Oncology Nurse Advisor November/December 2019 by Haymarket Media

www.OncologyNurseAdvisor.com

November/December 2019

FEATURE

CANCER IN THE ELDERLY Using EBM to Determine Procedure Competency in Nurses

FROM CANCERCARE

Significance of Assessing Malnutrition Status in Patients 65 and Older

Improving Communications With Patients and Families Affected by Breast Cancer

RADIATION & YOUR PATIENT

Brachytherapy Remains an Important Modality in Cervical Cancer Management

COMMUNICATION CHALLENGES

Nutritional status should be a key component of patient assessment in all cancer patients 65 years and older.

“The ‘Blessed Event’ Occurred”

ASK A PHARMACIST Difference Between irAEs and Traditional Therapy AEs

ISSUES IN CANCER SURVIVORSHIP

PRSRT STD US POSTAGE PAID PONTIAC IL PERMIT #60

Adolescents, Young Adults Report Concerns Regarding Their Sexuality

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Editor Joyce Pagán editor.ona@haymarketmedia.com

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

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HAYMARKET MEDIA Managing editor, Haymarket Oncology Lauren Burke VP, Content; Medical Communications Kathleen Walsh Tulley

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

General Manager, Medical Communications Jim Burke, RPh President, Medical Communications Michael Graziani CEO, Haymarket Media Inc Lee Maniscalco

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

Oncology Nurse Advisor (ISSN 2154-350X), November/December 2019, Volume 10, Number 6. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. Copyright © 2019. 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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CONTENTS 7

November/December 2019

IN THE NEWS • Patient Materials on Breast Cancer Not Optimal • Complementary Medicine Use Is Common Among Participants in Phase 3 Clinical Trials • Safety From Exposure to 5-Fluorouracil Varies by Connector Type on Infusion Lines • Neurologic Deficits Shorten Overall Survival in NSCLC With Brain Metastases at Diagnosis • Nurse-Led Service Improves TIVAD Delivery, Enhances Patient Quality of Life

• Low-Dose Methotrexate May Decrease Symptom Burden in MPNs and more …

ONCOLOGY NURSE ADVISOR FORUM • Staying Up-to-Date With Health Insurance Changes • Managing Adverse Effects of Olaparib in Relapsed Ovarian Cancer • Nurse-Provided Dietary Guidance for Patients With Cancer

• Reliable Information on Use of CBD Oil in Cancer Treatment

FEATURES Tools for Assessing, Managing Malnutrition in the Elderly Bryant Furlow

Using EBM to Determine Skill Competency in Nurses Patricia Wills Bagnato, MSN, APRN, CPNP-PC, CPHON®

Continues on page 6

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ISSUES IN CANCER SURVIVORSHIP Patient Aids That Emerged From Breast Cancer Survivors’ Journeys

CONTENTS 27

Unique products created by entrepreneurial cancer survivors to solve the most challenging issues cancer patients face.

November/December 2019

FEATURES Understanding “Chemobrain” in Patients With Cancer John Schieszer

Bette Weinstein Kaplan

JOURNAL REVIEW Recognition, Diagnosis of ChemotherapyInduced Peripheral Neuropathy in Cancer Patients Can Prevent Falls

A literature review of CIPN as a potential contributor to falls and injuries in patients with cancer. John Schieszer

RADIATION & YOUR PATIENT Brachytherapy Remains Important in Cervical Cancer Management Bryant Furlow

COMMUNICATION CHALLENGES “The ‘Blessed Event’ Occurred” Ann J. Brady, MSN, RN-BC, CHPN

THE TOTAL PATIENT The Nurse’s Role in Childhood Leuekmia From Disease Recognition to Survivorship Care

An overview of the nurse’s role when a diagnosis of leukemia is made for a child. Bette Weinstein Kaplan

FACT SHEETS Angiogenesis Inhibitors

ISSUES IN CANCER SURVIVORSHIP Adolescents, Young Adults Report Significant Concerns Regarding Their Sexuality Bette Weinstein Kaplan

FROM CANCERCARE Improving Interactions With Those Affected by Breast Cancer Joseline Lopez, MPsy

ASK A PHARMACIST Understanding How irAEs Differ From Traditional Therapy AEs Lisa A. Thompson, PharmD, BCOP

A review of the use of angiogenesis inhibitors. PUBLISHERS’ ALLIANCE: DOVE PRESS Physician and Patient Barriers to Radiotherapy Service Access: Treatment Referral Implications

A discussion on physician- and patient-related barriers to greater use of radiotherapy that may be contributing to a lack of referrals to radiation oncology. Cancer Management and Research

ON THE

WEB

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IN THE NEWS

ÂŠ SIMONKR / GETTY IMAGES

Patient Materials on Breast Cancer Not Optimal Although educational materials are considered to be a critically important component of treatment for women with breast cancer undergoing chemotherapy, patient comprehension of these materials is central to their usefulness. Furthermore, research on the experiences of these women as they relate to chemotherapy education has been limited. The aims of this study were 2-fold: to evaluate the readability and format of 5 commonly used printed or online chemotherapy educational materials using several standardized assessment measures and to evaluate the perceptions of women with breast cancer regarding the usefulness of these materials. Criteria for study eligibility included age 18 years or older, a new breast cancer diagnosis, and the ability to speak English; patients with stage IV disease, a recurrence of breast cancer, or cognitive impairment were excluded from the study. Demographic characteristics of the study population included a median age of 59 years; 50.0% were black, and 47.8% were white. All patients reported graduating from high school, with approximately 50% of patients having completed at least a 4-year college degree. In addition, the health literacy of this group was determined to be above a 9th-grade level. All educational materials evaluated were determined to be superior in terms of content, although the literacy demands of the chemotherapy educational booklets from SCOA, Susan G. Komen, and Breastcancer.org were classified as being particularly high. For example, all 5 educational materials required at least a 9th-grade reading level, but a mean reading level of 12th- to 13th-grade was determined to be necessary to understand the chemotherapy pages on the Breastcancer.org website. Another theme uncovered in this study was the dearth of illustrations to facilitate understanding, as well as the absence of culturally appropriate pictures or information. Read more at https://bit.ly/2XxtSaB.

Nurse-Led Program Conducts Follow-up After Resection for Lung Cancer The design and implementation of a specialist nurse-led program focused on regular surveillance imaging follow-up of patients treated with surgery for early-stage lung cancer were presented at the 2019 World Conference on Lung Cancer. Specifically, the program is for patients who have undergone resection for early-stage lung cancer and for whom adjuvant therapy has not been recommended or who have declined such treatment. It involves both face-to-face clinics and telephone clinics in which a specialist nurse with advanced practice skills communicates findings from

computed tomography (CT) scans of the chest, abdomen, and pelvis obtained every 6 months for the first 2 years following surgery, and annually thereafter for an additional 3 years. In the nurse-led program, patients are followed by the specialist nurse who coordinates the program and also triages the patient based on the CT scan results. Those patients meeting criteria for telephone communication, such as the ability to speak English and hear over the telephone, as well as the absence of cognitive impairment, receive surveillance imaging results by telephone if there are no abnormal findings or only minor changes requiring a repeat CT of the chest in 3 months. Continues on page 8

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IN THE NEWS

Read more at https://bit.ly/2rTH2Ts.

Complementary Medicine Use Is Common Among Participants in Phase 3 Clinical Trials Investigators from Canada reported at ESMO Congress 2019 that complementary medicine (CAM) products are concurrently used with conventional medicine, including natural products and homeopathy by as many as 20% of patients. CAM use highest in Until now, the use of complemenpatients with CRC. tary medicine had not been well studied in patients with cancer participating in phase 3 trials. Researchers examined patient characteristics and outcomes among complementary medicine users enrolled in phase 3 trials conducted by the Canadian Cancer Trials Group (CCTG). They mined data from 6 trials that included patients with metastatic breast cancer, colorectal cancer (CRC), or non-small cell lung cancer (NSCLC). Two of the investigators independently reviewed medications and any discrepancies were reviewed by a third investigator. The study included 3446 patients (17.7% with breast cancer, 44.4% with CRC, and 37.8% with NSCLC). The study demonstrated that 24,908 medications were being taken and 651 medications (2.6%) were considered complementary medicine products. The researchers found that 20.4% of patients were using complementary medicine, and its use in patients with lung cancer was associated with ECOG performance status of –1 vs +2 and weight loss of less than 5%. Among the patients with lung cancer, complementary medicine was also associated with nonsmokers and Eastern Asian ethnicity. Patients who were more likely to use complementary medicine had CRC and were aged 65 and younger. Patients with fewer sites of metastases and normal hemoglobin were also more likely to use complementary medicine. Among patients with breast cancer, complementary medicine use was more common in patients younger than 50. Read more at https://bit.ly/355DWKe.

Safety From Exposure to 5-Fluorouracil Varies by Connector Type on Infusion Lines More steps may be necessary to protect oncology nurses from contamination with 5-fluorouracil (5-FU). A new study is suggesting that the lowest contamination occurs with the use of connection QimoMale® + QimoFemale® compared with Luer Lock Male + Female or Luer Lock Male + Needleless connectors (BD-Q-Syte®). The findings, presented at ESMO Congress 2019, demonstrated contamination with 5-fluorouracil was similar between the Luer Lock Male + Female connector and the Luer Lock Male + Needleless connector. The team investigated the potential for contamination when disconnecting infusion lines of elastomeric pumps containing 5-fluorouracil with the 3 different connectors. They used a tissue mimicking a patient’s arm. Both end parts of the connection were cleaned with a wipe after disconnection, and the wipe, the gloves, and the tissues were analyzed separately for contamination with 5-fluorouracil. The investigators used 10 elastomeric pumps (Baxter-Folfusor®) for each type of connection. Findings showed that there was contamination with 5-fluorouracil on all 30 pumps. However, the level of contamination was highly varied, and the highest contamination levels were found on the wipes (end parts). The contamination levels on the tissues and on the gloves were found to be substantially lower. Significant differences were found between the 3 connectors with the wipes. The study showed the median contamination was 50% lower for QimoMale® + QimoFemale® compared with Luer Lock Male + Female, and 44% lower compared with Male + Needleless connectors. “The presence of 5-fluorouracil on the gloves supports the need of wearing gloves to protect nurses from exposure by skin contact during administration of cytotoxic drugs,” concluded the researchers. Read more at https://bit.ly/33W2jtV.

Neurologic Deficits Shorten Overall Survival in NSCLC With Brain Metastases at Diagnosis Researchers investigated the impact of neurologic symptom burden on mortality rates in patients with NSCLC brain metastases and found that the presence of neurologic symptoms was independently associated with a shorter survival. The diagnosis-specific graded prognostic assessment (DS-GPA) score is used to stratify common primary tumor

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From January 2013 to December 2017, 546 nurse specialistled face-to-face patient appointments in 189 clinics were held. In the first 12 months following the introduction of the telephone clinic in April 2017, 254 patient appointments were held by the nurse specialist in 51 clinics.

metastases to the brain into subgroups. The researchers conducted a multivariate analysis with DS-GPA and found that the presence of neurological symptoms was independently associated with a shorter survival prognosis from diagnosis of brain metastases (hazard ratio 1.19). For the study, the team analyzed a real-life cohort of 1531 patients with NSCLC brain metastases. Median age was 62 years; 57.4% were male, and 42.3% were female. Most of the patients (73.5%) had neurologic symptoms, including neurologic deficits (62.2%), symptoms of increased intracranial pressure (29.8%), and epileptic seizures (13.0%). Presence of increased intracranial pressure and seizures was found to have no impact on survival prognosis. However, median OS was significantly shorter for patients with neurologic defects compared with those without neurologic defects (7 months vs 11 months). Overall survival was also shorter for patients with memory disorders (6 months vs 8 months), ataxia (7 months vs 8 months), and vertigo (6 months vs 9 months). Read more at https://bit.ly/2XoQHNB.

Nurse-Led Service Improves TIVAD Delivery, Enhances Patient Quality of Life A nurse-led service of delivering totally implantable vascular access devices (TIVADs) is changing the playing field by reducing the number of catheterassociated complications and improving the quality of life for patients with metastatic cancer. The results of a Device use restores small nurse-led program implemented patient autonomy. at a hospital in Birmingham, United Kingdom, was presented at ESMO Congress 2019. Patients with metastatic cancer typically receive a peripherally inserted central catheter (PICC) for the administration of chemotherapy. However, PICCs are associated with a higher incidence of venous thromboembolism (VTE) and infections. They also need to be removed during treatment breaks and require weekly flushes. Patients often find PICCs inconvenient as they interfere with daily activities such as bathing, swimming, or even going on vacation for long periods of time. In a process that took 2 years, Matthew N. Fowler, MSc, developed a nurse-led TIVAD service that would not need any form of radiographic guidance using ECG. He received personalized clinical training and raised funds from several sources to purchase a required ultrasound machine. He has

since shared his training with his fellow nurses and implemented a nurse-led program. To date, 30 patients have received nurse-inserted TIVADs. One episode of VTE and no infections have occurred in the TIVAD group. In a previous group of 30 PICC insertions, 5 episodes of VTE and 3 infections occurred. Patients in the TIVAD group also report their ability to swim and the benefit of not undergoing weekly flushes. Read more at https://bit.ly/33Y4QU6.

Low-Dose Methotrexate May Decrease Symptom Burden in MPNs Results from this retrospective service evaluation of patients with myeloproliferative neoplasms (MPNs) treated with low-dose methotrexate for comorbidities not related to MPN showed in 3 case studies that patients experienced hematologic changes following the initiation and/or interruption of methotrexate. In one patient with polycythemia vera (PV), dose interruption of methotrexate due to renal impairment correlated with patient reports of pruritis. Restarting methotrexate correlated with the cessation of pruritis. Another patient with essential thrombocythemia (ET) was receiving hydroxycarbamide and began receiving methotrexate upon diagnosis of rheumatoid arthritis. The researchers noted that the combination of hydroxycarbamide and methotrexate decreased the patient’s platelet count to less than 400×109/L with no apparent toxicity. The third case study patient had long-term psoriasis when ET was diagnosed. When the psoriasis flared, this patient received low-dose methotrexate. During treatment with methotrexate, the patient’s platelet count continued to rise, but at a slower rate. Three patients with PV and 8 patients with ET were treated with methotrexate for comorbidities not related to MPN. Researchers assessed the burden of symptoms via MPN-10 in these patients compared with historic controls. Symptoms included fatigue, early satiety, abdominal discomfort, inactivity, concentration problems, night sweats, pruritis, bone pain, fever, and weight loss. Night sweats and fever were significantly improved in patients with PV and ET who received methotrexate, and abdominal discomfort, pruritis, and bone pain were significantly improved in patients with ET who received methotrexate. ■ Read more at https://bit.ly/2Qz6s37.

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

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

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

Eucharia Borden, MSW, LCSW, OSW-C, outpatient oncology social worker, Lankenau Medical Center, Wynnewood, Pennsylvania.

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

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

STAYING UP-TO-DATE WITH HEALTH INSURANCE CHANGES What are some strategies for keeping up with the ever-evolving health insurance changes patients bring to navigators? — Name withheld upon request This is not a job for any one person. The process needs to be addressed by several groups of caregivers working within the multidisciplinary team to provide the best care possible. Nurse navigators should know the basics of financial advocacy and what the most often utilized insurance plans cover for the patient cohort that they manage. If a navigator is new to the role or unsure of coverage, they should talk with the oncology social workers within their team. But they can also get additional education by participating in online programs, such as the Association of Community Cancer Centers (ACCC) Boot Camp (www.accc-cancer.org/home/learn/financial-advocacy/ boot-camp). Most hospital systems utilize multiple inpatient and outpatient social workers to assist patients with financial issues, along with the hospital’s patient finance coordinators. However, some hospitals are currently looking into a new position: Oncology Financial Navigator — a member of the multidisciplinary team who has a clinical background and experience working with the financial needs of patients, or someone with a business background who has been well trained in assessing clinical needs as well as financial ones. The ideal candidate has an extensive knowledge of community resources and excellent interpersonal skills to effectively interact between the medical team, patient and family, and outside agencies that may be needed to manage the ongoing care required by the oncology diagnosis and treatment. — Rosemarie A. Tucci, RN, MSN, AOCN

MANAGING ADVERSE EFFECTS OF OLAPARIB IN RELAPSED OVARIAN CANCER What are the recommendations for managing anemia in patients receiving Lynparza? — Name withheld on request Anemia is one of the most common and frequent adverse events that occurs in patients receiving olaparib (Lynparza), with an incidence rate of 22%. The severity of the anemia can lead to dose interruptions or reductions. Some studies have identified folate deficiencies in patients receiving olaparib for relapsed ovarian cancer. Most patients (90%) have experienced decreased hemoglobin, with 15% of patients experiencing grade 3-4 anemia. Recommendations are to transfuse blood products as needed; those patients with proven folate deficiencies should be started on folic acid, dose reduce per the guidelines, and monitor closely.1 — Jiajoyce R. Conway, DNP, CRNP, AOCNP

NURSE-PROVIDED DIETARY GUIDANCE FOR PATIENTS WITH CANCER What should nurses know to support their patients if an oncology nutritionist or clinical dietitian is not available to counsel a patient? — Name withheld on request

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There are many websites to offer patients for managing eating issues during cancer treatments, but first you need to know what the issues are. Talking to the patient and family members is where to start. Ask the patient to keep a food diary to get a real feel for what they can or cannot eat. Ask family members to aid the patient in this but remember that both sides of the discussion usually are fraught with personal bias: “Mom’s not eating enough” vs “I’m really full after eating 5 to 6 small meals a day.” And this bias can be cultural! The usual issues are appetite changes (not hungry or overeating), changes in taste and smell, problems with chewing or swallowing, constipation or diarrhea, dry mouth, fatigue, nausea and/or vomiting, mouth sores, and weight loss or gain. Nurses with years of experience can rattle off many suggestions for managing these issues but having something that patients and family members can refer to any time of the day or night makes life just a little bit easier. Websites are great, but having a handout is a plus. Here are a few recommended resources for patients: • Cancer Support Community: Diet & Nutrition (www.cancersupportcommunity.org/diet-nutrition) • American Cancer Society: Survivorship: During and After Treatment (www.cancer.org/treatment/survivorship-during-andafter-treatment.html) • National Cancer Institute: Eating Hints: Before, during, and after Cancer Treatment (www.cancer.gov/publications/ patient-education/eating-hints) • National Cancer Institute: Nutrition in Cancer Care (PDQ®)– Patient Version (www.cancer.gov/about-cancer/treatment/ side-effects/appetite-loss/nutrition-pdq)

• Oncology Nutrition: Cancer Dietitian (www.cancerdietitian. com); Eat Right to Fight Cancer (www.oncologynutrition.org/ erfc) — Rosemarie A. Tucci, RN, MSN, AOCN

RELIABLE INFORMATION ON USE OF CBD OIL IN CANCER TREATMENT I am getting more and more questions from my patients about CBD oil for the treatment of cancer. They seem to be reading about this online or hearing about it from family members. Are there any reputable resources I or my patients can use to learn more about this? — Name withheld on request The National Cancer Institute has detailed information on cannabis and cannabinoids in its online PDQ ® library, available in health professional (www.cancer.gov/about-cancer/treatment/cam/ hp/cannabis-pdq) and patient (www.cancer.gov/about-cancer/ treatment/cam/patient/cannabis-pdq) versions. Two other informative articles, also available online, are “What Is CBD Oil, and Can It Help People With Cancer?” (www. mskcc.org/blog/what-cbd-oil-and-can-it-help-people#what-do-weknow-about-cbd-oil-s-ability-to-fight-or-prevent-cancer) and “CBD Oil and Cancer: 9 Things to Know” (www.mdanderson.org/ publications/cancerwise/cbd-oil-and-cancer--9-things-to-know.h00159306201.html) — Lisa A. Thompson, PharmD, BCOP ■ REFERENCE 1. Shammo JM, Usha L, Richardson K, et al. First report of severe folate deficiency in women treated with olaparib for relapsed ovarian cancer. Blood. 2017;130(suppl 1):4748.

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

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2019 • ONCOLOGY NURSE ADVISOR 11

FEATURE | Nurse Assessment of the Older Patient

Tools for Assessing, Managing Malnutrition in the Elderly This review discusses decision making, interventions, and management of nutritional status in patients aged 65 and older with cancer. BRYANT FURLOW

The Society of Geriatric Oncology recommends routine assessment of nutritional status in all patients older than 65 years.

alnutrition is associated with problems swallowing, vomiting, and appetite loss, as well as 3 cancer types: lung, upper digestive tract, and head and neck cancers. Geriatric assessments for cancer treatment decision making should always include nutritional status evaluation. Nutritional interventions involve the identification of specific nutrition impact symptoms such as difficulty swallowing or loss of appetite, other conditions associated with malnutrition (eg, sarcopenia, anorexia, or cachexia), and a proactive, multidisciplinary approach to managing a patient’s symptoms and nutritional status. Poor nutrition is common and is associated with poor clinical outcomes among patients with cancer. Weight loss of just 5% of a patient’s body weight is associated with poorer tumor response to treatment and survival.1 Malnutrition can involve anorexia, malnutrition-associated sarcopenia (the loss of skeletal muscle mass and associated weakening), and cancer cachexia (an involuntary weight loss of at least 5% within 5 months or body mass index [BMI] less than 20 kg/m 2 with weight loss exceeding 2%).1-4 Malnutrition is particularly common among elderly patients, but it is also associated with lung cancer, upper digestive tract malignancies, and head and neck cancers among adult patients of all ages.2-5 Assessing nutritional status is a key component of geriatric assessment to guide cancer treatment decisions for elderly patients; geriatric assessment should always include assessments of physical function and nutritional status.5

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A recent evaluation of 4783 adult cancer patients in Brazil found that 45% had moderate or suspected malnutrition and 11.8% were severely malnourished.4 Not surprisingly, malnutrition was significantly associated with both specific, individual nutrition-impact symptoms (eg, appetite loss/anorexia, vomiting, and dysphagia/problems swallowing) and more than 3 nutrition-impact symptoms (which also include mouth sores, taste and smell alterations, stomach or abdominal pain, painful defecation, constipation, diarrhea, dyspnea, and fatigue).4-6 Malnutrition is frequently underdiagnosed among older adult patients with gastrointestinal cancers, impairing functional status, treatment success, quality of life, and clinical outcomes.1 NUTRITIONAL ASSESSMENT Because biological senescence and functional aging vary between patients, the Society of Geriatric Oncology recommends that all older adults (aged 65 years or older) with cancer be evaluated with a comprehensive geriatric assessment (CGA) that includes comorbidity, functional, nutritional, and psychosocial evaluations.1 Inventorying specific nutrition impact symptoms with a patient checklist that asks about the symptoms above on a scale of 1 (none) to 4 (a lot) can help health care teams to devise specific interventions to improve patients’ nutrition status.6 Several validated nutritional assessment tools are available, including the Malnutrition Screening Tool (MST), the MiniNutritional Assessment Short Form (MNA-SF), the Nutrition Risk Screening (NRS-2002) form, the Malnutrition Universal Screening Tool (MUST), and the Patient- and NutritionDerived Outcome Risk Assessment (PANDORA) Score.1,7-9 Each tool uses a scoring system to quantify factors such as weight loss, BMI, disease severity, fluid intake, and functional concerns that can affect nutritional status. There is no consensus on which of these tools is best, but screening with one of them should be undertaken at diagnosis, hospitalization, and at regular intervals throughout definitive and palliative care.1 INTERVENTIONS Malnutrition and nutritional interventions will include different symptoms and patient factors (such as age, performance status, and frailty) and disease factors, including primary tumor site, tumor stage, comorbidities, metastatic disease, and treatment plan. For example, patients undergoing chemotherapy for GI cancers will experience different nutrition impact symptoms than those undergoing chemoradiation for head and neck cancer. In addition, patients with advanced metastatic disease and short life expectancy are less likely to

benefit from aggressive nutritional interventions than patients with lower-stage cancers and longer life expectancies.1 Dietary counseling and planning are typically the responsibility of licensed dieticians, whereas oncology nurses are involved in symptoms management, patient education, and care, such as antiemetic pharmacotherapy for nausea, or analgesics for swallowing or abdominal pain, and appetite-stimulating progestin (megestrol acetate and medroxyprogesterone acetate) therapy.1 Supportive feeding via parenteral or enteral feeding might be necessary for patients whose symptoms prevent normal eating and food retention (without vomiting).1 Gastrostomy is recommended for long-term (4 weeks or longer) nutritional support; it is associated with better nutritional outcomes and patient convenience than nasogastric tubes.1 Short-term parenteral nutritional support is considered when enteral support is not possible, such as among patients with acute GI complications associated with radiation enteritis.1 Longterm enteral feeding complications such as tube obstruction, displacement, diarrhea, or intestinal motility issues resulting in constipation, can occur among patients of any age.1

Nutritional intervention decision making should involve patients as much as possible to ensure it is consistent with patient goals. At every stage, nutritional intervention decision making should involve patients as much as possible to ensure it is consistent with patient values and goals. When interventions are likely to prove futile, this should be communicated gently but plainly to patients and their caregivers to ensure informed decision making that respects patient autonomy as much as possible. ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Mislang AR, Di Donato S, Hubbard J, et al. Nutritional management of older adults with gastrointestinal cancers: an International Society of Geriatric Oncology (SIOG) review paper. J Geriatr Oncol. 2018;9(4):382-392. 2. Sharour LA. Improving oncology nurses’ knowledge, self-confidence, and self-efficacy in nutritional assessment and counseling for patients with cancer: a quasi-experimental design. Nutrition. 2019;62:131-134. References continue on page 29

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FEATURE | Advanced Practice Nursing

Using EBM to Determine Skill Competency in Nurses A review of evidence-based management confirms procedure volume used to determine nurse competency in performing BMA, BMX, and LP. PATRICIA WILLS BAGNATO, MSN, APRN, CPNP-PC, CPHON®

vidence-based management (EBM) provides the opportunity for clinical leaders to make decisions based on the best objective knowledge available, and avoid the pitfall of setting operational requirements based on personal experience.1 In pediatric oncology, treatment decisions are based on clinical evidence, trials, and protocols. The Institute of Medicine (IOM) calls for patient care that is safe, effective, efficient, timely, patient-centered, and affordable.2 Pediatric oncology patients undergo many procedures and rely on physicians and advanced practice providers (APPs) to perform the procedures safely, efficiently, and effectively. The APP director is responsible for the oversight of training and documentation of provider competency in the cancer center. A management decision made by the APP director with the input of another senior nurse practitioner (NP) was to document competency after performing 10 lumbar punctures (LPs), 10 bone marrow aspirates (BMAs), and 10 biopsies (BMXs). Leadership has asked for evidence of the minimum volume standard for establishing competency for procedures. The questioning of this management decision provided an opportunity to explore evidence regarding minimum number of procedures for establishing competency. OVERVIEW OF MANAGEMENT PRACTICE BMAs and BMXs are performed to diagnose malignancies or determine response to treatment

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for diseases such as leukemia, lymphoma, or bone marrow dysplasia.3 LPs are performed to diagnose central nervous system (CNS) leukemia, other CNS malignancies, or infection. These procedures are performed by physicians and APPs in this large pediatric cancer center. In 2018, 1339 procedures were performed in the postanesthesia care unit (PACU) [P. Wills Bagnato, Annual report on APP productivity to physician leadership. October 11, 2018]. All bone marrow (BM) procedures are conducted in the PACU treatment room where patients are sedated with propofol or anesthesia gas. This facility employs 8 APPs and 3 physicians who are trained to perform procedures and staff the PACU treatment room each month. The APP director is responsible for oversight of training and competency assessments. Literature on BM and LP procedures, a PowerPoint module with instructions on sampling, a copy of the facility’s policy on provider responsibility, and procedure checklists are provided to the trainee in advance of the practicum. Trainees are assigned to an experienced APP provider 1 day a week to begin training to perform BM procedures and LPs. Trainees must successfully complete 10 of each procedure — BMAs, BMXs, and LPs — and document pathology reports for the BMA and BMX procedures. The minimum requirement of 10 procedures was based on the recommendation of 2 senior NPs with more than 10 years of experience performing procedures and was approved by the section physician leadership. Even after the minimum number of procedures is performed, the APP trainee continues to train under direct supervision until fully credentialed as a billing provider. Before independent privileges are requested and granted by Medical Staff Services, the APP trainee must also be able to demonstrate the ability to run the show: coordinate the day’s procedures with the preoperative staff, conduct the intraprocedural process, and facilitate a smooth hand-off to the postoperative recovery team. This procedure training program may take up to 4 months for the APP trainee to obtain billing privileges, during which time the APP trainee continues to perform procedures weekly with supervision by a credentialed billing provider. Once billing privileges are granted and the APP is credentialed by Medical Staff Services to perform the designated procedures independently, the APP assumes an individual procedure clinical schedule of at least 1 day a month. The minimum requirement of performing 10 BMAs and 10 BMXs was recently questioned. This question necessitated a review of the evidence for required minimum volume of procedures to infer competency. Pfeffer and Sutton discuss the need for managers to make decisions based on evidence

The evidence would either confirm the appropriateness of this policy or redirect leadership to adopt a more evidence-based training plan. as opposed to experience.1 The evidence for a minimum requirement for procedures would either confirm the appropriateness of this policy or redirect leadership to adopt a more evidence-based training plan. EVIDENCE REVIEW

A literature review was conducted to identify references related to a minimum number of bone marrow or surgical procedures required to determine trainee competency. Various references from nursing and physician literature were identified. The Accreditation Council for Graduate Medical Education (ACGME) Review Committee provides established minimum numbers of procedures for residents to perform in emergency medicine (EM) rotations.4 Wen and colleagues conducted a cross-sectional descriptive study of EM trainees’ self-reported procedural competency for performing core procedures and resuscitation based on the ACGME guidelines. Residents in the EM program were to complete intubations, chest tube insertions, central venous access, internal cardiac pacing, procedural sedation, cricothyrotomy, lumbar puncture, and vaginal delivery; and to assess perceived competency.5 Each EM trainee was to complete each procedure at least 10 times; however, they exceeded the minimum volume required for all but 3 of the procedures and endorsed their competency for performing those procedures. The investigators found that competency was reported to be lower for procedures in which the minimum requirement of 10 was not achieved: cricothyrotomy, pericardiocentesis, and internal cardiac pacing.5 Kyser and colleagues were concerned about the limited experience physician trainees were receiving in forceps deliveries, a complex but low-frequency procedure. Some hospitals determine the minimum requirement to obtain competency for some procedures as a percentage of that facility’s volume.6 The authors explored 2008 state inpatient data for childbirths in nine states — Arizona, California, Florida, Iowa, Maryland, New Jersey, North Carolina, Washington, and Wisconsin — and found a significantly low volume of forceps delivery.6 Of 835 hospitals in the 9 states, an analysis of 624,000 operative deliveries demonstrated that nearly 40% of hospitals

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Advanced Practice Nursing |

did not perform forceps deliveries and 50% performed 5 or fewer.6 The conclusion and concern were that training physicians and assuring competency is difficult with low volumes of procedures.6 Recommendations from Kyser’s team were to consider, develop, and test new training methods for technically complex procedures that occur in low volumes. In a different assessment of proficiency in procedures, Hernigou and colleagues conducted a study to explore the anatomy of the ilium for performing bone marrow aspirations and to identify risks of breaching the ilium on cadavers.7 The researchers identified that surgeons who performed fewer than 10 BM harvests had more breaches than those who performed more than 10 harvests (75 [31%] vs 19 [8%]) among 240 entry points each.7 Of these 3 studies, volume of procedures is reported to contribute to competency, and 10 is a common acceptable minimum.

Supervised training during which one performs the minimum number of procedures provides time for mentorship and learning strategies. The nursing literature was also explored to identify standards for training NPs in performing BM procedures. In an early study, BMX performed by NPs was compared with those by physicians.8 Although the length and quality of BMX were not significantly different, quality of BM aspirates were poorer (lack of spicules) in the procedures by NPs. The authors stated that NPs had difficulty with making adequate smears of the marrow. The BMX samples were found to be of equal quality, and the authors subsequently concluded that properly trained NPs can perform marrow procedures as effectively as physicians.8 More recently, Jackson and colleagues outlined competencies NPs must meet to perform BM procedures.3 They recommend that NPs perform 10 procedures under supervision to demonstrate competency. Kelly and colleagues reviewed BM procedures performed by NPs in Ireland, and found the quality of BM specimens obtained by NPs were comparable to those obtained by physicians.9 Once again, 10 was determined to be the required minimum number of procedures to document competency.9 This recommended minimum volume of procedures to demonstrate competency identified in the literature is commensurate with the required minimum in the pediatric cancer center. PRINCIPLES OF TRAINING AND LEARNING Exploring the evidence and validating the recommended minimum volume of procedures to incur competency is only

FEATURE

one component of training APPs. Jackson and colleagues outline the basic elements of a training program to establish procedural competency for performing bone marrow aspiration procedures.3 First, the training plan must provide standardized “written, verbal, and video instructions … on rationale, risks and benefits of the procedure, anatomy and physiology of biopsy sites and anatomic markings, equipment used to obtain a sample, the procedure itself, and the treatment implications of the findings.”3 The next steps are for the trainee to observe 10 procedures then begin hands-on training, performing 10 procedures under direct supervision. Lastly, all trainees must review the pathology reports for sample quality and adequacy.3 These steps illustrate basic elements of training, yet highlight constructs that deserve further discussion and appreciation. Ford and Meyer discuss the development of competencybased education for procedures performed in the actual work setting.10 The value of supervised training of APPs in the cancer center over a period of weeks to months provides the trainee the opportunity to develop the knowledge, skills, and attitudes for success in performing procedures. The trainer can provide immediate feedback, support, guidance, and insight, and help the learner develop confidence. Ford and Meyer discuss the Four Component Instructional Design (4C-ID) model that includes 4 components and 10 steps. The 4 components include learning tasks, supportive information, procedural information, and part-task practice. Integrated into these 4 components are steps that analyze cognitive strategies and rules, mental models, utilize prerequisite knowledge, and design procedural models and part-task practice. Cognitive steps of learning are applied to each component of the task as the task increases in complexity.10 APPs in the cancer center receive the didactic information regarding policies and procedures and are trained under supervision over a period of time. Supervised training during which one performs the minimum required number of procedures provides time for mentorship and learning strategies for performing procedures on various types of patients and in various challenging scenarios. Ford and Meyer discuss the development of competency based on Merrill’s 5 principles of instruction: • Learners are engaged in solving real-world problems; • Existing knowledge is activated as a foundation for new knowledge; • New knowledge is demonstrated to the learner; • New knowledge is applied by the learner; • New knowledge is integrated into the learner’s world.11 Literature on establishing procedural competency and principles of training provides evidence to support required

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2019 • ONCOLOGY NURSE ADVISOR 25

FEATURE | Advanced Practice Nursing A well-trained procedure team of APPs can perform procedures safely, efficiently, and effectively, and provide high-quality care.

Patricia Wills Bagnato is assistant professor, Baylor College of Medicine, and director – advanced practice providers, Texas Children’s Cancer and Hematology Centers, Houston, Texas.

volumes but also provides the theoretical background to improve and support the training process.

2. Formulating new rules to redesign and improve care. In: Institute of

REFERENCES 1. Pfeffer J, Sutton RI. Evidence-based management. Harv Bus Rev. 2006;84(1):62-74, 133. Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington,

DISCUSSION

DC: National Academies Press; 2001. https://www.ncbi.nlm.nih.gov/

Important constructs in the learning and training process have been identified in this review of evidence that will strengthen the training of APPs in the cancer center. The minimum volume of procedures appears to have been validated; however, a more structured process for moving an APP from procedure provider to trainer needs to be developed. The preceptor utilizes the competency checklist and procedural policies, but each preceptor teaches based on his or her own clinical experience. The preceptor’s abilities to teach are not formally assessed before the preceptor is assigned a trainee. Future directions to strengthen the procedure training program will include developing a train-the-trainer competency checklist. A focus group will be held with current trainers to discuss their philosophies and steps in the training process.10 The principles of teaching will be reviewed and guidelines for trainers will be developed and documented. These foundational guidelines for performing and teaching procedures will be available for future APPs, and for review and revision as practices and equipment evolve.

books/NBK222277/. Accessed November 26, 2019. 3. Jackson K, Guinigundo A, Waterhouse D. Bone marrow aspiration and biopsy: a guideline for procedural training and competency. J Adv Pract Oncol. 2012;3(4):260-265. 4. Accreditation Council for Graduate Medical Education (ACGME). Emergency medicine defined key index procedure minimums. Review committee for emergency medicine. https://www.acgme.org/ Portals/0/PFAssets/ProgramResources/EM_Key_Index_Procedure_ Minimums_103117.pdf?ver=2017-11-10-130003-693. Accessed November 26, 2019. 5. Wen LS, Nagurney JT, Geduld HI, Wen AP, Wallis LA. Procedure competence versus number performed: a survey of graduate emergency medicine specialists in a developing nation. Emerg Med. 2012;29(10):822-825. 6. Kyser KL, Lu X, Santillan D, et al. Forceps delivery volumes in teaching and nonteaching hospitals: are volumes sufficient for physicians to acquire and maintain competence? Acad Med. 2014;89(1):71-76. 7. Hernigou J, Picard L, Alves A, Silvera J, Homma Y, Hernigou P. Understanding bone safety zones during bone marrow aspiration from the iliac crest: the sector rule. Int Orthop. 2014;38(11):2377-2384.

CONCLUSION

8. Lawson S, Aston S, Baker L, Fegan CD, Milligan DW. Trained nurses can

Medical and nursing literature support 10 as a minimum volume of procedures to incur procedural competency for BMAs, BMXs, and LPs. A comprehensive BM and LP education program for APPs should include procedure guidelines with the requisite didactic and hands-on training, and instruction guidelines for APP trainers. The IOM calls for safe, efficient, and effective patient care. A well-trained procedure team of APPs can perform procedures safely, efficiently, and effectively, and provide high-quality care for pediatric oncology patients in the cancer center. ■

obtain satisfactory bone marrow aspirates and trephine biopsies. J Clin Pathol. 1999;52(2):154-156. 9. Kelly M, Crotty G, Perera K, Dowling M. Evaluation of bone marrow examinations performed by an advanced nurse practitioner: an extended role within a haematology service. Eur J Oncol Nurs. 2011;15(4):335-338. 10. Ford R, Meyer R. Competency-based education 101. Procedia Manuf, 2015;3:1473-1480. 11. Merrill MD. First principles of instruction. Educ Technol Res Dev. 2002; 50(3):43-59.

ONA Navigation Summit • Seattle, WA • June 11-13, 2020 View the agenda and register to attend at ONANavigationSummit.com

26 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2019 • www.OncologyNurseAdvisor.com

FEATURE | Adverse Effects

Understanding “Chemobrain” in Patients With Cancer A review of new research into the incidence and potential noncancer causes of cognitive changes experienced by patients receiving chemotherapy.

Cognitive impairment may have multiple causes and a more lasting effect on patients undergoing treatments for cancer.

JOHN SCHIESZER

reater emphasis should be given to formally defi ning chemobrain, and oncology nurses may want to move it higher on their lists of priorities, according to researchers. The cognitive impairment experienced by many patients treated with chemotherapy, referred to as chemobrain, can be subtle yet persistent. Some patients report difficulties related to memory and attention even months after they have completed treatment. “I do believe that chemobrain/cognitive changes should be assessed at every visit, just like pain and neuropathies,” said Kelly Moore, RN, of the Moncrief Cancer Institute at the University of Texas (UT) Southwestern in Dallas. Ms Moore and her colleagues conducted a pilot study to explore the onset of chemobrain in patients who recently began chemotherapy treatment and in patients who have been receiving chemotherapy for an extended period of time.1 The prospective observational study produced rather disappointing findings, but highlighted how urgently diagnostic tools for cognitive decline are needed. “I thought that the patients’ cognitive testing tools would reflect greater cognitive decline in my patients, but it was minimal,” Ms Moore told Oncology Nurse Advisor. A high percentage of participants were verbally reporting symptoms of cognitive decline at their clinic visits, but the cognitive assessments tools didn’t show that. “I didn’t feel my collection tools detected those changes,” Ms Moore said. “My biggest takeaway from the study is that

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2019 • ONCOLOGY NURSE ADVISOR 27

FEATURE | Adverse Effects larger studies need to be performed to specifically investigate how chemobrain happens and what interventions may be appropriate to treat it.” IS COGNITIVE DECLINE A BIGGER CONCERN THAN EVER?

Catherine M. Bender, PhD, RN, professor and endowed chair in oncology nursing at the University of Pittsburgh School of Nursing in Pittsburgh, Pennsylvania, suggests that there needs to be caution when using the term “chemobrain.” Many factors contribute to the problem of deterioration in cognitive function in patients with cancer, only one of which is the treatment. “For example, we now know that some individuals with cancer — up to 35% — have poorer cognitive function than their healthy counterparts (matched by age and education) before they begin cancer treatment. Several factors including mood and characteristics of the disease itself may be contributing to this poorer, pretherapy cognitive function,” Dr Bender explained to Oncology Nurse Advisor.

Older persons are more likely to be taking medications for comorbidities, which also may be associated with poorer cognitive function. Due to improved methods for diagnosing cancer early while it is still treatable and advancements in treatment, cancer survivors are living much longer. Subsequently, some are experiencing long-term effects of the disease and its treatment. Decline in cognitive function is one of those potential long-term consequences. “That factor alone is contributing to the increasing numbers of individuals experiencing the problem. There is also evidence that longer duration of therapy and higher doses of therapy are associated with greater risk for experiencing treatment-related changes in cognitive function,” she continued. There also is evidence that suggests some newer forms of therapy, such as immunotherapies, may also be associated with deteriorations in cognitive function. Studies are needed to systematically evaluate this issue, noted Dr Bender. Older persons with cancer are more vulnerable to changes in cognitive function due to cancer and cancer therapy. In addition to their age, they are more likely to have comorbidities and to be taking medications for those comorbidities, which also may be associated with poorer cognitive function. “But not all older adults with cancer experience changes in cognitive function,” she said. Some evidence suggests that older adults

who adopt healthy lifestyles that include physical activity and a healthy diet may be less vulnerable to these effects. MANAGING COGNITIVE DECLINE

Currently, no proven interventions are established for managing deteriorations in cognitive function in patients with cancer. However, Dr Bender reports that a great deal of research examining the efficacy of interventions to prevent or manage cognitive deterioration is ongoing. Some investigators are assessing behavioral interventions, such as teaching patients about the basis of the cognitive decline, how to recognize situations that exacerbate the problem, and methods for coping during times of high cognitive demand. “Some of these coping mechanisms include things like meditation techniques. Others are looking at the impact of physical activity on cognitive function,” Dr Bender said. “There is growing evidence that physical activity is associated with better cognitive function in healthy older adults. Some, including our group, are examining whether this extends to individuals with cancer as well,” she added. Steven Morris, RN, a clinical nurse manager in oncology and bone marrow transplantation at Siteman Cancer Center and Barnes-Jewish Hospital in St Louis, Missouri, said there are more cancer survivors today, yet he is not seeing a big uptick in “chemobrain.” “I don’t feel we have seen a major increase or decrease either way. My perspective is from an inpatient point of contact. We have always seen very sick patients,” said Mr Morris. Slight improvements in the tools for assessing cognitive function have been achieved, but this is an area that is lacking, noted Ms Moore. Anna C. Beck, MD, professor of internal medicine at the Huntsman Cancer Institute at the University of Utah School of Medicine in Salt Lake City, agrees that research is scarce. She also believes that this issue will become a greater concern as baby boomers enter their 7th, 8th, and 9th decades of life. “The problem may seem like it is becoming more prevalent because there are now more cancer survivors,” Dr Beck told Oncology Nurse Advisor. Currently, there are more than 15 million cancer survivors, and this number is expected to grow to 30 million. This is related to improvements in cancer screening and longer life expectancy, as well as more effective treatment options. A POTENTIAL BIOMARKER IDENTIFIED A team led by Alexandre Chan, associate professor in the Department of Pharmacy at the National University of Singapore (NUS) Faculty of Science, recently investigated levels of biomarkers in relation to “chemobrain” to better

28 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2019 • www.OncologyNurseAdvisor.com

understand its cause. The team characterized plasma levels of the biomarker dehydroepiandrosterone (DHEA) and its sulfated form (DHEAS) to be biological determinants of cognitive function. DHEAS is a neurosteroid that helps regulate brain development and function, but whether its levels correlate with cognitive function or are associated with the onset of “chemobrain” was previously unknown.

Characterizing presence of cognitive impairment is challenging because no definitive diagnostic criteria have been accepted. For this study, researchers recruited 81 patients with early-stage breast cancer who had no prior exposure to chemotherapy or radiotherapy and were scheduled to receive chemotherapy treatment with curative intent. This was a multicenter, prospective cohort study conducted in the National Cancer Centre Singapore and KK Women’s and Children’s Hospital between 2011 and 2016. The researchers found that patients with early-stage breast cancer who had a higher plasma DHEAS level prior to chemotherapy had a lower risk of experiencing cognitive decline in the specific domains of verbal fluency and mental acuity.2

have been accepted, explained Dr Beck. It’s also very difficult to understand confounding factors, such as cognitive changes associated with menopause, concomitant brain irradiation, or preexisting cognitive changes such as age-related decline or prior traumatic brain injuries. “Other treatment-related side effects can be additive, such as fatigue, sleep deprivation, anxiety, or pain. So, all of these factors have to be controlled for when assessing prevalence,” she said. Most data on cognitive impairment in cancer survivors were obtained from survivors of breast and hematologic cancers. Survivors of other cancers may not be well represented because of this focus. “Most efforts have focused on treatment of cognitive impairment, not prevention. Examples include medications used for cognitive impairment associated with dementia (eg, donepezil, nemantidine) or CNS stimulants (eg, modafinil, methylphenidate),” said Dr Beck. But nonpharmacologic measures, such as some apps associated with brain training, biofeedback, or relaxation techniques, have been shown to be helpful. ■ John Schieszer is a medical reporter based in Seattle, Washington. REFERENCES 1. Moore K, Stutzman S, Priddy L, Olson D. Chemobrain: a pilot study exploring the severity and onset of chemotherapy-related cognitive impairment. Clin J Oncol Nurs. 2019;23(4):411-416. 2. Toh YL, Shariq Mujtaba J, Bansal S, et al. Prechemotherapy levels

UNDERSTANDING OF COGNITIVE IMPAIRMENT STILL ELUSIVE

of plasma dehydroepiandrosterone and its sulfated form as

Characterizing the presence or severity of cognitive impairment is challenging because no definitive diagnostic criteria

breast cancer receiving chemotherapy. Pharmacotherapy. 2019;

Malnutrition in the Elderly

predictors of cancer‐related cognitive impairment in patients with 39(5):553-563.

6. Omlin A, Blum D, Wierecky J, Haile SR, Ottery FD, Strasser F. Nutrition impact symptoms in advanced cancer patients: frequency and spe-

Continued from page 13

cific interventions: a case-control study. J Cachexia Sarcopenia Muscle. 3. Abd Aziz NAS, Teng NIMF, Zaman MK. Geriatric nutrition risk index is comparable to the Mini Nutritional Assessment for assessing nutritional status in elderly hospitalized patients. Clin Nutr ESPEN. 2019;29:77-85. 4. de Pinho NB, Martucci RB, Rodrigues VD, et al. Malnutrition associated with nutrition impact symptoms and localization of the disease:

2013;4(1):55-61. 7. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-464. 8. Kaiser MJ, Bauer JM, Ramsch C, et al; MNA-International Group.

results of a multicentric research on oncological nutrition. Clin Nutr.

Validation of the Mini Nutritional Assessment short-form (MNA-SF): a

2019;38(3):1274-1279.

practical tool for identification of nutritional status. J Nutr Health Aging.

5. Bruijnen CP, van Harten-Krouwel DG, Koldenhof JJ, Emmelot-Vonk MH, Witteveen PO. Predictive value of each geriatric assessment domain

2009;13(9):782-788. 9. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN Working

for older patients with cancer: a systematic review. J Geriatr Oncol.

Group. Nutritional risk screening (NRS-2002): a new method based on

2019;10(6):859-873.

analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-336.

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RADIATION & YOUR PATIENT

Cervical cancer seen on MRI

Brachytherapy Remains Important in Cervical Cancer Management Bryant Furlow Brachytherapy plays an established role in managing locally advanced cervical cancer, but its use has been in decline since the widespread adoption of intensity-modulated radiation therapy (IMRT). Two recently published consensus statements clarify the roles of brachytherapy in the treatment of primary cervical cancer and recurrent disease.

ervical cancer is diagnosed in an estimated 528,000 women worldwide each year, and another 266,000 die annually.1 The current standard of radiation oncology care for women with stage IB-IVA locoregional

cervical cancer involves external beam radiotherapy (EBRT) plus concurrent cisplatin-based chemotherapy and brachytherapy.1 Image-guided or adaptive brachytherapy employs sequential re-imaging with each brachytherapy treatment session to adapt brachytherapy dose and placement as tumors regress and change shape, sparing nontarget, healthy tissue from irradiation.1 Despite brachytherapy’s longstanding role in cervical cancer management, its use has declined markedly over recent years, with the increasing availability of highly conformal EBRT techniques such as IMRT and stereotactic body radiation therapy (SBRT).1-3 (The same is true for prostate cancer, for which critics have claimed IMRT is overutilized, partly because of more attractive reimbursements.3,4) The US Centers for Medicaid & Medicare Services (CMS) does not reimburse brachytherapy as well as IMRT; brachytherapy is more time-consuming than IMRT or 3-dimensional conformal radiotherapy and reimbursement rates do not always cover costs, meaning that brachytherapy can become a source of financial loss to radiation oncology departments.3 Radiation oncology centers are increasingly managed as community-based hospital-owned satellite facilities, as well; smaller centers with fewer radiation oncologists are less equipped for the time demands and complexity of integrated cervical brachytherapy.3 Some might argue that the supplantation of brachytherapy by IMRT makes clinical sense. IMRT allows sharp anatomic irradiation gradients, with higher radiation doses delivered to target tumor tissue while sparing adjacent, nontarget tissue. IMRT has allowed dose escalation in cervical cancer radiotherapy.1 But recent declines in brachytherapy for locally advanced cervical cancer

have been accompanied by a decline in survival for these patients, raising concerns that patients might frequently be denied brachytherapy even when it might improve their survival times.1-3 Evidence also shows that declines in the use of brachytherapy for locally advanced cervical cancer has hit African American and Native American women particularly hard, with these patients being even less likely than others to receive brachytherapy, possibly helping to explain racial disparities in cervical cancer survival rates.1,5 Authors of one recently published retrospective study of more than 16,000 patients concluded that improved access to brachytherapy might improve overall survival rates and help to ameliorate racial disparities in cervical cancer outcomes.5 SUPPORT FOR BRACHYTHERAPY A recent survey of 81 members of the American Brachytherapy Society (ABS) suggested that cervical brachytherapy is widely underutilized, in part because of inadequate training of medical residents and inadequate maintenance of brachytherapy skills.2 The increased time requirements of brachytherapy planning and delivery were also seen as potential barriers to use by many survey respondents.2 The Society of Gynecologic Oncology (SGO) and the ABS recently released a statement emphasizing brachytherapy’s continued, critical role as a component of primary radiation therapy for women with cervical cancer.1 “Despite insufficient evidence that IMRT or SBRT constitute an equivalent technique to brachytherapy, national database studies indicate a disturbingly high rate of their usage in lieu of brachytherapy and thus nonadherence to established criteria for highquality primary radiation treatment

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2019 • ONCOLOGY NURSE ADVISOR 31

RADIATION & YOUR PATIENT for cervical cancer,” they wrote.1 “[E]xternal beam radiation therapy combined with high-quality brachytherapy has been an established treatment course for women with locoregional cervical cancer for nearly 100 years. Advances in the use of

The evidence base suggests adding EBRT to IORT might improve outcomes. chemotherapy and image-guided brachytherapy have shown promise to increase the number of women cured and decreased the number of women harmed. Despite this, recent data has suggested that other modalities unproven to be equivalent to these tried-and-true techniques are being increasingly utilized in some centers.” COORDINATING TREATMENT COMPONENTS

The SGO/ABS statement spotlighted computed tomography (CT) and magnetic resonance imaging (MRI)guided adaptive brachytherapy and the feasibility of delivering coordinated EBRT and brachytherapy at different treatment centers “without compromising treatment time and outcome in areas where access to brachytherapy might be limited.”1 However, patient navigation and careful coordination of care are crucially important for multifacility delivery of EBRT and brachytherapy.1 Coordination requires multidisciplinary cooperation between gynecologic, radiation, and medical oncology teams and support staff such as patient navigators and scheduling staff.1 Integrated EBRT/brachytherapy treatment plans should always include these seven components1:

• Date of radiation initiation, with cisplatin chemotherapy initiation within 5 days, preferably on a Monday or Tuesday.1 • Dates for subsequent cycles of chemotherapy, with labs checked weekly.1 • Brachytherapy planning.1 • Decision making about gynecologic oncologist’s role in the first brachytherapy fraction (to place a disposable Smit sleeve tube).1 • Initial imaging date for brachytherapy planning and subsequent repeat imaging schedules for adaptive brachytherapy.1 • Hematologic toxicity management planning, including filgrastim as indicated for adequate neutrophil counts prior to brachytherapy and availability of transfusion and growth factor support for neutropenia.1 • Insurance authorizations for EBRT and brachytherapy to avoid interruptions in treatment plan completion.1

prior radiotherapy increases the risk of radiotoxicities associated with re-irradiation.6 But IORT after salvage surgery might reduce this risk while eliminating residual disease. Although limited, the evidence base suggests adding EBRT to IORT might improve outcomes.6 “[T]he addition of IORT to salvage resection for isolated recurrence of gynecologic cancers has not been evaluated prospectively,” and although retrospective data suggest improved local control, they do not conclusively demonstrate that IORT improves survival, the statement authors cautioned.6 ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Holschneider CH, Petereit DG, Chu C, et al. Brachytherapy: a critical component of primary radiation therapy for cervical cancer: from the Society of Gynecologic Oncology (SGO) and the American Brachytherapy Society

When EBRT and brachytherapy are performed at separate treatment centers, plans should specify which clinicians will plan and deliver radiation boosts.1 IMRT and SBRT have proven to be poor substitutes for cervical cancer brachytherapy, the authors concluded, although the available evidence base is based largely on relatively small studies.1 There is evidence that brachytherapy delivers a superior biologic effective dose compared with IMRT.1

(ABS). Gynecol Oncol. 2019;152(3):540-547. 2. Ma TM, Harkenrider MM, Yashar CM, Viswanathan AN, Mayadev JS. Understanding the underutilization of cervical brachytherapy for locally advanced cervical cancer. Brachytherapy. 2019;18(3):361-369. 3. Schad M, Kowalchuk R, Beriwal S, Showalter TN. How might financial pressures have impacted brachytherapy? A proposed narrative to explain declines in cervical and prostate brachytherapy utilization [published online August 19, 2019]. Brachytherapy. doi: 10.1016/j.brachy.2019.07.001 4. Furlow B. US urology clinics overprescribe

ANOTHER OPTION The ABS recently published a consensus statement on intraoperative radiotherapy (IORT) recommending consideration of using IORT in managing recurrent cervical cancer when microscopic diseasepositive surgical margins are a concern, although IORT is not a standard of care for treating recurrent cervical cancer.6 Managing locoregional cervical cancer recurrence can be difficult because

prostate radiotherapy. Lancet Oncol. 2011;12(2):122. 5. Alimena S, Yang DD, Melamed A, et al. Racial disparities in brachytherapy administration and survival in women with locally advanced cervical cancer. Gynecol Oncol. 2019;154(3):595-601. 6. Tom MC, Joshi N, Vicini F, et al. The American Brachytherapy Society consensus statement on intraoperative radiation therapy. Brachytherapy. 2019;18(3):242-257.

32 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2019 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

“The ‘Blessed Event’ Occurred” Ann J. Brady, MSN, RN-BC, CHPN

“Okay,” I took in a deep breath, “let’s go over our strategy for managing this. We’ve got to throw the kitchen sink at it.” His celebratory call meant that after no BM for 5 to 6 days, he had followed my directions and had a large BM. This was his “blessed event” since he said he thought it felt like what he imagined giving birth to a large baby would be like. Constipation can be a huge problem, pun intended. What can we do as oncology nurses to adequately educate our patients to avoid constipation? While many patients experience constipation as a result of medications, many do not know the best way to manage it.

While many patients experience constipation as a result of medications, many do not know the best way to manage it.

laughed out loud when I listened to the voice mail from Harry. Then I listened again, and laughed some more. Harry is an older, jovial gentleman, always quick with a joke or witty retort. His brand of humor bordered on being over the top, yet he managed to walk the line so that his comments were funny and insightful rather than shallow and merely a byproduct of anxiety. CASE

The message he left me was, literally, the end result of a long conversation we’d had about opioid-induced constipation (OIC). The day before we’d gone over what a good bowel movement (BM) regimen would look like for someone requiring opioids to manage their pain. “So,” I instructed, “the goal is for you to have a soft formed BM every 1 to 2 days.” He stared at me like I had 2 heads. “Oh. The last BM I had was 5 days ago.”

DISCUSSION

Oncology patients are likely to experience pain at some point during their treatment. Statistics vary slightly, but of those undergoing cancer treatment, 55% will experience pain. That number rises to 70% to 75% in those with advanced cancer.1 Opioids are a big part of cancer pain management, and when opioids are used, there will be issues with bowel management and constipation. One interesting statistic is the average cost for an emergency department (ED) visit for constipation, as noted in a study from 2011, was $3060.2-3 Of course, the dollar amount does not include the suffering incurred in the days leading up to a decision to go to the ED, and the experience of the ED visit itself. Those are incalculable in the monetary projection, and yet we know for oncology patients, many of whom have limited energy or perhaps even remaining time, the idea of spending hours in the ED is a tragedy that should be avoided. I don’t

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COMMUNICATION CHALLENGES

I tell my patients right from the beginning that whenever I ask them about their pain, I will also ask about their bowels.

know anyone who wants to be constipated or wants to end up needing to be disimpacted. A good bowel regimen is an essential bit of patient education that is often overlooked — after all there is an unspoken assumption that everyone knows how to manage their bowels, right? How do we as nurses address the potential for constipation? By starting a bowel regimen on day 1 of opioid therapy, knowing and communicating to our patients that even 1 dose of an opioid will slow down bowel stimulation. For our patients on opioid therapy or even those who have taken occasional opioids there are some common misunderstandings that can lead to constipation or other complications. “I’m drinking plenty of fluids and eating fruits and vegetables.” Patients taking opi-

oids need a stimulant laxative — a “push.” Often we will hear a patient report, “I’m drinking plenty of fluids and taking Colace.” And yet they are constipated. The mechanism of action for opioids is to block the opioid receptors. There are opioid receptors in the gut that are, in effect, blocked by the use of opioids. The usual process of stool being formed and the presence of it stimulating peristalsis is blocked. The correct medication for opioid-induced constipation (OIC) is a stimulant laxative. The likelihood of patients on opioids who will experience constipation is almost absolute. Even 1 or 2 doses of opioids will disrupt the usual bowel pattern. A good BM regimen starts with the initiation of opioids. Do not wait. Of course, there are exceptions: Someone who is freshly postop from abdominal surgery may not be a candidate for a stimulant laxative. This will be determined by the surgeon, yet should still be addressed. A person on chemo that is causing diarrhea and who is also on opioid therapy may not require a stimulant laxative. Radiation therapy to the pelvis may eliminate the need for a laxative at least during therapy.

Colace and extra fluids help with “mush” but without the “push” of the stimulant laxative the formed stool will just sit there, and as it does, fluid is absorbed from it so it becomes harder and more difficult to pass. What are the best stimulant laxatives? Senna and Dulcolax are both readily available over-the-counter stimulant laxatives. Senna is also available in liquid form if needed. Many patients remember the mush-andpush explanation. “I’m not taking the opioids because the constipation is so bad.” What a terrible

choice to have to make: Do I accept being in pain because I don’t want to be constipated, or do I manage my pain and accept being constipated? Why must it be an either/ or question? The reason to take less pain medication is because of less pain. Opioid constipation must be managed from the initiation of opioid therapy. (Repeat this again and again!) “My usual pattern is,” “I’m not eating very much.” Although knowledge of a patient’s

prior bowel management history is important, in the setting of cancer treatment, it is less significant. Chemotherapy, radiation, opioid use, and use of ondansetron (Zofran) and other medications will alter normal bowel pattern. Instead of focusing on what has been the pattern and even what they have used in the past for constipation, we want our patients to focus on what we are striving for. The goal is a soft-formed BM every 1 to 2 days. Soft and formed means a BM that is the consistency of soft serve ice cream (sorry for the analogy if you love soft serve ice cream). Volume of stool will correspond to amount of food intake. But even if not eating, patients should have a small, soft, and formed BM. Remind patients that the lining of their gut is like their skin and that it is sloughing off cells and continuing to make secretions in their GI tract which is enough to form a small stool.

34 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2019 • www.OncologyNurseAdvisor.com

Good bowel management should not be a second thought. Each time we assess for pain we must assess bowel function. I tell my patients right from the beginning that whenever I ask them about their pain, I will also ask about their bowels. This alerts them to the potential issue, and also communicates and educates them on the importance of good bowel management. Then to add a little humor, I tell them that if we follow a good regimen we won’t need a back-up plan, pun intended. ■

REFERENCES 1. van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: systematic review and metaanalysis. J Pain Symptom Manage. 2016;51(6):10701090.e9. 2. Corban C, Sommers T, Sengupta N, et al. Fecal impaction in the emergency department: an analysis of frequency and associated charges in 2011. J

I tell them that a good [BM] regimen won’t need a back-up plan, pun intended.

Clin Gastroenterol. 2016;50(7):572–577. 3. Sommers T, Corban C, Sengupta N, et al. Emergency department burden of constipation in the United

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

States from 2006 to 2011. Am J Gastroenterol. 2015;110(4):572-579.

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Adolescents, Young Adults Report Significant Concerns Regarding Their Sexuality Bette Weinstein Kaplan

s there an adolescent or young adult who is not concerned about his or her sexuality? Sexual thoughts feature prominently among young people whether they are healthy or ill, and they are certainly significant for those adolescents and young adults who have reproductive cancers. The National Cancer Institute defines adolescents and young adults (AYAs) as persons who are between the ages of 15 and 39 years.1 These young people go through all of the physical, emotional, cognitive, and social transitions that define this stage of life. The problem is that they are also dealing with a life threatening disease that can wreak havoc on all of those changes. The turmoil that results was the focus of a study undertaken at the University of Leipzig and the University of Applied Sciences Zittau/ Goerlitz, in Germany.2 Approximately 14,000 people aged 18 to 39 years received a cancer diagnosis in Germany in 2013. Posttreatment survival rate among this population was approximately 80%, which was well above the German average. The researchers noted that patients and survivors in this age group are not really knowledgeable of the ways that cancer can inf luence their sexuality. Prior research with this patient group specifically concentrated on reproductive cancer and how the disease affects the sex organs, not sexuality.2

Unique challenges that these young people have distinguish them from both younger children and older adults with cancer. Many of them are on their way to adulthood like other adolescents; but unlike other adolescents, their approaching independence is hampered by their need to be dependent on medical professionals as well as continued dependence on their parents. The German researchers wanted to gain knowledge about sexual satisfaction in this group of young people. They hoped to compare the sexuality of AYA patients with reproductive cancers, for whom there is a large knowledge base, with the sexuality of patients in this age group who have other types of cancer. They also evaluated AYA patients’ supportive care needs. STUDY POPULATION AND DEMOGRAPHICS

Patients were recruited from 16 acute care cancer hospitals, 2 local tumor registries, and 4 cancer rehabilitation clinics that specialize in treating AYA patients. Eligibility criteria included age at diagnosis between 18 and 39 years and their first diagnosis of any cancer was within the prior 48 months.2 A total of 577 patients — 153 men and 424 women — were enrolled in the study; all participants were asked to complete a study questionnaire. Of this cohort, 478 had completed acute

treatment such as surgery, chemotherapy, radiation, or transplantation; 99 patients were still on hormone or antibody treatment per standard oncology guidelines.2 The researchers asked all participants about their social demographics, quality of life, social support, and satisfaction with their sexuality and sexual partnerships. The sexuality category covered sexual attraction, efficiency, contacts, response, partner interaction, and communication.2 In addition, participants were asked about their cancer diagnosis and treatments. Compared with the women who did not have reproductive cancers, those with reproductive cancers had more children, were older, and more of them had partners. Most diagnoses for women were breast cancer (36%), Hodgkin lymphoma (16%), and gynecologic cancers (12%). For the men, most diagnoses were testicular cancer (33%), Hodgkin lymphoma (22%), and non-Hodgkin lymphoma (13%). Interestingly, the rate of participants with melanoma (3%) was significantly lower than the national rate (18%). CANCER AND SEXUALITY The researchers found that cancer does have an impact on sexuality; 80% of the women with a reproductive cancer and 52% of the men with a nonreproductive cancer said cancer had changed their sex

36 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2019 • www.OncologyNurseAdvisor.com

lives, even in small ways. Additionally, cancer patients who have partners are more satisfied with their sexuality, younger patients are more satisfied

Sexuality issues should be brought up routinely in counseling sessions. than older patients, and male patients are more satisfied than female patients. Similar to the results of prior research, the German group found that patients with reproductive cancers experienced increased sexual impairment and decreased sexual satisfaction. However, when the patients discussed their sexuality after their cancer diagnosis, no discernible difference was observed in psychological burden between female

patients with reproductive cancers and those with nonreproductive cancers. Even though the women with reproductive cancers were more likely to have impaired sexual responses, they still reported a similar degree of sexual satisfaction as their counterparts with nonreproductive cancers.2 The researchers’ theory is that the physiological effect of having cancer is less significant than the psychological burden that any cancer imposes. The researchers conclude that the concerns regarding sexuality of all AYA patients, not just those with reproductive cancers, should be addressed. 2 Questionnaire responses disclosed that one-third of all AYA participants had sexual problems and were dissatisfied with their sex lives, and that they wanted support to deal with these problems. Consequently, the researchers advise that sexuality issues and strategizing how to deal with them should

be brought up routinely in counseling sessions with all AYA patients. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, LiveStrong™ Young Adult Alliance. Closing the Gap: Research and Care Imperatives for Adolescents and Young Adults with Cancer. Report of the Adolescent and Young Adult Oncology Progress Review Group. Bethesda, MD: National Cancer Institute; 2006. NIH Publication No. 06-6067. https://www.cancer.gov/types/ aya/research/ayao-august-2006.pdf. Accessed November 26, 2019. 2. Mütsch J, Friedrich M, Leuteritz K, et al. Sexuality and cancer in adolescents and young adults — a comparison between reproductive cancer patients and patients with non-reproductive cancer. BMC Cancer. 2019;19(1):828.

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FROM

ACTIVE LISTENING The first step to effective communication is listening.1 Active listening is the highest level of listening; it involves paying focused attention to what is being said without interruption, without judgment, and with interest and understanding.2 Effective active listening is crucial to get a sense of how we can better help patients and establish rapport and trust.3 Active listening also involves assessment, making sure we heard and understood what was said correctly and checking for understanding by repeating to the speaker what we heard. Although we often believe understanding is instant and simple, sometimes deeper meanings are missed. I will never forget the moment when a patient stated, “It’s Breast Cancer Awareness Month and I feel like I was diagnosed all over again.” This patient had been in remission for 17 years, so one might have

Improving Interactions With Those Affected by Breast Cancer Joseline Lopez, MPsy

expected relief or a lack of heavy emotion. However, after assessing her statement and seeking explanation, I realized that she was experiencing the same emotions she felt when she was first diagnosed. This year she was not in the spirit to celebrate remission as she usually was in October. She also felt guilt due to the

expectations placed on her as a “survivor.” Examining her statement allowed me the opportunity to understand what she was feeling, and it increased my knowledge of her emotional state. Assessment leads to correction if a misunderstanding occurs, which can lead to the creation of trust for further dialogue. In this way we can better serve our patients. CHOOSING WORDS WISELY AND PROVIDING SUPPORT

The words we use are as important as the way we listen actively and attentively. Serving patients is a daily task for those in the health care field, especially the nurses who do so intimately; but in our routines, it can be easy to forget the unintended power of simple communication. The words nurses use can certainly strengthen patient/nurse connections and foster further communication and trust.4 However, common words and phrases can easily have unintended and detrimental effects, words such as warrior, journey, and survivor. On their face, these words seem to have very positive meanings, but they may not match the emotional environment of the person you are addressing. So in our longing to make patients feel better, we wind up using words that have negative impacts in times of crisis. Neutral terms contribute to an openness in how our patients can express themselves and can create a safe environment for more personally tailored communication.5 The words we use make assumptions about how our patients view their conditions and experiences. Assumptions

The words nurses use can certainly strengthen patient/nurse connections and foster further communication and trust. 38 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2019 • www.OncologyNurseAdvisor.com

ctober is Breast Cancer Awareness Month, a time when patients with breast cancer and their loved ones experience a variety of emotions and memories. Breast Cancer Awareness Month can be a time of remembrance for those who have lost a loved one, a time to celebrate survivors, or a time to face the reality of life after a breast cancer diagnosis. Whatever the situation may be, breast cancer affects everyone differently, and it is important to meet those impacted at the places where they are mentally and emotionally, including the way they describe their situations.

Ask questions that can lead to open, forthright responses.

• • • •

that are faulty or do not match that patient’s own feelings about themselves can cause communication to break down or even lead to unintended emotional fallout. Maintaining a language of openness and neutrality that will enable them to guide the contexts of these conversations to best suit their needs is far better; then, as the relationship continues, the language they use can be adopted and used by you. Many words and phrases should be avoided when speaking to a person affected by breast cancer, unless the person uses them first to express themselves. • • • • • • • • • • • •

Warrior Fighter Survivor Floating along the diagnosis process Journey Be one with your diagnosis Peaceful surrender New adventure to overcome New normal Battle Your Cancer Hero

War Don’t worry Everything is going to be okay Think positive

The following examples are neutral words and phrases that may be used when speaking to persons affected by breast cancer. • Patient with breast cancer • Diagnosis • I can see why you labeled the cancer that way • I hear what you are saying • I can see why you are worried • It’s normal to feel that way • Thank you for sharing that with me

PROVIDING SOURCES OF SUPPORT

When speaking to patients, providing support is crucial. There are many ways to provide support, and our use of language and how we listen are as vital as any. In my time at CancerCare, I have seen this played out many times. In addition to the above, I invite you to explore what we are able to offer. ■ Joseline Lopez is with the CancerCare Co-Payment Assistance Foundation. REFERENCES 1. Hunsaker PL, Alessandra AJ. The New Art of Managing People, Updated and Revised: Person-to-Person Skills, Guidelines, and

At the same time, seek to ask questions that can lead to open, forthright responses. Because these questions do not make assumptions about your patient’s frame of mind, they are less likely to guide them accidentally into unwanted emotional territory.

Techniques Every Manager Needs to Guide, Direct, and Motivate the Team. New York, NY: Free Press; 2008. 2. Jahromi VK, Tabatabaee SS, Abdar ZE, Rajabi M. Active listening: the key of successful communication in hospital managers. Electron Physician. 2016;8(3):2123-2128. 3. Jones JE, Pfeiffer JW. The 1975 Annual

• How do you feel about your breast cancer diagnosis? • Where do you see yourself in reference to other patients with breast cancer? • How are you coping with the diagnosis? • Are there any terms or phrases that you like to use when describing how you feel in regard to the diagnosis?

Handbook for Group Facilitators. La Jolla, CA: University Associates; 1975. 4. Gonzalez TD. Impact of Active Listening Training at a California State Hospital: A Quantitative Study [dissertation]. Phoenix, AZ: University of Phoenix; 2009. 5. Pantilat SZ. Communicating with seriously ill patients: better words to say. JAMA. 2009;301(12):1279-1281.

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ASK A PHARMACIST CD19 molecules (pink) on a leukemia cell

Understanding How irAEs Differ From Traditional Therapy AEs Is there a difference between adverse reactions to immunotherapy and adverse reactions to traditional cancer therapies? What is happening with these reactions, if they are not different? — Name withheld on request

Adverse effects to traditional cancer therapies and other targeted therapies are generally related to the drug’s mechanism of action. For example, myelosuppression or mucositis may occur in patients receiving cytotoxic chemotherapy that targets fast-growing cells; cardiotoxicity is related to the drug’s impact on cardiac cells; and in rare situations, a patient’s immune

system may be triggered by a drug to attack healthy tissue. With the expanding use of immunotherapy, we are seeing immune-related adverse events (irAEs) more frequently. irAEs are similar to traditional chemotherapy adverse events in that they are related to the therapy’s mechanism of action. Immune checkpoint inhibitors work by blocking checkpoints that regulate the immune system response. Blocking these checkpoints activates the immune system. In some patients, this can result in the immune system attacking healthy organs, producing an immunerelated adverse event. Similar to traditional cancer therapyrelated AEs, irAEs can vary in severity; however, they are different in a few major ways. • Immune-related adverse events may affect any organ system in the body and may occur at any point during treatment. irAEs most frequently affect the skin, GI tract, lungs, and endocrine system. They can also affect the central nervous system or cause more widespread symptoms. • Given the variety of organ systems irAEs can affect, clinical guidelines recommend considering an irAE as a potential cause for nearly any adverse effect a patient reports during treatment with an immune checkpoint inhibitor, even if they appear to be unrelated. Patients should be instructed to tell all their health care

providers that they are receiving immunotherapy so that irAEs can be detected and treated promptly. • Immune-related AEs are primarily treated by stopping the immunotherapy agent — either temporarily or permanently, depending on severity — and/or by starting treatment with corticosteroids to blunt the immune response. Whether to restart the immunotherapy depends on irAE severity, time to resolution, and overall clinical picture of the patient. The dose and route of steroids used also depends on irAE severity. In some situations, additional immunosuppressive medications may be required. Symptom management and monitoring as appropriate (eg, hemodialysis in a patient with severe immune-related nephritis or thyroid hormone replacement in a patient with immune-related hypothyroidism) is an important component of treating an irAE. Guidelines published by the American Society of Clinical Oncology (ASCO Clinical Practice Guideline: Management of Immune-Related Adverse Events From Immune Checkpoint Inhibitor Therapy) and the National Comprehensive Cancer Network (NCCN Clinical Practice Guidelines in Oncology [NCCN Guidelines®] Management of ImmunotherapyRelated Toxicities) are available online to aid with diagnosis, severity grading, and management of irAEs. ■

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

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