Oncology Nurse Advisor Sept/Oct 2015

ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015

September/October 2015

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

CHILDHOOD CANCER

Survivors face challenges due to late effects from AYA cancers

SURVIVORSHIP

Counseling survivors on family building options

RADIATION & YOUR PATIENT

OCCUPATIONAL SAFETY

Essential nursing: Ensuring a safe workplace and risk reduction on the job Nurses are responsible for adhering to drug handling practices that ensure their own health and safety.

Counseling on female sexual health after radiotherapy

COMMUNICATION CHALLENGES

Inquiry before advocacy

THE TOTAL PATIENT

Emotional harm as the new ‘human error’ in health care

REFLECTIONS

Will men talk about their prostate cancer symptoms?

VOLUME 6, NUMBER 5

ASK A PHARMACIST

Hydration regimens for cisplatin

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DOSAGE AND ADMINISTRATION Do not administer CYRAMZA as an intravenous push or bolus.

Recommended Dose and Schedule The recommended dose of CYRAMZA is 10 mg/kg administered by intravenous infusion over 60 minutes on day 1 of a 21-day cycle prior to docetaxel infusion. Continue CYRAMZA until disease progression or unacceptable toxicity.

Premedication Prior to each CYRAMZA infusion, premedicate all patients with an intravenous histamine H1 antagonist (e.g., diphenhydramine hydrochloride). For patients who have experienced a Grade 1 or 2 infusion reaction, also premedicate with dexamethasone (or equivalent) and acetaminophen prior to each CYRAMZA infusion.

Dose Modifications Infusion-Related Reactions (IRR) • Reduce the infusion rate of CYRAMZA by 50% for Grade 1 or 2 IRRs. • Permanently discontinue CYRAMZA for Grade 3 or 4 IRRs. Hypertension • Interrupt CYRAMZA for severe hypertension until controlled with medical management.

• Permanently discontinue CYRAMZA for severe hypertension that cannot be controlled with antihypertensive therapy.

Proteinuria • Interrupt CYRAMZA for urine protein levels ≥2 g/24 hours. Reinitiate treatment at a reduced dose of 8 mg/kg every 3 weeks once the urine protein level returns to <2 g/24 hours. If the protein level ≥2 g/24 hours reoccurs, interrupt CYRAMZA and reduce the dose to 6 mg/kg every 3 weeks once the urine protein level returns to <2 g/24 hours.

• Permanently discontinue CYRAMZA for urine protein level >3 g/24 hours or in the setting of nephrotic syndrome.

Wound Healing Complications • Interrupt CYRAMZA prior to scheduled surgery until the wound is fully healed.

Arterial Thromboembolic Events, Gastrointestinal Perforation, or Grade 3 or 4 Bleeding • Permanently discontinue CYRAMZA. For toxicities related to docetaxel, refer to the current respective prescribing information.

PATIENT COUNSELING INFORMATION • Hemorrhage: Advise patients that CYRAMZA can cause severe bleeding. Advise patients to contact their health care provider for bleeding or symptoms of bleeding including lightheadedness.

• Arterial thromboembolic events: Advise patients of an increased risk of an arterial thromboembolic event.

• Hypertension: Advise patients to undergo routine blood pressure monitoring and to contact their health care provider if blood pressure is elevated or if symptoms from hypertension occur including severe headache, lightheadedness, or neurologic symptoms.

• Gastrointestinal perforations: Advise patients to notify their health care provider for severe diarrhea, vomiting, or severe abdominal pain.

• Impaired wound healing: Advise patients that CYRAMZA has the potential to impair wound healing. Instruct patients not to undergo surgery without first discussing this potential risk with their health care provider.

• Pregnancy and fetal harm: Advise females of reproductive potential of the potential risk for maintaining pregnancy, risk to the fetus, and risk to postnatal newborn and infant development and to use effective contraception during CYRAMZA therapy and for at least 3 months following the last dose of CYRAMZA. • Lactation: Advise patients not to breastfeed during CYRAMZA treatment.

• Infertility: Advise females of reproductive potential regarding potential infertility effects of CYRAMZA.

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Additional information can be found at www.CYRAMZAhcp.com.

Eli Lilly and Company, Indianapolis, IN 46285, USA Copyright © 2015, Eli Lilly and Company. All rights reserved.

RB-L HCP BS 04MAY2015 CYRAMZA® (ramucirumab) injection

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

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 7

CONTENTS 12

IN THE NEWS • Dietary intervention primes triple-negative breast cancer cells for targeted therapy • Dog-sled expedition shows adapted physical activities benefit children with cancer • Prostate cancer treatment is trending toward risk-specific therapies … and more

18

ONCOLOGY NURSE ADVISOR FORUM • Likelihood of lung cancer screening update • Immune checkpoints, simply put • Port functionality with irinotecan administration • Appropriate use of tomosynthesis mammography

12

37

20

40

September/October 2015

FEATURES Nurses’ duty is to reduce risks and ensure workplace safety Pamela J. Haylock, PhD, RN, FAAN

25

Survivors of AYA cancers face challenges from late effects Bryant Furlow

31

Counseling cancer survivors on family building options Bette Weinstein Kaplan

33

48 FIND US ON

STAT CONSULT Filgrastim-sndz (Zarxio)

Continues on page 10

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The Pharmacology Courses You Need Available now on myCME! Developed by NPACE, one of the nation’s leading providers of nurse practitioner continuing nursing education, these courses will help you meet your state and national certification pharmacology credit requirements in one convenient web-based location.

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ISSUES IN CANCER SURVIVORSHIP Understanding the stress of Latina cancer patients

CONTENTS 37

September/October 2015

RADIATION & YOUR PATIENT Counseling on female sexual health after radiotherapy Bryant Furlow

40

COMMUNICATION CHALLENGES Inquiry before advocacy Ann J. Brady, MSN, RN-BC

43 THE TOTAL PATIENT

Clinicians are rallied to view emotional harm as the new ‘human error’ in health care Bette Weinstein Kaplan

44 FROM CANCERCARE

Supporting the cancer patient’s long-distance caregiver Carly O’Brien, LCSW, OSW-C

46 REFLECTIONS

Tell me about your prostate cancer symptoms …

Neal Shore, MD, FACS

48

ASK A PHARMACIST Hydration regimens for cisplatin

Cultural differences in the Latino community result in unique stressors for these patients after a cancer diagnosis. This study identified some of those stressors.

Bette Weinstein Kaplan

FROM CANCERCARE Cancer changed my body: Talking about body image with teens Communication and honesty are key when discussing cancer and treatment options with adolescents with cancer.

Sarah Paul, LMSW

STAT CONSULT Nivolumab (Opdivo) A programmed PD-1 blocking antibody indicated for the treatment of unresectable or metastatic melanoma and metastatic squamous non-small cell lung cancer.

Lenvatinib (Lenvima) A kinase inhibitor indicated for treatment of locally recurrent or metastatic, progressive, radioactive iodine-refractory differentiated thyroid cancer.

VIDEO Moral distress in delivering end of life care Dr. Kevin Brazil, professor of Clinical Epidemiology and Palliative Care at McMaster University, discusses the moral distress that can occur when health care providers feel they cannot provide the level of care they want to provide their patients.

Lisa A. Thompson, PharmD, BCOP

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IN THE NEWS Dietary intervention primes triple-negative breast cancer cells for targeted therapy A diet that starves triple-negative breast cancer cells of an essential nutrient primes the cancer cells to be more

easily killed by a targeted antibody treatment. Senior author, Vincent Cryns, MD, professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison, said this study lays the foundation for a clinical trial to determine if a low-methionine diet will help improve outcomes in women with triple-negative breast cancer.

“We’ve shown that removing methionine can have a specific effect on a molecular pathway that regulates cell death to increase the vulnerability of cancer cells to treatments that target this pathway,” Cryns said. “What’s particularly exciting about our findings is that they suggest that a dietary intervention can increase the effectiveness of a targeted cancer therapy.”

Specifically, the researchers showed that when triple-negative breast cancer cells were deprived of methionine, an essential nutrient abundant in meat, fish, some legumes, and nuts, but low in fruits and vegetables, the stressed cancer cells responded by increasing the amount of TRAIL-R2, a receptor on the cell’s surface. This resulted in the breast cancer cells becoming very sensitive to an antibody that binds to TRAIL-R2 and triggers them to die. “What we didn’t anticipate is that the normal, noncancer cells didn’t upregulate the receptor under methionine stress the way the tumor cells did,” Cryns said. “This shows that diet can help expose a targetable defect in cancer cells.”

The research team believes that their laboratory studies may pave the way for a clinical trial in patients with breast cancer to examine the effectiveness of a low-methionine diet in combination with a TRAIL-R2 monoclonal antibody. When used alone, TRAIL-R2 antibodies have not been effective in patients with metastatic solid tumors.

Breakthrough identifies how mutated genes reprogram blood stem cells in leukemia Researchers have made a breakthrough in understanding how mutated genes in leukemia reprogram blood stem cells and send them spiraling out of control. The findings help to explain the early development of leukemia, representing the essential first Acute myeloblastic step to developing new treatments for leukemia (AML) patients based on these findings.

The role of one specific mutation in the FLT3 gene found in acute myeloid leukemia (AML) was investigated in the study by

Professors Peter Cockerill, PhD, and Constanze Bonifer, PhD, both of the University of Birmingham, United Kingdom. FLT3 is a protein that normally ensures that blood stem cells produce just the right number of blood cells every day. When mutated, it sends the wrong signals and keeps the stem cells expanding out of control, swamping the body with abnormal blood cells.

The team found that the mutated FLT3 protein used one specific signaling pathway inside the cell to activate more than 1,000 different targets within the DNA, leading to the abnormal activation of more than 100 genes in patients with the mutation. Leukaemia and Lymphoma Research, a cancer charity in the United Kingdom, funded the project.

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

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© THINKSTOCK

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

A common perception of the pediatric cancer patient is of a frail youth whose childhood experiences are tragically curtailed by the disease. But the results of a new preliminary study show that children with cancer may benefit from a different kind of treatment: a healthy dose of adventure.

The study follows eleven children ages 10 to 18 years, and five chaperones including doctors and nurses, on a dog-sledding expedition organized by the French nonprofit Sourire à la Vie, which supports the use of adapted physical activity for young cancer patients.

All eleven children received adapted physical training and exercises before the expedition. The children successfully completed the program without harm, and they demonstrated statistically significant improvement in both physical and psychological health. The children participated in other activities, such as snow exercises, as well as caring for the sled dogs.

“One of the main reasons why we chose dog sledding was to create a unique sportive experience based on change of scenery and building a strong relationship with animals,” explained study author Frédéric Sotteau, founder of Sourire à la Vie. Read more at https://bit.ly/1Og5iCd.

New approach to treating B-cell acute lymphoblastic leukemia shows promise A new compound that locks a disease-related protein into an inactive position stifled the growth of an aggressive type of B-cell acute lymphoblastic leukemia (B-ALL) in laboratory and animal tests, according to a new study. When the compound was combined with a steroid, the leukemia was reduced even further and the animals lived longer than they did when treated with the compound alone.

The study involved a variety of B-ALL in which the cancer cells carry a rearrangement of the gene CRLF2. One of the most inviting targets on B-ALL cells with CRLF2 rearrangements is a signaling protein called JAK2. In this study, the researchers tested a type II JAK2 inhibitor.

The inhibitor, called CHZ868, binds JAK2 into a tightly clenched position that prevents it from functioning. The agent was tested in laboratory samples of B-ALL with CRLF2 rearrangement, in mice with the disease, and in mice implanted with human B-ALL tissue.

“In each case, we saw good activity: leukemia cells died, JAK2 signaling was suspended, and survival rates increased,” the researchers reported. Especially encouraging was the lack of bone marrow problems in the treated mice, a possible side effect of JAK2 inhibitors, Weinstock added.

Read more at https://bit.ly/1YdoqnC.

Lower doses of resveratrol are more effective at reducing colorectal cancer growth Smaller doses of resveratrol, a chemical found in red grapes, are more effective at preventing colorectal cancer in mice than high doses, according to new research. Previous research looked at high doses of purified resveratrol to study its potential to prevent cancer.

Research shows less This is the first study to look at the resveratrol is better effects of a lower daily dose, the equivalent to the amount of resveratrol found in one large (approximately 250 mL) glass of red wine, and compare it with a dose 200 times higher.

Results from colorectal cancer-prone mice given the smaller dose showed a 50% reduction in tumor size while the high dose showed a 25% reduction. Lower doses of resveratrol were twice as effective as the higher dose in stopping tumor growth, although this effect was only seen in animals fed a high-fat diet.

Resveratrol is a naturally occurring chemical found in grape skins and other plants. This study opens up new avenues for the role of purified resveratrol in preventing cancer, but suggests that it may only be effective for people with a specific genetic make-up, particular diets, and lifestyles. However, this does not mean drinking red wine reduces cancer risk, as drinking alcohol increases the chances of developing the disease.

Read more at https://bit.ly/1KStQAS.

Aspirin reverses obesity cancer risk Research has shown that a regular dose of aspirin reduces the long-term risk of cancer in those who are overweight in an international study of people with a family history of the disease due to Lynch syndrome. The research team,

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 13

© THINKSTOCK

Dog-sled expedition shows adapted physical activities benefit children with cancer

The Pharmacology Courses You Need Available now on myCME! Developed by NPACE, one of the nation’s leading providers of nurse practitioner continuing nursing education, these courses will help you meet your state and national certification pharmacology credit requirements in one convenient web-based location.

• Satisfy the new ANCC pharmacotherapeutic requirement • Clinically relevant topics, latest updates, clinical pearls, and tools you can implement immediately • Created by NPs, for NPs

Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. ®

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IN THE NEWS

Read more at https://bit.ly/1F3cbE1.

Prostate cancer treatment is trending toward risk-specific therapies After decades of overtreatment for low-risk prostate cancer and inadequate management of its more aggressive forms, patients are now more likely to receive medical care matched to level of risk. In the first study to document updated treatment Prostate cancer care trends, researchers found that from matches risk level 2010 to 2013, 40% of men with lowrisk prostate cancer opted for active surveillance, in which the disease is monitored closely with blood tests, imaging studies, and biopsies. Treatment is deferred unless these tests show evidence of progression.

Meanwhile, men with higher-risk tumors are more likely to undergo surgical removal of the prostate and/or radiation, localized treatments that are more effective than androgen-deprivation therapy alone.

Patients with low-risk disease seeking treatment may be younger and motivated by anxiety, perhaps related to a family history of cancer, or obstructive urinary symptoms.

The authors hope the results of their study will generate

renewed discussion on the merits of PSA screening. PSA levels are frequently elevated in men with prostate cancer, but testing has invited controversy, because it has led to unnecessary treatment in men with low-risk disease.

Read more at https://bit.ly/1McEy2a.

Research identifies factors in ‘Angelina Jolie effect’ on breast cancer screening Angelina Jolie received widespread media attention in 2013 when she told the public that she had tested positive for BRCA1 and subsequently underwent a double mastectomy.

Now research shows that this publicity influenced some women’s A molecular model intentions to seek out similar genetic of BRCA1 testing.

“We put a questionnaire online within 3 days of Jolie’s announcement, to see if the announcement influenced anyone’s intention to get genetic testing,” said lead author Kami Kosenko, PhD, an associate professor of communication at North Carolina State University in Raleigh.

“We also wanted to see if there were any variables, such as whether people felt they identified with Jolie, that were associated with people who were influenced by Jolie’s announcement.”

Of the 229 female study participants, researchers found that 30% intended to undergo testing to see if they carried the BRCA1 gene, with 23% saying they would probably undergo testing and 7% saying they would definitely do so.

“Women who identified more strongly with Jolie were more likely to intend to get the genetic testing regardless of whether they had a family history of cancer than women who did have a family history of cancer but did not identify with Jolie,” Kosenko said. The findings suggest that when it comes to a celebrity’s impact on the public, that impact depends in part on the extent to which the public identifies with the celebrity.

Read more at https://bit.ly/1NDO55L.

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LEFT: © THINKSTOCK; RIGHT: © EVAN OTO / SCIENCE SOURCE

from Newcastle University and the University of Leeds in the United Kingdom, found that being overweight more than doubles the risk of bowel cancer in people with Lynch syndrome, an inherited genetic disorder that affects genes responsible for detecting and repairing damage in the DNA. Approximately half of these people develop cancer, mainly colorectal and uterine cancers. However, over the course of a 10-year study, the team found taking a regular dose of aspirin could counteract this risk.

The randomized controlled trial is part of the CAPP 2 study involving scientists and clinicians from more than 43 centers in 16 countries that followed nearly 1,000 patients with Lynch syndrome, in some cases for more than 10 years.

The international team is now preparing a large-scale follow-up trial and wants to recruit 3,000 people across the world to test the effect of different doses of aspirin. The trial will compare two aspirin a day with a range of lower doses to see if the protection offered is the same. Information on the next trial can be found at www.capp3.org.

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

Jiajoyce R. Conway, DNP, CRNP, AOCNP, oncology nurse practitioner at Cancer Care Associates of York in York, Pennsylvania.

Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/ PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS, clinical pharmacist specialist, Clear Lake Regional Medical Center, Webster, Texas.

Donald R. Fleming, MD, hematologist/oncologist, Cancer Care Center, Davis Memorial Hospital, Elkins, West Virginia.

QUESTIONS & ANSWERS LIKELIHOOD OF LUNG CANCER SCREENING UPDATE Although screening for lung cancer has been available for only a short amount of time, I see many people who would benefit from screening who do not meet the current recommendations (30 pack year smoking history).

What is the likelihood we will soon see an update to the recommendations for lung cancer screening? —Mark Courtney, AAS, RRT The 30 pack year smoking history is not the only recommendation that currently limits who could benefit from screening. Currently, only people older than 50 years with a smoking history of more than 20 years and at least one other risk factor, or those older than 55 years with a smoking history of 30+ pack years who have quit smoking more than 15 years before screening, are eligible.1 Several studies have investigated whether low-dose screening outweighs the radiation-induced cancer risk in patients younger than 55 years, with overall outcomes negating the benefits of early screening.

Since the CMS has agreed that low-dose lung cancer screening is appropriate for people who are covered by Medicare and are older than 55 years with the guidelinestated smoking history and/or other risk factors, it seems probable that this will remain the standard. However, as of this writing ( July 2015), CMS is not yet paying for this screening for Medicare patients. —Rosemarie A. Tucci, RN, MSN, AOCN REFERENCE 1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Lung cancer

Kerstin L. Lappen, RN, MS, ACNS, ACHPN, clinical nurse specialist, palliative care consult service, Abbott Northwestern Hospital, Allina Health System, Minneapolis, Minnesota.

K. Lynne Quinn, RN, MSN, CRNP, AOCNP, director of oncology, Bryn Mawr Hospital and Bryn Mawr Health Center, Bryn Mawr, Pennsylvania.

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

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

screening. Version 1.2015. Fort Washington, PA: National Comprehensive Cancer Network; 2015.

IMMUNE CHECKPOINTS, SIMPLY PUT Please help me to understand immune checkpoints in an easy way to be able to explain it to lung cancer patients. Any videos, algorithm, or table would be helpful, too. —Name withheld on request An important function of the immune system is its ability to distinguish between normal cells and cells that are foreign, such as a virus, bacteria, or cancer cell. This ability ensures that the immune system attacks the foreign cells, leaving the healthy cells to thrive. Immune checkpoints are the molecules that identify substances (proteins) that indicate the presence of foreign cells in the body.

When the immune checkpoints identify proteins from a foreign substance, it turns on (activates) the immune response to attack any cell with those proteins. Proteins from normal cells turn off (inactivate) the immune response. In this way, foreign cells are destroyed but healthy cells are not destroyed.

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Regardless of the agent being infused, using the proper needle with the subcutaneous power ports, properly assessing reservoir size, and using appropriate power loc safety system are important.

However, cancer cells develop from normal cells that become altered and grow out of control and may not have proteins that activate the immune response. Immunotherapy manipulates the immune system response to identify cancer cells as foreign, thereby counteracting the cancer cells’ ability to hide from the immune system.

“Checkpoint Inhibitors: Taking the Brakes Off the Immune System,” a short video from the Cancer Research Institute (CRI; www.cancerresearch.org), uses simple animation to explain how these agents work. The video is part of CRI’s video series “Immunotherapy: 5 Ways to Stop Cancer.” —The Editors SOURCE • Cancer immunotherapy. American Cancer Society Web site. http://www.cancer.org/treatment/treatmentsandsideeffects/ treatmenttypes/immunotherapy/index. Accessed August 31, 2015.

PORT FUNCTIONALITY WITH IRINOTECAN ADMINISTRATION Subcutaneous power ports seem to rarely function properly when administering irinotecan. I find CathFlo is needed every 2 weeks. The port functions properly when the regimen changes. Is there an explanation for why this happens? —Name withheld on request The literature has no documentation specific to malfunctions of subcutaneous power ports and irinotecan specifically. However, regardless of the agent being infused, using the proper needle with the subcutaneous power ports, properly assessing reservoir size, and using appropriate power loc safety system per institution guidelines are important. If these are not used, this can lead to port malfunction and infusion complications can occur.

—Jiajoyce R. Conway, DNP, CRNP, AOCNP

APPROPRIATE USE OF TOMOSYNTHESIS MAMMOGRAPHY With the availability of tomosynthesis mammography, should women at high risk for developing breast cancer still undergo annual MRI? —Maggie Siebeneichen, BSN, BA, RN Most practice standards, including guidelines from the National Comprehensive Cancer Network (NCCN), Version 1.2015,

recommend the use of tomosynthesis as the screening tool for all women if available, but especially for women at high risk for developing breast cancer.1 At this time, annual MRI testing is only recommended for women with the following risks: • A pedigree suggestive of or a known genetic predisposition for breast cancer, starting at age 25 for hereditary breast and ovarian cancer or individualized based on earliest onset in the family; • Received thoracic radiation therapy between ages 10 years and 30 years; • As an adjunct to screening mammography for women whose lifetime risk of breast cancer development, as defined by models based on family history, is greater than 20%.

Tomosynthesis is preferred rather than MRI because diagnostic probability of MRI is questionable for in situ cancers. In addition, MRI has higher cost, is a more invasive procedure secondary to required contrast, and has a slow scan time.

Data from a Dartmouth-Hitchock Medical Center study on DCIS and invasive breast cancers is currently being analyzed and may answer this question better.2 The researchers were attempting to compare tomosynthesis vs MRI with respect to standard references, necessary re-excision rates of each modality, and evaluate patient satisfaction.

For now, tomosynthesis should be used for screening over MRI unless one or more of the above-mentioned risk factors exists.

—Rosemarie Tucci, RN, MSN, AOCN REFERENCES 1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines).

Breast cancer screening and diagnosis. Version 1.2015. Fort Washington, PA: National Comprehensive Cancer Network; 2015.

2. Digital breast tomosynthesis versus contrast enhanced magnetic resonance imaging (MRI) for breast cancer staging [ClinicalTrials.gov identifier NCT01060085]. ClinicalTrials.gov Web site. https://www. clinicaltrials.gov/ct2/show/NCT01060085. Last verified May 2015.

Accessed August 3, 2015.

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FEATURE | Occupational exposure safety

Nurses’ duty is to reduce risks and ensure workplace safety Compliance with safety protocols can minimize risks from occupational exposure to antineoplastic drugs. Are you doing all you can do?

PAMELA J. HAYLOCK, PhD, RN, FAAN

E

© BRUNO BOISSONNET / SCIENCE SOURCE

vidence of antineoplastic drug exposure—agents themselves and genotoxicity biomarkers—was identified in the urine of nurses who prepared and administered antineoplastic drugs in 1979, and nurses in oncology care settings were alerted to the potential risks associated with exposure to these agents.1 Since then, data support the adverse effects of exposure to antineoplastic drugs (cytotoxicity, genotoxicity, teratogenicity, and carcinogenicity), reproductive health risks among health care workers, and congenital malformations among infants born to exposed personnel. 2,3 US guidelines for safe handling of antineoplastic drugs were devised more than three decades ago ( Table 1). With the exception of suggested inclusion of closed system transfer devices (CSTDs or closed systems), recommended safe handling procedures and personal protective equipment (PPE) have not been significantly revised since their introduction.4-7 EFFICACY OF CURRENT CONTROL PRACTICES

Despite adherence to safety guidelines and use of PPE in health care settings, occupational exposure and absorption of antineoplastic drugs continues to be detected at disturbing levels.8-10 Evidence of contamination in multiple and varied health care settings, recognition of exposures beyond pharmacy and nursing/ patient care areas, and demonstrated health risks 20 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

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FEATURE | Occupational exposure safety TABLE 1. PPE for health care workers who work with hazardous drugs Policies for PPE use and worker compliance with PPE use and policies Availability and use of appropriate PPE • Double gloves tested for use with hazardous drugs • Nonpermeable gowns • Respiratory protection Engineering controls • Class II biological safety cabinets/compounding aseptic containment isolators • Closed IV systems • Closed system drug transfer devices • Robotic systems • Ventilation Conduct environmental sampling when analytical methods are available Compare performance of controls against recommended standards Key: PPE, personal protective equipment.

Source: National Institute for Occupational Safety and Health, US Department of Health and Human Services Personal Protective Equipment for Health Care Workers Who Work with Hazardous Drugs. Cincinnati, OH: Department of Health and Human Services; 2009.

DHHS (NIOSH) publication 2009-106. http://www.cdc.gov/niosh/docs/wp-solutions/ 2009-106/pdfs/2009-106.pdf. Accessed September 2, 2015.

to more than eight million health care workers—just in the United States—coalesce as an issue that will not go away.11 In a statewide survey, 16.9% of Michigan oncology nurses working outside of hospital inpatient units self-reported chemotherapy exposure to skin or eyes.12 In a more recent multisite report, Friese and colleagues found evidence of exposure to antineoplastic drugs, not surprisingly, after acute spills but, perhaps surprisingly, as a result of routine drug handling.10 Such data underscore the need to increase adherence to safe handling procedures among potentially exposed health care workers, and highlight the need to implement more effective protection of potentially exposed workers.

In its most recent recommendations relating to medical surveillance of health care personnel, the National Institute of Occupational Safety and Health (NIOSH) expanded the list of jobs that may involve exposure to hazardous drugs13,14 ( Table 2).

A project conducted in British Columbia identifies challenges to reducing inadvertent exposure to antineoplastic agents, concluding that control practices do not appear effective in eliminating surface contamination and/or occupational exposure to antineoplastic drugs.15 Polovich and Clark examined relationships among factors affecting oncology nurses’ use of hazardous drug safe-handling

precautions.16 Their findings indicate that “exposure knowledge, self-efficacy for using personal protective equipment, and perceived risk of harm from exposure was high; total precaution use was low.”16 The authors’ suggested interventions include fostering a positive workplace safety climate and reducing barriers. Similarly, Friese and colleagues report collegial relations with physicians were poorer among workers who reported spills.10 No available data demonstrate a correlation between workers’ age and occupational exposure to hazardous antineoplastic drugs or adherence to PPE. Nevertheless, a 10-member nurse advisory council—all subject matter experts—assembled in August 2014 by Equashield, a leading developer of CSTDs, reached a consensus opinion concerning generational differences in uptake of adherence to recommended PPE. Younger nurses, those of childbearing age, seem more likely to be concerned about exposure risk and outcomes. Yet younger nurses are most often mentored by baby-boomer nurses who seem relatively unconcerned about known adverse effects of antineoplastic drug exposure. For sure, many if not most experienced nurses serving as mentors are beyond childbearing age, and perhaps, perceive minimal personal risks. In fact, no long-term data are available or is being collected to assess and document effects of chronic longterm exposure.11 HAZARDOUS DRUG EXPOSURE AS A WORKPLACE SAFETY ISSUE

Nurses have critical roles in developing policies and procedures to foster a culture of safety in the workplace, and in oncology settings, responsibilities include safe handling of hazardous drugs and selection, introduction, and adherence to correct use of PPEs. Workplace safety in the context of hazardous drug exposure is complex and challenging, involving interdependencies that surround the problem. There is no quick and easy solution in sight. Davis and colleagues contend: “A basic tenet of employment is the provision of a safe workplace. It may be impossible to remove all risk but it is imperative that risk is minimized.”11 The proposed USP <800> protocol mandates the use of CSTDs for nurses administering hazardous drugs, and NIOSH now suggests that, in addition to use of PPE, “closed system drug transfer devices for both pharmacy and nursing personnel can provide an additional level of protection.”17 An effective CSTD, as defined by NIOSH, is a system that “mechanically prohibits the transfer of environmental contaminants into the system and the escape of hazardous drug or vapor concentrations outside the system.” 7

22 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

TABLE 2. Jobs with potential workplace exposure to hazardous drugs

ASSESSING EFFICIENCY AND EFFECTIVENESS OF CSTDs

Occupational safety experts contend that CSTD use should not be optional; that purchase and use of these devices must be viewed as a cost of doing business.18 Variables to consider when purchasing and implementing a closedsystem transfer device include efficacy, cost, and ease of use.

For nurses in particular, two key areas should be assessed when selecting a CSTD. First, the efficacy of the system in containing hazardous drugs, vapors, and aerosols should be a key concern. Systems that are truly closed have a full pressure equalization system (rather than a vented system, as some closed systems have). Without completely containing the contents within a closed system, the environment is susceptible to contamination by hazardous drug vapors and aerosols.19 Other key routes of exposure that should be closed by an effective CSTD include the syringe, needle, connection ports, and the syringe barrel and plunger.20 These four routes can be closed by using needleless or needle-safe systems in which the needle is never exposed, using a truly dry connector system that prevents drug residuals at connection points even after multiple connections (including between drug vial and syringe, between syringe and infusion bag, and between connector pieces on tubing sets), using a syringe that is fully encapsulated at the back of its barrel and has a sealed plunger to prevent plunger contamination and major spills by accidental removal of the plunger.

A second major consideration for nurses when implementing a CSTD is the system’s ease of use. This includes the number of steps required to use the system, time/

ANA Code of Ethics for Nurses Provision 5 maintains that nurses owe “the same duties to self as to others.” efficiency of process, and the ease of connecting various pieces. Berdi and colleagues assessed the efficiency of three CSTD brand name devices for compounding hazardous drugs.18 The authors found that having “simple, intuitive connections ensure consistent use and ease the staff training process.”18 Although this article examined the efficiency of CSTDs in pharmacy use, a logical assumption is that the fewer the steps, and the easier the processes involved,

Environmental service workers (housekeeping, laundry, maintenance workers) Home health care workers Nurses (RNs, ARNPs, LPNs) Operating room personnel Pharmacists and pharmacy technicians Physicians and physician assistants Veterinarians and veterinary technicians Workers who ship, transport, or receive hazardous jobs

the higher the adoption and consistent use of CSTDs will be among nurses as well.

SUMMARY: WORKPLACE SAFETY IN ONCOLOGY SETTINGS Risk In today’s cancer care settings, safety as it relates to antineoplastic drugs primarily addresses patient safety.

Beardwood and Kainer contend that “professional risk in nursing practice is seldom discussed” and has yet to be recognized as a problem.21 The American Nurses Association Code of Ethics for Nurses Provision 5 maintains that nurses owe “the same duties to self as to others,” including the responsibility to promote health and safety.22 Minimizing risk to health care workers is nurses’ responsibility.22 Further, “nurses should model … [avoidance of ] unnecessary risks to health or safety in the course of their professional and personal activities.”22 Put simply, minimizing risks associated with exposure to antineoplastic drugs is a nursing duty.

State-of-the-science protection Hazardous drug containment and worker safety must be a primary concern in cancer care settings. Although nurses have not always been involved in product evaluation, selection, and purchasing decisions, nurses must demand an official seat at the table when hazardous drug safety devices are considered. Some experts indicate that use of CSTDs in compounding and administration processes is no longer optional. Instead, organizational resources should be directed toward identifying the CSTD best suited for that setting, and developing, implementing, and monitoring of safety devices to ensure workplace safety.

Medical surveillance Health care workers exposed to infectious diseases and radiation are routinely monitored

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 23

FEATURE | Occupational exposure safety in the workplace. Although NIOSH recommends medical surveillance of health care workers who prepare, administer, transport, and dispose of hazardous drugs, these measures are not required or practiced in most health care settings.

Recommended elements of a medical surveillance program include collection of workers’ medical, reproductive, and occupational history, physical examination, laboratory studies, and biological monitoring.13 Polovich and Clark advocate implementation of a registry of data connecting nurses’ exposure history and health outcomes.16 Without data on occupational exposure to hazardous drugs, its true impact remains unknown.16 ■

9. Kopp B, Schierl R, Nowak D. Evaluation of working practices and surface contamination with antineoplastic drugs in outpatient oncology health care settings. Int Arch Occup Environ Health. 2013;86(1):47-55.

10. Friese CR, McArdle C, Zhao T, et al. Antineoplastic drug exposure in an ambulatory setting: a pilot study. Cancer Nurs. 2015;38(2):111-117.

11. Davis J, McLauchlan R, Connor TH. Exposure to hazardous drugs in healthcare: an issue that will not go away. J Oncol Pharm Pract.

2011;17(1):9-13.

12. Friese CR, Himes-Ferris L, Frasier MN, et al. Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. BMJ Qual Saf. 2012;21(9):753-759.

13. National Institute for Occupational Safety and Health, US Department of Health and Human Services. Medical Surveillance for Healthcare Workers

Pamela Haylock is an adjunct faculty for the Online RN to BSN Program at Schreiner University in Kerrville, Texas, and chairs Equashield’s Nurse Advisory Council, which seeks to develop strategies to increases nurses’ awareness of issues around occupational exposure to hazardous drugs.

She is a past president of the Oncology Nursing Society.

Exposed to Hazardous Drugs. Cincinnati, OH: Department of Health and Human Services; 2012. DHHS (NIOSH) publication No. 2013-103 (Supersedes 2007-117).

14. Hon CY, Teschke K, Chua P, et al. Occupational exposure to antineoplastic drugs: identification of job categories potentially exposed throughout the hospital medication system. Saf Health Work.

REFERENCES 1. Falck K, Gröhn P, Sorsa M, et al. Mutagenicity in urine of nurses handling cytostatic drugs. Lancet. 1979;1(8128):1250-1251.

2. Connor TH, Lawson CC, Polovich M, McDiarmid MA. Reproductive health risks associated with occupational exposures to antineoplastic drugs in health care settings: a review of the evidence. J Occup Environ Med. 2014;56(9):901-910.

3. Lawson CC, Rocheleau CM, Whelan EA, et al. Occupational exposures among nurses and risk of spontaneous abortion. Am J Obstet Gynecol.

2012;206(4):327.e1-328.

4. Oncology Nursing Society, American Society of Clinical Oncology, Hematology/Oncology Pharmacy Association. Ensuring healthcare worker safety when handling hazardous drugs. Oncology Nursing

2011;2(3):273-281.

15. Teschke K, Chu W. Healthcare Workers and Antineoplastic Drugs: Identifying the Determinants of Exposure and Current Challenges to Reducing Exposure. Richmond, BC, Canada: WorkSafe BC; 2012. Project RS2008-OG01.

16. Polovich M, Clark PC. Factors influencing oncology nurses’ use of hazardous drug safe-handling precautions. Oncol Nurs Forum.

2012;39(3):E299-E309.

17. Connor TH. Safe handling of hazardous drugs. CDC Centers for Disease Control and Prevention Web site. http://blogs.cdc.gov/niosh-scienceblog/2014/05/21/hazardous-drugs/. Posted May 21, 2014. Accessed September 2, 2015.

18. Berdi F, Powell MF, Sanz C, et al. Assessing the efficiency of CSTDs

Society Web site. https://www.ons.org/advocacy-policy/positions/

for compounding. 2015;12(7):4. Pharm Purchasing Prod. 2015;12(7):4.

practice/hazardous-drugs. Accessed September 2, 2015.

http://www.pppmag.com/article/1717/July_2015_Hazardous_Drug_

5. Neuss MN, Polovich M, McNiff K, et al. 2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. Oncol Nurs Forum. 2013;40(3):225-233.

6. Polovich M, ed. Safe Handling of Hazardous Drugs. 2nd ed. Pittsburgh, PA: Oncology Nursing Society; 2011.

Handling/Assessing_the_Efficiency_of_CSTDs_for_Compounding/.

Accessed September 2, 2015.

19. Clark BA, Sessink PJ. Use of a closed system drug-transfer device eliminates surface contamination with antineoplastic agents. J Oncol Pharm Pract. 2013;19(2):99-104.

20. Smith ST, Slaczky MC. Syringe plunger contamination by hazardous drugs: a comparative study. J Oncol Pharm Pract. 2014;20(5):381-385.

7. National Institute for Occupational Safety and Health, US Department

http://www.rivosem.com.tr/wp-content/uploads/2015/04/Syringe-

of Health and Human Services. Preventing Occupational Exposures

Plunger-Contamination-by-Hazardous-Drugs-A-Comparative-Study.

to Antineoplastic and Other Hazardous Drugs in Health Care Settings.

Cincinnati, OH: Department of Health and Human Services; 2004. DHHS (NIOSH) publication 2004-165. http://www.cdc.gov/niosh/docs/2004165/pdfs/2004-165.pdf. Accessed September 2, 2015.

8. Suspiro A, Prista J. Biomarkers of occupational exposure to anticancer agents: a minireview Toxicol Lett. 2011;207(1): 42-52.

pdf. Accessed September 2, 2015.

21. Beardwood BA, Kainer JM. Exploring risk in professional nursing practice: an analysis of work refusal and professional risk. Nurs Inq. 2015;22(1):50-63.

22. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association; 2015.

24 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

FEATURE | AYA survivors

Survivors of AYA cancers face challenges from late effects New study strengthens the case that survivors of adolescent and young adult cancers may struggle in later adulthood with brain and emotional function.

BRYANT FURLOW

© THINKSTOCK

T

he long-term consequences of childhood cancer and its treatment for survivors are fairly well understood, and can include neurodevelopmental impacts with implications for social and emotional wellbeing and educational attainment.1 But less is known about the challenges faced by survivors of cancers diagnosed during adolescence and early adulthood (AYA). Adolescence and early adulthood represent a pivotal period of brain development, and physical, emotional, and psychosocial maturation, experts emphasize.

The distinct needs and challenges of the AYA patient population, and the need for specialized oncology nursing for these patients, has been better recognized in recent years.2-4 The patient advocacy group Critical Mass: The Young Adult Cancer Alliance has spotlighted the needs of AYA cancer patients and survivors, and workgroups organized by the National Cancer Institute, Institute of Medicine, and LIVESTRONG have explored the roots and a broad range of impacts of AYA cancers’ effects on the lives of survivors.5 Now, authors of a new analysis by the Childhood Cancer Survivor Study (CCSS) report that the risk of poor functional outcomes faced by survivors of childhood cancers, is also a reality for AYA cancer survivors.6 Adolescence and early adulthood represent a “critical period of development, and cancer during this period can impact neurocognitive and emotional function and disrupt vocational attainment,” the authors note.6 Continues on page 30

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 25

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FEATURE | AYA survivors The findings bolster the case that AYA patients face challenges in the classroom and the workplace that can disrupt some survivors’ attempts to become independent adults, says Professor Brad Zebrack, PhD, MSW, MPH, at the University of Michigan’s School of Social Work in Ann Arbor, Michigan. Zebrack, who was not involved in the CCSS report, studies the effects of cancer on the psychosocial development of adolescents and young adults.

“While most childhood cancer survivors will survive many years beyond their diagnosis and treatment, the [CCSS report] is consistent with prior research in that some longterm survivors will still struggle with psychological and social, as well as physical effects of treatment for months or

Non-brain-directed therapy is also associated with increased risks of neurocognitive impacts among survivors. even years,” Zebrack tells Oncology Nurse Advisor. “These effects have implications for young people as they move into their later teenage and early adult years.”

The CCSS analysis is based on 2,589 survivors of AYA cancers with diagnoses between the ages of 11 years and 21 years.6 Compared with siblings, AYA cancer survivors reported higher rates of anxiety and depression, and problems with memory and emotional regulation, report lead author Pinki K. Prasad, MD, of the Louisiana State University School of Medicine in New Orleans, and coauthors.6 Few differences were noted between survivors of childhood and AYA leukemia or brain cancer, but AYA patients with lymphoma or sarcoma appear to face lower risks of psychosocial and neurocognitive impacts in later adulthood.6 Patients with lymphoma or sarcoma diagnoses during AYA years reported lower levels of distress and neurocognitive issues than did children with those cancer types.6 However, the authors note that no such differences were apparent among survivors with CNS tumors or leukemia.6 Survivors of cancers diagnosed during AYA years were “significantly less likely than sibling controls to have attained post-high school education, to be working full time, to be married, or to be living independently, and social outcomes were related to neurocognitive symptoms,” the authors conclude.6

Self-reported task inefficiency (eg, time required to complete a task), depression, and somatization (the expression of anxiety as physical symptoms) were each linked to unemployment risk in adult survivors of AYA cancers.6 These problems “have the potential to handicap young adults as they move toward the end of formal schooling, seek jobs or career opportunities, establish themselves as independent adults, and enter into intimate emotional and sexual relationships,” Zebrack says.

“A key finding is the association between unemployment with neurocognitive function and psychological distress, particularly depression,” Zebrack notes. “This is consistent with some of my own prior research.”

The youngest study participants included in the AYA analysis were 11 years old because that is the average age at which girls experience the onset of puberty.6 Onset of puberty among boys occurs, on average, by age 10 years.6 Cancer treatment for adolescents can be longer and more challenging than treatment for younger children with cancer.6 “Cancer treatment during this time has the potential to interfere with adolescents’ separation from caregivers, autonomy with regard to planning social and academic schedules, participation in social activities, and maintaining privacy, particularly of their bodies.”6 Key neuroanatomical and functional brain maturation processes continue into early adulthood.6 “Areas such as the prefrontal cortex, which coordinate executive functions, mature later than areas that are associated with sensory and motor tasks,” they report.

Patients with leukemia or brain tumors were more likely to have undergone chemoradiotherapy, the authors noted—a well established predictor of neurocognitive late effects.6 But AYA lymphoma and sarcoma survivors are not treated with chemoradiotherapy, allowing analysis of chemotherapeutic impacts on neurocognitive outcomes.

Patients with lymphoma or sarcoma and who had undergone corticosteroid treatment, for example, had higher rates of somatization, anxiety, and problems with task efficiency and memory.6 Anxiety and memory problems were also associated with steroid treatment during younger adolescence (age 11 to 14 years).6 The biological mechanisms responsible for these impacts are not yet well understood. Direct effects of radiation and other treatments on brain tissue were long believed to explain neurodevelopmental, cognitive, and psychosocial impacts such as memory impairment.6 But non-brain-directed therapy is also associated with increased risks of neurocognitive impacts among survivors of childhood cancers.6 Continues on page 42

30 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

FEATURE | Family options in survivorship

Counseling cancer survivors on family building options A leading cancer institute developed an online course that teaches oncology nurses about cancer survivors’ fertility options and prospects for adoption.

BETTE WEINSTEIN KAPLAN

D

epending on the treatment received, female and male survivors who want to start or add to a family may not be able to conceive. Do cancer survivors face barriers when they want to adopt children? This is often a topic of discussion among patients and their nurses and other health care providers, but are oncology nurses actually prepared to discuss such matters?

The H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, instituted an 8-week training program, Educating Nurses about Reproductive Issues in Healthcare (ENRICH), to ensure that oncology nurses are better prepared to counsel patients about fertility options and adoption.1 The course aims to teach them about the options available that may reduce a patient’s risk of infertility, and to be able to offer guidance about adoption as an alternative.

© THINKSTOCK

LEVERAGING THE NURSE/PATIENT RELATIONSHIP

Of course, the relationships that oncology nurses have with their patients are unique; nurses are often the earliest and closest clinical contacts for patients and their families throughout the long course of treatment and into survivorship. A logical assumption is that they would be part of family discussions about reproductive health and family building.

Gwendolyn P. Quinn, PhD, senior member, Department of Health Outcomes and Behavior, Division of Population Science at the Moffitt www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 31

FEATURE | Family options in survivorship Cancer Center, and colleagues describe the institute’s program using the experience of 77 nurses from 15 states who completed the online program.2 As part of the program, participants located a local, state, or international adoption agency and, using a guideline, interviewed an intake counselor or administrator. An advisory panel of communication and reproductive health experts developed the interview guide according to the

The nurses found that some international adoption agencies prevented survivors from adopting newborns. program’s curriculum objectives and the purpose of the assignment. Participants then summarized the answers they received for data analysis.

Question categories were cost of adoption, challenges faced by cancer survivors wishing to adopt, reservations of birth parents, and changes that the institution planned in order to increase adoption awareness.

Most of the nurses were surprised at the high cost of adoption fees, which ranged from $3,000 to $75,000. The most commonly quoted fees were between $20,000 and $30,000, but could be lower if the child to be adopted was older or special needs. Grants or federal assistance might also lead to a fee reduction in some cases.

CANCER SURVIVORS AS PARENTS-TO-BE The nurses found that an average of 10 cancer survivors per agency sought to adopt each year. However, some agency administrators did not know how many survivors sought to adopt; they did not track whether prospective parents were cancer survivors because this was not information they had to report.

Physician’s letter Most agencies require a medical history from prospective parents as well as a statement of health that may be given to the birth mother. Although the nurse interviewers did not find many additional requirements for cancer survivors who wanted to adopt, one requirement was that applicants who had had cancer often needed to present a physician’s letter describing the health of each prospective parent. This requirement could place difficult restrictions on the survivor, as some agencies require survivors to be free of cancer for 5 years when they apply to adopt. Some of the

participants identified agencies that went further, requiring the oncologist to submit a letter detailing the patient’s history and overall prognosis, with the option of contacting the oncologist for more information. One nurse interviewer reported, “The [medical history] could be difficult for an adoption agency to interpret … No physician could ever guarantee that a patient is cured, even after the 5-year remission gold standard.”2 Life expectancy Long-term survivorship was often an important consideration for allowing a cancer survivor to adopt; some agencies wanted assurances of a normal life expectancy.

Infertility counseling The staff of some agencies said that they recommended grief counseling and support for cancer survivors wanting to adopt because “infertility represents a loss and entering the adoption world will trigger feelings of grief all over again.”2 Financial implications Most of the nurses who interviewed adoption agency representatives found that normal high adoption fees could be a major barrier for a future adopter with a history of cancer, given the high medical expenses incurred during treatment of their disease.

Other difficulties Survivors who wish to adopt must deal with the wait time associated with adoption, and the greater health restrictions and documentation requirements imposed by many countries in international adoptions. The nurses found that some international adoption agencies prevented survivors from adopting newborns. In these cases, the potential adopters could only adopt special needs or older children, while some countries would not let cancer survivors adopt at all.

THE BIRTH PARENTS’ PERSPECTIVE The participants in the program also asked the agency representatives whether they knew how the birth mothers felt about choosing a cancer survivor to be the adopter.

Most of the nurses were surprised to learn that a history of cancer was not usually a deterrent, since the goal of the agency was to place the child in a loving home, and health history was only one factor in the equation. In fact, more than half of the agencies responded that the birth mother might feel more positive toward a potential parent who has a greater value for life, now that she or he has overcome such personal adversity.2 ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

REFERENCES 1. ENRICH Program. http://www.rhoinstitute.org/. Accessed August 31, 2015.

2. Quinn GP, Zebrack BJ, Sehovic I, et al. Adoption and cancer survivors: findings from a learning activity for oncology nurses [published online ahead of print July 14, 2015]. Cancer. 2015;121(17):2993-3000.

32 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

STAT CONSULT

Filgrastim-sndz (Zarxio) Drug type

• Leukocyte growth factor

Indications

• Decrease the incidence of infection‚ as manifested by febrile neutropenia‚ in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a significant incidence of severe neutropenia with fever • Reduce the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia (AML) • Reduce the duration of neutropenia and neutropeniarelated clinical sequelae (eg‚ febrile neutropenia) in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation (BMT) • Mobilize autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis Mechanisms of action

• Filgrastim-sndz, which is biosimilar to filgrastim, is a granulocyte colony-stimulating factor (G-CSF) • Filgrastim-sndz acts on hematopoietic cells by binding to specific cell surface receptors, thereby stimulating proliferation, differentiation commitment, and some end-cell functional activation Dosage and administration

• Patients with cancer receiving myelosuppressive chemotherapy or induction and/or consolidation chemotherapy for AML ——Recommended starting dose is 5 mcg/kg/day subcutaneous injection, short IV infusion (15 to 30 minutes), or continuous IV infusion

• Patients with cancer undergoing bone marrow transplantation ——10 mcg/kg/day given as IV infusion for no longer than 24 hours • Patients undergoing autologous peripheral blood progenitor cell collection and therapy ——10 mcg/kg/day subcutaneous injection ——Administer for at least 4 days before first leukapheresis procedure and continue until last leukapheresis • Administer orally with or without food • Continue until disease progression or unacceptable toxicity • Direct administration of less than 0.3 mL is not recommended due to potential for dosing errors • Administer f ilgrastim-sndz at least 24 hours after cytotoxic chemotherapy and at least 24 hours after bone marrow infusion, if applicable • Administer filgrastim-sndz daily for up to 2 weeks or until the absolute neutrophil count (ANC) has reached 10‚000/mm 3 following the expected chemotherapyinduced neutrophil nadir in patients receiving myelosuppressive therapy • Administer filgrastim-sndz for at least 4 days before the first leukapheresis procedure and continue until the last leukapheresis • Patient self-administration and administration by a caregiver may benefit from training by a health care professional Dose adjustments

• Patients with cancer receiving myelosuppressive chemotherapy ——Consider dose escalation in increments of 5 mcg/

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 33

STAT CONSULT kg for each chemotherapy cycle‚ according to the duration and severity of the ANC nadir ——Recommend stopping filgrastim-sndz if the ANC increases beyond 10‚000/mm 3 • Patients with cancer undergoing BMT ——ANC >1,000/mm 3 for 3 consecutive days ■■ Reduce to 5 mcg/kg/day • If ANC decreases to less than 1,000/mm 3 at any time during the 5 mcg/kg/day administration, increase to 10 mcg/kg/day, and then these steps ——If ANC remains >1,000/mm3 for 3 consecutive days ■■ Discontinue filgrastim-sndz ——If ANC decreases to <1,000/mm 3 ■■ Resume at 5 mcg/kg/day • Patients undergoing autologous blood progenitor cell collection and therapy ——Monitor neutrophil counts after 4 days of filgrastimsndz‚ and discontinue if the white blood cell (WBC) count rises to >100‚000/mm 3 Specific populations

• Pregnancy ——Pregnancy Category C ——Filgrastim-sndz should be used during pregnancy only if the potential benefit justifies postential risk to fetus • Nursing mothers ——Filgrastim-sndz may be excreted in human milk ——Exercise caution if filgrastim-sndz is administered to women who are breastfeeding • Pediatric ——No difference overall differences in safety or pharmacokinetics • Geriatric ——No overall differences in safety between older and younger patients • Renal impairment ——No dose adjustment is recommended for patients with renal impairment • Hepatic impairment ——No dose adjustment is recommended for patients with hepatic impairment Contraindications

• A history of serious allergic reactions to human G-CSF such as filgrastim or pegfilgrastim products Cautions

• Acute respiratory distress syndrome (ARDS) ——Evaluate patients who develop fever and lung

infiltrates or respiratory distress for ARDS ——Discontinue filgrastim-sndz in patients with ARDS • Capillary leak syndrome (CLS) ——CLS has been reported after G-CSF administration, including filgrastim products, and is characterized by hypotension, hypoalbuminemia, edema, and hemoconcentration ——Episodes vary in frequency, severity, and may be life-threatening if treatment is delayed ——Patients who develop symptoms of capillary leak syndrome should be closely monitored and receive standard symptomatic treatment, which may include a need for intensive care • Cutaneous vasculitis ——Hold f ilgrastim-sndz therapy in patients with cutaneous vasculitis ——Filgrastim-sndz may be started at a reduced dose when the symptoms resolve and the ANC has decreased • Leukocytosis ——Patients with cancer receiving myelosuppressive chemotherapy ■■ To avoid the potential risks of excessive leukocytosis‚ it is recommended that filgrastim-sndz therapy be discontinued if the ANC surpasses 10‚000/mm 3 after the chemotherapy-induced ANC nadir has occurred ■■ Monitor CBCs at least twice weekly during therapy ——Peripheral blood progenitor cell (PBPC) collection and therapy ■■ During the period of administration of filgrastimsndz for PBPC mobilization in patients with cancer, discontinue filgrastim-sndz if the leukocyte count rises to >100,000/mm 3 • Serious allergic reactions ——Permanently discontinue filgrastim-sndz in patients with serious allergic reactions • Sickle cell disorders ——Sickle cell crisis, in some cases fatal, has been reported with the use of filgrastim products in patients with sickle cell trait or sickle cell disease • Simultaneous use with chemotherapy and radiation therapy not recommended • Splenic rupture ——Evaluate patients who report left upper abdominal or shoulder pain for an enlarged spleen or splenic rupture • Thrombocytopenia ——Monitor platelet counts Continues on page 36

34 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

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STAT CONSULT Adverse effects

• Most common adverse reactions in patients ——With nonmyeloid malignancies receiving myelosuppressive anticancer drugs (≥5% difference in incidence compared with placebo) ■■ Pyrexia, pain, rash, cough, and dyspnea ——With AML (≥2% difference in incidence) ■■ Pain, epistaxis, and rash ——With nonmyeloid malignancies undergoing myeloablative chemotherapy followed by BMT (≥5% difference in incidence) ■■ Rash ——Undergoing peripheral blood progenitor cell mobilization and collection (≥5% incidence) ■■ Bone pain, pyrexia, and headache What to tell your patient

• Filgrastim-sndz is a synthetic form of granulocyte colony-stimulating factor (G-CSF) ——G-CSF is a substance produced by the body ——G-CSF stimulates the growth of neutrophils, a type of white blood cell important in the body’s fight against infection • Before you take filgrastim-sndz, tell your doctor about all of your medical conditions, including ——An allergy to latex ——Receiving radiation therapy ——Sickle cell disorder ——Pregnant or plan to become pregnant ——Breastfeeding or plan to breastfeed • Filgrastim-sndz may cause spleen rupture ——Your spleen may become enlarged and can rupture.

This can cause death.

——Call your doctor right away if you have pain in the left upper abdomen (stomach area) or your left shoulder • Filgrastim-sndz may cause acute respiratory distress syndrome (ARDS) ——ARDS is a serious lung problem that causes shortness of breath with or without a fever, trouble breathing, or a fast rate of breathing ——Call your doctor or get emergency medical help right away if you experience any of these symptoms • Filgrastim-sndz may cause serious allergic reactions ——Serious allergic reactions may occur as ■■ A rash over your whole body ■■ Dizziness ■■ Fast heart rate ■■ Shortness of breath

Sweating Swelling around your mouth or eyes ■■ Wheezing ——If you have any of these symptoms, stop using filgrastim-sndz and call your doctor or get emergency medical help right away • Filgrastim-sndz may cause capillary leak syndrome (CLS) ——CLS is when fluid leaks from blood vessels into the body’s tissues ——Symptoms of CLS may become life-threatening ——Get emergency medical help right away if you develop any of these symptoms ■■ A general feeling of tiredness ■■ Dizziness or feeling faint ■■ Feeling of fullness ■■ Swelling of your stomach-area ■■ Swelling or puffiness and are urinating less often ■■ Trouble breathing • Other serious side effects that may be caused by this medication include ——Decreased platelet count (thrombocytopenia) ■■ Your doctor will check your blood during treatment with filgrastim-sndz ■■ Tell your doctor if you have unusual bleeding or bruising ——Increased white blood cell count (leukocytosis) ■■ Your doctor will check your blood during treatment with filgrastim-sndz ——Inf lammation of your blood vessels (cutaneous vasculitis) ■■ Tell your doctor if you develop purple spots or redness of your skin • The most common side effect are aching in the bones and muscles • Filgrastim-sndz injections are given as an intravenous (IV) infusion or a subcutaneous injection (under your skin) • Your doctor may decide subcutaneous injections can be administered at home by you or your caregiver ——You will be instructed on how to prepare and inject a dose of the drug ——You should not inject a dose of filgrastim-sndz less than 0.3 mL (180 mcg) from the prefilled syringe.

——If you are receiving filgrastim-sndz because you are also receiving chemotherapy, the last dose should be injected at least 24 hours before your next dose of chemotherapy ——Store filgrastim-sndz syringes in the refrigerator ■■

■■

Prepared by Jason Hoffman, PharmD, RPh.

36 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

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RADIATION & YOUR PATIENT

Counseling on female sexual health after radiotherapy Bryant Furlow The impact of acute and late radiotherapy toxicities on women’s sexual health are frequently neglected during cancer treatment.

But women should be cautioned about sexual dysfunctions and told about posttreatment sexual rehabilitation options early in their treatment, not just in survivorship, experts tell Oncology Nurse Advisor.

R

adiotherapy and other cancer treatments can profoundly change a woman’s sexual anatomy, function, and overall sexual health.1-3 Women undergoing radiotherapy for gynecologic or rectal cancers—particularly those receiving pelvic brachytherapy or external-beam radiation fields that include the sexual organs—are at particular risk for sexual

dysfunction.4 Radiotherapy is frequently an adjuvant to surgical interventions that destroy or modify sexual organs.4 Radiotherapy and other treatments for breast or brain cancer can also affect a woman’s sexuality by contributing to chronic fatigue, lack of physical strength, diarrhea, or depression5 ( Table 1).

Pelvic radiotherapy’s acute and late toxicities can be specific to sexual anatomy and function, such as vulvar atrophy and vaginal fibrosis, stenosis, shortening, or discharge.1-3 Changes in vaginal anatomy and function make dyspareunia—pain during sexual intercourse—the most common sexual problem reported by cancer survivors.2 Women frequently suffer a triad of distressing sexual problems after pelvic radiotherapy, says Michael Krychman, MD, of the Southern California Center for Sexual Health and Survivorship Med icine, in New por t Beach, California. “They experience severe vaginal dryness with painful penetration and associated lowered sexual interest,” he explained in an interview with Oncology Nurse Advisor.

“The vagina gets narrow, pale, dry, and inelastic. That makes intercourse very uncomfortable and painful.”

The impact is not only physical; these changes can have profound effects on a patient’s self-image, relationships, psychological well-being, and overall quality of life. Yet these issues are widely underappreciated in the clinic, according to Krychman and others.2 “Sexual health concerns are rarely addressed in the clinical situation, in the acute crisis of cancer care, qualityof-life issues often fall by the wayside.”

But “times are changing,” Krychman was quick to add. “Many now understand that cancer is a chronic illness and aftercare may begin at the time of diagnosis,” he explained.

The Nationa l Comprehensive Cancer Net work (NCCN ) has issued a Guideline for Survivorship specific to women’s sexual dysfunction after cancer treatment.1 The NCCN Survivorship Panel noted that overall, the evidence base for interventions is nascent, and more research is needed. But based on consensus and recommendations from the American College of Obstetricians and Gynecologists (ACOG), they have promulgated recommendations that can be tailored to a particular patient’s situation and needs1,6 (See “NCCN survivorship panel recommendations” ).

More than 20 survey and questionnaire instruments have been developed for assessing patient-reported outcomes after radiotherapy for

Vaginal dilation is an important part of the discussion on sexual rehabilitation. gynecologic cancers.7 Of these, the Female Sexual Function Index (FSFI) is the most widely used for assessing treatment effects on women’s sexual health.7,8 The five-item Brief Sexual Symptom Checklist can also be used as a primary screening tool.1,9 ONCOLOGY NURSES CAN HELP PATIENTS FIND THEIR ‘NEW NORMAL’

Oncology nurses are vital when it comes to helping patients understand their sexual health during and after cancer treatment.10 “Many patients may feel more comfortable broaching the topic of sexuality and sensuality with their

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 37

RADIATION & YOUR PATIENT TABLE 1. Radiotherapy-related female sexual issues Changed body odors Cognitive changes Depression or anxiety Dyspareunia Fatigue Libido changes Loss or impairment of ability to orgasm Loss of normal bowel or bladder function or control Loss of normal skin sensation Lymphedema Self-image problems Skin changes Sleep disruption Vaginal atrophy (shortening, stenosis) Vaginal dryness Vaginal fibrosis Vaginal pain or discomfort Sources: Mirabeau-Beale KL, Viswanathan AN. Quality of life (QOL) in women treated for gynecologic malignancies with radiation therapy: A literature review of patientreported outcomes. Gynecol Oncol. 2014;134:403-409. doi:10.1016/j.ygyno.2014.05.008; Sanchez Varela V, Zhou ES, Bober SL. Management of sexual problems in cancer patients and survivors. Curr Probl Cancer. 2013;37(6):319352. doi:10.1016/j.currproblcancer.2013.10.009.

nurses—nurses are often the frontline providers of information and assessment, and often they can implement simple strategies to help ease the burden of sexual problems,” Krychman explained.

Talking with patients about sexual health need not wait for survivorship referrals. “I see more and more pretreatment consultations,” said Krychman.

“Women—and men—want to know the impact on sexuality as they enter and emerge through treatment. It is vital to provide information along the course of the patient’s journey.”

Frequently, the nurse must ask about sexual functioning before a patient will share her concerns. Patients should understand how to access information when they are ready and able to

deal with their sexual health issues, Krychman noted. “Knowing that services are available is important.”

Interventions frequently do not return a patient’s sexual health to where things were before her cancer diagnosis. Instead, providers should talk with patients about seeking a new normal, working to mitigate impacts to sexual activity.

SEXUAL REHABILITATION AFTER RADIOTHERAPY

Sexual rehabilitation is a multidisciplinary endeavor, addressing a patient’s physical, psychosocial, and body imagerelated sexual health issues. The evidence base is small but the NCCN Survivorship Panel released recommendations that can be tailored to an individual patient’s needs.1 “Regardless of disease site, all patients describe a degree of compromise in physical and social functioning, as well as sexual dysfunction,” noted the authors of a recent study of patient quality of life after radiotherapy for gynecologic cancers.7 Vaginal stenosis and shortening are frequently addressed with vaginal dilators—a set of silicone or plastic tapered devices of different sizes that are used regularly to slowly stretch the vaginal walls to gradually reduce dyspareunia.11-13 Vaginal estrogen supplementation can help with vaginal atrophy that proves unresponsive to other therapies, but should be prescribed only after a detailed discussion with patients about risks and potential benefits.2 The idea of dilator use should be raised by the radiation oncologist before treatment begins, says Rinske Bakker, a psychologist and PhD candidate at Leiden University Medical Center’s Department of Gynecology in Leiden, The Netherlands.

“This introduction can contain an introduction about treatment

consequences for the patients’ sexuality and that vaginal dilator use is recommended,” she said. Bakker and her colleagues interviewed experts to develop a sexual-rehabilitation intervention strategy for women who undergo pelvic radiotherapy.11,12 Their team is one of the few in the world specifically studying postradiotherapy sexual rehabilitation. Their Delphi panel agreed that patients should be informed about vaginal dilation if they were sexually active before treatment (whether or not they have a partner), were treated with radiotherapy for cervical or vaginal cancer, or underwent external beam radiotherapy with brachytherapy, Bakker reported.

“No consensus was reached about whether or not to provide the same information to vulvar or endometrial patients, patients older than 70 years, and patients that were not sexually active before treatment,” Bakker cautioned. “Some professionals recommend informing all patients; others recommend to tailor information depending on type of treatment, age, wish to retain sexual activity, and personal and medical situation.”

Oncology nurses should provide extensive information about dilator use during the patient’s first follow-up appointment, Bakker told Oncology Nurse Advisor. “This information should contain the rationale with which dilator use is prescribed and the instructions for dilator use. An informational brochure and/or web site are desirable.”

The provider should always initiate information provision and support, even if the patient does not take the initiative, Bakker emphasized. Vaginal dilation is an important part of the discussion on patients’ sexual rehabilitation; it gives patients the impression that sexuality is a topic that can always be discussed.

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That information should also be provided whether or not the patient is sexually active, to identify any sexual distress issues, Bakker added.

“Oncology nurses should provide simple sexological and practical advice, and should be able to refer a patient to a sexologist if this is not sufficient.”

Each treatment center should identify which provider will be responsible for supporting patients during sexual rehabilitation. Oncology nurses can play a key role in providing psychological and practical patient support during sexual rehabilitation and vaginal dilator use.

Patient adherence to dilator use is inconsistent. Communication is key to overcoming barriers to use.

Their use should be monitored, and should always be discussed at followup appointments, Bakker said. That makes it easier for the oncology nurse to identify and discuss barriers to use, through motivation or practical advice.

Some patients report finding dilators hard and clinical, and others report more positive experiences with alternatives

such as vibrators. “The Delphi panel also agreed that the patient may use a vibrator if preferred and agreed upon what features a dilator should at least have,” Bakker said. Therefore, “we decided to let the patient decide.”

If a patient has a sexual partner, involving the partner during follow-up meetings at which dilator information is given to patients may be beneficial. “Whether or not the partner is actively involved during dilator use itself should depend on the patients’ needs,” Bakker noted.

“The patient could have a preference for support or for privacy, for example.” ■

3. Damast S, Alektiar KM, Goldfarb S, et al.

Sexual functioning among endometrial cancer patients treated with adjuvant highdose-rate intra-vaginal radiation therapy. Int J Radiat Oncol Biol Phys. 2012;84(2):e187-e193.

4. Lindau ST, Abramsohn EM, Matthews AC. A manifesto on the preservation of sexual function in women and girls with cancer [published online ahead of print March 25, 2015]. Am J Obstet Gynecol. 2015;213(2):166174. doi:10.1016/j.ajog.2015.03.039.

5. Rodrigues AC, Teixeira R, Teixeira T, et al.

Impact of pelvic radiotherapy on female sexuality. Arch Gynecol Obstet. 2012;285(2):505-514.

6. American College of Obstetricians and Gynecologists Committee on Practice

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

Bulletins-Gynecology. ACOG Practice Bulletin No. 119: female sexual dysfunction. Obstet Gynecol. 2011;117(4):996-1007.

REFERENCES 1. Denlinger CS, Carlson RW, Are M, et al.

7. Mirabeau-Beale KL, Viswanathan AN. Quality of life (QOL) in women treated for gyneco-

Survivorship: sexual dysfunction (female),

logic malignancies with radiation therapy:

version 1.2013. J Natl Compr Canc Netw.

a literature review of patient-reported out-

2014;12(2):184-192.

2. Falk SJ, DIzon DS. Sexual dysfunc-

comes. Gynecol Oncol. 2014;134(2):403-409.

8. Rosen R, Brown C, Heiman J, et al. The

tion in women with cancer. Fertil Steril.

Female Sexual Function Index (FSFI): a mul-

2013;100(4):916-921.

tidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191-208.

9. Hatzichristou D, Rosen RC, Derogatis LR, et al.

NCCN survivorship panel recommendations • Vaginal dryness or dyspareunia (pain during sex) can be alleviated with water-, oil-, or silicone-based lubricants and moisturizers.

Recommendations for the clinical evaluation of men and women with sexual dysfunction.

J Sex Med. 2010;7(1Pt2):337-348.

10. Krychman M, Millheiser LS. Sexual health

• Sexual function may be improved, and dyspareunia alleviated, with pelvic floor muscle training.

issues in women with cancer. J Sex Med.

• Vaginal dilators are recommended for vaginal fibrosis, stenosis, and sexual aversion.

11. Bakker RM, Vermeer WM, Creutzberg CL, et

• Vaginal estrogen pills, rings, or creams may be effective in treating vaginal dryness, discomfort, and dyspareunia in postmenopausal women; however, the evidence base of this intervention for cancer survivors is limited.

• Referrals for psychotherapy, sexual and couples counseling, and gynecologic care should be given as appropriate, and ongoing partner communication should be encouraged.

Key: NCCN, National Comprehensive Cancer Network.

Source: Denlinger CS, Carlson RW, Are M, et al. Survivorship: sexual dysfunction (Female), Version 1.2013. J Natl Compr Canc Netw. 2014;12(2):184-192.

2013;10(Suppl1):5-15. al. Qualitative accounts of patients’ determinants of vaginal dilator use after pelvic radiotherapy. J Sex Med. 2015;12(3):764-773.

12. Bakker RM, ter Kuile MM, Vermeer WM, et al.

Sexual rehabilitation after pelvic radiotherapy and vaginal dilator use: consensus using the Delphi method. Int J Gynecol Cancer.

2014;24(8):1499-1506.

13. Miles T, Johnson N. Vaginal dilator therapy for women receiving pelvic radiotherapy.

Cochrane Database Syst Rev. 2014;9:CD007291. doi:10.1002/14651858.CD007291.pub3.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 39

COMMUNICATION CHALLENGES

Inquiry before advocacy

©THINKSTOCK

Ann J. Brady, MSN, RN-BC

We want to be advocates for our patients. But sometimes in our eagerness to do what is best for a patient, we make assumptions.

I

nquiry before advocacy is an adage used in business and also in palliative care.1 It reminds us to ask questions before suggesting solutions, to look before you leap.

Can you think of a time in your practice when you jumped to the solution before clearly understanding the problem? What happened?

CASE “What are we doing here?” The intensive care unit (ICU) nurse nodded toward Mary Jane’s room. I was in the ICU to check on Mary Jane and assess and manage her symptoms.

“What do you mean?” I asked.

“I was just wondering what the plan is for her.” Again, she indicated Mary Jane.

“We are going to have another family meeting today.”

This time she shook her head like she was saying no and said, “Good. Someone needs to figure it out.”

As working nurses, our practice is built on knowledge and experience. We draw on our professional experiences to help us understand our patients and to grasp the family dynamics of those we care for. So it can be easy to think we have a full appreciation of a situation when we do not. We have cared for other patients with the same diagnosis, at the same age, with a similar response to treatment. We see how families behave, predictably and, sometimes, in unexpected ways. We know what denial looks like. We know what is reasonable. We know what we would do if it were our family member. Years of experience can lead us to think we have seen it all. We want to be advocates for our patients. But sometimes in our eagerness to do what is best for a patient, we make assumptions. The experience that is a foundation to our practice can sometimes get in the way.

That is exactly what happened recently with two patients. In both situations, wellmeaning staff (nurses, doctors, and social workers) thought they knew what was best, but their experience blinded them.

Knowing the nuts and bolts of what is happening medically does not necessarily translate to fully understanding a situation.

Full understanding requires inquiry, and inquiry takes time. Because time is often in short supply, we can fall back to knowing what is best.

The first patient, Mary Jane, was 52 years old and otherwise healthy. She had stage IV cancer but was stable and getting treatment for her cancer when she developed pneumonia. Although she required intubation Mar y Jane’s

40 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

pneumonia was considered treatable and potentially reversible. But after several days in the ICU a lack of inquiry reared its head. Because of her advanced cancer the questions started.

“Is this what she wants or is it what the family wants?” and “Should we be treating her when she is terminal, wouldn’t it be kinder to let her go?” and “Why is the family extending her suffering.”

All three of the questions were asked based on concern for her. When Mary Jane was asked if she wanted to keep the tube in place, she lifted her hand up toward the ceiling. Many felt that was her way of signaling her desire to go up to heaven.

It is not that I think the nurses and others were wrong to pose the questions, but embedded in them was a bias, and that bias was based on an assumption that turned out to be incorrect. The implicit belief was that, with an incurable stage IV cancer, we were promoting futile care. The questions were not geared toward open inquiry; they were geared toward assumptions.

The second scenario had similarities to the first. Carla also had an advanced cancer, but in this case a complication meant a trip to the OR for revision of an open wound. After surgery Carla went to ICU for observation, where her code status changed back to her pre-op DNR; except that did not make sense to one of her caregivers, who encouraged the family to reinstate full code status. The rationale was that since she was full code during surgery, and that the surgery itself indicated a shift in outlook, making her DNR was incongruent. Or so it was argued to the family. Later the family reported being deeply disturbed by the push back from the nurse. They had struggled to make a decision about surgery and had carefully explored the options. Now they wondered if they had made the wrong decision by resuming DNR. Had they made the wrong decision when choosing surgery?

DISCUSSION On the surface these two cases share similarities. Both feature complicated patient cases with advanced cancer, and both resulted in questions related to their care. Interestingly, in one there were questions about continuing care, whereas in the other, it was a question about when to stop. In Mary Jane’s case, the patient and family had a clear understanding of the risk of intubation and the chances of her recovering from pneumonia. In Carla’s case, the family had deliberated over surgery before making the decision.

There was another significant similarity between the two. Extensive conversations about goals of care had taken place and those conversations were documented in the electronic medical record. In Mary Jane’s case, the perception was that the family was torturing her. This misperception persisted as it was transmitted from one caregiver to the next without truly asking the family or Mary Jane what their goal was. Because she was intubated, communicating with her was difficult; however, she was able to confirm that she felt her remaining time was of value to her and accepted her suffering as a way of sharing her faith. Her desire was for the end of her life to be a witness to others. She was peaceful and calm. Everyone wanted what was best for her. Mary Jane died not long after. She did not recover from

Advocacy is about ensuring the patient’s voice is heard, not about imposing upon them what we think is appropriate.

JOIN THE CONVERSATION • Can you think of a time in your practice when you jumped to the solution before clearly understanding the problem?

• What happened?

Go to OncologyNurseAdvisor.com/challengesinquiry to talk with your colleagues about how you advocate for a patient when differing opinions can have a significant impact on patient care decisions.

ON THE

WEB

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 41

COMMUNICATION CHALLENGES pneumonia, but she and her family were satisfied that they made the effort. Advocacy is about ensuring the patient’s voice is heard; it is not about imposing upon them what we think is appropriate.

Even when there is no doubt, it is important to clarify, reaffirm, and inquire.

Carla was discharged home with hospice. Her wound did heal but she was not a candidate for further chemotherapy treatment. A practitioner orders for life-sustaining treatment (POLST) was filled out, and she and her family were satisfied with the choices they made during her hospitalization.

The willingness of nurses and other caregivers to advocate for Mary Jane and Carla was exemplary, yet it was incongruent with what they or their families expressed

as their wishes. Instead it was congruent with what some of the staff felt was appropriate. One assumption centered on the futility of the care provided. Surely the patient and family must not have understood or they would have made other choices. Advocacy is an important part of nursing care. Often we are the voice for the patient, and it is our responsibility to explain and help to make sense of what is happening to our patients. In the cases of Mary Jane and Carla, advocacy without inquiry first was misguided. We must learn to ask first and then listen before acting. Even when there is no doubt, it is important to clarify, reaffirm, and inquire. And listen. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

REFERENCE 1. Thompson MP. The skills of inquiry and advocacy: why managers need both. Manage Commun Q. 1993;7(1):95-106. doi:10.1177/0893318993007 001005.

Feature: AYA survivors

REFERENCES

Continued from page 30

1. Late effects of treatment for childhood cancer—for health professionals (PDQ). National Cancer Institute Web site. http://www.

The treatment protocols used with the CCSS cohort are now more than 20 years old.6 However, despite reductions in treatment intensity over that period, other studies have shown that the pattern of cognitive impairment remains quite similar.6 Nor can the causal directions of the reported associations be determined because of the cross-sectional nature of the study, Zebrack cautions.

“We can’t know whether being unemployed causes impaired task function and depression or if depression and impaired function reduces survivors’ ability to become employed,” he explains. “But the association observed still serves as a rationale for developing and implementing psychosocial support interventions for childhood cancer patients that can be implemented while going through treatment—to possibly prevent or diminish the likelihood of these long-term effects occurring, or during off-treatment survivorship, when these young people may need and benefit from support as they may struggle with depression or inability to secure a job.” ■

cancer.gov/types/childhood-cancers/late-effects-hp-pdq. Updated May 18, 2015. Accessed August 11, 2015.

2. Williams KA. Adolescent and young adult oncology: an emerging subspecialty. Clin J Oncol Nurs. 2013;17(3):292-296. doi:10.1188/13.

CJON.292-296.

3. Robison LL, Hudson MM. Survivors of childhood and adolescent cancer: life-long risks and responsibilities. Nat Rev Cancer.

2014;14(1):61-70.

4. Coccia PF, Altman J, Bhatia S, et al. Adolescent and young adult oncology. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2012;10(9):1112-1150.

5. Casillas J. National Cancer Policy Forum/LIVESTRONG workshop on addressing the needs of adolescents and young adults with cancer [video]. National Academies of Sciences Enginerring Medicine Web site. http://iom.nationalacademies.org/Activities/Disease/ NCPF/2013-JUL-15/Day%202/Session%204/22-Casillas.aspx. Accessed August 11, 2015.

6. Prasad PK, Hardy KK, Zhang N, et al. Psychosocial and neurocognitive outcomes in adult survivors of adolescent and early young adult cancer: a report from the Childhood Cancer Survivor Study [published

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

online ahead of print July 6, 2015]. J Clin Oncol. 2015;33(23):2545-2552. doi:10.1200/JCO.2014.57.7528.

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THE TOTAL PATIENT

© THINKSTOCK

Clinicians are rallied to view emotional harm as the new ‘human error’ in health care Bette Weinstein Kaplan

O

ver the years some dreadful mistakes have been made in health care, resulting in physical and emotional harm for the unfortunate patients. The situation was partially recognized in the 1999 Institute of Medicine (IOM) landmark report, To Err is Human: Building a Safer Health System, which addressed the inadequate procedures for preventing physical harm that existed in health care at that time.1 The report advised practitioners to take immediate action to raise standards and expectations for improvements in safety.1 Improvements did follow, and over the ensuing years health care practitioners have been able to identify and prevent many situations that would have resulted in physical harm.

THE OTHER PATIENT HARM

A recently published commentary on preventable patient harm used central line-associated bloodstream infections as an example of the impact of the IOM report.2 Those infections are often preventable now, but in 1999 they were actually accepted as predictable and common complications that caused physical—and possibly emotional— harm. The authors are with the Hospital Medicine Program at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, where lead author Lauge Sokol-Hessner, MD, is

associate director of Inpatient Quality.

With the improvements made in preventing physical harm to patients, Sokol-Hessner and colleagues advise that now the health care profession needs to address emotional harm in a similar way. 2 They explained, “Emotional harms can erode trust, leave patients feeling violated and damage patient-provider relationships.

Such injuries can be severe and long lasting, with adverse effects on physical health. Failure to acknowledge and systematically address these harms ensures that they continue.”2 Sokol-Hessner and colleagues note that the case for preventing emotional harm and disrespect is at the same stage patient safety was at prior to 1999, before reforms to physical harm were put into place. Emotional injuries are known to occur, but with no system in place to evaluate them, the causes are not understood. Similarly, although evidence suggests that emotional harms may be more prevalent than physical harms, no reliable estimates are available on how frequently they occur.

As a result, preventing these harms from happening again is difficult.2 DEFINING EMOTIONAL HARM The 1999 IOM report states “it is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer

healing and comfort.”1 Taking this to heart, the BIDMC group invited representatives of various disciplines at the medical center to join a focus group on preventing emotional harms. Thus, the BIDMC Respect and Dignity Workgroup was formed, comprising representatives from the departments of health care quality, patient safety, r isk management, per for mance

A culture of respect for patients entails staff that is respectful of each other. assessment and regulator compliance, ethics, social work, palliative care, communications, community relations, patient relations, interpreter services, hospital governance, and the Patient Family Advisory Council.

The Respect and Dignity Workgroup def ined emotional harm as something that affects a patient’s dignity by the failure to demonstrate adequate respect for the patient as a person. 2 This definition takes into account that not every case of emotional harm is the result of human action. It might be the result of the Continues on page 45

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FROM

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C

aring for a loved one with cancer is no easy feat; for many, caregiving is unfamiliar territory with no clear path.

Providing that care from a distance can create additional challenges and concerns for the more than 7 million people in the United States who fulfill this role. Long-distance caregivers often feel the need to qualify their role; since they are generally not in a position to be providing direct care on a daily basis, they may not feel that they can be considered a caregiver. In turn, they may not know about supportive and practical resources available to them. This can leave them feeling more isolated, and can increase their distress.

Long-distance caregivers frequently report feelings of guilt, sadness, and disconnect related to their caregiver role. They often share feeling out of the loop, as it may take more time for them to gain access to information and updates about their loved one and their care, which can lead to anxiety and feelings of helplessness. In addition to the emotional impact of long distance caregiving, a host of practical and logistical challenges often arise. Traveling to be closer to the patient or taking time off to provide more direct care can be costly, creating financial strain.

All of these challenges illustrate that long-distance caregivers need support in navigating their role. Here are some ways health care professionals and other support resources can best help.

Validate the unique role of the long distance caregiver. Help them to explore what their role will look like, including specific responsibilities, as

Supporting the cancer patient’s long-distance caregiver Carly O’Brien, LCSW, OSW-C

well as what they want to provide, such as practical and/or emotional support.

Use a strengths-based approach to help draw out what they are good at; consider what skills come most easily or naturally for them. For example, perhaps a caregiver is particularly skilled at navigating complex insurance issues, or knows exactly what to say to help the patient feel hopeful at any given

time. Paying attention to these unique characteristics and helping a caregiver to see them as strengths can help them strategize opportunities for providing support in a meaningful way.

Encourage open communication.

Long-distance caregivers will benefit from talking with the patient about his or her wants and needs related to their care up front. Clear communication is essential, as the caregiver may not be there to witness needs as they come up. This will allow caregivers to better gauge what kind of approach to adopt, rather than making assumptions. However, patients commonly leave out certain information as a way of protecting the long-distance caregiver.

Therefore, long-distance caregivers may also want to be connected with people who see the patient more regularly, as these people can more adequately assess how their loved one is really doing.

Help long distance caregivers determine what they can provide for their loved one, even from far away.

Oftentimes, long-distance caregivers focus on the challenges or limitations they have in providing care from a distance rather than on the things they can do for the patient. Long-distance caregivers can help the patient consider questions to ask their doctors, sort through resources and information, or coordinate insurance benefits. They can also provide emotional support by calling or e-mailing to check in, sending care packages, or providing a sense of normalcy by engaging the patient in conversations on topics other than cancer.

Flexibility is key. The patient’s needs will ebb and flow throughout

Many caregivers report that having two different networks of support—a home team and an away team—is most helpful.

44 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

the continuum of care, and thus the long-distance caregiver needs to practice flexibility as well. There may be times when the patient is feeling well and wants to maintain more independence, while at other times, may require a more hands-on approach.

In some cases, distance can be protective. Reminding caregivers of the opportunity for self-care, and independence that can be achieved while being farther away from the patient can help them to reframe and feel more equipped for the caregiver role.

Enlist multiple avenues for support.

Many long-distance caregivers report that having two different networks of support—a home team and an away team—is most helpful. This ensures that the caregiver has a strong support system both when they are with the patient and when they are not. Longdistance caregiving takes a lot of time and energy, so caregivers need support that is flexible, too. An ever-available

Total Patient Continued from page 43

disease process itself or the result of a compromising surgical oncology procedure. The emotional harm might stem from the technique used to instruct a patient about the care of a colostomy bag, or it might come from a simple lack of privacy during an infusion due to limited space on the outpatient oncology unit.

A group of medical students observing during an examination could certainly cause emotional harm to the patient.

Some databases keep track of instances of physical harm, containing feedback from patients and family, whereas other data compile adverse events caused by

online support group may be more helpful than a more structured weekly commitment. CancerCare and other similar organizations offer caregiverspecific online support groups that are available 24 hours a day, 7 days a week.

Prescribe a high dose of self-care.

Long distance caregivers are often bal-

Long-distance caregivers may benefit more from checking in with themselves. ancing responsibilities of their own including family and career, as well as the unique challenge of caregiving from afar, and often overlook their own needs. Self-care is necessary for them to cope with all of these different and complex parts of their lives. Long-distance

caregivers may see any free moment as an opportunity to visit with the patient or get into caregiver mode. However, they may in fact benefit more from first checking in with themselves about how to spend moments of respite.

Prepare for visits. Encourage the longdistance caregiver to consider what physical changes might have occurred in the patient since their last visit (ie, hair loss, weight changes, mobility) to help create appropriate expectations and anticipate triggers for sadness and worry.

Ultimately, in order to best support long-distance caregivers, it is important to acknowledge them as an integral part of a patient’s care. Listening to the needs of this population and helping them gain access to valuable resources and information goes a long way in improving outcomes for both the caregiver and patient. ■ Carly O’Brien is an oncology social worker and the Caregiver Program Coordinator at CancerCare.

health care providers. Researchers certainly can use these sources to identify reports of emotional harm as well.

However, the BIDMC authors caution, these data probably do not accurately report the total burden of emotional harm because, until now, awareness of emotional harm or expectation that it matters has been limited.2 Thus, encouraging patients and staff to report such occurrences is up to the health care providers and institutions.

emotional harm among patients can only encourage respect and consideration among staff as well. ■

ADDITIONAL BENEFITS

2. Sokol-Hessner L, Folcarelli PH, Sands KE.

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

REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington DC: National Academy Press, 2000.

A culture of respect for patients entails a staff that is respectful of each other as well as the patient. Creating an environment that rigorously prevents

Emotional harm from disrespect: the neglected preventable harm [published online ahead of print June 17, 2015]. BMJ Qual Saf. 2015;24(9):550-553.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 45

REFLECTIONS

© THINKSTOCK

W

ithin the United States, prostate cancer is the second most commonly d iag nosed sol id tumor malignancy, accounting for approximately 220,800 cases in 2015, resulting in approximately 28,000 deaths, with approximately 11,000 initial diagnoses being advanced disease, ie, disease radiologically confirmed as outside of the prostate.

A survey has recently been conducted to better understand patient and caregiver perceptions regarding the symptoms associated with advanced prostate cancer and how both patient and caregiver experiences impacted their therapeutic decision making with their clinicians, including both physicians and nurses.

Unfortunately, even though the survey suggests that 97% of men with advanced prostate cancer acknowledge they are comfortable talking to their clinicians about their prostate cancer symptoms, less than half actually do specifically detail their complaints or concerns regarding their symptoms at each visit.

In fact, almost one-third (30%) of men with prostate cancer-related bone metastases experienced pain for 7 months or more before they received a confirmatory diagnosis that their prostate cancer had metastasized to the bones.

The International Prostate Cancer Symptoms Survey is a global survey commissioned by the International Prostate Cancer Coalition (IPCC) with the support of Bayer HealthCare.

Ten countries, including representation

Tell me about your prostate cancer symptoms …

Neal Shore, MD, FACS

from North America, Europe, and Asia, participated. In the United States, 410 patients with advanced prostate cancer and 95 caregivers were surveyed online and via phone

by Harris Poll between February 12 and April 13, 2015, and the United States is the first country site to report its findings.

Key US results include nearly 7 in 10 men living with prostate cancer

(68%) admitted to sometimes ignoring symptoms such as pain. There are multiple factors that could contribute to this finding. For example, 55% acknowledged that they felt their daily pain and discomfort is just something they have to live with, 22% reported they feel mentioning their pain makes them feel weak or depressed, while 71% of survey respondents admitted that they were not sure of the exact cause of their pain (cancer- or noncancerous-related).

Although early stage prostate cancer usually causes no symptoms, symptoms oftentimes emerge as the disease progresses, and the most common site for metastases is the bone.

The survey noted, if asked directly, men with advanced disease and their caregivers describe difficulty walking or climbing stairs, unexplained new onset of pain, troubled sleep, changes in daily physical activities, and new usage of over-the-counter pain relievers—which may all ref lect signs of advancing prostate cancer.

These symptoms can have a major impact on daily quality of life, but men with advanced disease do not always recognize these symptoms, and even if they do, it is clear from the survey that they and their caregivers are not always forthcoming in communicating with their clinical team of physicians and nurses. Importantly, the physician and nursing team should also ref lect upon strategies and sensitivities to improve this communication.

Improved patient-caregiver communication with the nurse-physician team truly matters, as approximately

Key US results include 68% of men living with prostate cancer admitted to sometimes ignoring symptoms such as pain.

46 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2015 • www.OncologyNurseAdvisor.com

90% of men with advanced prostate cancer will develop bone metastases, impairing not only survival but also quality of life. Caregivers can provide a perspective on their loved one’s disease that patients themselves oftentimes lack.

The sur vey documented that a lthoug h on ly 44% of pat ient respondents reported that pain often limits their activities, one-third more caregivers (74%) reported that their loved one’s pain often significantly limited their activities. Therefore, diagnosing and treating bone-related symptoms at the earliest onset is of critical importance for patients with advanced prostate cancer. A multidisciplinary approach, inclusive of the nurse, physician, caregiver, and patient perspective will lead to enhanced shared decision making when it comes to assessing the benefits

of approved therapies, ensuring that these therapies are not initiated too late, or, worst case scenario, not ever administered.

Achieving efficiency of communication ensures that timely therapy can ensue.

Achieving clarity and efficiency of communication for all stakeholders of patient care ensures that the connectivity between symptomatology and advanced disease is best understood and that discussion for timely therapy can ensue. When asked what would motivate survey respondents to share their pain symptoms with their

physicians and nurses, they reported several factors.

• If it helped increase quality of life (80%); • If it kept the cancer from getting worse (68%); and • If it helped increase activity levels (68%).

The survey addresses the importance for men to be proactive and speak up about their symptoms when they have appointments with their doctor. The IPCC and Bayer recently introduced “Men Who Speak Up,” a nationwide movement to increase awareness of the symptoms of advancing prostate cancer and supply informational tools and resources to help men take action regarding their disease by ensuring and facilitating comfortable and productive conversations with the entire health care team, which should improve therapeutic decision making. ■

Do you have a story you want to share?

Oncology Nurse Advisor welcomes narrative essays from oncology nurses for Reflections, our narrative medicine blog.

Write 800 to 1,200 words about a patient or life experience that was meaningful to you or a perspective on oncology patient care, and email the manuscript to editor.ona@haymarketmedia.com.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2015 • ONCOLOGY NURSE ADVISOR 47

© THINKSTOCK

ASK A PHARMACIST

Hydration regimens for cisplatin I have started a new chemotherapy job and the staff does not add potassium, magnesium, and mannitol to the hydration regimens for cisplatin, even at 200 mg IV doses of cisplatin. I have not ever heard of not adding these drugs. Is there any evidence to support adding or not adding these agents to the hydration for cisplatin?

—Name withheld on request

Cisplatin is used for the treatment of many cancers. One dose-limiting adverse effect of cisplatin is nephrotoxicity. Cisplatin is predominantly excreted by the kidneys, and concentrations in the kidneys are higher than in the blood or other tissues. As a result, the tubular epithelial cells of the proximal renal tubules may be damaged. Cisplatin also causes nephrotoxicity by causing vasoconstriction in the renal microvasculature, reduced renal blood flow, and expression of pro-inflammatory cytokines.

Nephrotoxicity due to cisplatin is cumulative and associated with higher doses and duration of therapy. The risk of nephrotoxicity may also be increased by concomitant administration of other nephrotoxic medications (eg, the aminoglycoside antibiotics) in patients with preexisting renal dysfunction, or in elderly or pediatric patients. Patients may experience impaired renal function, affecting clearance of cisplatin and other medications, elevations in serum creatinine (SCr) and blood urea nitrogen (BUN), and may also experience electrolyte wasting. Alterations in serum electrolytes including hypomagnesemia, hypokalemia, hyponatremia, hypocalcemia, and hypophosphatemia have been reported in studies evaluating various doses of cisplatin.

Patients should be monitored for nephrotoxicity at baseline and prior to each dose of cisplatin, with labs including SCr, BUN, and electrolytes such as potassium and magnesium.1 To reduce the risk of nephrotoxicity, it is recommended that patients be hydrated with 1 to 2 liters of IV fluids. Hydration is recommended to induce diuresis and reduce the concentration of cisplatin in the kidneys.

Isotonic saline (0.9% sodium chloride) is recommended for hydration fluids, and many centers also include potassium and magnesium in these hydration fluids due to the risk of electrolyte wasting.

Mannitol and furosemide have also been used to increase diuresis, although there are no clinical studies

demonstrating that these interventions are superior to hydration alone. Some references recommend that cisplatin be infused over several hours in solution with mannitol; however, this duration of cisplatin infusion is not appropriate for many chemotherapy regimens.2 Amifostine has also been studied to reduce nephrotoxicity with cisplatin.

A study administering amifostine to patients with ovarian cancer who were receiving high doses of cisplatin (100 mg/m 2) demonstrated a reduction in the incidence of nephrotoxicity (defined as a 40% or greater reduction in creatinine clearance) from 33% to 10% with the addition of amifostine.

Amifostine is recommended by the American Society of Clinical Oncology for prevention of cisplatin-induced nephrotoxicity in patients with ovarian or non-small cell lung cancer who are receiving doses of cisplatin of 100 mg/m2 or higher; however, there is no data to support use of amifostine for this purpose in other settings.2 ■ REFERENCES 1. Hensley ML, Hagerty KL, Kewalramani T, et al.

American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol. 2009;27(1):127-145.

2. Cisplatin [prescribing information]. Paramus, NJ: WG Critical Care, LLC; 2015. http://www. accessdata.fda.gov/drugsatfda_docs/ label/2015/018057s083lbl.pdf. Revised February 2015. Accessed September 8, 2015.

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

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