ONA September/October 2017 by Haymarket Media

ONCOLOGY NURSE ADVISOR â&#x20AC;¢ SEPTEMBER/OCTOBER 2017

September/October 2017

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

CANCER IN THE ELDERLY

FEATURE

Distress Assessment for Psychosocial Support in Head and Neck Cancer

FEATURE

Invisible Burdens: Complexities of Caregiving

JOURNAL REVIEW

Recognizing Checkpoint Inhibitor-Related Pneumonitis

COMMUNICATION CHALLENGES

When to Just Listen as Family Members Try to Cope

THE TOTAL PATIENT

Virtual Reality: Connecting Patients to the Outside World

FROM CANCERCARE

Preventing Body-Trauma Triggers During Radiotherapy

VOLUME 8, NUMBER 5

ASK A PHARMACIST

CDK Inhibitors Compared

Super-Elders: Are They Candidates for Curative Radiation Therapy? Fractionation alternatives or therapy de-escalation are important options when deciding to treat the very old more aggressively.

Time-saving clinical tools for patient-centered care. OncologyNurseAdvisor.com provides all of the tools you need to better care for your patients. • Cancer treatment regimens

• Easy-to-use medical calculators

• Downloadable patient fact sheets

• Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today.

PUBLISHING STAFF Editor Joyce Pagán editor.ona@haymarketmedia.com

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EDITORIAL BOARD

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Ann J. Brady, MSN, RN-BC Huntington Cancer Center Pasadena, California

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Oncology Nurse Advisor (ISSN 2154-350X), September/October 2017, Volume 8, Number 5. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. Oncology Nurse Advisor is available for single copy purchases at the following rates. Price per copy: USA $20; Foreign $30. To order call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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 2017 • ONCOLOGY NURSE ADVISOR 3

CONTENTS 10

IN THE NEWS • ASCO Updates Its Antiemetic Guidelines • Palliative Care Should Focus on Symptoms, Not Diagnoses • Immunotherapy Response Rates Reduced With Concomitant Cannabis Use … and more

ONCOLOGY NURSE ADVISOR FORUM • Timing Blood Type and Crossmatch With Daratumumab • False-Positive Phenomenon

NAVIGATOR NOTES Better Health Systems for Patient Navigation

September/October 2017

Cam McClellan Teems, MA

26 28 30

FEATURES Distress Assessments Influence Psychosocial Support Referrals Cheryl A. Jones, DNP, MBA, OCN; Emily Johnson, PhD; Barbara J. Edlund, PhD, ANP, BC

History of Periodontal Disease Increases Women’s Cancer Risk Bette Weinstein Kaplan

Invisible Burdens: Coping With the Complexities of Caregiving Sarah Kelly, MSW, LCSW

Novel Tool Aids Education on Diagnostic, Prognostic Tests Megan Garlapow, PhD

50 FIND US ON

JOURNAL REVIEW Intervention Improves At-Home Pain Management and EOL Care John Schieszer, MA

Continues on page 9

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4 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

PATIENT EDUCATION: FACT SHEETS Coping With Lymphedema: A Patient Guide

CONTENTS

September/October 2017

Fact sheet explains lymphedema and describes ways in which a patient may manage symptoms of this common adverse effect of cancer treatment. Mammograms

JOURNAL REVIEW Importance of Recognizing Checkpoint Inhibitor-Related Pneumonitis John Schieszer, MA

“Light” Cigarettes and Cancer Risk

Fact sheet examines so-called “light” cigarettes, associated cancer risks, and tar yields ratings.

STAT CONSULT • Ibrutinib (Imbruvica) • Decitabine (Dacogen)

RADIATION & YOUR PATIENT Super-Elders: An Emerging Challenge for Radiation Oncology Bryant Furlow

COMMUNICATION CHALLENGES You Don’t Say: When to Just Listen as Family Members Try to Cope Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Depressive Symptoms Predict Declining Health in Caregivers of Patients With Cancer Bette Weinstein Kaplan

THE TOTAL PATIENT Virtual Reality Lets Patients Connect With the Outside World or Explore a New One Bette Weinstein Kaplan

FROM CANCERCARE Preventing Body-Trauma Triggers During Radiation Therapy Andrea Cantor, LMSW

Fact sheet reviews the types of mammograms, false-positive and false-negative results, digital mammography, and tomosynthesis mammography.

ASK A PHARMACIST CDK Inhibitors Compared Lisa A. Thompson, PharmD, BCOP

PUBLISHERS’ ALLIANCE: DOVE PRESS Oncological Safety and Cosmetic Outcomes in Oncoplastic Breast Conservation Surgery, a Review of the Best Level of Evidence Literature

This review examines oncological safety in oncoplastic breast conservation surgery, local recurrence, and patient outcome, postoperative complications, and cosmetic outcomes. Breast Cancer: Targets and Therapy

Emerging Treatments for HER2-Positive Early-Stage Breast Cancer: Focus on Neratinib

This research reviews available data on the role of the HER2 pathway in breast cancer and on the different targeted agents for the treatment of patients with early-stage HER2-positive disease, with a particular focus on neratinib. OncoTargets and Therapy

ON THE

WEB

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 9

IN THE NEWS

The effectiveness of antiemetic therapy for chemotherapy-induced nausea and vomiting (CINV) has increased greatly. Adhering to the regimens, especially when dealing with the emetic risk associated with specific chemotherapy regimens, leads to better outcomes and control. An expert panel convened by the American Society of Clinical Oncology (ASCO) updated its guidelines for antiemetic therapy for oncology. A significant update to the guidelines is the inclusion of olanzapine, an atypical antipsychotic, in the antiemetic regimens for adult patients. The following are a few of the key recommendations from the guidelines. Strong recommendations for adults Patients receiving cisplatin and other high-emetic-risk monotherapy should be offered a combination of 4 drugs comprising a neurokinin 1 (NK1) receptor antagonist, a serotonin (5-HT3) receptor antagonist, olanzapine, and dexamethasone. Olanzapine and dexamethasone should be continued for days 2 to 4. Patients receiving anthraUpdate adds olanzapine to cycline plus cyclophosphamide should be offered a adult antiemesis regimen combination of 4 drugs comprising an NK1 receptor antagonist, a 5-HT3 receptor antagonist, olanzapine, and dexamethasone. Olanzapine should be continued for days 2 to 4. Patients receiving moderate-emetic-risk agents excluding carboplatin AUC ≥4 mg/mL should be offered a combination of 2 drugs comprising a 5-HT3 receptor antagonist and dexamethasone on day 1. Patients receiving carboplatin AUC ≥4 mg/mL should be offered a combination of 3 drugs comprising an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone. Cannabinoids Evidence for the use of medical marijuana remains insufficient to recommend its use to control and manage CINV. Only the US FDA-approved cannabinoids — dronabinol and nabilone — remain recommended as antiemetic agents. Strong recommendations for pediatric patients Those receiving high-emetic-risk antineoplastic agents should be offered a combination of 3 drugs comprising a 5-HT3 receptor antagonist, dexamethasone, and aprepitant. Patients unable to receive aprepitant should be offered a combination of 2 drugs comprising a 5-HT3 receptor antagonist and dexamethasone. Patients unable to receive dexamethasone should be offered a combination of 2 drugs comprising palonosetron and aprepitant. Patients receiving low-emetic-risk antineoplastic agents should be offered ondansetron or granisetron. Those receiving minimal-emetic-risk antineoplastic agents should not be offered routine prophylactic antiemetic therapy. Patients undergoing treatment with a moderate-emetic-risk antineoplastic agent who are unable to receive dexamethasone should be offered a combination of 2 drugs comprising a 5-HT3 receptor antagonist and aprepitant. This is a new weak recommendation. The recommendations were based on a systematic review of 41 publications. The authors conclude saying “the Expert Panel reiterated the importance of using the most effective antiemetic regimens that are appropriate for antineoplastic agents or radiotherapy being administered. Such regimens should be used with initial treatment, rather than first assessing the patient’s emetic response with less-effective treatment.” Read more at http://bit.ly/2wlLoAW.

10 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

ASCO Updates Its Antiemetic Guidelines

Use of antiperspirants and deodorants has been shown to improve the quality of life in patients. Despite prior studies not finding any significantly increased risk of dermal toxic effects associated with deodorant use, however, physicians typically recommend against OSLD measurements its use for patients undergoing breast clear deodorant use radiotherapy. Researchers assessed data acquired from an online, anonymous survey to which both patients and practitioners responded regarding skin care and radiation therapy. Optically stimulated luminescent dosimeters (OSLDs) were also used to measure the surface dose of aluminum zirconium tetrachlorohydrex glycine, an ingredient used in standard and extra-strength antiperspirants and deodorants, on a tissue equivalent for multiple sequential gantry angles. Of the surveyed patients, 73 of 92 patients reported that they were advised by their health care providers to avoid antiperspirant use before radiation. Of the surveyed practitioners, 86 of 108 reported that they recommended against deodorant use. Analysis of the OSLD measurements showed no significant differences in surface dose regardless of deodorant application, gantry angles measured, and aluminum concentration of antiperspirant applied. Read more at http://bit.ly/2wm5XwQ.

CDK4/6 Toxicities and Interactions Management in Breast Cancer An overview of potential drug interactions and adverse effects as seen in the use of cyclin-dependent kinase (CDK) 4/6 inhibitors in patients with breast cancer addressed management strategies that can be applied in clinical practice. CDK4/6 inhibitors are tolerated fairly well in patients with cancer. The agents work by blocking the activity of regulatory enzymes, preventing cell division and tumor growth. Palbociclib is approved as first-line therapy for metastatic hormone receptor (HR)-positive breast cancer in combination with letrozole and as second-line therapy in combination with fulvestrant. Ribociclib is approved for first line therapy

of metastatic HR+ breast cancer in combination with any aromatase inhibitor, and the FDA has granted abemaciclib Breakthrough Therapy designation. Palbociclib/ribociclib should not be administered with concomitant strong CYP3A inhibitors; if this is unavoidable, the dose should be reduced. Strong CYP3A4 inducers should also be avoided as this can reduce the plasma concentration of palbociclib/ribociclib. Plasma concentrations of CYP3A4 substrates with a narrow therapeutic index may increase if coadministered with palbociclib/ribociclib. Abemaciclib should not be concomitantly administered with strong CYP3A4 inducers or inhibitors. The most frequently observed adverse events with palbociclib/ribociclib were hematologic, with neutropenia occurring most often. However, unlike chemotherapy induced-neutropenia, CDK4/6-induced neutropenia is rapidly reversible. CDK4/6-induced neutropenia should be managed with supportive care and dose adjustments. Abemaciclib has a lower incidence of neutropenia, but fatigue and gastrointestinal adverse events occur at a higher frequency. Nausea and vomiting can be treated with standard antiemetic therapies, but may cause QT prolongation if coadministered with the CDK4/6 inhibitors. Read more at http://bit.ly/2vpgIS1.

Accurate View of Prognosis Ensures Terminally Ill Make Value-Consistent EOL Care Decisions Approximately 60% of terminally ill patients have accurate prognostic awareness of their condition and tend to become more aware as their condition deteriorates. Prognostic awareness is an important aspect of decision making at end of life (EOL) that allows for better quality of life and care, and prepares patients for death. For this study, the researchers differentiated prognostic awareness into 4 states: unknown and not wanting to know; unknown but wanting to know; inaccurate awareness; accurate awareness. They followed 247 patients with cancer during the last 6 months of care, and estimated the time patients spent in each state, as well as the likelihood of transitioning between states. Patients were interviewed every 2 weeks to determine their awareness. Patients’ prognostic awareness stayed relatively stable, particularly for those who were accurately aware. If patients transitioned, they were generally into a higher state of prognostic awareness. At time of death, the investigators found

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 11

Deodorant, Antiperspirant Use During Radiation Therapy for Breast Cancer Not Detrimental

IN THE NEWS

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

Niraparib Maintains Quality of Life in Recurrent Ovarian Cancer Administering niraparib to patients with recurrent ovarian cancer after a complete response (CR) or partial response (PR) to platinum-based chemotherapy may allow patients to continuously maintain their quality of life (QOL) during treatment. The ENGOT-OV16/NOVA trial (ClinicalTrials.gov Identifier: NCT01847274) previously demonstrated that niraparib significantly prolonged progression-free survival (PFS) in patients with recurrent ovarian cancer following CR or PR. Study authors analyzed patient-reported outcomes (PROs) associated with QOL, and the Functional Assessment of Cancer

Therapy-Ovarian Symptoms Index (FOSI) and European Quality of Life Scale 5-Dimensions (EQ-5D-5L) were used to evaluate individual patient-reported symptoms in the niraparib and placebo groups. Results of the study showed no significant difference in mean PRO scores between the niraparib and placebo arms. Adjusted health utility index (HUI) scores were comparable at baseline in both study arms, but average adjusted HUI scores prior to progression trended higher for the niraparib arm. Patients’ overall health utility was not negatively impacted by hematologic toxicities. Read more at http://bit.ly/2f8YlGs.

Prevalence of Aggressive Cancer Care at End of Life Remains Unchanged Trends of aggressiveness of cancer care near the end of life (ACCEoL) have remained unchanged in adult patients despite increasing resources for integrated palliative care. The purpose of this study was to evaluate the recent time trends Surgery, hospital and frequency of ACCEoL of adult stay predict ACCEoL patients with varying cancer types. Study authors analyzed data from the Hospital Morbidity Database (HMD), and noted characteristics such as primary cancer site and presence of metastatic disease. The primary outcome was a composite ACCEoL indicator that compiled the presence of 1 to 14 individual indicators in the last 30 days of life or the use of chemotherapy, immunotherapy, or biological agents in the last 14 days of life. The primary outcome stayed consistent over time, and despite statistically significant changes in some individual indicators, none of the changes were considered clinically meaningful. Results show that the rate of ACCEoL was 71.1%, with 69.9% in patients with metastases, compared to 72.6% in others. The prevalence of ACCEoL also varied by type of primary cancer, with 62.7% in breast to 79.3% in hematologic cancers. The most common individual indicators of ACCEoL application were more than 14 days in hospital and surgery. The least frequent individual indicators were permanent tracheostomy and percutaneous gastrostomy. Read more at http://bit.ly/ 2xO7jEx.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 17

(IRRs) may easily be managed by administering preinfusion and postinfusion medications. Two previous phase 3 studies, CASTOR (ClinicalTrials. gov Identifier: NCT02136134) and POLLUX (ClinicalTrials. gov Identifier: NCT02076009), demonstrated that D may decrease the risk of MM progression or death in patients by more than 60% when administered in combination with standards of care but may also cause high rates of IRR. Patients in CASTOR received bortezomib and dexamethasone (Vd) ± D, and in POLLUX received lenalidomide and dexamethasone (Rd) ± D. All patients receiving D received preinfusion dexamethasone, paracetamol, and diphenhyd ramine. Patients with high-risk respiratory complications also received diphenhydramine, a short-acting β2 adrenergic receptor agonist, and control medications for lung disease after D infusion. In CASTOR and POLLUX, 13% and 7% of patients received postinfusion medication, respectively. The durations of D infusion were approximately 7.0, 4.3, and 3.4 hours, in the first, second, and subsequent infusions, respectively, for both trials. Results showed that IRRs occurred in 45% and 48% of patients, with 98% and 86% of IRRS occurring during the initial infusion in CASTOR and POLLUX, respectively. The median time to onset of IRR after initiating the first D infusion was 84 minutes and 90 minutes in CASTOR and POLLUX, respectively. Most IRRs were grade 1 to 2, and no IRRs of grade 4 or greater were reported. Two patients in the CASTOR trial discontinued therapy due to IRR. One patient in the POLLUX trial discontinued daratumumab due to a grade 3 IRR but continued receiving Rd.

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. 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.

QUESTIONS & ANSWERS TIMING BLOOD TYPE AND CROSSMATCH WITH DARATUMUMAB The effects of daratumumab on red blood cells can last up to 6 months; therefore, type and crossmatch are recommended prior to starting daratumumab to prevent delays in transfusion crossmatching. But crossmatch is typically only good for a number of days — certainly not 6 months. If type and crossmatch is obtained before initiating treatment, what good would that do if a transfusion is required a month later? — Name withheld on request Crossmatch prior to daratumumab administration should not supersede any local policies your blood bank or institution has regarding timelines for crossmatching. Recommendations are that crossmatch, with or without additional testing such as red blood cell phenotyping, should be obtained prior to initiating daratumumab to serve as a reference. When requesting a unit of blood for a patient receiving daratumumab, the blood bank should be advised of the patient’s therapy as well as any information on file (eg, the baseline type and crossmatch or other testing) to facilitate timely results and blood products. For more information on this subject, the manufacturer has made the following available: www.darzalexhcp.com/shared/product/darzalex/darzalex-informationon-assay-interference.pdf. — Lisa A. Thompson, PharmD, BCOP

FALSE-POSITIVE PHENOMENON Daratumumab can cause erratic false positives in the blood antibody screen and crossmatch obtained prior to a transfusion. Does this phenomenon occur with other monoclonal antibodies? —Name withheld on request The issues with blood crossmatch are due to daratumumab’s effects on CD-38, which is also expressed on red blood cells; therefore, the phenomenon is not expected to occur with other monoclonal antibodies currently on the market that do not bind to CD-38 receptors on red blood cells. — Lisa A. Thompson, PharmD, BCOP READ MORE ABOUT DARATUMUMAB, MULTIPLE MYELOMA

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

1. Gleason C, Catamero DD. Immunotherapy in multiple myeloma. Semin Oncol Nurs. 2017;33(3):292-298. 2. Sherbenou DW, Mark TM, Forsberg P. Monoclonal antibodies in multiple myeloma: a new wave of the future. Clin Lymphoma Myeloma Leuk. 2017;17(9):545-554. 3. Lokhorst HM, Plesner T, Laubach JP, et al. Targeting CD38 with daratumumab monotherapy

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

in multiple myeloma. N Engl J Med. 2015;373(13):1207-1219.

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

18 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

NAVIGATOR NOTES Better Health Systems for Patient Navigation Cam McClellan Teems, MA

searching for data across different systems presents many problems for both navigators and patients, including time wasted, duplicative communication, and lack of clarity about important steps in the treatment plan. To be optimally effective and productive in serving patients — a top priority of nearly every navigator I have ever met — navigators need better systems with easier access to integrated data so they can understand where patients have been in their treatments, where they are going next, and other vital information that makes every patient

unique (especially relative to distress, possible depression, and financial and logistical challenges to treatment). AND SO THE SEARCH BEGINS … When patients reach out directly or are referred to navigators, the navigator must piece together the patient’s case. The navigator starts by looking for the all-important pathology reports that describe initial tumor details. These may be in the navigator’s hospital EHR. Abnormal imaging reports or consults describing symptoms are also useful. Then, patient records need to be gathered from the specialty physicians (surgeon, medical oncologist, radiation oncologist, etc) to whom the patient has been referred and who might be part of the treatment care team. By this time, the navigator has likely looked in at least 2 information systems, called 4 people, and maybe created documentation for the patient in the EHR and her own navigation system — if she is lucky enough to have one. THE DISCONNECTED CARE TEAM The fragmented information and technology landscape often reflects the fact that navigators are operating within disconnected care teams. Care team members often use different systems, each designed for their own narrowly defined needs. The result is that no one has complete patient information, although they should if they are to do their jobs optimally. For example, navigators’ notes can be a gold mine for others on the care team. But if captured in a care coordination system, other care team members may

All oncology care clinicians must willingly share patient data on a system that supports the navigators and care coordinators. www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 19

n the decades since oncology navigation became a practice embraced by many hospitals, some things have changed while others have remained the same. Treatment techniques and research protocols have become more sophisticated and advanced, but the technology used by nurse navigators and care coordinators has been frozen in time. Yes, moving from paper-based charts and sticky notes to Excel spreadsheets represents progress. But navigators are essential to providing quality oncology care and the vast majority are using badly outdated or ill-suited technology to support their patients in the push to better outcomes. Thus, cancer navigators must spend hours — not all of them productive — searching multiple information technology (IT) systems to gather the information and insight they need to effectively support patients. Typically, information about patients with cancer in active-treatment resides in: • Hospital electronic health record (EHR) systems, • Multiple oncology information systems, and • Practice-based EHRs. Then, there is the highly valuable information that patients possess about their conditions, which may not be collected in any of the provider-centric systems. It is another set of data that needs to be reviewed, and may be in the form of phone calls, emails, or even texts. This deep and wide trove of information requires navigators to be data mining experts, as well as clinical supporters for their patients. The constant

NAVIGATOR NOTES not have access to those notes, preventing them from seeing the big picture. Thus other members of the care team frequently reach out to the nurse navigator for a fuller view of the patient, often seeking information about distress levels, access issues, or other matters that may affect care adherence or a patient’s understanding of their treatment plans. As oncology clinicians struggle with new standards and requirements for value-based care, they turn to navigators, whose phones are ringing more than ever. An unbiased, patient-centered system for aggregated data could solve this problem. All care team members could log in and look at a full patient record, including all past and planned treatment events, comorbidity and symptom information, distress levels, adherence issues, etc. Even better: a care coordination system could proactively send valuable information to all stakeholders. AND THE SEARCH CONTINUES … Once patients have their first consult to determine a treatment plan for their cancer, the data become more complex and widespread. Let’s look at a typical breast cancer case: The patient’s pathology report is likely in the hospital’s EHR. That information accompanies her when she meets with a surgeon to talk about her diagnosis, possible breast conservation, the need for adjuvant medical oncology, and next-step oncology such as chemotherapy and radiation, and the surgeon is likely to be using a practice-based system. The patient may go to the hospital for some imaging to determine extent of disease, where more information is entered into the hospital EHR, and maybe to an outside laboratory for genetic testing, which has its own systems. Next, she will visit other oncology clinicians for an initial consult where data are captured in a practice-based EHR or an oncology information system.

Treatment plans are often designed in separate oncology information systems — one for medical oncology and one for radiation oncology. That’s at least 5 records systems navigators must check to keep up with their patients’ cases. Furthermore, none of the systems include structured or dedicated fields for documenting the essential information navigators collect: how does the

When data is held hostage — willingly or not —the patient suffers. patient feel about her diagnosis; is she experiencing depression or anxiety; and does she need help with transportation, childcare, or co-payments. THE LUCKY ONES AND THEIR SYSTEMS

Ideally, navigation and care coordination systems are centered on patients and contain information from all the stakeholders involved in the patient’s care: the hospital, physicians, joint-ventured cancer centers, county-employed social workers, and so on. No one owns the record or has one that trumps all others. Instead, patient data are at the core with all case information in one place and managed by the navigator, who is best positioned to see the big picture. Hospital EHRs are not designed to support multidisciplinary oncology care coordination or navigation. With physicians, hospital employees, and business associates as primary users, their sole purpose of hospital EHRs is to warehouse information about billable events inside the facilities and maintain corresponding electronic records. Patient navigation and care coordination

systems should be designed to extend beyond the walls of a single facility, incorporate nonclinical events, and be truly patient-centric. All oncology care clinicians must willingly share patient data on a system or platform that supports the navigators and care coordinators in the interest of achieving the best possible patient outcomes. When data is held hostage — willingly or not —the patient suffers. Legislative planners had this scenario in mind when care coordination was exempted from the Health Insurance Portability and Accountability Act (HIPAA) of 1996 [§ 164.506(c)(2)]. Care coordination platforms or systems must have appropriate business associate agreements in place with all of those accessing and providing information for the patient. Each of the covered entities may disclose the relevant PHI for care planning purposes, as long as there is HIPAA Security Rule compliance. Data are easily filtered to include only relevant information for care coordination. BETTER TECHNOLOGY SUPPORTS A COMMITMENT TO NAVIGATION

One more thing that has not changed since the 1990s: the passion and commitment of navigators and care coordinators to serve patients. That’s a good thing, of course. Ask any patient about the knowledge of their navigator, they will tell you that navigators save lives, greatly reduce suffering, and help physicians provide the best possible care. But, in my decades-long experience in the navigation community, it’s become clear that better systems would help them to work more effectively and productively to achieve better outcomes — both for their patients and their employers. ■ Cam McClellan Teems is a long-time oncology care coordination consultant and certified navigator.

20 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

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FEATURE | Head and Neck Cancer

Distress Assessments Influence Psychosocial Support Referrals QI project demonstrates the benefits of conducting routine assessments for patient distress, and the challenges of implementing the initiative. CHERYL A. JONES, DNP, MBA, OCN; EMILY JOHNSON, PhD; BARBARA J. EDLUND, PhD, ANP, BC

Continuing distress assessments ensure patients receive appropriate psychosocial support.

n 2005, the National Academy of Medicine (NAM), formerly the Institute of Medicine, began the arduous task of evaluating the effect psychosocial factors have on the care of patients with cancer. The 2008 report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, included recommendations for improving assessment of psychosocial distress, providing psychosocial support, and reimbursement for psychosocial services so that patients could receive holistic care. The authors of the report noted that establishing a patient-provider partnership is critical to assessing and providing psychosocial services that can improve patient outcomes.1 The definition of distress, specific to a patient with cancer, is: a multifactorial unpleasant emotional experience of a psychological, social, and/ or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.2 Distress and the inability to cope can affect a patient’s quality of life, adherence to complex treatment regimens, and overall survival or return to health.1 Specifically, patients with head and neck cancer (HNC) have high levels of pretreatment distress as well as comorbid depression and anxiety.3 In addition, surgical and radiation treatments for head and neck cancers often leave patients with debilitating physical defects that affect their ability to speak, swallow, and breathe, making this patient population more vulnerable to

22 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

experiencing psychosocial distress.4 Along with comorbid conditions and challenges presented by treatment, these patients are also more likely to have tobacco and alcohol abuse problems.5 As a result, patients with HNC often lack adequate coping skills and support systems. Nursing assessment of patient distress on an inpatient surgical oncology unit at an academic medical center in the southeastern United States was found to be inadequate. The purposes of this quality improvement (QI) project were to collect additional evidence to support implementing a distress assessment program for patients with cancer and to suggest steps oncology nurses can take to advocate for consistent and programmatic assessment of distress in their patients. Equipped with this information, the oncology nurse will be better prepared to provide patients with the psychosocial support they need.

A patient-provider partnership is critical to providing psychosocial services that can improve outcomes. PLAN-DO-STUDY-ACT METHOD UTILIZED

This quality improvement project was initiated with the support of the HNC surgical team, the unit nurse manager, and the HNC program coordinator at the project site. The project director was a staff nurse on the unit and a student completing a doctoral nurse practitioner program. The project followed a Deming’s (plan-do-study-act [PDSA]) framework for QI programs and was administered on a 24-bed, surgical oncology inpatient unit. The instrument used for the intervention was the National Comprehensive Cancer Network (NCCN) distress

Brief Screening Process for Distress EVALUATION Exhibits signs/ symptoms of moderate to severe distress or scores ≥4 on screening tool

Patient completes NCCN DT/PL

Treat unrelieved physical symptoms according to disease-specific or supportive care guidelines

Exhibits signs/ symptoms of mild distress or scores <4 on screening tool

Primary oncology team performs clinical assessment for: • High-risk (eg, periods of vulnerability, risk factors) • Practical problems • Family issues • Spiritual/religious concerns • Physical disabilities • Social problems • Anxiety, depression, and/or emotional problems

TREATMENT Refer to appropriate services

If necessary

Primary oncology team + available resources

Mental health

Social work and counseling

Follow-up and communication with primary oncology team and family/ caregivers Key: DT, distress thermometer; NCCN, National Comprehensive Cancer Network; PL, problem list.

Chaplaincy

Algorithm describes the process recommended by NCCN guidelines for assessment of distress and referral to appropriate psychosocial services for patients with cancer.

Source: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Distress Management. Version 2.2017 — September 7, 2017. Fort Washington, PA: National Comprehensive Cancer Network; 2017.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 23

FEATURE | Head and Neck Cancer thermometer and problem list (DT/PL), a short self-assessment instrument developed for and validated in cancer populations. The instrument was given to surgical patients on admission to the HNC inpatient unit. The nurse reviewed patients’ completed DT/PL forms and, if appropriate, referred patients for psychosocial support via the electronic medical record (EMR). Once a referral occurred, a psychiatric liaison nurse (PLN) provided psychosocial support services and consulted with the medical team. To assess project efficacy, the project director averaged and compared preintervention and post intervention referral rates for PLN services.

Postintervention data demonstrated that referrals to PLN services for patients with HNC were improved by the use of the NCCN DT/PL. INTERVENTION HELPFUL BUT NEEDED MORE SUPPORT

Analysis of the data for the 3-month preintervention period revealed that 5.96% of patients admitted to the HNC unit were provided with a referral to PLN services. Referrals made to the psychiatric liaison nurse during this period were based on unit nurses’ clinical judgment of patients’ perceived or stated distress or mood. In addition, benefits from psychosocial interventions varied due to discontinuity of care caused by the rotating schedule of the nursing staff. Although inconsistent patient screening hampered determining the return rate for completed DT/PL forms, postin tervention data demonstrated that referrals to PLN services for patients with HNC were improved by the use of the NCCN DT/PL. Raising staff awareness of the need to screen patients and routine reminders helped to increase participation in the intervention. The referral rate during the postintervention phase was 7.74% of patients admitted to the HNC unit. The increase in average referral rates between the 2 time periods is likely not a true representation of the number of patients with HNC who experienced distress during their hospitalization. One of the limitations of this project was staff participation. Shortly after implementation, we saw a significant decrease in the number of completed forms returned. To reinvigorate staff participation, the project director gave verbal reminders during daily staff meetings and placed visual reminders where staff nurses conducted change-of-shift reporting. However, this had minimal effect on the return rate of completed forms.

At this stage of the PDSA QI process, the project director reviews the information regarding average referral rates and lessons learned about staff participation. Future recommendations to the unit’s nurse shared governance committee will determine whether to incorporate the NCCN DT/PL into the electronic medical record. IMPLICATIONS FOR PRACTICE

This quality improvement project was based on current evidence that oncology centers should routinely assess patients with cancer for psychosocial distress using a standardized tool. For the inpatient population of patients with HNC, the unit nurses are responsible for identifying and assessing patient distress. Unit nurses should also educate patients with HNC on the support services that are available within their cancer institution. Staff nurses who are responsible for distribution and evaluation of the completed forms should be included in the program design and implementation to enhance ownership and improve sustainability. Based on information gained in this project, oncology nurses should advocate for implementation of a distress assessment program in their practice settings. Doing so will allow oncology nurses to ensure consistent psychosocial assessment and referral to support services for patients with head and neck cancers across the care continuum. ■ Cheryl Jones is a DNP with the Department of Otolaryngology and an adjunct clinical instructor, Emily Johnson is an assistant professor, and Barbara Edlund is a professor; all at the College of Nursing, Medical University of South Carolina in Charleston. REFERENCES 1. Institute of Medicine. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington DC: The National Academies Press; 2008. 2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Distress Management. Version 1.2017 — June 16, 2017. Fort Washington, PA: National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf. Accessed September 15, 2017. 3. Buchmann L, Conlee J, Hunt J, Agarwal J, White S. Psychosocial distress is prevalent in head and neck cancer patients. Laryngoscope. 2013;123(6):1424-1429. 4. Semple C, Parahoo K, Norman A, McCaughan E, Humphris G, Mills M. Psychosocial interventions for patients with head and neck cancer. Cochrane Database Syst Rev. 2013;(7):CD009441. doi: 10.1002/14651858. CD009441.pub2 5. Head and neck cancers: what causes cancers of the head and neck. National Cancer Institute website. http://www.cancer.gov/types/headand-neck/head-neck-fact-sheet#q2. Accessed September 15, 2017.

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

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5/18/16 11:49 AM

FEATURE | Risk Assessment

History of Periodontal Disease Increases Women’s Cancer Risk A study of women enrolled in the WHI-OS found that those with a history of the oral condition had a higher risk for developing some cancers. BETTE WEINSTEIN KAPLAN

Periodontal disease is an increasingly important risk factor as nearly half of adults have the condition.

esults of an important study demonstrated that women with a history of periodontal disease have a significantly higher risk of developing breast, gallbladder, esophageal, lung, or melanoma skin cancer compared with women who do not have a history of periodontal disease.1 A number of studies have investigated the connection between periodontal disease and incident cancer before this one, including some studies of site-specific cancers.2-4 Prior investigations have also explored hypotheses for the connection, such as infected saliva accumulating in the esophagus, colon, or even the lungs.1 However, this is the first large-scale study to investigate a connection between postmenopausal women, periodontal disease, and cancer risk. All participants were already enrolled in the Women’s Health Initiative Observational Study (WHI-OS), the first national study involving US women and the first in older women. WHI-OS is an ongoing nationwide prospective study of risk factors for morbidity and mortality involving 93,976 women who were enrolled between 1994 and 1998 when they were ages 50 to 79 years. Annual follow-up data are collected via self-report.5 For this prospective study, researchers administered self-report follow-up surveys from 1999 through 2003. They tracked the participants for up to 15 years (mean follow-up, 8 years). Using the follow-up questionnaires, they evaluated cancer development in the participants through 2013. Because the Year 5 follow-up questionnaire was specifically related to oral health and

26 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

periodontal disease, it served as the baseline. Women who did not return that year’s questionnaire or whose information was incomplete were excluded from this study. Other exclusion criteria included having a history of any invasive cancer prior to Year 5, missing follow-up information after Year 5, and missing information on smoking status. The final research cohort after exclusions included 65,869 postmenopausal women aged 54 to 86 years, of whom 7149 developed cancer during the 8-year follow-up period. ASSESSING SIGNIFICANCE OF RISK FACTORS

Data on risk factors, which in this study were considered to be confounding variables, were collected from participants’ responses on their original WHI-OS enrollment forms. Risk factors assessed included demographics (age, race/ethnicity, educational level, region of residence), medical history (family history of cancer, history of diabetes), health behaviors (recreational physical activity, smoking status, pack-years of smoking, secondhand smoke exposure), diet and nutrition (alcohol consumption, total dietary energy intake, fruit and vegetable intake, total [dietary and supplement] intake of calcium and vitamin D), and menopausal hormone therapy use.1 Participants’ weight and height were also measured at enrollment, and trained examiners at the clinical centers calculated their body mass index (BMI). However, none of those factors increased the risk of developing cancer in an appreciable way — not even smoking.1 A statistically significant increase in total cancer risk of 14% was seen in participants with a history of periodontal disease, making it the most significant risk factor in this study.1 “Our findings demonstrate that periodontal disease history is associated with an increased risk of total cancer in this cohort of postmenopausal women, and persists regardless of smoking status,” reported the researchers.1 In addition to demonstrating the link between breast, esophageal, lung, and melanoma skin cancers and periodontal disease, this study also found a relationship between gallbladder cancer and periodontal disease. Interestingly, periodontal disease was not associated with cancer of the liver, pancreas, or lower digestive tract. Jean Wactawski-Wende, PhD, dean of the School of Public Health and Health Professions and a SUNY distinguished professor at the University at Buffalo, and senior investigator of the study, described results from another study on the risk of cancer related to periodontal disease in women, the OsteoPerio Study, which did not rely on data from self-reports. This ongoing study includes more than 1000 WHI participants

from the University at Buffalo center. In this smaller cohort, participants underwent comprehensive periodontal assessments; investigators also found risk of cancer was higher among those with a history of periodontal disease. “However, the small sample size limited our ability to look carefully at specific cancer sites,” said Dr Wactawski-Wende. “We continue to follow these women and are now looking at the microbiome in the plaque samples taken from the women.”6 DENTAL HYGIENE AS PREVENTIVE MEDICINE Research on the association between cancer and periodontal disease is of increasing public health importance. The Centers for Disease Control and Prevention (CDC) estimates that approximately 47.2% of adults aged 30 years and older in the United States have some form of periodontal disease, ranging from mild to severe. Furthermore, 70% of adults aged 65 years and older have moderate to severe periodontal disease.7 Dr Wactawski-Wende advises that proper dental hygiene is the most effective way to mitigate this risk. She said a good resource for both clinicians and patients is the American Academy of Periodontology. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Nwizu N, Marshall JR, Moysich K, et al. Periodontal disease and incident cancer risk among postmenopausal women: results from the Women’s Health Initiative Observational Cohort. Cancer Epidemiol Biomarkers Prev. 2017;26(8):1255-1265. 2. Wen BW, Tsai CS, Lin CL, et al. Cancer risk among gingivitis and periodontitis patients: a nationwide cohort study. QJM. 2014;107(4):283-290. 3. Michaud DS, Liu Y, Meyer M, Giovannucci E, Joshipura K. Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study. Lancet Oncol. 2008;9(6):550-558. 4. Tezal M, Sullivan MA, Hyland A, et al. Chronic periodontitis and the incidence of head and neck squamous cell carcinoma. Cancer Epidemiol Biomarkers Prev 2009;18(9):2406-2412. 5. Anderson G, Cummings S, Freedman LS, et al. Design of the Women’s Health Initiative clinical trial and observational study. The Women’s Health Initiative Study Group. Control Clin Trials 1998;19(1):61-109. 6. Mai X, LaMonte MJ, Hovey KM, et al. Periodontal disease severity and cancer risk in postmenopausal women: the Buffalo OsteoPerio Study. Cancer Causes Control. 2016;27(2):217-228. 7. CDC: half of American adults have periodontal disease [news release]. Chicago, IL: American Academy of Periodontology; September 4, 2012. https://www.perio.org/consumer/cdc-study.htm. Accessed August 16, 2017.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 27

FEATURE | Caregiver Support

Invisible Burdens: Coping With the Complexities of Caregiving Caregivers of patients with brain tumors often bear additional challenges, as these patients often experience cognition-related adverse effects.

Workshops and peer groups offer effective support for caregivers

SARAH KELLY, MSW, LCSW

aregiving for someone with cancer presents numerous challenges, but when the diagnosis is malignant brain tumor, caregivers may experience unique and complex challenges that differ from those experienced with other diagnoses. With the tumor site located in the brain, patients and caregivers face the challenge of managing not only physical symptoms but cognitive symptoms as well. Activities of daily living and cognitive abilities such as memory, language, motor skills, and mood can be impacted. Adverse effects of treatments — radiation, chemotherapy, surgery — may add additional challenges. These physical and cognitive changes have a significant impact not only on the patient, but on the caregiver as well. An estimated 23,800 malignant brain tumors will be diagnosed in 2017.1 Although there is not a vast amount of research on caregivers of persons with a primary malignant brain tumor, the existing research provides important insights on how to best address the challenges faced and improve caregivers’ preparedness. From the start, caregivers find themselves in a rapidly evolving situation with a short timeframe in which to adjust to the diagnosis, start of treatment, and their new role as a caregiver.2 They immediately take on multiple roles: patient advocate, patient navigator, financial manager, household manager, and personal care provider, among others. These roles may change and new roles may be added throughout the course of the patient’s treatment, and caregivers often maintain

28 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

their former roles of parent or employee as well. Given these changes and added roles, caregivers may feel unprepared to provide care and overwhelmed by the responsibilities.3 In addition, the increased responsibilities can put a significant strain on the caregiver’s relationship with the patient and with other supports that may result in reduced overall support.4 Many caregivers report physical symptoms such as exhaustion, as well as emotional symptoms such as depression and anxiety.5 Help for the Helper A literature review conducted in 2015 identified a total of 36 descriptive and 6 intervention studies on factors contributing to caregiver distress. Its purpose was to open a discussion for future research and possible ways to improve health outcomes for caregivers. Findings suggest caregiver distress is related to economic burden, unmet needs, low levels of social support, spirituality, and caregiver mastery.5 Those of us who work with this unique population witness these findings first-hand. How can we address caregivers’ unmet needs and improve their health outcomes, as well as the patient’s? The literature review found that educational programs, along with therapeutic interventions, may help reduce caregiver distress.5 Taking into account these findings and variations in caregiver populations, a combination of interventive techniques are needed to address caregivers’ multidimensional needs and improve caregiver preparedness. Educational intervention is essential. Caregivers need to be engaged through programs that encompass individual intervention, workshops, and classes on diagnosis, treatments, and possible adverse effects. In addition, caregivers need structured educational programs on financial concerns, employment issues, legal issues, and other practical matters. Educational publications and websites that can be referred to provide a sense of agency and assuredness. Caregivers also need psychotherapeutic, psychoeducational, and other supportive interventions. Individual counseling and support groups can be a significantly effective tool for reducing distress. Different modalities such as in-person, telephonic, and online groups can meet the individual needs of numerous types of caregivers. Peer support and sharing information are

FIND US ON

incredibly helpful in normalizing the caregiver experience, particularly when addressing the uniqueness of this diagnosis. Peer matching services and other peer supports should be considered, as well. The Caregiver’s Journey Lastly, continued assessment is needed. As the patient’s journey changes, so does the caregiver’s. What do these caregivers of patients with malignant brain tumors need along the illness trajectory? What has been effective in reducing distress and what has not? Oncology health professionals have a vital role in providing access and needed information and support to caregivers. Through assessment exploration, open communication, and creative planning we can help this unique population not only navigate the cancer journey, but do so with a sense of purpose and meaning. Services from CancerCare are free to patients with cancer and their caregivers. Additional organizations that offer services and information that may be helpful to caregivers of patients with brain cancer include the American Brain Tumor Society, Family Caregiver Alliance, and Cancer.net. CancerCare services are free to patients with cancer and their caregivers. ■ Sarah Kelly is the Older Adult Program Coordinator at CancerCare. REFERENCES 1. What are the key statistics about brain and spinal cord tumors? American Cancer Society website. https:/www.cancer.org/cancer/ brain-spinal-cord-tumors-adults/about/key-statistics.html. Accessed September 12, 2017. 2. McConigley R, Halkett G, Lobb E, Nowak A. Caring for someone with high-grade glioma: a time of rapid change for caregivers. Palliat Med. 2010;24(5):473-479. 3. Arber A, Hutson N, Guerrero D, Wilson S, Lucas C, Faithfull S. Carers of patients with primary malignant brain tumour: are their information needs being met? Br J Neurosci Nurs. 2010;6(7):329-334. 4. Schubart JR, Kinzie MB, Farace E. Caring for the brain tumor patient: family caregiver burden and unmet needs. Neuro Oncol. 2008;10(1):61-72. 5. Sherwood PR, Cwiklik M, Donovan HS. Neuro-oncology family caregiving: review and directions for future research. CNS Oncol. 2016;5(1):41-48.

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FEATURE | Biomarkers

Novel Tool Aids Education on Diagnostic, Prognostic Tests A newly developed resource educates patients about biomarker tests and helps nurses counsel patients on the significance of their results. Biomarker tests are predicted to play a more significant role in diagnosis and treatment of cancer.

MEGAN GARLAPOW, PhD

new program and resource designed to educate patients and help them understand how biomarker testing informs treatment of colorectal cancer (CRC) was launched in late June 2017 by Fight Colorectal Cancer, a nonprofit patient advocacy organization, with support from Eli Lilly and Company. The program, Biomarked: Know Your Body. Get Tested, better elucidates biomarkers and their important role in the treatment of CRC.1,2 Andrea Lee, RN, oncology program manager at Methodist Dallas Medical Center in Dallas, Texas, and Harvey Murff, MD, MPH, associate professor of medicine at Ingram Cancer Center at Vanderbilt University in Nashville, Tennessee, spoke with Oncology Nurse Advisor about the roles of health care providers in guiding patients toward and through biomarker testing to inform treatment for colorectal cancer.

ONA: Which patients with CRC are most likely to benefit from biomarker testing? Lee: Patients need to be aware that any 2 can-

cers are not necessarily alike. With advances in technology, we can target different cancers with specific drugs. It really depends on which biomarkers are present. All patients should undergo microsatellite instability (MSI) testing. Patients with more advanced CRC should have a Ras panel test. It is critical for patients to be informed about biomarker testing. Murff: This falls into 2 major categories. Sometimes testing is performed for prognostic 30 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

information, and sometimes testing is performed to help guide therapy. Where you are likely to find the most tangible benefit is with biomarker testing related to therapy. One strategy for treating metastatic CRC is to block the epidermal growth factor (EGFR) pathway, which seems to be turned on in colorectal cancer. The way we block it is to shut it off at the receptor, but if you go downstream from that, certain mutations that some people have keep the pathway running no matter what you do to the receptor. As a result, medicines such as cetuximab do not seem to work in patients who have these mutations, which are in a gene called Ras. Patients given EGFR inhibitors who had Ras mutations received no benefit. These results were so striking that recommendations were made to test for Ras mutations prior to administering EGFR inhibitors. Nonetheless, there remains a portion of patients who do not have Ras mutations yet still do not respond to the therapy. The other area for which we conduct biomarker testing is prognosis. The most studied prognostic biomarker in CRC has to do with MSI. Patients with high MSI (MSI-H) actually have a better prognosis. Although some data suggest this could direct therapy, it is not as well established as the Ras mutation. Testing for MSI-H can identify Lynch syndrome, a hereditary condition that could inform the need for a patient’s family members to undergo cancer screenings. ONA: How can oncology nurses guide patients in the decision to undergo biomarker testing and help them understand what the results mean? Lee: Oncology nurses can ask the doctor to order the testing,

then help the patient understand the significance of the results. Fight CRC has amazing patient resources that are great for the treatment room, particularly with their Biomarked campaign. They keep the information accessible, which is critical for guiding patients during intensely stressful times. Sending patients home with resources that they can reference when they have questions is important. Nurses can help empower patients to be their own advocate by providing information and education on biomarkers, offering take-home materials, and encouraging patients to be an advocate for their own care. Murff: Good clinician education is critical. Any results that require some kind of genetic biomarker testing are not always clear-cut. Ras testing has become widely implemented and is folded into the FDA recommendations for using EGFR inhibitors. Most insurance will cover it so, in many centers, patients with metastatic CRC will undergo Ras testing, but there are limitations. There is no standard test, as there are a lot of different kits with a range of results. Patients could receive

a false positive result, for example, and not receive a therapy. These tests also do not explain all [cases] of nonresponsiveness, so clinicians need to be careful not to mislead patients into thinking they are guaranteed their cancer will respond to therapy. Clinicians need to understand the limitations to these tests and communicate them accordingly with their patients. ONA: What resources are available to help patients with CRC understand biomarkers? Murff: Fight CRC has put together a pamphlet that is useful for

both clinicians and patients as part of their Biomarked campaign. A lot of patients lacked sufficient knowledge about biomarker tests, so Biomarked delivers a better education message. ONA: Is there anything you would like to say in closing? Lee: One of the things you see as a nurse in oncology is that

the level of anxiety patients experience changes learning, memory. Patients often forget questions they intended to ask. Physicians might deliver a lot of information, little of which a stressed patient retains. Nurses can empower patients to know what questions to ask, such as the status of biomarkers. They can be tremendously helpful in enabling patient proactivity. Writing notes for patients and keeping educational materials in the office can help them improve a patient’s experience. Murff: Part of the reason it’s important to think about this now is because we are probably at the cusp of what will be a much larger explosion of these biomarker tests, particularly for metastatic CRC. Only a few biomarkers are really established in clinical care right now, but many more are being examined. In the next couple of years, we will probably have many more of these coming out. Getting a handle on how that impacts therapy is important as the expected surge of available biomarker tests will increase the complexity of information a clinician needs to communicate to the patient. We prefer to be on the front end of this, educating people. ■ Megan Garlapow is a medical writer based in Tempe, Arizona. REFERENCES 1. Fight Colorectal Cancer launches Biomarked to educate on the role of biomarkers in cancer treatment [news release]. Springfield, MO: Fight Colorectal Cancer; June 27, 2017. http://www.prnewswire.com/ news-releases/fight-colorectal-cancer-launches-biomarked-toeducate-on-the-role-of-biomarkers-in-cancer-treatment-300480065. html?tc=eml_cleartime. Accessed September 21, 2017. 2. Biomarked. https://fightcolorectalcancer.org/biomarked/. Accessed September 21, 2017.

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JOURNAL REVIEW

upport and education for caregivers via a nurse-led intervention is shown to improve end-of-life (EOL) care for patients with cancer, according to a study conducted by a team of nurses from the University of Southampton, Cardiff University, and University of Leeds. The study, published in Palliative Care, reports on a novel approach that focuses on helping the caregivers learn medication management, symptom recognition, and other aspects of caring for patients with cancer. The researchers developed an approach called The Cancer Carers’ Medicines Management (CCMM) intervention. CCMM addresses a caregiver’s beliefs, knowledge, and skills, and promotes selfevaluation of competence. The nurses involved in the development of CCMM look to continue refining the intervention and hope it will be evaluated in a trial to determine its effectiveness in improving caregivers’ management of pain medicines and other end-of-life care for patients with cancer. “Oncology nurses have a key role in preparing and supporting patients and their families to manage cancer pain at home. Helping people with cancer manage symptoms is important if they are to live as well as possible,” said Jane Hopkinson, a professor of nursing at Cardiff University, Cardiff, Wales, and a co-investigator in the study. THE STUDY CCMM was tested in a 2-arm, parallel group, randomized controlled

Intervention Improves At-Home Pain Management and EOL Care John Schieszer, MA

feasibility trial conducted at 2 sites: one in South Wales and the other in southern England. The researchers believe this is the first study of its kind to be developed with input from caregivers. Additional input was solicited from oncology patients, palliative care nurses, pharmacists, and physicians. The caregivers completed question naires prior to receiving CCMM instruction at the nurse’s home visit. The nurses addressed caregivers’ questions and reinforced the intervention instructions at subsequent routine home visits. WHAT WAS LEARNED The CCMM intervention compared well with current practice. It provided a more systematic and comprehensive approach to supporting caregiver management of patient care. In addition, the team found the intervention was

acceptable to the nurses as well as the caregivers. The study demonstrated this is a feasible approach that could be easily adopted in any community. Nurses participating in the pilot study particularly valued the toolkit resource, which included information about opioids and simple charts for documenting pain and medication administration. This resource also proved to be of immediate practical value to the caregivers. The study results revealed positive behavioral changes in medication management such as better understanding of opiate use and improved response to patients’ requests for pain relief. Current systems used to record medication administration were also improved with use of CCMM, the researchers reported. “Managing pain medicines in the home is a complex task. A structured approach to education in the necessary knowledge and practical skills can help cancer carers feel able to assist patients in the management of pain,” Ms Hopkinson told Oncology Nurse Advisor. IMPLICATIONS FOR NURSES The researchers noted that at-home management of pain medications for patients with cancer can be difficult and stressful for the caregivers. Yet, there is a significant lack of reliable research on effective methods for supporting caregivers of this patient population. In most cases, caregivers are expected to administer medications, evaluate their effectiveness, then appropriately monitor the patient and interpret Continues on page 47

Cancer centers are increasingly recognizing that deeper and more meaningful engagement with caregivers can reduce hospital stays and incidence of infections and complications. 32 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

JOURNAL REVIEW

he growing use of immunotherapy is changing the role of the oncology nurse, and the ability to quickly identify problems early in the care continuum may be key to improving clinical outcomes. Pneumonitis is a rare but life-threatening adverse event associated with immune checkpoint inhibitors, including cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death-1 (PD-1) inhibitors. In a review article published in Cancer Management and Research, researchers report that oncology nurses need to be aware of multiple possible clinical presentations. The researchers contend early recognition and prompt initiation of steroids may be critical to improve outcomes. In more severe cases, additional immunosuppressive agents may be warranted. “The presentation a lot of times can be mild with a persistent cough and some mild shortness of breath,” said Benedito Carneiro, MD, co-director, Developmental Therapeutics Program of the Division of Hematology/ Oncology and an assistant professor at Northwestern University Feinberg School of Medicine, Chicago, Illinois. “It is different from some of the other autoimmune side effects. Pneumonitis can be more subtle.” He reports that the growing use of checkpoint inhibitors and PD-1 inhibitors calls for a greater understanding of the clinical manifestations, diagnosis, and treatment of pneumonitis.

Importance of Recognizing Checkpoint InhibitorRelated Pneumonitis John Schieszer, MA THE STUDY

In this review article, Dr Carneiro and colleagues write that pneumonitis has varied presenting symptoms and radiographic manifestations. Currently, cryptogenic organizing pneumonia (COP) and nonspecific interstitial pneumonia (NSIP) appear to be the most commonly reported radiographic findings. However, acute interstitial pneumonia (AIP), acute respiratory distress syndrome (ARDS), and hypersensitivity pneumonitis (HP) have also been reported by clinicians. The current review summarizes the incidence of pneumonitis during treatment with various checkpoint inhibitors and it also examines the prognostic significance of tumor type. Certain known risk factors are associated with a higher likelihood of

developing drug-induced lung injury. These include advanced age, existing pulmonary lesions or decreased baseline respiratory function, history of pulmonary surgery, oxygen administration, and radiation exposure to the lung. However, the authors note that which risk factors may predispose patients to developing pneumonitis after immunotherapy is unknown. Although the role of smoking is unclear, non-small cell lung cancer (NSCLC) is known to be a risk factor for pneumonitis-related death, according to the review. WHAT WAS LEARNED

Checkpoint inhibitor-related pneumonitis (CIP) can be difficult to diagnose because it is so similar to other conditions common in cancer patients. The symptoms can include nonproductive cough and unresolved dyspnea. Dr Carneiro writes that fever and chest pain are less common symptoms. Hypoxia may occur and progress rapidly to respiratory failure. The researchers note that CIP may appear on a computed tomography (CT) scan before it becomes clinically evident. “The person who gets the first call is the nurse, so they play a critical role,” Dr Carneiro said in an interview with Oncology Nurse Advisor. Nurses need to be on the lookout for new respiratory symptoms or a persistent cough or a shortness of breath, he explained. The researchers report that the time to resolution of mild-to-moderate pneumonitis may be 2 to 8 weeks. Studies suggest that steroids do not seem to

[Dr Carneiro] reports that the growing use of checkpoint inhibitors and PD-1 inhibitors calls for a greater understanding of the clinical manifestations, diagnosis, and treatment of pneumonitis. www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 33

JOURNAL REVIEW

interfere with the efficacy of immunotherapy. However, the researchers write that further investigation is warranted to confirm this observation. IMPLICATIONS FOR NURSES

There are now a growing number of approved anti-PD-1 agents, including ipilimumab for the treatment of metastatic melanoma. Pembrolizumab and nivolumab were granted approval for the treatment of advanced NSCLC, renal cell carcinoma (RCC), and melanoma. In addition, atezolizumab was recently approved for bladder cancer. “They will

be used more. [PD-1 inhibitors] have been approved for many different types of cancer and they represent a new class of drugs and their uses are expanding rapidly,” said Dr Carneiro. Large clinical trials involving patients with advanced melanoma, NSCLC, and RCC have documented serious adverse effects associated with checkpoint inhibitors. The rates may be as high as 60% to 80% of patients. The researchers of the review report PD-1 inhibitors tend to have a lower rate of adverse events compared with the CTLA-4 inhibitors. However, combining the

2 types of inhibitors has a higher rate than either approach alone. “We need to increase the awareness of the symptoms and the importance of early diagnosis. That is what triggered this review. We need to increase the awareness that there are symptoms that frequently can be attributed to other things,” said Dr Carneiro. ■ REFERENCE Chuzi S, Tavora F, Cruz M, et al. Clinical features, diagnostic challenges, and management strategies in checkpoint inhibitor-related pneumonitis. Cancer Manag Res. 2017;9:207-213.

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34 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

STAT CONSULT Ibrutinib (Imbruvica) Drug type

• Ibrutinib is a Bruton’s tyrosine kinase (BTK) inhibitor indicated for the treatment of certain leukemias and lymphomas and chronic graft versus host disease (cGVHD) in adult patients.

Indications

• Mantle cell lymphoma (MCL) in patients who have received at least 1 prior therapy • Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) • CLL/SLL with 17p deletion • Waldenström’s macroglobulinemia (WM) • Marginal zone lymphoma (MZL) in patients who require systemic therapy and have received at least 1 prior antiCD20-based therapy • Chronic graft versus host disease after failure of 1 or more lines of systemic therapy Mechanism of Action

• Ibrutinib is a small-molecule inhibitor of Bruton’s tyrosine kinase that forms a covalent bond with a cysteine residue in the BTK active site, leading to inhibition of BTK enzymatic activity. ——BTK is a signaling molecule of the B-cell antigen receptor and cytokine receptor pathways. ——In signaling through the B-cell surface receptors, BTK activates pathways necessary for B-cell trafficking, chemotaxis, and adhesion. • Nonclinical studies show that ibrutinib inhibits malignant B-cell proliferation and survival in vivo as well as cell migration and substrate adhesion in vitro. Dosage and Administration

• Mantle cell lymphoma and marginal zone lymphoma ——560 mg (four 140-mg capsules) orally once daily until disease progression or unacceptable toxicity

• Chronic lymphocytic leukemia/small lymphocytic lymphoma ——As monotherapy or in combination with bendamustine and rituximab (administered every 28 days for up to 6 cycles) ■■ 420 mg (three 140-mg capsules) orally once daily until disease progression or unacceptable toxicity • Waldenström’s macroglobulinemia ——420 mg (three 140-mg capsules) orally once daily until disease progression or unacceptable toxicity • Chronic graft versus host disease ——420 mg (three 140-mg capsules) orally once daily until cGVHD progression, recurrence of an underlying malignancy, or unacceptable toxicity. • Administration ——White opaque capsules for oral administration ——140 mg per capsule ——Swallow whole with water; do not open, break, or chew the capsules Dose Adjustments

• Interrupt ibrutinib for any grade 3 or greater nonhematologic toxicity, grade 3 or greater neutropenia with infection of fever, or grade 4 hematologic toxicity. • Treatment can be reinstated at the starting dose once symptoms of toxicity are resolved to grade 1 or baseline (recovery). ——If the toxicity recurs, reinstate treatment after resolution or recovery at a dose reduced by 1 capsule (140 mg) per day. ——A second dose reduction may be considered if needed;

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 35

STAT CONSULT however, if toxicities persist or recur after 2 dose reductions, discontinue ibrutinib. • Recommended dose modifications after toxicity occurs ——MCL and MZL (starting dose 560 mg) ■■ 1st occurrence: Restart at 560 mg daily (4 capsules) ■■ 2nd occurrence: Restart at 420 mg daily (3 capsules) ■■ 3rd occurrence: Restart at 280 mg daily (2 capsules) ■■ 4th occurrence: Discontinue ibrutinib ——CLL/SLL, WM, and cGVHD (starting dose 420 mg) ■■ 1st occurrence: Restart at 420 mg daily (3 capsules) ■■ 2nd occurrence: Restart at 280 mg daily (2 capsules) ■■ 3rd occurrence: Restart at 140 mg daily (1 capsule) ■■ 4th occurrence: Discontinue ibrutinib • B-cell malignancies ——Coadministered with moderate CYP3A inhibitor, posaconazole ≤200 mg twice daily, voriconazole at any dose ■■ Ibrutinib 140 mg once daily ■■ Interrupt dose as recommended ——Coadministered with posaconazole at doses >200 mg twice daily or other strong CYP3A inhibitors ■■ Avoid concomitant use ■■ If these inhibitors will be used short-term (eg, as anti-infectives for 7 days or less), interrupt ibrutinib • Chronic graft versus host disease ——Moderate CYP3A inhibitor ■■ Ibrutinib 420 mg once daily ■■ Modify dose as recommended ——Posaconazole immediate-release tablet 200 mg twice daily or delayed-release tablet 300 mg once daily, or voriconazole at any dose ■■ Ibrutinib 280 mg once daily ■■ Modify dose as recommended ——Posaconazole at other higher doses or other strong CYP3A inhibitors ■■ Avoid concomitant use ■■ If these inhibitors will be used short-term (eg, as anti-infectives for 7 days or less), interrupt ibrutinib • Hepatic impairment ——Mild (Child-Pugh class A): 140 mg daily ——Moderate or severe (Child-Pugh class B or C): avoid use of ibrutinib • Missed dose should be taken as soon as possible on the same day with a return to normal schedule the following day ——Do not take extra capsules to make up for a missed dose Specific Populations

• Pregnancy ——No available data on use of ibrutinib in pregnant

women; however, it can cause fetal harm based on findings from animal studies • Nursing mothers ——Consider the benefits of breastfeeding along with the mother’s clinical need for ibrutinib, and any potential adverse effects on the breastfed child from ibrutinib or from the underlying maternal condition • Females and males of reproductive potential ——Both females and males should avoid conceiving a child during treatment and for 1 month after the last dose • Pediatric ——Safety and effectiveness not established • Geriatric ——No overall differences in safety and efficacy observed between younger and older patients • Hepatic impairment ——Avoid use in patients with moderate or severe hepatic impairment (Child-Pugh class B and C) ——Monitor patients for adverse reactions and follow dose modification guidance as needed Boxed Warnings and Contraindications

• None Cautions

• Atrial fibrillation ——Periodically monitor clinically for atrial fibrillation. ——Obtain an ECG if arrhythmic symptoms (eg, palpitations, lightheadness) or new onset dyspnea develops ——If symptoms persist, consider the risks and benefits of ibrutinib treatment and follow dose modification guidelines • Cytopenias ——Check complete blood counts monthly ——Treatment-emergent grade 3 or 4 cytopenias including neutropenia, thrombocytopenia, and anemia have occurred in patients with B-cell malignancies treated with single-agent ibrutinib treatment • Embryo-fetal toxicity ——Ibrutinib can cause fetal harm. ——Patients should avoid conceiving a child and/or pregnancy while taking ibrutinib and for 1 month after ending treatment • Hemorrhage ——Monitor for signs of bleeding ——Risk of hemorrhage may increase in patients receiving antiplatelet or anticoagulant therapies ——Consider withholding treatment for at least 3 to 7 days presurgery and postsurgery based on the type of surgery and the risk of bleeding

36 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

• Hypertension ——Monitor patients for new onset hypertension or hypertension that is not adequately controlled after starting ibrutinib ——Initiate treatment or adjust existing medications as appropriate • Infections ——Consider prophylaxis according to standard of care in patients at increased risk for opportunistic infections ——Monitor and evaluate for fever and infections; treat appropriately • Second primary malignancies ——The most frequent second primary malignancy was non-melanoma skin cancer • Tumor lysis syndrome ——Assess the baseline risk (eg, high tumor burden) and take appropriate precautions ——Monitor patients closely and treat as appropriate

inhibitors may increase plasma concentrations of ibrutinib, which may increase the risk of drug-related toxicity ——Avoid foods that contain strong or moderate inhibitors of CYP3A (eg, grapefruit and Seville oranges) during treatment • Coadministration with strong CYP3A inducers may decrease ibrutinib concentrations. ——Avoid coadministratration with CYP3A inducers • Posaconazole and voriconazole ——See dose adjustment information for B-cell malignancies and cGVHD What to Tell Your Patient

Drug Interactions

• Ibrutinib is a type of anticancer medication called a kinase inhibitor. • This is an oral medication administered as tablets. ——The number of tablets you take is based on the dose your doctor has prescribed, and may change if a dose is reduction is needed. • You should take ibrutinib once a day at approximately the same time each day. ——If you miss a dose, take it as soon as possible on the same day and return to your regular schedule the following day ——Do not take extra capsules to make up for a missed dose. • Swallow the capsules whole with water. Do not open, break, or chew the capsules. • Tell your oncology team about any medications you are taking including all other prescription medicines and any over-the-counter drugs, vitamins, and herbal products. • You may experience loose stools or diarrhea. ——Tell your nurse or doctor if this symptom persists. • You should drink plenty of fluids to maintain adequate hydration. • Tell your doctor if you have any medical or dental procedures planned for during your treatment. ——Your ibrutinib treatment may need to be interrupted before the procedure and for a short term after. • You may experience adverse effects from this medication. If you experience any of these symptoms, tell your nurse or doctor. ——Blood in stools or urine ——Chest discomfort ——Chills ——Confusion ——Dizziness ——Fainting ——Fever

• Coadministration with strong or moderate CYP3A

Continued on page 40

Adverse Effects

• The most common adverse reactions in patients (≥20%) with B-cell malignancies (MCL, CLL/SLL, WM, and MZL): ——Anemia ——Bruising ——Diarrhea ——Fatigue ——Hemorrhage ——Musculoskeletal pain ——Nausea ——Neutropenia ——Pyrexia ——Rash ——Thrombocytopenia • The most common adverse reactions in patients (≥20%) with cGVHD: ——Anemia ——Bruising ——Diarrhea ——Fatigue ——Hemorrhage ——Muscle spasms ——Nausea ——Pneumonia ——Stomatitis ——Thrombocytopenia

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 37

STAT CONSULT Decitabine (Dacogen) Drug Type

• Decitabine is a nucleoside metabolic inhibitor

Indication

• Myelodysplastic syndrome (MDS) including previously treated and untreated, de novo, and secondary MDS of all French-American-British subtypes (refractory anemia, refractory anemia with ringed sideroblasts, refractory anemia with excess blasts, refractory anemia with excess blasts in transformation, and chronic myelomonocytic leukemia) and intermediate-1, intermediate-2, and highrisk International Prognostic Scoring System Groups Mechanism of Action

• Believed to exert its antineoplastic effects after phosphorylation and direct incorporation into DNA and inhibition of DNA methyltransferase, causing hypomethylation of DNA and cellular differentiation or apoptosis ——Inhibits DNA methylation in vitro, which is achieved at concentrations that do not cause major suppression of DNA synthesis ——Decitabine-induced hypomethylation in neoplastic cells may restore normal function to genes that are critical for the control of cellular differentiation and proliferation ——In rapidly dividing cells, the cytotoxicity of decitabine may also be attributed to the formation of covalent adducts between DNA methyltransferase and decitabine incorporated into DNA. ——Nonproliferating cells are relatively insensitive to decitabine Dosage

• Treatment regimen – Option 1 ——15 mg/m2 by continuous infusion over 3 hours repeated

every 8 hours for 3 days. Repeat cycle every 6 weeks. • Treatment regimen – Option 2 ——20 mg/m2 by continuous infusion over 1 hour repeated daily for 5 days. Repeat cycle every 4 weeks. Administration

• Aseptically reconstitute with 10 mL of sterile water for injection • Immediately after reconstitution, the solution should be further diluted with 0.9% sodium chloride injection or 5% dextrose injection to a final drug concentration of 0.1 to 1.0 mg/mL • Unless used within 15 minutes of reconstitution, the diluted solution must be prepared using cold (2˚C to 8˚C) infusion fluids and stored at 2˚C to 8˚C (36˚F to 46˚F) for up to a maximum of 4 hours until administration Dose Adjustments

• Treatment regimen – Option 1 ——If hematologic recovery (ANC ≥1,000/μL and platelets ≥50,000/μL) from a previous treatment cycle requires more than 6 weeks, delay the next cycle and temporarily reduce the dose as follows. ■■ Recovery requires 6 to 8 weeks: »» Delay dosing for up to 2 weeks »» Temporarily reduce dose to 11 mg/m2 every 8 hours (33 mg/m 2/day, 99 mg/m 2/cycle) upon restarting therapy ■■ Recovery requires 8 to 10 weeks: »» Assess for disease progression via bone marrow aspirates

38 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

»» In absence of progression, delay dose up to 2 more weeks »» Temporarily reduce dose to 11 mg/m2 every 8 hours (33 mg/m 2/day, 99 mg/m 2/cycle) upon restarting therapy »» Maintain or increase dose in subsequent cycles as clinically indicated • Treatment regimen – Option 2 ——If myelosuppression is present, delay subsequent treatment cycles until recovery (ANC ≥1,000/μL platelets ≥50,000/μL) is achieved • Nonhematologic toxicity ——If any of the following nonhematologic toxicities are present after the first cycle, do not restart decitabine until toxicity is resolved. ■■ Serum creatinine ≥2 mg/dL ■■ SGPT, total bilirubin ≥2 times ULN ■■ Active or uncontrolled infection

dysfunction; therefore, should be used with caution in these patients Boxed Warnings and Contraindications

• None Cautions

• Neutropenia and thrombocytopenia ——Perform complete blood counts and platelet counts prior to each dosing cycle and as needed to monitor response and toxicity • Pregnancy ——Can cause fetal harm. Advise women of potential risk to fetus ——Women of childbearing potential and men with female partners of childbearing potential should use effective contraception and avoid pregnancy Adverse Effects

Specific Populations

• Pregnancy ——Can cause fetal harm when administered to a pregnant woman. There are no adequate and well-controlled studies in pregnant women. • Nursing mothers ——Whether decitabine or its metabolites are excreted in human milk is not known ——A decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. • Females and males of reproductive potential ——Women should avoid conceiving a child during treatment and for 1 month after last dose. ——Men should avoid conceiving a child during treatment and for 2 months after last dose. • Pediatric ——Safety and effectiveness in pediatric patients have not been established • Geriatric ——No overall differences in safety or effectiveness were observed between younger and older patients • Renal impairment ——There are no data on use in patients with renal dysfunction; therefore, should be used with caution in these patients • Hepatic impairment ——There are no data on the use in patients hepatic

• Most common adverse reactions in patients (>50%) ——Anemia ——Neutropenia ——Pyrexia ——Thrombocytopenia Drug Interactions

• Drug interaction studies with decitabine have not been conducted • In vitro studies in human liver microsomes suggest that decitabine is unlikely to inhibit or induce cytochrome P450 enzymes • In vitro metabolism studies have suggested that decitabine is not a substrate for human liver cytochrome P450 enzymes • As plasma protein binding of decitabine is negligible (<1%), interactions due to displacement of more highly protein bound drugs from plasma proteins are not expected What to Tell Your Patient

• Decitabine is a type of anticancer medication called a nucleoside analogue. • Decitabine is administered as an intravenous (IV) infusion into your vein over 3 hours, and is repeated every 8 hours for 3 days • Tell your nurse if you experience nausea. ——You can be given medication before your treatment to prevent nausea. • You may experience side effects. Tell your nurse doctor

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 39

STAT CONSULT if you experience any side effects or symptoms that do not go away or bother you. • Call your nurse or doctor as soon as possible if you experience any of these symptoms: ——Blood in urine or stool ——Bruising ——Cough ——Difficulty swallowing ——Dyspnea ——Excessive bleeding ——Gingival pain and swelling ——Low-grade fever ——Perirectal pain and irritation ——Rash ——Recurrent sinusitis and otitis ——Sore mouth ——Skin abscesses • Decitabine may cause harm to an unborn fetus if given

Ibrutinib (Imbruvica) Continued from page 37

——Lightheadedness ——Palpitations ——Prolonged or uncontrolled bleeding ——Severe headache ——Shortness of breath ——Weakness • Report any symptoms you experience or any symptoms that persist or bother you to your nurse or doctor as soon as possible. • Some patients taking ibrutinib developed hypertension. Your oncology team will monitor your blood pressure throughout treatment. ——If you are already taking antihypertensive medication, your medication may need to be adjusted. • A second primary malignancy may develop. The most common is non-melanoma skin cancer. ——You should inspect your skin and report any changes or suspicious findings to your oncology care team. • Tumor lysis syndrome is a condition caused by large numbers of tumor cells being killed off at the same time. Its symptoms include ——Decreased urination, diarrhea, fatigue, muscle cramps or twitches, nausea, numbness or tingling, vomiting, weakness

to a pregnant woman • Females of childbearing potential ——Use an effective contraceptive during treatment and for 1 month after you complete treatment ——Tell your nurse or doctor if you are pregnant or become pregnant during treatment • Males with female partners of childbearing potential ——You should use an effective contraceptive during treatment and for 2 months after you complete treatment. • Nursing mothers ——Whether decitabine is excreted in human milk is not known. Tell your doctor or nurse if you are nursing or plan to nurse while you are receiving this therapy. ——A decision should be made about whether to discontinue nursing or discontinue the drug, taking into account the importance of this medication to you. ■ Prepared by James Nam, PharmD.

• If you experience any of these symptoms, call your nurse or doctor immediately. • Ibrutinib may harm an unborn fetus if taken during pregnancy. • Women of childbearing potential are advised to avoid pregnancy ——Use an effective form of birth control during the time you are taking ibrutinib and for 1 month after taking your last dose. • Nursing mothers ——There is no information regarding the presence of ibrutinib or its metabolites in human milk ——You should discuss the development and health benefits of breastfeeding vs your clinical need for this medication, as well as any potential adverse effects on the breastfed child from ibrutinib or from your underlying condition with your doctor. • Men should avoid fathering a child while undergoing treatment ——Use an effective form of birth control during the time you are taking ibrutinib and for 1 month after taking your last dose. • You should read the FDA-approved Patient Information provided and discuss anything you do not understand or any question you may have with your doctor or nurse. ■ Prepared by Joyce Pagán.

40 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

Super-Elders: An Emerging Challenge for Radiation Oncology Bryant Furlow The number of people with cancer diagnosed at age 85 years or older — so-called super-elders — is increasing sharply, posing challenges for radiation oncology planning. Geriatric oncology evaluations and careful communication to identify patients’ goals and priorities for care will play important roles in personalizing treatment plans.

s the US population ages, radiation oncology will see increasing numbers of elderly and super-elder (older than 85 years) patients whose potential benefits, information needs, comorbidities, radiation dose regimens, and treatment toxicity vulnerabilities can differ importantly

from those of younger patients, according to a collection of papers published in the International Journal of Radiation Oncology Biology Physics (known as “the Red Journal”).1-7 The US Census Bureau predicts that by 2050 there will be as many super-elders as there are young children (younger than 5 years), and that by 2030, older adults will represent onefifth of the US population and 70% of patients with newly diagnosed cancer.1,3 “The elderly, and particularly those older than 85 [years], are the fastestgrowing age demographic in most of the developed world,” noted Anthony L. Zietman, MD, FASTRO, the editorin-chief of the Red Journal and a radiation oncologist at the Harvard Medical School and Massachusetts General Hospital Cancer Center, in Boston. Super-elders are a “new and rapidly growing demographic, never previously encountered in our evolutionary past,” Dr Zietman noted.2 UNIQUE CHARACTERISTICS These patients tend to be frail. Their capacity to repair tissue damage and to recover from stressful events is not what it once was.2 Both cancer and its treatment can take a heavier toll on these patients than on younger populations. Treatment toxicity can “undermine dignity, independence, and the will to live,” Dr Zietman wrote.2 “Elders with neuropathy may be unable to dress themselves; muscle loss may render them bedbound; and those who become incontinent, or deaf, or blind, may become socially isolated.” But clinical trials exclude patients with comorbidities that are typical in advanced older age, leading to an underappreciation of the real-world side effects of treatment in the oldest patients.3

“In medicine, we have an entire specialty — pediatrics — that is dedicated to children because of their distinctive biology and vulnerabilities,” Dr Zietman said. “I believe that we need to think about the elderly differently, also. There are pressing questions involved in cancer care for elderly, including both biological and philosophical considerations. Can we assess the elderly and tailor their cancer treatments in a way that saves their lives without ruining their lives? How little treatment can we give yet still be effective? How can we leverage new technologies to reduce the side effects of treatment?” In the United States, more than half of patients with cancer undergo radiotherapy at some point during their care, Dr Zietman noted.1 Because older patients are more often not eligible for — or prefer to avoid — surgical interventions, radiotherapy seems likely to play a larger role in the care of these patients than in younger people.1 The emergence of more precise externalbeam radiotherapy modalities such as stereotactic body radiotherapy (SBRT), stereotactic radiosurgery (SRS), and possibly, proton therapy, might reduce irradiation of healthy nontarget tissues in a manner that allows greater use in elderly patients than was possible with older radiotherapy technology.1 But the optimal role for radiotherapy in the treatment of very old patients is not yet entirely clear. CHANGING PRIORITIES When cancer is diagnosed in young people, it is likely to be the most immediate threat to their long-term survival and quality of life. That is not always the case with the very old. “Prostate cancer is probably the best studied in this regard,” Dr Zietman noted.2 “Most low-risk cancer will

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 41

RADIATION & YOUR PATIENT not threaten a patient’s life within the decade, and probably not within 2. Restraint is clearly preferred, and the evidence suggests that this is now commonly the case.” Even treatment of high-risk prostate tumors can be deferred for the very old, Dr Zietman added.2 These patients can be treated with androgen deprivation alone. Once a decision is made to treat the very old more aggressively, however, treatment de-escalation or fractionation alternatives to the standard of care for younger patients are important considerations.2 “Experienced physicians are as aware of the risks of overreach as they are of undertreatment, and often limit radiation dose, shrink fields, or de-intensify chemotherapy in a patient-tailored fashion,” Dr Zietman explained. 2 “If we plan treatment, can we make it better match the elder’s life: their immobility, their reliance on rides, their propensity to fatigue?” Hypofractionation is one “low-hanging fruit” in treatment planning for very old patients, Dr Zietman argued.2 Truncated hypofractionated radiotherapy regimens offer comparable clinical effectiveness and quality of life for super-elder men with prostate cancer as standard regimens, and similar findings have been found for women with breast cancer, noted Benjamin Movsas, MD, FASTRO, of the Henry Ford Health System in Detroit, Michigan.3 Approximately 1 in 5 older cancer patients have an Eastern Cooperative Oncology Group (ECOG) performance

FIND US ON

status of 2 or higher.4 Geriatric assessments such as the abbreviated Comprehensive Geriatric Assessment or Onco-Geriatric Screening Tool need to be used more widely, say experts in geriatric radiation oncology, to better tailor integrated treatment plans in light of patient functional status, vulnerabilities, and goals.3,4 Patients’ priorities can differ importantly from those typical among younger patients facing cancer, Dr Zietman noted.2 Shared decision-making that includes patients can be more challenging with older patients, who are more likely to have cognitive impairment and communication issues.

her understanding, followed by clarifying or providing additional information in simple language, before confirming her understanding.6 “Older women desire information and have more agency and input in the decision-making process than prior literature would suggest,” reported Shi-Yi Wang, MD, PhD, and coauthors from Yale University School of Medicine and School of Public Health in New Haven, Connecticut.5 ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Cancer research journal devotes special issue

[Elders’] priorities can differ from those typical among younger patients.

to radiation therapy and the elderly [news release]. Arlington, VA: American Society for Radiation Oncology; June 15, 2017. 2. Zietman AL. Frailty is our destiny: an introduction to the Red Journal’s special edition on radiation therapy in the elderly. Int J Radiat Oncol Biol Phys. 2017;98(4):713-714. 3. Movsas B. Radiation therapy in elderly persons: an old issue with new approaches. Int J

Most older women with breast cancer report that they themselves are the primary decision-maker when it comes to whether or not they will undergo radiotherapy.5 Effectively communicating with elderly patients requires confirming that patients understood what they were told; members of the cancer care team should reiterate information about prognosis, disease progression, and treatment goals, using qualitative rather than quantitative descriptions where possible.6 The “ask-tell-ask” approach involves asking the patient for

Radiat Oncol Biol Phys. 2017;98(4):715-717. 4. Extermann M. Cancer in the elderly: moving the needle toward evidence-based personalized oncology. Int J Radiat Oncol Biol Phys. 2017;98(4):718-720. 5. Wang SY, Kelly G, Gross C, et al. Information needs of older women with early-stage breast cancer when making radiation therapy decisions. Int J Radiation Oncol Biol Phys. 2017;98(4):733-740. 6. Fakhreddine MH, Galvan E, Pawlowski J, Jones WE III. Communicating effectively with elderly cancer patients. Int J Radiat Oncol Biol Phys. 2017;98(4):741-742.

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42 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

You Don’t Say: When to Just Listen as Family Members Try to Cope Ann J. Brady, MSN, RN-BC

about her I don’t think I would have liked her anyway. I know I’m not supposed to say that. I honestly tried to give her a chance, tried to look past her demeaning tone, past her outright verbal challenges — no one knows what they are doing in this hospital, if I weren’t here there’s no telling what would be missed. But her eye rolling did me in. It was the final insult. Truth is, I had a difficult time not taking it personally. CASE

I knew that nothing we said was likely to make a difference.

knew it within the first moments of meeting her. As soon as she crossed her arms against her chest, rolled her eyes, and said, “You’re 2 minutes late.” I knew that nothing we said was likely to make a difference. Her mind was made up before we arrived. Meeting with us was an exercise in futility but one we had to undertake, like dotting the i’s and crossing the t’s, so to speak. Mary Jane was the Guardian of the Galaxy with super hero powers to protect her sister. But she was mean. Cranky. Argumentative. I don’t like to be warned about difficult patients or families. I prefer to form my own impressions. But Mary Jane had a legend of a reputation. The history and physical for her sister included the following: “Patient’s sister Mary Jane is extremely confrontational.” No one could take her on and win. The truth was, in spite of what I heard or read

In spite of her negative energy and dismissive tone, Mary Jane had agreed to meet with us. The patient, however, was confused and unable to participate. Although Mary Jane consented to meet with us, she maintained her disagreeable attitude throughout our conversation. The first 10 minutes were spent with her disgorging the details of the many medical things she felt had not been done correctly. She wasn’t satisfied just complaining about the current hospitalization, she went far back in time, to encounters we had no part in. Throughout her discourse she managed to incorporate personal verbal jabs: “I don’t trust anyone taking care of her. No one knows what they’re doing, including all of you.” “My sister isn’t in pain, it’s only that the nurses who work here are too stupid to figure out what she needs.” I watched Mary Jane as she spoke, how she moved her hands in the air, how she shook her head with each statement. She upset me. We had so much to offer, if she would only let us. And her sister needed us, she really did. When Mary Jane

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 43

COMMUNICATION CHALLENGES

[Mary Jane] was desperate to hold on to her perception of what was going on with her sister.

finally stopped talking, our palliative care physician started by reviewing the current situation. As the meeting continued, my mind was filled with ideas of what I might say to get Mary Jane to listen. Surely there was something. If I concentrated, I’d find just the right thing to say and somehow it would make her adjust her attitude. Surely it was fixable. But I spent so much time thinking about what I wanted to say to neutralize her toxicity that I missed the chance to truly listen to her. Which meant I was not as tuned in to the situation as I needed to be. Ignoring what she said and instead formulating a response was easy. Yet this was more about what I saw as she spoke than it was about what she said. Body language. Mary Jane’s body language was screaming at me, but I was only listening to her words. If I’d paid attention to what I saw, I’d have noticed the set of her jaw. She was desperate to hold on to her perception of what was going on with her sister. Letting go of her belief would leave her with nothing. I might have noticed her shoulders as she leaned forward, might have seen the tension she held in them. If I’d listened to her body language, I might have seen that her darting glances were because she knew if she looked me in the eye she would see that I knew things she did not want to admit to. Of course, her body language was subject to my interpretation. I might have been mistaken. However, by failing to fully appreciate the context of her statements I missed the other cues, the subtext. Mary Jane and her sister grew up in Eastern Europe and were on the brink of being teenagers when World War II started. They relied on each other to survive and immigrated to the United States at the end of the war. Neither had married and so they lived their entire lives together. With her sister clearly in decline, I wondered how much of the anger and argumentative style was driven by their shared history. When her sister dies, Mary Jane will be the lone survivor of her family of origin.

DISCUSSION

“You don’t say,” was one of my grandfather’s favorite sayings. He used it the way we might say whatever or really. It was a verbal place holder, a way of showing surprise or a new understanding of the circumstances. And of course, there is also the literal definition: don’t speak, you do not say anything. I had my “You don’t say” moment with Mary Jane. It happened near the end of our meeting, when I shifted my focus away from getting even verbally and really stopped myself. I kept myself from eye rolling or my own expressions of disbelief. I’m not sure what made me stop. It might have been a flash of vulnerability I saw in her, but I settled back in the chair and just watched. Mary Jane’s confrontational style and words were meant to do exactly what they did: keep us away and allow her to keep her denial intact so she could protect her sister. We were the enemy because, to her way of thinking, we — all of us involved in her sister’s care — were forcing her to accept the unacceptable. The purpose of our meeting was not to convince Mary Jane of anything. We were there to support her and to help her make sense of the situation, neither of which she would allow. At the end of the meeting she thanked us, which was a nice surprise, then tempered her gratitude by saying, “it was a waste of time though.” I could look at this story of Mary Jane and her sister as an example of a communication challenge that failed. But I learned something about my own practice from Mary Jane. I realized that even with many years of experience and a certain level of expertise, I can learn more. I can open myself up and look past words. I knew all of this before because I have done this before. But Mary Jane’s level of vitriol blindsided me, and I reacted to her words. I have Mary Jane to thank for teaching me, once again, the absolute importance of listening and not talking. You don’t say. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

44 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

Depressive Symptoms Predict Declining Health in Caregivers of Patients With Cancer Bette Weinstein Kaplan

aring for a family member or close friend with cancer is a difficult task that can be accompanied by significant negative consequences for the caregiver. The patient may benefit from the care, and demonstrate an improvement in health, but often this positive result occurs at the expense of the caregiver’s health. In a recent study, researchers found the physical health of caregivers declined steadily in a cascade of events initiated by symptoms of depression without other indications of failing physical health. SURVIVORS AND CAREGIVERS Kelly M. Shaffer, PhD, and her team at Memorial Sloan Kettering Cancer Center, in New York, New York, and at the University of Miami, Florida, recruited cancer survivors from a number of state cancer registries. The participants had a common type of cancer and had named an adult family member or close friend as their caregiver during his or her illness. The caregivers were aged 18 years or older, fluent in either English or Spanish, and a US resident. The study included 664 cancer caregivers, with twice as many women as men. The women were middle-age, well educated, primarily employed, and were often caring for their spouse. The men in the study were typically older, had a high school education, a median income of $40,000, and were

caring for someone other than their spouse. Although the patients with male caregivers had better cancer prognoses than those with female caregivers, the male caregivers reported that their own physical health was poorer at the start of the study than did the female caregivers.

Treat depressive symptoms in a timely fashion, preferably during the acute phase of the patient’s cancer. DATA COLLECTION For the study, caregivers self-reported on their physical health at several time points using the American Cancer Society’s National Quality of Life Survey for Caregivers. The initial report was at 2 years postdiagnosis (T1). Follow-up data was collected at 5 years (T2) and 8 years (T3) postdiagnosis. At T1, caregivers’ physical health was a bit better than the national average. They also reported on stress; selfesteem as it related to providing care; extent of emotional, informational, and other types of social support they received; and any depressive symptoms.

The caregivers who reported the most significant depressive symptoms at T1 also experienced a greater decline in physical health over the ensuing 6 years. As the study progressed, depressive symptomatology continued to be the only predictor of a decline in caregivers’ physical health. CONCLUSION The investigators note that there are many challenges and stressors implicit in providing optimum care for someone so ill. When the patient is a spouse or other loved one, the challenges are that much greater, and the risks for becoming burned out, depressed, and physically ill become more prevalent. The researchers observed, “Existing psychosocial interventions with caregivers have shown limited effect on caregiver depressive symptoms.” They suggest treating depressive symptoms with effective antidepressant and antistress interventions in a timely fashion, preferably during the acute phase of the patient’s cancer. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE Shaffer KM, Kim Y, Carver CS, Cannady RS. Depressive symptoms predict cancer caregivers’ physical health decline [published online June 29, 2017]. Cancer. doi: 10.1002/cncr.30835

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 45

THE TOTAL PATIENT COURTESY OF ROYAL TRINITY HOSPICE

Virtual Reality Lets Patients Connect With the Outside World or Explore a New One Bette Weinstein Kaplan

he Royal Trinity Hospice in London may be the United Kingdom’s oldest hospice, but it incorporates some of the newest, most cutting-edge palliative care techniques available. The hospice is the only palliative care specialty provider in central and southwest London, offering inhome and inpatient nursing and medical care within a community of 750,000 people. The institution’s mission is “to provide skilled, compassionate care and support to people with progressive, life-limiting illnesses and those close to them.”1 At any one time, Trinity cares for approximately 700 residents. In addition to benefitting from skilled nursing and medical care, residents and their loved ones receive support through counseling and bereavement services and such resources as physical and occupational therapy, music and art programs, pet therapy, and therapeutic massage. Now Trinity’s hospice residents can experience something totally new: a therapeutic intervention using virtual reality (VR). HOW THE TECHNIQUE IS USED

Virtual reality (VR) is a video technology that generates realistic photographic or animated 3-dimensional and 360-degree images accompanied with sounds from the actual environment. When donning a VR headset and headphones, the viewer is surrounded

by visuals and sounds that give the impression of being physically present in that environment. Turning to the right, for example, the viewer will see and hear what was happening on that side when the video was filmed. Turning around to see what is behind, the viewer will experience what was going on in that direction. The viewer feels totally immersed. VR has been used with animation for gaming so the player feels as though he or

VR is adaptive to a hospitalized patient who yearns to do things outside. she is actually in the game or fantasy. It is similarly adaptive to a hospitalized patient who yearns to do things outside of the hospital, but cannot. VR as a treatment intervention came about as the result of a collaboration between Royal Trinity Hospice and Flix Films in London. The project is managed jointly by Letizia Perna-Forrest, head of Patient and Family Support at Trinity, and Leon Ancliffe, founder and managing director of Flix Films. Mr Ancliffe had used VR to help an immobile patient with amyotrophic

lateral sclerosis (ALS) who longed to swim with dolphins. After Mr Ancliffe had made a VR film creating that virtual experience for her, the patient told him it had given her the sense of movement that her disease had taken away, and that she had actually felt as if she was swimming. The videographer realized there was a place for VR in health care and joined with the hospice therapist to research the feasibility and effectiveness of VR therapy in a palliative care/ hospice situation. The team has been delivering VR to residents in the hospice with great success. The technology allows residents to relive memories, return to places of emotional significance, or check something off their “bucket list.” The Trinity project was featured on the BBC One program “Inside Out London.”2 The collaborators believe VR is most beneficial for hospice residents who still have full range of motion and cognitive, auditory, and visual capabilities. PATIENT-CENTERED CONTENT Flix Films has created a special Royal Trinity/Flix Films playlist using VR material readily available to the public that has been screened for content and appropriateness. The residents can choose any of the experiences in the playlist, although most opt for one that is evocative of a memorable place or

46 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

experience. They choose a place they wish to go back to or something they wish they could still be able to do or experience for the first time. Each VR session is brief, 3 minutes long, because some residents may get dizzy from the experience. Residents who respond well can request a total of 4 sessions. Patients seem to understand the concept, if only in the abstract. Many are skeptical, but curious. “It’s fantastic to watch the patients’ faces change during their first VR experience!” said Ms Perna-Forrest. Although people seem delighted with the experience, the VR team hopes their study will help them understand the obvious psychological and physiological effects of VR. For example, one middle-aged resident with cancer began to cry as she removed the headset, explaining to her nurse that the VR experience had given her joy, which she had not felt for a long time.

COMPLEMENTS NURSING CARE The nursing staff tells the VR team that they are excited to see the technology being used in this way. The hospice nurses feel the VR experience gives residents the opportunity to leave their beds, leave the unit, and escape to

another place that is not about death, dying, or even being a hospice resident. “There is a wonderful buzz about VR amongst staff. Many have never tried it for themselves, so there is also curiosity from their end,” Ms PernaForrest explained. For residents who

1. Royal Trinity Hospice. https://www.royal

Journal Review

and quality of life for cancer patients,” Dr Case told Oncology Nurse Advisor. She said cancer centers in the United States are increasingly recognizing that deeper and more meaningful engagement with caregivers can reduce hospital stays and incidence of infections and complications. Dr Case said that greater engagement with the caregivers can lead to improved patient care while helping the caregivers at a critical time with “everything from medication management and instruction in wound care to guidance on how to juggle the stresses they’re facing,” said Dr Case. The researchers suggest that health care professionals provide caregivers with more information, training, and continuing support. “Carer education

is an evolving area of oncology practice. This is because cancer services are moving closer to home, partly in response to patient preference. In the future, we hope to extend the scope of the CCMM toolkit to include medicines used to manage other cancer symptoms in the community,” said Ms Hopkinson. ■

Continued from page 32

symptoms with little or no training. Furthermore, many have preconceived views about pain and opioid use. These issues must be addressed, explained Amy Allen Case, MD, clinical chief and associate professor of oncology, Department of Supportive and Palliative Care, Roswell Park Cancer Institute. “I’m not surprised by these findings, but I am encouraged to see increasing evidence on how to make palliative approaches as effective and efficient as possible. Any type of intervention focused on helping caregivers is worthwhile and reflects an underused opportunity to improve both outcomes

VR enriches the [patient] experience and complements the care nurses give.

have tried the VR experience, it has led new sharing of experiences and memories. The Trinity team believes VR enriches the resident experience and complements the care nurses and other health care professionals give. To explore its benefits further, the Trinity team is preparing to launch a formal study on the effect of a VR experience at the end of life. They look forward to helping other facilities adopt this new technology. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES trinityhospice.london. Accessed September 13, 2017. 2. BBC One Inside Out London. Virtual reality helps hospice patients. http://www.bbc. co.uk/programmes/p04yxc8z. April 3, 2017. Accessed September 13, 2017.

John Schieszer is a medical writer based in Seattle, Washington. REFERENCE Latter S, Hopkinson JB, Lowson E, et al. Supporting carers to manage pain medication in cancer patients at the end of life: a feasibility trial [published online July 5, 2017]. Palliat Med. doi: 10.1177/0269216317715197

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 47

adiation therapy is one of the most heavily valued and relied upon treatments for many cancers in the United States; it is administered daily, all over the country. In a nutshell, radiation damages cells by destroying the genetic material that controls how they grow and divide. Although both healthy and cancerous cells are damaged during radiation therapy, the goal is to destroy as few of the healthy cells as possible. However, many patients with cancer do not fully take stock of the scope of changes that have occurred within their bodies before undergoing radiation treatment because they may not be aware of the possible implications. During radiation therapy, patients are asked to hold still in a position their nervous system may identify as potentially body-harming, triggering the patient’s “fight, flight, or freeze” response. This event can occur in patients who have had a prior experience in which they had no choice but to freeze. As a result, they may suddenly find themselves re-experiencing the trauma symptoms that were recorded in their nervous system during their therapy session.1 These patients may benefit from psychoeducation on somatic experiencing (SE). This practice can prevent the patient re-experiencing a prior trauma or at least mitigate the symptoms. Any patient undergoing radiation therapy could potentially benefit from psychoeducation on SE as well.2

Preventing Body-Trauma Triggers During Radiation Therapy Andrea Cantor, LMSW

Trauma symptoms can arise when residual energy from a traumatic experience isn’t let go from the body. Rather than being discharged, the energy stays trapped in the nervous system where it is detrimental to the body and mind,

according to Peter A. Levine, PhD, a psychologist and expert in somatic therapy.3 Dr Levine explains that trauma is recorded within the nervous system. During a traumatic experience, our bodies may freeze as a way to disengage or disassociate our minds from our bodies to protect us from the cognitive experience of any physical trauma.3 A traumatic experience can be reactivated by exposure to a “fight, flight, or freeze” situation. Traumatic stress symptoms in the sympathetic nervous system may manifest as hyperarousal, constriction, increased heart rate, difficulty breathing, cold sweats, tingling, muscular tension, chronic pain, inability to sleep or relax, anxiety or panic, mania, rage outbursts, hypervigilance, racing thoughts, and/or worry. Over-activation of the parasympathetic nervous system may manifest as disconnection, low energy, exhaustion, numbness, low muscle tone, poor digestion, low heart rate, low blood pressure, poor immune system function, depression, dissociation, apathy, disconnection in relationships, and/or underresponsive behavior. These symptoms are not ideal, of course, and some may incontrovertibly deter any treatment plan, not to mention make the experience even more miserable for the patient.1,4 In the current model for healing trauma, trauma itself is viewed as a natural and normal part of life, not a mistake, disease, or aberration. Medical professionals can use SE to frame cancer as an internal threat; teach and normalize the fight, flight, or freeze response;

Clinicians need to help patients destigmatize reactions based in human wiring, for example the desire to run from the doctor’s office, and understand that these reactions are normal. 48 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com

FROM

and identify potential triggers for the nervous system. Treatments such as radiation or anesthesia are potentially perceived as both medicine and danger, and so patients tend to immobilize and enter freeze states, when they cannot effectively fight or flee their own body. Clinicians need to help patients destigmatize reactions based in human wiring, for example the desire to run from the doctor’s office, and understand that these reactions are normal.2 SE attempts to connect the patient to their body and bring them back to the “here and now” of where they are located — not in any trauma-inducing experience. One example of an SE method is sensation tracking. With sensation tracking, the patient is asked to describe what they are feeling or experiencing at that moment, where in their body they are feeling the sensation, and encourages them to describe the sensation they are experiencing as much as possible. This therapy is informed by these other biologically based, trauma-informed skills: • Grounding (sensory) • Resourcing (pain calls louder than pleasure; noticing neutral and pleasant sensations) • Pausing (slowing, interrupting) • Titration • Pendulation (between awareness of

ease/disease, natural, prompt when “stuck”) Body-trauma reactivation can be prevented. Some things patients can do to prevent or lessen their re-experiencing of trauma symptoms include: • Support oneself through touch • Reach out to resources and support services • Notice what is normal or pleasant • Locate bodily, felt sense sources (eg, Where do you feel the least itchy? or What part of you is most settled right now?) and external ones (eg, a stone in your pocket, a painting on the wall) • Practice corrective experiences: competent protectors exercises (eg, focus on “good” doctors/nurses, successful past procedures); utilize support system. • Practice principles that restore balance

and Valerie Linet, LCSW, gave oral presentations on Somatic Experiencing. They spoke about the relevance of SE in the treatment of cancer. I referred to their oral presentations abundantly in this article. For more information or access to Somatic Experiencing services, oncology nurses can contact Valerie Linet, LCSW-R SEP, at Oncology Support Program, HealthAlliance Hospital (845-339-2071 ext 101). For information regarding her private practice, Ms Linet can reached by phone at 845-418-3118 or by email at Valerielinetlcsw@gmail.com Additional information about trauma is available at www.traumahealing.org. Andrea Cantor is social worker and online group moderator at CancerCare. REFERENCES 1. Whipple SA. Intro to Somatic Experiencing. Oral presentation at: CancerCare Staff Development Training; May 12, 2017;

Utilizing some of these tools in com-

New York, NY.

bination may significantly affect cancer patients’ radiation treatment experiences in a positive way. The effects of SE treatment are far reaching and may be effective in treating other illness that are linked to experience of trauma, as well.2 ■

2. Linet V. Finding ease and inner balance: SE

Author’s note As part of an oncology social worker training event conducted at CancerCare’s New York City offices, Scott A. Whipple, LCSW,

4. van der Kolk B. The Body Keeps the Score: Brain,

tools for cancer support. Oral presentation at: CancerCare Staff Development Training; May 12, 2017; New York, NY. 3. Levine PA. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books; 2010. Mind, and Body in the Healing of Trauma. New York, NY: Penguin Group; 2014.

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

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2017 • ONCOLOGY NURSE ADVISOR 49

ASK A PHARMACIST

CDK6 triggers cancer cell growth and proliferation

CDK Inhibitors Compared What is the difference between the CDK inhibitors? —Name withheld on request

At the time of this writing, there are 2 cyclin-dependent kinase (CDK) inhibitors approved for use in the United States: palbociclib (Ibrance) and ribociclib (Kisqali). A third agent, abemaciclib, is currently in development but is not yet approved for use by the Food and Drug Administration (FDA). These CDK inhibitors work by inhibiting CDK 4 and CDK 6. These 2 CDKs trigger growth and proliferation of cancer cells, particularly in hormone receptor (HR) positive, HER2negative breast cancer cells, thus their inhibition by CDK 4/6 inhibitors causes cell cycle arrest. Palbociclib was granted FDA approval as an initial endocrine therapy for metastatic breast cancer for use in combination with letrozole (Femara) in early 2015; in 2016, for use in combination with fulvestrant in patients who had

failed prior endocrine therapy; and its original indication was expanded in 2017 to include any aromatase inhibitor (eg, anastrozole [Arimidex] or exemestane [Aromasin]). All palbociclib approvals are for women with HR-positive, HER2-negative metastatic breast cancer. Ribociclib was granted FDA approval in 2017 as an initial endocrine therapy for women with HR-positive, HER2negative metastatic breast cancer in combination with any aromatase inhibitor. The efficacy of these 2 agents have not been compared head-to-head, so the decision regarding which agent to use is based upon adverse effects, formulary status, and other considerations. Both palbociclib and ribociclib are dosed once daily on a 21 days on/7 days off schedule. The adverse effects of palbocicib and ribociclib are similar, with both agents causing high rates of neutropenia (greater than 70%) as well as anemia (18% to 24%), headache (21% to 22%), and fatigue (36% to 37%) when given in combination with letrozole. Nausea has been reported in 51% of patients receiving ribociclib compared to 35% of patients receiving palbociclib, however thrombocytopenia is reported more frequently with palbociclib (15%). Additionally, elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) have been reported with ribociclib. ■

NATIONAL PRESCRIPTION DRUG TAKE BACK DAY OCTOBER 28, 2017 The next event will be held on Saturday, October 28, 2017. These events, promoted by the Drug Enforcement Administration (DEA) and local law enforcement, provide the general public with a way to dispose of unused medications. Many medications are accepted at these events, including controlled substances such as opioid pain medications, to prevent their abuse by other persons and allow for safe disposal. The most recent event, held on April 29, 2017, collected more than 900,000 pounds (450 tons!) of medications — the most for a single National Take Back Day yet. In addition, the National Association of Drug Diversion Investigators maintains a list of dropbox locations where unwanted medications can be disposed of year-round. This list, searchable by address and location, is available at www.RXDrugDrop Box.org/. These dropboxes are typically located in a law enforcement agency facility or a pharmacy, and are secure (once a medication is inserted, it cannot be removed except by personnel trained to operate the dropbox).

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

50 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2017 • www.OncologyNurseAdvisor.com