Oncology Nurse Advisor January/February 2020 by Haymarket Media

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January/February 2020

RADIATION & YOUR PATIENT FEATURE

A Review of Nurse-Led Efforts to Standardize Practices

FEATURE

The Effect of False-Negative Results in DTC Genetic Tests

Cerebral Radiation Necrosis in Nontarget Brain Tissue

THE ONA INTERVIEW

Immunotherapy and Breast Cancer with Adam M. Brufsky, MD

ISSUES IN CANCER SURVIVORSHIP

Cerebral radiation necrosis remains an incompletely understood dose-limiting complication of radiotherapy.

Multinational Consensus Panel Confirms Benefits of Exercise for Cancer Survivors

THE TOTAL PATIENT

Brokering Early Palliative Care: How Nurses Approached a Misunderstood Topic

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At the Helm: Navigating Into the Next Decade Seattle, Washington • June 11-13, 2020 Now in its 6th year, the ONA Navigation Summit continues to be the premier educational event for nurse navigators who are eager to discover transformational developments in the field. Summit Highlights Include: • Keynote: Navigating Health Insurance • Breakouts Session Topics: Immunotherapy, Generalist Navigation, Rare Tumors, CAR-T Therapy, Breast Cancer, and Gastrointestinal Cancers • NEW This Year: Two-hour hands-on workshops that feature interactive skills training on Advanced Concepts in Navigation, Navigation 101, and Navigating in Rural Areas • 2nd Annual ONA Navigation Awards

Don’t wait — visit ONANavigationSummit.com to secure your spot at this can’t-miss event.

ACCREDITATION INFORMATION AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is awarded up to 12 contact hours.

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EDITORIAL BOARD Eucharia Borden, MSW, LCSW, OSW-C Lankenau Medical Center Wynnewood, Pennsylvania Jiajoyce R. Conway, DNP, CRNP, AOCNP Cancer Care Associates of York York, Pennsylvania Leah A. Scaramuzzo, MSN, RN-BC, AOCN Kalispell Regional Healthcare Kalispell, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania

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Oncology Nurse Advisor (ISSN 2154-350X), January/February 2020, Volume 11, Number 1. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, 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. Copyright © 2020. 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.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 1

CONTENTS 4

January/February 2020

IN THE NEWS • Caspofungin and Lower Risk of Invasive Fungal Disease in Young Patients With AML • Corticosteroids May Be Effective for Managing Cytokine Release Syndrome Associated With CAR-T Therapy • Travel Distance Shown to Be a Rural-Urban Disparity in Access to Specialized Cancer Care • Early Steroid Use May Mitigate Adverse Effects Associated With Axicabtagene Ciloleucel CAR-T Therapy

• Risk of Cardiac Heart Failure, Arrhythmia Increased With Anthracycline for Lymphoma • Broad-Spectrum Antibiotics Do Not Appear to Significantly Increase Risk of Acute Graft-Versus-Host Disease • Symptom Management Is Primary Reason Patients With Breast Cancer Seek Medical Cannabis and more …

12 8

FEATURES A Review of Nurse-Led Efforts to Standardize Practices Leah A. Scaramuzzo, MSN, RN-BC, AOCN

The Effect of False-Negative Results in DTC Genetic Tests John Schieszer

14 FIND US ON

Tool Predicts Risk of Persistent Opioid Use After Treatment Bette Weinstein Kaplan

OncologyNurseAdvisor.com

facebook.com/OncologyNurseAdvisor

@ONAcom

linkedin.com/company/oncology-nurse-advisor

2 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2020 • www.OncologyNurseAdvisor.com

www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP Many Young Adult Hematopoietic Cell Transplant Survivors May Need Returnto-Work Interventions Post Transplant Data from the Center for International Blood and Marrow Transplant Research demonstrate a need to develop return-to-work interventions for patients who have undergone hematopoietic cell transplant as treatment of malignant, as well as nonmalignant, conditions. Tiffany Garbutt, PhD

THE ONA INTERVIEW Immunotherapy and Breast Cancer with Adam M. Brufsky, MD John Schieszer

RADIATION & YOUR PATIENT Cerebral Radiation Necrosis in Nontarget Brain Tissue Bryant Furlow

COMMUNICATION CHALLENGES Decision Paralysis, Limited Options Ann J. Brady, MSN, RN-BC, CHPN

ISSUES IN CANCER SURVIVORSHIP Multinational Consensus Panel Confirms Benefits of Exercise for Cancer Survivors Bette Weinstein Kaplan

JOURNAL REVIEW Targeted Screening for Breast Cancer in Men at High Risk May Improve Early Detection A long-term study sought to delineate risk factors for male breast cancer and to identify the potential benefits of screening mammography for men at high risk of breast cancer. John Schieszer

FACT SHEET Asbestos Exposure and Cancer Risk A review of how asbestos is used and health hazards related to the material. PUBLISHERS’ ALLIANCE: DOVE PRESS Immunotherapy for the Treatment of Breast Cancer: Emerging New Data A review of treatment options, advances in immunotherapy, and emerging drugs for triple-negative breast cancer. Breast Cancer: Targets and Therapy

THE TOTAL PATIENT Brokering Early Palliative Care: How Nurses Approached a Misunderstood Topic

Role of Olaparib as Maintenance Treatment for Ovarian Cancer: The Evidence to Date A review of use, indications, and clinical safety and efficacy of olaparib, a PARP inhibitor, in the treatment of ovarian cancer, including in patients with BRCA mutations.

Bette Weinstein Kaplan

OncoTargets and Therapy

FROM CANCERCARE The Benefits of Yoga for Patients With Cancer Marlee Kiel, LMSW

ON THE

WEB

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 3

IN THE NEWS

The results of a final analysis of a phase 3 trial comparing antifungal prophylaxis and caspofungin with fluconazole in children and adolescents undergoing chemotherapy for the treatment of acute myeloid leukemia (AML) revealed a significantly lower rate of invasive fungal disease among patients in the caspofungin arm. Although antifungal prophylaxis with posaconazole is recommended in clinical practice guidelines for adults with AML at risk of prolonged chemotherapy-related neutropenia, a reliable pediatric dosing schedule for posaconazole is lacking. This trial compared the efficacy and safety of fluconazole with caspofungin in pediatric, adolescent, and young adult patients with AML treated with chemotherapy. The primary outcome measure was the percentage of patients in each study arm with invasive fungal disease. The final study analysis included 260 and 257 patients who were randomly assigned to the fluconazole and caspofungin arms, respectively. At the final analysis, the 5-month cumulative incidence of invasive fungal disease was significantly lower for patients in the caspofungin arm compared with those receiving fluconazole (3.1% vs 7.2%; P =.03). Regarding treatment toxicity, 32.8% of patients treated with caspofungin and 38.4% of those receiving fluconazole experienced at least 1 grade 4 or 5 nonhematologic adverse event during chemotherapy cycles 1 to 5. The authors noted that “the findings suggest that caspofungin may be considered for prophylaxis against invasive fungal disease, although study interpretation is limited by early termination due to an unplanned interim analysis that appeared to have suggested futility.” Read more at https://bit.ly/ONA02201.

Corticosteroids May Be Effective for Managing Cytokine Release Syndrome Associated With CAR-T Therapy Cytokine release syndrome (CRS) is a potentially life-threatening inflammatory response caused by chimeric antigen receptor T-cell (CAR-T) therapy. The use of corticosteroids has been suggested as a possible method to mitigate this toxic response. Until now whether such use would compromise CAR-T treatment success has been unclear. In a study presented at the 61st American Society of Hematology (ASH) Annual Meeting & Exposition, held in

Orlando, Florida, researchers found that corticosteroid use did not influence the efficacy and kinetics of CAR-T cells in patients with relapsed/refractory B-cell acute lymphoblastic leukemia. The study included 68 patients, 28 adults, and 40 children younger than 18 years. Forty-two patients, including 10 patients with grade 3 CRS, 30 patients with grade 2 CRS, 1 patient with graft-versus-host disease, and 1 patient with neurotoxicity, were administered dexamethasone and/or methylprednisolone. Steroids were started at a low dose and were gradually increased if CRS symptoms did not resolve. Once CRS

4 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2020 • www.OncologyNurseAdvisor.com

Caspofungin and Lower Risk of Invasive Fungal Disease in Young Patients With AML

was improved, steroid treatment was gradually reduced and stopped. The effects of steroid use were evaluated 30 days after T-cell infusion and followed up monthly. Twenty-six patients received only supportive care without steroids. The researchers found no difference in complete remission rate between the steroid and nonsteroid group (92.2% vs 92.3%), indicating that even high-dose steroids did not interfere with treatment response. Patients who received steroids also had higher average CAR-T cell counts in peripheral blood at day 11 of treatment. Lastly, no significant differences in B-cell aplasia were noted in patients followed up more than 2 months post treatment. The authors concluded, “corticosteroids do not compromise the treatment efficacy and kinetics of CAR-T cells, [and] could be [used] as a feasible and effective approach to manage CAR-T associated CRS.”

People living within ZCTAs with higher rates of poverty, located in the South and West regions of the United States, and/or of American Indian/Alaska Native ethnicity were more likely to be more than 60 miles away from cancer clinicians. “To mitigate potential negative consequences due to long travel distances, multifaceted community solutions have been proposed. Mobile cancer screening, telemedicine, and home-based early-stage chemotherapy are commonly proposed solutions to address travel barriers,” the authors noted. They concluded, “State public health agencies, community health care facilities, and cancer care physicians, as well as other health care networks, could work together to target underserved and low-income populations and provide affordable travel options to repeated outpatient care for patients affected by cancer.” Read more at https://bit.ly/ONA022012.

Read more at https://bit.ly/ONA02205.

Risk of Cardiac Heart Failure, Arrhythmia Increased With Anthracycline for Lymphoma Lymphoma is often treated with anthracyclines. However, as lymphoma survival rates continue to rise, so does the risk of developing anthracycline-induced cardiovascular disease (CVD). In a study presented at the 61st ASH Annual Meeting & Exposition, held in Orlando, Florida, researchers found anthracycline use to be associated with an increased risk of cardiac heart failure and arrhythmia. The recent prospective study included 3063 patients with lymphoma who did not have cardiovascular disease prior to lymphoma diagnosis. The patients completed a risk factor questionnaire and were contacted every 6 months for the first 3 years after diagnosis to assess disease status; retreatment; and any onset of cardiovascular diseases, including congestive heart failure (CHF), coronary artery disease (CAD), valvular disease (VHD), and arrhythmia. At a median follow-up of 6.9 years, there were 280 confirmed cases of cardiovascular disease post lymphoma, including 86 CHF, 78 CAD, 40 VHD, and 164 arrhythmia. At 5 and 10 years, the cumulative incidence of CVD was 6% and 10.7%. Anthracycline treatment, male sex, and increasing age, as well as some lifestyle choices including former smoker, current smoker, body mass index (BMI) more than 30 kg/m2 were associated with increased risk of overall CVD. After adjusting for cardiac risk factors, anthracycline was significantly associated with an increased risk of CHF and arrhythmia, but not VHD or CAD. The number of anthracycline cycles was also significantly associated with an increased risk of CVD, with 0, 1 to 5, 6, and more than 6 anthracycline cycles associated with CVD incidences of 5%, 6.9%, 7.4%, and 7.7%, respectively. More specifically,

the number of anthracycline cycles was also associated with significantly increased hazard ratios for CHF and arrhythmia. “Both traditional CVD risk factors and treatment with anthracyclines was associated with an increased risk of developing CVD, and anthracyclines were a risk factor for arrhythmia and CHF in particular. Prevention of CVD in lymphoma patients will need to address both treatment and traditional lifestyle factors,” concluded the study authors. Read more at https://bit.ly/ONA02207.

Broad-Spectrum Antibiotics Do Not Appear to Significantly Increase Risk of Acute Graft-Versus-Host Disease A diverse microbiome after hematopoietic cell transplantation (HCT) is associated with higher risk of acute graft-versus-host disease (aGVHD). Broad-spectrum antibiotics, which are often prescribed for neutropenic fever, a common post-HCT sympExposure window tom, may promote gastrointestinal may prove to be key. microbiota diversity and increase the risk of aGVHD. However, according to study findings presented at the 61st ASH Annual Meeting & Exposition, held in Orlando, Florida, broad-spectrum antibiotics do not significantly increase the risk of aGHVD, although further studies are needed. The study explored 3 distinct classes of broad-spectrum antibiotics commonly used to treat neutropenic fever: antipseudomonal cephalosporins, antipseudomonal penicillins, and carbapenems. Treatment was classified as no, low (1 to 3 days), or high (> 3 days) exposure. Data from 2501 children aged 1 to 21 years who underwent their first HCT for acute leukemia at 35 hospitals from 2004 to 2017 were identified from the Center for International Blood and Marrow Transplantation Research (CIBMTR) and the Pediatric Health Information System (PHIS) databases and evaluated. Approximately 52.2% of patients were exposed to antipseudomonal cephalosporins, 24.1% were exposed to antipseudomonal penicillins, and 18.2% were exposed to carbapenems for at least 1 day. One-third of the patients developed aGVHD. In an unadjusted multivariable model accounting for patient demographics, transplant characteristics and aGVHD risk factors, high exposure to cephalosporins and carbapenems significantly increased the risk of aGVHD. Antipseudomonal

6 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2020 • www.OncologyNurseAdvisor.com

were also no differences in CAR-T cell expansion between the 2 cohorts (59 cells/uL in the early steroid group vs 42 cells/uL in previous cohort). Lastly, the cohort that received earlier steroid treatment had lower levels of key biomarkers indicative of severe neurologic events. Overall earlier steroid use appears to reduce the incidence of CAR-T associated CRS and neurologic events. However, the study authors caution, “Conclusions are limited by the nonrandomized study design, differences in population sizes, and in baseline characteristics between cohorts. Optimizing [adverse events] management is important to improve the benefit-risk profile of CAR-T cell therapy.”

penicillins showed the same trend but were not statistically significant. However, when the model was adjusted to account for exposure to other antibiotics within the same window, captured as fluoroquinolones and intravenous vancomycin, none of the antibiotic classes showed significant association with aGVHD risk. “Adjusted point estimates suggest exposure to carbapenems may confer some additional aGHVD risk,” wrote the authors. “Further exploration of different exposure windows is planned to understand if the identified associations change with capture of earlier or later antibiotic exposures.” Read more at https://bit.ly/ONA02208.

Symptom Management Is Primary Reason Patients With Breast Cancer Seek Medical Cannabis A study looking at the symptom profile of patients with breast cancer seeking medical cannabis has found that women with nonmetastatic and metastatic disease sought medical cannabis for symptomatic management of pain, anxiety, insomnia, nausea, and anorexia. The researchers reviewed Pennsylvania’s new medical marijuana program and found that patients with breast cancer seeking medical cannabis reported an average of 3 symptoms. The study findings, which were presented at the 2019 San Antonio Breast Cancer Symposium in Texas, showed that pain was often experienced along with insomnia and anxiety. The study included 54 patients with cancer, 31 of whom had breast cancer (22 had nonmetastatic disease and 9 had metastatic disease). There were significant age differences among the patients, ranging from 26 years to 86 years (median age, 64). The study showed 16 of the 22 (73%) women with nonmetastatic disease chose cannabis for pain. Among these 16 women, 25% (4 patients) developed chemotherapy-induced peripheral neuropathy (CIPN) and 19% (3 patients) experienced exacerbation of preexisting muscle/joint pain from hormonal therapy. Among the 22 patients with nonmetastatic breast cancer, 11 (50%) had insomnia and 10 (45%) had anxiety, and 8 women reported they were suffering from both insomnia and anxiety. One of the 22 women reported nausea and 3 women reported they were recreational users who wanted to upgrade to medical-grade products. Among the 9 patients with metastatic breast cancer, 8 (89%) sought medical cannabis for cancer pain and 8 (89%) sought it for anxiety. Three women (33%) wanted the

medical cannabis for insomnia; the same number of women wanted it for anorexia (33%) and nausea (33%). Overall, 50% of patients with pain expressed concern over opioid use and wanted to avoid its use. Read more at https://bit.ly/ONA022010.

Recognition of Dermatoscopic Characteristics of Neck Melanomas May Facilitate Earlier Diagnosis A retrospective study of neck lesions suspicious for melanoma showed that malignant melanomas were significantly more likely to be characterized by irregular hyperpigmentation compared with melanocytic nevi located on the neck. These findings were Peculiar aspects may published in Dermatology. aid early detection. Although the head and neck is considered a single anatomic unit, less is known about the clinical and histopathological characteristics of melanomas occurring on the neck compared with the face and scalp. Images of lesions suspicious for melanoma located on the neck of consecutive patients that were excised between 2011 and 2018 were assessed macroscopically, as well as through dermatoscopic image analysis. When available, reflectance confocal microscopy (RCM) images of these lesions were examined. Of the 31 neck lesions evaluated, 21 and 10 were determined to be melanoma and nevi, respectively, on biopsy. A comparison of the clinical characteristics of patients with melanoma and benign melanocytic lesions showed those in the former group were more likely to be older with a mean age of 60.4 years compared with 37.9 years for those with lesions determined to be nevi (P <.001). In addition, neck melanomas were more likely than benign melanocytic lesions to be located on areas of the skin damaged by the sun (76.2% vs 30%; P =.02). Dermatoscopic images of these lesions showed melanomas were more likely than nevi to exhibit irregular hyperpigmentation (blotches) (P =.04) as well as irregular hyperpigmented areas (P =.02). The study authors noted that “neck melanoma has peculiar clinical and dermoscopic aspects that could help clinicians to distinguish it from naevi and to diagnose melanoma earlier.” ■ Read more at https://bit.ly/ONA022011.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 7

FEATURE | Oncology Nursing

A Review of Nurse-Led Efforts to Standardize Practices Nurses working in a small health care organization in rural Montana sought to align inpatient/outpatient and adult/pediatric nursing practices. LEAH A. SCARAMUZZO, MSN, RN-BC, AOCN

ASCO/ONS Chemotherapy Administration Safety Standards include requirements for annual competency evaluations.

he American Society of Clinical Oncology/ Oncology Nursing Society (ASCO/ ONS) Chemotherapy Administration Safety Standards and the Commission on Cancer (CoC) include requirements for annual competency evaluations and comprehensive, continued education for staff.1 The changing world of cancer treatment underscore this rationale. At a small health care organization located in rural northwestern Montana, nurses recognized the need for chemotherapy competency evaluations due to a dearth of standardization between inpatient and outpatient, adult and pediatric oncology nursing; the organization lacked chemotherapy competencies, an oncology nurse educator, and opportunities for oncology nurses across settings to discuss practices. Oncology nurses identified variances in practice, as well as a disconnect between staff in the inpatient and outpatient settings. Many had little knowledge of each other’s respective work areas. Staff that worked in adult and pediatric oncology also noted numerous differences in care of patients receiving chemotherapy. To standardize the practice and network with other oncology nurses from the inpatient and outpatient setting, a team of nurses developed a hands-on Skills Day event for all evaluations of chemotherapy nurses using a scenario approach. INCONSISTENCIES IN PRACTICES Led by the acute care educator, a team was assembled that included nursing staff and nurse managers

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from the oncology adult inpatient unit and outpatient infusion, the hospital infusion area staff, an educator from the pediatric inpatient unit, and staff from outpatient pediatric oncology infusion. The team met twice monthly and identified practice variances in chemotherapy administration, personal protective equipment, extravasation, hypersensitivity reaction, safe handling of body fluids, hazardous drug disposal, and spill management. Reasons for the variances included differences in policies and procedures; equipment; resources for inpatient and outpatient areas; difficulties locating updated and current standards, as well as guidelines; lack of staff knowledge; and limited continuing education on the subject areas. The team gathered all policies regarding caring for oncology patients throughout the organization and found policies for inpatient and outpatient nursing were different, including variations in content for the same procedure. Some policies contained outdated references and were not easily accessible to staff. For example, the hazardous drug spill policy was located under the pharmacy department and not easily accessible to nursing. Team members gathered current literature as evidence for updating practices. Policies and procedures regarding all aspects of chemotherapy administration were updated and merged to encompass inpatient as well as outpatient areas. Additional search terms were included to allow staff to readily locate these policies. INCONSISTENCIES IN EQUIPMENT Next, the work group gathered equipment used during care of patients undergoing chemotherapy. Variations were found in gowns, gloves, spill kits, extravasation kits, hazardous drug trash bins, IV tubing set-up for administration, and bags for disposal of linens contaminated with body fluids. Current practice standards were then reviewed as a group, and decisions were made to update the equipment. Staff worked with the organization’s materials management department to obtain equipment. All equipment was brought up-to-date and standardized across the adult and pediatric, and inpatient and outpatient, areas. Job aids were created to assist staff with just-in-time information about the equipment (nursing staff had noted that infrequency of chemotherapy administration was a contributing factor to the variances).

The team found that some policies for inpatient and outpatient nursing were different, including variations in content for the same procedure. extravasation management of vesicants and irritants via peripheral and central venous access devices, cleanup of hazardous drug spills, handling body fluids and contaminated linen of patients receiving hazardous drugs, and management of a patient experiencing a hypersensitivity reaction. The event was held in the hospital’s simulation lab over multiple days throughout the week, including during day and night shifts, to allow all staff an opportunity to attend. Oncology nursing staff from all areas volunteered to lead stations through a train-the-trainer approach. Staff feedback from the event was extremely positive, and many participants commented that it was long overdue and were excited to meet the staff “from the other side.” In the evaluation tool, many participants reported feeling more competent and confident in caring for patients undergoing treatment. After the event, the management team often found staff were networking more often with the different oncology areas when caring for a patient receiving chemotherapy. FINISHING TOUCHES Next steps for the team include standardizing education resources provided to patients and families. The group is also developing an intranet site to serve as a clearinghouse for justin-time education and job aids. Oncology nurses practicing in rural settings lack resources, time, and opportunities to standardize and update evidence-based practices. Frontline nursing staff have the ability to make major contributions to their practice and might consider taking the lead in creating a similar project to bridge gaps between inpatient and outpatient oncology departments. This project is easily adaptable in any organization and can significantly improve continuity of care. ■ Leah Scaramuzzo is RN oncology clinical coordinator for Kalispell Regional Healthcare in Kalispell, Montana. REFERENCE

NURSE TRAINING

1. Neuss MN, Gilmore TR, Belderson KM, et al. 2016 Updated American

To assist with knowledge acquisition, the group developed scenario-based, hands-on skills stations. The skills stations included chemotherapy administration set up with IV tubing,

Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology. Oncol Nurs Forum. 2017;44(1);31-43.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 9

FEATURE | General Oncology

The Effect of False-Negative Results in DTC Genetic Tests Researchers highlight that false-negative results can be incorrectly reassuring and could prevent patients from receiving appropriate preventive care. JOHN SCHIESZER

Although DTC companies provide disclosures on the limitations of their tests, these disclosures may be difficult for patients to understand.

new study is suggesting that direct-toconsumer (DTC) genetic tests that rely on a limited variant screening approach often yield clinical false-negative results, leaving people with incomplete information.1 The findings from the study, which were presented at the American Society of Human Genetics (ASHG) 2019 Annual Meeting, in Houston, Texas,2 found that a clinical false-negative result can be incorrectly reassuring, and could stop people from receiving preventive care. “We wanted to provide data that quantifies how a limited screening strategy does or does not identify the information clinicians need to guide patient care. Until our paper, discussions of the limitations of the screening strategies offered via direct-to-consumer testing lacked data quantifying those limitations. We sought to provide it,” said Edward Esplin, MD, a clinical geneticist at Invitae Clinical Laboratories in San Francisco, California. Limited variant screening tests provide information on a small specific set of genetic variants widely known to be associated with risk of a disease. However, every gene can have thousands of potential variants that are associated with disease. Currently, the US Food and Drug Administration (FDA) has approved DTC genetic screening tests for genetic risk of breast, ovarian, and colorectal cancer. Dr Esplin and his colleagues analyzed FDAauthorized limited variant screening tests for the MUTYH gene (detects 2 variants associated

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FEATURE | General Oncology

with colorectal cancer common in people with northern European ancestry) and for BRCA1 and BRCA2 (detects 3 variants associated with breast cancer commonly occurring in people of Ashkenazi Jewish descent). The study included 270,806 patients who had been referred by health care providers for MUTYH genetic testing, and 119,328 who had been referred for BRCA1/2 genetic testing. Among those referred for MUYTH genetic testing, the tests would have missed 40% of people with mutations in both MUTYH genes. In addition, 22% of carriers of mutation in 1 MUTYH gene would also have been missed. In the group referred for BRCA1/2 genetic testing, study results showed that approximately 19% would have received a false-negative result. Dr Esplin’s team also analyzed the rate of false negatives among patients with different ethnic backgrounds. They found results for MUTYH genetic testing would have been clinical false negative for 100% of Asians, 75% of blacks, 46% of Hispanics, and 33% of whites. In the group undergoing BRCA1/2 genetic testing, the numbers were similar: 98% of Asians, 99% of blacks, 94% of Hispanics, and 94% of whites would have received clinical false-negative results. “The recommendation to not use limited screening strategy testing for clinical decision-making is well placed,” Dr Esplin said in an interview with Oncology Nurse Advisor. Variant screening strategies would have missed clinically significant genetic variants in the vast majority of patients at risk for breast and colorectal cancer. These results underscore the need to use comprehensive clinical genetic testing results for any health decisions, he added. Pamela N. Munster, MD, co-leader of the Center for BRCA Research at the UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco, California, said these study findings accurately reflect the ever increasing problem of putting very relevant medical tests in the hands of the consumer without assuring that they fully understand what the test is not testing. “We will never be able to regulate information, however, it speaks to the important need of providing the necessary understanding of [these] tests and their relevance and limitations,” Dr Munster explained to Oncology Nurse Advisor. “I feel very strongly that genetic testing is here to stay, so let’s educate the consumer on what they are getting and how to read the fine print.” There is nothing misleading about these tests if the person is able to understand the intricacies of large scale genotyping and the concept of select population founder mutations, she explained. Kara N. Maxwell, MD, PhD, assistant professor of medicine and genetics at the Perelman School of Medicine at

Limited variant screening tests give information on a small specific set of genetic variants that are known to be associated with risk of a disease. the University of Pennsylvania in Philadelphia, said Dr Esplin’s study from Invitae could be viewed as conflicted given the genetic testing company stands to benefit from endorsing the type of testing compared with the direct-to-consumer model. “However, I do not believe this to be the case in this study and applaud the authors on taking a scientific approach to this issue,” explained Dr Maxwell. “In the academic community, many genetics providers believe that DTC genetic testing is doing a great disservice to patients.” The clinical genetics field is accumulating increasing numbers of examples of people who warrant genetic testing feeling falsely reassured by negative DTC genetic testing, particularly those tests that focus on ancestry-specific genetic mutations. Although the DTC companies properly provide disclosures on the limitations of their testing, this is a field that is fast-paced and difficult to understand. “I strongly recommend that patients with a family or personal history of cancer discuss genetic testing with their physicians, who can refer [them] to appropriate genetic testing programs as indicated,” Dr Maxwell stressed. Meagan Farmer, MS, a genetic counselor at the University of Alabama at Birmingham, said health care providers should be asking why consumers are seeking DTC testing. What is it they’re really looking for? Then use this as a bridge to medical grade genetic testing, when appropriate. “If a patient brings a health care provider a DTC test result, he/she should not throw it away because of the results of studies like this. That provider should look at the result, assess the patient’s medical/family history and concerns, and determine whether additional medical grade testing may be appropriate,” Ms Farmer explained to Oncology Nurse Advisor. ■ John Schieszer is a medical reporter based in Seattle, Washington. REFERENCES 1. Researchers quantify limitations of health reports from direct-to-consumer genetic tests [news release]. American Society of Human Genetics; October 17, 2019. Accessed January 7, 2020. 2. Esplin ED, et al. Limitations of direct-to-consumer genetic screening for hereditary breast, ovarian, and colorectal cancer risk. Oral presentation at: ASHG 2019 Annual Meeting; October 15-19, 2019; Houston, TX. Abstract 235.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 11

FEATURE | Oncology Nursing

Tool Predicts Risk of Persistent Opioid Use After Treatment UCSD researchers identified clinical risk factors and created a risk score to identify patients who might benefit from a proactive approach. BETTE WEINSTEIN KAPLAN

he opioid epidemic imposes scrutiny on clinicians and patients alike; with particular emphasis on cancer survivors who require the drugs to manage their pain. How does the clinician determine who is at risk for persistent opioid use and abuse? A group of radiation oncologists and pain specialists from the University of California San Diego (UCSD) sought to answer this vital question, and presented their findings at the 2019 American Society for Radiation Oncology (ASTRO) Annual Meeting, held in Chicago, Illinois.1 More than 50% of oncology patients who receive curative treatment suffer from moderate to severe pain that can be relieved by opioids, according to WHO pain guidelines.2 Although these medications are accepted for relief of such acute pain, their use in situations where patients have chronic pain (lasting for more than 3 to 6 months) is not well defined. There are risks associated with long-term administration, such as medication tolerance and loss of efficacy over time. The potential of toxicity can lead to conditions such as depression, difficulty concentrating, and sedation, and the patient may also develop hyperalgesia or hypogonadism. There are also the well-known risks of dependence, misuse and abuse, and accidental overdose. The authors of this study support adopting the clinical practice guideline of the American Society of Clinical Oncology (ASCO) when using opioids to achieve optimal pain management, using risk mitigation strategies such as judicious opioid

12 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2020 • www.OncologyNurseAdvisor.com

use, drug screening, adherence monitoring, and strategies for alternative pain management.1,3 CREATING A RISK SCORE The radiation oncologists sought to identify clinical risk factors and create a risk score, utilizing an evidence-based risk stratification approach to identify patients who might benefit from a proactive approach by the oncology nurse or other clinician. Their efforts resulted in the Cancer Opioid Risk Tool, a validated prediction tool for assessing the risk of persistent opioid use 1 to 2 years after treatment, estimating risk as low (<5%), intermediate (5%-25%) and high (>25%). The researchers used the Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI) database, which contains detailed electronic health record information on all veterans within the VA health care system. This database provided data on 106,732 veteran cancer survivors whose cancer had been diagnosed between 2000 and 2015.1 Common diagnoses among the VA patients were 1 of 12 noncutaneous, nonhematologic malignancies, including cancer of the bladder, breast, colon, esophagus, head and neck, kidney, liver, lung, pancreas, prostate, rectum, or stomach. The study group included patients who were treated with surgery, radiation therapy (RT), or both and who were alive without disease recurrence 2 years after treatment had begun.1 Two models of the Cancer Opioid Risk Tool are available on the website: Full and Lite. Using an automated algorithm, the risk for persistent opioid use is calculated based on data entered by the clinician. The lite model uses 5 variables: age, presence of depression, alcohol abuse, prior opioid use, and whether treatment included chemotherapy. The more complex, full, model uses those 5 variables plus employment status, psychiatric diagnoses, race, tobacco use, body mass index (BMI) category, type of cancer, disease stage, and local treatment.

Risk factors first reported in the San Diego study were younger age, white race, BMI, unemployment at the time of cancer diagnosis, lower median income, use of chemotherapy, increased comorbidity, and tobacco use. Substantially increased odds of persistent opioid use were associated with patients who had a history of prior alcohol abuse, nonopioid drug abuse, chronic or intermittent opioid abuse, and depression.1 Study limitations included whether research on mostly male military veterans would translate to a civilian population of both sexes. Also, veterans who saw combat were exposed to mental and physical trauma at higher rates than the general population, and this could increase their risk for opioid dependence or abuse.1

The Cancer Opioid Risk Tool is a validated prediction tool that seeks to assess the risk of persistent opioid use 1 to 2 years after treatment. MANAGING PATIENTS AT RISK The authors note that the absolute rate of persistent opioid use, abuse, and dependence was relatively low among the cohort of VA cancer survivors, especially among those who were opioid-naïve. They believe that improved risk stratification will allow for personalized risk assessment and improve the safety of pain management in cancer survivors. A more robust validation of the newer full tool will require a prospective study. Strategies that can help clinicians better manage patients at risk of persistent opioid use include establishing a signed treatment agreement, educating patients and their caregivers on the risks of abuse and/or misuse, and avoiding high risk formulations while minimizing lower total daily medication doses. ■

RISK FACTORS FOR PERSISTENT OPIOID USE

The radiation oncologists determined that the rates of persistent posttreatment opioid use among the VA cohort varied by type of cancer and prior opioid use. Significant findings included: • Patients with prostate cancer patients had the lowest rate of opioid use (5.3%). • The highest rate of opioid use (19.8%) was observed in patients with liver cancer. • The main variable for persistent opioid use after cancer treatment was the patient’s history of opioid use before a cancer diagnosis.1

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Vitzthum LK et al. Predicting persistent opioid use, abuse and toxicity among cancer survivors [published online November 22, 2019]. J Natl Cancer Inst. doi: 10.1093/jnci/djz200 2. World Health Organization. Cancer Pain Relief : With a Guide to Opioid Availability. 2nd ed. Geneva, Switzerland; 1996. Accessed January 13, 2020. 3. Paice JA et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325-3345.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 13

THE ONA INTERVIEW

Immunotherapy and Breast Cancer John Schieszer

ONA spoke with Adam M. Brufsky, MD, about studies presented at ESMO 2019 to get his take on the potential of immunotherapy for patients with breast cancer.

he 2019 European Society of Medical Oncology (ESMO) Congress in Barcelona featured some promising studies involving novel combination therapies that may improve outcomes for women with advanced breast cancer. New data presented at the Congress showed that treatment with a CDK4/6 inhibitor plus fulvestrant could help improve overall survival in women with hormone receptor-positive (HR+), HER2– advanced breast cancer. Researchers presented data from 2 studies that included 2 different patient populations and different CDK4/6 inhibitors. Findings on abemaciclib plus fulvestrant in patients with advanced breast cancer after failure of endocrine therapy and regardless of menopausal status were also presented.1 As well as data on ribociclib plus fulvestrant as first- or second-line therapy only in postmenopausal patients.2 New studies also presented at this year’s meeting suggest that immunotherapy may be appropriate for certain subtypes of triple-negative breast cancer. Oncology Nurse Advisor talked to Adam M. Brufsky, MD, PhD, associate chief in the Division of Hematology/Oncology and co-director of the Comprehensive Breast Cancer Center at the University of Pittsburgh School of Medicine, in Pennsylvania, about how immunotherapy is changing the treatment of advanced breast cancer. ONA: What were some novel approaches to managing breast cancer discussed at ESMO Congress 2019?

DR BRUFSKY: Some of the newer studies had to do with the use of immunotherapy in breast cancer. There was one study in particular that used immunotherapy as part of neoadjuvant therapy added to chemo in early breast cancer. The study shows that immunotherapy potentially improves response rates and hopefully survival. The KEYNOTE-522 study was a phase 3 study looking at pembrolizumab plus chemotherapy vs placebo plus chemo as neoadjuvant treatment, followed by pembrolizumab vs placebo as adjuvant treatment for early triple-negative breast cancer.3 So, it could potentially improve survival in women who have early stage disease and have triple-negative breast cancer. So, that was one big approach that looked promising. ONA: In your view, what new approaches may have the greatest impact on breast cancer treatment? DR BRUFSKY: The new approaches that may have a significant impact are the fact that the CDK4 inhibitors, which included palbociclib, ribociclib, and abemaciclib, may be added as a form of therapy for early metastatic breast cancer, and it turns out that when you add them to fulvestrant, you have an improvement in overall survival. So, we knew these agents improved progressionfree survival (PFS), but it now looks like they improve overall survival in metastatic breast cancer. We didn’t know that before, and we really have not had a lot of agents that improve overall survival in metastatic breast cancer but now we do.

14 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2020 • www.OncologyNurseAdvisor.com

ONA: In what ways is the management of triple-negative breast cancer evolving? DR BRUFSKY: Experts are now saying that we probably should be using immunotherapy for certain subtypes of triple-negative breast cancer. They have identified a particular marker, the PD-L1, on the immune cells in triple-negative breast cancer and found that these [patients] will respond to immunotherapy. One abstract that was presented focused on performance of PD-L1 immunohistochemistry (IHC) assays in unresectable locally advanced or metastatic triple-negative breast cancer. Research is showing the disease responds to immunotherapy.4 We now have a good biomarker for immunotherapy to predict long-term response from these agents. The KEYNOTE-119 study was a phase 3 study of pembrolizumab vs single-agent chemotherapy for metastatic triple negative breast cancer, and it was a negative study.5 These researchers found that immunotherapy did not work. In my opinion, it shows that we probably need to use it early in the course of the disease. Another interesting study investigated whether trilaciclib improves overall survival when added to gemcitabine/carboplatin for patients with metastatic triple negative breast cancer.6 This was a small study and we really are not sure whether trilaciclib is really going to go forward. The investigators really don’t know how it works. They think it is an immunostimulant, but they don’t have a lot of data

on it. It is interesting, but it is a small trial and we will just have to what to see where it goes. A study looking at the prognostic value of tumor infiltrating lymphocytes in patients with early-stage triple negative breast cancers in the absence of chemotherapy was rather interesting. This study sort of tells us what we already knew. If the immune cells are already infiltrating a cancer, then the cancer will respond better to immunotherapy.7 It is an interesting study and it shows how this can help with a prognosis in triple-negative breast cancer. ONA: What effects, if any, are concerns regarding cardiotoxicity having on breast cancer treatment decisions? DR BRUFSKY: This is a great question. In a study looking at radiotherapy-induced cardiovascular mortality in female patients with breast cancer, investigators tried to look at whether radiation therapy on the left side influenced the mortality of women with breast cancer.8 So, it is very interesting. We have to figure out if it matters if the radiation is on just the right side or the left side. A study that was highlighted at the meeting was a 4-arm randomized, double-blind, controlled trial evaluating the efficacy and safety of cardiotoxicity prevention in patients with nonmetastatic breast cancer treated with anthracyclines with or without trastuzumab.9 On this abstract, it is still a little bit early, but what they found was interesting. When

“They have identified a particular marker, the PD-L1, on the immune cells in triplenegative breast cancer and found that these [patients] will respond to immunotherapy.”

Take-home points for oncology nurses • New data reported at the ESMO Congress 2019 suggest that treatment with a CDK4/6 inhibitor plus fulvestrant may help improve overall survival in women with HR+, HER2– advanced breast cancer. • Immunotherapy may have a place in the early treatment of breast cancer. One study demonstrated that using immunotherapy as part of neoadjuvant therapy added to chemo in early breast cancer may improve response rates and hopefully survival. • Immunotherapy may be appropriate for certain subtypes of triple-negative breast cancer. A new study suggests that testing for PD-L1 may help identify which patients with triple-negative breast cancer may respond to immunotherapy. • Biomarkers may help in the prevention of cardiotoxicity in patients with breast cancer. In addition, adding an ACE inhibitor or other agents may help prevent heart failure in patients treated for advanced breast cancer.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 15

THE ONA INTERVIEW

“It is good that we are trying to delve into what is really going on ... and how to prevent it. We clearly don’t want someone to be cured of their breast cancer just to develop heart failure.”

combining trastuzumab with an anti-HER2 agent with anthracyclines, you can have a lot of cardiotoxicity. So, in this trial they are trying to decide how to affect that by adding ACE inhibitors and other agents that help heart failure prophylactically. It is an attempt to help prevent heart failure. A separate preliminary study examined new ways of preventing cardiotoxicity. Investigators looked at the usefulness of NT-ProBNP as a biomarker of cardiotoxicity in breast cancer patients treated with trastuzumab. NT-ProBNP is a marker for heart failure and they are trying to see if it can help us figure out who is going to develop cardiotoxicity on trastuzumab.10 These are all approaches that have promise, but they are not final yet. It is good that we are trying to delve into what is really going on here exactly and how to prevent it. We clearly don’t want someone to be cured of their breast cancer just to develop heart failure.

2. Slamon DJ, Neven P, Chia S, et al. Overall survival (OS) results of the phase III MONALEESA-3 trial of postmenopausal patients (pts) with hormone receptor-positive (HR+), human epidermal growth factor 2-negative (HER2–) advanced breast cancer (ABC) treated with fulvestrant (FUL) ± ribociclib (RIB). Ann Oncol. 2019;30(suppl_5):mdz394.007. 3. Schmid P, Cortés J, Dent R, et al. KEYNOTE-522: phase III study of pembrolizumab (pembro) + chemotherapy (chemo) vs placebo (pbo) + chemo as neoadjuvant treatment, followed by pembro vs pbo as adjuvant treatment for early triple-negative breast cancer (TNBC). Ann Oncol. 2019;30(suppl_5):mdz394.003. 4. Rugo HS, Loi S, Adams S, et al. Performance of PD-L1 immunohistochemistry (IHC) assays in unresectable locally advanced or metastatic triple-negative breast cancer (mTNBC): post-hoc analysis of IMpassion130. Ann Oncol. 2019;30(suppl_5):mdz394.009. 5. Cortés J, Lipatov O, Im SA, et al. KEYNOTE-119: phase III study of pembrolizumab (pembro) versus single-agent chemotherapy (chemo) for metastatic triple-negative breast cancer (mTNBC). Ann Oncol. 2019;30(suppl_5):mdz394.010.

ONA: Were any of the presentations you attended surprising in terms of findings/outcomes?

6. O’Shaughnessy J, Wright GS, Thummala A, et al. Trilaciclib improves overall survival when given with gemcitabine/carboplatin (GC) in patients with metastatic triple negative breast cancer

DR BRUFSKY: No, not really. The big trial,

KEYNOTE-522, was probably the biggest abstract, although its findings did not really surprise anyone. The trial investigated use of immunotherapy for early stage triple-negative breast cancer. The findings showed an improvement in pathological complete response rate. I don’t think we were surprised by that, but that was the biggest abstract. We were also not surprised by the survival data from the CDK4/6 inhibitors in metastatic ER-positive breast cancer. But we were pleasantly surprised that these trials were good news. ■

(mTNBC) in a randomized phase II trial. Ann Oncol. 2019;30(suppl_5):mdz394.011. 7. Park JH, Jonas SF, Dieci MV, et al. Prognostic value of tumor infiltrating lymphocytes (TILs) in patients with early-stage triple negative breast cancers (TNBC) in the absence of chemotherapy. Ann Oncol. 2019;30(suppl_5):mdz240.001. 8. De Ridder M, Mulliez T. Estimating radiotherapyinduced cardiovascular mortality in female breast cancer patients. Ann Oncol. 2019;30(suppl_5):mdz240.015. 9. Livi L, Barletta G, Martella F, et al. Pre-specified interim analysis of the SAFE trial (NCT2236806): a 4-arm randomized, double-blind, controlled study evaluating the efficacy and safety of

John Schieszer is a medical reporter based in Seattle, Washington.

cardiotoxicity prevention in non-metastatic breast cancer patients treated with anthracyclines with or without trastuzumab. Ann Oncol.

REFERENCES 1. Sledge GW, Toi M, Neven P, et al. MONARCH 2:

2019;30(suppl_5):mdz240.039. 10. Blancas I, Martín C, Martín-Pérez FJ, et al. Usefulness of

overall survival of abemaciclib plus fulvestrant in

NT-ProBNP as a biomarker of cardiotoxicity in breast

patients with HR+, HER2– advanced breast cancer.

cancer patients treated with trastuzumab. Ann Oncol.

Ann Oncol. 2019;30(suppl_5):mdz394.006.

2019;30(suppl_5):mdz240.041.

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Axial postcontrast T1-weighted magnetic resonance image shows left periventricular enhancement (arrow) induced by radiation.

Cerebral Radiation Necrosis in Nontarget Brain Tissue Bryant Furlow

erebral radiation necrosis (CRN) is a relatively common but poorly understood radiation dose-limiting complication of radiotherapy, involving brain tissue necrosis emerging after radiotherapy for brain tumors or head and neck cancers. Risks vary with radiotherapy modality, dose, treatment volumes, and fractionation schedules, and possibly, concurrent chemotherapy — but the molecular pathogenesis of this condition remains unclear. CRN represents a challenge

to patient cognitive performance and quality of life, but surgical interventions can slow or halt CRN progression and palliate its clinical symptoms. Low-dose bevacizumab appears to play a promising role in CRN management. CRN was first recognized more than 50 years ago but remains an incompletely understood dose-limiting complication of radiotherapy. It involves necrosis of nontarget, healthy brain tissue following intracranial or regional radiotherapy for primary or metastatic brain tumors or head and neck cancers.1,2 CRN typically occurs 6 months or more after treatment but can sometimes emerge much earlier. Early detection and treatment are important because of the potentially profound effects on patients’ quality of life, including neuropsychiatric sequelae.3 CRN can also be fatal due to cerebral edema-associated elevated intracranial pressure and herniation or cerebral hemorrhage.3-6 No clinical definitive guidelines exist for its treatment but surgery and corticosteroids can slow or halt CRN progression and several other treatment strategies are undergoing development, including low-dose bevacizumab, pentoxifylline, and hyperbaric oxygen therapy.4-7 Minimally invasive laser interstitial thermal ablation is also under study.6 Treatments have not yet been compared in prospective, head-to-head clinical trials, however. Despite advances in molecular pathology of CRN, its physiological underpinnings are still not entirely understood, but among patients with lung cancer and brain metastasis, oncogenic driver EGFR or ALK mutations and treatment with tyrosine kinase inhibitors appear to increase CRN risk.1,2,4,5 Inflammatory cytokine pathways and edema are believed to be involved in CRN progression. Radiation modality, dose, treatment

volumes, and fractionation schedules appear to be modulating factors, as might immunotherapy or concurrent chemotherapy, although the latter associations remain controversial.1,2,4,5 Intensity modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT) have improved radiotherapeutic sparing of healthy nontarget brain tissue, theoretically reducing CRN risk.6 However, brachytherapy is associated with up to a 50% risk of CRN, and CRN remains a significant dose-limiting toxicity for stereotactic radiotherapy (SRT).5,6 CRN is a diagnostic challenge because symptomatology can vary dramatically and radiographic imaging modalities do not always allow differentiation between it and recurrent brain metastases.4,5 Therefore, magnetic resonance imaging (MRI) has become a preferred imaging modality for detecting and characterizing CRN.6 Advanced MRI and positronemission tomography (PET) brain tumor imaging protocols have been developed that can identify and differentiate brain tumor, necrosis, and edema.6 Diagnostic peripheral blood sample (“liquid biopsy”) tests that detect glioblastoma-shed tumor cells and expression of inflammatory molecules with which CRN might be detected, are also under development.6 Neuropsychiatric assessments should be undertaken when CRN is suspected.3 TREATMENT

First-line palliative corticosteroid therapy can mitigate inflammatory cytokine pathways and reduce edema, although no clinical trials have been undertaken to validate this strategy.6 Pulsed corticosteroid therapy (eg, dexamethasone 4-16 mg/day in 1 or 2 fractions for 4 to 6 weeks with gradual tapering) reportedly can ameliorate CRN symptoms, but benefits tend to decline over time.6 Continued on page 21

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 17

RADIATION & YOUR PATIENT

COMMUNICATION CHALLENGES

Decision Paralysis, Limited Options Ann J. Brady, MSN, RN-BC, CHPN

Throughout the trajectory of their treatment, patients have few options. NCCN guidelines are reviewed, strategies for managing symptoms are explained. But I would argue that treatment recommendations are not true options to make a decision over. “It’s up to you,” we say. But really, is it? Who wants to choose between two bad possibilities? And so, our patients get on board. Some are fully engaged; most are reasonably compliant. Some are not. Some are pleasant and easy to work with, some are grumpy or whiny and present a challenge in managing their care. But most, at least initially, will choose what is recommended, then ask for accommodations. Fear is a terrific motivator.

Oncology nurses may be able to better assist patients making hard decisions with support rather than clarity.

cancer diagnosis brings with it many challenges and much suffering. Dealing with physical symptoms from the cancer, from the treatment of the cancer, or both is difficult enough. And yet there is more. Cancer is greedy. It impacts a person physically, and it impacts the person emotionally and spiritually. One of the more complicated effects is that it takes away a person’s control over their own decision making. Sometimes I wonder if that is why there are patients who, once they hear their diagnosis, are lost to follow up. They walk away because it is a way to exercise choice, something they have control over when everything is out of control. Throughout treatment there are hundreds of times a patient is ostensibly given a choice: surgery or no surgery, chemo or no chemo, medication for pain or nausea or no medication. Yet what kind of choices are they truly when the patient and loved ones have been forced into a place they do not want to be?

CASE

Philip had a polyp that was found during a routine colonoscopy. In retrospect, he admitted he’d been having some mild symptoms but nothing that alarmed him. After all, he had rationalized, he was getting older and likely the changes he noted were from that. But the polyp that was discovered was too large to remove, and the biopsy indicated a malignancy. He was sent to a colorectal surgeon and after some additional diagnostic testing, the surgeon recommended surgical excision. The proposed surgery was a big operation, and Philip listened carefully as it was explained to him. “Do you have any questions?” the surgeon asked. “What if I don’t have the surgery?” “It will keep growing. Eventually it will cause a blockage.” Philip paused, and then with a wry smile, said to the surgeon, “So, I really don’t have a choice, do I?”

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The room was completely silent for a moment until the surgeon said, “Not really.” Philip is a pragmatic sort of guy. He saw the irony of being caught between two terrible choices. He was able to say he wanted the surgery, though it was a decision by default. What happens when a patient or family is presented with two options and rather than making a definitive choice, they get stuck? Not a fight-or-flight reaction; instead they freeze in place. Essentially, they become paralyzed and unable to make a decision. I most often see this when a patient has a recurrence or when their treatment does not produce the hopedfor response. They have done everything they were expected to do and now face a decision to continue in spite of a diminishing margin of return or to stop. Their choices have narrowed into two equally unpalatable options. A patient named Mary said, “If I don’t continue chemo, it is like I am giving up. How can I give up when I’ve fought for so long?” Frank said, “Everyone I know is praying for a miracle. I don’t want to disappoint them.” Alfredo said, “I really want to stop treatment but my doctor says she has another drug for me to try. What should I do?” DISCUSSION These are complex questions. As always, understanding the context of the question is vital. When we, as health care providers, are asked difficult questions by our patients and families, to feel that we should have an answer is normal. They look to us because of our experience and expertise to help them decide.

But rather than answer their question with what I believe is the best clinical choice, I answer with a question of my own, with the goal of gathering more information. Because as it turns out in many of these situations, there is no right or wrong answer. One way to start a dialogue is to acknowledge what a challenging position the patient is in. “Sounds like you are facing a difficult situation. Tell me more about what you think your options are.” Putting the choice in context is also important. For Mary’s question I might ask, “What does not giving up mean for you today?” And follow up with, “What might it mean for you tomorrow?” The answer may be different. Her answer might be, “I don’t want to give up, but I don’t know how I can keep going this way.” Right away this gives more context. The core of her struggle is linked to feeling physically depleted. Asking for clarification can help our patients by letting them hear, spoken out loud by themselves, how they view their choices. Oddly, we do not need to clarify for them, which is what we may focus on; rather we need to support them so they can clarify it to themselves. Decision paralysis is more than a struggle with making a decision. It is also a struggle over limited options. A recurring communication challenge for nurses is in listening to, clarifying, and supporting our patients when faced with debilitating decisions. ■

Rather than answer their question with what I believe is the best choice clinically, I answer with a question of my own, with the goal of gathering more information.

Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California.

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ISSUES IN CANCER SURVIVORSHIP

Multinational Consensus Panel Confirms Benefits of Exercise for Cancer Survivors Bette Weinstein Kaplan

here is one prescription that is applicable to almost everyone, healthy or not: Exercise. Exercise is especially helpful to cancer survivors, which now comprises more than 15.5 million people in this country, a number that continues to rise.1 However, although the benefits of exercise are becoming increasingly clear, actually putting it into practice can be difficult for someone who is fatigued, older, or returning to work while continuing to cope with their disease as well as comorbidities. Although in the past cancer patients were advised to rest and remain inactive, that changed in 2010 when guidelines advising the opposite were drawn up by experts in exercise and oncology. At that time, the American College of Sports Medicine (ACSM) met with oncology specialists and concluded that studies of survivors of breast and prostate cancers showed clear benefit from participating in exercise programs. These experts found that such programs improved survivors’ physical functioning and fitness, helped with their cancer-related fatigue, and generally enhanced their quality of life. Those preliminary recommendations have been updated by subsequent research; since then, results of more than 2500 randomized controlled trials on the importance of exercise have been published. The 2018 ACSM International

Multidisciplinary Roundtable on Physical Activity and Cancer Prevention and Control convened international exercise and rehabilitation professionals to update current evidence-based recommendations. Forty representatives from 20 worldwide organizations were in attendance. Their goals were to cover: (1) the role of exercise in cancer prevention and control; (2) the efficacy of exercise to improve cancer-related health outcomes (acute, late, and long-term effects); and (3) the translation of evidence into clinical and community settings. Attendees provided new evidence-based prescriptions for exercise testing and training using the acronym FITT — frequency, intensity, time, type. The program included safety precautions and other considerations specifically for cancer survivors. The guidelines based each exercise prescription on research that identified the optimal type, intensity, or frequency of exercise, and classified FITT prescriptions based on whether the supporting evidence was strong, moderate, or insufficient. STRONG EVIDENCE OF BENEFIT Anxiety The exercise prescription for

reducing anxiety in cancer survivors is moderate-intensity aerobics 3 times per week for 12 weeks or twice a week for 6 to 12 weeks if resistance training is added. Resistance training by itself does not reduce anxiety.

Depressive symptomatology This effect is significantly reduced with the same prescription of moderate-intensity aerobics 3 times a week for at least 12 weeks or twice a week for 6 to 12 weeks if resistance training is added. Resistance training by itself does not reduce depressive symptoms. Cancer-related fatigue Moderateintensity aerobics 3 times a week for at least 12 weeks can significantly reduce cancer-related fatigue both during and after cancer treatment. Adding resistance training can be effective, particularly for patients with prostate cancer. Health-related quality of life

(HRQOL) Moderate-intensity aerobics combined with resistance exercise 2 to 3 times a week for at least 12 weeks can lead to improved HRQOL during and after treatment. Lymphedema A progressive resistance program focused on large muscle groups 2 to 3 times a week with the caveat of “start low, progress slow” is safe; importantly, the Roundtable stresses that a fitness professional supervise these sessions. There is not enough evidence supporting aerobic exercise in lymphedema to draw conclusions. Physical function Self-reported physical function can improve with moderate intensity aerobics, resistance training, or both modalities combined 3 times a week for 8 to 12 weeks. Again, supervised exercise is the most effective.

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MODERATE EVIDENCE OF BENEFIT Bone health, sleep Exercise may

improve bone health and sleep in some situations. However, results of recent research in cancer survivors concluded that evidence of exercise improving bone health and sleep has been inconsistent. INSUFFICIENT EVIDENCE OF BENEFIT

Evidence on the benefits of exercise for several conditions is insufficient. The researchers stress that further research is needed to determine the benefits of exercise on cardiotoxicity, chemotherapy-induced peripheral neuropathy (CIPN), cognitive function, falls, nausea, pain, sexual function, and treatment tolerance.

Radiation Continued from page 17

Prolonged corticosteroid therapy can cause gastrointestinal bleeding and infectious complications like thrush or pneumonia.6 It can also compound CRN - associated neuropsychiatric symptoms because of steroid-induced psychosis.6 Corticosteroid-refractory CRN sometimes requires surgical resection of necrotic foci but edema must be monitored for several weeks after surgery.6 Surgical biopsy allows histopathological confirmation of CRN or recurrent tumor tissue. In contrast, a nascent clinical trial evidence base is emerging for low-dose bevacizumab.6,7 Bevacizumab appears to slow CRN progression by disrupting vascular endothelial growth factor (VEGF) but patients should be monitored for hypertension, thrombosis, ischemia, and renal dysfunction.6 Preliminary findings

MOVING THROUGH CANCER: RECOMMENDATIONS

The ACSM initiated the “Moving Through Cancer” program to help clinicians incorporate exercise into their patients’ treatment plans. The new recommendations include: • Exercise is important for all adults for the prevention of cancer, and specifically lowers risk of colon, breast, endometrial, kidney, bladder, esophagus, and stomach cancer; • Breast, colon, and prostate cancer survivors should incorporate exercise into their day-to-day routine; • Exercising improves fatigue, anxiety, depression, physical function, and quality of life; • The increasingly robust evidence base on the positive effects of exercise for

from a small phase 2 study concluded that ultra-low-dose bevacizumab (1 mg/kg once every 3 weeks for 3 or more cycles) is an effective alternative to standard-dose bevacizumab therapy.7 The study enrolled only 21 CRN-symptomatic patients, all of whom had undergone SRT; all but one had cerebral edema, which improved for 19 patients (95%) with ultra-low-dose bevacizumab.7 MRI CRN image intensity also declined significantly (P =.001).7 No grade 3 or higher adverse events were reported for this regimen.7 Additional, larger studies with longer follow-up are needed to validate those hopeful but preliminary findings, the authors emphasized.7 ■

Exercise is important for all adults for the prevention of cancer. cancer patients should be translated into practice. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Campbell KL et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019 Nov;51(11):2375-2390.

2. Gil-Salu JL. Comments on the review article “Cerebral radiation necrosis: diagnostic challenge and clinical management” [English edition]. Neurologia. 2018;33(4):275-276. 3. Holmes EG et al. Psychiatric care of the radiation oncology patient. Psychosomatics. 2017;58(5):457-465. 4. Rahmathulla G et al. Cerebral radiation necrosis: a review of the pathobiology, diagnosis and management considerations. J Clin Neurosci. 2013;20(4):485-502. 5. Loganadane G et al. Brain radiation necrosis: current management with a focus on nonsmall cell lung cancer patients. Front Oncol. 2018;8:336. 6. Ali FS, Arevalo O, Zorofchian S, et al. Cerebral radiation necrosis: incidence, pathogenesis,

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

diagnostic challenges, and future opportunities. Curr Oncol Rep. 2019;21(8):66. 7. Zhuang H, Zhuang H, Shi S, Wang Y. Ultra-

REFERENCES

low-dose bevacizumab for cerebral radiation

1. Giglio P et al. Cerebral radiation necrosis.

necrosis: a prospective phase II clinical study.

Neurologist. 2003;9(4):180-188.

Onco Targets Ther. 2019;12:8447-8453.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 21

THE TOTAL PATIENT

Brokering Early Palliative Care: How Nurses Approached a Misunderstood Topic Bette Weinstein Kaplan

ncology nurses are in an ideal position to recommend early palliative care for patients. For this reason, in a recent Canadian study on brokering palliative care, researchers looked at the role of nurses as advocates for early palliation.1 Oncology nurses in Canada have different roles than their counterparts in the United States; staff nurses cannot refer patients for palliative care, but advanced practice nurses and nurse practitioners can. They identify patients who would benefit from early palliation and introduce or “broker” the concept to the patient and the doctor. A stigma is still associated with palliative care as some clinicians continue to believe that the concept undermines a curative intervention. However, palliative care can be effectively introduced along with other treatments, and the combination of care improves patient symptoms and quality of life. Nurses, because of their routine interactions with patients, can participate in deciding who would benefit from palliation, acting as intermediaries between the oncologist and the patient in such situations. Researchers undertook a study to explore the unique psychosocial processes utilized by ambulatory care oncology nurses in introducing early palliative care to those patients the nurses felt would benefit from it. The

study took place at Princess Margaret Cancer Centre, a comprehensive cancer hospital in Toronto, Canada. Ambulatory care clinics, organized by disease site and primarily staffed by oncologists, advanced practice nurses, and registered nurses, provide outpatient oncology care. A number of the clinics are led by nurses and nurse practitioners, who in turn address patients’ symptoms and treatment concerns with the oncologist. For the study, the Canadian group recruited 20 nurses: 10 nurse practitioners, 6 staff nurses, and 4 advanced practice nurses. Eighteen of the nurses were female; all ranged in age from 25 to 64. The primary goal of the research was “to conceptualize the psychosocial processes” involved in brokering palliative care by oncology nurses. The secondary goal was to determine how nurses draw on their relationships with patients when providing care. An oncology nurse who was a postdoctoral research fellow at the time conducted the one-on-one interviews, either in person or on the phone; each interview lasted approximately 1 hour. BROKERING PALLIATIVE CARE To “sell” palliative care to patients, a nurse would approach a patient and say, “We have a team here in the hospital. They’re really strong doctors and nurses

and they help patients manage all these symptoms.” Aware of the stigma of palliative care, the nurse would not actually mention the term palliative care until the end of the discussion. Some nurses would bring the subject up “in the moment.” One clinical nurse specialist told the interviewer that sometimes she tells the patient, “I’m going to push this door open. You can close it and tell me to shut down.” That leaves the decision to the patient. Staff nurses were particularly aware of the restriction of brokering early palliative care within the parameters of their roles. Staff nurses could not make a formal palliative care referral without first clearing it with the attending physicians. Oncology nurses employed “wait and see” and “build trust, then discuss” strategies to introduce the concept of early palliative care to patients. WAIT AND SEE With the “wait and see” approach, nurses would mention the concept, then wait and see how willing patients were to hear about the benefits of early palliative care. They then took a step back if they saw that the patient was not ready after all, but would go forward with the idea if the patient wanted to hear more about the process. Continued on page 24

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cancer diagnosis can consume all areas of a patient’s life, especially their mental state. Implementing self-care and relaxation into their routines while maintaining a busy schedule of treatment and the requirements of their own lives is incredibly important for those living with cancer. Yoga is an ancient practice that originated in India and connects the mind and body through breath, movement, and meditation. It has taken the United States and the rest of the world by storm. Patients with cancer that practice yoga regularly find their quality of life and the complications of their emotional and physical states have drastically improved. Yoga has the ability to reduce the psychological stress caused by one’s diagnosis as well as helping manage the physical symptoms and side effects of treatment.

The Benefits of Yoga for Patients With Cancer Marlee Kiel, LMSW

PSYCHOLOGICAL AND EMOTIONAL IMPACT

Patients often report increased anxiety and depression after receiving a cancer diagnosis. Common symptoms that can coincide this time in a patient’s life include difficulty sleeping, fatigue, inability to focus, and increased negative thought patterns. Yoga has been proven to reduce psychological distress, including symptoms of anxiety and depression.1 It can be challenging for patients with cancer to prevent their minds from wandering, dwelling on the past, or worrying

self-regulation and awareness, which can make it easier for patients to cope with the stressful situations that inevitably arise after a cancer diagnosis.2 These skills can be used to proactively manage the many stressors that patients face. Yoga can also facilitate a spiritual experience and inner peace, which can be lost when initially diagnosed. A CancerCare client who participated in a biweekly young adult yoga program agreed. “I enjoy coming to the mat because I am able to focus solely on myself and my body,” the client explained. “I tune out work, doctor appointments, and cancer.” If done in a studio, yoga can foster a sense of community and camaraderie, decreasing feelings of isolation that can be caused by a cancer diagnosis. Yoga and meditation are not only useful while in treatment. The mindfulness achieved while practicing yoga carries into posttreatment survivorship. It can help limit anxiety caused by longer gaps between doctor visits, the fear of recurrence, and the uncertainties of follow-up scans. MANAGEMENT OF PHYSICAL SIDE EFFECTS

about the future. Meditation and deep breathing exercises allow patients an opportunity to clear their mind and focus on their breath, this intentional practice opens up a space for patients to feel grounded and helps them to focus on the present moment in time. Yoga a lso creates a sense of

Yoga can also be used as a tool to manage the various side effects that result from cancer treatment, including chemotherapy, radiation, and surgery. A variety of different stretches and movements, which should be tailored to meet the specific needs of the patient, can reduce pain and stiffness. Postures that target the abdomen can assist with side effects such as loss of appetite and chemotherapy-induced nausea and

Yoga practice can help patients cope with their cancer and manage the physical symptoms and side effects of treatment. www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2020 • ONCOLOGY NURSE ADVISOR 23

FROM vomiting.1 The management of these symptoms can improve patients’ ability to sleep, therefore improving their ability to function and their quality of life. In 2006, a study on yoga was done at the University of Texas M.D. Anderson

after a time of discomfort, disconnect, and what might have felt like betrayal of systems that once seemed to function normally.

Postures that target the abdomen can manage loss of appetite, nausea.

Determining how to squeeze yoga into their routines when patients are busy with treatment may feel overwhelming. An essential point for doctors, nurses, and social workers to make to patients is the importance of taking care of their bodies and minds. Yoga is a great option because it is affordable, noninvasive, and can be adapted based on the patient’s needs.2 Yoga can also serve as a segue to more intense workouts when first starting to exercise after treatment. As another participant of the CancerCare yoga program stated, “I wasn’t able to exercise while I was in treatment. Yoga is the perfect way for me to ease myself back into physical activity.” Patients should speak with their doctors to ensure that yoga is right for them prior to practicing. They need to be aware of any physical limitations

Cancer Center consisting of 61 women who were receiving 6 weeks of radiation treatment for breast cancer. Half of the women enrolled in the trial participated in yoga twice weekly, while the remainder of the women didn’t participate in yoga at all. The researchers found that women who participated in yoga reported having more energy, less sleepiness, improved physical functioning, and improved overall quality of life.3 Yoga can also help patients rebuild a positive relationship with their bodies

Total Patient Continued from page 22

Many felt that patients were less threatened by nurses than by physicians, since oncologists concentrated on achieving a cure, whereas nurses were more involved with supporting the patient, which fits in with the concept of palliative care. Build Trust, Then Discuss

Using the “build trust, then discuss” approach, the nurse often found an appropriate space in the close nursepatient relationship to build trust, discuss early palliative care and how

IMPLEMENTING YOGA INTO YOUR ROUTINE

it could help, and address the stigma associated with it. The strength of the nurse doing this is that the patient perceived the nurse as less threatening than the oncologist, and more engaged with the patient’s emotional issues and day-to-day concerns. The researchers felt that early palliative care for patients and their families could be made more accessible if all nurses received training in the theory of palliative care. They could then participate more fully in making referrals within the limitations of their practice roles. The Canadian group also recommended creating a nonhierarchical,

they might have to know what practice suits them. If new to yoga, it is best to start with a licensed instructor to learn the proper techniques and accommodations. Once a patient is familiar with the practice, yoga can be done in the comfort of one’s home. Breathing techniques and exercises can be done almost anywhere, which is what makes them so valuable. Ultimately, yoga can have tremendous benefits for anyone undergoing treatment for cancer, both for emotional and physical reasons, and can have ongoing benefits as patients continue their care. ■ Marlee Kiel is an oncology social worker at CancerCare. REFERENCES 1. Rao RM et al. Role of yoga in cancer patients: expectations, benefits, and risks: a review. Indian J Palliat Care. 2017;23(3);225-230. 2. Heeter C, Lehto R. Benefits of yoga and meditation for patients with cancer. Oncol Nurs News. 2018;12(4);37. 3. Yoga. Breastcancer.org website. https://www. breastcancer.org/treatment/comp_med/ types/yoga. Accessed January 14, 2020.

interprofessional practice model in oncology that would be collaborative and enable a joint approach among nurses and oncologists toward introducing early palliative care.1 ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Mohammad S, Savage P, Kevork N, Swami N, Rodin G, Zimmermann C. “I’m going to push this door open. You can close it”: a qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care [published online October 29, 2019]. Palliat Med. doi: 10.1177/0269216319883980

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HONOR A NAVIGATOR OR TEAM Seattle, Washington June 12, 2020 The 2nd annual ONA Navigation Awards will recognize outstanding achievements in the field of oncology navigation. Nominate your peers or your team by March 13th. Winners will be announced in Seattle at the 2020 ONA Navigation Summit. Award Categories Include: • Innovations in Oncology Navigation • Outstanding Oncology Navigation Program • Excellence in Navigation • And More!

Visit ONANavigationSummit.com to view the awards criteria and submit your nomination. # O N A AWA R D S