Oncology Nurse Advisor Nov/Dec 2013 Issue by Haymarket Media

ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013

November/December 2013

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FREE CONTINUING EDUCATION INSIDE! Vertebroplasty is effective for managing myelomatous VCFs, PAGE 16

IN THE NEWS

New section: Navigator Notes from NCONN

FEATURE

SIDE EFFECT MANAGEMENT

Management of vertebral compression fractures due to multiple myeloma Vertebroplasty can prevent spinal collapse and relieve severe bone pain

Effectively maintaining nutritional status during cancer therapy

COMMUNICATION CHALLENGES

What I did not say

ISSUES IN CANCER SURVIVORSHIP

Motion and mobility before and after cancer treatment

VOLUME 4, NUMBER 6

THE PATIENT’S VOICE

5 things I now know about melanoma

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Oncology Nurse Advisor (ISSN 2154-350X), November/December 2013, Volume 4, Number 6. P ublished 6 times annually by Haymarket Media Inc, 114 West 26th Street, 4th Floor, New York, NY 10001. Oncology Nurse Advisor is available on a paid subscription basis at the following annual rates: USA $75, Canada $85, all other Foreign $110; Single copy price: USA $20; Foreign $30. To order, visit our Web site at www. OncologyNurseAdvisor.com or call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2013 • ONCOLOGY NURSE ADVISOR 1

CONTENTS 12

November/December 2013

IN THE NEWS • BMN 673 promising in BRCA cancers • LLLT improves common HNSCC side effect • NCONN Navigator Notes • Breast cancer survivors troubled most by postmastectomy pain

CONTINUING EDUCATION Vertebroplasty is effective for managing myelomatous VCFs Jayne C. Kasian, BA, BN, CON(C), MN; Laura Johnson, RN(NP), MN

FEATURE How to maintain nutritional status during cancer therapy Carolyn Farhy, MS, RD, LDN; Gretchen Skwer, RN, LDN; Rosemarie A. Tucci, RN, MSN, AOCN

STAT CONSULT Bendamustine (Treanda)

RADIATION & YOUR PATIENT Respiratory motion management: Essential to radiotherapy Bryant Furlow

C101: EMPOWER YOUR PATIENT Health literacy: A missing piece of the puzzle in the cancer journey Sarah Krug

FIND US ON

COMMUNICATION CHALLENGES What I did not say Ann J. Brady, MSN, RN-BC

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JOIN OUR COMMUNITY Submit a question to an oncology nurse advisor Have a question? Our panel of oncology clinicians is available to answer your questions. Submit questions to editor.ona@HaymarketMedia.com.

ISSUES IN CANCER SURVIVORSHIP Physical therapy and cancer: Motion and mobility before and after cancer treatment Bette Weinstein Kaplan

FROM CANCERCARE Online support groups: A psychosocial network Erin Columbus, MSW, LCSW

THE PATIENT’S VOICE 5 things I now know about melanoma Suzanne Wolfe

ASK A PHARMACIST What research is available on paroxetine and chemoprevention drug? Lisa A. Thompson, PharmD, BCOP

Answer the ONA poll question ONA asks… Answer our poll question and compare your opinions with those of your colleagues on key nursing issues at OncologyNurseAdvisor.com Subscribe to ONA newsletters Stay current with daily news reports and special series from key oncology conferences on our Web site, sign up for our e-newsletters at OncologyNurseAdvisor.com/subscribe. Earn CE credits Each issue offers one new CE activity co-provided by the Nurse Practitioner Healthcare Foundation. Activities are active for 2 years. Socialize electronically

ON THE

WEB

FEATURE ARTICLE Building a bridge between oncology and physical therapy Dan Neel

Keep up with the oncology field through our social media. We’re on Twitter and Facebook. Now, we’re on Pinterest, too. Follow us!

FEATURE ARTICLE Integrating CAM therapies into oncology care Kathy Boltz, PhD

THE TOTAL PATIENT Palliative care clinicians explain 10 points about the value of palliative care Bette Weinstein Kaplan

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2013 • ONCOLOGY NURSE ADVISOR 7

IN THE NEWS AN INVESTIGATIONAL new PARP inhibitor, BMN 673, is showing early responses in patients with heavily pretreated, advanced, BRCA-related breast and ovarian cancers. Phase I clinical trial results were presented in Boston, Massachusetts, at the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics, held October 19-23, 2013. The proteins, PARP 1 and PARP 2, recruit proteins that can repair the damage associated with loss of BRCA proteins. Mutations in BRCA genes often result in inefficient repair of damaged DNA, which increases the risk for developing certain cancers, including cancers of the breast and ovary. Inhibiting PARP, therefore, prevents the repair of damaged DNA, leading to cell death. Although some PARP inhibitors have been tested in various settings, none are approved to date. Zev A. Wainberg, MD, assistant professor of medicine at the Jonsson Comprehensive Cancer Center of the University of California Los Angeles School of Medicine reported that BMN 673, the most potent PARP inhibitor in clinical development, has optimized pharmaceutical

properties. It is well-absorbed orally, has substantial singleagent antitumor activity, and has a long half-life allowing once-daily dosing. High objective and clinical benefit response rates were observed in BRCArelated breast and ovarian cancers at low, oral, once-daily doses. “The clinical data to date are promising and compare favorably with results from clinical trials with other PARP inhibitors,” said Wainberg. Based on this phase I study, Wainberg and colleagues feel there is a good chance that patients with BRCA-related cancers who meet the study eligibility criteria can achieve disease control for a meaningful period of time with relatively few side effects. Wainberg added that randomized trials are still necessary.

Molecular model of the BRCA1 protein

BMN 673 is well-absorbed orally, has substantial single-agent antitumor activity, and has a long halflife allowing once-daily dosing.

The phase I trial evaluated the safety and efficacy of BMN 673 in a two-stage dose escalation/expansion study. So far, Wainberg and colleagues have recruited 39 and 41 patients to the escalation phase and expansion phase, respectively. Patients were 18 to 82 years old and had undergone one to 13 prior therapies. Fifty participants—18 with breast cancer, 28 with ovarian cancer, three with pancreatic cancer, and one with prostate cancer—had BRCA mutations in their tumors. To date, among the patients with BRCA mutations in their tumors, 44% of those with ovarian cancer and 44% with breast cancer had an objective response. Overall, 82% of the ovarian cancer patients and 72% of the breast cancer patients had clinical benefit. In patients receiving the 1-mg dose recommended for future trials, 50% of the breast cancer patients with BRCA mutations had an objective response and 86% had clinical benefit. Of the three patients with pancreatic cancer, two have had stable disease. Fewer than 20% of the patients had grade 3 adverse events including fatigue, anemia, neutropenia, and thrombocytopenia. One patient had a grade 4 toxicity. Given the high objective and clinical benefit response rates in breast cancer patients, the investigators have recently initiated a phase 3 trial in metastatic breast cancer with BRCA mutations. ■

BMN 673 promising in BRCA cancers

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LLLT improves common HNSCC side effect

NC NN

National Coalition of Oncology Nurse Navigators

Navigator Notes The National Coalition of Oncology

A DEFINITIVE TRIAL has indicated that low-level laser therapy (LLLT) reduces the occurrence of canker sores and improves quality of life in patients with head and neck squamous cell carcinoma (HNSCC) who are undergoing concurrent chemoradiotherapy. Almost all patients with HNSCC develop canker sores resulting from different modalities of treatment. No effective preventive strategy is currently available for canker sores, but prospective trials of LLLT in patients with HNSCC undergoing chemoradiotherapy showed promising results. The trial, led by Héliton Spindola Antunes, DDS, MSC, PhD, at the Brazilian National Cancer Institute (INCA) in Rio de Janeiro, Brazil, was conducted with 94 patients with HNSCC undergoing chemoradiotherapy. One group of 47 patients received LLLT, and the other 47 patients received a placebo. Only three patients receiving LLLT developed severe canker sores, whereas 19 patients in the placebo group developed severe canker sores. In the LLLT group, 59.6% of patients were free of canker sores compared with 21.3% in the placebo group. The LLLT group had less severe oral pain and, as a result, used fewer opioid analgesics. They were also less likely to require gastrostomy throughout the cancer treatment. ■

Nurse Navigators (NCONN) is the first association to identify, support, and connect nurses in oncology who navigate patients through the cancer continuum. There are many definitions of the role of the navigator that range from clinical nurses to volunteer survivors. Oncology nurse navigators (ONNs) are clinical professionals acting as a map or compass through the confusing process of diagnosis, treatment, and survivorship. A navigation program ideally, should include a multiple disciplinary team of professionals working in parallel with one another to address every aspect of a patient’s needs. The primary role of the navigator is to remove barriers and obstacles that patients encounter. Barriers may be real or perceived. In these economic times, understanding the ways in which navigation can improve the patient experience and outcomes is essential for all types of health care providers, and can play a part in health care reform. This discipline is dedicated to the holistic care of the patient with cancer. These patients and their families are in need of physical, mental, emotional, psychosocial, and spiritual support throughout the cancer continuum. There are numerous health care professionals involved in every patient’s care, but none is there throughout the entire journey to navigate the patient and family around barriers, identifying resources and services needed to improve quality of life, trust, and satisfaction in the system. ONN interventions can help reduce gaps in care. Through a streamlined approach, clients have access to timely delivery of services, diagnosis, and treatment.

Navigator roles vary widely, some work primarily with clients who have a diagnosis of cancer, however, many work in the community. These community nurse navigators have worked diligently to develop trusting relationships and interventions that are essential to improving the overall wellbeing of the greater population. Primary intervention strategies involve development of community health screening and educational programs. Many ONNs collaborate with community partners including congregations, not-for-profit programs, health clinics, and statewide organizations to provide screening and education to the high-risk under- and uninsured clients who may be unable to access health services due to cultural, financial, or linguistic barriers. The goal of these types of programs is to educate people on the importance of prevention and early detection techniques that can help to reduce late-stage cancers. Collaboration, communication, advocating on behalf of our patients, and translating the medical information is essential to our clients making the most informed decisions about their care. The essence of what ONNs bring to the nursing forum is more than just course plotting. These nurses bring knowledge, individualism, trust, critical thinking, and handholding, as well as a variety of other important skill sets, that help patients make educated decisions concerning their treatment planning in a timely manner. Most importantly, ONNs build relationships within their communities that foster trust in the health care system and improve education and screening, thus improving the health and well-being of the people they serve. To learn more about ONNs and the NCONN, visit www. nconn.org or email info@nconn.org. ■ Outside Front

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IN THE NEWS

FDA Update Obinutuzumab (Gazyva) received FDA approval for use in combination with chlorambucil to treat patients with previously untreated CLL. The drug is approved with a boxed warning regarding Hepatitis B virus reactivation and progressive multifocal leukoencephalopathy. FDA granted orphan drug designation to ADXS-HPV for the treatment of HPV-associated head and neck cancer. ADXSHPV is an immunotherapy that target cells expressing the HPV gene E7 Ibrutinib (Imbruvica) received FDA approval for the treatment of mantle cell lymphoma, a rare and aggressive blood cancer, in patients with MCL who have received at least one prior therapy. Crizotinib (Xalkori) capsules were granted FDA regular approval for the treatment of metastatic NSCLC in patients whose tumors are ALKpositive as detected by an FDA-approved test. FDA expanded the approved uses of sorafenib (Nexavar) to treat late-stage (metastatic) differentiated thyroid cancer. The new use is intended for patients with locally recurrent or metastatic, progressive differentiated thyroid cancer that no longer responds to radioactive iodine treatment. ■

Breast cancer survivors troubled most by postmastectomy pain WOMEN WITH breast cancer who undergo surgery rate persistent postmastectomy pain as the most troubling symptom. Surgery is part of the treatment for more than 40% of the 200,000 US women with breast cancer. Researchers from the University of Pittsburgh evaluated 611 women who had undergone total or partial mastectomy and were treated with chemotherapy, radiation, and/or hormone therapy. The objective was to determine which factors— demographics, tumor size, pain severity, treatments, stress, and psychological factors—contribute to postmastectomy pain. Their study was published in The Journal of Pain (2013;14[10]:1185-1195). Previous research has provided little consensus regarding the most important determinants of pain following mastectomy. Earlier studies had small sample sizes and

ONA ASKS …

Applying distresslowering measures or medications can help women avoid developing persistent pain after mastectomy.

focused on just one group of variables. For this research, the authors used a much larger sample, which allowed them to study a large number of variables at the same time. Results showed no evidence linking the type of mastectomy performed, tumor size, or the occurrence of treatment side effects with the development of postmastectomy pain. However, psychosocial variables were found to be important predictors, specif ically anxiety, depression, impaired sleep, somatization, and catastrophizing. The researchers stated that providing those patients who are at highest risk with more intensive perioperative therapy, applying cognitive-behavioral therapy, or applying other distress-lowering measures or medications may help these women to avoid developing persistent pain after mastectomy. ■

YES

Which strategy have you found most successfully minimizes barriers and misunderstanding when you educate your patients? Go online to answer our poll question. We’ll publish the results and a new question in the next issue. …AND YOU ANSWERED In the last issue, we asked how you handle a discussion in which a patient wants to explore all the possible outcomes of their diagnosis.

3.8%

7.7% 88.5%

I let the patient play out all scenarios and correct any misinformation I encourage the patient to stay positive, and remain silent when some scenarios are mentioned I refer the patient to the social worker

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CONTINUING EDUCATION Disclosure of Conflicts of Interest The Nurse Practitioner Healthcare Foundation (NPHF) assesses conflict of interest with its instructors, planners, reviewers, and other individuals who are in a position to control the content of CE activities. All relevant conflicts of interest that are identified are thoroughly vetted by NPHF for fair balance, scientific objectivity of studies utilized in this activity, and patient care recommendations. NPHF is committed to providing its learners with high quality CE activities and related materials that promote improvements or quality in health care. The faculty: Jayne C. Kasian, BA, BN, CON(C), MN, and Laura Johnson, RN(NP), MN, reported no financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CE activity. The planners, reviewers, and staff: Fiona J. Shannon, MHS, FNP; Joyce Pagan; Kristen Childress, DNP, ARNP; Connie Morrison-Hoogstede, MN, ANP, AOCNP; and Genean M. Page, RN, OCN, reported no financial relationships or relationships to products or devices they or their spouse/ life partner have with commercial interests related to the content of this CE activity.

EDUCATIONAL OBJECTIVES After participating in this activity, clinicians should be better able to • Differentiate the two types of vertebroplasties, percutaneous vertebroplasty and balloon kyphoplasty • Describe the pathophysiology that leads to vertebral fractures in multiple myeloma • Describe the risks and benefits of percutaneous vertebroplasty

Vertebroplasty is effective for managing myelomatous VCFs Jayne C. Kasian, BA, BN, CON(C), MN; Laura Johnson, RN(NP), MN STATEMENT OF NEED/PROGRAM OVERVIEW Approximately 75% of patients with multiple myeloma will experience bone pain, and new vertebral fractures occur in approximately 15% to 30% of these patients. Nurses’ interactions with patients from diagnosis through treatment make them the ideal person to recognize changes in a patient’s functioning and to initiate interventions such as percutaneous vertebroplasty for vertebral compression fractures. The minimally invasive procedure is relatively low-risk but relies on careful patient selection based on nursing assessments. Nurse awareness of this treatment option and the patient selection criteria may be a significant factor in the use of percutaneous vertebroplasty to relieve patients’ back pain and improve their quality of life. CE INFORMATION

Title: Vertebroplasty is effective for managing myelomatous VCFs Release date: December 15, 2013 Expiration date: December 15, 2015 Estimated time to complete this activity: 36 minutes

Free continuing nursing education credit of 0.6 is available. After reading the article, go to mycme.com to register, take the posttest, and receive a certificate. A score of 80% is required to pass. Please note that the posttest is available only on myCME.com. The article may also be viewed at OncologyNurseAdvisor.com and on the Nurse Practitioner Healthcare Foundation Web site: www. nphealthcarefoundation.org. For more information, contact Fiona Shannon at fiona@nphealthcarefoundation.org. This continuing nursing education activity is provided by the Nurse Practitioner Healthcare Foundation (NPHF).

Disclaimer The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of or imply endorsement by Nurse Practitioner Healthcare Foundation, American Nurses Credentialing Center, or Haymarket Media Inc.

NPHF is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

As this article contains only a review, participants have an implied responsibility to use this newly acquired information while also consulting other appropriate sources of information in order to gain full understanding of the topic.

Co-provided by the Nurse Practitioner Healthcare Foundation and Haymarket Media Inc.

Target audience: This activity has been designed to meet the educational needs of registered nurses and nurse practitioners involved in the management of patients with cancer. Media: Journal article and Web site (myCME.com;

OncologyNurseAdvisor.com; nphealthcarefoundation.org)

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CONTINUING EDUCATION

Vertebroplasty is effective for managing myelomatous VCFs The minimally invasive procedure provides effective, immediate relief from the pain of vertebral compression fractures due to multiple myeloma. JAYNE C. KASIAN, BA, BN, CON(C), MN; LAURA JOHNSON, RN(NP), MN

ultiple myeloma is an incurable blood cancer of the plasma cells. However, the expansion of novel treatments has significantly prolonged overall survival to the extent that it can now be considered more of a chronic disease. During the illness trajectory, bone destruction is the most frequent cause of patient morbidity and mortality.1,2 Symptomatically, bone involvement afflicts 70% to 100% of patients with myeloma and leads to distressing skeletal pain related to a variety of complications including pathological fractures, vertebral body collapses, and hypercalcemia.1-5 The challenge is to effectively manage both bone pain and vertebral compression fractures (VCFs). This article reviews the role of vertebroplasty as an effective intervention in the treatment of symptomatic vertebral compression fractures in patients with multiple myeloma.

MYELOMA BONE DISEASE Multiple myeloma is a blood cancer that leads to the transformation of plasma cells, a type of Acrylic bone cement (orange) injected into the L2 vertebra to p revent spinal collapse.

TO TAKE THE POST-TEST FOR THIS CE ACTIVITY

and apply for 0.6 contact hours, please go to myCME.com/CEDecember2013

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white blood cell located within the bone marrow, resulting in an overproduction of monoclonal immunoglobulins. These plasma cells proliferate at an unrestricted rate, overcrowding the marrow and diminishing the production of other normal cells. In healthy bones, bone remodeling is a seamless process whereby osteoclasts break down old or damaged bone, and osteoblasts lay down new bone. In patients with myeloma, malignant plasma cells within the bone marrow release cytokines that cause the surrounding bone to break down faster than it can be repaired. This process upsets bone metabolism by creating an imbalance between osteolytic and osteoblastic activity, which promotes the removal of compact bone.1,3 This leads to a vicious cycle of perpetual bone loss accompanied by a spreading of myeloma plasma cells, and eventually bone destruction.3 Patients with myeloma are then susceptible to both diffuse loss of bone mass, as well as the development of focal bone lytic lesions, which increase the risk of fracture. Of these skeletal-related complications, the vertebral bodies of the spine are the most likely to be affected by multiple myeloma.1,4,6 When myelomatous lytic lesions involve the vertebrae, vertebral stabilization is of utmost importance to prevent the sequelae of a compression fracture. Vertebral compression fractures are associated with unrelenting bone pain and resultant immobility. As a result, VCFs may severely diminish quality of life, compromise pulmonary function, increase the risk of developing deep vein thrombosis and pressure ulcers, interrupt sleep, increase fatigue, exacerbate emotional distress, produce analgesic-related constipation, and increase the risk of spinal cord compression.5,7 In addition, VCFs may lead to the development of kyphosis, a spinal deformity. This particular deformity is associated with numerous complications including anorexia, due to compression of the abdominal contents; decreased activity tolerance, due to compromised lung capacity; and further spinal deformity, due to an altered center of gravity.4 VERTEBRAL FRACTURE REPAIR Vertebral pain is the most prevalent symptom of myelomatous bone disease. Systemic treatment of the disease itself is the most effective means of relieving vertebral pain, as it may slow the process of further bone destruction. Systemic treatment may be accompanied by various adjunctive interventions such as analgesic and bisphosphonate medications, targeted radiation, and open spinal surgery. These interventions are critical components of the treatment plan and may be indicated at some point in the disease trajectory. However, when used in isolation of other interventions, these treatments alone will not effectively restore the strength of collapsed vertebrae, nor will they provide immediate pain

relief. Satisfactory pain management and improved spinal integrity are best achieved through multidisciplinary collaboration. A relatively new and minimally invasive surgical procedure used to repair vertebral fractures is percutaneous vertebroplasty. Percutaneous vertebroplasty is a minimally invasive vertebral augmentation procedure for the management of painful vertebral compression fractures. The successful use of this procedure was first documented in France in the mid-1980s, where it was used to treat painful vertebral collapses secondary to hemangiomas and osteoporosis.3,7 Since then, the procedure has also shown promise for patients with painful myelomatous vertebral compression fractures. Percutaneous vertebroplasty is a relatively short procedure (15 to 20 minutes per vertebrae) with the aim to provide nearly immediate pain palliation as well as restoration of vertebral function.5,7 The pain relief achieved through this procedure can improve functional abilities and enhance overall quality of life.1,3,7,8 Most importantly, the rapid results of this procedure allow the continuation of systemic treatment, which is the key to controlling the progressive nature of multiple myeloma.7

Vertebroplasty should be explored for myelomatous vertebral fractures associated with pain intractable to conservative management strategies. The palliative vertebroplasty procedure is performed by an interventional radiologist, orthopedic surgeon, or neurosurgeon and is usually done under local anesthetic with the patient in the prone position.5,6 In general, the portions of the spine that can be safely accessed via the percutaneous route are vertebrae T3 to L5. Experienced operators can safely perform this procedure up to the cervical area.4 Once the targeted vertebrae are confirmed, a small cutaneous dorsal incision is required.2 Under continuous fluoroscopic guidance, an 11- or 13-gauge trocar is placed in the damaged vertebral body via percutaneous extrapedicular or transpedicular approach.2,5-7 The needle is advanced into the anterior third of the fractured vertebral body until it reaches midline.5 At this position, a viscous cementlike mixture consisting of polymethylmethacrylate (PMMA) powder, barium sulfate powder, and an antibiotic powder for infection prophylaxis is then inserted into the vertebral body.5 The PMMA functions to restore the compressive strength of the vertebrae

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CONTINUING EDUCATION | Vertebroplasty with the ultimate goal of alleviating intractable local pain and preventing a compression fracture.5 After the procedure, the incision is sutured, and the patient requires strict bed rest for 1 to 2 hours to allow cement polymerization.9 Further imaging must be completed to identify postvertebroplasty artifacts before the patient can be discharged home. This postoperative CT scan is intended to rule out cement extravasation and becomes the new baseline for comparison with subsequent images.8 The short procedure is typically a day surgery, with same-day discharge.

Not all vertebral compression fractures are painful; therefore, other possible causes of the patient’s pain must be explored. Balloon kyphoplasty is a similar, newer procedure in which the spinal augmentation is achieved by first inflating a balloon inside the fractured vertebrae to create a void or cavity. The balloon is then deflated and removed, and PMMA is inserted into the newly created cavity of the affected vertebral body.5 As with vertebroplasty, kyphoplasty can stabilize the vertebrae with the additional potential benefits of restoring vertebral height and correcting kyphosis. These advantages are coupled with a lower potential risk of cement extravasation compared with vertebroplasty.3 Vertebroplasty typically requires a unipedicular approach, while kyphoplasty often requires a bipedicular approach using a larger specialized cannula.3 As a result, kyphoplasty is a more expensive procedure. Kyphoplasty is a more complex procedure, requires a longer time to complete, and patients may be more likely to need general anesthetic; therefore, vertebroplasty may be preferred in some cases. At present, well-conducted, randomized, controlled trials showing evidence that supports kyphoplasty as superior to vertebroplasty for either osteoporosis or tumor-related vertebral compression fractures is insufficient.10 Efficacy of each procedure rests in the experience of the operator.

IDENTIFYING THE IDEAL CANDIDATES Vertebroplasty should be explored for those patients with myelomatous vertebral fractures associated with well-localized, disabling pain intractable to conservative management strategies such as analgesic medications, bed rest, use of braces, and rehabilitation services. Suitable candidates

for the surgery will also have experienced both functional decline and diminished quality of life. The patient, caregiver, and members of the multidisciplinary team, including the oncology nurse, oncologist, radiologist, and spinal surgeon, must be involved in deciding whether or not a patient is a candidate for this procedure. A thorough assessment and consultation is required to identify those who will benefit from the intervention. Multiple factors are reviewed including clinical presentation, performance status, functional capacity, location of the fracture, extent of disease, and quality of life.5 The presence of localized pain is the most important indication for vertebroplasty; however, a clear correlation must be made between the patient’s reports of pain and the level of fracture. Not all VCFs are painful; therefore, other possible causes of the patient’s pain must be explored.4 Additional indications for vertebroplasty include perioperative and postoperative surgical risks that preclude open spinal surgery.1,3,5-7 Contraindications for vertebroplasty include uncorrected coagulopathy, severe cardiopulmonary insufficiency, systemic or local infection at the site of planned injection, intolerance to prone positioning, spinal cord compression or symptomatic epidural compression of the neural elements, and allergy to procedure-related drugs and materials.4-7,9 Prior to selection for the vertebroplasty procedure, each patient must undergo a preoperative work-up that includes, but is not limited to, a recent chest radiograph, an electrocardiogram (EKG), and baseline blood work including international normalized ratio (INR) to rule out coagulopathy. After addressing these initial considerations, imaging studies are necessary to further determine candidacy and to rule out other causes of back pain.5 Plain radiographs can be used to identify bone thinning, lytic lesions, and fractures. These radiographs are also necessary to ensure visualization of pedicles, to establish route of entry prior to fluoroscopy, and to ensure there is no evidence of osseous destruction, meaning that the dorsal vertebral wall is intact.7 Further imaging is required to obtain a more detailed visualization of any damaged bone. Computed tomography (CT) scans help determine the exact location and severity of a fracture. In addition, CT scans can further reveal the extent of osseous destruction of the posterior vertebral cortex. Magnetic resonance imaging (MRI) has the advantage of showing the detail of the bone marrow and can evaluate for nerve root compression without exposing the patient to radiation. If the MRI reveals significant epidural soft tissue disease or cord compromise, consultation with radiation oncology is recommended prior to exploring vertebroplasty, as the mass size may need to be reduced through radiation treatment before vertebral augmentation.4,7 In addition, if vertebral

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lysis is evident, vertebroplasty may be used as an adjunct to radiation to prevent tumor growth.5 POTENTIAL BENEFITS OF VERTEBROPLASTY

Percutaneous vertebroplasty is now considered a suitable therapeutic option for myelomatous vertebral compression fractures. The procedure is minimally invasive, well tolerated with low complication rates, and provides both immediate and long-lasting pain relief.1,3,5,6,9,11 This procedure is preferred over other treatment options as it is usually performed under local anesthesia and allows for same-day discharge from hospital.2,3,7 Successful spinal augmentation often improves patient mobility and decreases the need for analgesics thus avoiding the troublesome side effects of these medications.3,5,8 A recent retrospective study of patients who had undergone vertebroplasty noted significant improvements in patients’ reports of fatigue, depression, anxiety, drowsiness, and difficulty thinking as a result of spinal augmentation.11 The PMMA powder used in the procedure may have some antitumor effects that could produce additional long-lasting benefits for patients with multiple myeloma. Researchers

The therapeutic relationship with your patient can facilitate early identification of changes in your patient’s functional status. hypothesize that this benefit may be related to cytotoxic and thermal effects that can destroy pain receptors and nerve endings in the affected vertebrae.3,5,7,8,10 In addition, once PMMA is inserted into vertebrae, the space-occupying effect that occurs may also inhibit future growth of tumor cells.10 Regardless if this holds true or not, vertebroplasty is associated with a wide range of benefits, most notably the rapid pain relief and increased performance status ensuring patients with multiple myeloma can continue their systemic treatment. POTENTIAL COMPLICATIONS OF VERTEBROPLASTY Although vertebroplasty is known to be an effective treatment with a low complication rate, the procedure does have potential risks.6 Most patients will experience some level of discomfort during administration of the local anesthetic. Additionally, as in any procedure in which the skin is penetrated, there is a potential risk of infection.8 The most serious perioperative risk is leakage of the cement out of the vertebral body through fracture fissures or vertebral

vein fissures.1,3,5,6,8,10 This complication is more likely to occur when patients have myeloma with osteolytic destruction of cortical bone and disruption of the posterior wall.4,5 The risk is further escalated when multilevel vertebroplasty is attempted and when the maximum of 4 cc of PMMA per vertebrae is exceeded.4,10 Cement leakage into the epidural space and perivertebral veins is usually asymptomatic but can lead to pulmonary embolism and neurologic problems such as myelopathy and radiculopathy.1,2 A more serious problem may occur if the leakage is in a dangerous location such as the spinal canal, requiring emergent spine surgery to decompress the spinal canal.5 The potential consequences of cement leakage must be weighed against the overall benefit intended to be achieved by percutaneous vertebroplasty in patients with multiple myeloma. IMPLICATIONS FOR NURSING PRACTICE The therapeutic relationship with your patient can facilitate early identification of changes in a patient’s functional status that may be secondary to significant new or progressive back pain. Nurses can initiate discussions with members of the health care team regarding the change in patient status and the possible role of percutaneous vertebroplasty in a patient’s care plan. When a consensus that the patient is an appropriate candidate for vertebroplasty is reached, patient education about the goals of treatment, the potential risks and benefits, and the procedure itself is a critical first step. The results of the pain assessment and the imaging studies are included in the consultation process with the oncology, radiology, and neurosurgery departments. A formal referral, which includes all vertebral imaging results, is sent to an interventional radiologist, who can assist in identifying vertebrae that may be amendable to treatment.8 Nurse assessment of potential candidates’ initial (baseline) pain should be performed using a validated pain inventory; this same inventory should then be used in the postprocedure and follow-up assessments to ensure consistency. A visual analogue scale (VAS) of pain is one of the most common inventories used among patients with myeloma. However, it is not inclusive of the other symptoms and disabilities experienced by patients with myelomatous VCFs. The Roland-Morris Disability Questionnaire is a more reliable outcome measure for evaluating the preoperative status and the postoperative efficacy of vertebroplasty.9,11,12 This tool is easily accessible (available online), simple to administer, well-validated, specific to back pain, and appropriate for assessing vertebroplasty outcomes.12 Because the pain relief from vertebroplasty can be sustained for 6 months or longer, the outcome assessment should be

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CONTINUING EDUCATION | Vertebroplasty The procedure is known to provide rapid pain relief, decrease disability, and significantly improve patients’ quality of life.

REFERENCES 1. La Maida GA, Giarratana LS, Acerbi A, et al. Cement leakage: safety of minimally invasive surgical techniques in the treatment of multiple myeloma vertebral lesions. Eur Spine J. 2012;21(suppl 1):S61-S68. doi:10.1007/s00586-012-2221-3. 2. Masala S, Anselmetti GC, Marcia S, et al. Percutaneous vertebroplasty in multiple myeloma vertebral involvement. J Spinal Disord Tech.

used at baseline, and repeated at 1 week, 1 month, 6 months, and 1 year postoperatively.9 This pre- and postoperative comparison documents the outcome of vertebroplasty for pain relief and improved quality of life. Appropriate aftercare of the patient includes nursingdirected health teaching, particularly with respect to the increase in mobility that is expected with optimized pain control. Patients should be encouraged to resume activity as tolerated, but to avoid heavy lifting for at least 6 weeks. A timely referral to physiotherapy is indicated for guidance regarding gentle exercise in the postoperative period.4

2008;21(5):344-348. doi:10.1097/BSD.0b013e3181454630. 3. Anselmetti GC, Manca A, Montemurro F, et al. Percutaneous vertebroplasty in multiple myeloma: prospective long-term follow-up in 106 consecutive patients. Cardiovasc Intervent Radiol. 2012;35(1):139-145. doi:10.1007/s00270-011-0111-4. 4. Hussein MA, Vrionis FD, Alison R, et al; International Myeloma Working Group. The role of vertebral augmentation in multiple myeloma: International Myeloma Working Group Consensus Statement. Leukemia. 2008;22(8):1479-1484. doi:10.1038/leu.2008.127. 5. Wu AS, Fourney DR. Supportive care aspects of vertebroplasty in patients with cancer. Support Cancer Ther. 2005;2(2):98-104. doi:10.3816/ SCT.2005.n.003.

CONCLUSION

Since its inception in the 1980s, percutaneous vertebroplasty has proven to be a safe, effective, and durable treatment for the pain associated with vertebral compression fractures.3 Among patients with vertebral fractures secondary to multiple myeloma, vertebroplasty is an important adjunct to other standard treatments such as analgesic medications, systemic treatments, and radiation therapy.5 The procedure is known to provide rapid pain relief, decrease disability, and significantly improve patients’ quality of life. Therefore, all affected patients should be assessed as potential candidates for vertebroplasty. Members of the nursing profession are an integral part of the patient care team as both advocates and assessors of patient status particularly in patients with multiple myeloma and painful malignant vertebral compression fractures. Their contribution can ensure patients receive the most effective treatments. ■

6. Tancioni F, Lorenzetti M, Navarria P, et al. Vertebroplasty for pain relief and spinal stabilization in multiple myeloma. Neurol Sci. 2010;31(2):151157. doi:10.1007/s10072-009-0197-5. 7. Chen LH, Hsieh MK, Niu CC, et al. Percutaneous vertebroplasty for pathological vertebral compression fractures secondary to multiple myeloma. Arch Orthop Trauma Surg. 2012;132(6):759-764. doi:10.1007/ s00402-012-1474-y. 8. Garland P, Gishen P, Rahemtulla A. Percutaneous vertebroplasty to treatment painful myelomatous vertebral deposits—long-term efficacy outcomes. Ann Hematol. 2011;90(1):95-100. doi:10.1007/s00277-010-1021-2. 9. Chew C, Ritchie M, O’Dwyer PJ, Edwards R. A prospective study of percutaneous vertebroplasty in patients with myeloma and spinal metastases. Clin Radiol. 2011;66(12):1193-1196. doi:10.1016/j.crad.2011.08.004. 10. Chew C, Craig L, Edwards R, et al. Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol. 2011;66(1):63-72. doi:10.1016/j.crad.2010.09.011. 11. Mendoza TR, Koyyalagunta D, Burton AW, et al. Changes in pain and other symptoms in patients with painful multiple myeloma-related vertebral fracture treated with kyphoplasty or vertebroplasty. J Pain.

Acknowledgment The authors dedicate this article to the respectful memory of Dr. Ade Olujohungbe and his compassionate care for patients with multiple myeloma. They also thank Ruth Holmberg, librarian at CancerCare Manitoba, for her assistance with the literature search for this article. Jayne Kasian is a nurse practitioner at CancerCare Manitoba, in Winnipeg, Manitoba, Canada. Laura Johnson is a nurse practitioner in the emergency department at Health Sciences Centre, and an instructor at the University of Manitoba in Winnipeg, Manitoba, Canada, in the Nurse Practitioner program.

2012;13(6):564-570. doi:10.1016/j.pain.2012.03.003. 12. Trout AT, Kallmes DF, Gray LA, et al. Evaluation of vertebroplasty with a validated outcome measure: the Roland-Morris Disability Questionnaire. AJNR Am J Neuroradiol. 2005;26(10):2652-2657. http://www.ajnr.org/cgi/pmi dlookup?view=long&pmid=16286418. Accessed November 6, 2013.

TO TAKE THE POST-TEST FOR THIS CE ACTIVITY and apply for 0.6 contact hours, please go to myCME.com/CEDecember2013

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FEATURE | Nutrition for cancer patients

How to maintain nutritional status during cancer therapy This primer on diet and nutrition focuses on counseling patients on how, what, and when to eat to maintain their weight and nutritional status.

Recommend small meals consisting of a complex carbohydrate, a lean protein source, and a healthy fat. Safe CAM therapies are meditation to relieve stress and ginger to relieve nausea.

CAROLYN FARHY, MS, RD, LDN; GRETCHEN SKWER, RD, LDN; ROSEMARIE A. TUCCI, RN, MSN, AOCN

utritional intervention is an integral step in the care process for patients undergoing treatment and recovery of cancer. A wealth of evidence-based statistics supports the importance of good nutritional balance throughout the continuum of cancer care. Healthy eating practices can alleviate certain side effects as well as maintain strength and endurance before, during, and after cancer treatments. While interventions should be individualized, overall general guidelines for symptom management can be helpful for patients and caregivers. Regardless of whether a clinical dietitian is part of the health care team that works with patients with cancer, nurses need basic knowledge of nutrition and its role to assist patients along their journey. The primary goals of nutrition therapy are to prevent or reverse nutrient deficiencies, preserve lean body mass, minimize and manage the impact of nutrition-related symptoms and side effects, and maximize quality of life. However, with the increased emphasis on cancer prevention and recurrence, opportunities exist to promote healthy lifestyle behaviors and eating habits. Nutritional status and appetite should be assessed at each patient visit. The question “Have you had an increase/decrease in your appetite or weight since your last visit?” is a starting point for this assessment. A patient-generated scoring assessment can help caregivers better understand

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2013 • ONCOLOGY NURSE ADVISOR 21

FEATURE | Nutrition for cancer patients the needs of the patient and allow an appropriate referral to a clinical dietitian as necessary.1 However, although the majority of cancer patients may experience a decrease in appetite and weight loss through treatment, some patients—especially those with breast cancer receiving hormonal therapy—may have the opposite experience. Nutrition interventions should be individualized to the therapy and nutritional impact affecting the patient. This article presents guidelines for helping patients maintain adequate nutrition intake throughout the course of their cancer treatment and nutrition-related care tips for specific types of cancer.

Oncology patients have weakened immune systems from the cancer or its treatment, and as a consequence are at increased risk for infection. Special precautions are necessary to avoid food-borne illnesses. Proper hand washing and carefully washing fresh or raw fruits and vegetables are essential food-handling practices. Furthermore, all food, especially raw meats and fish, should be obtained from reputable sources. Bacteria growth is the main culprit of food-related infections. Hot foods should be kept hot (above 140°F) and cold foods should be kept cold (below 40°F) to inhibit bacteria growth.

NUTRITION MANAGEMENT One of the most significant nutritional issues that can arise during cancer treatment is malnutrition. Side effects from chemotherapy, radiation, immunotherapy, and surgery can contribute to deterioration in nutritional status. Overall survival rates, performance status, productivity, and quality of life can decline concurrently with weight loss in cancer patients.2

DIETARY TECHNIQUES FOR MANAGING SIDE EFFECTS

Once nausea or vomiting subsides, consuming high-calorie, highprotein foods is essential to make up for any resulting weight loss. Eating well-balanced and nutritious meals requires planning and preparation. Advise patients and their caregivers to have foods and drinks that are easy to consume readily available for when they can eat. Keeping their pantries, refrigerators, and freezers stocked with an assortment of healthy foods can help patients maintain their nutrition, especially during periods when their appetite is low from treatment. Prepackaged foods, available in the freezer section of grocery stores, should be used with caution. These foods may contain high levels of sodium and saturated fat and lower amounts of nutrients such as fiber, vitamins, and minerals. Intake of these food items should be minimal or avoided.3 Instead, encourage patients to create their own easy-to-eat and ready-to-serve foods to maintain energy and strength during treatment. For example, prepare food ahead of time and freeze it. Single-serving packages of nuts, whole grain crackers, granola bars, and fruit can help patients have the foods they like in amounts they can tolerate available for treatment periods when nausea, vomiting, or fatigue impede eating.

Managing the side effects of radiation and chemotherapy is crucial to enabling patients to complete their recommended course of treatment. Although predicting exactly how a prescribed treatment may affect a patient is difficult, some side effects directly affect the patient’s appetite and ability to consume necessary calories. Reducing the discomfort inherent with common side effects can ensure that associated weight loss is minimized and treatment can be completed as planned. Nausea and vomiting is common and can be caused by the cancer, chemotherapy, or radiation therapy. Eating smaller, more frequent meals throughout the day can ease these side effects for many patients. In addition, foods should be served at room temperature to eliminate strong odors. Fatty, greasy, or spicy foods should be avoided. Antinausea medications or hard candies (eg, peppermints, lemon drops) may also help relieve nausea. In some cases, physicians may order an appetite stimulant, such as megestrol acetate (Megace), to improve a patient’s oral intake. Over-the-counter (OTC) oral liquid nutrition supplements (such as Ensure or Boost) can be recommended for patients who are unable to meet their nutritional needs through food alone. These products are designed to be meal supplements, not meal replacements, and patients should still try to eat solid foods. If a patient is vomiting, sipping clear liquids as often as possible aids in maintaining hydration. These side effects, generally, do not last for long periods of time; so, patients should be reminded to eat when they are hungry or not experiencing nausea. Once the nausea or vomiting has subsided, consuming high-calorie, high-protein foods is essential to make up for any resulting weight loss. Alterations in bowel movements are another side effect of medications; treatments; or certain cancers, specifically lower GI-tract cancers. Gastrointestinal resections, pain medications, along with changes in diet may change the

22 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

Basic Nutrition Requirements Patients may find eating six to eight small, well-balanced, nutritious meals and snacks easier to tolerate than fewer, larger meals during treatment. Consuming small amounts of food frequently throughout the day helps alleviate nausea symptoms. To maximize the nutrition provided through these smaller meals, each meal should consist of a complex carbohydrate, a lean protein source, and a healthy fat. Complex carbohydrates Fruits, vegetables, and whole grains are complex carbohydrates. Incorporating at least five servings of fruits and vegetables each day provides essential vitamins, minerals, and phytochemicals, as well as fiber. Whole grains are also an excellent source of fiber and nutrients, and consuming these types of grains is important to maximize carbohydrate intake. They can help alleviate GI effects such as constipation. Whole grains include whole grain breads, whole grain cereals (oatmeal, shredded wheat, bran flakes), whole wheat pasta, and brown rice. At least half of carbohydrate consumption from grains should be from whole grains. Lean protein Consumption of lean protein sources helps keep up strength and rebuilds tissue. Protein needs are higher in cancer patients to prevent catabolism, or the depletion of muscle mass, potentially from the cancer itself as well as during the different stages of treatment; therefore, consuming adequate amounts of lean protein is crucial for patients with cancer. Lean protein sources include fish, low-fat dairy products, nuts, eggs, and legumes. A meal or snack substituting legumes (eg, lentils, chickpeas, or soybeans) for meat at least once a week is recommended since they are typically low in fat, contain no cholesterol, and are high in protein, folate, potassium, iron and magnesium. Soybeans, for example, contain all of the amino acids needed to make a complete protein, just like meat.

Fats Healthy fats help the body repair cells. Monounsaturated and polyunsaturated fatty acids are healthy fats. These types of fats are linked to improved blood cholesterol levels, stabilize insulin levels, lower blood pressures, and protect against heart disease. Sources include canola and olive oils, avocado, fish, nuts, and seeds. Diets high in saturated fats have been linked to elevated total cholesterol levels, which could lead to heart disease and stroke. Fluids Adequate hydration helps prevent fatigue, light-headedness, dry mouth, altered taste (metallic taste), and nausea during the course of cancer treatment. Recommended fluid intake for men is about 3.7 liters of water a day; recommended fluid intake for women is about 2.7 liters a day. A large portion of fluids come from foods consumed; therefore, overall recommendations for both men and women is to consume 8 to 12 cups of liquids each day. Maintaining adequate hydration is especially important for those patients experiencing vomiting or diarrhea because they are susceptible to dehydration due to resultant fluid loss. Sugar-sweetened drinks add large amounts of calories to the diet, which can ultimately lead to weight gain and may affect cancer outcomes. Many foods and drinks that are high in added sugar do not offer needed nutrients and may replace more nutritious food choices. To prevent weight loss or regain weight lost from the cancer and its treatment, foods that are nutrient-dense are recommended. Patients should limit their intake of foods and drinks with added sugar, which lack nutrients and are only calorically-dense. Caffeinated beverages should be consumed in moderation. They can increase the risk of dehydration and sodium excretion from the body, which may contribute to fatigue, headaches, and nausea. The severity of some side effects of chemotherapy (eg, fatigue, nausea, and even headaches) can be worsened by dehydration.

SOURCES • Eldridge B, Hamilton K. Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago, IL: American Dietetic Association; 2003. • National Institutes of Health, US Department of Health and Human Services. Eating Hints: Before, During and After Cancer Treatment. Bethesda, MD: National Institutes of Health; 2011. NIH publication 11-2079. http://www.cancer.gov/cancertopics/coping/eatinghints. Accessed September 17, 2013.

consistency of the bowel movement and the transit.2 Either diarrhea or constipation may be the outcome. Fiber and fluid are two main nutritional components that relieve constipation. Both soluble and insoluble fibers are helpful. Soluble fibers, found in foods such as barley, nuts, beans, and some fruits and vegetables, including broccoli, carrots, apples, and citrus fruits, help to slow digestion. Insoluble fibers add bulk to the stool, and are found in

whole grains and vegetables. However, these foods should not be recommended to patients who are prescribed a lowresidue diet. A low-residue diet is often recommended to patients when there is a narrowing of the bowel caused by either inflammation or surgical alteration. Radiation to the gastrointestinal tract can also cause damage and require a patient to follow a low-residue diet.2 Low-residue diets, also referred to as

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FEATURE | Nutrition for cancer patients low-fiber diets, include foods that are easy for the body to digest and slow down bowel movements (eg, beans, legumes, and many raw fruits and vegetables). Nuts and seeds should be avoided. Furthermore, drinking the recommended 8 to 12 cups of fluid each day helps minimize constipation. Overthe-counter medications and laxatives may also be necessary, but should be used with caution to avoid adverse effects. In addition, as with all with all medications and supplements, patients should be sure to notify their doctor when taking laxatives to be sure there are no negative interactions with the other drugs. Patients who complain of abdominal gas should limit their intake of carbonated beverages, broccoli, cabbage, cauliflower, cucumbers, dried beans, peas, and onions. OTC products such as Beano, a natural digestive enzyme, or simethicone (Gas-X), can help eliminate gas caused by the sugar in beans and some vegetables, but it will not help gas caused by excessive fiber or lactose. These medications should not be used as a primary method of controlling abdominal gas.4

CAM therapies are widely used by cancer patients, and nurses should not overlook discussing them with patients. Diarrhea can lead to weakness, poor appetite, dehydration, and weight loss. Patients who experience diarrhea should drink clear liquids throughout the day. High-sodium foods and sports drinks may help a patient to stay hydrated and will replace lost electrolytes. Other foods that should be encouraged are those high in potassium (eg, baked potatoes, oranges, and bananas) and foods high in pectin (eg, applesauce). Greasy, fried, spicy, or very sweet foods should be avoided. Antidiarrheals can assist with limiting this side effect. Keeping a detailed food journal is helpful for patients who experience gastrointestinal side effects. Some people can tolerate foods that others cannot. A 62-year-old male with GI cancer presented with difficulty managing his bowels. He was asked to keep a food diary, closely monitoring what he ate by writing down the foods and the amounts he consumed. When an episode of either diarrhea or constipation occurred, the patient was able to trace the cause back to the food he ate and would then eliminate that food from his diet. The patient used over-the-counter medications when

TABLE 1. Mouth rinse 1 quart water ¾ teaspoon salt 1 teaspoon baking soda Combine all ingredients in a container and mix well.

necessary, but overall, he was able to control his bowels solely based on what he ate. Sore mouth or difficulty chewing and swallowing is a common effect experienced by patients with cancer, especially those with head and neck cancers. These patients should be advised to eat soft, bland-tasting foods served at room temperature. Pureeing or liquefying foods will make swallowing easier. Foods moistened with broth, sauces, gravy, or olive oil are also easier to swallow. Choosing fats such as olive oil as opposed to butter will help the patient’s overall health by avoiding unhealthy fats. Adding healthy fats, as well as a protein powder, to drinks and foods can help these patients maintain their weight. In addition, careful attention to food temperatures is helpful (eg, lukewarm, rather than hot, foods are less irritating to the mouth). Encourage patients to rinse often with a baking soda and water mouth rinse to remove food and germs and enhance healing2 ( Table 1). Dry mouth or thick saliva may occur as a result of radiation therapy, some types of chemotherapy, and some medications. Patients with dry mouth may have difficulty eating and have a higher risk of developing dental cavities or mouth infections.5 Smoking, chewing tobacco, alcohol, and caffeine can make the dryness worse, and should be avoided. Eating moist foods and drinking fluids throughout the day helps loosen sticky secretions that can cause the mouth to feel dry. Changes in taste and smell caused by cancer and its treatment can affect a patient’s appetite. Seasonings and sweeteners, such as honey, can make foods taste more appealing and may increase food intake. Regular mouth rinsing and brushing the teeth may also improve how food tastes. Bitter or metallic taste may be alleviated with sugar-free lemon drops, gum, or mints. Using plastic utensils, rather than stainless flatware, may also help. Appetites can be improved by avoiding hot foods, which tend to have stronger smells and flavors and may turn off the patient’s sense of needing to eat. CANCER-SPECIFIC GUIDELINES In addition to universal nutrition-related difficulties for patients with cancer, some cancers produce specific side effects. The following guidelines are specific for these more common disease sites. Continued on page 32

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FEATURE | Nutrition for cancer patients Head and neck cancer Patients with head and neck cancer often experience a sore mouth and have difficulty chewing. These patients should be evaluated for oral thrush to determine if that is the cause of the side effects, and treatment should focus on the cause of the oral thrush. Other steps can be taken to ease patients’ discomfort. • Serve soft, bland-tasting foods at room temperature. Pureeing or liquefying foods make them easier to swallow and lukewarm, rather than hot, foods are less irritating to the mouth. • Moisten foods with broth, sauces, gravy, or fats (oil or butter). • Rinse often with a mouth rinse to remove food and germs and enhance healing.6 • Investigate potential need for a PEG tube to maintain nutrition and hydration during therapy. Breast cancer These patients often have issues with weight gain, rather than weight loss, due in part to hormonal therapies. • Review caloric intake versus activity levels. • Recommend exercises for maintaining strength and general conditioning specifically for patients with breast cancer. • Suggest maintaining a low-fat, plant-based diet with attention to soy products. Lung cancer These patients generally require surgery, chemotherapy, and radiation. Some of the recommendations for patients with head and neck cancers are helpful for patients with lung cancer. • Soft, bland foods served at room temperature. Pureeing or liquefying foods makes them easier to swallow. • Moisten food with broth, sauces, gravy, or fats (oil or butter). • Increased protein is needed for tissue-building benefits; oral liquid supplements can provide additional protein. Colorectal cancer The most significant issue for these patients may be GI tract function, depending on the extent of the surgery required. Careful review of their nutritional needs and bowel functions are essential. • Understanding of the surgical procedure and its physical alterations to the GI tract. • Identify foods that make bowel movements too loose or too hard (rare), or produce too much gas. • Eat more low fiber foods, such as white starches, because they are better tolerated than whole grains. • Recommend fruits and vegetables with hard skins or peels, or stringy parts.

CAM THERAPIES Complementary and alternative therapies (CAM) are widely used by cancer patients, and nurses should not overlook

discussing them with patients. Complementary therapies are those that are administered alongside conventional, evidence-based treatments. Meditation to reduce stress and ginger to relieve nausea are examples of complementary therapies that can help control symptoms and improve how the patient is feeling. Alternative therapies, on the other hand, are treatments that are promoted as cancer cures; however, they have not been scientifically tested and, therefore, lack proven safety and efficacy.5 In addition, some alternative therapies may even counteract scientifically proven treatments. Patients and caregivers often search the Internet for solutions, but they should be reminded that not everything they read

Scientific evidence does support the belief that all nutrients for optimal cancer outcomes should come from natural foods and well-balanced diet. is fact. As a general rule, commercial diets such as the Anti-Cancer Diet, the Maker’s Diet, the Paleo Diet, the anti-inflammatory diet, vegan and macrobiotic diets, and The South Beach Diet are not recommended for patients undergoing cancer treatment, as each is limited in meeting the nutritional needs of cancer patients. Some supplements actually impede cancer treatment, so nurses should ask patients for a list of the over-the-counter medications he or she may be using. Antioxidant vitamins A, E, and C, plus glutathione and selenium, are extremely dangerous to take with chemotherapy because they may reduce the efficacy of the chemotherapy by protecting the cancer cells. Herbal supplements, such as St. John’s wort and ginkgo biloba, may also impede cancer treatment. St. John’s wort, for example, can speed up or slow down the metabolism of the chemotherapy drug, changing its effects. Ginkgo biloba, a natural blood thinner, can cause spontaneous bleeding and seizures.7 Safe complementary and alternative therapies include meditation and ginger as mentioned above. Unfortunately, studies have not provided the hard evidence necessary to make general conclusions about the majority of other therapies, supplements, and products. Scientific evidence does support the belief that all nutrients for optimal cancer outcomes should come from natural foods and a wellbalanced diet.2 Continued on page 34

32 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

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FEATURE | Nutrition for cancer patients CONCLUSION Nutrition is always important but becomes critical for a patient undergoing cancer treatment. Eating a healthy diet will provide patients with the essential nutrients needed to fight the disease and relieve the side effects of the disease and its treatment. Providing patients with information, resources, and encouragement increases the chance of positive outcomes. Utilizing a multidisciplinary approach to nutrition, as well as treatment modalities, can increase the patient’s ability to maintain strength and endurance, tolerate care, and move toward survivorship. ■

2. Marian M, Roberts S. Introduction to the nutritional management of oncology patients. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones and Bartlett Publishers; 2010:7,12. 3. Lanford J. Salt (sodium) and Cancer. Oncology Nutrition, a dietetic practice group of the Academy of Nutrition and Dietetics. http://dpgstorage.s3.amazonaws.com/ondpg/documents/b2bb9268e052da5/ ondpg_-_salt_and_cancer_handout.pdf. Accessed December 3, 2013. 4. Orenstein BW. 6 ways to treat excessive gas. Everyday Health Web site. http:// www.everydayhealth.com/digestive-health/gas/diagnosing-and-treatingexcessive-gas.aspx. Last updated July 1, 2009. Accessed December 3, 2013 5. Hyodo I, Amano N, Eguchi K, et al. Nationwide survey on complementary and alternative medicine in cancer patients in Japan. J Clin Oncol.

Carolyn Farhy and Gretchen Skwer are oncology outpatient dietitians with Lankenau Medical Center, Wynnewood, Pennsylvania. Rosemarie Tucci is an oncology program manager at Lankenau Medical Center in Wynnewood, Pennsylvania.

2005;23(12):2645-2654. 6. National Institutes of Health, US Department of Health and Human Services. Eating Hints: Before, During and After Cancer Treatment. Bethesda, MD: National Institutes of Health; 2011. NIH publication 11-2079. http://www. cancer.gov/cancertopics/coping/eatinghints. Accessed December 3, 2013.

REFERENCES

7. Wood-Moen R. Vitamins, cancer & chemotherapy. Livestrong.com. http://

1. Marino MJ, Patton A, eds. Cancer Nutrition Services: A Practical Guide for Cancer Programs. Rockville, MD: Association of Community Cancer Centers; 2012.

www.livestrong.com/article/318898-vitamins-cancer-chemotherapy/. Accessed December 3, 2013.

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34 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

STAT CONSULT Bendamustine (Treanda) Drug type

• Alkylating agent

Indications

■■

• Indicated for the treatment of chronic lymphocytic leukemia (CLL) and indolent B-cell non-Hodgkin lymphoma (NHL) that has progressed during or within six months of a treatment with rituximab or a rituximab-containing regimen Mechanism of action

• Bendamustine is a bifunctional mechlorethamine derivative ——Forms covalent bonds with nucleophilic moieties resulting in interstrand DNA crosslinks and eventually cell death of both quiescent and dividing cells ——The exact mechanism of action of bendamustine remains unknown Dosage and administration

• Chronic lymphocytic leukemia ——100 mg/m 2 infused intravenously over 30 minutes on days 1 and 2 of a 28-day cycle for up to 6 cycles ——Dose adjustments ■■ Hematologic toxicity »»Grade 3 or greater toxicity: 50 mg/m2 on days 1 and 2 »»If Grade 3 or greater toxicity recurs: 25 mg/m2 on days 1 and 2 ■■ Nonhematologic toxicity »»Grade 3 or greater toxicity: 50 mg/m2 on days 1 and 2 • Non-Hodgkin lymphoma ——120 mg/m 2 infused intravenously over 60 minutes on days 1 and 2 of a 21-day cycle for up to 8 cycles ——Dose adjustments

Hematologic toxicity

»»Grade 4 toxicity: 90 mg/m2 on days 1 and 2 »»If Grade 4 toxicity recurs: 60 mg/m2 on days 1

and 2 Non-hematologic toxicity »»Grade 3 or greater toxicity: 90 mg/m2 on days 1 and 2 »» If Grade 3 toxicity recurs: 60 mg/m2 on days 1 and 2 • Special populations ——Renal impairment ■■ Bendamustine has not been studied in patients with CrCl <40 mL/min ■■ The use of bendamustine in patients with CrCl <40 mL/min is not recommended ——Hepatic impairment ■■ Bendamustine has not been studied in patients with moderate or severe hepatic impairment (AST or ALT 2.5-10× ULN and total bilirubin 1.5-3× ULN) ■■ The use of bendamustine in patients with moderate to severe hepatic impairment is not recommended ■■

Pregnancy and lactation

• Pregnancy category D • Lactation ——Unknown whether distributed in breast milk ——Breastfeeding not recommended during therapy Cautions

• CBCs should be performed every week initially ——Nadir seen in the third week of therapy Continued on page 36

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STAT CONSULT ——Prior to each dosing cycle, ANC should be >1 × 109/L and platelet count should be >75 × 109/L • Severe anaphylactic reactions have occurred, particularly in the second and subsequent cycles of therapy • Tumor lysis syndrome is associated with bendamustine treatment ——Usually occurs during the first treatment cycle ——Without treatment may result in acute renal failure and death • Skin reactions such as rash, toxic skin reactions, and bullous exanthema have occurred with the use of bendamustine • Secondary malignancies can occur after treatment with bendamustine • Assure good venous access prior to starting bendamustine infusion and monitor the site for redness, swelling, pain, infection, and necrosis during administration Adverse effects

• Nonhematologic adverse reactions in CLL (≥5%) ——Asthenia, chills, diarrhea, fatigue, fevers, herpes simplex, hypersensitivity, hyperuricemia, nasopharyngitis, nausea, pruritus, rash, vomiting, weight loss • Nonhematologic adverse reactions in NHL (≥5%) ——Abdominal distension, abdominal pain, anorexia, arthralgia, asthenia, chest pain, chills, constipation, cough, decreased appetite, dehydration, diarrhea, dizziness, dry mouth, dry skin, dyspepsia, dyspnea, fatigue, fevers, gastroesophageal reflux disease, headache, hyperhidrosis, hypotension, infection, insomnia, nausea, night sweats, pain, peripheral edema, pruritus, rash, stomatitis, tachycardia, vomiting, weight loss, wheezing Drug interactions

• No formal clinical assessments of drug interactions with bendamustine have been conducted. • Bendamustine is metabolized via cytochrome P450 CYP1A2 to form active metabolites ——Inhibitors of CYP1A2 (fluvoxamine, ciprofloxacin, etc.) have the potential to increase plasma concentrations of bendamustine and decrease concentrations of the active metabolites ——Inducers of CYP1A2 (omeprazole, smoking, etc.) have the potential to decrease bendamustine and increase concentrations of its active metabolites What to tell your patient

• Your doctor has ordered the anti-cancer medicine, bendamustine, to help treat your illness. • Bendamustine is an alkylating agent that is used to treat

NHL and CLL. It works by inhibiting cell growth and promoting cell death. • Tell your nurse or doctor if you are allergic to bendamustine, mannitol (Osmitrol, Resectisol), or any other medications. • Make sure your nurse or doctor knows if you are breastfeeding, have kidney disease, liver disease, a bone marrow disorder, or any kind of infection. • You should not plan to have children while receiving chemotherapy or for a while after treatments. ——Bendamustine may harm the fetus. ——Men and women should be advised to avoid becoming pregnant throughout treatment and for 3 months after bendamustine therapy has stopped. ——Both you and your partner should use a reliable method of birth control to prevent pregnancy. • Do not breastfeed while you are taking bendamustine. • Make a complete list of all prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take and give a copy of the list to your nurse or doctor. ——You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. This list is also important information to carry with you in case of emergencies. • Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. • Some side effects can be serious. Call your doctor immediately if you experience any of these symptoms: ——Allergic reaction; blistering, peeling, or red skin rash; chest pain; changes in urination; chest pain; dry mouth; fevers, chills, sore throat; excessive tiredness; headache; heartburn; increased thirst; joint pain, stiffness, or swelling; lightheadedness or fainting; muscle cramps; nausea; rapid weight gain; sores on the lips, nose, eyes, or genitals; stomach pain or tenderness; unusual bleeding or bruising; vomiting; weakness; weight loss • Tell your doctor if any of these symptoms are severe or do not go away ——Decreased weight ——Diarrhea, constipation, loss of appetite, or upset stomach ——Mild skin rash or itching ——Stuffy or runny nose ——Trouble with sleeping • Bendamustine may cause other side effects. Call your nurse or doctor if you have any unusual problems while using this medication. ■ Prepared by Ashley Purohit, PharmD.

36 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

RMM techniques are used to reduce radiation to nontarget tissues.

Respiratory motion management: Essential to radiotherapy Bryant Furlow

s precise hypofractionated radiotherapies such as stereotactic body radiotherapy (SBRT) become widely available, managing the subtle breathing-associated movement of tumors and adjacent organs during radiotherapy is an increasingly important challenge. Technological innovations such as real-time imaging guidance (tumor tracking) can help reduce the impact of intrafraction respiratory motion on radiation dose delivery, but respiratory motion management (RMM)—particularly respiratory gating and breath hold—remains crucial to the effective implementation of treatment plans.

Radiotherapy planning involves the use of computed tomography (CT) imaging data to calculate external radiation beam paths that can deliver prescribed radiation doses to target tumors while minimizing irradiation of healthy nontarget tissues. Survival rates for patients with lung cancer might improve with radiation dose escalation, but dose escalation requires thinner margins around target tissues to avoid radiation toxicity.1 Imaging studies can be obtained between radiotherapy sessions to account for changes in tumor and organ size and position over time. This can allow target adjustments for subsequent dose fractions and the maintenance of narrow treatment margins.1,2 But tumor and nontarget organ motion caused by the patient’s breathing during radiotherapy delivery can also complicate the delivery of intended dose distributions. While anatomical changes between radiotherapy fractions appears to have a larger effect on target dose distribution in lung cancer than does intrafraction tumor motion, respiratory motion does appear to impact dose delivery and can increase radiation to nontarget tissues, potentially escalating the risk of radiation-association toxicities.1,2 Therefore, patient treatment plans must account for respiration-associated changes in tumor position and contours, and plan for the management or minimization of respiratory motion during dose delivery.3 Precise dose targeting is integral to recent advances in radiotherapy techniques such as intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy. Stereotactic radiosurgery was pioneered for the treatment of intracranial tumors; today, SBRT is used with increasing frequency as a noninvasive alternative to surgery in the treatment of solid tumors of the lung

and liver to deliver therapeutic radiation doses in fewer, higher-dose fractions (hypofractionation) than regimens used with traditional external-beam radiotherapy.2 Hypofractionation’s higher per-fraction radiation doses make respiratory motion a major challenge.2,4 RMM is therefore a crucial component of treatment planning, particularly for hypofractionated radiotherapy of the breast, lungs, or liver.2 Two broad strategies improve dose precision when intrafraction respiratory motion is an issue: intrafraction image guidance and RMM.3 Real-time image

RMM techniques are typically employed to minimize residual motion issues. guidance (ie, image-guided radiotherapy [IGRT]) can provide 3-dimensional (3D) tumor tracking and accommodation of target volume motion and tumor contour deformation.2,5 But even when tumor tracking is used, RMM techniques are also typically employed to minimize residual motion issues.2 RESPIRATORY MOTION MANAGEMENT

The primary goal of RMM is to reduce respiratory motion during irradiation. Common techniques for achieving that goal include patient breath hold and respiratory gating. Foam blocks or body frames, which also ensure consistent patient position between radiotherapy treatments, are other devices used to immobilize the patient.2,6 In SBRT of the lung or liver, abdominal

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RADIATION & YOUR PATIENT compression can also be used; the upper abdomen is pushed downward using an adjustable SBRT body frame pressure plate, forcing shallow respiration and minimizing respiratory tumor motion.2 Both breath hold and respiratory gating function to time radiation delivery during a specific phase of respiration (expiration or inspiration/inhalation). Breath hold forces maintenance of that phase of respiration during dose delivery, with the radiation beam being held (beam off ) when that phase of respiration can no longer be maintained.2 Respiratory gating uses technology to achieve the same goal, timing beam on/off sequences to ensure that radiation is delivered during a specific phase of respiration.2 Both RMM techniques involve pretreatment planning with time-correlated (so-called 4D) CT image data to measure a patient’s respiration. Respiratory volumes are monitored using spirometers.2 Inspiration-phase treatment allows better separation of lung tumor target volumes and adjacent lung nontarget tissues, reducing toxicity risks, but expiration-phase treatment appears to be more reproducible.2,7 Inspirationphase breath hold appears to be easier to perform for patients undergoing SBRT to the lung.2 Respiratory gating allows the patient to breathe freely during radiotherapy. Monitoring equipment automatically

FREE!

controls the beam on/off timing, using cameras or pressure sensors. Breath hold, in contrast, requires pretreatment instruction, patient practice and coaching, and close monitoring of adherence during radiation delivery. As members of the radiotherapy team, oncology nurses are responsible for ensuring patient understanding and adherence to respiratory motion management efforts.3 In addition to such clinical tasks as monitor-

Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Schmidt ML, Hoffmann L, Kandi M, et al. Dosimetric impact of respiratory motion, interfraction baseline shifts, and anatomical changes in radiotherapy of non-small cell lung cancer. Acta Oncol. 2013;52(7):1490-1496. 2. Zhang GG, Yu HHM, Stevens CW, et al. Motion management in stereotactic body radiotherapy. J Nucl Med Radiat Ther. 2012;S:6.

RMM techniques involve planning with time-correlated CT image data.

doi:10.4172/2155-9619.S6-012. 3. Matsuo Y, Onishi H, Nakagawa K, et al. Guidelines for respiratory motion management in radiation therapy. J Radiat Res. 2013;54(3):561-568. 4. Furlow B. Experts discuss their predictions for radiation medicine. Oncol Nurse Advis. 2011;2(4):39-41. http://media.oncology nurseadvisor.com/documents/26/ona_

ing patients’ oxygen saturation, oncology nurses are typically responsible for pretreatment patient RMM instruction and assessment of patient comprehension and adherence to those instructions.3 Monitoring breath hold involves more than keeping a close eye on the spirometer. Patients’ stress, discomfort, or anxiety can cause them to breathe more rapidly, complicating breath-hold efforts. Verbal instructions delivered in a calm and soothing manner help create a more relaxing environment during radiotherapy.3 ■

radiation_0811-1_6354.pdf. Accessed November 2, 2013. 5. McClelland JR, Hawkes DJ, Schaeff ter T, King AP. Respiratory motion models: a review. Med Image Anal. 2013;17(1):19-42. 6. Benedict SH, Yenice KM, Followill D, et al. Stereotactic body radiation therapy: the report of AAPM Task Group 101. Med Phys. 2010;37(8):4078-4101. doi:10.1119/1.3438081. 7. Peng Y, Vedam S, Chang JY, et al. Implementation of feedback-guided voluntary breath-hold gating for cone beam CT-based stereotactic body radiotherapy. Int J Radiat Oncol Biol Phys. 2011;80(3):909-917.

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C101: EMPOWER YOUR PATIENT

Health literacy: A missing piece of the puzzle in the cancer journey Sarah Krug

Arming a patient with tools for success goes well beyond providing brochures and a list of Web sites for reference.

ith a transformation of the health care landscape underway and the focus on quality care and improved outcomes, considering the whole complex patient rather than simply addressing their disease or symptoms is imperative. Limited time for interaction between clinicians and patients and wide availability of information and resources allow patients to play a more active role in their care. Not only are they making more informed treatment decisions, but patients are also making decisions about their overall health care and well-being and managing their disease’s effects and emotional impact on daily life. Through an integration of efforts, patients are empowered to take ownership and responsibility for their own health, participate in the decision making process, and personalize the steps taken based on their individual needs and choices. Much more is expected of the patient: self-assessment of health status (eg, side effect and adverse event recognition), recollection of relevant health history, ability to utilize and understand information in health care follow-up, and navigation of insurance issues, etc. However, 90 million adults have trouble understanding and acting on health information, per an Institute of Medicine (IOM) report on health literacy.1 What factors enable patients to navigate their journey and take more accountability for their health? What does the oncology

care team need to consider? Arming a patient with tools for success goes well beyond providing brochures on their newly diagnosed disease and a list of Web sites for reference. Other factors come into play. Health literacy and patient health are intertwined and fundamental literacy is a strong predictor of health status. The IOM defines health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”1 Evidence shows that patients often misinterpret or do not understand much of the information provided by clinicians due to low health literacy. KNOW WHAT PATIENTS KNOW Does the patient have health information skills, including the ability to read, comprehend, and analyze the information provided? This does not equate to reading ability or the number of years of education, but rather a complex combination of reading, listening, analytical, and decision-making skills. It also requires the ability to synthesize these skills and apply them to health care situations. A well-educated patient who thrives in other areas (eg, the workplace) may not have an adequate literacy to thrive in a health care environment. In addition, many patients may be interfacing with the health care system for the first time. The ability to carry out what may seem like simple tasks (ie, deciphering

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C101: EMPOWER YOUR PATIENT

Ultimately, a future with improved outcomes is contingent on the evolution of the role of the patient.

instructions on prescription drug bottles, calculating medication dosages, identifying and tracking symptoms, interpreting consent forms, and understanding medical education brochures) and important instructions requires strong health information skills. This skill set includes six types of literacy. • Visual literacy Interpret graphs, symbols, charts, diagrams, or visual data. • Numeric literacy Calculate or reason numerically • Scientific literacy Understand the basics on how science and medicine work • Computer literacy Utilize a computer to access and comprehend information • Information literacy Apply relevant information when making decisions • Cultural literacy Interpret and act on health information through the lens of dynamic characteristics shaped by collective beliefs, customs, and social identity.

n informed consent document may be too complex for a patient to interpret; as a result, the patient may make suboptimal decisions about accepting or declining interventions. A patient may be provided with information but not understand how to weigh risks and benefits, make decisions, and ultimately take action. Every patient is unique, and nurses should not automatically assume the information given is understood, even if the

Questions to consider … • What basic information must a patient know that will be useful for them to make an informed decision? • Do your patients know where and how to access credible information that is easy to understand? • Is reinforcement of the education throughout the journey part of your strategy? • Does timing of the delivery of education play a role in adequate selfmanagement and adherence? • Have clinicians delivering education been trained on health literacy? • Do you use tools designed to assess the literacy level of your patients?

TABLE 1. Red flags that a patient may have low health literacy Asks fewer questions Identifies medications by appearance rather than by label information Inability to name medications, explain their purpose, or give the dosage Inability to provide a coherent, sequential medical history Lack of adherence to treatment protocol Lack of follow-though with tests and referrals Patient frequently misses appointments Registration forms are incomplete

patients look over the written information and state that they do understand it. Health literacy awareness among clinicians should be promoted and literacy screenings utilized to ensure no patient is left behind ( Table 1). Information must be tailored to meet the needs and abilities of the patient and ensure they have the skills to comprehend it and make collaborative decisions with their clinicians. Strategies need to account for differing experiences, abilities, knowledge, cultural beliefs, practices, and communication skills. Areas associated with health literacy include, but are not limited to, the following. • Communication between the patient and clinician • Medical instructions, drug labeling interpretation, and adherence • Patient education material and resources • Evaluation of information for credibility • Informed consent • Interpretation of test results • Medical and insurance forms • Analysis of relative risks and benefits • Provision of accurate and relevant patient history Improvements in health literacy have been linked to extended longevity; improved quality of life, patient safety, and patient outcomes; reduced prevalence of chronic disease, health disparities, and medical errors; and lowered health care-related costs. Do you Continued on page 46

40 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

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COMMUNICATION CHALLENGES

What I did not say

Ann J. Brady, MSN, RN-BC

What I did not say, I didn’t say because I was uncertain of how to say it.

ifficult patients present us with their own communication challenges. It can be easy to get caught up in the swirl of complaints. Do you avoid those situations or address them directly?

CASE I arrived at Sam’s hospital room in time to hear him say to his nurse, “I’m tired of people getting in my business. I told you I need something for pain. What part of that don’t you understand?” His nurse, Kirsten, rolled her eyes when she came out of the room. I followed her to the nurse’s station. “Sounds like he is having pain.” I said. “It’s always something with him. I’ve taken care of him for 2 days in a row and I’m glad I’m off tomorrow.” She rolled her eyes again. What I said was, “He’s a handful.” “That’s one way of describing him.”

Another nurse chimed in, “He is driving all of us nuts.” When Kirsten hurried past me her body language communicated more than her words. What I didn’t say was, “Give him a break, he’s dying of cancer.” Or, “Sam takes a little getting used to.” Or, “I don’t think you should talk about him that way.” Sam was admitted to the ICU with abdominal pain, anasarca, and shortness of breath. By the time he was transferred to the DOU, he had outworn his welcome. On his transfer out of the ICU one of his nurses said, “Wow, glad to see him go.” Everywhere he went he alienated the staff. I had known Sam for more than a year, yet whenever I saw him I was never sure which Sam I would meet; the sweet intent one who looked at me with dark brown eyes that creased at the edges when he said, “How you doing today?” or the angry, almost paranoid person who looked at me with the same dark brown eyes suddenly deep as a black cave, surprising me with his quick shift in temperament as he abraded me by saying, “What do you know, anyway?” I had gotten used to expecting his mood swings, though I was never certain what set them off. We came to terms. A little humor went a long way. When he targeted me, I wagged my finger at him and said, “Oh, no. Let’s stay on track, Sam.” I had to remind myself that his fluctuating temperament was not his fault, that his lack of education did not mean he was stupid. He was entrenched in certain behaviors and didn’t want to change. He’d had surgery and chemo, and had lived with pain for a long time. I reviewed the care plan with him several times. He was

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COMMUNICATION CHALLENGES

What I didn’t say bothers me, but it directs my interactions with other patients.

supposed to call before he came to the cancer center to pick up a prescription, but instead he would just show up. The secretary would call me and hand the phone to him, and I said the same thing each time: “You’ll have to wait. I’ll be there as soon as I can.” And he said the same thing each time: “Okay.” He didn’t call ahead of time because he wasn’t sure how he would feel in the morning. To get to the center he had to take two buses and walk several blocks, never certain how long it would take him. We became his port, and he was tethered to us by his need for pain medication. Sam had his own ideas about how to take pain medication, refusing a long-acting pain medication and instead relying on immediaterelease pain meds. Somehow that made more sense to him. His previous addiction to illicit drugs fueled his resistance to taking a long-acting. Regardless of my efforts at educating him about long acting versus short acting, addiction versus dependence, he told me, “I know more about addiction than you do,” which was true. I abandoned any idea of getting him to change his pain medication regimen; instead, I was the one to adjust. We could do a better job controlling his pain, and for a while I tried to insist he follow our recommendations. But to no avail. Finally, we settled on a pain management plan he was willing to adhere to. To assuage my need to direct his regimen, I told him, “OK, we’ll do it your way; but if it doesn’t work, maybe we can try my way.”

JOIN THE CONVERSATION • What do you do when other health care providers make negative comments about patients? • How do you frame questions to others in difficult situations?

ON THE

WEB

Go to OncologyNurseAdvisor.com/challenges_difficult to join the conversation in the Comments section on handling difficult conversations with or about patients.

DISCUSSION How could I expect the floor nurse to understand Sam after 2 days when I was still trying to figure him out after a year? He was difficult, yet his volatile personality hovered over a core I could only describe as sweet, a soft filling he hid well. It took me a year to understand how afraid he was and that he had probably lived his whole life in fear. What I did not say to the nurse, I didn’t say because I was uncertain of how to say it. If I commented in a way that sounded like a scolding, I would alienate his nurses. If I said something defensive, his nurses might feel justified in their negative attitude. Yet agreeing with those negative comments was more than unprofessional; it was a kind of betrayal of Sam. Even in so-called ideal circumstances, effective communication is a challenge. And difficult conversations are by nature difficult. In an interesting irony, as I was mulling over how else I might have managed the situation, I observed a colleague handle a potentially problematic situation. A doctor, one known to be difficult, was loudly expressing her dissatisfaction with a patient discharge. Rather than explain what happened or getting defensive, my colleague said to the physician, “Tell me more about your concerns.” It was simple and neutral. And it worked. When the nurses complained about Sam, I might have said the same thing. Next time I face a difficult conversation, I will try a similar approach. As for Sam, he died on his own terms, at home without hospice or home health, as independent as ever. Cranky, I’m sure. Scared. Probably with pain we might have managed if he had let us. What I didn’t say bothers me, but it directs my interactions with other patients. Cranky, obstinate Sam, and the sometimes sweet, humorous Sam, are part of my practice and a reminder that I can do a better job communicating. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

42 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

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ISSUES IN CANCER SURVIVORSHIP

Physical therapy and cancer: Motion and mobility before and after cancer treatment Bette Weinstein Kaplan

urviving cancer takes more than surgery, chemotherapy, and radiation. It takes rehabilitation, and ideally, includes prehabilitation, according to Julie Silver, MD, an associate professor at Harvard Medical School.1,2 Silver learned about the importance of oncology prehabilitation and rehabilitation the hard way—by having cancer herself in 2003. Recovering from grueling treatment for breast cancer at 38 years old, she was surprised at how ill she was. There was no aftercare in place, and with no mention of cancer rehabilitation she really struggled to recover and go back to work. She said, “I did some exercise testing, and I tested out as a woman in her 60s. So I had aged three decades in a matter of months through cancer treatment.”3 BUILDING A STAR PROGRAM

Silver realized there was a sizeable gap in oncology services available to patients. Utilizing her training as a physiatrist, she initiated a program of prehabilitation before cancer treatment as well as rehabilitation therapy after treatment. Launched in 2009, STAR Program (Survivorship Training and Rehabilitation) certified rehabilitation is offered by many facilities throughout the United States. Cancer rehabilitation addresses the findings of the 2010 National Health Interview Survey. The survey results demonstrated that many

of the health-related quality-of-life (HRQOL) difficulties experienced by cancer survivors are physical.4 In that study, investigators evaluated 1,822 cancer survivors and 24,804 persons who had never received a cancer diagnosis.4 Although almost 25% of survivors reported being in poor physical health, only 10.2% of those with no history of cancer said their health was poor.4 When

Patients’ actual functionality should be assessed, not simply their HRQOL. asked about mental health, 10.1% of survivors reported being in poor mental health, while only 5.9% of persons who had no cancer diagnosis said their mental health was poor.4 Silver noted that there is often a significant overlap between the physical and psychological components of distress experienced by cancer survivors, creating a real need for rehabilitation that is rarely delivered.1,2 THE NUMBERS ARE ASTONISHING In a study of 163 women with metastatic breast cancer, more than 90% of the participants needed rehabilitation after their cancer treatments.5

However, fewer than 30% of them actually received it.5 Many similar studies show that cancer survivors continue to suffer for many reasons after their treatment ends, and this leads to further problems. As Silver wrote, “A leading cause, or perhaps even the leading cause, of emotional distress in cancer survivors is physical disability.”1 Study after study finds patients experiencing psychological distress that is disproportionate to their cancer diagnosis or physical state. The physiatrist provides multidisciplinary care that addresses the physical, vocational, and rehabilitation needs of a cancer patient. Patients’ actual functionality should be assessed, not simply their quality of life. Activities of daily living (ADLs) are important. But, they require a low level of functionality, and most survivors can accomplish them readily. Silver recommends rehabilitation focus on the impairments that affect other activities: Can the patient use her arm well enough to handle a car or use public transportation? Can the patient eat in a normal manner so he can each lunch in a public place without being embarrassed? If the patient cannot perform tasks beyond basic activities of daily living, physical, occupational, and speech rehabilitative therapies plus targeted exercise programs are essential. The STAR Program helps hospitals and other health care facilities develop cancer rehabilitation service lines that

44 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2013 • www.OncologyNurseAdvisor.com

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ISSUES IN CANCER SURVIVORSHIP coordinate care among diverse providers. The therapist identifies the problem, sets realistic goals for the patient, and then applies specific modalities to treat the impairment. PREHABILITATION

A hallmark of Silver’s program is prehabilitation, a physical therapy regimen that prepares patients physically as well as emotionally for their cancer treatments. As Silver learned, oncology treatment can deplete and age a patient. The prehabilitation goal of the STAR Program is to strengthen and condition, so when the onslaught of treatment occurs, the damage is reduced. Targeted exercises and psychological counseling can go a long way toward faster recovery from treatment. BARRIERS TO CARE

The effectiveness of prehabilitation and rehabilitation is limited by patient access, and some patients will experience barriers to this care. Insurance coverage can be an issue. Although most insurance plans cover cancer rehabilitation, policies may have caps on how much they cover. Patients should be screened early for physical impairments, and the

C101: Empower Your Patient Continued from page 40

have strategies and tactics in place to ensure your patients understand the information you convey to them? A few simple techniques can be incorporated into the patient-nurse interaction to pave the path toward success. • Focus on what patients need to know and need to do in three to five key points • Repeat and summarize messages • Use the teach-back method, in which the patient explains your instructions

impairments should be addressed before they can progress too far. Therefore, oncology clinicians should routinely refer their patients for rehabilitation. That is getting better: the American College of Surgeons’ Commission on Cancer recently published new program standards for survivor care that include

2. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatmentrelated morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil. 2013;92(8):715-727. 3. Gotbaum R. Cancer rehab begins to bridge a gap to reach patients. Shots: NPR Health News from NPR Web site. http://www.npr.

Targeted exercises and counseling goes a long way toward faster recovery.

org/blogs/health/2013/02/18/172099043/ cancer-rehab-begins-to-bridge-a-gap-toreach-patients. Published February 18, 2013. Accessed November 13, 2013. 4. Weaver KE, Forsythe LP, Reeve BB, et al. Mental and physical health-related quality of life among U.S. cancer survivors: population estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers

recommendations for improved access to cancer rehabilitation.6 For more information about the STAR Program, visit www.OncologyRehabPartners.com. ■

Prev. 2012;21(11):2108-2117. 5. Cheville AL, Troxel AB, Basford JR, Kornblith AB. Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. J Clin Oncol.

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

2008;26(16):2621-2629. 6. American College of Surgeons. Cancer Program Standards 2012, Version 1.2:

REFERENCES

Ensuring Patient-Centered Care. American

1. Silver JK, Baima J, Mayer RS. Impairment-

College of Surgeons Cancer Programs

driven cancer rehabilitation: an essential

Web site. http://www.facs.org/cancer/coc/

component of quality care and survivorship.

programstandards2012.html. Accessed

CA Cancer J Clin. 2013;63(5):295-317.

November 13, 2013.

back to you in their own words, to confirm the patient’s understanding • Use visuals to improve understanding and recall; use plain language that you would use when speaking with a friend. The health care team should take active steps toward enabling patients to become empowered as an equal partner in care. Ultimately, a future with improved outcomes is contingent on the evolution of the role of the patient. What strategies have you adopted to minimize barriers and misunderstanding as you educate your patients? ■

Sarah Krug is CEO of Cancer101.org, an organization that empowers patients and caregivers to take control over their diagnoses, navigate the cancer journey, and partner with their healthcare team to make informed decisions through a variety of tools and resources. REFERENCES 1. Institute of Medicine Committee on Health Literacy. Health literacy: A prescription to end confusion. http://www.iom.edu/~/ media/Files/Report%20Files/2004/HealthLiteracy-A-Prescription-to-End-Confusion/ healthliteracyfinal.pdf. Accessed December 3, 2013.

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FROM

Online support groups: A psychosocial network Erin Columbus, MSW, LCSW

As with telephone and face-toface support groups, online groups allow participants to connect with others who are in a similar situation.

nternet access allows countless patients and caregivers to research their diagnosis online. Many of these same users may not realize that psychosocial support can be found there as well. Online support groups are a crucial lifeline for people facing cancer. As with telephone and face-to-face support groups, online groups allow participants to connect with others who are in a similar situation. Members have the opportunity to share coping tips and practical advice. Most importantly, online support groups provide a virtual safe space in which members can voice their feelings, concerns, and anxieties without fear of judgment or reproach. Nat ion a l nonprof it org a n i z at ion CancerCare recently sponsored an informal survey of 125 online support group participants. The results showed 88% of respondents acknowledged that “being part of an online group helped me feel more emotionally connected,” and 93% agreed that “participation in an online support group helped me feel less isolated.” A group member observes: We are a community of very different people from very different backgrounds who find ourselves joined by the common thread of our similar experiences. I can’t tell you how many times I thought I was utterly alone in the world in what I was feeling only to come here and find that several people here faced the same fears and struggles. Online groups are a relatively new medium in psychosocial care. Former CancerCare client Cindy B. acknowledges that participating

in an online support group would have made a tremendous difference in her care. Cindy’s story is truly amazing—she is a 16-year lung cancer survivor who maintains an active lifestyle today, even working part-time to provide support and information to CancerCare clients. Cindy came to CancerCare in the late 1990s to attend a face-to-face support group to discuss her fears and anxieties. “I wanted to talk to people who had gone through what I’d just gone through,” Cindy explains. Her support group helped her understand what to expect from life as a cancer survivor. “Being able to talk to people who had been there and could understand where I was coming from was what I totally needed,” she says. She adds, however, that she would have opted to participate remotely, due to lingering fatigue she experienced from treatment.

ide effects are just one of the barriers to face-to-face support group attendance. High transportation costs are an obstacle as well. While many treatment centers offer counseling and support groups, many of these groups are informational and do not address patients’ and caregivers’ emotional needs. Patients may also feel reluctant to return to their treatment center or hospital due to an association with unpleasant treatments. Geographic barriers may also be obstacles, especially for patients and caregivers in rural areas who may not have access to face-to-face groups. Online support groups can provide a vital feeling

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of belonging and community, regardless of any physical or geographical limitations. Many patients and caregivers understandably feel more comfortable participating from their own home. Others may prefer online groups because they can anonymously share their difficult emotions. Some groups allow members to communicate their feelings any time, day or night. This can be particularly useful for the caregiver, for example, who is sleepless at 2 AM and wants to share how they are feeling.

here are different types of online support groups to accommodate patients’ and caregivers’ diverse needs. Many groups have an open format, which means they have no time limit and few restrictions on who can participate. Others follow a closed format, in which members must register before participating. CancerCare’s online support group model resembles a message board structure and is asynchronous, as opposed to a live chat. This type of group is only accessible to registered members, and is available 24 hours a day, 7 days a week. Participants can write comments, answer questions, and read and respond to posts from other members—all at their own convenience and free of charge. All of CancerCare’s support groups are moderated by licensed oncology social workers, though other organizations’ groups in this format may be moderated by volunteers or patient assistance professionals. Working with a professional oncology social worker may help patients and caregivers feel particularly safe to share difficult feelings, and may provide them with deeper insights into their situation and experiences.

FIND US ON

Several professional organizations host online groups, including the American Cancer Society (www.cancer.org). Some cancer-specific organizations, such as the Leukemia and Lymphoma Society (www. lls.org) and the American Brain Tumor Association (www.abta.org) provide message boards. They may also provide referrals to support groups. Online support groups are also available in a listserv format. This format allows members to email questions and comments to every member of a mailing list. (Note that the number of messages members receive may be high, as emails are sent to all members on the list). One such listserv is the Association of Cancer Online Resources (ACOR) (www. acor.org). A third type of online support group format is the chat group, in which an online conversation takes place in real time. Online chat groups are generally held at a specific time and day. Patients and caregivers who benefit the most from online support groups, unsurprisingly, enjoy writing, are comfortable communicating online, and have easy access to the Internet. When choosing to recommend an online support group to a patient or caregiver, consider what format would best suit them. Is the group open, or closed? What is the structure? Are members’ identities protected? Is there a moderator? What are his or her credentials? With the increase of Internet-savvy patients and caregivers, you should familiarize yourself with the numerous options available to cancer patients for online support. ■

FROM

Patients and caregivers who benefit the most from online support groups, not surprisingly, enjoy writing.

Erin Columbus is program director of online services, CancerCare.

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THE PATIENT’S VOICE

5 things I now know about melanoma Suzanne Wolfe

ore than 2 million people in the United States will receive a diagnosis of skin cancer in 2013. A few months ago, I became one of them. Ironically, I’d gone to see my dermatologist because I thought my dad had skin cancer. He had admitted that the large mole on his head had changed in recent months, but he was not inclined to do anything about it, leaving the worrying to my mother and me. I was finally able to cajole him into going to the doctor by scheduling a joint appointment—I would have a preventive body check, and he would have the mole examined. When the office visit was over, my father walked out with the assurance that his mole was benign. I walked out with an ache in my foot where the doctor had just sliced off a piece of skin. A week later, I received the biopsy results: melanoma. I was concerned, of course, but not as much as I might have been had the news of the diagnosis been delivered in a different way. My dermatologist, while making clear that I needed to seek surgical treatment without delay, spoke to me in the same low-key, easy manner she always had. I appreciated that, and it helped me to digest the news. Although melanoma is the least common form of skin cancer, it is also the most deadly. Mine was detected at stage 1, so I count myself among the lucky ones. Now, at 53 years old, I am wiser to the ways of melanoma. Here is what I’ve come to know.

Melanoma does not necessarily look that bad The photos of skin cancer I remem-

ber seeing in educational brochures practically screamed “Cancer!” But the mole my dermatologist shaved off looked like a plain old mole to me. It did not seem to fit the ABCDE skin cancer mnemonic (Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, Evolving). Turns out, the asymmetry in the left and right sides of the mole was there, but it was subtle and visible only when viewed through a magnifying lens. The mole met the evolving criterion, too, having become more elevated in the 3 years since my last skin check; I just had not paid enough attention to how it used to look to notice the change. Recognizing even a single change in a mole may be crucial to detecting the cancer early, because some melanomas meet only one or two of the ABCDE criteria.

Melanoma can occur where the sun doesn’t do much shining My melanoma was sand-

wiched between two toes. Other potential sites that do not get much, if any, sun exposure include the soles of the feet, palms of the hands, fingernails or toenails, and genital area. Melanomas that are not in plain sight can be among the most deadly because the patient may not notice the cancer until it is well progressed.

Removing a mole for biopsy is not the same as removing the cancer The type of

biopsy my dermatologist performed, one of several techniques commonly used, was quick and simple but not deep and wide. I did not realize

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THE PATIENT’S VOICE

that once the visible mole was removed, the full thickness of skin beneath it and a wide margin of skin around it would need to be surgically excised. Further treatment might be needed based on results of the postsurgical tissue analysis, which would definitively stage the cancer, as well as on other medical findings. In my case, the ’tween-the-toes location made removal of the melanoma complicated and necessitated the hands of an expert plastic surgeon, who excised the area and then placed a skin graft during an hour-long operation. In the weeks that followed, I would be doing twice-daily dressing changes, hopping around on crutches, and later walking with the aid of a cane as the foot healed and my mobility returned.

More than one specialist may need to be involved, even if the melanoma is thin My skin cancer was diagnosed

by a dermatologist, treated by a plastic surgeon, and reviewed by an oncologist, who examined me for evidence of spread to lymph nodes—an examination that helped determine whether I needed to undergo a lymph node biopsy before the melanoma was removed. Thankfully, I did not, but I felt good for having been checked out and relieved that I had an oncologist in place should the postop pathology tests indicate I needed one. The oncology nurse who was present during my examination, and who was clearly an integral part of the care team, exuded warmth, kindness, and optimism—a combination that did much to overcome my discomfort at finding myself in the unexpected role of cancer patient.

Dermatologic check-ups belong on the preventivehealth short list Like many women, I am vigilant

about going for mammography every year. But having had no unusual findings in past dermatologic body checks, an annual examination fell off my to-do list, especially since I believed myself to be at low risk (all those summers not going to the beach!). My must-do list sure has changed. Because my risk for developing melanoma again is about 9 times greater than someone who has never had melanoma before, I will be going for check-ups every few months for the next few years.1 And I plan to keep going as often as advised, knowing that the risk will never completely go away. Indeed, a recent study found that recurrence of melanoma more than 10 years after initial treatment is not uncommon.2 Suffice it to say, I have a newfound appreciation for the importance of body checks—such a simple, low-tech preventive measure—and the need to become familiar with one’s own skin. A message whose importance, I’ve come to realize, is much more than skin deep. ■ Suzanne Wolfe is scientific director/senior editorial manager for PRI Healthcare Solutions, New York, New York. REFERENCES 1. Bradford PT, Freedman M, Goldstein AM, Tucker MA. Increased risk of second primary cancers after a diagnosis of melanoma. Arch Dermatol. 2010;146(3):265-272. 2. Faries MB, Steen S, Ye X, Sim M, Morton DL. Late recurrence in melanoma: clinical implications of lost dormancy. J Am Coll Surg. 2013;217(1):27-34.

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ASK A PHARMACIST

What research is available on paroxetine and chemoprevention drugs? Can the drug paroxetine mesylate (Brisdelle) be given to patients taking a chemoprevention drug such as raloxifene (Evista) or any of the aromatase inhibitors? I have read research on tamoxifen and paroxetine, but not seen any research on the other chemoprevention drugs. —Maggie Siebeneichen, RN, BSN, BA

Tamoxifen and raloxifene (Evista) are FDA-approved for the prevention of breast cancer in women at increased risk of breast cancer.1 Tamoxifen and the aromatase inhibitors (exemestane [Aromasin, generic], anastrozole [Arimidex, generics], letrozole [Femara, generics]) are used in the adjuvant therapy of women with ER/ PR positive breast cancer.2 Women

receiving treatment with these agents may experience hot flushes and other menopausal symptoms.3 Paroxetine is a selective serotonin reuptake inhibitor (SSRI) that may be used to treat hot flushes and depression. Paroxetine also inhibits cytochrome P-450 (CYP) 2D6, the enzyme responsible for converting tamoxifen to its active metabolites. Because this may reduce the efficacy of tamoxifen, concomitant use of tamoxifen with paroxetine and f luoxetine (Prozac) should be avoided.2 Other therapies (eg, venlafaxine [Effexor]) are preferred as they have less impact on tamoxifen metabolism. Raloxifene and the aromatase inhibitors are not significantly impacted by CYP2D6 inhibitors and inducers, but may have interactions with other medications due to how they are metabolized. For example, exemestane is metabolized by CYP3A4 and coadministration of 3A4 inducers (eg, carbamazepine [Tegretol], St John’s wort)

may reduce its exposure and efficacy. Therefore, either avoiding this combination or adjusting the dose of exemestane in patients receiving a strong CYP3A4 inducer is recommended. It is important to note that drugdrug interactions may be caused by mechanisms other than CYP enzymes; for instance, raloxifene may affect the binding of other drugs such as warfarin (Coumadin) and diazepam (Valium) and impact the effects of these medications. Due to the variety of drug-drug interactions that may occur, a pharmacist review of the complete list of the patient’s medications and any vitamins or supplements is essential to identify interactions with these treatments. ■ REFERENCES 1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Breast Cancer Risk Reduction. Version 1.2013. National Comprehensive Cancer Network Web site. http://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf. Accessed November 11, 2013. 2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Breast Cancer. Version 3.2013. National Comprehensive Cancer Network Web site. http://www.nccn. org/professionals/physician_gls/pdf/breast. pdf. Accessed November 11, 2013. 3. Thompson LA. Hot flushes on tamoxifen [Ask A Pharmacist]. Oncol Nurse Advisor. 2011;2(2):48. http://www.oncologynurseadvisor.com/hot-flushes-on-tamoxifen/ article/265805/. Accessed November 11, 2013.

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

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