Oncology Nurse Advisor November/December 2020 by Haymarket Media

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November/December 2020

SPECIAL EDITION

Nursing Interventions Key to Managing Adverse Effects of Treatments IN THE NEWS Outcomes for Interval Breast Cancers â&#x20AC;¦ and more

FEATURE Benefits of Surgical Palliative Care as Part of Cancer Care

Understanding Ambiguous Loss and Grief

PRSRT STD US POSTAGE PAID PONTIAC IL PERMIT #60

COMMUNICATION CHALLENGES

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

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Oncology Nurse Advisor (ISSN 2154-350X), November/December 2020, Volume 11, Number 5. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. Copyright © 2020. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

4 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2020 • www.OncologyNurseAdvisor.com

CONTENTS 14

November/December 2020

IN THE NEWS • Outcomes Worse for Interval Breast Cancers • Patients With CRC Report Receiving Inadequate Nutritional Support • Patients With Cancer, Physicians Reported Satisfaction With Telemedicine Care

• Workshop Improves Communications With Patients About Sexual Health • Nurse Survey: Oncology Care in the Context of Limited English-Language Proficiency • Hip, Vertebral Fracture Risk Increased in Patients With MPNs

• A Missed Premedication Ameliorated by Standard Dose of Dexamethasone • Immunotherapy Plus Radiotherapy After Surgery Improves OS in Tumors With Brain Metastases

FEATURE

FIND US ON

Benefits of Surgical Palliative Care as Part of Cancer Care Bette Weinstein Kaplan

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RADIATION AND YOUR PATIENT Understanding Radiotherapy: Defining the Roles of Dosimetry, Medical Physicists

CONTENTS

November/December 2020

This review discusses how medical physicists and dosimetrists ensure the effectiveness of radiotherapy in the treatment of cancer. Bryant Furlow

ISSUES IN CANCER SURVIVORSHIP SPECIAL EDITION: ADVERSE EFFECT MANAGEMENT 19

Skin Flare Reactions in Cutaneous T-Cell Lymphoma Susan Moench, PhD, PA-C

Using a grading system for skin flare reactions increases potential for continuing administration of mogamulizumab despite the occurrence of this adverse effect, reported nurse researchers during the 2020 ONS Bridge, a virtual conference.

Retrospective study demonstrates that outcomes of 2-stage breast reconstruction are stable over the long term, with high patient and surgeon satisfaction. Bette Weinstein Kaplan

FROM CANCERCARE AEs and Treatment Adherence in Mantle Cell Lymphoma Susan Moench, PhD, PA-C

Researchers at UT MD Anderson Cancer Center in Houston described tools that support patient adherence to acalabrutinib in the setting of MCL in a published report.

Long-Term Aesthetic Outcomes of Breast Implants Shown to Be Stable, Study Shows

Strategies for Optimizing Adherence to Selinexor in Multiple Myeloma

Cancer and Fibromyalgia: Addressing the Needs of Patients Despite Limited Research

In addition to being common yet serious diseases, both cancer and fibromyalgia bring a high burden of physical pain and negative effects on mental health. Mary Hanley, LMSW

Joyce Pagán

Nurse researchers presented a protocol used to manage adverse effects in patients with relapsed/refractory MM who are receiving selinexor and dexamethasone during the 2020 ONS Bridge, a virtual conference.

PUBLISHERS’ ALLIANCE: DOVE PRESS

ONS Issues Guidelines for Prevention, Management of Lymphedema

Investigators from the Mayo Clinic in Jacksonville, Florida, review treatment strategies for mCRPC using CDK4/6 inhibitors and combination therapies.

Susan Moench, PhD, PA-C

Key recommendations from the Oncology Nursing Society clinical practice guidelines for the prevention and management of lymphedema in breast cancer survivors.

COMMUNICATION CHALLENGES Ambiguous Loss and Grief Ann J. Brady, MSN, RN-BC, CHPN

Novel Therapeutic Strategies for CDK4/6 Inhibitors in Metastatic Castrate-Resistant Prostate Cancer

OncoTargets and Therapy

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Visit www.OncologyNurseAdvisor.com today.

IN THE NEWS Outcomes Worse for Interval Breast Cancers Despite population screening, a high prevalence of breast cancer following a normal screening mammogram was observed from results of a registry-based cohort study. Data from 69,025 women aged 50 to 64 years included in 3 datasets collected between 2004 and 2010 in Canada were combined for this study. Information on breast cancer and long-term prognoses were analyzed. Interval cancers were defined as a breast cancer diagnosed within 24 months of a normal screening mammogram and noncompliance was designated when a breast cancer diagnosis occurred more than 2 years after a previous mammography. The included women had a total of 212,579 mammograms and 1687 cases of invasive breast cancer. Among cancers, 705 were screen-detected, 501 were detected outside of the screening program, 275 were among noncompliant women, and 206 were interval cancers. At a median follow-up of 7 years, 170 women had died from their breast cancer. Of these women, 94 were detected outside of screening programs, 29 had been interval cancers, 27 had been noncompliant, and 20 had been screen-detected. Mortality risk was higher among women with interval cancers compared with women with screen-detected cancers. These data indicated that substantial inadequacies exist in current breast cancer screening programs in Canada, in which lethal cancers were missed during examination or that screening intervals were insufficient to detect lethal cancers among patients.

Patients With CRC Report Receiving Inadequate Nutritional Support Researchers from the University of Sheffield observed, during a cross-sectional survey, that patients with colorectal cancer (CRC) were not receiving sufficient nutritional support. Seventy-five survivors of CRC were recruited through social media and support groups in 2017. Participants responded to a 6-section online questionnaire that assessed demographics, cancer history, and nutrition. Participants had early and late stage CRC of the rectum or colon with a colostomy. Most had finished treatment. The most commonly reported nutritional difficulties during their cancer treatment were diarrhea, uncertainty of what to eat, loss of appetite, and alterations of senses. Most participants reported receiving no nutritional advice, many of whom were unaware that advice existed or that

they had access to it. Among those who were advised, they received the advice from a nurse, general dietitian, or a cancer dietitian. Some respondents reported receiving conflicting advice. Despite little clinical support, 73.3% of participants reported seeking nutritional advice, most commonly from cancer charity websites or general medical advice online. Read more at https://bit.ly/ONA1220d.

Patients With Cancer, Physicians Reported Satisfaction With Telemedicine Care Patients with cancer and their clinicians were satisfied with the quality of care provided by telemedicine. Houston Methodist Cancer Center shifted from in-person patient

14 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2020 • www.OncologyNurseAdvisor.com

Read more at https://bit.ly/ONA1220g.

Hip, Vertebral Fracture Risk Increased in Patients With MPNs Results of a retrospective analysis showed a significantly elevated risk of bone fractures in patients with myeloproliferative neoplasms (MPNs), especially polycythemia vera (PV) compared with the overall population. In this study, researchers anaFractures more lyzed data from the Swedish Cancer common with PV. Registry and the Swedish National Board of Health and Welfare to determine the risks of hip and vertebral fracture in a cohort of adult patients with MPNs compared with the entire adult population during the period from 1995 to 2015. At a mean follow-up of 6.34 years, incidences of hip and vertebral fractures were 5% and 1.3%, respectively, in the overall patient cohort with MPN. Based on the incidence of hip fracture for the entire Swedish population, the observed-to-expected number of hip fractures in the entire cohort of patients with MPN, those with PV, and those with essential thrombocythemia were 1.20, 1.37, and 1.02, respectively. Furthermore, similar comparisons of the observed-to-expected number of vertebral fractures revealed ratios of 1.94 for the overall cohort with MPN, 2.09 for those with polycythemia vera, and 1.50 for patients with essential thrombocythemia. Read more at https://bit.ly/ONA1220f.

A Missed Premedication Ameliorated by Standard Dose of Dexamethasone Researchers from the Ottawa Hospital Cancer Centre observed that a fixed-dose steroid replacement was superior to a physician-directed strategy prior to starting docetaxel. In a clinical trial, 60 patients who missed a steroid premedication dose were randomized 1:1 to receive 8 mg dexamethasone or a physician-directed replacement between 2016

and 2018. Patients were assessed for time to start docetaxel and adverse events. Patients were aged mean 59.1 years and had cancers of the breast, gastrointestinal tract, prostate, or lung. They were prescribed docetaxel with cyclophosphamide, docetaxel monotherapy, 5-fluorouracil/epirubicin/cyclophosphamide prior to docetaxel, or docetaxel-oxaliplatin-5-fluorouracil; and were on their first, second, third, fourth, fifth, or sixth chemotherapy cycle. The physician-guided strategies included 8 mg, 20 mg, 12 mg, 10 mg, or 4 mg intravenous dexamethasone; 8 mg oral dexamethasone; or no additional dexamethasone. Average time from randomization to docetaxel treatment was 21.2 minutes shorter among patients in the fixed-dose group (mean, 62.2 ± 41.1 mins; median, 47.5 mins) compared with the physician-directed cohort (83.4 ± 48.0 mins; median, 61 mins). The study authors concluded that 8 mg dexamethasone should be the standard care for patients who missed a steroid dose prior to starting chemotherapy. Read more at https://bit.ly/ONA1220i.

Immunotherapy Plus Radiotherapy After Surgery Improves OS in Tumors With Brain Metastases In this retrospective study, researchers abstracted data on patients aged 19 years or older with a variety of metastatic solid tumor cancers diagnosed between 2010 and 2016 from the National Cancer Database (NCDB). Patients had undergone definitive surgery of the primary cancer site as well as standard treatment with chemotherapy, radiotherapy, or chemoradiation therapy, with or without immunotherapy. Patients underwent chemotherapy alone, radiotherapy alone, chemoradiation alone, chemotherapy plus immunotherapy, radiotherapy plus immunotherapy, or chemoradiation plus immunotherapy. A key study finding was that the median OS of patients treated with immunotherapy was 22.60 months compared with 15.08 months for those not treated with immunotherapy. Furthermore, an analysis of the different treatment groups revealed that median OS in patients who received radiotherapy with immunotherapy was 20.53 months compared with 10.09 months for those treated with radiotherapy alone. With respect to chemoradiation, median OS was 28.52 months and 20.21 months with and without immunotherapy, respectively. ■ Read more at https://bit.ly/ONA1220b.

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was. Specific recommendations included having an interpreter in the unit, employing a greater proportion of bilingual staff, making materials available in more than 1 language, and offering language training at no cost.

FEATURE | Best Practices

Benefits of Surgical Palliative Care as Part of Cancer Care A literature review confirms the benefits of integrating specialty palliative care into the care continuum for patients with cancer undergoing surgery.

Specialty palliative care in the surgical setting has been shown to improve patient outcomes and satisfaction with care.

BETTE WEINSTEIN KAPLAN

alliative care is a practice that has come into its own. Specialty palliative care refers to care provided by dedicated palliative care teams, and primary palliative care denotes the care that the team in a specialty provides. Thus, in the oncology setting, primary palliative care relies on the oncology team, although optimizing surgical palliative care requires incorporating both specialty and primary palliative care.1 Clinical practice guidelines from the American Society of Clinical Oncology (ASCO) recommend dedicated palliative care services for patients with advanced cancer early in the course of their diseases, ie, while they are undergoing active treatment, in both the inpatient and outpatient settings. The ASCO recommendation notes that “referral of patients to interdisciplinary palliative care teams is optimal.”2 Marisa R. Moroney, MD, and Carolyn Lefkowits, MD, MPH, MS, conducted a review of studies on integration of palliative care in surgical oncology.1 Their review included these findings: • Researchers who randomized 461 patients with an advanced cancer (estimated survival, 6 to 24 months) to standard oncology care or oncology care plus specialty palliative care found that patients in the palliative care arm had significantly improved quality of life and better symptom management, spiritual well-being, and satisfaction with their care. Continues on page 18

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FEATURE | Best Practices • A trial in which 322 patients with advanced cancer were randomized to receive “psychoeducational” telephone consultations with an advanced practice nurse who had specialty palliative care training found that the patients in the nurses’ palliative care group had better quality of life, symptom management, and mood. The telephone consultations focused on symptom management, social support, and communication, as well as advanced care planning. • In a study of patients with breast or gynecologic cancer, patients at different points in the disease course terminated their cancer-directed therapies and followed up with planned specialty palliative care. Researchers found that patients who received early palliative care had better quality of life, fewer episodes of depression, and required less chemotherapy in the last 6 weeks of life, compared with those whose palliative care was later. The researchers noted that earlier palliative care was an independent predictor of overall survival. • A study involving patients who had undergone surgery for gynecologic cancer demonstrated improved symptoms within 1 day of their inpatient specialty palliative care consultation.1 UNDERSTUDIED AND UNDERUTILIZED Given that integrated palliative care has increasingly proven its efficacy in studies on surgical patients, and that ASCO recommends it for all patients with advanced cancer, expectations are that palliative care would be a common addition to surgical practice. However, that is not the case. In fact, palliative care is underutilized. For example, in a study of medical and surgical patients with cancer diagnoses who had undergone major surgery within the last year of life, less than 50% of all patients and significantly fewer of the surgical patients received palliative care or a hospice consultation.1 Several studies showed that formal education in palliative care skills is lacking, despite the recommendations of the Accreditation Council of Graduate Medical Education (ACGME) and the Society for Surgical Oncologists (SSO), who have advocated for training in palliative care skills to be integrated into graduate medical education. A number of studies evaluating fellowship training in surgical oncology disciplines concluded that there is very little formal education in palliative care skills. One study found that only 51% of fellows were exposed to the specialty palliative care service during their fellowship, 46% had never observed faculty discussing goals of care with a patient, and 57% had never received critiques on their own palliative care skills.1

SEEK OUT SELF-EDUCATION OPPORTUNITIES “If you have a good palliative care team at your hospital, you can pick up many good tips that can really serve you and your patients just by your going to and observing family meetings,” notes Robert Milch, MD, a founder of the surgical palliative care movement. “My dad was also a surgeon and always conveyed to me that what went on in the operating room was but a small part of the totality of the care of the patient. That sensitized me to always take a holistic view of the patient and the practice of medicine.

Given that integrative palliative care has increasingly proven its efficacy, expectations are that it would be a common addition to surgical practice. “Once we come to the realization that most of what we do is ultimately palliative, that leads us to be able to redefine good outcome. It provides a continuity in caring that we often lose,” he added.3 Surgical specialty clinicians who do not have formal training in palliative care and want to introduce specialty palliative care into their practice should take advantage of the palliative care nurse’s expertise. They can refer patients to outpatient care soon after a cancer diagnosis or consult the inpatient palliative care team. Through collaborating with the oncology nursing staff and other integrated palliative care services, they can integrate their surgical goals with the treatment, quality of life, and comfort goals of their patients. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Moroney MR, Lefkowits C. Evidence for integration of palliative care into surgical oncology practice and education. J Surg Oncol. 2019;120(1):17-22. doi:10.1002/jso.25454. 2. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017;35(1):96‐112. doi:10.1200/jco.2016.70.1474 3. Dr. Robert Milch: Surgical Palliative Care Pioneer. The Surgical Palliative Care Podcast. January 13, 2020. Accessed October 14, 2020. https://thesurgicalpalliativecarepodcast.buzzsprout. com/740810/2454425-dr-robert-milch-surgical-palliative-carepioneer

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SPECIAL EDITION: ADVERSE EFFECT MANAGEMENT

Skin Flare Reactions in Cutaneous T-Cell Lymphoma Grading system increases potential for continuing mogamulizumab treatment.

standard of care for managing skin flare reactions associated with mogamulizumab infusion in the treatment of patients with mycosis fungoides or Sézary syndrome was described in a poster presentation at the ONS Bridge, a virtual conference.1 Both mycosis fungoides and Sézary syndrome are forms of cutaneous T-cell lymphoma. Malignant T-cells associated with mycosis fungoides generally reside in the skin, whereas Sézary syndrome is characterized by circulating clonal malignant T cells that typically affect the skin. Both conditions are associated with the presence of erythroderma, rashes, and other types of skin lesions, as well as pruritis and pain. Mogamulizumab-kpkc, a monoclonal antibody directed against CCR4, a CC chemokine receptor, was approved by the US FDA in 2018 for the treatment of relapsed/refractory mycosis fungoides and Sézary syndrome in adult patients who received at least 1 prior line of systemic therapy. However, treatment can be complicated by the occurrence of dermatologic toxicity, particularly acute skin flare reactions. To facilitate the appropriate management of skin-related adverse effects (AEs) of mogamulizumab while also minimizing infusion scheduling interruptions, a standardized grading system along with supportive care guidelines were developed within the context of a case study series of 12 patients treated with mogamulizumab over a 6-month period. A key element of this grading system is that infusion disruption is considered only in the case of grade 4 skin reactions. Although no intervention was recommended for patients with grade 1 AEs (skin eruptions or erythema without associated symptoms), topical steroid creams were included as an option for patients with grade 2 AEs (skin eruptions or erythema with pruritus, pain, or other associated symptoms). Both topical and oral steroids were proposed for patients with grade 3 AEs (widespread skin eruption

Management of skin reactions should be based on severity, with infusion disruption avoided unless grade 4 toxicity occurs.

with erythroderma, ulceration, or vesicular eruption with associated symptoms). Topical and oral steroids, as well as oral antibiotics and considering a delay in mogamulizumab administration, are options for patients with grade 4 AEs (generalized erythroderma, exfoliative, ulcerative, or bulbous dermatitis, with associated symptoms and infection). Of note, considering skin biopsy was also mentioned for patients with grade 4 skin-related AEs to distinguish between mogamulizumab-related skin toxicity and disease progression. The authors noted that “effectively managing the patient’s expectations of the side effects of mogamulizumab prior to starting therapy increases patient compliance with the recommended treatment protocol.” Of the 12 patients treated with mogamulizumab, grade 2 or higher skin flare reactions occurred in 10 within the first 6 weeks following treatment initiation. Seven of the 10 patients experienced good long-term disease control, defined as “a decrease in skin involvement or a decrease in blood involvement as evidenced on flow cytometry, lasting greater than 3 months, on or off therapy.” ■ —Susan Moench, PhD, PA-C

REFERENCES 1. Brown C, Foss FE. Acute skin flare reactions and long term skin improvements in CTCL with mogamulizumab. Presented at: ONS Bridge; September 8-17, 2020. Accessed September 8, 2020. https://ons. confex.com/ons/2020/ap/eposter.cgi?eposterid=1022.

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SPECIAL EDITION: ADVERSE EFFECT MANAGEMENT

urse-led approaches for facilitating patient adherence to treatment with acalabrutinib for relapsed/refractory mantle cell lymphoma (MCL) were described in a recently published report.1 MCL is an aggressive form of B-cell non-Hodgkin lymphoma (NHL) associated with extensive lymphadenopathy, as well as extranodal involvement and a poor prognosis. In most patients with MCL, treatment with typical frontline therapeutic approaches involving combination chemotherapy and immunotherapy or intensive chemotherapy is initiated at diagnosis. Initial treatment may be followed by hematopoietic stem cell transplantation (HSCT) or maintenance therapy with rituximab. However, although many patients with MCL respond to initial therapy, most will experience a relapse of disease. Based on the results of a single-arm, open-label, phase 2 study that evaluated acalabrutinib, a highly selective, oral BTK inhibitor, in patients with relapsed/refractory MCL,2 this agent received accelerated approval by the US FDA

Although treatment discontinuation rate was low in this study, nearly one-third of patients experienced an acalabrutinib dose delay.

for the treatment of adult patients with MCL who have received at least one prior line of therapy. Safety findings from the phase 2 trial in patients with MCL included mostly grade 1/2 AEs reported by patients, including all-grade headache (38%), diarrhea (36%), bleeding events (33%), fatigue (28%), cough (22%), and myalgia (21%). In addition, grade 3/4 AEs included infections (15%), with pneumonia being the most common (6%); anemia (10%); and neutropenia (10%); as well as bleeding events and cardiac adverse events in approximately 2% and 3% of patients, respectively. Although the rate of acalabrutinib-related treatment discontinuation was low in this study (approximately 5%), nearly one-third of patients experienced an acalabrutinib dose delay, with the most common causes attributed to vomiting (5%), pneumonia (4%), and nausea (3%). No treatment-related deaths occurred on the study. In addition to following recommendations included in the acalabrutinib prescribing instructions, both on- and off-protocol nurse management included the following: • Careful monitoring and documentation of symptoms prior to initiation of acalabrutinib; • Pill diaries for patients to track adherence to treatment (acalabrutinib is dosed twice daily) and identify missed doses; • Follow-up telephone calls and recommendations for use of cell phone alarms to improve adherence; • Toxicity diaries for patients to track occurrence of AEs; • Patient education regarding AE management and the importance of medication adherence, as well as reeducation at follow-up visits; • Management of grade 1/2 AEs using nurse intervention and over-the-counter medications, such as loperamide for diarrhea and acetaminophen for headache, rather than dose reductions and recommendations to exercise regularly to alleviate fatigue, although myalgia was managed with the prescription dopamine promoter ropinirole, if needed. “These strategies allowed for the tracking of occurrences of nonadherence, providing the opportunity to advise and educate patients and to manage AEs more effectively,” the authors of the report noted. ■ —Susan Moench, PhD, PA-C

REFERENCES This article is available in its entirety, including the references, at https:// bit.ly/AEmgtforMCL

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AEs and Treatment Adherence in Mantle Cell Lymphoma

SPECIAL EDITION: ONCOLOGY NAVIGATION

SPECIAL EDITION: ADVERSE EFFECT MANAGEMENT

Strategies for Optimizing Adherence to Selinexor in Multiple Myeloma

ptimal supportive care that includes patient education and anticipatory management of common adverse effects (AEs) can improve adherence to treatment protocols and result in better response rates in patients receiving selinexor for relapsed/refractory multiple myeloma (MM). These findings were demonstrated in an AE management protocol presented during the Oncology Nursing Society (ONS) Bridge, a virtual conference. Multiple myeloma is the second most common hematologic cancer. In July 2019, the US FDA granted accelerated approval to selinexor in combination with dexamethasone for adult patients with relapsed/refractory MM who have received at least 4 prior therapies and whose disease was refractory to at least 2 immunomodulatory agents, at least 2 proteasome inhibitors, and an anti-CD38 monoclonal antibody. Approval was based on data from the STORM protocol (ClinicalTrials.gov Identifier: NCT02336815). Selinexor is an oral small molecule therapy that inhibits exportin1 (XPO1)-mediated nuclear export of tumor suppressor proteins and oncogenic mRNAs involved in cancer-cell growth. The recommended dose is selinexor 80 mg oral and dexamethasone 20 mg oral on days 1, 3, 8, 10, 15, 17, 22, and 24 of a 28-day cycle. In this poster presentation, Erika Florendo, RN, ANP-BC, and colleagues discussed the supportive care measures and

strategies used at Mt Sinai Hospital (MSH) in New York, New York, to improve tolerability and increase response rates. Commonly reported adverse effects (AEs) of selinexor include nausea, anorexia, fatigue, thrombocytopenia, and hyponatremia. Of the 123 patients enrolled in STORM Part 2, 28 were treated at MSH and demonstrated longer overall response rates (53.6% in MSH vs 26.2% in overall STORM population) and fewer discontinuations due to AEs (3.7% vs 18.8%). Patients treated at MSH received the following prophylactic medications: ondansetron 8 mg orally 3 times a day, olanzapine 2.5 mg orally daily at night, and rolapitant 180 mg orally every 2 weeks. In addition, patients were given intravenous (IV) fluids 1 to 3 times a week, as needed, and referred for a nutritional consult at baseline and at regular intervals. Daily oral methylphenidate at a dose of 10 mg was administered to relieve fatigue that was unresponsive to selinexor dose modifications. Thrombocytopenia was mitigated with platelet transfusions and romiplostim 10 mcg/kg subcutaneously weekly on selinexor off days. Hyponatremia was treated aggressively with IV fluids and sodium chloride 1 g orally 3 times a day. Additional strategies used to improve adherence included providing a medication diary and a calendar for tracking appointments, involving social work, and educating both the patient and the caregiver regarding medications and antiemetic schedules. Anticipatory guidance and implementing a day 3 phone call to ensure adherence to medication schedule and to discuss potential adverse effects were also effective. Finally, a visiting nurse may be needed to help patients with medication administration and polypharmacy. “Optimization of supportive care and oral adherence is critical to maintain patients on treatment longer to get better response rates in this triple class refractory population,” Ms Florendo concluded. She went on to recommend that oncology nurses focus patient education on common AEs and necessary evaluation/supportive care measures. ■ —Joyce Pagán

REFERENCE Florendo E, Mancia IS, Thomas J. Symptom management for patients with relapsed and refractory multiple myeloma receiving therapy with selinexor (Xpovio™). Presentation at: Oncology Nursing Society (ONS) Bridge; September 8-17, 2020. Accessed November 19, 2020. https://ons.confex. com/ons/2020/ap/eposter.cgi?eposterid=1046

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ONS Issues Guidelines for Prevention, Management of Lymphedema

he Oncology Nursing Society (ONS) released clinical practice guidelines focused on approaches to prospectively follow patients at risk of cancer treatmentrelated lymphedema, reduce the likelihood of the condition developing in these patients, and conservatively treat those who develop lymphedema secondary to cancer treatment.1 Most often occurring secondary to treatment, cancer survivors with damaged lymphatic systems have a lifetime risk of developing lymphedema. Hence, approaches to monitor its occurrence and reduce the risk of it developing are key elements of management. Furthermore, although lymphedema is not considered curable, multimodality nonsurgical approaches may be employed as a means of reducing its associated morbidity. The guidelines, developed by a panel comprising oncology nurses at all levels of practice, a lymphedema specialist, and a patient representative, are based on evidence from 2 systematic reviews and meta-analyses of randomized and nonrandomized prospective studies.2,3 Regarding these guidelines, the authors noted that involvement of a therapist knowledgeable about diagnosis and

treatment of lymphedema — a trained, certified lymphedema therapist — is important. They further stated that patient education is an important component of self-care and should be included throughout the surveillance and treatment trajectory for lymphedema. Key recommendations regarding surveillance of patients considered at risk of cancer treatment-related lymphedema include: • Prospective surveillance is recommended for all patients who have undergone cancer-related surgery. • Pretreatment assessment for women scheduled for breast cancer surgery or radiation therapy is recommended; followed by posttreatment assessment by a nurse or lymphedema therapist; interval assessments conducted at 1, 3, 6, 9, and 12 months; then bi-annual assessments for 1 to 3 years subsequently moving to annually. With respect to approaches to reduce the likelihood of developing cancer treatment-related lymphedema, recommendations include: • Delay initiating exercise until at least 7 days after surgery for those at risk of truncal/extremity edema • Initiate programmed and supervised exercise that includes resistance and strengthening exercises at least 7 days after surgery for those at risk of truncal/extremity edema • Use of compression garments for those at risk for lower extremity lymphedema • Postsurgical scar massage for those at risk of extremity, truncal, or head and neck lymphedema. Finally, the panel recommended complete decongestive therapy (CDT) as the standard of care for patients who develop cancer treatment-related lymphedema, including manual lymphatic drainage (MLD) through a light, skin stretching massage; compression therapy; skin care approaches; resistance exercise; and water-based exercise or yoga. Moreover, although the guideline panel recommended that the first phase of CDT be conducted by a certified lymphedema specialist, they recommend a second phase of CDT corresponding to lifelong self-management to be carried out by the patient and/or caregiver. ■ —Susan Moench, PhD, PA-C

The panel recommended CDT as the standard of care for treatmentrelated lymphedema.

REFERENCES This article is available in its entirety, including the references, at https:// bit.ly/Lymphedemaguide

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SPECIAL EDITION: ADVERSE EFFECT MANAGEMENT

COMMUNICATION CHALLENGES

Ambiguous Loss and Grief

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

[Ambiguous loss] is grief over a loss of what was before but also grief over the loss of what was meant to be.

mbiguous loss is a term coined by the psychologist Pauline Boss in the 1970s. The true nature of the term refers to losses that have no clear definition to them, with no closure or clear understanding.1,2 For example, those who lost a loved one when the Twin Towers fell on 9/11 never had a body to confirm the death. They knew their loved one had perished and were able to verbalize that their loved one was dead but at the same time, with no body and so much unknown about those last moments, they also held out the hope that somehow their loved one may have survived. Logic and emotion collided, and grief was ground into them as certainly as the dust from the towers. Today, in the midst of the COVID pandemic and perhaps because of it, we have a small window into the unknown journey every cancer patient is forced to make. Although cancer is a different experience than COVID, there are similar components to it. Better understanding of it on the part of

nurses might help us as we face communication challenges with our patients. Ambiguous loss follows a similar pathway through COVID and cancer. It is a loss that occurs without closure or clear understanding. It is grief over a loss of what was before — life before COVID or cancer — but also grief over the loss of what was meant to be, their future now unrecognizable. It is the kind of loss that leaves people searching for answers, which complicates and delays the process of grieving, and can result in unresolved grief. It holds within it the unknown. Questions arise such as: What happened to those who perished on 9/11? When will the pandemic be over? What happens after the pandemic? Those questions are similar to the questions and uncertainty our patients with cancer face. What is next? What if the treatment doesn’t work? And there is another aspect to it that is comparable: The person facing the new diagnosis never expected this to happen. How do they adjust to the changes? How did they end up here in this oncologist’s office, at the imaging center facing an MRI, waiting to go into surgery not knowing what the doctors will find until they get in there? What happens if the chemo/ immunotherapy/surgery/radiation does not work? Vulnerability is ever present, and no one can truly answer their questions. DISCUSSION None of us knows for certain how each person will respond to treatment. We provide information based on what we have seen. Statistics are numbers, albeit important numbers, but they are not the sum of a person’s life and value. No one can explain why one

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COMMUNICATION CHALLENGES

We can offer support without judgment. We can encourage soothing behaviors such as meditation, music, prayer.

person got cancer and someone else did not. The inexplicable part, the uncertainty and the vulnerability are one thing, but the other part, the ambiguous part, is this: What has cancer taken away from their expectation for the future? Each of us has a picture, a photo album if you will, of what the future will look like and those imagined pages of anticipated experiences are torn away by their diagnosis. What was held as fact is gone. How does a person mourn for something they expected to have, to suffer the loss of something that never actually existed? I have asked many questions in this column and yet provide few answers. The context of each person’s experience will impact how we relate and communicate with them. Perhaps one reality of COVID is how it illuminates the dark corners of the unknown, the place where all of us are existing while COVID rules the world. The threat is real for all of us. With COVID none of us are onlookers, we are part of the whole, the collective. Yet with our cancer patients we are onlookers. Perhaps the uncertainty we are all feeling with COVID can help us better understand the ambiguous loss patients with cancer confront with their diagnosis and treatment. COVID and cancer are both threats to our physical body. Our natural instinct is to protect our bodies. Over my years of caring for oncology patients there is one group in particular that I have an internal struggle to understand. They are the patients who forego traditional treatment and instead are either lost to follow-up or who reject traditional therapy in favor of alternative therapies. Yet when those therapies fail, as we know they will, these patients return for conventional treatment and often with disease that has spread beyond what it would have otherwise. When I encounter them now facing advanced cancer and complex symptoms, I find my internal voice saying over and again, “Why didn’t you pursue treatment?” The answer is complicated and often does not make sense to others. Yet it does to the patient. There is no point in asking the question out loud. Done is done.

But I feel inclined to draw on our COVID experience to reference in my practice with patients like this. In an effort to protect themselves from the harsh reality of a cancer diagnosis, some will twist reality to match their internal narrative. They become convinced that their cancer is different, or that they themselves are different and so cannot tolerate the usual treatment. Yet in so doing, they set themselves up for failure. The micro focus that leads to the decision to disregard conventional treatment disregards the bigger picture. I believe it is a similar mechanism that drives some to reject the science of COVID, to ignore the warnings and to choose to battle the smallest of details — wearing a mask, for example. Ambiguous loss is loss without resolution. Right now, COVID does not have a predictable resolution. Cancer, regardless of prognosis, has an unpredictable nature as well. Communication challenges are inherent in this ambiguity. How we approach that challenge is connected not to resolution but to understanding how complex a person’s reaction to cancer may be. There is a paradox to it. The harder we try to flash the mirror of reality, the more they may withdraw. There is little point in arguing. Rather, we can offer support without judgment. We can encourage soothing behaviors such as meditation, music, prayer. We do not have to correct misconceptions. We do need to be honest, but we can also answer the questions at hand and stop at the wall that was erected. It is not easy to be an onlooker when what we want to do is illuminate and educate. It is its own challenge. But sometimes communication requires no words. ■ Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California. REFERENCES 1. Boss P. Ambiguous Loss: Learning to Live With Unresolved Grief. Harvard University Press; 2000. 2. Ambiguous Loss. Pioneered by Pauline Boss, Ph.D. Accessed November 19, 2020. https://www. ambiguousloss.com

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