ONA May/June 2016 by Haymarket Media

ONCOLOGY NURSE ADVISOR â&#x20AC;¢ MAY/JUNE 2016

www.OncologyNurseAdvisor.com

May/June 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

IN THE NEWS

Highlights from ONA Navigation Summit, ONS Congress 2016

FEATURE

Implementing an Effective Distress Screening Process

RADIATION & YOUR PATIENT

CANCER SURVIVORSHIP

Study Finds Connection Between Metastasis Site and Survival in mCRPC Participants with bone metastases (72.8%) had the second longest survival (21.3 months).

Managing Breakthrough Pain During Radiotherapy

COMMUNICATION CHALLENGES

Facing a Juncture in Cancer Care

THE TOTAL PATIENT

Initiating Palliative Care in the ED Improves QOL and Survival

FROM CANCERCARE

The Importance of an Initial Assessment VOLUME 7, NUMBER 3

ASK A PHARMACIST

Traveling While On Oral Chemotherapy

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Oncology Nurse Advisor (ISSN 2154-350X), May/June 2016, Volume 7, Number 3. 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 • MAY/JUNE 2016 • ONCOLOGY NURSE ADVISOR 1

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CONTENTS

May/June 2016

IN THE NEWS • Overall Benefits of Vaporized Nicotine Products Outweigh Harms, Says International Panel • New Drug Combination Before Surgery May Improve Outcomes for Advanced HER2+ Breast Cancer • Blood Plasma Genotyping Predictive of Treatment Benefit in NSCLC

ONA Navigation Summit

• The CHNA: Building the Backbone of a Navigation Process

• The Role of Physical Therapy in the Continuum of Cancer Care

ONS Congress 2016 • Patient Satisfaction Improves With Nurse-led Response to Patient Feedback • Retooled Medication Education Improves HCAHPS Scores • Oncology Nurse-led Team Can Reduce Treatment Delays, Hospitalizations … and more

40 20

FEATURES Distress: Implementing an Eﬀective Screening Process Heather Askren, DNP, NP-C, RN, OCN; Susan DeCrane, PhD, RN, ACNS-BC; Kathleen Abrahamson, PhD, RN; Cynthia Keith, MSN, PMHCNS, BC

48 FIND US ON

Psychosocial Support From a Partner Improves Outcomes Bette Weinstein Kaplan

Continues on page 6

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ISSUES IN CANCER SURVIVORSHIP

CONTENTS

May/June 2016

The Samfund: Helping Young Adult Patients Navigate the Financial Impact of Cancer Care The Samfund is a not-for-profit organization dedicated to easing the lasting financial effects of cancer treatments for young adults with the disease. Bette Weinstein Kaplan

STAT CONSULT 32 STAT CONSULT • Daratumumab (Darzalex) • Necitumumab (Portrazza) 38 RADIATION & YOUR PATIENT Managing Breakthrough Pain During Radiotherapy Bryant Furlow

40 COMMUNICATION CHALLENGES Facing a Juncture in Cancer Care Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP A Relationship Is Seen Between Metastasis Site and Overall Survival in Men With mCRPC Bette Weinstein Kaplan

44 THE TOTAL PATIENT Initiating Palliative Care in the Emergency Department Improves QOL and Survival Bette Weinstein Kaplan

46 FROM CANCERCARE The First Call: The Importance of an Initial Assessment

Venetoclax (Venclexta) Venetoclax is a BCL-2 inhibitor indicated for the treatment of patients with chronic lymphocytic leukemia (CLL) with 17p deletion who have received at least 1 prior therapy.

PATIENT EDUCATION: FACT SHEET Access to Investigational Drugs This fact sheet explains investigational drugs and the process by which patients with cancer may obtain them.

ONCOLOGY NURSE ADVISOR VIDEOS ONS Congress 2016 Children’s Voices on Experiencing Radiotherapy, Design and Implementation of the Cancer Warrior Exercise Program, and more

PUBLISHERS’ ALLIANCE: LIBERTAS ACADEMICA A Review of Systemic Treatment in Metastatic Triple-negative Breast Cancer The review examines the standard systemic and future treatment options in metastatic triplenegative breast cancer. Breast Cancer: Basic and Clinical Research

Stephen Homsey; Kellie Webb

ASK A PHARMACIST Taking Oral Chemotherapy on the Road; Olanzapine as an Antiemetic

ON THE

WEB

Lisa A. Thompson, PharmD, BCOP

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IN THE NEWS Overall Benefits of Vaporized Nicotine Products Outweigh Harms, Says International Panel

Disparities in Gut Microbiome Could Lead to Biomarkers for Estrogen-driven Breast Cancer Disparities in the gut microbiome between healthy people and women with estrogen-driven breast cancer may indicate possible biomarkers based on the microbiome that could help to mitigate the risk of certain cancers. The estrobolome is the gut bacterial Gut microbiome may genes that are capable of metabolizing mitigate cancer risk estrogens in gut bacteria. Residential microbes, whose population includes bacteria, viruses, Archaea, and eukaryotes, are increasingly recognized for

playing important roles in health and disease. The human gastrointestinal tract has up to 1011 bacterial cells per gram of luminal content. Their collective genome, the gut metagenome, has vastly more individual genes than the human genome. The function of the microbiome affects the host, both locally and distantly. Disequilibrium can contribute to disease, including malignancy. To determine the effects that estrobolome may have on estrogen levels and human breast cancers, Sylvia Adams, MD, from the Laura and Isaac Perlmutter Cancer Center, New York University Langone Medical Center in New York City, and colleagues are currently conducting a study comparing microbiota between postmenopausal healthy women and patients who have developed estrogen-driven cancers.

E-cigarettes have a strong potential to improve population health by reducing or displacing cigarette use. International top tobacco experts urged the US Food and Drug Administration (FDA) to have a broad open-minded perspective when it comes to regulating vaporized nicotine products, especially e-cigarettes. Their publication synthesized much of the evidence published so far on e-cigarettes. They found that the use of these products can lead to reduced cigarette smoking overall with a potential reduction in deaths from cigarette smoking. “We’re concerned the FDA, which has asserted its right to regulate e-cigarettes, will focus solely on the possibility that e-cigarettes and other vapor nicotine products might act as gateway to cigarette use,” said David T. Levy, PhD, the study’s lead author and a professor in the department of oncology at the Georgetown Lombardi Comprehensive Cancer Center in Washington, DC. The authors stated that smoking rates in the United States have fallen by half since they peaked in the 1960s, but smoking still leads to premature mortality. Levy explained that the experts estimate that exclusive e-cigarette use has approximately 5% of the mortality risks of smoking. Further, evidence suggests that e-cigarettes have a strong potential to improve population health by reducing or displacing cigarette use in countries where cigarette prevalence is still high and smokers are interested in quitting. Research from the United States, Canada, and England has found that cigarette smoking rates have fallen more in the last 2 years than they have in the previous 4 or 5 years, and that this trend has coincided with the increase in e-cigarette use. The authors anticipate that their suggested framework will be controversial due to an ongoing debate about whether e-cigarettes will complement or undermine tobacco control efforts. The authors also warned that heavy regulation and taxation of e-cigarettes will counteract the benefit that these products can provide.

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IN THE NEWS

Read more at http://bit.ly/1OfNfO9.

Oncology Nurse-led Team Can Reduce Treatment Delays, Hospitalizations An oncology nurse-led team approach can reduce treatment delays and hospitalizations and improve quality of care for patients with head and neck cancer. Patients with head and neck malignancies often have complex psychosocial and medical issues; therefore, it Approach reduces is imperative that clinicians provide treatment delays continuous evaluation and resources to this high-risk population. In April 2014, oncology nurses at Steward Saint Anne’s Regional Cancer Center in Fall River, Massachusetts, identified potential treatment-related sequelae that resulted in significant treatment delays when patients were receiving concomitant chemoradiotherapy. “We found that our patients were not receiving proper education and care after treatment, because they were not being referred for speech and swallow, resulting in increased infection rates and hospitalizations,” said Helena Viveiros, RN, BSN, OCN. Their concerns were validated during a nursing-initiated 1.5 year review of their institution’s morbidity and mortality

records. Specifically, they found that these issues result in a 59% risk of significant treatment delay with or without hospitalization. Because previous research has demonstrated that nursing interventions can help minimize treatment delays and hospitalizations, oncology nurses at Saint Anne’s created a multidisciplinary team that included social workers, dieticians, speech therapists, palliative care nurses, surgeons, radiation therapists, and the treating physicians, with the purpose of identifying interventions to limit treatment delays and interruptions. The team developed and implemented an algorithm with the nursing staff in the surgery department to ensure timely referral to home care services for gastric tube management and early referral for swallow and speech therapy. “Gastric tubes were put in by the surgeon, but there was no follow-up or just 1 teaching session for patients,” Viveiros said. “We needed to support our patients better.” “We collaborated with the gastrointestinal physicians and home care services to provide aggressive supportive care,” Viveiros said. Aggressive supportive care measures were performed both during and after treatment. Furthermore, the team developed detailed educational materials for oral care and symptom management for distribution to patients and their caregivers. They also established a protocol for biweekly oncology nursing visits during radiation to evaluate and quickly manage adverse events. If there were no adverse effects from treatment, the plan of care was continued; if adverse effects were present, the physician was notified and nursing interventions were initiated. Following a 6-month review of 28 patients after implementing these interventions, the researchers found that hospitalizations and treatment delays were reduced by 34%. The team continues to meet monthly and performs chart reviews every 3 months to further improve this oncology nurse-led team approach. “Oncology nurses can have a significant impact on patient outcomes, allowing patients to complete their prescribed course of treatment with minimal delay of treatment and hospitalization,” Viveiros concluded. Read more at http://bit.ly/1TDpNX2.

For full news stories visit OncologyNurseAdvisor.com

Simulation-based competencies were not used for management of chemotherapy spills. Results showed that at baseline, approximately 52% rated themselves as confident or extremely confident in the 4 core areas compared with approximately 96% at 3 months. However, 82% and 77.5% of nurses rated themselves as confident or extremely confident at 9 months and 12 months, respectively. In regard to chemotherapy extravasations specifically, approximately 26% rated themselves as confident or extremely confident at baseline vs approximately 94% at 3 months. Further, an estimated 65% reported that they were confident or extremely confident in skills as an oncology nurse at baseline compared with nearly 96% at 8 months. “Overall, the nurses agreed or strongly agreed that simulation-based learning was an overwhelmingly valuable experience,” Ness noted. The researchers also plan to evaluate the impact of simulation-based training on the rate of chemotherapy errors and near misses.

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FEATURE | Distress Screening

Distress: Implementing an Effective Screening Process The highest points of distress experienced by patients with cancer are identified in a study designed to guide the distress screening process. HEATHER ASKREN, DNP, NP-C, RN, OCN; SUSAN DeCRANE, PhD, RN, ACNS-BC; KATHLEEN ABRAHAMSON, PhD, RN; CYNTHIA KEITH, MSN, PMHCNS, BC

he impact of a cancer diagnosis on a patient’s emotional and psychological well-being has the potential to affect treatment response and adherence, as well as quality of life.1 New cancer diagnoses and deaths are estimated to number 1 665 540 and 585 720, respectively, in a 1-year period.2 In addition, an estimated 13.7 million Americans are undergoing curative or palliative treatments for cancer or being monitored closely as cancer free.3 Patients face times of remission intermingled with times of active treatment or metastatic disease.3 Patients with cancer have different experiences and challenges when coping with the disease, and assessment of issues defined as psychosocial distress is paramount in oncology settings.4 The National Comprehensive Cancer Network (NCCN) defines psychosocial distress as “an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems that are disabling, such as true depression, anxiety, panic, and feeling isolated or in a spiritual crisis.”5 Because psychosocial distress is a significant issue for patients with cancer, the Institute of Medicine made psychosocial care an integral part of cancer care in its report, Cancer Care for the Whole Patient:

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Meeting Psychosocial Health Needs, with an imperative to implement assessment plans.6-8 Likewise, the American College of Surgeons agreed that holistic care, including a psychosocial standard, be phased into cancer care by 2015.9 More recently, the NCCN recommended changing the term to simply distress to reduce stigma and increase the likelihood for self-reporting.10 DEFINING OUR POPULATION AND ITS NEEDS

Patients with cancer should be screened for distress at least once during a pivotal point in their cancer journey.11 Each facility can choose the time when a screening should occur. Statement of the problem Over the last 2 decades, with advances in detection and treatment of cancer, survival rates have increased.10 With this improvement in survival, there are now long-term side effects that can contribute to distress symptoms.12 Patients’ struggles with financial, social, physical, psychosocial, and spiritual concerns are documented.13 Purpose The purpose of this project was to implement distress screening in both the hospital and community care settings and use sample results to identify distress levels and common problems patients experience. In this study, we addressed 3 questions. • Do patients who report a distress score of 5 or higher have a greater number of problems than those who report a distress score of 4 or lower? • Is cancer-related distress scored differently by patients’ gender, age, and cancer type? • Does the cancer-related distress score correlate to the number of treatments received? Setting This study was conducted at 3 separate locations. Location A is a 6-bay infusion center within a medium-size midwest acute care hospital accredited by the American College of Surgeons Commission on Cancer for 30 consecutive years. The other 2 facilities are located in the same medical complex. Facility B is a medical oncology office with a 12-bay treatment area, and facility C is a radiation oncology office with 2 linear accelerators. Instruments NCCN developed distress guidelines to help the treatment team best treat distress in the cancer patient.10 Within the distress guidelines is a distress thermometer. The thermometer measures patient distress on a scale of 0 (no distress) to 10 (the highest level of distress experienced in the previous week). Patients who reported their distress as a 4 or lower were managed within the clinical setting. Patients who reported their distress as a 5 or higher met directly with the researcher to ensure that a plan was in place to meet their needs.

TABLE 1. Distress Levels Reported Level

Percent Reporting Level (N)

22% (12)

16% (9)

15% (8)

11% (6)

9% (5)

3% (2)

9% (5)

2% (1)

6% (3)

2% (1)

In addition to overall distress, the tool lists problems in 5 topic areas (practical, family, emotional, spiritual/religious, and physical) that may be contributing to the patient’s distress over the previous week, with space to list other problems. The patient checks yes or no to each potential problem. The researchers added questions to collect data on gender and age, and cancer characteristics (eg, cancer type, year of diagnosis, prior and/or concurrent treatment, and current point in treatment cycle). The 2 treatment-related questions were included to determine if the patient’s distress was associated with the previous treatment and/or the current point in treatment. Study population A total of 55 people participated in this research study. Most respondents were female (69%; N = 38),

ADDITIONAL DATA FROM THIS STUDY Go to the online version of this article at http://bit.ly/1WLt9P8 for the following additional tables: • Study Participant Demographics • Participants’ Disease and Treatment Demographics • Responses to Problems on NCCN Distress Thermometer

ON THE

WEB

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FEATURE | Distress Screening and age 66 to 75 years (36%; N = 20). The most common cancer types were breast (26%; N = 14), lung (18%; N = 10), and colorectal (16%; N = 9). In addition, 11 other cancer types were represented in this study. Sixty-two percent (N = 34) of participants were receiving chemotherapy, and the remaining patients (38%; N = 21) were undergoing radiation treatment. One patient was receiving concurrent chemotherapy and radiation; this patient’s results were included once under radiation as the survey was completed on the day of a radiation treatment. Most diagnoses occurred in 2014 (46%; N = 25) or 2015 (13%; N = 7). Prior radiation or a different chemotherapy regimen was reported by 46% of participants (N = 25). Cycle/week of chemotherapy or number of radiation treatment was coded and divided into first cycle/week, second cycle/week, third cycle/week to halfway point, halfway point to second-to-last cycle/week, and last cycle/ week. Nine participants (5%) reported palliative treatment until end of life and 15 (27%) could not remember at what point in their treatment plan they were. Participants were asked to rate their distress level over the previous week using the number scale on the thermometer ( Table 1). The most common response was 0 (22%; N = 12), followed closely by 1 (16%; N = 9), and 2 (15%; N = 8). Only 1 patient called the nurse navigator to locate more resources, and this was related to insurance and financial needs. Self-report of problems Participants were asked to check “Yes” or “No” for each item on a list of 38 problems, divided TABLE 2. Distress Level by Participant Characteristic Mean (N)

Range

Male

2.7 (17)

0–9

Female

3.2 (38)

0–10

26-35 years

6.0 (1)

36-45 years

0.6 (3)

0–1

46-55 years

5.3 (9)

1–10

56-65 years

4.1 (16)

0–9

66-75 years

1.7 (20)

0–6

>76 years

2.3 (6)

0–7

Gender

Age

into 5 categories. Practical problems, ranked in order of percentage of “Yes” responses, were: insurance/financial (32.7%), treatment decisions (27.3%), transportation (10.9%), work/ school (5.5%), housing (3.6%), and child care (0%). Family problems, per the same ranking order, were: family health issues (21.8%), dealing with a partner (12.7%), dealing with children (10.9%), and ability to have children (0%). Emotional problems, per the same ranking order, were: worry (43.6%), fears (40%), sadness (38.2%), loss of interest in usual activities (34.5%), nervousness (30.9%), and depression (27.3%). Spiritual/religious concerns are not divided into subcategories; only 7.3% of respondents checked “Yes” for this item. Ranked in order of percentage of “Yes” responses, physical problems were: fatigue (63.6%), pain (45.5%), dry or itchy skin (43.6%), memory/concentration (40%), constipation (40%), sleep (38.2%), nausea (36.4%), eating (32.7%), appearance (29.1%), getting around (29.1%), tingling in hands/feet (27.3%), nose dry/congested (25.5%), diarrhea (25.5%), indigestion (25.5%), feeling swollen (23.6%), breathing (18.2%), bathing/dressing (10.9%), mouth sores (10.9%), sexual (10.9%), changes in urination (9.1%), and fevers (7.3%). Distress level by number of problems Participants who scored their distress as 4 or lower (N = 40) reported fewer problems over the last week, with a mean score of 7.45 (range, 2-17). Participants who scored their distress as 5 or higher (N = 15) reported twice as many problems with a mean score of 14.4 (range, 4-21). Some participants scored their distress as a 5 or higher but reported fewer problems than those participants who scored their distress as a 4 or lower. Distress level by demographics Most of our participants were females who also reported more distress during treatment than the male participants. Scores for both groups represented a wide range of distress. One male rated his distress as a 9 on the thermometer, and 1 female rated her distress at the highest score, 10 ( Table 2). Most participants were age 66 to 75 years, and they reported the second-lowest distress scores. The groups reporting the highest distress scores were 26 to 35 years (mean distress score 6) and 46 to 55 years (mean distress score 5.3). Mean distress scores for participants by cancer type were lung cancer, 4 (range 0-8 problems); breast cancer, 3.8 (range 0-9); head and neck cancer, 3.2 (range 2-6). Although only 4 participants had head and neck cancer, their distress ranked third among the cancer types represented in our study (Table 3). Participants undergoing radiation therapy reported higher distress than those undergoing chemotherapy. Mean scores were 3.8 vs 2.6, respectively. Distress level by treatment Among the participants who had undergone prior treatment with either radiation or

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chemotherapy, mean distress score was 3.8 (range 0-10). One participant reported receiving concurrent chemoradiation treatment and a distress score of 3. The participants with no prior treatment had a mean distress score of 2.5 ( Table 4). Distress was further evaluated in relation to number of treatments. Participants reporting the highest level of distress (mean 5.8) were in their second cycle of chemotherapy or week of radiation treatment. This was a sharp increase compared with the mean distress score (3.7) of those in their first cycle/week of treatment. The lowest mean score (2.7) was for the third cycle/week to halfway point of treatment. At the halfway point and beyond, mean distress scores increased again to 3.5 and 3.4, respectively, for the halfway point to second-to-last cycle/week and the last cycle/week. Five participants reported receiving palliative treatment until end of life, and their mean score was higher (3.8). DISCUSSION

The distress screen requirement for accredited cancer programs has impacted all facilities. Each program must determine the optimal time to screen and how to assist its patients. In this project, we explored the distress experienced by patients with cancer in relation to their demographics, past treatment, and the relationship between problems and distress levels. Using the information obtained, we can implement changes that improve the current screening and referral process for our patients. For the purpose of this study, we made the following assumptions: The participants in this study may be at risk for cancer-related distress. The participants will answer all questions truthfully. One limitation of this study, however, is that it is a cross sectional study and data were obtained at one point in time. Current experiences of that day could have affected participants’ answers. For example, if the patient had not rested well the night before, this may reflect as a higher level of distress than if the patient had slept better. There is the possibility that a view may change over time related to a change in the circumstances. DEMOGRAPHICS AND RISK FOR DISTRESS Our results showed that females had a higher level of distress than males. However, females are more likely to express emotions and discuss psychological distress than males.14 Females are also more open with their feelings and more comfortable discussing emotions. Overall, the average distress score for most of the participants was 3. The 46-to-55-years age group had a mean distress score of 5.3. This could be attributed to being the

TABLE 3. Distress Level by Cancer and Treatment Type Type

Mean (N)

Range

Breast

3.8 (14)

0–9

Lung

4.0 (10)

0–8

Colorectal

3.2 (9)

0–10

Prostate

2.0 (2)

0–4

Lymphoma

2.2 (4)

0–9

Renal Cell

4.0 (1)

Bone

0.0 (1)

Head and neck

3.2 (4)

2–6

Gynecologic

2.6 (3)

0–5

Multiple myeloma

1.5 (2)

1–2

Leukemia

3.0 (1)

Myelodysplastic syndrome

0.0 (1)

Brain

0.0 (1)

Melanoma skin

2.0 (2)

1–3

Radiation

3.8 (21)

0–10

Chemotherapy

2.6 (34)

0–9

Cancer Type

Treatment Type

sandwich generation, meaning they are both raising children and caring for aging parents. Their caregiving responsibilities could be placing a higher level of stress on them while they are facing cancer treatment. Further assessment of this age group would help identify their unique needs. Whether one cancer type causes patients more distress than another has been investigated in other studies, with similar results. More patients in our study had breast cancer, so small sample size in the other cancer types may account for differences in mean scores. Mean distress score in patients with lung cancer was 4. The fact that lung cancer is the second most common cause of death in both men and women could cause more distress.15 The other notable diagnosis was head and neck cancers. Our results were similar to a study by Singer and colleagues that

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FEATURE | Distress Screening TABLE 4. Distress Level by Prior and Current Treatment Treatment

Mean (N)

Range

Yes

38 (25)

0–10

2.5 (19)

0–8

Concurrent

3.0 (1)

Cannot remember

2.3 (10)

0–9

First cycle/week

3.7 (4)

2–5

Second cycle/week

5.8 (6)

1–10

Third cycle/week to halfway point

2.7 (11)

0–6

Prior Treatment

Number of Treatments

Halfway point to second-to-last cycle/week

3.5 (4)

0–9

Last cycle/week

3.4 (10)

0–8

Palliative till end of life

3.8 (5)

0–9

Cannot remember

1.6 (15)

0–8

showed patients with head and neck cancers experience more emotional distress.16 TREATMENT EXPERIENCE AND DISTRESS Mean distress score was higher for participants undergoing radiation (3.8) than for those receiving chemotherapy (2.6). Radiation is typically administered daily for several weeks, challenging patients and families in regard to transportation, gas, or managing side effects. The specific problems identified between the 2 treatment modalities should be explored further. Mean distress score was higher for those patients who had no prior cancer treatment, possibly due to newly diagnosed or earlier stage disease. A patient who has undergone prior chemotherapy or radiation treatment may have already identified resources to assist with coping or financial needs. The patient in our study who was undergoing concurrent treatment with radiation and chemotherapy reported a distress score of 3. When working with a patient receiving concurrent treatment, consider that distress could be higher as they are undergoing 2 intense treatments simultaneously.

Reported distress levels were different at various points in patients’ treatment cycles. Of those patients who could remember their number of treatments, lower distress levels were reported by those in their third treatment cycle to the halfway point (mean score 2.7). The highest distress levels were reported during the second cycle/week of treatment (mean score 5.8). Causative factors include initial experiences with treatment, acute awareness of side effects, receiving bills, or facing emotional changes. Between the second and third cycle/week through the halfway point, the patient is adjusting to the new schedule and finding ways to adapt. Once the patient is past the halfway point, the distress score increases again. Further research could explore the relationship between distress level and number of treatments, and identify an optimal point for assessment. IMPLICATIONS FOR HEALTH CARE Policy With commitment from facilities to enact policy

changes, screening procedures need to be evaluated. Based on these results, screening more than once during treatment is necessary. The distress screening policy should consider the points when distress is likely to be higher. This study indicates that point is at the second cycle/week of treatment, and distress should also be assessed before the end of treatment as well. In addition, a policy change in regard to nursing education is needed. Nurses should undergo training on distress screening annually. Education could be accomplished through posters, testing, or even during yearly simulations. Identifying the value of screening to the nurse is imperative. Economics As with any change to a process, the economic impact needs to be considered. Evidence shows that when patients feel their emotional needs are not being met, they are more likely to seek out other clinics and emergency care services.4,17 Implementing a change would cost very little. The nurse at the chair-side should be able to assist a patient who reports a distress score of 4 or lower. A patient who reports a score of 5 or higher could be referred to the oncology nurse navigator (ONN). The ONN can take the lead in assisting the patient, families, and caregivers. ONNs are more likely to be aware of local, regional, and national support resources, as there are benefits in developing resources that meet a variety of needs. Future studies could compare the benefits of distress screening and referral to an ONN with outcomes for patients not screened for distress. Outcome measures include utilization of emergency and primary care offices for problems not

24 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2016 • www.OncologyNurseAdvisor.com

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addressed in the oncology setting. From there, lobbying and networking with insurance companies could assist in improved mental health coverage. Institutions Health care institutions should embrace the change and see this as best practices for treating psychosocial distress in the clinical setting. Patients should no longer be treated for 1 problem at a time. Recognizing that distress impacts a patient’s cognitive and emotional function as well as quality of life is essential.18 Assessing and treating distress early could decrease hospital admissions. The cost of adding distress screening to routine assessment is minimal. Health care institutions should evaluate the need for outpatient mental health services for patients with cancer. Even though mental health is considered an essential part of overall health, it is often overlooked.19 Mental health also impacts other aspects of overall health, including employment, personal, and family life. In our study, worry, fear, sadness, nervousness, and depression were patient concerns we encountered. Depression can be overpowering for anyone, but for the patient with cancer, it can affect how well they cope with treatment.20 Developing a mental health program that provides individual and group support is necessary to meet more patients’ needs. One in 3 adults with cancer experience anxiety.21 Support groups and other resources are needed for patients who do not need formal mental health care but could benefit from support services. Health care institutions should consider developing professionally led support groups, as these are preferred over patient-led groups.22 There is strength in numbers; patients find it helpful to meet someone with a similar experience.23 There are currently no active profes-

shown that in some settings, nurses often score a patient’s distress significantly lower than the patient does. Recognizing the impact screening can have on quality-oflife will best allow for meeting patients’ needs.25 Our study adds to the body of knowledge that screening for distress can make a difference in the lives of our patients and provides another example that demonstrates the value of change.

Our project demonstrates that patients experience distress at different levels, but it does impact most patients.

3. Redmond M. Screening for distress in patients with cancer. J Contin Educ

CONCLUSION Cancer distress is a serious concern. Our project demonstrates that patients experience distress at different levels, but it does impact most patients manifesting as common problems such as fatigue; pain; dry, itchy skin; and worry. The patients in this study were more likely to experience distress during the second cycle/week of treatment; however, future studies should follow a patient through treatment to determine whether this is a common point for distress. The study was important to the facilities involved to further develop policies and support changes to the distress screening process. ■ Heather Askren is an oncology nurse practitioner at Franciscan St Elizabeth in Lafayette, Indiana; Susan DeCrane is an assistant professor, Kathleen Abrahamson is an assistant professor, and Cynthia Keith is a clinical associate professor, all at Purdue University, West Lafayette, Indiana. REFERENCE 1. Baken DM, Wooley C. Validation of the Distress Thermometer, Impact Thermometer and combinations of these in screening for distress. Psychooncology. 2011;20(6):609-614. 2. Seigel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64(1):9-29. Nurs. 2015;46(5):201-202. 4. Clark PG, Rochon E, Brethwaite D, Edmiston KK. Screening for psychological and physical distress in a cancer inpatient treatment setting: a pilot study. Pscyhooncology. 2011;20(6):664-668. doi:10.1002/pon.1908. 5. NCCN practice guidelines for the management of psychological distress. National Comprehensive Cancer Network. Oncology (Williston Park). 1999;13(5A):113-147. 6. Carlson LE, Bultz BD. Benefits of psychosocial oncology care: improved

sionally led support groups within the community setting where our study took place. Nursing Nurses are vital to implementing and sustaining a distress screening process. They are the frontline staff who can assist with identifying patients’ support needs.24 Nurses are often best able to identify and provide resources that help meet patients’ needs, which may already occur during conversations with the patient. Despite this, research has

quality of life and medical cost offset. Health Qual Life Outcomes. 2003;1:8. doi:10.1186/1477-7525-1-8. 7. Institute of Medicine report: recognizing psychosocial health needs to treat the whole patient. J Oncol Pract. 2008;4(3):128-130. 8. Institute of Medicine of the National Academies. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington DC: National Academies Press; 2007. Continued on page 29

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18. Clark PG, Bolte S, Buzaglo J, Golant M, Daratsos L, Loscalzo M. From distress guidelines to developing models of psychosocial care: current

Continued from page 25

best practices. J Psychosoc Oncol. 2012;30(6):694-714. 9. Wagner LI, Spiegel D, Pearman T. Using the science of psychosocial care to implement the new American College of Surgeons Commission on Cancer distress screening standard. J Natl Compr Canc Netw. 2013;11(2):214-221. 10. Holland JC, Kelly BJ, Weinberger MI. Why psychosocial care is difficult

19. Sturgeon S. Promoting mental health as an essential aspect of health promotion. Health Promot Int. 2006;21(suppl1):36-41. doi:10.1093/ heapro/dal049. 20. Walker J, Hansen CH, Martin P, et al. Prevalance, associations, and ade-

to integrate into routine care: stigma is the elephant in the room. J Natl

quacy of treatment of major depression in patients with cancer: a cross-

Compr Canc Netw. 2010;8(4):362-366.

sectional analysis of routinely collected clinical data. Lancet Psychiatry.

11. Oncology Nursing Society. Oncology Nurse Navigator Core Competencies.

2014;1(5):343-350. doi:10.1016/S2215-0366(14)70313-X. 21. Mehnert A, Brähler E, Faller H, et al. Reply to: Dekker J, Braamse A, van

Pittsburgh, PA: Oncology Nursing Society; 2014. 12. Harrington CB, Hansen JA, Moskowitz M, Todd BL, Feuerstein M. It’s not over when it’s over: long-term symptoms in cancer survivors—a system-

Linde ME, Voogd AC, Beekman A, Verheul HM. One in three patients with cancer meets the criteria for mental disorders: What does that mean? J Clin Oncol. 2015;33(25):2826-2828.

atic review. Int J Psychiatry Med. 2010;40(2):163-181. 13. Andrykowski MA, Steffens RF, Bush HM, Tucker TC. Disparities in mental health outcomes among lung cancer survivors associated with ruralness of residence. Pscyhooncology. 2014;23(4):428-436. doi:10.1002/pon.3440. 14. Loscalzo M, Clark K. Gender opportunites in psychosocial oncology. In:

22. Slevin ML, Nichols SE, Downer SM, et al. Emotional support for cancer patients: what do patients really want? Br J Cancer. 1996;74(8):1275-1279. 23. Tehrani AM, Farajzadgen Z, Rajabi FM, Zamani AR. Belonging to a peer

Goerling U, ed. Psycho-Oncology. Heidelberg, Germany: Springer-Verlag

support group enhances the quality of life and adherence rate in

Berlin Heidelberg; 2014:31-47.

patients affected by breast cancer: a non-randomized controlled clinical

15. Lung cancer. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/cancer/lung/. Accessed May 6, 2016. 16. Singer S, Krauss O, Keszte J, et al. Predictors of emotional distress in patients with head and neck cancer. Head Neck. 2012;34(2):180-188.

trial. J Res Med Sci. 2011;16(5):658-665. 24. Mårtensson G, Carlsson M, Lampic C. Do oncology nurses provide more care to patients with high levels of emotional distress? Oncol Nurs Forum. 2010;37(1):E34-E42. 25. Schofield P, Carey M, Bonevski B, Sanson-Fisher R. Barriers to provision

doi:10.1002/hed.21702. 17. Harding M. Health-promotion behaviors and psychological distress in cancer survivors. Oncol Nurs Forum. 2012;39(2):E132-E140.

of evidence-based psychosocial care in oncology. Psychooncology. 2006;15(10):863-872. doi:10.1002/pon.1017.

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FEATURE | Psychosocial Support

Psychosocial Support From a Partner Improves Outcomes Study confirms improved socioeconomic status, psychosocial support, and self care tend to result in improved survival for married patients with cancer. BETTE WEINSTEIN KAPLAN

eing married enables most patients with cancer to live longer than their unmarried peers. While this had been known for some time, a recently published study by Scarlett Lin Gomez, PhD, of the Cancer Prevention Institute of California, and María Elena Martínez, PhD, of the University of California San Diego School of Medicine, and their colleagues furthers the discussion.1 The team suggests that one reason for the discrepancy might be because married patients are more likely to obtain their diagnoses early on in the disease process, when treatment is usually more effective. In addition, married patients are more likely to have healthier lifestyles, including more physical activity and more healthful dietary habits, than their single counterparts. They are more apt to take advantage of cancer screening opportunities, and when cancer is identified, their treatment is more successful. However, this study goes beyond the social aspect of survival to focus on “the impact of economic resources as a contributing factor for marriage-associated survival differences.”1 800 000 PATIENTS, 10 CANCER SITES

For this project, the research team utilized population-based data from the California Cancer Registry for first primary invasive cancers in males and females older than 18 years. This gave them information on approximately 800 000 adults with invasive cancer diagnosed in the years 2000 to 2009. Patients were followed through 2012. 30 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2016 • www.OncologyNurseAdvisor.com

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Cancer sites for males were prostate, lung and bronchus, colon, non-Hodgkin lymphoma (NHL), bladder, liver and intrahepatic bile duct (liver and IBD), leukemia, pancreas, stomach, and esophagus. For females, the sites were breast; lung; colon; corpus and uterus, not otherwise specified; NHL; ovary; pancreas; leukemia; brain and other nervous system; and liver and IBD. Patient characteristics included marital status, age, address and stage at diagnosis, year of diagnosis, race/ethnicity, sex, histology, first course of treatment (surgery, radiation, and/or systemic hormone agents), as well as primary and secondary payment sources. Health insurance status was coded hierarchically as no insurance; any public, military, or Medicaid/Medi-Cal (including Medicare/Medicaid) insurance; private insurance only; Medicare only or with private insurance; and unknown. The team noted that mortality risks usually do not vary much among unmarried subcategories, thus although they conducted their primary analyses with marital status coded as married and unmarried, the unmarried consisted of never married, separated, divorced, and widowed. STUDY POPULATION DEMOGRAPHIC The cohort included 393 470 males and 389 697 females. More males were married (70%) than females (51%). The unmarried patients differed from the married ones in several ways: they lived in lower socioeconomic neighborhoods, tended to have public insurance or no insurance, had more advanced disease at diagnosis, often had not undergone any radiation or surgery, and were more likely to be black. Ninety-eight percent of patients had health insurance, and most plans were private insurance. Risk of death was 25% higher for the uninsured than for privately insured patients. Those on public insurance also had a higher risk of death compared with those with private insurance. A survival distinction was seen among the different racial and ethnic groups. Unmarried blacks fared the worst. Married whites survived longer than married Hispanics and Asian/ Pacific Islanders. Interestingly, Hispanic and Asian/Pacific Islanders who were born in the United States lived longer than those who were born outside the country.1

FIND US ON

The investigators did not find that mortality rates were associated with specific types of cancer; however, more favorable survival rates were seen in persons with breast cancer, prostate cancer, and non-Hodgkin lymphoma. SOCIAL SUPPORT IS VITAL The researchers found that mortality rates decreased as socioeconomic status increased, and most notably, mortality rates also decreased for those patients who were married. These statistics may be due to married patients having a

Nurses should ask unmarried patients if anyone in their social network could help them. larger combined income with all the advantages that brings, including access to private insurance. They may also be due to the more social environment of marriage lending more psychological support. “Evidence suggests that higher levels of social support are directly correlated with biologic processes that may mitigate the harmful physiologic effects of stress by directly inhibiting tumor progression through immunologic or neuroendocrine pathways,” the investigators concluded.1 With the crucial role of social support confirmed and the number of patients with cancer growing, the researchers suggest that nurses, physicians, and other health care providers ask their unmarried patients if there is anyone in their social network who could help them get through their illness from both the physical and emotional standpoints. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Gomez SL, Hurley S, Canchola AJ, et al. Eﬀects of marital status and economic resources on survival after cancer: a population-based study [published online ahead of print April 11, 2016]. Cancer. doi:10.1002/cncr.29885.

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STAT CONSULT

Daratumumab (Darzalex) Drug Type

• Human CD38-directed monoclonal antibody

Indications

• Treatment of patients with multiple myeloma who have received at least 3 prior lines of therapy, including a proteasome inhibitor (PI) and an immunomodulatory drug (IMiD), or who are double-refractory to a PI and an IMiD Mechanism of Action

• CD38 is a transmembrane glycoprotein expressed on the surface of hematopoietic cells and has multiple functions, such as receptor mediated adhesion, signaling, and modulation of cyclase and hydrolase activity • Daratumumab is an IgG1κ human monoclonal antibody that binds to CD38 and inhibits growth of CD38 expressing tumor cells by inducing apoptosis • Myeloid derived suppressor cells and a subset of regulatory • T cells express CD38 and are susceptible to daratumumab mediated cell lysis Dosage and Administration

• 16 mg/kg intravenously • Administer only as an intravenous infusion after dilution • Administer weekly from week 1 to week 8, every 2 weeks from week 9 to week 24, every 4 weeks from week 25 on, until disease progression Infusion Rates

• First infusion ——Dilution volume = 1000 mL ——Initial rate = 50 mL/hour • Second infusion ——Escalate only if there were no grade 1 or greater infusion reactions during the first 3 hours of first infusion

——Dilution volume = 500 mL ——Initial rate = 50 mL/hour • Subsequent infusions ——Escalate only if there were no grade 1 or greater infusion reactions during a final infusion rate of ≥100 mL/ hr in first 2 infusions ——Dilution volume = 500 mL ——Initial rate = 100 mL/hour • Rate increment = 50 mL/hour every hour • Maximum rate = 200 mL/hour • Preinfusion medication ——Administer preinfusion medications to reduce risk of infusion reactions to all patients approximately 1 hour prior to every infusion of daratumumab as follows: ■■ IV corticosteroid (methylprednisolone 100 mg, or equivalent dose of an intermediate-acting or longacting corticosteroid), plus »» Following second infusion, dose of corticosteroid may be reduced (methylprednisolone 60 mg IV) ■■ Oral antipyretics (acetaminophen 650 to 1000 mg), plus ■■ Oral or IV antihistamine (diphenhydramine 25 to 50 mg or equivalent) • Prophylaxis for herpes zoster reactivation ——Initiate antiviral prophylaxis to prevent herpes zoster reactivation within 1 week of starting daratumumab and continue for 3 months following treatment • Postinfusion medication ——Administer postinfusion medication to reduce risk of delayed infusion reactions to all patients as follows: ■■ Oral corticosteroid on first and second day after all infusions Continued on page 34

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STAT CONSULT

• None

——Type and screen patients prior to starting treatment ——Inform blood banks that a patient has received daratumumab • Inference with determination of complete response ——Daratumumab can be detected on both serum protein electrophoresis (SPE) and immunofixation (IFE) assays used for clinical monitoring of endogenous M-protein ——This interference can impact determination of complete response and of disease progression in some patients with IgG kappa myeloma protein

Specific Populations

Adverse Effects

• Pregnancy ——May cause fetal myeloid-cell or lymphoid-cell depletion and decreased bone density • Nursing mothers ——Benefits of breastfeeding should be considered along with mother’s clinical need for daratumumab and any potential adverse effects on the breastfed child from daratumumab or from the underlying maternal condition • Pediatric ——Not established • Geriatric ——No overall differences in safety or effectiveness were observed between geriatric patients and younger patients • Renal impairment ——No dose adjustment necessary for patients with preexisting renal impairment • Hepatic impairment ——No dose adjustment recommended for mild hepatic impairment ——Daratumumab has not been studied in patients with moderate to severe hepatic impairment • Females of reproductive potential ——Advise females of reproductive potential to use effective contraception during treatment and for 3 months after final dose

• Most common adverse reactions (≥20%): ——Anemia ——Back pain ——Cough ——Fatigue ——Infusion reaction ——Lymphopenia ——Nausea ——Neutropenia ——Pyrexia ——Thrombocytopenia ——Upper respiratory tract

——For patients with a history of obstructive pulmonary disorder, consider prescribing postinfusion medications such as short-acting and long-acting bronchodilators, and inhaled corticosteroids ■■ Following first 4 infusions, if patient experiences no major infusion reactions, these additional inhaled postinfusion medications may be discontinued Dosage Adjustments

Warnings and Precautions

• Infusion reactions ——Interrupt daratumumab for infusion reactions of any severity ——Permanently discontinue infusion in case of lifethreatening infusion reactions • Interference with cross-matching and red blood cell antibody screening ——Treatment with daratumumab results in a positive indirect antiglobulin test (Coombs test)

Drug Interactions

• None What to Tell Your Patient

• Daratumumab is a prescription medicine used to treat multiple myeloma • The drug is only for people who have received at least 3 prior treatments for their disease, including a proteasome inhibitor and an immunomodulatory agent, or those who did not response to a proteasome inhibitor and an immunomodulatory agent • Before you take daratumumab, tell your nurse or doctor about all of your medical conditions, including if you: ——Have a history of breathing problems ——Have had shingles • Daratumumab may cause side effects in the fetus. Tell your nurse or doctor if are pregnant or plan to become pregnant ——Females who are able to become pregnant should use an effective method of birth control during treatment and for at least 3 months after your final dose ——Talk to your nurse or doctor about birth control methods that you can use during this time Continued on page 37

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STAT CONSULT

Necitumumab (Portrazza) Drug Type

• Epidermal growth factor receptor (EGFR) antagonist

Indications

• First-line treatment of patients with metastatic squamous non-small cell lung cancer (NSCLC), in combination with gemcitabine and cisplatin Mechanism of Action

• Necitumumab is a recombinant human IgG1 monoclonal antibody that binds to human EGFR and blocks binding of EGFR to its ligands • Expression and activation of EGFR has been correlated with malignant progression, induction of angiogenesis, and inhibition of apoptosis Dosage and Administration

• Absolute dose of 800 mg • Administer only as an intravenous infusion on days 1 and 8 of each 3-week cycle until disease progression or unacceptable toxicity • Administer diluted necitumumab via infusion pump over 60 minutes through a separate infusion line prior to gemcitabine and cisplatin infusion • Flush line with 0.9% NaCl at end of infusion Premedication

• For patients who have experienced a previous grade 1 or 2 infusion-related reaction (IRR), premedicate with diphenhydramine HCl (or equivalent) prior to all subsequent necitumumab infusions. • For patients who have experienced a second occurrence of grade 1 or 2 infusion-related reaction, premedicate for all subsequent infusions with diphenhydramine HCl (or equivalent), acetaminophen (or equivalent), and

dexamethasone (or equivalent) prior to each necitumumab infusion. Dosage Adjustments

• Infusion-related reactions — Reduce the infusion rate of necitumumab by 50% for grade 1 IRR — Stop the infusion for grade 2 IRR until signs and symptoms have resolved to grade 0 or 1 ■ Resume necitumumab at 50% reduced rate for all subsequent infusions — Permanently discontinue necitumumab for grade 3 or 4 IRRs Dermatologic toxicity

• Withhold necitumumab for — Grade 3 rash or acneiform rash until symptoms resolve to grade ≤2, then resume necitumumab at reduced dose of 400 mg for at least 1 treatment cycle ■ If symptoms do not worsen, may increase dose to 600 mg and 800 mg in subsequent cycles • Permanently discontinue necitumumab if — Grade 3 rash or acneiform rash do not resolve to grade ≤2 within 6 weeks, — Reactions worsen or become intolerable at a dose of 400 mg, — Patient experiences grade 3 skin induration/fibrosis, or — Grade 4 dermatologic toxicity Specific Populations

• Pregnancy — Not established, but based on its mechanism of action,

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STAT CONSULT necitumumab can cause fetal harm or developmental anomalies • Nursing mothers ——Because of potential for serious adverse reactions in breastfed infants, advise a nursing woman not to breastfeed during treatment with necitumumab and for 3 months following final dose • Pediatric ——Not established • Geriatric ——Higher incidence of thromboembolic events, including pulmonary embolism, in patients age 70 years and older compared with those younger than 70 years • Renal impairment ——Renal function has no impact on exposure to necitumumab based on the population PK analysis of clinical trial data • Hepatic impairment ——Mild or moderate hepatic impairment has no impact on exposure to necitumumab based on population PK analysis Boxed Warnings

• Cardiopulmonary arrest and/or sudden death ——Closely monitor serum electrolytes, including serum magnesium, potassium, and calcium, with aggressive replacement when warranted during and after necitumumab administration • Hypomagnesemia ——Monitor patients for hypomagnesemia, hypocalcemia, and hypokalemia prior to each necitumumab dose during treatment and for at least 8 weeks following completion of necitumumab ——Withhold necitumumab for grade 3 or 4 electrolyte abnormalities ——Replete electrolytes as medically appropriate Contraindications

may be administered in these patients once electrolyte abnormalities have improved to grade 2 or lower ——Replete electrolytes as necessary • Venous thromboembolic events (VTE) and arterial thromboembolic events (ATE) ——Discontinue necitumumab for severe VTE or ATE • Dermatologic toxicities ——Monitor for dermatologic toxicities and withhold or discontinue necitumumab for severe toxicity ——Limit sun exposure • Infusion-related reactions ——Monitor for signs and symptoms during and following infusion ——Discontinue necitumumab for severe reactions • Increased toxicity in non-squamous NSCLC ——Necitumumab should not be used in patients with non-squamous disease as it can cause more serious and fatal toxicities compared with chemotherapy alone • Embryo-fetal toxicity ——Can cause fetal harm ——Advise females of reproductive potential of the potential risk to a fetus and to use effective contraception Adverse Effects

• Most common adverse reactions of necitumumab in combination with gemcitabine and cisplatin (≥10%) ——Diarrhea ——Dermatitis acneiform ——Stomatitis ——Headache ——Hemoptysis ——Hypocalcemia ——Hypokalemia ——Hypomagnesemia ——Hypophosphatemia ——Rash ——Vomiting ——Weight loss

• None Warnings and Precautions

• Cardiopulmonary arrest ——Closely monitor serum electrolyes during and after necitumumab • Hypomagnesemia ——Monitor prior to each infusion and for at least 8 weeks following the completion of necitumumab ——Withhold necitumumab for grade 3 or 4 electrolyte abnormalities; subsequent cycles of necitumumab

Drug Interactions

• Necitumumab may increase maximum serum concentration of gemcitabine What to Tell Your Patient

• Necitumumab is a prescription medicine used to treat metastatic squamous NSCLC • It is only used in combination with gemcitabine and cisplatin chemotherapy • Before you take necitumumab, tell your health care

36 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2016 • www.OncologyNurseAdvisor.com

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provider about all of your medical conditions and about all the medicines you take • Necitumumab will be given to you by IV infusion into your vein • The infusion should be completed within 2 hours • Necitumumab is typically given weekly for 2 weeks of each 3-week cycle • Your clinician will decide how many treatments you will receive • You may also receive medications before each dose of necitumumab to reduce the risk of infusion-related reactions • You have an higher risk of decreased blood levels of magnesium, potassium, and calcium while receiving this drug. ——Your physician will give you medicines to replace the electrolytes ——Take these medicines exactly as advised by your physician • You will have an increased risk of developing blood clots while receiving necitumumab

• Minimize your sun exposure, wear protective clothing, and use sunscreen while receiving necitumumab • Notify your clinician immediately if you experience signs and symptoms of infusion reactions such as fever, chills, or breathing problems • You should not plan on becoming pregnant while receiving necitumumab • You should use effective contraception during treatment with necitumumab and for 3 months following final dose • Do not breastfeed during treatment with necitumumab and for 3 months following the final dose • Most common side effects of necitumumab include ——Hypocalcemia, hypokalemia, hypomagnesemia, hypophosphatemia, rash, vomiting • These are not all of the possible side effects of necitumumab • Tell your healthcare provider if you have any side effect that bothers you or that does not go away • Call your doctor for medical advice about side effects

Daratumumab (Darzalex)

»» Chills, dizziness, headache, itching, nausea, rash, shortness of breath, throat tightness, vomiting, wheezing ——Changes in blood test results ■■ Daratumumab can affect the results of tests used to identify your blood type ■■ These changes can last for up to 6 months after your final dose ■■ Your nurse or doctor will order blood tests to identify your blood type before you start treatment ■■ Tell all of your health care providers that you are being treated with daratumumab prior to receiving blood transfusions • Most common side effects of daratumumab include: ——Back pain ——Cold-like symptoms (upper respiratory tract infection) ——Cough • These are not all of the possible side effects of daratumumab. ——Tell your nurse or doctor if you experience any side effects that bother you or that do not go away. • Call your nurse or doctor for medical advice about side effects.

Continued from page 34

——Are breastfeeding or plan to breastfeed • Tell your nurse or doctor about all the medicines you take • Daratumumab will be given to you by IV infusion into your vein • The infusion should be completed within 15 hours • Daratumumab is typically given weekly for the first 8 weeks, then every 2 weeks for 16 weeks, and then every 4 weeks after that • Your doctor will decide how many treatment you will receive • You will also receive medications before each dose of daratumumab and on the first and second day after each dose to reduce the risk of infusion reactions • Daratumumab may cause serious side effects ——Infusion reactions ■■ Infusion reactions are common with daratumumab and can be severe ■■ If you experience infusion reactions, your nurse or doctor may stop your infusion temporarily or completely stop your treatment ■■ Tell your nurse or doctor right away if you experience:

Prepared by Jason Hoffman, PharmD, RPh.

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RADIATION & YOUR PATIENT

Managing Breakthrough Pain During Radiotherapy Bryant Furlow Inadequate control of cancer pain and breakthrough pain during radiation therapy planning and treatment procedures can interrupt treatment schedules and impact the accurate delivery of therapeutic radiation doses to tumor tissue, diminishing the potential benefits of radiotherapy. A recent study demonstrated that fentanyl pectin nasal spray quickly alleviates breakthrough cancer pain during radiotherapy procedure positioning.

ancer pain affects more than half of patients but is an oftenneglected facet of cancer treatment planning and delivery.1 This is particularly true for cancer radiotherapy, which has a complex relationship

with cancer pain. For example, radiotherapy plays an important role in helping to relieve cancer pain, such as that arising from bone metastases. But cancer pain can also disrupt the planning and delivery of therapeutic irradiation to tumors.2,3 Breakthrough cancer pain is a particular challenge with no one solution for all patients. Episodes are transitory, often described as flares.4 Flares can be predictable, but may also be unpredictable, and onset of pain can abruptly build up to maximum intensity in 3 to 30 minutes.1,4 Unlike oral biologics or infused chemotherapy agents, radiation therapy frequently requires patients to place their bodies in uncomfortable positions and hold those positions for simulation procedures and treatment-planning imaging in addition to the actual delivery of treatment fractions.2,3 These positions and maneuvers can trigger episodes of breakthrough pain.3 Breakthrough pain in this setting disrupts efforts to position the patient and execute the radiotherapy treatment plan. Furthermore, routine radiation therapy procedures and maneuvers can exacerbate breakthrough pain severity depending on the source of the cancer pain (eg, tumor location) and positioning maneuvers attempted.2,3 Surveys indicate that pain is poorly managed in as many as 39% of radiation oncology patients, diminishing patient adherence and radiation course completion on schedule.1,5,6 FAST-ACTING OPTION The need for rapid intervention during breakthrough pain episodes renders management with oral opioids suboptimal, although several opioid interventions have been explored.4 General anesthesia precludes patient

participation in radiotherapy procedures.3 Several rapid-analgesia interventions have been studied, including intranasal opioids, inhaled opioids, parenteral morphine delivery, and the investigational use of sublingual ketamine with local anesthetics.4 Oral (buccal) fentanyl, a fast-acting analgesic also studied for managing breakthrough cancer pain, has been found to be superior to oral morphine and other opioid medications, particularly among patients who developed opioid-tolerant pain—notably, patients with prostate or breast cancer are frequently not opioid-tolerant.1,4 Fentanyl pectin nasal spray (FPNS) similarly provides faster pain relief and higher levels of patient-reported satisfaction with pain relief than other

Oral fentanyl was found to be superior to oral morphine and other opioids. opiates, such as immediate-release morphine sulfate, both in radiation-procedure and radiation-induced acute oral mucositis settings.7-11 The rapid onset of pain relief associated with FPNS makes it appealing for the treatment of both unanticipated and predictable pain in the radiotherapy setting.1,3 Case studies suggest patient-reported intensity of breakthrough cancer pain can be markedly diminished during radiotherapy, from a 7 or 8 on a 10-point scale—10 representing pain as bad as can be imagined—down to a 2.1 A recent study involving 27 patients with advanced cancer, most of whom

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(n = 20) had bone metastases, who experienced moderate-to-severe breakthrough cancer pain associated with routine radiotherapy procedures, found patient-reported breakthrough pain scores were reduced by 50% or more at 15.5 minutes after administration of FPNS 100 to 400 µg.3 Pain relief was reported at 3 to 15 minutes after FPNS administration.3 FPNS was well-tolerated, with only 1 patient discontinuing participation in the study because of intense dizziness and nausea. Overall, the researchers found “a gain in health-related quality of life, decreasing the pain and economic cost per patient.”3 “FPNS offers rapid absorption and analgesia,” reported Isabel Prieto, MD, lead author of the study, and colleagues at the Department of Radiation Oncology, Fundación Jiménez Díaz University in Madrid, Spain.3 “It is particularly eﬃcient and well accepted by radiotherapy patients. Such relief allows the necessary procedures to be completed accurately, without additional needless suffering for patients, and maintaining radiotherapy department productivity.” The researchers called for clinical trials to formally compare the tolerability and eﬃcacy of FPNS and other treatments for breakthrough cancer pain.3 ■

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

and patient satisfaction with fentanyl pectin nasal spray for breakthrough pain in cancer. J Palliat Med. 2014;17(10):1150-1157.

REFERENCES 1. Bell BC, Butler EB. Management of predict-

doi:10.1089/jpm.2014.0089. 8. Moleron R, Cerezo L, Ruiz A, Hervas A,

able pain using fentanyl pectin nasal spray in

Mañas A, De la Torre A. Ability of

patients undergoing radiotherapy. J Pain Res.

intranasal transmucosal fentanyl in pec-

2013;6:843-848. doi:10.2147/JPR.S54788.

tin to prevent breakthrough pain epi-

2. Prieto I, Pardo J, Marin J, et al. Fentanyl pectin nasal citrate to control breakthrough pain provoked by routine radiation therapy procedures and maneuvers in advanced

sodes in patients with radiation-induced oropharyngeal mucositis. Eur J Cancer. 2015;51(suppl3):S233. 9. Bossi P, Locati L, Bergamini C, et al. Fentanyl

cancer patients. Int J Radiat Oncol Biol Phys.

pectin nasal spray as treatment for incident

2013;87(2):S566.

predictable breakthrough pain (BTP) in

3. Prieto I, Pardo J, Luna J, et al. Facilitation of

oral mucositis induced by chemoradio-

accurate and eﬀective radiation therapy

therapy in head and neck cancer. Oral

using fentanyl pectin nasal spray (FPNS)

Oncol. 2014;50(9):884-887. doi:10.1016/j.

to reduce incidental breakthrough pain due to procedure positioning. Scand J Pain. 2016;11:52-58. doi:10.1016/j.sjpain.2015.12.001. 4. Davis MP. Recent development in thera-

oraloncology.2014.06.013. 10. Portenoy RK, Burton AW, Gabrail N, Taylor D; Fentanyl Pectin Nasal Spray 043 Study Group. A multicenter, placebo-controlled,

peutics for breakthrough pain. Expert Rev

double-blind, multiple-crossover study of

Neurother. 2010;10(5):757-773. doi:10.1586/

Fentanyl Pectin Nasal Spray (FPNS) in the

ern.10.41.

treatment of breakthrough cancer pain. Pain.

5. Pignon T, Fernandez L, Ayasso S, Durand MA, Badinand D, Cowen D. Impact of

2010;151(3):617-624. 11. Fallon M, Reale C, Davies A, et al; Fentanyl

radiation oncology practice on pain: a cross-

Nasal Spray Study 044 Investigators Group.

sectional survey. Int J Radiat Oncol Biol Phys.

Eﬃcacy and safety of fentanyl pectin nasal

2004;60(4):1204-1210.

spray compared with immediate-release

6. Janjan N. Do we need to improve pain man-

morphine sulfate tablets in the treatment of

agement in the radiation oncology depart-

breakthrough cancer pain: a multicenter, ran-

ment? Nat Clin Pract Oncol. 2005;2(3):130-131.

domized, controlled, double-blind, double-

7. Torres LM, Revnic J, Knight AD, Perelman M.

dummy multiple-crossover study. J Support

Relationship between onset of pain relief

Oncol. 2011;9(6):224-231.

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COMMUNICATION CHALLENGES

Facing a Juncture in Cancer Care

Ann J. Brady, MSN, RN-BC

This question is always a challenge to answer: “How long do you think I’ve got?” But it is most perplexing close to the end of life.

ow do you answer the question, “How long do you think I’ve got?” Is it easier to answer difficult questions when the patient still has treatment options available? This question is always a challenge to answer: “How long do you think I’ve got?” It can be asked at any time during the course of treatment but is most perplexing close to the end of life. Many patients will go on hospice and die at home, but sometimes, due to circumstances, they will remain hospitalized and some will die there. As the family keeps vigil, one question arises nearly every time we are in the patient’s room. “How much longer do you think?” It is a question that asks for a definite response, and one that is difficult for the patient or family to ask. Once they pose the question, they may be faced with information they did not expect or truly want to hear.

CASE Walter had advanced lung cancer and was hospitalized for altered mental status (AMS) and pain. He was half way through palliative radiation (XRT), but it was put on standby because his confusion made it impossible for him to hold still for his treatment. His delirium was disturbing to the family, yet they retained hope. If he calmed down, he could continue XRT and his condition would improve. “Can’t we just give him anesthesia so he can go to sleep and get his treatment?” It was a simple question. More than anything, they hoped he could complete his treatment. In order for that to occur, they focused on how to get past the hurdle of him moving during XRT. If only it were that simple. The bigger picture was that in spite of chemo and radiation his disease had progressed to the point where he was agitated in a way that was not fixable. More radiation was not going to reverse the steady progression of his disease. He was dying, but he was strong at the same time. He pulled out his IV and repeatedly tried to climb out of bed. “See,” his son said, “he is very strong.” He was, but he wasn’t, too. Sheila had a presumed diagnosis of pancreatic cancer. Presumed because she had not had a biopsy to confirm it. She was cachectic and too weak for treatment. Sheila said to her children and caregivers she had had a long life and did not want treatment. Her family agreed she could not tolerate treatment, yet they asked, “Don’t we need to know what exactly it is? Shouldn’t she have a biopsy?” Phyllis had recurrent cancer of the cervix. She’d had a pelvic exenteration, which failed to heal properly, and had developed 2 fistulas

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and chronic infections. The resulting wounds were stage 4, and though theoretically capable of healing, they had not improved and were a chronic source of infection. It was an unbreakable loop. Her physician and nurses repeatedly suggested it was time for hospice, but Phyllis was clear in her goals. As long as she could interact with family and friends, she wanted to continue dressing changes and antibiotics. Steven, an 80-year-old gentleman, was confused but logical at the same time. He’d been admitted after a fall at home and was found to have a mass in his colon. His capacity for decision making was suspect as he had paranoid ramblings and easily lost focus during conversations. His daughter was his DPOA. She wanted to let him have a say in making decisions. Given his level of confusion and the inherent risk of surgery, sending him home without surgery or treatment was a reasonable option. Everything was moving in that direction, and he and his daughter had a hospice info visit to find out about hospice and make arrangements. During the hospice info visit, Steven said, “But if I don’t have surgery then it is only going to get worse.” DISCUSSION In each of these scenarios the patient/family faced a juncture in what their care would include moving forward. The sense of wanting to “make the right decision” implied that there was one right decision. How do we, as nurses, address these complicated choices when we are asked what we think they should do? A common thread in each example was confusion over focus as a result of a change in the course of their disease. For Walter, his family was focused on the completion of his XRT in spite of the fact that his condition had changed. The destination they sought and expected, a full course of XRT, was sidelined and their goal was completion of the treatment he had begun. To what end? Helping them understand that while he appeared to be physically strong, his confusion was actually an ominous sign.

And allowing them to express their concerns while reminding them of the bigger picture helped them to let go of XRT. For Sheila, the purpose of having a biopsy was so her family would not second guess themselves later. Having a definitive diagnosis was not directed toward treatment but rather toward providing information to her children. Sheila was able to tell her children it did not matter if her diagnosis was confirmed by biopsy, she did not want treatment. To what end, then, was the information from a biopsy going to make a difference? Establishing that the information would not change her decision helped ease the burden on her children. In the first 2 cases the shift was in understanding what the difference would be by not doing something—not completing XRT and not performing a biopsy. In the next 2 scenarios, the focus was on the patient making a choice that did not fit with the recommendations. Phyllis was tired of having to explain her reasons for refusing hospice. Going home on hospice meant stopping antibiotics and the dressing changes could not be done 2 to 3 times per day as they were in the hospital. She was clear on her choice. She knew she was going to die but wanted as much time as possible. Eventually she made the decision to go home on hospice. Continued on page 42

The sense of wanting to “make the right decision” implied that there was one right decision.

JOIN THE CONVERSATION • Are there times when you feel you have missed the mark on establishing for yourself the purpose of offering or not offering treatment? • How do you resolve that discrepancy? Go to http://bit.ly/1X4cbcO for the online version of this article and share with your colleagues your thoughts on resolving the discrepancy in what treatments are offered or not offered to patients nearing end of life.

ON THE

WEB

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COMMUNICATION CHALLENGES

My focus in situations such as these is to help patients and their families and the caregivers clarify the goals of care.

And fi nally, there was Steven. He was clear enough to understand what would happen if he did not have surgery. He and his daughter agreed to surgery feeling that it was a step toward preventing an obstruction. His daughter said having surgery was a case of, “One and done.” Neither she nor her father thought chemo was something they would consider. All 4 situations presented a challenge in communication. How do we help our patients and families make sense of the bigger picture? It is easy to get caught in details and miss the bottom line. There is a church near my home that I pass on my way to work. Each week they post a new inspirational saying. A couple of weeks ago the saying was, “What Is The Point?” I drove the rest of the way to work thinking of patients like these 4. My focus in situations

such as these is to help patients and their families and the caregivers clarify the goals of care. Also to stay objective and remain supportive if they struggle with difficult choices. What do you think you might say when a family pushes for XRT when a patient is confused, as Walter was? Do you think having a definitive biopsy and diagnosis is essential for patients like Sheila? What do you say to a patient like Phyllis who continues with care you know is not curative? When you have a patient like Steven, with waxing and waning confusion, does that impact the choices he may be offered? ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

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A Relationship Is Seen Between Metastasis Site and Overall Survival in Men With mCRPC Bette Weinstein Kaplan

ite of metastasis is key to the length of time a patient can survive metastatic castrationresistant prostate cancer (mCRPC), according to new research. In the largest study on the topic to date, scientists have found that survival is contingent on the organs where the metastases are located.1 The results of the recently published meta-analysis came from a team led by Susan Halabi, PhD, professor of biostatistics at Duke Cancer Institute in Durham, NC. Her colleagues on the project came from cancer research centers in the United States, China, France, Australia, Canada, and the United Kingdom. FOUR SITES STUDIED The meta-analysis substantiates earlier studies with small patient samples. The premise for undertaking this project was that the median overall survival time of men with mCRPC who had lung metastases would be shorter than for those who had metastases to the bone. Further, the investigators theorized that the survival time for men who had metastases to the lung with or without bone involvement would be longer than for those patients who had liver metastases. There were 4 sites identified for metastatic disease: lymph node only, bone with or without lymph node involvement with no visceral metastases, any lung metastases without liver disease, and any liver

metastases. The investigators searched PubMed and ClinicalTrials.gov for phase 3 clinical trials of docetaxel in patients with chemotherapy-naïve mCRPC. Docetaxel was the only chemotherapy agent included; it was the standard of care in most of the available trials, including those of patients with visceral metastases. The researchers analyzed data from 9 phase III clinical trials that comprised 8820 men. The study dates were from 1999 to 2015. The subjects’ median age was 68 years; the majority of subjects were white; 94% of the patients had performance status of 0 to 1. Median prostate-specific antigen (PSA) was 97 ng/ml, hemoglobin was 12.9 g/dL, and alkaline phosphatase was 138 U/L. The median follow-up time among surviving patients was 21.8 months (range: 0-91.2) with a total of 5470 deaths. CLASSIFICATION The sites of metastatic disease were the criteria for classifying the subjects into the visceral or non-visceral groups. Those in the visceral disease group had soft tissue metastases at sites other than lymph node, as well as metastatic disease to lung, liver, adrenal glands, brain, and unspecified “others.” There were 3 categories of patients in the visceral disease group: patients with liver metastases were categorized as liver patients even if they had other metastases; patients with lung metastases were

categorized as such unless they also had liver metastases; and patients with non-hepatic, non-pulmonary visceral metastases (such as adrenal, kidney, and others) were in the third category. To qualify for the non-visceral disease

The meta-analysis substantiates earlier studies with small patient samples. group, men had either lymph nodeonly disease, or bone metastases with or without nodal involvement. The largest group of patients was in the bone metastases category (72.8%). The second-largest group had visceral disease (20.8%) with lung and/or liver metastases. Lymph node–only disease was present in 6.4% of patients, and 3.0% had non-lung, non-liver visceral disease. After the exclusion of some other ineligible participants 8736 patients were included in the final meta-analysis. BLOOD VALUES The lymph node–only group had the lowest median PSA and alkaline phosphatase values, but they had the highest median hemoglobin levels in comparison Continued on page 45

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THE TOTAL PATIENT

Initiating Palliative Care in the Emergency Department Improves QOL and Survival Bette Weinstein Kaplan

ost patients with advanced cancer resort to the emergency department (ED) for care at some point as their disease progresses, at which time the immediate crisis is dealt with and a future course of treatment is most likely to be set. Depending on the patient’s condition, a number of services will intervene, including hospice. However, despite the fact that research has shown that early palliative care interventions improve patient outcomes, palliative care is not frequently introduced in the ED.1-3 Researchers at Mount Sinai Medical Center in New York City, sought to evaluate the differences between patients with advanced cancer who receive a palliative care consultation when they visit the ED and those who do not receive such a consultation.4 The parameters they looked at were quality of life (QOL), depression, health care utilization, and, ultimately, survival for each patient. STUDY PARTICIPANTS: PATIENTS AND CLINICIANS

The researchers enrolled 136 patients between June 2011 and April 2014 in a single blind, randomized clinical trial. For the trial, 67 patients were assigned to the usual care group and 69 were assigned to the palliative care intervention group. The mean age of patients was 58 years and 55 years, respectively, and each group was divided approximately

in half between male and female participants. Study criteria included a diagnosis of advanced cancer, never having received a palliative care intervention, negative results on cognitive screening, and fluency in English or Spanish. The hospital palliative care team comprised of a nurse practitioner, physician, social worker, and chaplain. The palliative care consultation was divided into 3 parts:

QOL for patients in the palliative care group was markedly improved. symptom assessment and treatment, goals of care and advance care plans, and transition planning. Team members maintained communication with each patient in the study’s palliative care arm, as well as with the patient’s family and health care teams on a regular basis. Patients in the usual care arm could receive a palliative care consultation if the admitting or oncology team requested one. PALLIATIVE CARE PROVEN EFFECTIVE

The Functional Assessment of Chronic Illness Therapy–General Measure (FACT-G) scale was used to assess QOL;

in this tool, a higher score indicates better QOL. Participants were assessed at baseline, 6 weeks, and 12 weeks. At 12 weeks, QOL among patients in the palliative care intervention group was better than that of patients in the usual care group. Assessments of patients in the palliative care arm demonstrated an increase of 5.91 points from baseline on the FACT-G scale at week 12 (standard deviation, 16.65), compared with patients in the usual care arm, whose score was 1.08 points. OTHER OUTCOMES No difference was seen in depression among participants in both groups from baseline to either week 6 or week 12. Hospice use was compared between both groups at 180 days, and although the palliative care group utilized hospice more (28%) than the usual care group (25%), the difference was not statistically significant. Use of the intensive care unit was also not statistically different between the 2 groups. Survival time at 1 year after enrollment was longer in the palliative care group (41 of 69 patients died) compared with the usual care group (44 of 67 patients died). Patients in the palliative care intervention group lived almost 5 months longer than those in the usual care group; however, the

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difference did not prove to be statistically significant because of the highly variable length of survival within the patient cohort. CONCLUSION

The researchers found that enrolling patients with advanced cancer into early palliative care intervention at entry into the ED made a significant difference in the patient’s QOL. The researchers emphasize that this was a diverse group in terms of the type of cancer the patients had, as well as their race, ethnicity, and socioeconomic status. However, despite these differences, QOL for the patients in

Survivorship Continued from page 43

to the other patients. The liver metastases group had the highest alkaline phosphatase and lowest hemoglobin median levels. Men with bone and nodal disease had the highest median PSA. RISK OF DEATH

Patients with lung disease had a significantly greater risk of death than men with bone disease, and those with liver disease had a significantly greater risk of death than those with lung disease. OVERALL SURVIVAL

When the researchers evaluated overall survival using Kaplan-Meier curves, the results were 31.6 months for patients with lymph node–only disease, 21.3 months for those who had bone disease, 19.4 months for lung disease, and 13.5 months for patients with liver disease. In fact, survival of men who had liver disease was substantially worse than overall survival of men who had lung

the palliative care group was markedly improved. The researchers report their findings in regard to the benefits of early palliative care interventions are not only critical for patients, but are also significant for those in the health care community who may be able to initiate palliative care earlier in the course of a patient’s treatment. ■

advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930): 1721-1730. 2. Strand JJ, Kamdar MM, Carey EC. Top 10 things palliative care clinicians wished everyone knew about palliative care. Mayo Clin Proc. 2013;88(8):859-865. 3. Osta BE, Palmer JL, Paraskevopoulos T, et al. Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center. J Palliat Med. 2008;11(1):51-57.

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

4. Grudzen CR, Richardson LD, Johnson PN, et al. Emergency department–initiated palliative care in advanced cancer: a randomized

REFERENCES

clinical trial [published online ahead of print

1. Zimmermann C, Swami N, Krzyzanowska M,

January 14, 2016]. JAMA Oncol. doi: 10.1001/

et al. Early palliative care for patients with

disease. There was very little difference in survival times between patients with lung metastases and those who had bone metastases, whether or not there were nodes involved. Thus the median survival times for patients with lung and

This study showed that overall survival depends on the sites of metastases. bone metastases were 15 months to 22 months and 17 months to 23 months, respectively. Men who had lung disease (with or without bone involvement) did not live as long as those who had bone disease (with or without nodal involvement).

jamaoncol.2015.5252.

docetaxel showed that overall survival clearly depends on the sites of metastases. Patients with lung metastases lived longer than those with liver metastases, while those who had lymph node–only disease lived longer than those with lung metastases. The lymph node–only disease group had the longest survival time of all patients. The researchers suggest that the results from this large meta-analysis demonstrate how little is known about the development of different metastatic patterns of mCRPC. They call for more research to identify underlying disease mechanisms and the development of novel treatment approaches. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Halabi S, Kelly WK, Ma H, et al. Meta-analysis evaluating the impact of site of metastasis on overall survival in men with castration-

CONCLUSION

resistant prostate cancer [published online

This study of almost 9000 men with mCRPC who were treated with

ahead of print March 7, 2016]. J Clin Oncol. doi:10.1200/JCO.2015.65.7270.

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FROM

n initial assessment is the clinician’s chance to learn about the client’s past history, both medically and socially. Through the lens of cancer, it may include how the cancer was discovered, the treatment course, family support, and financial stressors. The initial assessment also allows patients to see if their needs will be met by CancerCare, and sometimes also by the clinician.

The First Call: The Importance of an Initial Assessment

A BIG FIRST STEP

Stephen Homsey; Kellie Webb

Oftentimes, the call to CancerCare is a patient’s first experience with counseling services. We understand that making that first call may be uncomfortable. Frequently, patients are assessed at this point, and this assessment is their first chance to truly gauge what to expect from their experience with CancerCare. The patient is afforded an opportunity to explain what his or her expectations of counseling are, as well as the clinician being able to facilitate a safe and understanding space for the patient to tell his or her story to an unbiased listener. This flow of information hopefully eases any anxiety between the patient and the clinician. The goal of the assessment and therapy itself is to foster a therapeutic alliance between the clinician and the patient. This alliance is often the most important step in eliciting information and is achieved through the clinicians’ techniques, overall tone, and body language. Although the clinician is asking the questions, the patient is also assessing the clinician by asking questions such

as “Is this someone I can trust with my story?” “Is it a safe space to say things that I haven’t been able to before?” If you have ever been on the other side of an assessment, you can recognize how the questions we ask patients reveal their vulnerability.

COPING WITH A CRISIS While conducting an initial assessment, we at CancerCare take into consideration that the person on the other side of the phone is not only vulnerable due to the nature of the questions we are asking, but understand that they are possibly experiencing a crisis situation. Two things are unique to an initial assessment of an oncology patient.1 First, the patient is likely on edge, anxious, or troubled due to the crisis at hand. Second, despite the patient’s current crisis, flexibility and openmindedness are needed because any needs and therapy goals discussed during an initial assessment are likely to change over time.1 Everyone defines crisis differently, and we cannot expect any 2 people to handle the same situation exactly the same; thus we try to learn how the patient has previously handled stressors. This will provide clues to the patient’s coping mechanisms as well as social supports and allow the patient a chance to feel empowered. Whether coping with an initial diagnosis, a fear of recurrence, or even the transition from acute care to survivorship, the patient can feel up to the challenge. We should take extra care during this assessment so the client feels comfortable talking with us and opens up so as to get as accurate an assessment as possible. THE FAMILY MATTERS

Cancer does not just affect the person with the diagnosis; it affects the entire family as well. As clinicians, we should consider the entire family as the patient so the sociocultural dynamics within the family and what role these have in

By showing genuine empathy toward family members, we could be opening a door for them to consider counseling. 46 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2016 • www.OncologyNurseAdvisor.com

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the client’s coping skills are included in our assessment. The initial phone call might not be for counseling at all, but instead from a caregiver seeking financial assistance for their loved one. By showing genuine empathy toward family members and what they are going through, we could be opening a door for them to consider counseling.

The therapeutic alliance is built from the moment the phone is picked up because we are never sure who we will be speaking with or what they are experiencing. CancerCare provides a consistently nurturing place that allows those who call to have a safe space to be heard. For those who have been touched by cancer, this is genuinely irreplaceable. ■

Download the

Stephen Homsey and Kellie Webb were serving as oncology social worker interns with CancerCare at the time this article was written. REFERENCE 1. Christ G, Messner C, Behar L, eds. Handbook of Oncology Social Work: Psychosocial Care for People with Cancer. New York, NY: Oxford University Press; 2015.

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ASK A PHARMACIST

Taking Oral Chemotherapy on the Road; Olanzapine as an Antiemetic As summer approaches, many patients with chronic myeloid lymphoma (CML) who are taking oral chemotherapy drugs have questions about taking their drugs while travelling. What advice can they be given regarding this?

medical devices at www.tsa.gov/travel/ special-procedures. Medicines that need to be refrigerated can be stored in a cooler, and many hotels can provide a refrigerator, if needed (although patients should call ahead to confirm availability). If travelling by car, patients should be sure to keep their medicine with them at all times, as car interiors can heat up very quickly during the summer months. All medicines should be kept in their original containers while travelling, for easy identification if necessary. Patients travelling internationally may want to bring a prescription and/or recent note from their oncologist that states the medicine’s generic name and the reason for taking it. Another important consideration is to have a sufficient supply of the medicine to last their trip. Most insurance providers can do a one-time “vacation override” to permit a patient to get an early fill of their medicine. Importantly, patients should bring more than enough medicine to cover their trip to account for potential travel delays. Depending on the destination and length of their trip, patients may wish to bring enough medicine to cover an additional week or more.

—Name withheld on request

There are many things for patients and their oncology care teams to think about regarding travel while undergoing treatment with oral chemotherapy. When travelling by air, patients should keep their medicines in their carry-on bag. This protects the patient in case of lost luggage, and prevents the medicine from being damaged by extreme heat or cold. The TSA web site provides detailed information about travelling with medicines and other

Some patients receive olanzapine (Zyprexa) as an antiemetic. Is this a typical use of this drug? —Name withheld on request

Olanzapine is an antipsychotic that affects dopamine, serotonin, catecholamines, acetylcholine, and histamine. Olanzapine-containing antiemetic regimens are one option in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for prevention of nausea and vomiting with moderate or high emesis risk chemotherapy regimens. In clinical studies, an olanzapinecontaining regimen was similarly effective compared with an aprepitant containing regimen. Some studies have shown a trend toward less delayed nausea and vomiting with olanzapinecontaining regimens; although in a phase 3 trial, this was not statistically significant. The typical prophylactic dosing in this setting is olanzapine 10 mg by mouth prior to chemotherapy, followed by 10 mg daily on days 2, 3, and 4. This is used in combination with dexamethasone 20 mg on day 1 and a 5-HT3 antagonist. Adverse effects of olanzapine include sedation, dry mouth, and dizziness. I typically advise patients to take their doses on days 2 to 4 in the evening to better manage the sedation. Longterm continuous use of olanzapine may be associated with dyslipidemia, hyperglycemia, diabetes, and weight gain; however, these are not typically reported when olanzapine is used intermittently with chemotherapy as described above. ■

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

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