ONA November/December 2016 by Haymarket Media

ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016

November/December 2016

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

CASE STUDY

Managing a False High Potassium Level in a Patient With Lymphoma

FEATURE

Chemotherapy Side Effects: Expectations Impact Patient Experience

RADIATION & YOUR PATIENT

Gero-Oncology: Anticipating the Needs of a Growing Elderly Patient Population

ISSUES IN CANCER SURVIVORSHIP

Tablet App Allows Intubated Patients to ‘Speak’

THE TOTAL PATIENT

Card Game Eases End-of-Life Discussions With Patients and Caregivers

FROM CANCERCARE VOLUME 7, NUMBER 6

The Impact of Physical Changes from Breast Cancer on Self-Image

RARE CANCERS

Developing a Unique Protocol for Secondary Urethral Carcinoma The clinical challenge was to create an administration protocol that maximized exposure of the papillary urethral carcinoma (inset) to the optimal dose of chemotherapeutic agent.

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Oncology Nurse Advisor (ISSN 2154-350X), November/December 2016, Volume 7, Number 6. P ublished 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th 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

4 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

CONTENTS

November/December 2016

IN THE NEWS • NCCN ‘Just Bag It’ Campaign Aims to Promote Safe Vincristine Handling • Psychoeducational Intervention Effective for Reducing Fear of Melanoma Recurrence • Recommendation Against PSA Screening • Higher Protein Intake May Modestly Improve Breast Cancer Survival • Longer Maintenance Therapy Duration May Improve Survival in Myeloma … and more

NAVIGATOR NOTES Impact of Navigation on a Colonoscopy Screening Program

Jason Hoffman, PharmD, RPh

CASE STUDY Managing a False High Potassium Level in a Patient With Lymphoma Amy Walton, RN, BSN, CMSRN, OCN

FEATURES Developing a Unique Protocol to Treat Urethral Carcinoma Tammy L. Litrico, RN, BSN, OCN

44 FIND US ON

Chemotherapy Side Effects: Expectations vs Outcomes Bette Weinstein Kaplan

Continues on page 6

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STAT CONSULT

CONTENTS

Dexrozoxane (Zinecard) A cytoprotective agent indicated for reducing the incidence and severity of cardiomyopathy associated with a cumulative dose of doxorubicin in women with metastatic breast cancer who will continue to receive doxorubicin therapy.

November/December 2016

29 STAT CONSULT • Nivolumab (Opdivo) • Pembrolizumab (Keytruda) 37

RADIATION & YOUR PATIENT Gero-Oncology: Anticipating the Needs of Elderly Patients With Cancer Bryant Furlow

ISSUES IN CANCER SURVIVORSHIP Resistance Training Improves Posttreatment Outcomes for Breast Cancer Survivors Loss of bone density related to chemotherapy and adjuvant therapy for breast cancer can lead to debilitating and vertebral fractures. This discussion reviews the impact of resistance training for these patients.

COMMUNICATION CHALLENGES The Bounty of Failure

Bette Weinstein Kaplan

Ann J. Brady, MSN, RN-BC

PATIENT EDUCATION: FACT SHEET

ISSUES IN CANCER SURVIVORSHIP App Allows Patients Whose Speech Is Hampered to Voice Their Needs and Wants

Pathology Reports This fact sheet examines pathology reports, including tissue collection methods, the way in which tissue samples may be processed, and details typically included in such reports.

Bette Weinstein Kaplan

Lenvatinib (Lenvima) Updated slides on lenvatinib, a kinase inhibitor indicated for DTC and RCC in specific clinical settings.

THE TOTAL PATIENT Card Game Makes End-of-Life Discussions Easier on Patients With Cancer and Caregivers Bette Weinstein Kaplan

45 FROM CANCERCARE The Impact of Physical Changes from Breast Cancer on Self-Image

PUBLISHERS’ ALLIANCE: DOVE PRESS Hepatocellular Carcinoma: A Review This research examines the screening modalities, diagnosis, staging, and treatment of hepatocellular carcinoma (HCC), the most common primary liver malignancy. Journal of Hepatocellular Carcinoma

Stacy Lewis, MSW, LMSW, ACHP-SW

ASK A PHARMACIST Biosimilars; Chemotherapy and GERD Medications Lisa A. Thompson, PharmD, BCOP

ON THE

WEB

6 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

IN THE NEWS NCCN ‘Just Bag It’ Campaign Aims to Promote Safe Vincristine Handling The National Comprehensive Cancer Network (NCCN) has launched the “Just Bag It” campaign for the safe handling of vincristine, a chemotherapeutic agent used primarily in the treatment of patients with leukemia and lymphoma.1,2 Vincristine should always be administered intravenously. Though highly effective as a treatment for these hematologic malignancies, it is also a neurotoxin that causes peripheral neuropathy when given intravenously and significant neurotoxicity if given intrathecally into the spinal fluid. To prevent fatal instances when vincristine is administered intrathecally, the NCCN developed the “Just Bag It” campaign to ensure the proper administration of vincristine and to render it impossible to accidentally administer the medication into the spinal fluid. “The mistake fortunately does not happen often, but if it happens once, it’s too many times because it is a fatal medical error,” Robert W. Carlson, MD, CEO of NCCN, stated during a press conference. The campaign encourages health care providers to implement a policy to always dilute and administer vincristine in a mini IV-drip bag, rather than a syringe, in order to avoid potentially deadly medication errors. “It’s really important that we realize that these avoidable medical errors are not just a statistic,” Dr Carlson added. “What is important about them is that they impact people in a very strong and negative way.” All 27 NCCN Member Institutions have adopted guidelines in line with this recommendation, which are also supported by the Oncology Nursing Society, Institute for Safe Medication Practices, the Joint Commission, and the World Health Organization.

Gene Therapy Alleviates DoxorubicinInduced Cardiotoxicity Although doxorubicin is commonly used to treat many cancers, its use is limited due to cumulative cardiac atrophy and body wasting in patients receiving the drug. Treatments to reverse these effects are limited. Because VEGF-B promotes coronary arteriogenesis, physiological cardiac hypertrophy, and ischemia resistance, the researchers hypothesized that VEGF-B may prevent doxorubicin-induced blood vessel rarefaction. For the study, the researchers administered an adenoassociated viral vector expressing VEGF-B or a control vector to normal and tumor-bearing mice 1 week before treatment with doxorubicin. Doses given to the mice were comparable to the concentrations used in human treatment.

The researchers found that the gene therapy completely inhibited doxorubicin-induced cardiac atrophy and wholebody wasting, prevented capillary rarefaction in the heart, and improved endothelial function in the doxorubicintreated mice. In addition, the researchers noted left ventricular volume was increased without compromising cardiac function, expression of the gene associated with pathologic remodeling was reduced, and cardiac mitochondrial respiration was improved. Furthermore, the gene therapy did not have an effect on doxorubicin concentrations in serum or tissue, nor did it augment tumor growth. Read more at http://bit.ly/2eNRJ0V. Continued on page 8

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Read more at http://bit.ly/ 2f9m5Zl

IN THE NEWS

Evidence suggests that women with myeloproliferative neoplasms such as polycythemia vera and essential thrombocythemia have a higher risk of maternal and fetal complications, which ultimately poses challenges during pregnancy. MPNs do not harm To examine maternal and fetal outpregnancies comes of women with myeloproliferative neoplasms, researchers analyzed data from 58 pregnant women with essential thrombocythemia, polycythemia, or myelofibrosis who participated in the United Kingdom Obstetric Surveillance System between 2010 and 2012. During that period, there were 58 live births. Results showed that the incidence of miscarriage was 1.7% (95% CI, 0.04-9.24) and the perinatal mortality rate was 1.7% (95% CI, 0.44-92.36), including both live and stillbirths. Researchers also found that the incidence of pre-eclampsia, postpartum hemorrhage, and postpartum hematoma were 9%, 9%, and 3.5%, respectively. No maternal deaths or thrombotic events were reported. A total of 45% of mothers required induced delivery, with all undergoing Caesarean section. Most women delivered at term, with 22% of neonates being below the tenth percentile for growth and 13% requiring admission to the neonatology unit. Of note, there were no neonatal deaths. Read more at http://bit.ly/2fFT8Yv.

Longer Maintenance Therapy Duration May Improve Survival in Myeloma Although maintenance therapy with lenalidomide has demonstrated improved clinical outcomes following autologous hematopoietic stem cell transplantation (aHSCT) among patients with multiple myeloma, the ideal duration of therapy remains unclear. For the study, investigators analyzed data from 464 patients with multiple myeloma who received lenalidomide after aHSCT between 2007 and 2013. Of those, 46% began therapy less than 4 months after transplantation. Results showed that median progression-free survival was 38 months and median overall survival was 78 months. Investigators found that lenalidomide treatment for more than 2 years was associated with an 87% reduction in the risk of

progression and a 91% decrease in the risk of death compared with those on maintenance therapy for 2 years or less. Researchers further observed a trend toward improved progression-free survival and overall survival for patients treated for more than 3 years vs those on maintenance for 3 years or less. There was no difference in survival between patients who initiated maintenance lenalidomide less than 4 months after autologous HSCT and those who began treatment 4 or more months afterward. Read more at http://bit.ly/2fRHud5.

Pilot Study Assesses Feasibility of Nurse-Led Sexual Rehabilitation Program Vaginal dilators are recommended to prevent vaginal shortening and stenosis after combined pelvic radiation therapy and brachytherapy; however, women often fail to use them, thereby leading to sexual problems. Therefore, researchers developed a nurse-led sexual rehabilitation intervention to target sexual recovery and vaginal dilation. To investigate the intervention’s feasibility, investigators specifically trained 4 oncology nurses to conduct the intervention. For the study, researchers enrolled 20 patients with an average age of 40 years treated with pelvic radiotherapy and brachytherapy for gynecologic cancer. Participants were evaluated using questionnaires on frequency of dilator use each month, sexual functioning, and sexual, psychological, and relational distress. Patients were also assessed through semi-structured interviews and some patients participated in consultation recordings. Of the 16 evaluable patients, 88% dilated regularly, either by having sexual intercourse or by using dilators, at 6 months and 75% of the evaluable 12 patients dilated regularly at 12 months. In addition, sexual function improved between 1 and 6 months after radiation therapy, with continued improvement at 12 months. The nurses reported having sufficient expertise and counseling skills to conduct the intervention and most participants perceived the intervention as helpful. Read more at http://bit.ly/2fAWUjm.

For full news stories visit OncologyNurseAdvisor.com

18 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

Women With Myeloproliferative Neoplasms Appear to Have Successful Pregnancies

NAVIGATOR NOTES

ncology patient navigators appear to play a vital role in improving access to colonoscopy screening in a medically disadvantaged community.1 As of 2015, all Commission on Cancer-accredited programs are required to provide patient navigation services. Patient navigators help people overcome barriers to increase access to cancer screening, diagnosis, and treatment in a timely fashion. They may also provide culturally appropriate patient education, offer peer counseling, and provide resources for financial assistance. As part of a randomized intervention trial investigating the efficacy of patient navigation in increasing colonoscopy completion, researchers sought to examine navigators’ activities to eliminate barriers to colonoscopy screening in a medically disadvantaged community. For the study, investigators analyzed service delivery and survey data from 420 patients receiving care at Boston Medical Center in Massachusetts between 2012 and 2014 who were navigated for colonoscopy screening. The intervention was conducted by 2 nonclinical navigators who spoke both English and Spanish, had experience in health care or community health settings, and were familiar with the local community. The navigators worked with patients to identify, reduce, and remove personal, cultural, structural, and health care system barriers to screening colonoscopy and to support patients through completion of the procedure. Most patients were either nonHispanic black or Hispanic, and

Impact of Navigation on a Colonoscopy Screening Program Jason Hoffman, PharmD, RPh

The study showed that navigators spent the most time evaluating patient barriers and needs; facilitating appointment scheduling; reminding patients of appointments; educating patients about colorectal cancer, the importance of screening, and the colonoscopy preparation and procedures; and arranging transportation for patients to get to their colonoscopy appointment. Investigators found that patient navigators spent an average of 44 minutes per patient. The study demonstrated that patients valued the navigators, particularly for providing emotional and peer support, as well as for explaining clearly screening procedures and bowel preparation. Nearly all of the patients rated their experience as good, very good, or excellent, and reported that they would recommend patient navigation services to others. As facilities strive to effectively and efficiently integrate navigation into their clinical services, these findings may help to further clarify the role of an oncology patient navigator in cancer screening and treatment programs within a medically disadvantaged population. In addition, these results may inform other cancer screening and treatment programs, including publicly funded health programs that support patient navigation services. ■ REFERENCE 1. Rohan EA, Slotman B, DeGroff A, Morrissey

approximately 56% of the 420 patients spoke English as their primary language. Approximately 80% reported incomes less than $50,000 per year and approximately 89% were publicly insured.

KG, Murillo J, Schroy P. Refining the patient navigation role in a colorectal cancer screening program: results from an intervention study. J Natl Compre Cancer Netw. 2016;14(11):1371-1378.

These findings may help to further clarify the role of an oncology patient navigator in cancer screening and treatment programs. www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 19

CASE STUDY

Managing a False High Potassium Level in a Patient With Lymphoma The patient’s history and current blood work results indicated a dangerously high potassium level. But a meticulously handled redraw proved it false. AMY WALTON, RN, BSN, CMSRN, OCN

sample to the laboratory. The repeat potassium level is 4.8.

Avoiding use of a tourniquet can prevent cell damage that leads to false lab results.

orders: ECG baseline and remote telemetry, as well as administering potassium-lowering medications such as Kayexalate, IV insulin, and dextrose push. The oncologist, however, says these are not needed as the patient is experiencing the phenomenon of pseudohyperkalemia. Instead, orders are to redraw the potassium level, attempt to not use a tourniquet, and hand-deliver the

DISCUSSION Anaplastic large cell lymphoma is a rare form of non-Hodgkin lymphoma. It has 3 different subtypes based on presentation at diagnosis and comprises only 3% of all cases of NHL annually.1 Patients usually present with symptomatic fever, night sweats, fatigue, loss of appetite, and swollen lymph nodes. The cutaneous form of the disease can either identify early disease or indicate disease progression. If localized, cutaneous disease has a successful cure rate with 5-year survival at 70% to 90% with a positive mutation. ALK-negative disease, as in this case, overall 5-year survival drops to 40% to 60%.2 Even if treatment is initially successful, some patients relapse despite achieving remission. This patient presented with severe disease burden as evidenced by his high WBC count, complaints of worsening symptoms, and newly developed infiltrating rash on his body. Pseudohyperkalemia is a phenomenon that occurs when very delicate lymphocytes, as those seen in lymphoid-type cancers, rupture and their intracellular contents are released in

20 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

CASE A 41-year-old male is admitted to the inpatient cancer care unit complaining of intractable pain. His history reveals a diagnosis of ALK-negative anaplastic large cell lymphoma, stage IV. He had initially achieved remission, relapsed, and has since failed several therapeutic options. A recent CAT scan showed progressing diffuse lymphadenopathy, and he has worsening malaise, fevers, and significant loss of appetite. The patient was in the clinic for multiple issues related to a worsening rash that is causing pain he no longer can manage at home. The rash is diffuse, purpuric in nature, and covers all extremities with focal areas on the finger joints, knees, ankles, and feet. The oncologist examined the rash at the patient’s last visit, noting it was probably lymphatic infiltrates from his high cell count and progression. On review of his admission labs, the following abnormalities are noted: WBC, 122,400; Hgb, 7.9; Plt count, 87,000. His chemistry yields a low magnesium level of 1.9 and a highly critical potassium level of 7.1. Knowing the significance of the potassium level, you immediately call the physician to get appropriate interventions, and ask for the following

the blood sample.4 This lysis can be caused by multiple variables, including a tourniquet tied too tight, delay in sample processing, the use of pneumatic tube transport, and temperature at time of sampling.5 In this case, the falsely high potassium level was caused by potassium leakage from the excessively high and extremely fragile lymphocytes. These cells break with minimal manipulation, and their cellular contents are released into the blood sample. At this facility, samples are transported to the laboratory via pneumatic tube system, which shakes the sample, leading to cell lysis. Because the potassium level was a false high, administering IV dextrose, insulin, and Kayexalate would actually cause the patient’s potassium level to drop below normal levels. Furthermore, some patients undergo emergent dialysis, which could cause severe drops in potassium levels.3 By eliminating the use of the pneumatic tube transport and immediately processing the sample, the lab test results accurately reflected that the patient’s potassium levels remained out of critical levels. ■

TEACHING POINTS

This case reinforced these important nursing concepts: • Pseudohyperkalemia, although rare, can occur in patients with lymphoid-type cancers, specifically in those with a high cell burden at diagnosis. • Review previous lab values, if available, and note preceding potassium levels. A previous abnormally high potassium level is predictive of this rare potassium elevation. • When collecting and handling the blood sample: avoid using a tourniquet, use gentle technique when drawing blood from the patient or a central access device, and when transferring the sample into the tube, minimize shaking the tube including hand-deliver samples to the laboratory. • Communicate the need for these interventions to all staff involved to assure every attempt is made to preserve the specimen and prevent lysis. • Treating a false potassium elevation can lead to serious complications related to a significant drop in circulating potassium.

REFERENCES

pseudohyperkalemia in chronic lympho-

1. Getting the facts: anaplastic large cell lym-

cytic leukemia: a longitudinal analysis. Leuk

phoma. Lymphoma Research Foundation website. http://www.lymphoma.org/ atf/cf/%7B0363cdd6-51b5-427b-be48-

pseudohyperkalemia: an important clinical

e6af871acec9%7D/ANAPLASTIC10.PDF.

entity in chronic lymphocytic leukemia.

Accessed October 12, 2016.

Case Rep Hematol. 2015;2015:930379. doi:

2. Hapgood G, Savage KJ. The biology and management of systemic anaplastic large cell lymphoma. Blood. 2015;126(1):17-25.

Amy Walton is a staff nurse at Billings Clinic, Inpatient Cancer Care in Billings, Montana.

Lymphoma. 2016;57(8):1952-1955. 4. Mansoor S, Holtzman NG, Emadi A. Reverse

3. Katkish L, Rector T, Ishani A, Gupta P. Incidence and severity of

10.1155/2015/930379. 5. Asirvatham JR, Moses V, Bjornson L. Errors in potassium measurement: a laboratory perspective for the clinician. N Am J Med Sci. 2013;5(4):255-259.

CASE STUD Y

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CASE An 80-year-old white woma the lesion did hyper tensio n with n visited a podiatnot improve. She then presents to and hypot hyroid ism prednisone, the derma toenai l (Figure rist, who removed the Oncovin, cyclop a persistent tologi 1). mide, and swollen lesion st for hosphaA punch biopsy doxorubicin left big toe. on her (R-EP followed by from the left Five month lesion was radiation therap OCH) visit, she had s before her toe obtain a complete dropped a showed a CD20 ed. The pathology response and y. She had water on her bottle of ice + dense of recurrent had toe. phoid Painless swellin infiltrate. Immu dermal lymdisease 3 monthno signs and erythe completing g ma develo nohistochemic stains were radiation therapy s after ped soon after, al positive for and the swellinin the toe (Figure 3). Mum1 and FOXP , bcl-2, progre ssed g slowly 1, consistent DISCUSSION in with primar cutaneous diff 6 weeks later, size. Approximately y use large Extran B-cell she presen odal lymph ma, leg type. lymphoorthopedist. omas are lymph The patient mas that evolve Radiographs ted to an to an oncolo was referre otive for fractur in nonlymphoid were negad gist. PET such as the scan showe tissue, hypermetabol gastrointesti nonsteroidal e. She was treated with d nal tract and skin. There anti-inflamma and left secondism in the left big toe are (NSA IDs) toe only (Figure primary cutane three main types of and oral antibiotory drugs The patien 2). tics, but t was treated mary cutane ous lymphomas: pricycles of ous rituxi mab, with four phoma (PCFC follicular center lymetopo side, L); primary Continues cutaneous on page 36

1. Go to our author guidelines at OncologyNurseAdvisor.com/author-guidelines 2. Scroll down to Case Study and “click here for a template to follow …” 3. Submit your Case Study to editor.ona@haymarketmedia.com.

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FEATURE | Urethral Carcinoma Protocol

Developing a Unique Protocol to Treat Urethral Carcinoma A multidisciplinary effort leads to a novel treatment plan for a patient with genitourinary cancer faced with a harsh treatment option. TAMMY L. LITRICO, RN, BSN, OCN

he incidence of urethral cancer is low. It represents less than 1.0% of all male malignancies, with its occurrence in African American males being double that of white males.1 Due to the nature of this disease, finding the research necessary to provide the best care for a patient is challenging. This study depicts how a collaborative effort by the multidisciplinary treatment team, including the patient, obtained the most favorable outcome. It also describes the steps involved in developing a new protocol when usual standards of care are not available.

Our protocol was designed to maximize exposure of the patient’s papillary urethral carcinoma (inset) to an optimal dose of mitomycin.

PATIENT HISTORY The patient is a 64-year-old male whose bladder cancer was initially treated via surgical interventions. His first surgery was a transurethral resection of bladder tumor (TURBT), performed in 2008. This was followed by multiple resections, and later a series of surveillance cystoscopies. In May 2015, a surveillance cystoscopy and subsequent biopsy revealed positive nodes for papillary urethral carcinoma. The nodes extended from the fossa navicularis to the bulbar urethra. At this time the only treatment offered was a penectomy, which the patient declined. Shortly afterward the patient relocated and presented to the urology department at our facility. He was offered the option of treatment with intraurethral mitomycin. As with this patient, many cases of urethral cancer develop in patients whose original cancer

22 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

was in the urinary bladder, with their urethral cancer developing some time after treatment is complete.2 Patients present most often with hematuria or dysuria, and their urethral cancer is found on follow-up cystoscopy. Further follow-up is usually CBC, chemistry, and liver function tests to determine if metastases are present.3 Biopsies are usually obtained in the operating room to avoid patient discomfort. MRI and CT are increasingly used to determine local invasiveness and for staging.4 The final diagnosis and determination of treatment plan is made on the basis of pathologic findings on biopsy. The dilemma with treatment for urethral cancer lies in the difficulty of exposing the urethra to topical chemotherapeutic agents to achieve the optimal response. Unlike conventional systemic therapy, optimal response is related to the concentration of the drug and duration of exposure. Prognosis for patients with urethral cancer is determined by the following factors: • Anatomical location: Distal tumors are usually considered more curable than proximal, and this appears to be true for both men and women. In males, a less favorable response occurs with proximal (bulbomembranous) and prostatic urethral tumors. • Tumor size • Tumor stage: The more advanced the tumor, the less likely a cure will be achieved, regardless of treatment. • Depth of invasion: Prognosis is less favorable for deeply invasive tumors. DEVELOPING OUR PROTOCOL Mitomycin gel was another potential option, but it is not available at our facility due to cost and unwanted side effects, such as pain and possible stricture of the urethra. We contacted a neighboring facility to collaborate over the proper administration of mitomycin but found they had no previous cases to follow, and most of the available research we found on using mitomycin was conducted in the United Kingdom and Australia. Therefore, this patient became our first patient treated with this method. In addition, with no documented standard for this treatment option, we had to develop our own protocol. Intraurethral mitomycin should not be confused with intravesical mitomycin. Intraurethral administration is to instill the medication directly into the urethra whereas intravesical administration is accomplished via instillation into the patient’s bladder. The original order was to “administer 40 mg of mitomycin reconstituted in 60 mL of normal saline” to be “directly

instilled into the urethra using a Toomey syringe.” The regimen is 6 treatments delivered once weekly. The patient was actively involved in his treatment from the beginning. We created a log to document each treatment, and the patient completed it by recording any symptoms he experienced after the prior treatment. For example, his notes in the log indicated that after the sixth treatment he experienced increased burning, hematuria, and a rash on his hands. He also reported increased stress with his significant other. The patient even helped us calculate the optimal medication dose. Applying his engineering background to our documented research, the patient determined the volume of a cylinder the size of an average male urethra: 8 inches

The dilemma with treatment for urethral cancer lies in the difficulty of exposing the urethra to topical chemotherapeutic agents. in length, with a diameter of 0.2 inches. Using these measurements, he determined that the amount of mitomycin he could comfortably hold in his urethra was 15 mL. Despite the physician’s order specifying a Toomey syringe, the pharmacy prepared the medication in a Luer Lock syringe. We tried to attach the Luer Lock onto a Foley catheter to instill the medication into the urethra. This was unsuccessful due to the lack of control; subsequently, less than 10 mL of the drug was actually instilled and retained. We needed to make a change to ensure optimal and safe drug administration. Working with the attending physician, the order was rewritten so the mitomycin would be prepared in “20 mL of saline using a Toomey syringe.” This improved ease of administration for the nursing staff and was better tolerated by the patient. Mitomycin must be handled carefully to ensure it does not come into contact with unprotected skin. Continued exposure to unprotected skin could lead to urethral sloughing and possible necrosis of the skin.5,6 Therefore, both the administering nurse and the patient wore full chemotherapy personal protective equipment, including gowns, gloves, and face shields, according to Oncology Nursing Society (ONS) guidelines. HOW THE PROCEDURE IS PERFORMED Before beginning the procedure, the patient is instructed to empty his bladder, then place a condom with a small hole

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 23

FEATURE | Urethral Carcinoma Protocol cut out at the tip over his penis. This provides a barrier to protect the penile skin from contact with the drug. The patient lies on the examination table with his head elevated. The nurse inserts the Toomey syringe directly into the urethra through the hole in the condom and gently instills the mitomycin. After instillation of as much mitomycin as the patient is able to tolerate, a penile clamp is placed directly over the condom, and the Toomey syringe is withdrawn when the clamp is snug to the penis. This helps prevent any leakage of the mitomycin.

Any discomfort was rare and usually occurred when the Toomey syringe was introduced into the penis and during instillation of the mitomycin. A condom catheter is then placed directly over the first condom to the level of the clamp and attached to a Foley drainage bag, which is used to collect the mitomycin as it drains from the urethra. After the recommended 15 minutes, the clamp is released and the remaining mitomycin, and any urine that may be present, is allowed to empty into the collection bag via gravity. The patient usually sits up with the drainage bag in place for approximately 10 to 15 minutes to ensure as much of the medication is drained into the collection bag as possible. In this way the chemotherapy agent remains contained in the closed system. The condom is removed and the entire set is disposed of in the designated chemotherapy waste container. The patient then washes his genitals and hands with soap and water to rinse off any remaining trace of the mitomycin mixture. An additional seventh treatment was ordered because the amount of mitomycin instilled and retained in the first treatment was less than the optimal 10 mL. The patient was able to adhere to the entire treatment regimen. Our patient experienced few side effects from his treatment. He did report a minimal amount of hematuria that lasted 1 to 2 days after treatment. Any discomfort was rare and usually occurred when the Toomey syringe was introduced into the penis and during instillation of the mitomycin.

the course of his treatment. However, he reported occasional increased discomfort and hematuria after intercourse. The importance of practicing safe sex following treatment was reinforced to both the patient and his partner. Using the PLISSIT (permission, limited information, specific suggestions, intensive therapy) model, the patient was allowed to explore sexuality issues as they became relevant during the course of his treatment. After the fourth treatment, sexuality was determined to be a stressor during chemotherapy. The patient reported increased tension due to both pain with intercourse and the need to continue to be sexually intimate with his partner. As these issues were discussed with the patient, the need for a mental health consult became evident. The patient’s counseling is ongoing at the time this article went to press. The patient was free of disease at his 3-month check. A single nodule was found at 6 months and was treated by surgical fulguration via cystourethroscopy. If further intervention is required, the urologist has determined that cystoprostatectomy with or without urethrectomy may be necessary. The patient will continue surveillance checks at 9, 12, and 18 months, as determined by his treating physician. NURSING IMPLICATIONS This case study demonstrates the importance of involving the patient in the treatment plan. It recognizes that collaborative efforts by all members of the treatment team are necessary to provide care based on best practices. When usual standards of care are not available, a protocol must be established to achieve optimal benefit for the patient. ■ Tammy Litrico is a nurse with the US Department of Veterans Affairs. REFERENCES 1. Swartz MA, Porter MP, Lin DW, Weiss NS. Incidence of primary urethral carcinoma in the United States. Urology. 2006;68(6):1164-1168. 2. Dalbagni G, Zhang ZF, Lacombe L, Herr HW. Male urethral carcinoma: analysis of treatment outcome. Urology. 1999;53(6):1126-1132. 3. Walsh PC. Surgery of Penile and Urethral Carcinoma. Philadelphia, PA: Saunders Publishing Company; 2002:2991-2993. 4. Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Publishing Company; 2010:691-694. 5. Brady JD, Assimos DG, Jordan GH. Urethral slough: a rare previously unreported complication of intravesical mitomycin. J Urol.

ADDRESSING THE IMPACT ON PATIENT SEXUALITY

Our patient was initially offered the option of sperm banking, but due to his age, he felt this was not necessary. He has a significant other and remained sexually active throughout

2000;164(4):1305. 6. Neulander EZ, Lismer L, Kaneti J. Necrosis of the glans penis: a rare complication of intravesical therapy with mitomycin c. J Urol. 2000;164(4):1306.

24 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

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FEATURE | Side-Effect Management

Chemotherapy Side Effects: Expectations vs Outcomes Nurses should be mindful of influencing patients’ expectations of side effect severity when educating them about breast cancer treatments. BETTE WEINSTEIN KAPLAN

hink positive. That is the take-away from a study of the relationship between patient expectations and medication side effects experienced by women with breast cancer. Researchers in Germany and the United States sought to understand the significance of patients’ expectations of the side effects they might experience from their treatment, in particular the nonspecific toxic effects of chemotherapy such as nausea, pain, and fatigue. Do these expectations play a role in what patients actually experience? Do expectations affect patients’ quality of life and how long they remain in treatment? Recent studies indicate that adverse side effects can result from factors unrelated to the pharmacologic agent, but rather from other factors. such as the person’s expectation of experiencing negative side effects. For example, patients with heightened expectations of negative side effects may actually experience these effects even if they were given a placebo, referred to as the nocebo effect.1 For this 2-year prospective clinical cohort study, the investigators enrolled 111 women who had undergone surgery for hormone receptor (HR)-positive breast cancer. Participation was initiated when the patients were about to start adjuvant endocrine treatment with tamoxifen, exemestane, or another aromatase inhibitor. They were given a booklet detailing the mechanism of action, benefits, and the 18 most common and serious side effects of the aromatase inhibitors.

26 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

Following a script to avoid influencing the patient’s expectations of negative effects, a trained clinician discussed the information provided with each woman after she had read the booklet. At that point, 9 women reported not expecting to experience any negative effects from their treatment, 70 reported anticipating mild side effects, and 32 women reported expecting their side effects to be moderate to severe. EXPECTATIONS AND OUTCOMES

Participants were evaluated for side effects twice after treatment initiation. At 3 months, 107 women were assessed; at 24 months, 88 women were assessed. After 2 years, the most commonly reported side effects were arthralgia (71%), weight gain (53%), myalgia (50%), and hot flushes (47%). In addition, nonspecific symptoms that could not be directly attributed to the medication were reported by some patients: back pain (31%), dizziness (26%), trouble breathing (24%), and palpitations (20%). At 3 months, 19 of the women who were anticipating more severe side effects actually experienced almost twice as many side effects than did the participants who were not as apprehensive. They also reported having a lower quality of life, and eventually dropped out of the study. After 2 years, the investigators saw a clear association between expectations of significant side effects at the beginning of the study and adherence to medication regimen at 3 and 24 months. Of those with low expectations of side effects, 87% adhered to the medication protocol. In contrast, only 69% of the patients with high expectations of side effects adhered to their medication protocol. Seventeen patients did not adhere to their protocols at all, and 15 women did

Women who were anticipating more severe side effects experienced almost twice as many side effects as those who were not as apprehensive. not complete the study (13 dropped out and were lost to follow-up and 2 died). CONCLUSION The researchers conclude that patients’ expectations of negative side effects influenced their experiences with adjuvant endocrine treatment for breast cancer. As seen in the nocebo effect, this was often irrespective of medical factors. The researchers also note that almost 40% of patients who were eligible for this trial chose not participate, perhaps because of negative expectations.1 The research team is currently conducting a randomized controlled trial to evaluate strategies to improve patients’ expectations. The trial is exploring how to discuss the potential for side effects, and ways to offer coping mechanisms without introducing nocebo-type effects. Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Nestoriuc Y, von Blanckenburg P, Schuricht F, et al. Is it best to expect the worst? Influence of patients’ side-effect expectations on endocrine treatment outcome in a 2-year prospective clinical cohort study. Ann Oncol. 2016 Aug 22. doi:10.1093/annonc/mdw266. [Epub ahead of print]

Oncology Nurse Advisor Newsletters keep you involved in all the action on OncologyNurseAdvisor.com Stay up-to-date with oncology-specific news Learn from your colleagues’ questions or participate in polls Read disease-specific features and stories Know when there’s something new Read the latest of our popular columns

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www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 27

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STAT CONSULT Nivolumab (Opdivo) Drug Type

• Programmed PD-1 blocking antibody

Indications

• BRAF V600 wild-type unresectable or metastatic melanoma, as a single agent • BRAF V600 mutation-positive unresectable or metastatic melanoma, as a single agent • Unresectable or metastatic melanoma, in combination with ipilimumab • Metastatic non-small cell lung cancer and progression on or after platinum-based chemotherapy • Advanced renal cell carcinoma, in patients who have received prior antiangiogenic therapy. • Classical Hodgkin lymphoma that has relapsed or progressed after autologous hematopoietic stem cell transplantation (HSCT) and posttransplantation brentuximab vedotin Mechanism of Action

• Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with PD-1 ligands PD-L1 and PD-L2 • This releases PD-1 pathway-mediated inhibition of the immune response, including the antitumor immune response Dosage and Administration

• Unresectable or metastatic melanoma ——As a single agent: 240 mg every 2 weeks ——With ipilimumab: 1 mg/kg, followed by ipilimumab on the same day, every 3 weeks for 4 doses, then nivolumab 240 mg every 2 weeks • Metastatic NSCLC and advanced RCC ——240 mg every 2 weeks

• Classical Hodgkin lymphoma ——3 mg/kg every 2 weeks • Administer infusion over 60 minutes through an intravenous line containing sterile, nonpyrogenic, low-protein binding in-line filter • Flush the intravenous line at end of infusion Dose Adjustments

• Withhold nivolumab for ——AST or ALT >3-5 × ULN or total bilirubin >1.5-3 × ULN ——Grade 2 diarrhea or colitis ——Grade 2 pneumonitis ——Grade 2 or 3 hypophysitis ——Grade 3 diarrhea or colitis when given as a single agent ——Creatinine >1.5-6 × ULN ——Grade 2 adrenal insufficiency ——Grade 3 hyperglycemia ——Grade 3 rash ——New-onset moderate or severe neurologic signs or symptoms ——Any other grade 3 adverse reaction • Resume nivolumab in patients whose adverse reactions recover to grade 0 or 1 • Interrupt or slow rate of infusion in patients with mild or moderate infusion reactions • Discontinue nivolumab in patients with severe or lifethreatening infusion reactions • No recommended dose modifications for hypothryoidism or hyperthyroidism Continued on page 30

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 29

STAT CONSULT • Permanently discontinue nivolumab for ——AST or ALT >5 × ULN or total bilirubin >3 × ULN ——Grade 3 diarrhea or colitis when administered with ipilimumab ——Grade 3 or 4 adrenal insufficiency ——Grade 3 or 4 pneumonitis ——Grade 4 diarrhea or colitis ——Grade 4 hypophysitis ——Grade 4 hyperglycemia ——Grade 4 rash ——Immune-mediated encephalitis ——Life-threatening or grade 4 adverse reaction ——Requirement for prednisone ≥10 mg/day (or equivalent) for >12 weeks ——Persistent grade 2 or 3 treatment-related adverse reactions lasting 12 weeks or longer ——Serum creatinine >6 × ULN Specific Populations

• Pregnancy ——May cause fetal harm ——Advise pregnant women of potential risk to a fetus • Nursing mothers ——Advise women to discontinue breastfeeding during treatment with nivolumab • Pediatric ——Not established • Geriatric ——No overall differences in safety of efficacy were reported between elderly patients and younger patients • Renal impairment ——No adjustments needed • Hepatic impairment ——Mild impairment: no dose adjustment needed ——Moderate or severe impairment: not studied • Females of reproductive potential ——Use an effective method of birth control during treatment and for at least 5 months after the last dose of nivolumab Boxed Warnings/Contraindications

• None Cautions

• Complications of allogeneic HSCT after nivolumab ——Monitor for ■■ Hyperacute graft-versus-host disease (GVHD) ■■ Grade 3 to 4 acute GVHD ■■ Steroid-requiring febrile syndrome

Hepatic veno-occlusive disease Other immune-mediated adverse reactions ——Transplant-related mortality has occurred • Embryo-fetal toxicity ——Nivolumab can cause fetal harm ——Advise of potential risk to a fetus and use of effective contraception • Immune-mediated colitis ——Withhold nivolumab when given as a single agent for moderate or severe, permanently discontinue for life-threatening, colitis ——Withhold nivolumab when given with ipilimumab for moderate, permanently discontinue for severe or life-threatening, colitis • Immune-mediated encephalitis ——Monitor for changes in neurologic function ——Withhold for new-onset moderate to severe neurological signs or symptoms and permanently discontinue for immune-mediated encephalitis • Immune-mediated endocrinopathies ——Withhold for moderate or severe and permanently discontinue for life-threatening hypophysitis ——Withhold for moderate and permanently discontinue for severe or life-threatening adrenal insufficiency ——Monitor for changes in thyroid function ■■ Initiate thyroid hormone replacement as needed ——Monitor for hyperglycemia ■■ Withhold for severe, permanently discontinue, for life-threatening hyperglycemia • Immune-mediated hepatitis ——Monitor for changes in liver function ——Withhold for moderate, permanently discontinue for severe or life-threatening, transaminase or total bilirubin elevation • Immune-mediated pneumonitis ——Withhold for moderate, permanently discontinue for severe or life-threatening, pneumonitis • Immune-mediated nephritis and renal dysfunction ——Monitor for changes in renal function ——Withhold for moderate or severe, permanently discontinue for life-threatening, serum creatinine elevation • Immune-mediated rash ——Withhold for severe, permanently discontinue for life-threatening, rash • Infusion reactions ——Discontinue nivolumab for severe and life-threatening infusion reactions ——Interrupt or slow the rate of infusion in patients with mild or moderate infusion reactions ■■ ■■

30 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

Adverse Effects

• Most common adverse effects with melanoma ——Nivolumab as a single agent ■■ Diarrhea, fatigue, musculoskeletal pain, nausea, pruritus, rash ——Nivolumab + ipilimumab ■■ Diarrhea, dyspnea, fatigue, nausea, pyrexia, rash, vomiting • Most common adverse effects with metastatic NSCLC ——Constipation, cough, decreased appetite, fatigue, musculoskeletal pain • Most common adverse effects with advanced RCC ——Arthralgia, asthenic conditions, back pain, constipation, cough, decreased appetite, diarrhea, dyspnea, nausea, rash • Most common adverse effects with classical Hodgkin lymphoma ——Cough, diarrhea, fatigue, pyrexia, upper respiratory tract infection Drug Interactions

• No formal pharmacokinetic drug-drug interaction studies have been conducted with nivolumab What to Tell Your Patient

• Nivolumab is a medicine that works with your immune system to treat your cancer ——It is used treat melanoma, lung cancer, kidney cancer, or Hodgkin lymphoma • Nivolumab can cause your immune system to attack healthy organs and tissues in many areas of your body and can affect the way they work • These problems may become serious or life-threatening and can cause death; they may happen anytime during treatment or even after your treatment has ended • Tell your nurse or doctor if you have ——An immune system problem such as Crohn’s disease, ulcerative colitis, or lupus ——Had an organ transplant ——Lung or breathing problems ——Liver problems ——Any other medical conditions • Tell your nurse or doctor about all medications you take • If you are pregnant or plan to become pregnant ——Based on animal studies, nivolumab may cause harm to the fetus when administered to a pregnant woman ——Nivolumab has the potential to be transmitted from the mother to the fetus ——Women of childbearing potential should to use

effective contraception method during treatment and for 5 months after the last dose. • If you are breastfeeding or plan to breastfeed ——Because of the potential for harm to the infant, you should discontinue breastfeading while receiving nivolumab • Your nivolumab dose is administered into your vein through an intravenous line over 60 minutes, usually every 2 weeks • When used in combination with ipilimumab, nivolumab is usually given every 3 weeks, for a total of 4 doses ——Ipilimumab will be given on the same day ——After that, nivolumab will be given alone every 2 weeks • Your doctor will decide how many treatments you need • A nurse or other clinician will draw blood samples from you for blood tests to monitor for side effects • Tell your nurse or doctor if you develop any of the following symptoms or they get worse ——Hormone gland problems ■■ Fatigue, hair loss, headache, mood changes, weight gain or loss ——Inflammation of the brain ■■ Confusion, fever, hallucinations, headache, memory problems, seizures, stiff neck, tiredness or weakness, ——Intestinal problems ■■ Blood in the stool or dark, tarry stools; diarrhea; severe stomach pain ——Kidney problems ■■ Ankle swelling, blood in urine, decreased urine production, loss of appetite ——Liver problems ■■ Abdominal pain, drowsiness, dark urine, severe nausea/vomiting, yellowing of skin or eyes ——Lung problems ■■ Chest pain, cough, shortness of breath ——Problems in other organs ■■ Eyesight changes, severe muscle weakness, severe or persistent muscle or joint pain ——Skin problems ■■ Itching, rash, skin blistering, ulcers in mouth or other mucous membranes • Nivolumab may cause ——Constipation; cough; decreased appetite; diarrhea; fatigue; infusion reactions; nausea; pain in muscles, bones, and joints; rash; shortness of breath; vomiting • Tell your nurse or doctor if you have any side effect that bothers you or that does not go away ■ Prepared by Jason Hoffman, PharmD, RPh.

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 31

STAT CONSULT Pembrolizumab (Keytruda) Drug Type

• Programmed PD-1 blocking antibody

Indications

• Unresectable or metastatic melanoma • Metastatic non-small cell lung cancer (NSCLC) in patients whose tumors express PD-L1 and who have disease progression on or after platinum-containing chemotherapy • Recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) in patients with disease progression on or after platinum-containing chemotherapy Mechanism of Action

• Binding of the PD-1 ligands to PD-1 receptor, found on T cells, inhibits T cell proliferation and cytokine production • Upregulation of PD-1 ligands occurs in some tumors and signaling through this pathway can contribute to inhibition of active T-cell immune surveillance of tumors • Pembrolizumab is a monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with PD-L1 and PD-L2, releasing PD-1 pathway-mediated inhibition of the immune response, including antitumor immune response Dosage and Administration

• Melanoma and NSCLC ——Pembrolizumab 2 mg/kg IV every 3 weeks • HNSCC ——Pembrolizumab 200 mg IV every 3 weeks • Administer via infusion over 30 minutes • In patients with melanoma and NSCLC ——Continue treatment until disease progression or unacceptable toxicity • In patients with head and neck cancer

——Continue treatment until disease progression, unacceptable toxicity, or up to 24 months in patients without disease progression Dose Adjustments

• Withhold pembrolizumab for ——Grade 2 pneumonitis ——Grade 2 or 3 colitis ——Grade 3 or 4 endocrinopathies ——Grade 2 nephritis ——AST or ALT >3× and up to 5× ULN or total bilirubin >1.5× and up to 3× ULN ——Any other severe or grade 3 treatment-related adverse reaction • Resume pembrolizumab in patients whose adverse reactions recover to grade 0 to 1 • Permanently discontinue pembrolizumab for any of the following ——Any life-threatening adverse reaction (excluding endocrinopathies controlled with hormone replacement therapy) ——Grade 3 or 4 pneumonitis or recurrent pneumonitis of grade 2 severity ——Grade 3 or 4 nephritis ——AST or ALT >5× ULN or total bilirubin >3× ULN ■■ For patients with liver metastases who begin treatment with grade 2 AST or ALT, if AST or ALT increases by ≥50% relative to baseline and lasts for at least 1 week ——Grade 3 or 4 infusion-related reactions Continued on page 34

32 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

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STAT CONSULT ——Inability to reduce corticosteroid dose to 10 mg or less of prednisone or equivalent per day within 12 weeks ——Persistent grade 2 or 3 adverse reactions (excluding endocrinopathies controlled with hormone replacement therapy) that do not recover to grade 0 to 1 within 12 weeks after last pembrolizumab dose ——Any severe or grade 3 treatment-related adverse reaction that recurs Specific Populations

• Pregnancy ——May cause fetal harm ——Advise pregnant women of potential risk to a fetus • Nursing mothers ——Advise women to discontinue breastfeeding during treatment with pembrolizumab and for 4 months after final dose • Pediatric ——Not established • Geriatric ——No overall differences in safety or efficacy were reported between elderly patients and younger patients • Renal impairment ——No adjustments needed • Hepatic impairment ——No adjustments needed • Females of reproductive potential ——Advise to use effective contraception during treatment with pembrolizumab and for at least 4 months following final dose Boxed Warnings

• None Contraindications

• None Cautions

• Embryo-fetal toxicity ——Pembrolizumab can cause fetal harm ——Advise of potential risk to a fetus and use of effective contraception • Immune-mediated colitis ——Withhold for moderate or severe, and permanently discontinue for life-threatening colitis • Immune-mediated hepatitis ——Monitor for changes in liver function ——Withhold or discontinue based on severity of liver enzyme elevations

• Immune-mediated pneumonitis ——Withhold for moderate, and permanently discontinue for severe, life-threatening, or recurrent moderate pneumonitis • Immune-mediated endocrinopathies ——Hyperglycemia ■■ Withhold in cases of severe hyperglycemia ——Hypophysitis ■■ Withhold if moderate; permanently discontinue if severe or life-threatening ——Thyroid function ■■ Monitor for changes ■■ Withhold or permanently discontinue for severe or life-threatening hyperthyroidism • Immune-mediated nephritis ——Monitor for changes in renal function ——Withhold for moderate, permanently discontinue for severe or life-threatening nephritis • Infusion-related reactions ——Stop infusion and permanently discontinue pembrolizumab for severe or life-threatening infusion reactions Adverse Effects

• Most common adverse reactions ——Anemia ——Constipation ——Cough ——Decreased appetite ——Diarrhea ——Dyspnea ——Fatigue ——Hypercholesterolemia ——Hyperglycemia ——Hypertriglyceridemia ——Hyponatremia ——Increased AST ——Lymphopenia ——Nausea ——Pruritus ——Rash Drug Interactions

• No formal pharmacokinetic drug-drug interaction studies have been conducted with pembrolizumab What to Tell Your Patient

• Pembrolizumab is a medicine that may treat your melanoma, lung cancer, or head and neck cancer by working Continued on page 36

34 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

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STAT CONSULT with your immune system • Pembrolizumab can cause your immune system to attack normal organs and tissues in many areas of your body and can affect the way they work • These problems can sometimes become serious or lifethreatening and can lead to death and may happen anytime during treatment or even after your treatment has ended • Before receiving pembrolizumab, tell your nurse or doctor if you — Have immune system problems such as Crohn’s disease, ulcerative colitis, or lupus — Have had an organ transplant — Have lung or breathing problems — Have liver problems — Have any other medical conditions — Are pregnant or plan to become pregnant — Are breastfeeding or plan to breastfeed • Tell your nurse or doctor about all medications you take including any herbal or nonprescription medications • Your oncology nurse will administer your dose of pembrolizumab through an intravenous line in your vein over 30 minutes, usually once every 3 weeks • Your doctor will decide how many treatments you need • Your oncology nurse will take blood for tests to check for side effects — It is important to keep all your scheduled appointments for blood work and other laboratory tests • Tell your oncology nurse if you develop any of these symptoms or the symptoms get worse — Lung problems ■ Cough ■ Chest pain ■ Shortness of breath — Intestinal problems ■ Blood in the stool or dark, tarry stools ■ Diarrhea ■ Severe stomach pain — Liver problems ■ Abdominal pain ■ Dark urine ■ Drowsiness ■ Severe nausea/vomiting

FIND US ON

•

• •

•

■ Yellowing of skin or eyes — Kidney problems ■ Ankle swelling ■ Blood in urine ■ Decreased urine production ■ Loss of appetite — Hormone gland problems ■ Dizziness ■ Fatigue ■ Hair loss ■ Headache ■ Mood changes ■ Weight gain or loss Tell your oncology nurse immediately if you experience signs and symptoms of infusion-related reactions, such as — Chills — Fever — Itching — Rash — Rigors — Wheezing Women of reproductive potential — You should use highly effective contraception while you are receiving pembrolizumab and for 4 months after your last dose Nursing mothers — You should not breastfeed while you are receiving pembrolizumab and for 4 months after your final dose Pembrolizumab may cause side effects, such as — Constipation — Cough — Decreased appetite — Diarrhea — Fatigue — Itching — Nausea — Rash — Shortness of breath Report any side effect that bothers you or that does not go away ■

Prepared by Jason Hoffman, PharmD, RPh.

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36 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

Gero-Oncology: Anticipating the Needs of Elderly Patients With Cancer Bryant Furlow A growing proportion of cancer patients are elderly — creating a demographic shift with important implications for cancer care, including radiotherapy. Integrating geriatric care into oncology nursing has never been more important.

s baby boomers age, the number of elderly patients with cancer will climb, as will the proportion of cancer patients who are elderly.1-4 By one estimate, a 67% increase in cancer incidence among adults older than 64 years will occur between 2010 and 2030, and the proportion of all cancers diagnosed in these older adults will have climbed from 61% to 70%.5

This shift has important implications for cancer care and oncology nursing, prompting experts to intensify calls for the wider integration of geriatric medicine into oncology care, including gero-oncology nursing.1,2,4,6-8 And efforts are under way to share knowledge and foster coordination between the geriatric and oncology nursing disciplines.2 Cancer management is often complex for patients who are elderly, as they are more likely than younger patients to have frailty and polypharmacy issues, lower tolerance for radiotherapy and chemotherapy toxicity, and more and different comorbidities.3,4,6,9,10 Fatigue and pain are also overriding problems among elderly cancer patients.7 And social, financial, and quality of life issues are additional factors that can distinguish elderly from younger patients with cancer.7 FRONT AND CENTER IN GERO-ONCOLOGY

The emerging field of gero-oncology involves increased awareness among geriatric nurses and health care providers about cancer prevention, screening, and early diagnosis, as well as increased appreciation among oncology specialists of the unique challenges of caring for elderly patients.11 Oncology nurses play a key role in preserving elderly patients’ autonomy and quality of life and in educating these patients about how to ask oncologists about the comparative risks and benefits of available treatment options, as well as frank appraisals of prognosis.12 Nursing efforts can be complicated by communication challenges among elderly patients, ranging from declines in hearing acuity to attention and neurocognitive issues that can impair comprehension and recall and, therefore, patients’ ability to comply with

instructions and treatment plans. These issues, combined with physical frailty, can often increase elderly patients’ levels of dependency on caregivers and members of their cancer care team. Oncology nurses are well positioned to help maintain as much of elderly patients’ independence and autonomy as possible.2 Recognition of problems commonly seen among the elderly should not reinforce ageist bias or the assumption that all elderly patients face poor prognosis or are not candidates for aggressive cancer treatment where appropriate.13 Functional and chronological age may differ in elderly patients, so patient tolerance of, and potential benefits from, treatment should be assessed, not assumed.14 RADIOTHERAPY AND ELDERLY PATIENTS

Senescence, or biological aging, involves changes in physiolog y, immune function, and the genome. But how these changes affect responses to irradiation is not clear.14 Because the risk of radiotoxicity is widely believed to increase with age among older adults, many elderly patients are not offered radiotherapy as a curative-intent cancer treatment.14 Among selected patients with good performance status, however, radiotherapy may offer benefits.14 Nevertheless, the optimal roles of radiotherapy and other cancer treatments remain unsettled for elderly patients, largely because of their underrepresentation in cancer clinical trials.15 The National Comprehensive Cancer Network (NCCN) and International Society of Geriatric Oncology (SIOG) have separately promulgated guidelines for elderly patient cancer care. And SIOG maintains a Radiotherapy in the Elderly Task Force, which published a Continued on page 40

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 37

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Take Charge of Your Career and Lead the Way for Your Nurse Navigator Program Join Us for the 3rd Annual ONA Navigation Summit at the Hyatt Regency Austin www.ONANavigationSummit.com

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What is the ONA Navigation Summit? This educational event was created to provide oncology nurse navigators and care coordinators with practice-based information focused on the most clinically relevant areas in oncology. Network with your colleagues from around the country and earn up to 12 CNEs* in just 3 days.

First Look at Topics to Be Covered: • • • • •

Resources for new navigators Communication and conflict management Supportive care Leadership strategies Case-focused presentations on gastrointestinal cancers, head and neck cancers, breast cancer, lung cancer, and more *Please note that the credit amount is subject to change.

This activity is jointly provided by the Oncology Nursing Society and Haymarket Media. Target Audience This educational activity is designed to address the needs of nurse navigators, care coordinators, oncology nurses, and advanced practice nurses involved in the management of people with cancer. Nursing Continuing Education The Oncology Nursing Society is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA. The Oncology Nursing Society is providing contact hours for this program and maintains responsibility for adherence to ANCC criteria. For more information about the accreditation of this program, please contact the Oncology Nursing Society at 1-866-257-4ONS or help@ons.org.

Stay up to date with program announcements and insights.

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RADIATION & YOUR PATIENT review of best practices and research priorities for geriatric radiation oncology in 2014.16 Even when clinical trial data is available, implementation of guideline recommendations for elderly patient cancer care has been a problem. For example, a decade after the 2004 publication of revised NCCN guidelines that, based on phase 3 clinical trial data, discouraged radiotherapy treatment of elderly patients with early-stage breast cancer, NCCN cancer centers have inconsistently implemented those changes.17 COMPREHENSIVE GERIATRIC ASSESSMENTS

The gold standard for evaluating elderly patients is the Comprehensive Geriatric Assessment (CGA) — a multifaceted, interdisciplinary approach to identifying elderly patients’ medical, functional, neurocognitive, and social situations or status, in order to inform treatment decision making and, ultimately, maintain their quality of life.2 The CGA includes detection of frailty, which, for example, appears to be a contraindication for radiotherapy among men with postprostatectomy relapse.9

The CGA comprises evaluations of social support, medication and polypharmacy, comorbidities, eyesight, hearing, recent weight loss, neurocognitive function (including assessment of clinical depression), fall risk,

Repeated CGAs can help spot emerging problems during and after treatment. and dependence on others for daily activity.2 It can predict elderly patients’ tolerance of radiotherapy and chemotherapy, quality of life, and prognosis (overall survival).2,18-20 And for up to half of elderly patients with cancer, the CGA identifies problems that were previously unrecorded in their medical records, providing otherwise missed opportunities for interventions and for better tailoring treatment plans to individual patient needs.2 CGA findings also influence treatment decisions in 20% of patients, according to one

2014 study,21 and repeated CGAs over time can help spot emerging problems during and after treatment. However, the CGA is rarely employed for patients with cancer, despite this evidence that its use can improve care planning and help predict outcomes.2 CGA-identified problems and interventions should be included in care plans, and periodic follow-up CGAs should be planned to allow revisions to the care plan.2 Training oncology nurses to perform the CGA has been deemed “crucial” in caring for elderly patients with cancer.20 In addition to calls for oncology nurses to become familiar with incorporating the CGA into clinical practice, some facilities, such as Memorial Sloan Kettering Cancer Center in New York City, have decided to staff geriatric nurses in inpatient units to help identify patients with whom CGA consultations are indicated.20 ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. References appear in the online version of the article at http://bit.ly/2gfWEFu.

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40 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

The Bounty of Failure

Ann J. Brady, MSN, RN-BC

When I am asked a question, I think of my mentor and how she made my mistake a pivotal learning point.

ow long were you a nurse before you felt competent? Is there a mistake you made early in your practice that you still remember? How did it impact your practice? Nurses love to tell stories; everything from the unbelievable to the embarrassing within the annals of their practice. The story I tell is uncomfortable for what it reveals about me as a new grad. I was working on a head and neck surgical oncology unit, back when radical neck surgeries were more common. I was still in new grad orientation and being mentored by a nurse with many years of experience. After one particularly busy shift, I gave her reports on each patient, which included vitals, meds passed, and other important data. After reviewing those reports with her, I mentioned that I had drained the JPs on one patient for a total output of 400 mL. “400?” she asked. It wasn’t until I heard the incredulity in her voice that I realized my mistake. My focus was on draining, measuring,

and tracking the Is and Os, but I failed to put the high output into context. I was so absorbed in the smaller tasks and making sure I got everything done that I missed what I should have noticed: high output likely indicated bleeding rather than the expected drainage. We didn’t exactly race down the hall to check on the patient, but we moved quickly. Luckily the bleeding had slowed and the patient was fine. And lucky for me, my mentor was gentle as she explained to me what I should have done and what I should have known to do in a way that didn’t make me feel stupid, just inexperienced. When I am asked a question that I think a nurse should know the answer to, I think of my mentor and how she made my mistake a pivotal learning point. CASE “I have a question for you.” I was at the computer charting in the electronic medical record and had not heard Allison approach. “Okay,” I turned in the chair to look her in the eye. “What is your question?” “I have a patient with a long medical history. Diabetes, high blood pressure, heart disease. He’s had 2 cycles of chemo and was admitted with a fever. He gave a list of his meds to the doctor, but he forgot to mention 1 or 2, so they didn’t get ordered. Do you think I should call the doctor now, or is it okay to leave a note for him?” What was the communication challenge in this interaction? What mattered was less about my answer and more about the question asked. Much of nursing practice evolves from experience itself. The action of asking a question, of making ourselves vulnerable by showing what we don’t know, should always be applauded. Creating an environment where it is safe to

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 41

COMMUNICATION CHALLENGES

And as we work side by side with nurses who have less experience, we should offer help and education in a way they can absorb.

ask questions — even when it seems like the answer is obvious or the knowledge base for assessing the situation should be there — is vitally important in the nursing practice. There is a saying, “There are no stupid questions.” I’m not sure that is wholly true. Some of the questions I hear are surprisingly uninformed. When you don’t know the answer, ask for help or clarification. That is the smart choice — far smarter than being afraid to ask or pretending you know when you don’t. I turned to Allison and asked several questions: What might happen if you don’t call the physician and you wait? Is it safe to wait until tomorrow? What might keep you from or make you hesitate to call? We then went through the patient’s med list and figured out which ones were missing. As we did, she was able to answer her own question. Just as it happened with my mentor, hearing it out loud brought clarity for Allison. What does a question have to do with failure? There was no failure on the part of the question Allison asked, but there was anxiety and uncertainty, a mental stalling out — a questioning of her knowledge. Allison looked embarrassed as we went through the critical thinking of decision making. As I watched her shake her head at herself, I offered a different story for her. “Have you ever driven a stick shift car?” She shook her head no. When my kids were learning to drive, we had an older car with a stick shift that they learned to drive on. Mastering a stick shift when you are learning to drive adds an extra degree of

JOIN THE CONVERSATION • How long were you a nurse before you felt competent? • Is there a mistake you made early in your practice that you still remember?

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Go to the online version of this article at https:// bit.ly/2fZJTjd and share the nursing experiences that helped shaped how you practice nursing with your colleagues.

difficulty. Throw a hill into the mix and it becomes even more challenging. For anyone who hasn’t driven a manual transmission car, you have to shift the car and work the clutch at the same time. When you shift on a hill, it is a tricky balance to keep from rolling backward. If you release the clutch too quickly, the engine stalls. One day my son wanted to drive me to the store so he could get more practice driving. It was only a mile away but the return trip was uphill. As he tried to finesse the clutch, he stalled out repeatedly. The usually short drive home took us 30 minutes. In utter frustration, he rested his head on the steering wheel, “I am so stupid! A complete failure!” But I told him, “Think of it this way. You have to stall out 500 times before you master driving with a clutch. And you just checked off 100.” At this point in the story, Allison took a deep breath and relaxed. DISCUSSION Teaching someone to drive is not easy. There are many things to be aware of all at the same time. Yet once you know how to drive, it’s easy. There are always new challenges, a drive you haven’t made before, an unfamiliar car, and other drivers, but our basic level of confidence stands up to it. Nursing practice is the same. We have to stay vigilant to detours and unexpected conditions. And as we work side by side with nurses who have less experience, we should offer help and education in a way they can absorb. If another nurse asks me a question that seems to have an obvious answer, I may wonder why the nurse doesn’t know. But communicating exasperation doesn’t create an atmosphere of learning. In fact, it does the opposite: creates a climate that devalues inquiry. For all of us in practice, it is essential to promote critical thinking, to contextualize the question, and to volunteer our professional experience. That’s why I always tell my story when someone asks, “Why didn’t he/she know that?” ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

42 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP App Allows Patients Whose Speech Is Hampered to Voice Their Needs and Wants Bette Weinstein Kaplan

eing able to communicate with another person is an essential human quality. A patient lying alone in a hospital room, intubated and in pain after surgery, should be able to tell a nurse that her incision hurts. Or that she’s frightened of being so ill and helpless. Or that she simply has to use the toilet. But more than half of the approximately 790,000 patients who are intubated in this country every year find conveying these basic concepts impossible — despite being awake and alert.1 Now, the new tablet-based communication app, Speak for Myself ™, will ease these patients’ fears. In an effort to empower the voiceless patient, Rebecca Koszalinski, RN, PhD, developed Speak for Myself while pursuing her doctoral degree under the guidance of Ruth Tappen, EdD, RN, FAAN , at Florida Atlantic University. “Speak for Myself is designed to provide a means for communication when the communication dysfunction is due to loss of or impairment of the physical structures needed to produce speech. This includes head and neck cancers as well as intubation or tracheostomy to support respiration,” explained Dr Tappen (RM Tappen, oral communication, September 9, 2016). The application enables a patient to communicate pain when he or she touches an onscreen body graphic to indicate where it hurts, and an analog

pain scale to indicate how badly it hurts. When the patient touches the “Speak” button then the onscreen body graphic, the app’s voice speaks, “It hurts here.” The app does more than help patients express pain. Speak for Myself lets patients request all types of needs, such as to use the bedpan or toilet or to be repositioned. It allows patients to express difficulty with breathing and the need for suctioning. Most compassionately, the application allows patients to express end of life wishes. The program runs on any tablet computer using any operating system, and it can translate more than 100 languages. The tablet is readily available and can stay with the patient. The device uses familiar text messaging methodology, so patient can express emotions. A user can begin typing a word and, by using predictive text, the application completes that word, or the user can continue typing to override the predicted word. Certain words are shortcuts so users do not have to type entire phrases and sentences. The patient can also customize a menu by touching the “Recent” tab and choosing from a list of all words and phrases that he or she has entered. This feature individualizes the application for each patient, eliminating unnecessary words and phrases. Speak for Myself was evaluated in a study of 20 patients — 6 women and 14 men — ranging in age from 45 to 91

years, who had endotracheal tubes for ventilator support or tracheostomies with diagnoses such as tongue metastasis, atrial fibrillation, arteriosclerotic heart disease, cardiogenic shock, endocarditis, neck abscess, renal failure, and status post-seizure activity.

Patients said they felt less frustrated, more in control ... when using the app. The study patients used the device for an average of 9 hours a day, and 2 patients kept it by their bedside overnight. When asked, the participants said they felt less frustrated, more in control, less frightened, and more empowered when using the app — especially because the medical staff or relatives who had tried to translate or speak for them did not always correctly interpret their needs. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Koszalinski RS, Tappen RM, Hickman C, et al. Communication needs of critical care patients who are voiceless. Comput Inform Nurs. 2016;34(8):339-344.

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 43

THE TOTAL PATIENT Card Game Makes End-of-Life Discussions Easier on Patients With Cancer and Caregivers Bette Weinstein Kaplan

ne of the most difficult discussions a nurse or family member can have with a terminally ill patient is about end of life (EOL) care. But this subject must be broached as the patient’s condition deteriorates and the outcome becomes clearer. Although there is no easy way to have this conversation, the new “Go Wish” tool can help.1 Go Wish — a card game about EOL wishes — was originally created by Coda Alliance to facilitate discussions involving relatives, nursing staff, and other caregivers about advanced care planning in assisted living facilities.2 Go Wish can be played anywhere, and by people of all educational levels — even those of advanced age who may have limited cognition — can use it without feeling that it is too difficult to understand or too simplistic. There are several ways to play: solitaire, with another patient or a caregiver, in a group, or even online. The idea is not for patients to create an itemized wish list, but rather to focus on goals and priorities. What wishes and ideas are most important to each patient, and for what reasons? This game engages the patient and nurse or caregiver in a discussion about EOL wishes. The game includes 36 cards, each containing a brief description of a value or goal that patients who are near death may consider important. The cards are

written in a positive tone and designed in a clear layout that is easy to read. Players identify the 10 cards that depict what’s most important to them, which often requires sorting and resorting, as shifting priorities shuffle the cards. In the process of labeling, patients may realize that what had seemed very important in the past, or even a few days ago, is now less urgent. Perhaps some legal issues have become a higher priority because they must be dealt with immediately. According to the card game creators: “The key is to identify the 10 most important things you want to make absolutely sure are clear to anyone who might have to speak on your behalf or make decisions for you.”1 A team at the University of Texas MD Anderson Cancer Center recently conducted a randomized controlled trial of 100 patients who had advanced cancer to see whether they preferred utilizing the Go Wish game or a list of wishes with the same number of items.3 Four groups of patients were chosen at random to complete either the Go Wish game or a checklist of wishes and then switched to the other intervention after 4 to 24 hours. The MD Anderson team created the list of wishes with the same 35 statements that the Go Wish cards used. All patients completed the StateTrait Anxiety Inventory for adults.4 The patients classified their wishes into 3 categories: very important,

somewhat important, or not important. The 10 most common wishes they identified as very important were: 1. Be at peace with God 2. Pray 3. Have family present 4. Be free from pain 5. Not be a burden to my family 6. Trust my doctor 7. Keep my sense of humor 8. Say goodbye to important people in my life 9. Have my family prepared for my death 10. Be able to help others Of the 50 patients who utilized both tests, 43 found the Go Wish instructions clear, 45 found the card game easy to understand, 39 said the card game did not increase their anxiety, and 31 said that conversations about EOL priorities were beneficial. Thirty-one of the 50 patients preferred the Go Wish game to the wish list for discussing EOL issues. Based on these study results, the MD Anderson team has called for multicenter prospective studies to increase understanding about EOL wishes of patients with advanced cancer and other terminal illnesses. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. References appear in the online version of the article at http://bit.ly/2fpN7Lq.

44 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

FROM

CHEMOTHERAPY AND RADIATION Prior to beginning chemotherapy, many women anticipate experiencing some level of common side effects, including nausea, fatigue, weight changes, and hair loss. For many, hair loss that accompanies chemotherapy is the first outwardly visible sign that they are undergoing cancer treatment and a signal that they have crossed over from health into illness, which can be particularly difficult to grapple with.1 In addition, many common breast cancer chemotherapy regimens can cause weight changes. And women undergoing

The Impact of Physical Changes from Breast Cancer on Self-Image Stacy Lewis, MSW, LMSW, ACHP-SW

breast radiation may experience localized changes to the impacted area, including blistering, peeling, and rashes. Although these changes are usually temporary, some women find that after radiation, their breast tissue has a different texture, with the skin appearing and feeling hardened or no longer smooth.

MASTECTOMY AND RECONSTRUCTION

For many women, a mastectomy can significantly challenge the way they perceive their body and their femininity. Whether a woman was informed that a mastectomy was medically necessary or she elected the mastectomy among other options (either prophylactically or instead of a lumpectomy), the loss of the breast(s) can represent a loss of a women’s previous body integrity and can result in body-image concerns. For many women, the loss of their natural breast(s) represents the loss of their former self, and as such, may need to be grieved. Many women facing the surgery, however, feel as though they cannot or should not allow themselves to entertain these feelings of loss because of internal and/or societal pressure to display strength and remain focused solely on survival. 2 Even if immediate reconstruction is available, the physical and emotional adjustment to the reconstructed breast(s) and altered physical appearance can take time. For some women, the reconstruction process can be prolonged and involve numerous surgeries; during this time, women may find their self-image in flux as they continually adapt to and integrate the physical changes into their new sense of self. LYMPHEDEMA Lymphedema can impact a woman far beyond her active treatment, and for many, this persistent, noticeable swelling of the extremities serves as a continued reminder of their cancer.3

For many women, a mastectomy can significantly challenge the way they perceive their body and their femininity. www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 45

fter receiving a breast cancer diagnosis, many women work closely with their oncologists to carefully map out an individualized medical treatment plan. But it can be difficult to plan for the emotional and self-image challenges that the treatment itself may present. Patients with cancers that can cause more readily noticeable physical alterations — and create a visual sign of their illness — may become more selfconscious and have a poorer self-image.1 Although any cancer diagnosis can present physical challenges and threats to self-image, breast cancer can particularly impact the way a woman views herself. Each stage of breast cancer treatment and recovery can bring about new physical changes that the woman will have to integrate into her evolving self-image. By being aware of the physical impacts of treatment and offering timely, sensitive interventions, clinicians can convey that a woman’s self-image concerns are valid and worthy of support.

FROM The swelling can make it difficult to use the impacted limb for everyday tasks, and wearing a compression garment can make women feel self-conscious. Women sometimes find that their previous clothing no longer fits or that they have to modify physical activity to accommodate the lymphedema—all of which can be frustrating. Studies have shown that women routinely report not feeling adequately informed by their medical team about the potential of lymphedema, 3 and having to confront a chronic condition after their treatment has ended can feel like another blow dealt by the cancer. WHAT CLINICIANS CAN DO

• Recognize that body-image concerns may be difficult for women to bring up; they may feel shame or that image and appearance concerns are not worthy of attention. By normalizing that women can struggle with these concerns during breast cancer treatment, the clinician gives the woman “permission” to have these feelings and discuss them. • Help patients locate wigs and/or scarves before all of their hair falls out. For many women, knowing that they have a wig on hand before they

need to use it is comforting and can reduce anxiety about the process. • If resources and/or insurance coverage allows, women may find it helpful to meet with a nutritionist and discuss ways to support healthy weight management during treatment. Clinicians can further assist women in locating exercise classes suitable to take during treatment. Some women find that actively partaking in group fitness classes or working to eat healthier can restore some of the control that cancer has taken away from them. • Assist women in locating proper postsurgical garments during mastectomy and reconstruction. Insurance may cover some of these items, but the cost can be prohibitive for others. Locate in-kind donations or financial assistance programs. Above all, clinicians should validate and support whatever mastectomy and/or reconstruction choice women make, understanding that each woman is the expert about what is right for her body. • Don’t be afraid to ask if a woman has discussed lymphedema with her doctor, and encourage her to have a conversation. If needed, help her locate compression garments and financial assistance.

• Refer women to peer mentoring programs where they can connect with other women who have had similar treatment experiences. Peer support can further normalize body-image concerns and model positive adaptation. Women who have pronounced body-image concerns may benefit from professional counseling referrals. CancerCare provides numerous free fact sheets on topics such as hair loss, prostheses, skin care, nutrition, lymphedema, and weight changes with additional education and tips on coping with body-image concerns. ■ Stacy Lewis is the Women’s Cancers Program Coordinator at CancerCare. REFERENCES 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. 2. Piot-Ziegler C, Sassi ML, Raffoul W, et al. Mastectomy, body deconstruction, and impact on identity: a qualitative study. Br J Health Psychol. 2010;15(3):479–510. 3. Heppner PP, Tierney CG, Wang Y, et al. Breast cancer survivors coping with lymphedema: what all counselors need to know. J Couns Dev. 2009;87:327–338.

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

46 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2016 • www.OncologyNurseAdvisor.com

ASK A PHARMACIST

Biologic drugs (right) vs small molecule drugs

Biosimilars; Chemotherapy and GERD Medications There is a lot of talk about biosimilar drugs. What makes a drug a biosimilar? —Name withheld upon request

The US FDA defines biosimilar drugs as products that are “highly similar to an FDA-approved reference [original] product” with no clinically meaningful differences in safety or efficacy.1 Although multiple analytic and clinical studies must be submitted to the FDA demonstrating this, the same extensive studies conducted for approval of the reference product are not required. The approval process for biosimilars is different from the process for approving generic medications because the structure of biologic medications is much more complex than that of traditional

medications. Their synthesis may also be much more complex. Because of this complexity, the biosimilar molecule has slight differences from the original product but exerts the same effects. A biosimilar can only be approved for the same indications as the reference product and must use the same dosage forms, route of administration, and strengths as the reference product. FDA criteria classifies these medications into 2 types: interchangeable biosimilars, which may be interchanged for the approved reference product at the pharmacy; and biosimilars, which may not be interchanged without an order from the prescribing clinician. This new type of medication has the potential to reduce drug costs nationwide. What is the interaction between oral chemotherapy and gastroesophageal reflux disease (GERD) medicines? —Name withheld on request

Some oral chemotherapy medications such as dasatinib (Sprycel) or erlotinib (Tarceva) are best absorbed in the presence of acid. Many medications used for the management of GERD suppress acid excretion in the stomach (eg, the proton pump inhibitor [PPI] omeprazole [Prilosec] or the H2 receptor antagonist [H2RA] famotidine [Pepcid]) or neutralize acid (eg, the antacid calcium carbonate [Tums, others]). By reducing the acid in the stomach and subsequently in the GI tract, PPIs,

H2RAs, or antacids can reduce absorption of some affected oral chemotherapy medications by more than 50%. In some instances, patients may require acid suppressing therapy while receiving treatment with an affected oral chemotherapy agent. In these cases, GERD medication and timing should be selected carefully. Traditional antacids such as calcium carbonate, separated from the oral chemotherapy drug by at least 2 hours, are preferred due to their short duration of effects. In some cases, an H2RA may be acceptable due to its intermittent duration of effects, particularly if the oral chemotherapy drug is given once daily. The H2RA should be taken at least 10 hours before and 2 hours after the oral chemotherapy. For example, if erlotinib is taken at 10 AM, the famotidine could be taken between noon and midnight. PPIs are best avoided in patients taking affected oral chemotherapy medications due to their long-lasting acid suppressing effects; the patient’s oncologist may need to be advised if shorteracting medications do not control the patient’s GERD symptoms. ■ REFERENCE 1. Information on biosimilars. US Food and Drug Administration web site. http:// www.fda.gov/Drugs/DevelopmentApproval Process/HowDrugsareDevelopedand Approved/ApprovalApplications/Therapeutic BiologicApplications/Biosimilars. Accessed October 12, 2016.

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

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2016 • ONCOLOGY NURSE ADVISOR 47