, DC; Abstract 30412. 2. PedsQL Measurement Model for the Pediatric Quality of Life Inventory. http:// www.pedsql.org/index.html. Accessed January 8, 2016. 3. Spielberger CD, Gorsuch RL, Lushene PR, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.

“CANINES AND CHILDHOOD CANCER” STUDY BY AMERICAN HUMANE ASSOCIATION. You can watch this video in the online version of this article, or use this quick link: http://bit.ly/1POjDEz.

worse physical function. Physical function measures included timed chair stand, physical performance battery, gait patterns, and falls in the past year.

The underlying impairments of CIPN put these women at risk for falls. The underlying impairments in the women with CIPN put these women at risk for falls. Peripheral neuropathy does not cause muscle weakness but rather effects movement and gait patterns.

In this study, women with CIPN had difficulty rising from a chair, possibly because their brain was not getting enough information from their feet about how quickly or forcefully to stand up. The researchers point out that their study’s findings indicate that commonly recommended exercise, such as walking, may be safer for women with CIPN when performed on a treadmill with handrails instead of outdoors. However, because neuropathy does not diminish leg strength, machinebased resistance training may not be beneficial. The researchers explained that rehabilitation efforts should focus on improving balance during upright movement and specific gait training. ■

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THE TOTAL PATIENT

Experiences, Dreams, and Visions: Easing Patients With Cancer Toward End of Life Bette Weinstein Kaplan

reams have been the subjects of songs and psychoanalysis, puberty and poetry. There are sweet dreams and there are nightmares … and then there are the dreams that comfort the dying. Although the dreams of hospice patients have not been subjected to a great deal of research, one recent study demonstrates that they can be meaningful and comforting for the person who is dying. End-of-life experiences (ELEs) occur frequently in people who are near death and can take different forms. End-oflife dreams and visions (ELDVs) are one type of ELE. These often manifest as visions that occur during a wakeful state, or dreams that the patient remembers after sleeping.1 DREAMS AND VISIONS OF THE DYING

Christopher W. Kerr, MD, PhD, and colleagues at the Center for Hospice and Palliative Care in Cheektowaga, New York, in partnership with James P. Donnelly, PhD, of Canisius College, Buffalo, New York, undertook a study to document ELE phenomena in patients at the facility. As part of the study design, they examined the content and subjective significance of ELDVs, and related their prevalence, content, and significance over time until the patient’s death.

The study included 59 patients ranging in age from 34 to 99 years who were in their last weeks of life. The patients were interviewed daily about their dreams and visions while they were in the hospice inpatient unit. They were asked to report on the content, frequency, and comfort level of their ELDVs. If it was possible to continue the interviews after a patient was discharged, the interview was conducted at the patient’s home or at the facility to which the patient was transferred. The researchers met with the patients each day until they died, were unable to communicate, found communication too stressful, or until the patient became delirious. Of the 59 patients in the study, 52 (88.1%) reported having at least 1 dream or vision. Almost half of the dreams or visions (45.3%) occurred while the patient was sleeping, 15.7% occurred while the patient was awake, and 39.1% occurred during both sleep and wakefulness. The patients reported that nearly all ELDV events (99%) seemed or felt real. Most patients reported a single ELDV each day (81.4%); some reports were of 2 (13.2%), 3 (4.1%), or 4 events (1.4%) on other days. RATING THE DREAMS The patients rated the degree of comfort or distress they associated with their ELDVs on a scale of 1 to 5, with

1 meaning extremely distressing and 5 meaning extremely comforting. The mean comfort rating for all dreams and visions was 3.59, with patients rating 60.3% of ELDVs as comforting or extremely comforting, 18.8% rated as distressing or extremely distressing, and 20.7% rated their dreams as neither comforting nor distressing. The patients felt that their dreams and visions were realistic, whether they occurred during sleep or while

The most common dreams and visions included friends and relatives. awake. They related dreams and visions of past meaningful experiences and reunions with loved ones who had already died, and who reassured and guided them. Others reported feeling as if they were preparing to go somewhere. The researchers noted that often patients’ dreams before dying were so intense that the dream continued from sleep to wakefulness, seeming to be reality. However, those patients who had ELDVs died peacefully and calmly. The most common dreams and visions included friends and relatives,

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THE TOTAL PATIENT either living or deceased. The patients found that dreams and visions that featured the deceased (friends, relatives, and animals/pets) were significantly more comforting than those of the living, of the living and deceased combined, or of other people and experiences. As participants approached death, comforting dreams and visions of the deceased became more prevalent. NOT DELIRIUM Clinicians should note that ELDVs are not hallucinations, and they are not the result of medications or confusion. These phenomena play an important role. Their content holds great meaning to the patient who nears the end of life. Patients who experience these phenomena are not delirious; they think clearly and are aware of their surroundings. In contrast to patients who are in a state of delirium, ELDVs typically occur in persons who have clear consciousness, heightened acuity, and awareness of their surroundings. Although the phenomena bring a sense

of impending death, they also evoke acceptance and inner peace. These are crucial distinctions, since if a dying patient with ELDVs is considered delirious and is treated as such, the medication may interfere with the

“ELDVs do not deny death, but in fact, transcend the dying experience ... “ comforting experience that ELDVs can bring to the patient during the dying process. Not being able to derive that comfort at the very end of life could lead to isolation and unnecessary suffering for the dying patient. Oncology nurses and other clinicians can play an important role in the dying process by not assuming that the patient experiencing ELDVs is delirious and needs more medication.

“The results of this study suggest that a person’s fear of death often diminishes as a direct result of ELDVs, and what arises is a new insight into mortality. The emotional impact is so frequently positive, comforting, and paradoxically life aﬃrming,” the hospice team explains. The person is dying physically but emotionally and spiritually, their identity remains present as manifested by dreams/visions. “In this way, ELDVs do not deny death, but in fact, transcend the dying experience, and present a therapeutic opportunity for clinicians to assist patients and their families in the transition from life to death, thereby providing comfort and closure.” ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Kerr CW, Donnelly JP, Wright ST, et al. End-oflife dreams and visions: a longitudinal study of hospice patients’ experiences. J Palliat Med. 2014;17(3):296-303.

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.

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FROM

ost of us are no strangers when it comes to stress and the common feelings of being tense in this non-stop, go-go-go society we live in. Furthermore, cancer treatment invokes a state of intensified stress on the human body. Stress is a blanket term used to describe tension in different facets of life. It manifests both physically and emotionally for patients with cancer; fatigue, soreness, anxiety, and depression are just some of the major byproducts of stress induced by treatment. More often than not, cancer treatment diminishes a person’s quality of life. From testing to diagnosis to posttreatment reality, the cancer journey poses physical and emotional challenges throughout. What can a patient do to help alleviate the naturally occurring response we call stress? Yoga. The ancient practice is nothing new. Much more than a form of physical exercise, yoga offers a plethora of benefits. Although it is not a cure for cancer, practicing yoga has the power to enhance a patient’s physical, mental, and emotional well-being. According to a Harvard Medical School Mental Health Letter, yoga reduces stress and anxiety which in turn reduces heart rate, lowers blood pressure, and eases respiration.1

©THINKSTOCK

MENTAL, EMOTIONAL, AND PHYSICAL HEALTH

Mental health is concerned with the mind, whereas emotional health is concerned with the heart. Emotions are believed to be fleeting whereas behaviors of the mind are relatively

Yoga Provides Mental, Emotional, and Physical Benefits Ashley Chookazian, LMSW

more consistent. Emotions invoke behavioral change, and thus influence overall mental health. This exemplifies the power of the mind-body connection experienced with yoga practice. In other words, how the body affects the mind. Yoga is said to bridge the mind and the body through moving meditations. People report feelings of

relaxation, calmness, and increased tolerance from a consistent yoga practice. Mental A racing mind of endless thoughts makes people restless, especially during the night, and promotes sleep difficulties. Thought disorders have a myriad of symptoms such as brain fog and agitation and can be exacerbated by cancer treatment. How do we soothe anxiety? A research study from the University of Rochester reported cancer survivors who attended twice-weekly yoga sessions reported improved sleep, reduced fatigue, and even better quality of life.2 The program included breathing exercises, gentle Hatha and restorative yoga postures, and mindfulness exercises. Yoga activates a relaxation response and can thus help relieve feelings of anxiety, and in turn, help patients achieve better sleep. The yoga practice engenders internal skills that allow patients to cope better throughout their cancer treatment. Emotional On an emotional level, yoga helps cancer patients reconnect with their body after undergoing chemotherapy, radiation, and/or surgery. Yoga provides a sense of improved wellbeing by focusing attention on moving from one pose to the next, allowing the person to connect to the present moment. The breathing and movements ease stress and allow patients to connect to their inner selves on and off the mat. This inner peace can translate to increased emotional coping skills during and after treatment. In addition, people can experience an improvement in their own spiritual connection, ability to think outside

People [with cancer] report feelings of relaxation, calmness, and increased tolerance from a consistent yoga practice. www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2016 • ONCOLOGY NURSE ADVISOR 45

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FROM the box, and social skills. Practicing yoga helps improve a person’s quality of life, in turn, improving the person’s relationship with the Self. The relationship with the Self is the building block for emotional stability and endurance during cancer treatment and ultimately, a person’s ability to cope. Physical Yoga aims to bring attention to the present moment by focusing on the breath. There are many different styles of yogic breathing, but the main element is to focus on inhaling through the nose and exhaling through the nose. This type of breathing shifts the balance from the sympathetic nervous system (also known as fight-or-flight response) to the parasympathetic nervous system, which promotes relaxation by slowing the heart rate. Chronic stress, such as the type brought on by cancer treatment, turns on the fight-or-flight response without any rest. The breath work in conjunction with gentle yoga poses is calming and restorative. It lowers breathing and heart rate, decreases blood pressure, and increases blood flow to the intestines and reproductive organs. In addition, the lymphatic system fights infection and disposes toxic waste products. A regular yoga practice increases lymph drainage. Furthermore, studies have

shown that a structured yoga practice during cancer treatment can greatly improve physical symptoms such as pain and fatigue.3 A SENSE OF COMMUNITY

Going through a cancer diagnosis and treatment can be an isolating experience. Family and friends may not know how to act or what to say. For the patient, this can lead to heightened anxiety or even depression. Yoga classes specifically created for patients with cancer allow them to connect with other patients in a different capacity

are opening up everywhere. Patients should find a studio nearby and experience its positive effects! ■ Note This article addresses yoga as a supplemental method to help a patient cope with the symptoms of cancer treatment and posttreatment life. Yoga is not considered a treatment for cancer. Ashley Chookazian is an oncology social worker at CancerCare. REFERENCES 1. Harvard Mental Health Letter. Yoga for anxiety and depression. Harvard Health

A great benefit of yoga is that it can be free and practiced anywhere, anytime.

Publications web site. http://www.health. harvard.edu/mind-and-mood/yoga-foranxiety-and-depression. Published April 1, 2009. Accessed January 8, 2016. 2. URMC study: yoga improves sleep, quality of life for cancer survivors. University of Rochester Medical Center web site. https:// www.urmc.rochester.edu/news/story/2866/ urmc-study-yoga-improves-sleep-quality-of-

than in a traditional support group. This creates a sense of belonging, reduces feelings of isolation, and improves social skills. Yoga for cancer is becoming more popular at treatment centers. A great benefit of yoga is that it can be free and practiced anywhere, anytime. Videos are offered online, and studios

life-for-cancer-survivors.aspx. Published May 20, 2010. Accessed January 8, 2016. 3. 9 ways yoga helps cancer patients during or after treatment. Botsford Blog web site. http://www.botsford.org/blog/index. php/2011/08/23/yoga-helps-cancertreatment/. Posted March 24, 2015. Accessed January 8, 2016.

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ASK A PHARMACIST

Understanding Drug Naming Nomenclature Why do the antibody drugs have such long names? Does any of that gobbledygook mean anything? —Name withheld on request

The generic names of most medications indicate their structure and pharmacological class (eg, penicillin and amoxicillin). Monoclonal antibodies are similar, and their names are quite descriptive once you are familiar with the nomenclature. Antibody names are composed of four main sections: prefix, target class, source, and stem. Stem When breaking down an antibody name, I usually start with the stem, or end of the word. Most currently marketed antibody names end with –mab, which indicates that the drug is a monoclonal antibody. Source The next-to-last syllable refers to the source of the antibody. This is not referring to the organism that was used to synthesize the antibody, but to the species on which the structure

of antibody was based (eg, to look like an antibody observed in mice). Some commonly used source terms include: • -o-: nearly 100% mouse source for the antibody structure • -xi-: antibodies that are partially human-like and partially other organism-like in structure • -zu-: antibodies that are humanized, or approximately 90% human-like • -u-: antibodies that are fully human in nature Target class The next preceding syllable is the target class, referring to the therapeutic use of the drug and/or the targeted types of disease states. Note, these may not always match up with all the uses of a drug in clinical practice, but are typically associated with the targeted disease states at the time the drug was in development. Some commonly used examples include: • -tu- or –tum-: drugs used to treat cancer • -li-: drugs that impact the immune system • -ci-: drugs that affect the circulatory or cardiovascular system Prefix The prefix is the first 1 or 2 syllables, which are designated by the manufacturer developing the drug. These must follow certain guidelines, and should also be designed in a way that reduces the risk of look-alike or sound-alike medication errors.1 Here are two examples of how the above nomenclature is used in drugs currently on the market.

Rituximab (Rituxan) is a monoclonal antibody (-mab) that is chimeric (-xi-) and one of its uses is to treat cancer (-tu-). Knowing that the drug is chimeric can be beneficial; typically drugs that are less human-like (eg, chimeric or mouse) may have higher rates of infusion reactions than antibodies with more human components (eg, humanized or human). Bevacizumab is a monoclonal antibody (-mab) that is humanized (-zu-) and has some effects on the cardiovascular system (-ci-). Knowing that the drug impacts the cardiovascular system makes sense when we consider that hypertension is an adverse effect of bevacizumab. ■ REFERENCE 1. United States Adopted Names Council. Naming guidelines: rules for coining names. American Medical Association Web site. http://www.ama-assn.org/ama/pub/ physician-resources/medical-science/united-states-adopted-names-council/namingguidelines.page? Accessed January 29, 2016.

HAVE A QUESTION? GET IT ANSWERED AND PUBLISHED HERE! If you have an oncology pharmacology-related question, send it to editor.ONA@haymarketmedia.com. We’ll forward it to Dr Thompson, and publish your question with her response on this page.

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

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