Oncology Nurse Advisor July/August 2020 by Haymarket Media

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July/August 2020

REFLECTIONS OVER A DECADE

EDITORIAL

Celebrating Milestones

A Review of Past Trends and Moving Forward With Oncology Nursing

COMMUNICATION CHALLENGES Finding Your Balance Amidst the Disruption of a Pandemic

ISSUES IN CANCER SURVIVORSHIP

Reviews and Updates on Survivorship Strategies Shown to Optimize Outcomes

THE TOTAL PATIENT

Supportive Oncodermatology: An Emerging Subspecialty in Multidisciplinary Cancer Care

ASK A PHARMACIST

PRSRT STD US POSTAGE PAID PONTIAC IL PERMIT #60

COVID-19: Treatment Delays; Take-Back Events

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Interactive video presentations from speakers Disease-specific breakout sessions Network and connect with fellow attendees Virtual Exhibit Hall Opportunity to earn up to 8 CNE credits And more!

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PUBLISHING STAFF

ADVERTISING STAFF

Editor Joyce Pagán editor.ona@haymarketmedia.com

Vice president, Oncology business development Henry Amato (646) 638-6096 henry.amato@haymarketmedia.com

Senior digital content editor Rick Maffei Oncology writer Susan Moench, PhD, PA-C Contributing writers Bryant Furlow Ann J. Brady, MSN, RN-BC, CHPN Bette Weinstein Kaplan Lisa A. Thompson, PharmD, BCOP Group creative director, Haymarket Medical Jennifer Dvoretz Graphic designer Vivian Chang Production editor Kim Daigneau

BUSINESS STAFF Vice president, Sales Operations & Production Louise Morrin Boyle

Manager, Multi-channel business development, Haymarket Oncology Marc A. DiBartolomeo (609) 417-0628 marc.dibartolomeo@haymarketmedia.com Associate account manager Kate O’Shea (646) 638-6028 kate.oshea@haymarketmedia.com

HAYMARKET MEDIA Editorial director, Haymarket Oncology Lauren Burke Vice president, Content; Medical Communications Kathleen Walsh Tulley

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

General manager, Medical Communications Jim Burke, RPh

Production manager Brian Wask brian.wask@haymarketmedia.com

President, Medical Communications Michael Graziani

Director of Audience Insights Paul Silver

CEO, Haymarket Media Inc Lee Maniscalco

Haymarket Media Inc Sales and Editorial offices 275 7th Avenue, 10th Floor, New York, NY 10001; (646) 638-6000 Subscriptions: www.OncologyNurseAdvisor.com/freesub Reprints: For reprints/licensing, contact Customer Service at custserv@haymarketmedia.com Permissions: https://www.copyright.com/get-permissions/ Unless otherwise indicated, persons appearing in photographs are not the actual individuals mentioned in the articles. They appear for illustrative purposes only.

Oncology Nurse Advisor (ISSN 2154-350X), July/August 2020, Volume 11, Number 3. 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 • JULY/AUGUST 2020 • ONCOLOGY NURSE ADVISOR 1

CONTENTS 18

July/August 2020

FROM THE EDITOR Celebrating Milestones Joyce Pagán

FEATURE Trends in Oncology Nursing: A Review of the Past 10 Years Vicki Moore, PHD

ISSUES IN CANCER SURVIVORSHIP Reviews and Updates on Survivorship Strategies Shown to Optimize Outcomes Bette Weinstein Kaplan

THE TOTAL PATIENT Supportive Oncodermatology: An Emerging Subspecialty in Multidisciplinary Cancer Care Bette Weinstein Kaplan

IN THE NEWS • ONS Guidelines on Cancer Treatment–Related Hot Flashes • PROs With Chemoradiotherapy in Treatment of Anal Cancer

COMMUNICATION CHALLENGES Finding Balance in the Disruption Ann J. Brady, MSN, RN-BC, CHPN

24 FIND US ON

ASK A PHARMACIST COVID-19: Treatment Delays; Take-Back Events Lisa Thompson, PharmD, BCOP

OncologyNurseAdvisor.com

facebook.com/OncologyNurseAdvisor

@ONAcom

linkedin.com/company/oncology-nurse-advisor

2 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2020 • www.OncologyNurseAdvisor.com

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.

IN THE NEWS

Clinical practice guidelines from the Oncology Nursing Society (ONS) on the management of hot flashes associated with surgery or drug-related therapy in women with breast cancer and men with prostate cancer were published in the Oncology Nursing Forum. Hot flashes can Over half of women undergoing affect quality of life. breast cancer treatment and approximately 80% of men receiving androgen-deprivation therapy (ADT) for prostate cancer may experience hot flashes. The interprofessional panel that developed the ONS guidelines emphasized that “nurses and other healthcare professionals need to know which patients are at risk for hot flashes and assess ... their degree of frequency, severity, and level of interference with quality of life.” For women with breast cancer who experience hot flashes, the panel suggested the use of an antidepressant over no treatment. Specifically, venlafaxine and paroxetine as an initial approach, with clonidine suggested for use in those not responding to the former agents. For men with prostate cancer experiencing cancer treatment–related hot flashes, the panel suggested the use of paroxetine or clonidine over no treatment. Furthermore, they suggested that women with breast cancer and men with prostate cancer experiencing hot flashes may benefit from physical activity, such as exercise or yoga, compared with no intervention. Read more at https://bit.ly/3eOifD3

PROs With Chemoradiotherapy in Treatment of Anal Cancer A study of patient-reported outcomes (PROs) in patients undergoing chemoradiation therapy for anal cancer suggests that patients initially experience a worsening of gastrointestinal (GI) symptoms with treatment, but that this worsening typically subsides within a few months of starting treatment. These findings were reported in JCO Oncology Practice.1 Patients included in this prospective analysis had nonmetastatic anal squamous cell carcinoma. All patients received definitive chemoradiotherapy, and they were given a survey

that consisted of the bowel subdomain of the EPIC questionnaire. EPIC scores for this subdomain were compared for subjects across timepoints at baseline and at 1 week, 3 weeks, 5 weeks, and 3 months after the start of therapy. The overall baseline median EPIC score for this population was 66, and at 1 week the median score had shifted to 82 (P =.009), signaling a worsening of symptoms. However, at 5 weeks, the median score had dropped to 54 (P =.025). Overall, from baseline to 3 months, there was not a significant difference in median score (P =.919). Read more at https://bit.ly/3hsxnI1

Less Frequent Vital Signs Monitoring in Low-Risk Patients Is Safe De-escalation of vital signs monitoring (VSM) in hematology-oncology patients using a nurse-led protocol that follows consensus low-risk criteria can maintain quality and safety of care. These findings were published in JCO Oncology Practice. Researchers conducted a problem analysis that identified the top 3 root causes of frequent VSM as perception of VSM, lack of concise clinical guidelines, and lack of nurse empowerment. The QIP team established criteria to identify low-risk patients and developed a nurse-led protocol for de-escalation, with the goal of reducing VSM of low-risk hematologyoncology patients by 50% within 4 months. Formal launch of the protocol occurred from October 2017 through September 2018. Of 1065 patients identified as low-risk, 108 (10.1%) required re-escalation of VSM, with none experiencing unexpected adverse outcomes. The most common reasons for re-escalation included fever (47.2%) and vital sign abnormalities (26.9%); nurses initiated 84.3% of the re-escalations. Review of all the re-escalations determined that none were deemed “not preventable with more frequent VSM.” A 50% reduction in the mean number of nurse encounters per month was achieved with the nurse-led de-escalation protocol. This produced a savings of 948.4 nurse encounters per month, amounting to a savings of 2731.5 nurse-encounter minutes per month. ■ Read more at https://bit.ly/30z4S4n

12 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2020 • www.OncologyNurseAdvisor.com

ONS Guidelines on the Management of Cancer Treatment–Related Hot Flashes

FROM THE EDITOR

Celebrating Milestones Joyce Pagán

he value of nursing is almost inestimable.” — The Lancet. In May we celebrated National Nurses Week, an annual event that marks the anniversary of the birth of Florence Nightingale. Celebratory events help grateful patients and fellow clinicians honor and thank those who respond to the same calling that guided the founder of modern nursing practice. This year National Nurses Week had a special meaning for several reasons. Year of the Nurse 2020 marks the 200th anniversary of the birth of Florence Nightingale. The World Health Organization (WHO) has chosen the milestone to mark 2020 as the International Year of the Nurse and the Midwife. The WHO has partnered with the International Confederation of Midwives, the International Council of Nurses (ICN), Nursing Now, a global campaign to increase the status of nursing, and the United Nations Population Fund to bring awareness to the challenges nurses face and to advocate for increased investment in the nursing and midwifery workforce. Pandemics and the Need for Nurses The COVID-19 pandemic has shone a bright light on nurses’ role within the healthcare team, but organizations throughout the world are working together to further investments in the nursing profession. The WHO, ICN, and Nursing Now published a landmark paper entitled “State of the World’s Nursing 2020” to define and support the role of nurses in patient care and world health care goals. 10 Years of Service This year Oncology Nurse Advisor celebrates 10 years of service to oncology nurses. In reminiscing through the first issue of ONA, which was published in

May 2010, I came across an Issues in Cancer Survivorship column that explained how a cancer center in Seattle, Washington, managed the H1N1 influenza outbreak — an eerily similar situation to the beginnings of the current COVID-19 pandemic. Other notable articles that have stood the test of time include a patient’s perspective on melanoma, an explanation of palliative care and hospice, and our most widely read article, “Large-volume IM injections: A review of best practices.” Our Move to Digital Over the years, ONA has worked diligently to keep up with the changes in oncology care. Not only has ONA evolved with the changes in nursing, how we deliver our content has also changed. Our goal is to be your main resource for all things oncology nursing. To achieve this goal, we are reducing the frequency of our print issues. We will continue to print special issues, but we are directing our editorial focus to expanding the ONA website to deliver information as close to real time as possible. In 2015 we launched the ONA Navigation Summit, an educational event focused on the unique challenges to navigating patients with cancer from diagnosis through survival. This too has transitioned to a digital event. Join us at the ONA Virtual Navigation Summit on September 12-13, 2020. Registration is free; visit www.ONANavigationSummit. com for more information. As we reflect on our 10-year anniversary, we’d like to congratulate all of our readers on the outstanding achievements made individually and collectively and for upholding incredible standards in patient care. Here’s to the International Year of the Nurse! ■

ONA works diligently to keep up with the changes in oncology care. Our goal is to be your main resource for all things oncology nursing.

www.OncologyNurseAdvisor.com • JULY/AUGUST 2020 • ONCOLOGY NURSE ADVISOR 13

FEATURE | 10-Year Anniversary

Trends in Oncology Nursing: A Review of the Past 10 Years A retrospective on how advances in oncology and changes in practices have influenced the growth of the oncology nurse profession. VICKI MOORE, PHD

hroughout the emergence of new treatments, novel delivery systems, and challenging new roles and practices, one thing has remained constant: Nurses are still the most trusted healthcare provider in the country. For that the publishing staff of ONA celebrates our 10 years with you, and looks forward to more years together. In honor of Florence Nightingale’s 200th birthday, the World Health Organization designated 2020 the Year of the Nurse and Midwife to recognize the critical impact nurses make on the communities in which they work.1 Oncology nurses play a vital role in improving the patient experience, from improved clinical outcomes to better qualitative experiences. As a nursing specialty, oncology nursing requires attention to detail and is fundamental for driving patient-centered care and integrating shared decision-making into the cancer care continuum. Furthermore, oncology nurses’ consistent implementation of standardized administration of cancer therapies can improve the safety, reliability, and overall patient experience, particularly as the treatment landscape of cancer evolves and changes rapidly.2 EVOLVING ROLES, ENDURING VALUE OF NURSES

The oncology nurse has traditionally been involved in multiple aspects of patient care, including patient assessment, patient education, coordination of care, supportive care, symptom 14 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2020 • www.OncologyNurseAdvisor.com

management, and often direct patient care during chemotherapy treatment.3 Oncology nurses also frequently operate as members of multidisciplinary care teams and may serve as patient advocates.4 Although many fundamentals of oncology nursing remain constant, technology has brought changes to the clinic. With the greater abundance of data and implementation of electronic health records and other technologies in recent years, skills and education in nursing informatics and telemedicine have grown in importance.5-7 Telemedicine continues to widen the opportunities for patient care, especially in more remote areas, and ongoing challenges include improving patient examination techniques and addressing policy barriers.7 Nurses consistently have been rated at the top of an annual Gallup poll of the most trusted professions in terms of honesty and ethics.8 Knowledge and commitment to dialogue have been shown to contribute to patient trust in nurses, and patient trust in healthcare providers may have a modest association with health outcomes.9,10 In a recent study from Italy, oncology nurses were found to demonstrate a high level of clinical competence, even in cases where oncology competence was less developed.11 In a 2018 survey in England of patients with cancer, 88% of respondents felt that their clinical nurse specialists mostly or always provided answers to important questions in terminology patients could comprehend.12 Additionally, nurses can play a critical role in shaping patient attitudes around the acceptance of dependence on care providers.13 KEY TRENDS IN CLINICAL PRACTICE Oncology nurses have worked in a changing therapeutic landscape. In the past, chemotherapy, surgery, and radiation therapy formed the mainstay of cancer treatments, but the emergence of newer types of therapies has fundamentally changed cancer care.14 Newer paradigms of treatment include targeted therapies and immunotherapy.14,15 In the field of immunotherapy, the past decade has featured the approvals of checkpoint inhibitors for the treatment of a variety of cancer types, leading to improvements in survival and reduced rates of adverse events in comparison with conventional treatments.16 In 2011, the US Food and Drug Administration (FDA) approved the checkpoint inhibitor ipilimumab, a cytotoxic T-lymphocyte antigen 4 (CTLA-4) inhibitor, for the treatment of advanced melanoma. This therapy has since expanded into the treatment of other cancers.16,17

Soon to follow in FDA approvals were several treatments directed at programmed cell death-1 (PD-1) proteins or PD-1 ligands, PD-L1 or PD-L2, beginning with the PD-1 inhibitor nivolumab, first approved in 2014 for treatment of melanoma.17,18 Nivolumab has since been approved for the treatment of kidney cancer, lung cancer, head and neck cancer, follicular lymphoma, and bladder cancer.18 These checkpoint inhibitor therapies have also been joined by pembrolizumab, atezolizumab, avelumab, durvalumab, and others, extending PD-1/PD-L1 inhibitor options for patients with a variety of cancer types and mutational loads.17,18

Chemotherapy, surgery, and radiation therapy formed the mainstay of cancer treatment, but newer types of therapies have changed cancer care. Another significant advance in cancer treatment to arise in the past decade has been the development of chimeric antigen receptor (CAR) T-cells as an immunotherapy tool.19 Since a report described the use of CD19 CAR T-cells in treatment of lymphoma in 2010, other studies have emerged in the treatment of relapsed or refractory B-cell cancers, demonstrating promising results.19 In August 2017, tisagenlecleucel-T was granted FDA approval as a treatment of B-cell acute lymphoblastic leukemia in children and young adults, demonstrating a complete remission rate of 60%.20 This approval was soon followed in October 2017 by the approval of axicabtagene ciloleucel for large B-cell non-Hodgkin lymphoma.20,21 Research also has ventured into the use of CAR T-cells for the treatment of solid tumors, though with results showing more limited success at this time.19,20 CAR T-cell therapies represent a promising new realm of cancer immunotherapy, but their use is not without hazards, such as cytokine release syndrome (CRS) and neurotoxicity.22 These risks vary by type of CAR-T therapy and can require careful management, a responsibility that oncology nurses often carry.22 Looking ahead, a recent review hints at challenges to overcome as the field of cancer immunotherapy matures.23 Some challenges relate to determining personalized approaches to treatment, some to the optimization of immunotherapy combinations, and others to our continually evolving understanding of the complexities of immune response.23 Rapid advancements in immunotherapy and CAR-T therapy

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FEATURE | 10-Year Anniversary highlight the incredible dynamism of oncology as a whole. Each newly approved therapy will carry its own host of benefits and potential issues with safety and tolerability. Caring for patients as they traverse their care has become the domain of oncology nurses, no matter the speed at which the field advances.

CONCLUSION New technologies in the past decade have driven advances in cancer treatments and in the growing use of electronic resources in patient care. Oncology nurses should remain alert to changes and ongoing trends to ensure their patients receive optimal treatment. ■

EMERGENCE OF THE ONCOLOGY NURSE NAVIGATOR The enactment of the Patient Protection and Affordable Care Act in March 2010 established a role for patient navigation in health care.24 With oncology’s rapidly changing therapeutic landscape, successfully coordinating care for patients across multidisciplinary teams can be supported by an oncology nurse navigator (ONN).25 Patients with cancer may struggle to navigate the healthcare system and experience confusion, trepidation, anxiety, and/or insufficient resources, but assistance from ONNs can partially or totally support overcoming these potential obstacles to optimal care.25

Vicki Moore is a medical writer based in Naches, Washington.

Caring for patients as they traverse their care has become the domain of oncology nurses, no matter the speed at which the field advances.

REFERENCES 1. World Health Organization. Key dates for nursing and midwifery discussions in May 2020. February 20, 2020. Accessed March 12, 2020. https:// www.who.int/news-room/detail/20-02-2020-key-dates-for-nursingand-midwifery-discussions-in-may-2020 2. Gross AH. What matters to the patient is what really matters: quality in oncology nursing. Clin J Oncol Nurs. 2015;19(2):144-145. 3. Rieger PT, Yarbro CH. Role of the oncology nurse. In: Kufe DW, Pollock RE, Weichselbaum RR, et al, eds. Holland-Frei Cancer Medicine. 6th ed. BC Decker; 2003. Accessed March 12, 2020. https://www.ncbi.nlm.nih.gov/ books/NBK13570/ 4. Cohen MZ, Ferrell BR, Vrabel M, Visovsky C, Schaefer B. What does it mean to be an oncology nurse? Reexamining the life cycle concepts. Oncol Nurs Forum. 2010;37(5):561-570. 5. Darvish A, Bahramnezhad F, Keyhanian S, Navidhamidi M. The role of nursing informatics on promoting quality of health care and the need for appropriate education. Glob J Health Sci. 2014;6(6):11-18.

Furthermore, ONNs serve as patient advocates, support and integrate organizational strategies for improved cancer care, and reinforce the use of evidence-based strategies in patient treatment.24,26 Involving ONNs earlier in care of patients, including at screening, can help with coordination of referrals, shorten time to diagnosis and treatment, expand patient and caregiver knowledge, improve adherence to care, and improve assessment of barriers.25,26 According to results from one pilot study, 5 core navigation metrics are applicable across navigation programs and include navigator competencies, navigation caseload, barriers to care, psychosocial distress screening, and interventions.27

6. Carr ER. Oncology nursing essentials: then and now. Clin J Oncol Nurs. 2015;19(2):223-225. 7. Doyle-Lindrud S. Telemedicine in oncology. Clin J Oncol Nurs. 2016;20(1):27-28. 8. Reinhart RJ. Nurses continue to rate highest in honesty, ethics [news release]. Gallup. January 6, 2020. Accessed March 12, 2020. https://news. gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx 9. Rørtveit K, Hansen BS, Leiknes I, Joa I, Testad I, Severinsson E. Patients’ experiences of trust in the patient-nurse relationship — a systematic review of qualitative studies. Open J Nurs. 2015;5(3):195-209. 10. Birkhäuer J, Gaab J, Kossowsky J, et al. Trust in the health care professional and health outcome: a meta-analysis. PLoS One. 2017;12(2):e0170988. 11. Iacorossi L, Gambalunga F, Di Muzio M, et al. Role and skills of the oncology nurse: an observational study. Ann Ig. 2020;32(1):27-37.

ADVOCATES FOR CLINICAL TRIAL PARTICIPATION

Oncology nurses can help to support patient participation in clinical trials.28 A continued trend of limited patient enrollment in cancer clinical trials is mostly attributed to structural and clinical barriers, but some eligible patients decline to participate or are not informed of their eligiblity.29 In one meta-analysis, eligible patients were found to participate more than half of the time when presented with the opportunity.29

12. National Cancer Patient Experience Survey 2018: National Results Summary. Quality Health Limited. Accessed March 12, 2020. https://www.ncpes.co.uk/reports/2018-reports/ national-reports-2018/4539-cpes-2018-national-report/file 13. Candela ML, Piredda M, Marchetti A, et al. Finding meaning in life: an exploration on the experiences with dependence on care of patients with advanced cancer and nurses caring for them. Support Care Cancer. Published online January 15, 2020. doi:10.1007/s00520-020-05300-8 14. National Cancer Institute. CAR T cells: engineering patients’ immune cells

16 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2020 • www.OncologyNurseAdvisor.com

to treat their cancers. Updated July 30, 2019. Accessed March 12, 2020.

23. Hegde PS, Chen DS. Top 10 challenges in cancer immunotherapy. Immunity. 2020;52(1):17-35.

https://www.cancer.gov/about-cancer/treatment/research/car-t-cells 15. Sutandyo N. New paradigm in treating cancer: right on target. Acta Med

24. Cantril CA. Overview of nurse navigation. In: Blaseg KD, Daugherty P, Gamblin KA, eds. Oncology Nurse Navigation: Delivering Patient-Centered

Indones. 2016;48(2):139-144.

Care Across the Continuum. Oncology Nursing Society; 2014:chap 1.

16. Suzuki S, Ishida T, Yoshikawa K, Ueda R. Current status of immuno-

Accessed May 18, 2020. https://cjon.ons.org/book/oncology-nurse-

therapy. Jpn J Clin Oncol. 2016;46(3):191-203.

navigation-delivering-patient-centered-care-across-continuum/

17. Dobosz P, Dzieciątkowski T. The intriguing history of cancer immu-

chapter-1-overview

notherapy [published online December 17, 2019]. Front Immunol.

25. Lubejko BG, Bellfield S, Kahn E, et al. Oncology nurse navigation:

doi:10.3389/fimmu.2019.02965

results of the 2016 role delineation study. Clin J Oncol Nurs.

18. Brassil KJ, Ginex PK. History of immunotherapy. In: Walker S, Dunphy EP,

2017;21(1):43-50.

eds. Guide to Cancer Immunotherapy. 1st ed. Oncology Nursing Society; 2018:chap 1. Accessed March 8, 2020. https://www.ons.org/sites/

26. Oncology Nursing Society. Role of the oncology nurse navigator throughout the cancer trajectory. Oncol Nurs Forum. 2018;45(3):283.

default/files/2018-10/0676_sample.pdf 19. Yang Y. Cancer immunotherapy: harnessing the immune system

27. Demonstrating value, sustainability of oncology navigation pro-

to battle cancer [published online September 1, 2015]. J Clin Invest.

grams [news release]. J Clin Pathw. Published March 5, 2020. Accessed

2015;125(9):3335-3337.

May 18, 2020. https://www.journalofclinicalpathways.com/news/ demonstrating-value-sustainability-oncology-navigation-programs

20. Sermer D, Brentjens R. CAR T-cell therapy: full speed ahead. Hematol

28. Flocke SA, Antognoli E, Daly BJ, et al. The role of oncology nurses in

Oncol. 2019;37 Suppl 1:95-100.

discussing clinical trials. Oncol Nurs Forum. 2017;44(5):547-552.

21. Riedell PA, Bishop MR. Safety and efficacy of axicabtagene ciloleucel in refractory large B-cell lymphomas. Ther Adv Hematol. 2020;11:2040620720902899.

29. Unger JM, Vaidya R, Hershman DL, Minasian LM, Fleury ME. Systematic

22. Dholaria BR, Bachmeier CA, Locke F. Mechanisms and management of

review and meta-analysis of the magnitude of structural, clinical, and

chimeric antigen receptor T-cell therapy-related toxicities. BioDrugs.

physician and patient barriers to cancer clinical trial participation. J Natl

2019;33(1):45-60.

Cancer Inst. 2019;111(3):245-255.

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 • Downloadable patient fact sheets

• Easy-to-use medical calculators • Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today. www.OncologyNurseAdvisor.com • JULY/AUGUST 2020 • ONCOLOGY NURSE ADVISOR 17

ISSUES IN SURVIVORSHIP © TOM WERNER / GETTY IMAGES

Reviews and Updates on Survivorship Strategies Shown to Optimize Outcomes Bette Weinstein Kaplan

he news on cancer survivorship has been mixed over the past 10 years. Although rates of death have gone down for most cancer sites, they have increased for others.1 For men, deaths from prostate and stomach cancers decreased, but they increased for cancers of the oral cavity and pharynx, soft tissue including the heart, brain and nervous system, pancreas, and melanoma.1 For women, deaths declined for the 3 most common cancers — breast, lung, and colorectal. However, deaths from cancers of the uterus, brain and nervous system, liver, soft tissue including the heart, and pancreas have increased. Deaths among women with cancer of the oral cavity and pharynx remained stable.1 Lung cancer deaths have declined by 4.8% per year among men and 3.7% per year among women. Despite this, lung cancer is still the leading cause of cancer death for both groups, accounting for approximately 25% of all cancer deaths.1 Over the past decade, Oncology Nurse Advisor has presented research on the cancer survivorship issues that patients look to oncology nurses for help with, ranging from adverse effect management, coping with being the atypical patient, and understanding treatment options. As part of our 10-year anniversary celebration, the editors revisited some of those reports and updated those earlier findings with the findings from more current studies.

CANCER-RELATED FATIGUE As more people survive cancer, more recognition has been given to the difficulties of living with the disease. A June 2010 article on cancer-related fatigue (CRF) covered theories as to cause and suggested exercise, counseling, and medication to alleviate it. Update The current philosophy is that patients with all levels of CRF deserve to have their fatigue addressed through education, counseling, and other modalities. Current treatment trends include exercise, yoga, physiotherapy, and sleep therapy, as well as dietary interventions. Clinicians may also consider prescribing psychostimulants or antidepressants when CRF is accompanied by depression.2 DEPRESSION The effects of depression on physical disease could predict the patient’s outcome (August 2010). Mortality in patients who exhibited symptoms of depression was up to 26% higher than in those who did not have symptoms. This has not changed. Update A 2018 study reported that “depressive symptoms, even in subthreshold manifestations, have been shown to have a negative impact in terms of quality of life, compliance with anticancer treatment, suicide risk, and likely even the mortality rate for the cancer itself.”3 The authors conclude

18 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2020 • www.OncologyNurseAdvisor.com

that more studies and treatment of depression in cancer patients with and without symptoms are needed. LYMPHEDEMA Weight lifting seemed to be a controversial therapy for reducing the risk of developing lymphedema after breast surgery in January 2011. However, this study showed that breast cancer survivors could benefit from participating in weightlifting programs. Update The news is even better now. A 2019 study prospectively evaluated the beneficial effect of heavy-load resistance exercise on lymphedema development in women receiving chemotherapy for breast cancer. The exercise does not increase risk of lymphedema.4 MALE BREAST CANCER In July 2010, few people talked about male breast cancer. It was a rarity, accounting for less than 1% of breast cancer diagnoses worldwide. The most common treatment was mastectomy with or without radiation. Chemotherapy plus tamoxifen and other hormonal therapies were used for men with node-positive tumors. Update The authors of a recent review cite the same incidence. Treatment recommendations continue to be adapted from trials for breast cancer in women; therefore, they call for more research on

male breast cancer, including a multinational consortium approach, such as the International Male Breast Cancer Program, because so few patients would be eligible for clinical trials.5 VITAMIN D AND PROSTATE CANCER

In a 2015 interview, Bruce W. Hollis, PhD, discussed his study on the effects of high vitamin D intake on men with prostate cancer. Dr Hollis reported that the men in his study who were treated with vitamin D3 demonstrated biochemical and molecular changes consistent with a decrease in inflammatory processes 2 months after prostatectomy compared with men who did not receive vitamin D3. Update A 2019 study reviewed the evidence of the effect of vitamin D supplementation on prostate cancer biomarkers and patient survival. According to the review, “current evidence suggests that vitamin D supplementation in conjunction with standard of care (eg, chemotherapy, radiation therapy) may confer clinical benefits such as a decrease in serum [prostate specific antigen] PSA levels and vitamin D receptor expression.” The authors call for further research to confirm the results.6 RESECTION FOR LUNG CANCER IN THE ELDERLY

A 2014 study from researchers at the University of Texas MD Anderson

Cancer Center in Houston, Texas, conducted a study to determine which modalities would be best for treating lung cancer in elderly patients. The study was a retrospective populationbased analysis that compared the oftenused lobectomy (removal of the entire lobe of lung) with sublobar resection (removal of the part containing the tumor) and stereotactic ablative radiotherapy (SABR), a type of radiation therapy comprising 3 to 5 sessions. They concluded that lobectomy is the treatment of choice for early-stage lung cancer in the elderly. Those who cannot tolerate surgery should be treated with SABR.

patient selection, management, and accurate lymph node staging. ■

Choice of method to use in the elderly with lung cancer is still controversial.

4. Bloomquist K, Adamsen L, Hayes SC, et al.

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Cronin KA, Lake AJ, Scott S, et al. Annual report to the nation on the status of cancer, part I: national cancer statistics. Cancer. 2018;124(13):2785‐2800. 2. Ebede CC, Jang Y, Escalante CP. Cancerrelated fatigue in cancer survivorship. Med Clin North Am. 2017;101(6):1085-1097. 3. Ostuzzi G, Matcham F, Dauchy S, Barbui C, Hotopf M. Antidepressants for the treatment of depression in people with cancer. Cochrane Database Syst Rev. 2018;4(4):CD011006. Heavy-load resistance exercise during chemotherapy in physically inactive breast cancer survivors at risk for lymphedema: a randomized trial. Acta Oncol, 2019;58(12):1667-1675. 5. Gucalp A, Traina TA, Eisner JR, et al. Male breast cancer: a disease distinct from female breast cancer. Breast Cancer Res Treat. 2019;173(1):37‐48.

Update The choice of which method

6. Petrou S, Mamais I, Lavranos G, et al. Effect

to use in the elderly patient with lung cancer is still controversial. A review paper published in 2019 found that “propensity-matched analysis showed significant association of sublobar resection with less blood loss, shorter operation time, chest drainage, and hospital stay, while with less lymph node removal when compared with lobectomy.”7 However the decision must consider

of vitamin D supplementation in prostate cancer: a systematic review of randomized control trials. Int J Vitam Nutr Res. 2018;88(1-2):100‐112. 7. Zhang Z, Feng H, Zhao H, et al. Sublobar resection is associated with better perioperative outcomes in elderly patients with clinical stage I non-small cell lung cancer: a multicenter retrospective cohort study. J Thorac Dis. 2019;11(5):1838‐1848.

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www.OncologyNurseAdvisor.com • JULY/AUGUST 2020 • ONCOLOGY NURSE ADVISOR 19

Supportive Oncodermatology: An Emerging Subspecialty in Multidisciplinary Cancer Care Bette Weinstein Kaplan

alliative care has become an accepted and important early intervention in the treatment of cancer. Defined as care that “improves the course of the disease in a number of ways, it minimizes a patient’s symptoms, increases his or her quality of life (QOL), and improves overall satisfaction.”1 As the practice continues to develop, new ways for oncology clinicians to aid their patients’ course of disease and quality of life are emerging. As part of our 10-year celebration, the editors of Oncology Nurse Advisor are also looking forward at emerging trends that may define oncology care in the next decade. A type of palliation that is making inroads in cancer care is supportive oncodermatology, a collaborative subspecialty between oncology and dermatology that aims to address the dermatologic adverse events associated with cancer therapy. An innovator in the field is Adam J. Friedman, MD, professor and interim chair of Dermatology and director of Supportive Oncodermatology, George Washington School of Medicine and Health Sciences in Washington, DC. IDENTIFYING A NEED FOR SPECIALIST CARE

The rapid development and use of targeted therapies have led to increased incidence of both established and new cutaneous toxicities. Although

supportive oncodermatology is still somewhat in its infancy, the field is making an impressive impact (email communication, Adam J. Friedman, May 2020). However, there is a dearth of data to support what clinicians are seeing in the clinic, so Dr Friedman and his colleagues initiated a study to better

Although still in its infancy, the field is making an impressive impact. document the impact of a dedicated clinic for these patients and to identify areas for improvement. They described how a comprehensive supportive oncodermatology program could improve patients’ quality of life in a recently published report.1 In a cross-sectional survey of patients who received care at the George Washington University Supportive Oncodermatology Clinic, the researchers sought to determine the role of dermatology within a multidisciplinary cancer care approach. Most of the patients were referred to the clinic by their oncologists. The survey was completed by 13 male patients and 21 female patients aged 45 to 64 years. The most common malignancies among the survey

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respondents were breast cancer (47%) and white blood cell disorders (24%). Study participants were referred to the oncodermatology clinic for treatment of adverse effects related to the skin (55%), nails (15%), and hair (12%). In their survey responses, patients reported that their nail-related adverse effects were treated with moisturizer, antibiotics, antifungals, vinegar soaks, urea, Nuvail™, and tazarotene. Seven percent of respondents were unable to recall what treatments they received. Those who experienced hair-related adverse effects were treated with minoxidil, scalp cooling caps, bimatoprost, and other therapies such as essential oils. One patient was unable to recall what treatment was administered for their hair-related adverse effects. Most patients received more than one type of treatment for nail, skin, and hair issues regardless of treatment area.1 QUALITY OF LIFE MEASURES

Before undergoing treatment at the oncodermatology clinic, patients reported an average quality of life (QOL) score of 6.5, which indicated a “moderate effect” on quality of life, compared with an average score of 3.8 after beginning treatment, which corresponded to a “small effect” on QOL. On average, after undergoing supportive treatment at the clinic, patients’ QOL category scores (physical symptoms, embarrassment,

clothes, social/leisure, work/school, close relationships) decreased, indicating a significant improvement in the effects of dermatology-related adverse effects on QOL. An exception was the QOL score for physical symptoms of itch, pain, or soreness. These scores did not demonstrate a significant decrease. The greatest difference in score reduction was for embarrassment.1 CARE STRATEGIES “Technically, we only have FDA [cleared] devices for cutaneous adverse events,” said Dr Friedman. Cleared and/or approved treatments include cooling caps and other barrier repair devices, as well as creams such as Biafi ne® topical emulsion for radiation dermatitis, the rash that develops from external beam radiation therapy. “However,” he added, “that doesn’t mean we don’t have a lot of tricks up our sleeves. Dermatologists are notorious for using treatments off-label effectively. Much of what we do in this arena falls into that category. We use topical steroids, anti-inflammatory antibiotics, oral isotretinoin, vinegar soaks, topical vasoconstrictors, and others. But, wellformulated research is needed and we are involved in that.” Dr Friedman advocates including dermatology “in the game from the

beginning.” Many patients undertake a “chemo class” before they start any treatment, and dermatology should be part of that pretreatment education and care. In a study of 379 cancer survivors who used a validated QOL tool, 67% of survivors felt that their dermatologic toxicities were worse than what they had expected, 84% were not referred to a dermatologist, and 54% thought they would have felt better had they been referred to a dermatologist.2 One major focus in this f ield is preventive strategies, Dr Friedman explained. Although data are limited, some small studies are showing that

A partnership with oncology nurses is essential for positive patient outcomes.

SKIN AWARENESS Dr Friedman advises being aware of and alert for the more common and expected adverse events that occur with both chemotherapy and targeted therapies. Oncology nurses should encourage their patients to be “skin smart.” Most of these drugs increase sun sensitivity, therefore, patients should apply a moisturizer that contains sunscreen to exposed areas daily. In addition, remind patients to always wash with mild soap and apply moisturizer to damp skin. A partnership between dermatologists and oncology nurses is essential for positive patient outcomes. “We need to collaborate more with oncology nurses,” he concluded. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Kaplan BW. Including palliative care at diagnosis benefits patients with advanced can-

if started in advance of cancer treatment, a combination approach of oral doxycycline, a mild topical steroid, and sunscreen can prevent papulopustular eruptions. If patients establish a routine of using a moisturizer on damp skin and creams containing urea on the hands and feet, they can potentially prevent some hand and foot reactions from occurring.1

cer. Oncol Nurse Advisor. 2012;3(3):41-42. 2. Aizman L, Nelson K, Sparks AD, Friedman AJ. The influence of supportive oncodermatology interventions on patient quality of life: a cross-sectional survey. J Drugs Dermatol. 2020;19(5):477-482. 3. Gandhi M, Oishi K, Zubal B, Lacouture ME. Unanticipated toxicities from anticancer therapies: survivors’ perspectives. Support Care Cancer. 2010;18(11):1461‐1468.

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COMMUNICATION CHALLENGES

Finding Balance in the Disruption

Ann J. Brady, MSN, RN-BC, CHPN

Perhaps the biggest challenge we face right now is how we communicate to ourselves.

e stood 6 feet apart, straddling the red Xs taped to the floor. The hospital cafeteria, typically bustling in the middle of the day, was populated with only a few staff members. There were no visitors, no distracted family members, and very few of the usual ancillary staff. We both wore scrubs and surgical face masks; her hair was pulled into a high ponytail. And though the overall feeling within the walls of the hospital was heavy with anticipation of what was to come, of how bad it may or may not be, there was a curious sense of camaraderie. Those of us still there were friendly and chatty. “Kind of a strange reality,” she said to me. Her brown eyes crinkled at the edges signaling the smile her surgical mask hid. I nodded agreement. “I miss normal,” I said. She was pretty and her voice was familiar, yet with her mask and scrubs, I couldn’t quite place her.

“Have a good day,” she said. “And don’t forget to wash your hands!” It wasn’t until I was paying for my food that all of the clues came together. She was the CNO of the hospital. I’d had conversations with her before, but she was always dressed fashionably, in lovely dresses and pants, and preferring heels to sensible tennies. I flat out had not recognized her. Our world is distorted right now. Our reality has been transformed. Things I knew and counted on, some of which I was even bored by, are altered to the point of being unrecognizable. The discomfort I feel is more than missing what was, it is grief and loss mixed in with a bit of trepidation. What will our new world look like? THE CHALLENGE Now more than ever how we communicate with our coworkers and our patients is challenged. As nurses we feel this in ways I venture to say no other healthcare provider does. We are the ones who provide the most hands-on care, literally and figuratively. We communicate by touch, by close proximity, and by a smile or an expression of concern. Those things are gone now, and I miss them. Because of COVID-19, instead of leaning in, we may feel more comfortable leaning out. Dr Fauci says we may never go back to innocently shaking hands when we meet. It may be a long while before we greet coworkers without the cover of a mask. Perhaps the biggest communication challenge we face right now is how we communicate to ourselves. The overwhelming loss of control can be so disorientating that we might forget our basic skills. One nurse questioned me about why a medication was

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ordered on a “COVID patient.” Before I could answer, he shrugged his shoulders. “Maybe this is part of a protocol.” I didn’t know the answer, but as he put the order in I asked him in response, “If this was not a COVID patient and a med was ordered that you had questions about, what would you do?” He paused for a moment and then said, “I’d ask the doctor.” It was obvious and yet not obvious. The fact that we are unfamiliar with COVID19 can make us forget that although we know little of the disease, we do know our nursing practice. The sense of vulnerability surrounding COVID-19 creates anxiety that can contribute to miscommunication. In this case, the communication challenge is about self-communication — what we tell ourselves. None of us know how to do this; it is unchartered territory. But what do we do when we are in unfamiliar surroundings? We rely on what we know. We rely on the parts of our practice we are certain of. DISCUSSION

This pandemic does more than challenge us by changing our practice. It challenges the way we process those changes. Instead of struggling to spend more time with our patients, we are working to spend the least amount of time in the room with them. The use of touch and facial expression to communicate to our patients is blocked by doors or masks. Confusing times lead to confusing feelings. The temptation may be to put our feelings “on the shelf,” to move through this pandemic by telling ourselves, “I’ll deal with that later, when this is all done.” Yet if we

We have to be cautious about holding too much in. It is okay to communicate that we are unsettled.

put our feelings on the shelf, when we get through this pandemic, the shelf may have collapsed under the weight of it. We have to be cautious about holding too much in. It is okay to communicate that we are unsettled. Nurses tend to respond to the tasks at hand, to push through and sometimes deny the stress. But we are stressed at work. We drive home through neighborhoods that are changed and arrive home to a life that is different. What we can do is acknowledge the stress this is causing. Creating a de-stress ritual can help. Since we are washing our hands so often, I’ve heard some use that time to whisper a prayer to themselves or maybe make the way they scrub their hands meditative. We can be purposeful on our commute home using the time for quiet deep breathing. I read of one family that takes their children out each day at 4:00 PM and lets them scream and holler for 5 minutes. We can scream in the car or in the shower. Each action communicates self-care, and each act of self-care is essential right now. Every aspect of how we live is impacted right now. How we practice is impacted. But we can talk about it. We can use this time to develop new ways of communicating, new strategies for connecting. And when this is over — and it will be over — although life and work and relationships are changed, we will incorporate what we learned from this into our practice and hopefully be stronger and more resilient in our profession. ■ Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California.

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 • JULY/AUGUST 2020 • ONCOLOGY NURSE ADVISOR 23

ASK A PHARMACIST

COVID-19: Treatment Delays; Take-Back Events Is there any guidance on which patients may be able to delay chemotherapy during the COVID-19 outbreak? — Name withheld on request

The risks of receiving immunosuppressive chemotherapy, as well as the trend toward increased complications in patients with cancer, have resulted in a lot of patients and oncology health care workers asking this question. Determining who should continue treatment for their cancer, how/if to modify treatment regimens, and how long treatment can safely be delayed is not an easy determination, and should be done with input from the patient

and healthcare team. Here are a few factors to consider: • The risks of delaying treatment (eg, a newly diagnosed acute leukemia vs maintenance therapy for a solid tumor) • If less immunosuppressive, effective treatment options are available • How to minimize in-person exposure (eg, switching from inpatient to outpatient administered chemotherapy, or changing from parenteral to oral regimens) • Patient-specific risk factors, such as other comorbidities • If any evidence or guidance is available for the disease setting At the time of this writing, the A mer ica n Societ y of Cl i n ica l Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) are maintaining resources for oncology health care providers and patients. The NCCN website also provides some disease-specific recommendations. Both sites are updated frequently, so it is important to check back as new information develops and new recommendations are published. Patients can find additional information about COVID-19 and how to protect themselves through the Centers for Disease Control and Prevention (CDC) and the American Cancer Society. Thank you all for your care and dedication to our patients living with cancer, especially during this time, and stay well!

When is the next DEA Drug TakeBack Day? — Name withheld on request

Given the need for social distancing due to the COVID-19 outbreak, the Drug Enforcement Agency (DEA) has postponed the National Prescription Drug Take-Back Day originally scheduled for April 25, 2020. The date for the next event has not been announced. If patients or caregivers need to dispose of unused medications before the next event, the Diversion Control Division website (www.deadiversion.usdoj.gov/ drug_disposal/index.html) provides information on disposal of unused drugs from the DEA, the Environmental Protection Agency (EPA), and the Food and Drug Administration (FDA). In addition, a list of year-round dropoff locations is available at https://apps2. deadiversion.usdoj.gov/pubdispsearch/ spring/main. Patients should contact a site prior to visiting, as many pharmacies and other locations may have limited hours during the COVID-19 outbreak. Resources for promoting participation in these events are available at https://takebackday.dea.gov/. The website’s Partnership Toolbox link includes posters and handouts in English and Spanish that encourage patients to dispose of their unused medicines responsibly. Since these events began, more than 6300 tons of unused medications have been collected. ■

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

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