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Providing Companionship for Cancer Patients in Their Last Hours

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Oncology Nurse Advisor (ISSN 2154-350X), March/April 2017, Volume 8, Number 2. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. Oncology Nurse Advisor is available for single copy purchases at the following rates. Price per copy: USA $20; Foreign $30. To order call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

Jiajoyce R. Conway, DNP, CRNP, AOCNP Cancer Care Associates of York York, Pennsylvania Marianne Davies, DNP, ACNP, AOCNP Smilow Cancer Center @ Yale New Haven New Haven, Connecticut Frank dela Rama, RN, MS, AOCNS Palo Alto Medical Foundation Palo Alto, California Donald R. Fleming, MD Cancer Care Center, Davis Memorial Hospital Elkins, West Virginia Susanne Menon, NP, OCN Center for Gynecologic Oncology Massachusetts General Hospital Cancer Center Boston, Massachusetts Leah A. Scaramuzzo, MSN, RN-BC, AOCN Billings Clinic, Inpatient Cancer Care Billings, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania

4 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

CONTENTS

March/April 2017

IN THE NEWS • ASCO Panel Endorses ACS Survivorship Guideline • Onset or Rapid Worsening of Diabetes May Indicate Pancreatic Cancer • Nurse-Calling Program Improves Retention Rates From First Treatment Visit … and more

SGO 2017 • Persistent Opioid Use After Radiation Therapy • HPV Vaccination Discussions Need to Focus on Education, Awareness

JOURNAL REVIEW Navigation: Extending the Role of Oncology Nurses

Megan Garlapow, PhD

FEATURES Movement Therapy Can Open Communications With Patients Tiffany Garbutt, PhD

Kinase Inhibitor-Related Adverse Effects in Metastatic Melanoma Debra Hughes, MS

45 FIND US ON

Artist Offers Novel Approach to Healing After Mastectomy Bette Weinstein Kaplan

Continues on page 11

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FIRST REPORT: SGO 2017 News from the Society of Gynecologic Oncology 2017 Annual Meeting on Women’s Cancer.

STAT CONSULT

CONTENTS

March/April 2017

34 STAT CONSULT • Vandetanib (Caprelsa) • Sorafenib (Nexavar) 40

Bosutinib (Bosulif) Bosutinib is a kinase inhibitor approved for the treatment of chronic, accelerated, or blast phase Philadelphia chromosome (Ph)-positive chronic myeloid leukemia (CML) with resistance or intolerance to prior therapy.

PATIENT EDUCATION: FACT SHEETS

RADIATION & YOUR PATIENT Novel Model Personalizes Radiation to Cell Genotype

Antiperspirants/Deodorants and Breast Cancer This fact sheet examines possible relationships between use of antiperspirants or deodorants and cancer risk.

Bryant Furlow

COMMUNICATION CHALLENGES Transference of Suffering Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Cancer Support Organization Rocks Age-Appropriate Cancer Care Centers for AYA Patients Bette Weinstein Kaplan

THE TOTAL PATIENT Volunteer Programs Provide Companionship to Cancer Patients in Their Last Hours Bette Weinstein Kaplan

50 FROM CANCERCARE Therapeutic Writing in Group Work for Patients With Cancer

ASK A PHARMACIST Arsenic and APL: Review of Therapy for an Acute Leukemia Lisa A. Thompson, PharmD, BCOP

PUBLISHERS ALLIANCE: DOVE PRESS Docetaxel-Associated Myalgia-Arthralgia Syndrome in Patients With Breast Cancer This research examines possible risk factors and effectiveness of treatments for docetaxelassociated myalgia-arthralgia syndrome. Breast Cancer: Targets and Therapy

Pediatric Hepatocellular Carcinoma: Challenges and Solutions This research examines the medical challenges presented by pediatric hepatocellular carcinoma (HCC). Journal of Hepatocellular Carcinoma

Caroline Edlund, LCSW-R

Blood-Forming Stem Cell Transplants This fact sheet reviews bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) as they relate to cancer treatment.

ON THE

WEB

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 11

IN THE NEWS ASCO Panel Endorses ACS Survivorship Guideline The American Society of Clinical Oncology (ASCO) has endorsed the American Cancer Society (ACS) guideline on head and neck survivorship care, emphasizing the need for multidisciplinary care for head and neck cancer survivors. Despite the limited availability of high-quality evidence to support many of the ACS’s recommendations, an ASCO Expert Panel determined that the American Cancer Society’s Head and Neck Cancer Survivorship Care Guideline, which was published in 2016, is clear, thorough, clinically practical, and helpful. The ASCO Expert Panel stressed the necessity for multispecialty, multidisciplinary, coordinated, and collaborative care. Specifically, the care of head and neck cancer survivors should take a team-based approach that includes primary care clinicians, oncology specialists, otolaryngologists, dentists, and other allied professionals. Because head and neck cancer survivors may experience late effects and morbidities, the Panel emphasized that the head and neck cancer team should educate primary care clinicians about the potential late and long-term effects of treatment and that primary care clinicians should evaluate for these effects during regular visits with survivors when regular follow-up with the head and neck cancer team ceases. Primary care clinicians should be aware of signs, symptoms, and physical examination findings related to disease recurrence or second malignancies; however, the ASCO Panel notes that specific investigations for surveillance of recurrences, such as imaging or endoscopies, should remain the responsibility of head and neck cancer specialists. The ASCO Panel also underscored the importance of screening and follow-up for depression, anxiety, and other psychosocial late effects among survivors of head and neck cancer. Primary care clinicians should discuss smoking cessation, alcohol consumption, appropriate dental hygiene, reduction of cardiovascular risk factors, nutrition strategies, and regular physical activity with survivors, as well.

Proportion of Never-Smokers With NSCLC Is on the Rise Approximately 10% to 15% of lung cancer cases in the United States occur in people who have never smoked tobacco; however, whether this rate is increasing is unclear. To examine whether the proportion of never-smokers developing lung cancer is increasing, researchers retrospectively analyzed data from 10,593 NSCLC cases and 1510 small cell lung cancer (SCLC) cases. The investigators collected demographic information obtained from 1990 to 2013 from the registries of 3 diverse

institutions: The University of Texas Southwestern Medical Center in Dallas, Parkland Hospital in Dallas, and Vanderbilt University Medical Center in Nashville, Tennessee. Results showed that the proportion of never-smokers who developed NSCLC increased from 8.0% during the period between 1990 and 1995 to 14.9% in 2011 to 2013. However, researchers found no statistically significant increase in the cases of SCLC (1.5% in 1990 to 1995 to 2.5% in 2011 to 2013) or squamous cell NSCLC among never-smokers from the 1990 to 1995 period to the 2011 to 2013 period. Read more at http://bit.ly/2n3COnN.

12 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

Read more at http://bit.ly/2majlmh.

JOURNAL REVIEW This new column aims to present studies in the literature that have practical or clinical relevance to oncology nursing.

he evolving role of the oncology nurse navigator (ONN) is unique from the roles of clinical and staff nurses, but a recent role delineation study (RDS) did not support the need for a separate ONN certification. Ideally, the role of the ONN focuses on health care needs of patients across different settings, simplifies transitions, and overcomes obstacles to high-quality care. While the roles of the ONN and the direct care nurse are similar, the ONN contributes uniquely to patient outcomes and to quality processes.1 “While the results of the RDS indicated that the primary tasks of the ONN are different from bedside/chairside oncology nurses, the knowledge needed by each group is quite similar. And since certifications are based on knowledge, a separate ONN certification is not supported at this time,” Barbara G. Lubejko, RN, MS, project manager on the education team at the Oncology Nursing Society (ONS), Pittsburgh, Pennsylvania, told Oncology Nurse Advisor in an interview. THE STUDY

For this study, published in the Clinical Journal of Oncology Nursing, ONS partnered with the Oncology Nursing Certification Corporation (ONCC) to conduct an RDS of oncology nurse

Navigation: Extending the Role of Oncology Nurses Megan Garlapow, PhD

navigators to reevaluate their role and to determine whether a separate certification for ONNs is warranted. WHAT WAS LEARNED The RDS was distributed to 5397 members of ONS and nonmembers identified as oncology nurse navigators or members of the ONS Nurse Navigator Special Interest Group. A total of 498 recipients (9% response rate) responded. The demographics of the respondents were representative of the group to which the RDS was sent. Of the respondents, 77% (n = 382) reported that their job title included the word “navigator,” and 59% were members of ONS. The RDS included 68 task statements, which were evaluated on average importance ratings and the rate at which respondents reported the task to

be specific to ONNs. Analyses revealed 4 critical concepts: access, barriers, care coordination, and communication. Several tasks indicate the ONN serves as the essential point of contact for patients and caregivers across the continuum of cancer care. The role of the ONN is, indeed, evolving and expanding. For example, some of the important tasks of the 2016 RDS, such as addressing psychosocial aspects across cancer care, were not prominent in a 2011 RDS. IMPLICATION FOR NURSES Differences in the role of oncology nurse navigators and that of clinical or staff nurses emerged when some tasks were associated more strongly with nurse navigation. “In the survey, we asked respondents what their main professional development needs were. We received an overwhelming response and found that the majority of needs focused on survivorship issues, new and emerging treatments, financial and insurance issues, and collecting and monitoring metrics and outcome data,” said Lubejko. These results could help outline areas for future expansion in navigation programs. ■ Megan Garlapow is a medical writer based in Tempe, Arizona. REFERENCE 1. Lubejko BG, Bellfield S, Kahn E, et al. Oncology nurse navigation: results of the 2016 Role Delineation Study. Clin J Oncol Nurs. 2016;21(1):A1-A8.

Several tasks indicate the oncology nurse navigator serves as the essential point of contact for patients and caregivers across the continuum of cancer care. 22 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

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FEATURE | Pediatric Oncology

Movement Therapy Can Open Communications With Patients Dr Lori Baudino, a clinical psychologist and dance/movement therapist, talks to ONA about a therapeutic program for children with cancer. TIFFANY GARBUTT, PhD

ypically, childhood is filled with laughter, dance, play, and unfiltered blissful movement. But children who suffer from cancer and childhood diseases have a different experience, one that is filled with hospitals, tests, pain, and restricted movement. Lori Baudino, PsyD, BC-DMT, a licensed clinical psychologist and board certified dance/ movement therapist offers children a way to cope with the psychological and emotional toll that accompanies serious childhood illness such as cancer and returns a small piece of childhood happiness through a unique approach called dance/movement therapy. Dance/movement therapy was introduced into western medicine in the 1940s and is the therapeutic use of movement to further the emotional, cognitive, physical, and social integration of the person.1,2 It is founded on the premise that the mind, body, and spirit are connected and that the body can heal itself through movement. Dance/movement therapy encourages patients to move, fosters body awareness, and allows for the expression of emotions through movement. This has been found to improve mood, body image, and overall quality of life.1 For children, it offers a distraction for that day, an opportunity for laughter and play, and a safe haven to share experiences and concerns.3, 4 Dr Baudino provides dance/movement therapy at Children’s Hospital Los Angeles through the Andrea Rizzo Foundation, a nonprofit

24 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

organization that offers grants to hospitals and schools to provide a qualified dance/movement therapist to children with cancer and childhood illness. Dance/movement therapy does not always include dance. “What I advocate for them to see is that I’m not expecting them to do anything. They are already moving, whether it’s their eyes blinking, their heart rate, their breathing, or their body shifting in their seat. Everything is movement. How they are experiencing their environment is movement,” explained Dr Baudino in an interview with Oncology Nurse Advisor. “What’s so incredible is that when I show them they are already capable of moving and they are moving, there’s so much acceptance, and so much excitement about the control that they have, that they are capable. Then across the board, what’s so magical is they do tend to move more,” continued Dr Baudino as she chuckled in fascination. “Just with that permission, to not have to do something for someone else. So it’s just kind of giving them this understanding that you don’t have to be anything other than what you are.”

Dr Baudino does not use dance/ movement therapy as physical therapy, but rather as psychological or emotional therapy. Indeed, dance movement therapies are tailored to individual patients and can look different each day. Some sessions might just be sitting and doing relaxation exercises; others might include going on a pretend journey where you are moving your body. Others may include looking at specific movements and noticing the location of pain. In each case, the session begins by acknowledging the body, the parts that are moving and the parts that are not moving and helping the patient to link these movements with what he/she might be experiencing physically or emotionally. Dr Baudino does not use dance/movement therapy as physical therapy, but rather as psychological or emotional therapy. Still some physical benefits are observed. “They might change in terms of smiling or feeling more relaxed or their breath changes, where they are more regulated and calm. I’m seeing children being able to increase movement range, where they felt like they can’t move and they seem to be restricted,” explained Dr Baudino. “I’m not moving

them, but they are increasing their range of movement, their flexibility, their strength.” “What I also see, with children especially, is with increased movement comes increased language. That’s that foundation, that building block, where once you have that full range of movement you have this way of feeling regulated and supported. Then you can articulate it, use that executive functioning, and communicate more,” said Dr Baudino. Once that communication is established, Dr Baudino and the patient problem solve-together to discern a plan for coping or handling pain, but ultimately the patient leads the solutions. Dr Baudino, who once tap-danced her grade-school book report, is passionate about dance/movement therapy and about helping her patients. “When there’s a challenge point, it’s just my job to try to find out, like a detective, what process works for the family, what will support them,” Dr Baudino explained. She described a couple of moments she experienced at the hospital prior to our interview. “It’s those moments, where I’m having a child be able to see that they are capable, and there’s this little gleam in their eye, and they say to me, ‘I didn’t know that I could do that. I didn’t know I could move. I didn’t know I had someone that could hear my feelings.’ You know even if a kid can be very angry and upset, that I’m still there when they’re being that way. I’ve had too many incredible sessions.” Dr Baudino also runs a private practice. To find a dance/ movement therapist near you, visit the American Dance Therapy Association Website. ■ Tiffany Garbutt is a medical writer based in Cary, North Carolina. REFERENCES 1. Baudino L. The best way to help your child – introducing dance/ movement therapy [video]. YouTube website. https://www.youtube. com/watch?v=LYH8FZTG338. Published June 5, 2016. Accessed March 9, 2017. 2. What is dance/movement therapy? American Dance Therapy Association Web site. https://adta.org/faqs/. Accessed March 9, 2017. 3. UCLA Health. Dance movement therapy | Mattel Children’s Hospital UCLA [video]. YouTube website. https://www.youtube.com/ watch?v=o3o2ii5rEaI&spfreload=1. Published January 19, 2016. Accessed March 9, 2017. 4. UCLA Health. Dance Movement Therapy at Mattel Children’s Hospital UCLA [video]. YouTube website. https://www.youtube.com/watch? v=O4KkQkv3vKk. Published February 8, 2011. Accessed March 9, 2017.

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 25

FEATURE | Metastatic Melanoma

Kinase Inhibitor-Related Adverse Effects in Metastatic Melanoma Although these 4 KIs effectively treat metastatic melanoma, nurses should be familiar with the management strategies for their potential adverse effects. DEBRA HUGHES, MS

Protein kinase inhibitors are the most studied class of drugs in the search for effective anticancer agents.

mong the 32 orally administered kinase inhibitors approved since 2001, the 4 that were approved between 2011 and 2015 for the treatment of metastatic melanoma — cobimetinib (Cotellic), dabrafenib (Tafinlar), trametinib (Mekinist), and vemurafenib (Zelboraf ) — have had a tremendous impact on patient response and overall survival.1-4 Patients treated with the combination of dabrafenib and trametinib, for example, have a reported response rate of 76%, with an average duration of response of 10.5 months.5 Prior to 2011, no effective treatment options were available for this patient population. Dabrafenib and vemurafenib are BRAF inhibitors, and cobimetinib and trametinib are MEK inhibitors.5 Neither dabrafenib nor vemurafenib are indicated to treat wild-type BRAF melanoma, and trametinib is not indicated to treat patients who have received prior BRAFinhibitor therapy.2-4 This article summarizes the adverse-effect management information included in the prescribing information for each of these 4 oral kinase inhibitors ( Table 1). Concomitant administration of cobimetinib with strong or moderate CYP3A inducers should be avoided, as should strong inhibitors and strong inducers of CYP3A4 or CYP2C8 with dabrafenib and vemurafenib.1,2,4 When administered with dabrafenib, loss of efficacy may result in agents that are sensitive substrates of CYP3A4, CYP2C8, CYP2C9, CYP2C19, or CYP2B6. 2 Vemurafenib can

26 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

increase concentrations of CYP1A2 substrates; those with a narrow therapeutic window should be avoided or, if coadministered, patients should be monitored closely for toxicities and the dose of the CYP1A2 substrate reduced.4 All 4 agents can cause fetal harm; therefore, women of childbearing potential should be advised of the risk to a fetus and to use effective contraception.1-4 Dabrafenib can render hormonal contraceptive ineffective, both during treatment and for 2 weeks after the last dose, requiring a nonhormonal method of contraception.2 Patients taking cobimetinib should continue contraception for 2 weeks following their last dose; for patients taking trametinib, contraception should be continued for 4 months after treatment has stopped.3 Breastfeeding is not recommended while undergoing treatment with any of these agents.1-4 Both male and female patients taking dabrafenib and trametinib may experience impaired fertility.2,3 Increased cell proliferation can occur with BRAF inhibitors; specifically, dabrafenib and vemurafenib may cause tumor promotion in BRAF wild-type melanoma. 2,4 Cobimetinib and trametinib have been linked to new primary malignancies, both cutaneous and noncutaneous; therefore, patients should be monitored for new malignancies before, during, and after treatment, including for up to 6 months after their last dose of cobimetinib.1,3 Patients taking vemurafenib should undergo dermatologic evaluation prior to treatment initiation, every 2 months while on therapy, and for up to 6 months following discontinuation. New primary cutaneous malignancies should be excised without adjusting vemurafenib dose. In addition, patients should be evaluated for symptoms or clinical signs of new noncutaneous squamous cell carcinoma, both before and during treatment with vemurafenib, with close monitoring for other malignancies also advised.4 ADVERSE EFFECTS AND MANAGEMENT

Prescribing information for the 4 kinase inhibitors include warnings and cautions for adverse effects. In this review, we discuss the management recommendations for effects involving these organ systems: cardiovascular, dermatologic, endocrine and metabolic, hematologic, hepatic, ocular, pulmonary, renal. Cardiovascular Cardiomyopathy can occur with cobimetinib, dabrafenib, and trametinib. Risk is increased in those patients treated with cobimetinib and vemurafenib vs vemurafenib alone.1-3 Recommendations suggest evaluating patients for left ventricular ejection fraction (LVEF) before initiating

cobimetinib; repeat the evaluation 1 month after treatment has started and every 3 months thereafter until treatment discontinuation. When restarting cobimetinib after a dose reduction or interruption, evaluate for LVEF at approximately 2, 4, 10, and 16 weeks, and as clinically indicated thereafter.1 Similarly, in patients receiving dabrafenib or trametinib as a single agent or with dabrafenib, assess LVEF via echocardiography or multigated acquisition (MUGA) scan prior to initiating treatment, at 1 month, and every 2 to 3 months thereafter.2,3

In uncomplicated DVT or pulmonary embolism, withhold trametinib for up to 3 weeks. It can be resumed at a lower dose if the patient improves. Dabrafenib should be withheld in cases of symptomatic cardiomyopathy or asymptomatic left ventricular dysfunction of more than 20% from baseline that is below the institutional lower limit of normal (LLN). Treatment may be resumed at the same dose level if the patient’s cardiac function recovers to at least the institutional LLN for LVEF and absolute decrease 10% or less compared to baseline.2 Trametinib should be withheld if absolute LVEF deceases by 10% from pretreatment values and is less than the institutional LLN.3 The agent should be discontinued in patients with symptomatic cardiomyopathy or persistent, asymptomatic left ventricular dysfunction greater than 20% from baseline below LNN that does not resolve within 4 weeks.3 Vemurafenib should not be initiated in patients who have uncorrectable electrolyte abnormalities, QTc greater than 500 ms, or long QT syndrome, or in those taking medicinal products known to prolong the QT interval. ECG and electrolytes (potassium, magnesium, and calcium) should be evaluated for 15 days, monthly during the first 3 months, and then every 3 months thereafter prior to and following treatment initiation or after dose modification for QTc prolongation. If a patient develops grade 3 QTc greater than 500 ms, withhold vemurafenib and permanently discontinue the agent if the QTc interval remains greater than 500 ms and increased more than 60 ms from pretreatment values after controlling for cardiac risk factors for QT prolongation. If a patient recovers to QTc 500 ms or lower at grade 2 or lower, vemurafenib can be restarted at a reduced dose.4 Continued on page 28

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FEATURE | Metastatic Melanoma TABLE 1. Kinase Inhibitors for Melanoma: Indication, Recommended Dose, and Administration1-7 Generic (Trade Name)

Indication

Recommended Dose

Administration

Cobimetinib (Cotellic)

Unresectable or metastatic melanoma with a BRAF V660E or V660K mutation, in combination with vemurafenib

60 mg orally, once daily for the first 21 days of each 28-day cycle until disease progression or unacceptable toxicity

Without or without food

Dabrafenib (Tafinlar)

Single agent: unresectable or metastatic melanoma with BRAF V600E mutation as detected by THxID BRAF assay

1150 mg orally, twice daily

At least 1 hour before or at least 2 hours after a meal

In combination with trametinib: unresectable or metastatic melanoma with BRAF V600E or V600K mutations as detected by an FDA-approved test Trametinib (Mekinist)

Single agent or in combination with dabrafenib: unresectable or metastatic melanoma with BRAF V600E or V600K mutations as detected by THxID BRAF assay

2 mg orally, once daily

At least 1 hour before or at least 2 hours after a meal

Vemurafenib (Zelboraf )

Unresectable or metastatic melanoma with BRAF V600E mutation as detected by cobas 4800 BRAF V600 Mutation Test

960 mg orally, twice daily

Take approximately 12 hours apart, with or without a meal

Dermatologic Cobimetinib is associated with severe rash and other skin reactions. Management recommendations include interrupt, reduce, or discontinue treatment in cases of intolerable grade 2 rash or grade 3, or 4 rash.1 First reduction is 40 mg daily, second reduction is 20 mg daily, and if the patient cannot tolerate the 20-mg dose, then discontinue the drug. Serious skin toxicity can occur with dabrafenib. This agent should be withheld for intolerable or severe skin toxicity. Treatment can resume at the next lower dose level in patients who improve or recover within 3 weeks.2 Patients receiving trametinib should be monitored for skin toxicities and secondary infections. The agent should be withheld for up to 3 weeks in cases of intolerable grade 2 skin toxicity or grade 3 or 4 skin toxicity. Patients who improve or recover within 3 weeks can resume treatment at a reduced dose. However, trametinib should be discontinued if these symptoms do not improve despite the interruption in treatment.3 Treatment with cobimetinib and vemurafenib was found to cause mild to severe photosensitivity. Patients should be advised to avoid sun exposure. They should wear protective clothing and use a broad spectrum UVA/UVB sunscreen and lip balm with SPF 30 or higher when outdoors. Grade 2 or greater photosensitivity with cobimetinib is managed with dose modifications.1 Vemurafenib should be permanently discontinued in cases of severe dermatologic reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis.4

Endocrine and metabolic Therapy with dabrafenib and trametinib can cause hyperglycemia requiring more intensive hypoglycemic therapy. Serum glucose levels in patients with preexisting diabetes or hyperglycemia should be monitored at initiation of treatment with either agent and as clinically appropriate.2,3 Hematologic Risk of hemolytic anemia in patients with a glucose-6-phosphate dehydrogenase deficiency is increased with dabrafenib; therefore, these patients should be monitored closely during treatment.2 Hemorrhage has been reported in patients who received dabrafenib with trametinib. For that reason, dabrafenib should be permanently discontinued for all grade 4 and any persistent grade 3 hemorrhage events. In cases of grade 3 events, withhold then continue treatment at the next lower dose level if improvement is seen.2 In clinical trials, cobimetinib and trametinib were associated with hemorrhagic events, including gastrointestinal and cerebral hemorrhages. If a grade 4 hemorrhagic event occurs or a grade 3 event does not improve, recommendations are to permanently discontinue treatment with both agents. Withhold treatment for grade 3 hemorrhagic events for up to 4 weeks. Treatment can be resumed at the next lower dose levels if grade 3 hemorrhagic event improves.1,3 Deep venous thrombosis (DVT) and pulmonary embolism (PE) have been reported in patients receiving trametinib with dabrafenib. Patients should be advised to seek immediate medical care if they develop any symptoms of DVT or PE: shortness of breath, chest pain, or swelling of an arm or leg.

28 ONCOLOGY NURSE ADVISOR â&#x20AC;˘ MARCH/APRIL 2017 â&#x20AC;˘ www.OncologyNurseAdvisor.com

If pulmonary embolism is life threatening, trametinib should be permanently discontinued. In uncomplicated DVT or PE, withhold the agent for up to 3 weeks. Trametinib can be resumed at a lower dose if the patient improves.3 Hepatic Hepatotoxicity has been reported in patients receiving cobimetinib; therefore, monitor liver function before treatment initiation and monthly during treatment.1 Risk for liver injury leading to functional hepatic impairment, including coagulopathy or other organ dysfunction was noted in clinical trials of vemurafenib. Laboratory tests to monitor transaminases, alkaline phosphatase, and bilirubin should be conducted before initiating treatment and monthly during treatment. If laboratory results indicate grade 3 or 4 adverse events with either cobimetinib or vemurafenib, interrupt treatment for up to 4 weeks. Treatment can be resumed with the next lower dose when results show improvement to grade 0 or 1. If the patient cannot tolerate the lowest dose, discontinue treatment.1,4

Clinicians should assess patients for visual signs and symptoms of uveitis such as a change in vision, photophobia, and eye pain. Ocular Serous retinopathy and retinal vein occlusion (RVO) have occurred with cobimetinib. Ophthalmologic evaluations at regular intervals and when patients report new or worsening visual disturbances are recommended. In patients who develop serous retinopathy, treatment may be interrupted until visual symptoms improve, and further managed with dose reduction or discontinuing treatment. Cobimetinib should be permanently discontinued in patients who develop retinal vein occlusion.1 Uveitis, including iritis and iridocyclitis, has been reported in patients receiving dabrafenib. Clinicians should assess patients for visual signs and symptoms of uveitis such as a change in vision, photophobia, and eye pain. If uveitis develops, administer ocular therapy and continue dabrafenib treatment without dose modification. In cases of severe uveitis or iridocyclitis, interrupt treatment and treat as clinically indicated. For persistent grade 2 or greater uveitis of 6 weeks or longer in duration, permanently discontinue treatment with dabrafenib.2 In clinical trials with trametinib, 4 cases of retinal vein occlusion, which can lead to macular edema, decreased

visual function, neovascularization, and glaucoma, were reported. Trametinib should be discontinued and an ophthalmologic evaluation performed within 24 hours of a patient report of vision loss or other visual disturbances. If retinal vein occlusion is confirmed, permanently discontinue trametinib. This agent has also been linked to retinal pigment epithelial detachment (RPED). If diagnosis of RPED is confirmed, withhold treatment; reduce the dose or discontinue therapy if no improvement is observed after 3 weeks.3 In clinical trials, vemurafenib has been associated with serious ophthalmologic reactions: uveitis (including iritis), blurry vision, and photophobia. Patients should be assessed for signs and symptoms of uveitis. If the condition develops, treat with steroid and mydriatic ophthalmic drops.4 Pulmonary Interstitial lung disease or pneumonitis occurred in 2% of patients treated with trametinib in clinical trials. If these events occur, permanently discontinue trametinib treatment. For patients who present with new or progressive pulmonary symptoms, such as cough, dyspnea, hypoxia, pleural effusion, or infiltrates, withhold trametinib pending investigation.3 Renal Serum creatinine measurements to assess for renal failure, which may include acute interstitial nephritis and acute tubular necrosis, should be obtained before initiating treatment with vemurafenib and periodically during treatment.4 Other Serious hypersensitivity reactions including anaphylaxis and drug reaction with eosinophilia and systemic symptoms (DRESS Syndrome) have been observed in patients taking vemurafenib. Discontinue the agent in patients who experience severe hypersensitivity reactions. Several cases, some severe, of radiation sensitization and radiation recall have also been reported in patients taking vemurafenib. Patients taking this agent concomitantly or sequentially with radiation therapy should be closely monitored.4 In a clinical trial of cobimetinib with vemurafenib, grade 3 or 4 creatinine phosphokinase (CPK) elevations over baseline were observed. Baseline serum CPK and creatinine levels should be obtained prior to initiating cobimetinib treatment, periodically during treatment, and as clinically indicated. If CPK is elevated, evaluate for signs and symptoms of rhabdomyolysis. Dose interruption or discontinuation may be necessary in patients who develop rhabdomyolysis.1 Serious febrile reactions have been reported when trametinib is used with dabrafenib, while the incidence and severity of pyrexia are increased with dabrafenib and trametinib.2,3 Dabrafenib should be withheld for a fever

www.OncologyNurseAdvisor.com â&#x20AC;˘ MARCH/APRIL 2017 â&#x20AC;˘ ONCOLOGY NURSE ADVISOR 29

FEATURE | Metastatic Melanoma of 101.3°F or higher,2 with trametinib withheld for a fever higher than 104°F. Both agents should be withheld for serious febrile reactions or fever accompanied by hypotension, rigors or chills, dehydration, or renal failure.2,3 Signs and symptoms of infection should be evaluated, with serum creatinine and other evidence of renal function monitored during and following severe pyrexia. Dose modifications are required.2,3

REFERENCES 1. Cotellic® [package insert] South San Francisco, CA: Genentech, Inc; 2016. 2. Tafinlar® [package insert] East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2016. 3. Mekinist® [package insert] East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2015. 4. Zelboraf™ [package insert] South San Francisco, CA: Genentech USA, Inc; 2016. 5. Melanoma Treatment (PDQ®) – Health Professional Version. National

CONCLUSION The impact of BRAF inhibitors and MEK inhibitors on patient response and overall survival has been significant. However, treatment with these agents includes risk of serious adverse effects. Nurses need to be alert for signs and symptoms of adverse effects and aware of initial steps in managing these events. In addition, the need to alert their oncology team about potential adverse effects cannot be overstated to patients. ■

Cancer Institute Web site. https://www.cancer.gov/types/skin/hp/ melanoma-treatment-pdq#section/_889. Accessed March 30, 2017. 6. FDA approves two drugs, companion diagnostic test for advanced skin cancer [news release]. Silver Spring, MD: US Food & Drug Administration; May 29, 2013. http://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm354199.htm. Accessed February 13, 2017. 7. FDA approves Zelboraf and companion diagnostic test for latestage skin cancer [news release]. Silver Spring, MD: U.S. Food & Drug Administration; August 17, 2011. http://www.fda.gov/NewsEvents/ Newsroom/PressAnnouncements/ucm268241.htm. Accessed

Debra Hughes is a medical writer based in Lusby, Maryland.

February 13, 2017.

Read Our Series on Kinase Inhibitor Side Effects The above article concludes Oncology Nurse Advisor’s series on managing side effects of treatment with kinase inhibitors. Here is information on the complete series. ▶ Kinase Inhibitors:

▶ A Review of

▶ Kinase Inhibitor-

A review of adverse effects and recommended management for 3 kinase inhibitors indicated for the treatment of gastrointestinal cancers.

Ibrutinib, idelalisib, ponatinib, and ruxolitinib are each associated with a variety of potential adverse effects and oncology nurses must be aware.

Although these 4 KIs effectively treat metastatic melanoma, nurses should be familiar with the management strategies for their potential adverse effects.

• imatinib mesylate (Gleevec) • regorafenib (Stivarga) • sunitinib (Sutent)

• • • •

In print: September/October 2016; pp 26-29

In print: January/February 2017; pp 26-31

In print: March/April 2017; pp 22-26

Online: http://bit.ly/2msYV7W

Online: http://bit.ly/2ndgfMZ

Online: http://bit.ly/2msO25W

Managing Side Effects in GI Cancers

Kinase Inhibitors for Hematologic Cancers

ibrutinib (Imbruvica) idelalisib (Zydelig) ponatinib (Iclusig) ruxolitinib (Jakafi)

Related Adverse Effects in Metastatic Melanoma

30 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

cobimetinib (Cotellic) dabrafenib (Tafinlar) trametinib (Mekinist) vemurafenib (Zelboraf)

You Asked for a Simpler CME Search

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FEATURE | Breast Cancer Survivorship

Artist Offers Novel Approach to Healing After Mastectomy A fine art painter works with breast cancer survivors and their clinical team to create a unique interpretation of the woman’s cancer journey. BETTE WEINSTEIN KAPLAN

urviving breast cancer does not have to mean living with a disfigured body. For some women, it means living with art. A creator of such living art is David Allen, a fine art painter and tattoo artist who transforms the bodies — and the lives — of women who have survived breast cancer. Although women who undergo breast reconstruction after mastectomy may choose to have a nipple tattooed on the reconstructed breast, that is not the type of tattooing, or micro-pigmentation, that Mr Allen prefers. He feels that despite it being a trompe l’oeil image, a clinical tattooed nipple lacks character, fades rather quickly, and bears no relationship to the survivor whose body and mind have been altered by her disease.1 Instead, this artist draws the eye away from the scarring and creates something elegant and beautiful. To do this, he turned to botanical imagery, finding that flowers, leaves, stems, and meandering branches are the most successful method of transforming a breast that has been altered and scarred by surgery. In the 10 years Mr Allen has been working with survivors, he has seen that as they move beyond illness and towards health the women personify the gentle change and growth symbolized by the flowering plants. Since the artist has created more than 140 tattoos of this type, the survivor community clearly embraces his art.

Tattoo transforms mastectomy scars

HANDLING TREATED SKIN Mr Allen tells his clients to wait 1 year after surgery before seeing him to ensure that all scarring

32 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

is thoroughly healed. He says that recently he has even been hearing from women before their operations. His clients often fly in from other countries just for the tattoo, but by the time they arrive he knows them quite well because he has spoken with them often on the phone, hoping to ascertain when they will be psychologically and physically ready. At this point he knows the areas they want the tattoo to cover. The artist may also talk with a woman’s oncologist or plastic surgeon because he is better able to plan his work if he knows details of the surgery and restoration. Often the women bring him images and operative reports.1

“I use pointillism. Just tiny little dots. . . . After what the woman’s skin has been through, I must be more gentle, more thoughtful.” Mr Allen is a painter, and his style of tattooing evokes his art. His work is delicate and feminine. He uses a light hand and mixes the ink with water, as with watercolor. He does not use large bold lines, even though it is the traditional tattoo style and said to last longer; Mr Allen says that technique does not lend itself to cover scarring. “You can trick the eye and do without that. It’s possible to be artistic and also cause minimal trauma. I use pointillism. Just tiny little dots. And it doesn’t affect the skin as much as the traditional tattoo. After what the woman’s skin has been through, I must be more gentle, more thoughtful,” he explains [D Allen, oral communication, February 17, 2017]. The skin’s response tells him how deep he is going. Some skin swells, but skin that has been irradiated barely responds at all. Mr Allen describes the skin as almost as if it is not alive. Because the skin is alive, he could damage it if he works in those areas too long. A tattoo can take from 2 to 5 hours, depending on the size of the breast, the placement, and the size of the tattoo. Because applying the tattoo is often painful, he takes quite a few breaks. Many women did not think they would feel pain

FIND US ON

because they believed nerve endings were destroyed by surgery or radiation. But Mr Allen said that when it hurts he reminds them, “Isn’t it cool that your nerve endings are firing back?” Mr Allen says that the process of having a tattoo like this gives the survivor control. She has gone through a long and arduous process where she has had no control at all. Then she made a life-changing decision to choose his art and take back control. With that mindset, he says, “These survivors just power through it. It’s incredible, they’re so strong.” EMPATHY IS ESSENTIAL He says that to do his work successfully he must have empathy: he must listen and be present, even though that can sometimes be difficult. Mr Allen notes that the women he works with trust him more when they know that he is present. He pays attention to nonverbal gestures, and says that sometimes their “Yes” may actually mean “No.” The result, he explains, is that he helps beautify an area that has been ravaged by something that tried to kill them. The outcome is an interesting and heartening one. Prior to getting their tattoos, these cancer survivors were used to baring their breasts because they had done it so many times in so many clinical situations. But after these tattoos are finished they cover themselves. Mr Allen says, “They get their bodies back, and they get to reclaim that. I just think it’s cool to offer a semblance of hope in a different and unconventional form — a form that exists at the intersection of art and medicine. These women know that someone has taken the time to do this with them and create a piece of art that is theirs. It is an intimate process that is done for just that person. For me it’s very humbling, because my art is a tattoo and tattoos are always degrading. My art walks away from me, and I usually never see it again. And that’s as it should be.” ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Allen D. Moving the needle on recovery from breast cancer: the healing role of postmastectomy tattoos. JAMA. 2017;317(7):672-674. doi:10.1001/ jama.2017.0474

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www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 33

STAT CONSULT Vandetanib (Caprelsa) Drug Type

• Kinase inhibitor

Indications

• Symptomatic or progressive medullary thyroid cancer in patients with unresectable locally advanced or metastatic disease • Use of vandetanib in patients with indolent, asymptomatic, or slowly progressing disease only after careful consideration of treatment-related risks of vandetanib Mechanism of Action

• In vitro ——Vandetanib inhibited epidermal growth factor (EGF)stimulated receptor tyrosine kinase phosphorylation in tumor cells and endothelial cells and VEGF-stimulated tyrosine kinase phosphorylation in endothelial cells • In vivo ——Vandetanib administration reduced tumor cell-induced angiogenesis, tumor vessel permeability, and inhibited tumor growth and metastasis in mouse models of cancer Dosage and Administration

• 300 mg once daily • Administer orally with or without food • Continue treatment until disease progression or unacceptable toxicity • Do not crush tablets • Tablets can be dispersed in 2 ounces of water by stirring for approximately 10 minutes (will not completely dissolve) • Do not use other liquids for dispersion • Swallow immediately after dispersion • Mix any remaining residue with 4 additional ounces of water and swallow

• Dispersion can be administered through nasogastric or gastrostomy tubes Dose Adjustments

• 300 mg daily dose can be reduced to 200 mg (two 100 mg tablets) and then to 100 mg for grade 3 or greater toxicities • Interrupt vandetanib for the following ——Corrected QT interval >500 milliseconds ■■ Resume at reduced dose when QT interval returns to <450 milliseconds ——Grade 3 or greater toxicity ■■ Resume at reduced dose when toxicity resolves to improves to grade 1 • Recurrent toxicities ——Reduce vandetanib dose to 100 mg after resolution or improvement to grade 1 severity, if continued treatment is warranted • Patients with renal impairment ——Reduce the starting dose to 200 mg in patients with moderate (creatinine clearance [CrCl] ≥30 to <50 mL/ min) and severe (CrCl <30 mL/min) renal impairment Specific Populations

• Pregnancy ——Pregnancy Category D ——May cause fetal harm; advise pregnant women of potential risk to a fetus • Nursing mothers ——Decision should be made whether to discontinue nursing or to discontinue vandetanib, taking into account importance to mother

34 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

• Females and males of reproductive potential ——Females of reproductive potential should avoid pregnancy ——Use effective contraception during treatment and for up to 4 months after last dose • Pediatric ——Not established • Geriatric ——Unclear whether older patients respond differently compared to younger patients • Renal impairment ——Vandetanib exposure is increased in patients with impaired renal function. ——Reduce the starting dose to 200 mg in patients with moderate (CrCl ≥30 to <50 mL/min) or severe (CrCl <30 mL/min) renal impairment • Hepatic impairment ——Not recommended in patients with moderate or severe hepatic impairment Boxed Warnings

• Vandetanib can prolong the QT interval, and torsades de pointes and sudden death have occurred in vandetanib recipients • Do not use vandetanib in patients with hypocalcemia, hypokalemia, hypomagnesemia, or long QT syndrome • Correct hypocalcemia, hypokalemia, and/or hypomagnesemia prior to vandetanib administration • Monitor electrolytes periodically • Avoid drugs known to prolong the QT interval • Only prescribers and pharmacies certified with the restricted distribution program are able to prescribe and dispense vandetanib

——Investigate unexplained nonspecific respiratory signs and symptoms ——Discontinue vandetanib for confirmed ILD • Ischemic cerebrovascular events, hemorrhage, heart failure, diarrhea, hypertension, and reversible posterior leukoencephalopathy syndrome ——Discontinue or interrupt vandetanib • Prolonged QT interval, torsades de pointes, and sudden death ——Monitor electrocardiograms and levels of serum potassium, calcium, magnesium and TSH ——Reduce vandetanib dose as appropriate • REMS program ——Vandetanib is available only through a restricted distribution program called the CAPRELSA REMS Program • Skin reactions ——Severe and fatal skin reactions, including toxic epidermal necrolysis and Stevens-Johnson syndrome, have occurred in patients treated with vandetanib ——Discontinue vandetanib for severe skin reactions Adverse Effects

• Most common adverse reactions are ——Abdominal pain ——Acneiform dermatitis ——Decreased appetite ——Diarrhea/colitis ——Headache ——Hypertension ——Nausea ——Rash ——Upper respiratory tract infections

Contraindications

Drug Interactions

• Do not use in patients with congenital long QT syndrome

• Avoid administration of vandetanib with anti-arrhythmic drugs ——eg, amiodarone, disopyramide, dofetilide, procainamide, sotalol • Avoid administration of vandetanib with drugs that may prolong QT interval ——eg, chloroquine, clarithromycin, dolasetron, granisetron, haloperidol, methadone, moxifloxacin, pimozide • Avoid concomitant use of known strong CYP3A4 inducers during vandetanib therapy • Avoid concomitant use of St John’s wort because it can decrease vandetanib exposure unpredictably

Cautions

• Embryofetal toxicity ——Vandetanib can cause fetal harm ——Advise women of potential risk to a fetus and to avoid pregnancy during and for 4 months following treatment with vandetanib • Interstitial lung disease ——Interstitial lung disease (ILD), including fatal cases, have occurred in vandetanib-treated patients

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 35

STAT CONSULT

• Use caution and closely monitor for toxicities when administering vandetanib with drugs that are transported by the organic cation transporter type 2 (OCT2) ——eg, amiloride, cimetidine, famotidine, metformin, oxaliplatin, pindolol, ranitidine, trimethoprim • Use caution and closely monitor for toxicities when administering vandetanib with digoxin What to Tell Your Patient

• Vandetanib is an anticancer medicine used to treat a certain type of thyroid cancer • Vandetanib can cause a change in the electrical activity of your heart called QT prolongation, which can cause irregular heartbeats that may lead to death • You should not take vandetanib if you have had a condition called long QT syndrome since birth • Your clinician should perform tests to check your blood levels of potassium, calcium, magnesium, and a thyroid hormone as well as electrical activity of your heart • Before receiving vandetanib, tell your clinician if you ——Have any heart problems, including a condition called congenital long QT syndrome ——Have an irregular heartbeat ——Take or have stopped taking a medicine that causes QT prolongation ——Have low blood levels of potassium, calcium, or magnesium ——Have high blood levels of thyroid-stimulating hormone ——Have high blood pressure ——Have skin problems ——Have a history of breathing problems ——Have a recent history of coughing up blood or bleeding ——Have diarrhea ——Have liver problems ——Have kidney problems ——Have seizures or are being treated for seizures ——Are pregnant or plan to become pregnant ——Are breastfeeding or plan to breastfeed • Vandetanib and certain other medicines can interact with each other and cause serious side effects • Tell your clinician about all medications you take, including over-the-counter medications and vitamins, especially if you take ——St John’s wort, medications for your heart, medicines that affect how your liver breaks down drugs • Take vandetanib exactly as your clinician tells you • Take vandetanib with or without food • Swallow tablets whole with water

• Do not crush or chew tablets • Vandetanib may cause serious side effects including ——Bleeding ——Breathing problems ——Heart failure ——High blood pressure ——Neurologic condition called reversible posterior leukoencephalopathy syndrome ——Serious skin reactions ——Stroke ——Thyroid hormones • Treatment with vandetanib poses a potential risk to a fetus ——If you are able to become pregnant, use effective contraception during treatment with vandetanib and for 4 months after last dose ——Inform your clinician of a known or suspected pregnancy • Whether vandetanib is transmitted through breastmilk to baby is unclear ——Consider discontinuing breastfeeding during treatment with vandetanib • Limit exposure to the sun ——Vandetanib can make your skin sensitive to the sun ——Use sun block and wear clothes that cover your skin, including your head, arms, and legs when you go outdoors while taking vandetanib and for 4 months after stopping your vandetanib treatment • Use caution before driving or using machinery ——Keep in mind vandetanib may make you feel tired, weak, or cause blurred vision • Vandetanib may cause ——Acne ——Diarrhea ——Feeling tired ——Headache ——High blood pressure ——Loss of appetite ——Nausea ——Rash ——Stomach (abdominal) pain ——Upper respiratory tract infections • Tell your clinician if you have any side effect that bothers you or that does not go away • Your body takes a long time to get rid of vandetanib, and you may be at risk for side effects after you have stopped your treatment. ■ Prepared by Jason Hoffman, PharmD, RPh.

36 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

STAT CONSULT Sorafenib (Nexavar) Drug Type

• Kinase inhibitor

Indications

• Unresectable hepatocellular carcinoma (HCC) • Advanced renal cell carcinoma (RCC) • Locally recurrent or metastatic, progressive, differentiated thyroid carcinoma (DTC) refractory to radioactive iodine treatment Mechanism of Action

• Sorafenib is a kinase inhibitor that decreases tumor cell proliferation in vitro • Sorafenib inhibits multiple intracellular (c-CRAF, BRAF, and mutant BRAF) and cell surface kinases (KIT, FLT- 3, RET, RET/PTC, VEGFR-1, VEGFR- 2, VEGFR- 3, and PDGFR-b[art: this needs to be lower case beta]) • Sorafenib reduced tumor angiogenesis in models of HCC and RCC, and increased tumor apoptosis in models of HCC, RCC, and DTC Dosage and Administration

• 400 mg twice daily • Administer orally without food • Continue treatment until disease progression or unacceptable toxicity Dose Adjustments

• Temporary interruption of sorafenib is recommend in patients undergoing major surgical procedures • Temporary interruption or permanent discontinuation may be required for ——Cardiac ischemia or infarction ——Hemorrhage requiring medical intervention

——Severe or persistent hypertension despite adequate antihypertensive therapy ——Gastrointestinal perforation ——QTc prolongation ——Severe drug-induced liver injury • Hepatocellular carcinoma and renal cell carcinoma ——When dose reduction is necessary, sorafenib dose may be reduced to 400 mg once daily ——If additional dose reduction is required, sorafenib may be reduced to a single 400 mg dose every other day • Differentiated thyroid carcinoma ——When dose reduction is necessary, sorafenib dose may be changed to 400 mg dose and 200 mg dose taken 12 hours apart ——If second dose reduction is required, sorafenib dose may be reduced to 200 mg twice daily ——If third dose reduction is required, sorafenib dose may be reduced to 200 mg once daily Specific Populations

• Pregnancy ——Pregnancy Category D ——May cause fetal harm ——Advise pregnant women of potential risk to a fetus • Nursing mothers ——Decision should be made whether to discontinue nursing or to discontinue sorafenib, taking into account importance to mother • Females and males of reproductive potential ——Use effective contraception during treatment and for at least 2 weeks after final dose

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 37

STAT CONSULT

• Pediatric ——Not established • Geriatric ——No overall differences in safety or efficacy observed between older and younger patients • Renal impairment ——No dose adjustment necessary for patients with mild, moderate, or severe renal impairment who are not on dialysis • Hepatic impairment ■■ No dose adjustment necessary for patients with mild or moderate hepatic impairment ■■ The pharmacokinetics of sorafenib have not been studied in patients with severe impairment Boxed Warnings

• None Contraindications

• Patients with known severe hypersensitivity to sorafenib or any other component of sorafenib • Sorafenib in combination with carboplatin and paclitaxel in patients with squamous cell lung cancer Cautions

• Bleeding ——Discontinue sorafenib if needed • Cardiac ischemia and/or infarction ——Consider temporary or permanent discontinuation of sorafenib • Dermatologic toxicities ——Interrupt and/or decrease dose ——Discontinue for severe or persistent reactions, or if Stevens-Johnson syndrome and toxic epidermal necrolysis are suspected • Drug-induced hepatitis ——Monitor liver function tests regularly ——Discontinue sorafenib for unexplained transaminase elevations • Embryofetal toxicity ——Advise women of potential risk to fetus and to avoid becoming pregnant • Gastrointestinal perforation ——Discontinue sorafenib • Hypertension ——Monitor blood pressure weekly during first 6 weeks of therapy and periodically thereafter • Impairment of TSH suppression in DTC

——Monitor TSH monthly ——Adjust thyroid replacement therapy in patients with thyroid cancer • QT prolongation ——Monitor electrocardiograms and electrolytes in patients at increased risk for ventricular arrhythmias Adverse Effects

• Most common adverse reactions are ——Alopecia ——Decreased appetite ——Diarrhea ——Fatigue ——GI and abdominal pain ——Hand-foot skin reaction ——Hemorrhage ——Hypertension ——Infection ——Rash ——Nausea ——Weight loss Drug Interactions

• Effect of strong CYP3A4 inducers on sorafenib ——Avoid concomitant use of strong CYP3A4 inducers when possible, as these drugs can decrease systemic exposure to sorafenib ■■ Examples of strong CYP3A4 inducers include: carbamazepine, dexamethasone, phenobarbital, phenytoin, rifampin, rifabutin, St John’s wort What to Tell Your Patient

• Sorafenib is an anticancer medicine used to treat a certain type of liver, kidney, or thyroid cancer • Do not take sorafenib if you are allergic to sorafenib or any of the other ingredients • Sorafenib is not for use with carboplatin and paclitaxel in squamous cell lung cancer • Before receiving sorafenib, tell your clinician if you ——Have allergies ——Have chest pain or heart problems, including a problem called congenital long QT syndrome ——Have bleeding problems ——Have high blood pressure ——Plan to have any surgical procedures ——Have lung cancer or are being treated for lung cancer ——Have kidney or liver problems in addition to kidney or liver cancer

38 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

——Are pregnant or plan to become pregnant ——Are breastfeeding or plan to breastfeed • Sorafenib and certain other medicines can interact with each other and cause serious side effects • Tell your clinician about all medications you take, including over-the-counter medications and vitamins, especially ——Carbamazepine, dexamethasone, neomycin, phenobarbital, phenytoin, rifampin, rifabutin, or warfarin • Take sorafenib exactly as your clinician tells you • Take sorafenib without food at least 1 hour before or 2 hours after a meal • If you miss a dose, skip missed dose, and take next dose at its regular time • Sorafenib may cause serious side effects including ——Decreased blood flow to heart and heart attack ——Bleeding problems ——High blood pressure ——A skin problem called hand-foot skin reaction ——Serious skin and mouth reactions ——An opening in wall of stomach or intestines ——Possible wound healing problems ——Changes in electrical activity of heart ——Liver inflammation ——Change in thyroid hormone levels • Treatment with sorafenib poses a potential risk to a fetus

——If you are able to become pregnant, use effective contraception during treatment with sorafenib and for 2 weeks after last dose ——Inform your clinician of a known or suspected pregnancy • Whether sorafenib is transmitted through breastmilk to baby is not clear ——Consider discontinuing breastfeeding during treatment with sorafenib • Sorafenib may cause ——Diarrhea ——Hair thinning or patchy hair loss ——Infection ——Loss of appetite ——Low blood calcium levels in people with thyroid cancer ——Rash ——Stomach (abdominal) pain ——Tiredness ——Nausea ——Weight loss • Tell your clinician if you have any side effect that bothers you or that does not go away • Store sorafenib tablets at room temperature in a dry place. ■ Prepared by Jason Hoffman, PharmD, RPh.

Kinase Inhibitors featured in Stat Consult Slideshows on OncologyNurseAdvisor.com Generic (Trade Name)

Indication

Quick Link

Bosutinib (Bosulif )

Chronic, accelerated, or blast phase Philadelphia chromosome (Ph)-positive chronic myeloid leukemia (CML) with resistance or intolerance to prior therapy

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Cabozantinib (Cabometyx)

Advanced renal cell carcinoma (RCC) with prior anti-angiogenic therapy

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Cobimetinib (Cotellic)

Unresectable or metastatic melanoma with a BRAF V600E or V600K mutation, in combination with vemurafenib

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Crizotinib (Xalkori)

ALK-positive and ROS1-positive metastatic non-small cell lung cancer (NSCLC)

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Imatinib (Gleevec)

Philadelphia chromosome positive chronic myeloid leukemia and relapsed Philadelphia chromosome positive acute lymphoblastic leukemia in adults

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Lenvatinib (Lenvima)

Locally recurrent or metastatic, progressive radioactive iodine-refractory differentiated thyroid cancer or advanced renal cell carcinoma following 1 prior anti-angiogenic therapy

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Regorafenib (Stivarga)

Metastatic colorectal cancer (CRC) or metastatic gastrointestinal stromal tumor (GIST)

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Ruxolitinib (Jakafi)

Intermediate or high-risk myelofibrosis, including primary myelofibrosis, post polycythemia vera myelofibrosis and post essential thrombocythemia myelofibrosis. .

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Vemurafenib (Zelboraf )

Unresectable or metastatic melanoma with BRAF V600E mutation

bit.ly/2odoK8H

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 39

©THINKSTOCK

RADIATION & YOUR PATIENT

Novel Model Personalizes Radiation to Cell Genotype Bryant Furlow Despite important technological innovations to allow more accurate and precise targeting for external-beam radiotherapy, such as intensity modulated radiation therapy (IMRT), and better consideration of patient and tumor characteristics, radiation oncology still has not yet developed tools analogous to HER2/neu testing to identify breast tumors that might respond to the targeted agent trastuzumab (Herceptin).1 But that might be changing.

ost cancer patients undergo radiation therapy but efforts to personalize radiation oncology have lagged behind advances in other treatment modalities, such as anticancer agents that target specific tumor mutation-affected gene pathways.

Intensity modulated radiation therapy and other beam targeting technologies, and advances in planning algorithms and imaging, represent important advances in more precisely delivering radiation to tumors while sparing healthy nontarget tissues.1 These advances are expected to improve tumor responses and reduce patient toxicity risks. But the therapeutic ratio could be improved further still if molecular tools were available for predicting patient and tumor radiosensitivities.1-4 Knowing tissue radiosensitivities in the target volume and candidate beam pathways would allow treatment planning that is better tailored to a particular patient’s biology and tumor biology. Tumor and nontumor cell genotypes can influence responses to radiation, affecting tumorcontrol efficacy and radiotoxicities. Predicting intrinsic radiosensitivities has therefore been called the Holy Grail of radiobiology.2 “Despite its common use in cancer treatment, radiotherapy has not yet entered the era of precision medicine, and there have been no approaches to adjust dose based on biological differences between or within tumors,”wrote Javier F. Torres-Roca, MD, of the Moffitt Cancer Center and Research Institute, Tampa, Florida.3 That partly reflects scarce funding; less than 2% of federal health research money goes to radiation oncology.1 But Torres-Roca and colleagues’ findings suggest a new path toward part of radiation therapy’s Holy Grail: predicting tumor radiosensitivity.3 The team developed a clinical genomic-adjusted radiation dose (GARD) model for individualizing radiotherapy based on their previously developed gene-expression radiosensitivity index.1,3 The clinically validated radiosensitivity index score is based

40 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

on expression of 10 tumor genes: AR, c-Jun, STAT1, PKC-β, RelA, cABL, SUMO1, PAK2, HDAC1, and IRF1.1,3 The radiosensitivity index was validated for patients with breast, esophageal, head and neck, and rectal tumors.1,3 Using 8271 tumor samples, the researchers calculated GARD using radiosensitivity index scores and a statistical-extrapolation model to predict radiotherapeutic effect on tumors at 20 disease sites.3 They then tested GARD associations with 538 radiotherapy patients’ outcomes using 5 clinical cohorts (the Erasmus Breast Cancer Cohort, The Cancer Genome Atlas Glioblast-oma Patient Cohort, the Karolinska Breast Cancer Cohort, Moffitt Lung Cancer Cohort, Moffitt Pancreas Cancer Cohort).3

The team developed a GARD model for individualizing radiotherapy. “GARD independently predicted clinical outcome in breast cancer, lung cancer, glioblastoma, and pancreatic cancer,” the Torres-Roca team reported.3 For example, for the Erasmus Breast Cancer Cohort, high GARD scores were associated with significantly longer 5-year distant-metastasis–free survival times (hazard ratio [HR] 2.11; 95% CI, 1.13-3.94; P =.018).3 Among patients with head and neck cancer, median GARD scores were higher in those with oropharyngeal tumors than other tumors (GARD 39.71 vs. 32.56; P =.042).3 That was consistent with better radiation therapy outcomes for patients with oropharyngeal cancer.3 Continued on page 42

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RADIATION & YOUR PATIENT

“Precision medicine encompasses all therapeutic applications for patient care,” they noted.3 “With multidisciplinary care becoming standard for most patients with cancer, it is crucial that precision medicine is expanded beyond medical oncology. GARD potentially provides a clinically actionable framework that could allow the integration of biological differences into radiotherapy dose.” GARD is the first tool that could allow radiation therapy planning to “depart from the uniform application of radiotherapy.”3 The authors called for genomically guided clinical trials of radiation therapy. “Their results show that GARD is superior to radiosensitivity index alone in predicting the radiotherapy effect of a given dose,” noted Philip Poortmans,

MD, of the Radboud University Medical Center, Nijmegen, the Netherlands, and coauthors, in a companion essay published alongside the paper from Torres-Roca’s team.1 But GARD is not yet ready for broad clinical use, and intratumor genetic heterogeneity might pose a challenge, Poortmans’ team warned.1 “We should be cautious not to generalize the current findings, especially in cases of unconventional radiotherapy (ie, hypofractionation, ablative radiotherapy, intraoperative radiotherapy, and particle therapy),” they wrote.1 Even if GARD does see adoption in clinical radiation therapy, real individualization of radiation oncology will still require consideration of clinical and pathological variables.1 ■

Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Poortmans P, Kaidar-Person O, Span P. Radiation oncology enters the era of individualised medicine. Lancet Oncol. 2017;18(2):159-160. doi: 10.1016/S1470-2045(16)30660-X 2. Andreassen CN. Searching for genetic determinants of normal tissue radio-sensitivity—are we on the right track? Radiother Oncol. 2010;97(1):1-8. 3. Scott JG, Berglund A, Schell MJ, et al. A genome-based model for adjusting radiotherapy dose (GARD): a retrospective, cohort-based study. Lancet Oncol. 2017;18(2):202-211. doi: 10.1016/S1470-2045(16)30648-9 4. Eschrich S, Zhang H, Zhao H, et al. Systems biology modeling of the radiation sensitivity network: a biomarker discovery platform. Int J Radiat Oncol Biol Phys. 2009;75(2):597-505.

Validating Genomic-Adjusted Radiation Dose (GARD) Scoring GARD scoring, a combination of the linear-quadratic (LQ) model and the gene-expression based radiosensitivity index (RSI), was validated using data from these 5 clinical cohorts. Higher GARD scores correlated with greater likelihood of clinically relevant response to radiation therapy.1,2 Cohort

Number of Samples

Treatment

GARD scores

Radiation Dose

End Point

Multivariable analysis

Erasmus Breast Cancer Cohort

263

Lumpectomy plus whole-breast radiotherapy with or without boost to the tumour cavity for T1-T3 N0 tumors

4.01-104.25

40-74 Gy 1.8-2 Gy/fraction

Distantmetastasisfree survival

HR 2.11 95% CI 1.1-3.9 P =.018

Karolinska Breast Cancer Cohort

Segmentectomy or mastectomy plus radiotherapy for T1-T3 N0-N1 tumors

8-60

50 Gy 25 fractions

Relapse-free survival

HR 7.4 95% CI 1.4-138 P =.014

Moffitt Lung Cancer Cohort

Surgical resection and postoperative radiotherapy for AMJCC version 6 stage IIIA or IIIB NSCLC

15-125

43.2-70 Gy

Local control

HR 3.4 95% CI 1.3-9.1 P =.016

Moffitt Pancreas Cancer Cohort

Surgical resection Radiotherapy with concurrent fluorouracil or gemcitabine

0.4-46.0

43.2-54 Gy 180 to 200 cGy/daily for 24-30 fractions

Overall survival

HR 1.9 95% CI 1.1-3.3 P =.019

TCGA Glioblastoma Cohort

Radiotherapy and concurrent temozolomide

16-40

Overall survival

HR 2.6 95% CI 1.1-6.0 P =.029

Key: AMJCC, American Joint Committee on Cancer; CI, confidence interval; HR, hazard ratio; NSCLC, non-small cell lung cancer; TCGA, The Cancer Genome Atlas. REFERENCES 1. Radiation oncology gets a dose of precision medicine [Consult QD – Cancer]. Cleveland Clinic website. https://consultqd.clevelandclinic.org/2017/02/radiation-oncology-gets-doseprecision-medicine/. February 14, 2017. Accessed March 29, 2017. 2. Poortmans P, Kaidar-Person O, Span. Radiation oncology enters the era of individualised medicine. Lancet Oncol. 2017;18(2):159-160.

42 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

Transference of Suffering Ann J. Brady, MSN, RN-BC

“I’m okay.” She shrugged. “But it sucks.” “Yeah, it does.”

A challenging patient case illustrates how caring for each other enables oncology nurses to provide better patient care.

watched Yvonne slump over the computer. Her fingers slowly clicked the keyboard as she entered data. At nearly 6:00 pm, her poor posture possibly only signaled that she was tired at the end of a long shift. But I knew she was taking care of a sweet young patient, Kerry, who was taking a long time to die. I was pretty certain the slouch in Yvonne’s shoulders were the result of emotional exhaustion. Compassion fatigue. It certainly met the criteria, yet the subtext to that description was tied to her suffering. With Kerry, more than with other patients or with all of our patients combined, the stress came from the sheer unfairness of the situation. How much suffering did one person have to endure? “How are you doing?” I asked. Yvonne looked up from the computer, and I nodded toward Kerry’s door. In the instant she registered that my question was about how she was handling a difficult situation, tears pooled in her eyes.

CASE Kerry’s care was hard on everyone involved, but perhaps hardest on the bedside nurses. One of her other nurses explained by saying, “the hardest part is not being able to connect with her.” Collectively the nurses on the unit decided to rotate their patient assignments. Too many days in a row was emotionally taxing. Yet needing to rotate carried its own burden and the nurses questioned their actions: Were we bad nurses if we requested a break? Did we need to hide our sadness from our coworkers? How can we decide to alternate assignments when Kerry had no choices in her care or her disease progression? “Kerry” was not her real name. It was the Americanized version. She fell in love and married a young American man traveling in her country. Their love was strong enough for her to leave her family and home and come to a country where she knew no one but her husband, where she did not know the language or culture. And then she got sick, really sick. A rare and aggressive cancer took residency in her body and refused to be stopped by surgery or chemotherapy. Kerry was too weak for more treatment but her care was too complicated for discharge. Managing her pain and nausea were a daily challenge. She suffered and suffered while we tried and tried. Some days were better than others. As soon as we thought we’d made a breakthrough at managing her symptoms, a bad day would march through and it was like starting from scratch. Kerry’s response was to withdraw from the overwhelming

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 43

COMMUNICATION CHALLENGES

The best we could do was to acknowledge the difficulty and to support each other as we cared for Kerry.

situation. So many caregivers were in and out of her room that she turned her head and closed her eyes when you entered. Through it all her husband stayed at the bedside, essentially moving in to the hospital. Her sweetness was revealed through his fidelity to her. He held her hand, whispered questions to her and relayed the answers to whose ever turn it was to care for her. It was beautiful yet unnerving at the same time. He suffered too, yet demanded little from us. He asked for refills of water or help turning her when it was convenient for staff: “I don’t want to bother you guys. I know how busy everyone is.” Yvonne wasn’t the only one to cry while providing care. A simple mention of Kerry’s room number was enough to prompt a sigh and a head shake from RNs, PCAs, PTs, and RTs — often accompanied by tears. We wanted to do something! We wanted to fix her or at the very least make her comfortable. We wanted to feel we had done something to improve her situation. We wanted to care for her and feel the small reward of having made a difference. But that goal proved elusive. The rapid progression of disease coupled with a language barrier, with her emotional withdrawal, and with the complicated nature of her care, left all of us feeling powerless. The sense of powerlessness added to the suffering of the staff. It was what made us tear up. DISCUSSION We knew the trajectory of her illness, which carried its own burden, yet had to maintain the face of hope even though we knew her situation was hopeless. Our unwillingness to project that knowledge onto her husband trapped us in a lie of omission. We witnessed his hope rise: there was a new chemo to try! And then fall: her scans showed progression of disease. What we went through is a classic example of compassion fatigue. Yet there was little fatigue involved; instead it was laced with the sheer power of feeling powerless, and

hopeless, a sense of foreboding, and a constancy of suffering none of us could make sense of. “She is so young.” “It’s so unfair.” “This is the worst thing I’ve ever seen.” And “Can’t we do something?” Try as we might it felt like nothing we did was helpful. We couldn’t change the outcome we knew was approaching. Was there something we could do for Kerry? There was no answer to that question. But it prompted another question: What could we do for ourselves? Kerry taught us many things. The learning curve was steep. There were missteps. Most of what I personally learned was from the things we could have done better for each other. Because the situation was so extreme, we had to separate from it in order to take care of ourselves. Some of what we did was organic and natural. We reached out to each other. The charge nurse and manager made sure to check in with whoever was taking care of Kerry that day. But we also needed someone from outside the fold. The chaplain made regular visits. The social worker from palliative care and the rest of that team made an effort to explain any changes that were made to medications. The focus of this column is communication challenges. But this case was one where there was not a clear way of addressing those challenges. We knew we were overwhelmed. The best we could do was to acknowledge the difficulty and to support each other as we cared for Kerry. Kerry’s death was not a surprise yet it sent shock waves. We all wanted to know what those last moments were like. Who was with her? Her family was there. Was she comfortable and peaceful? Yes, she was. Now that she is gone the challenge is to address our grief, to avoid burying it or diminishing its impact. The challenge is to keep communicating. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

44 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP

Cancer Support Organization Rocks Age-Appropriate Cancer Care Centers for AYA Patients Bette Weinstein Kaplan

his is a difficult place to be: negotiating through the years between childhood and adulthood, wanting to simultaneously assert your evolving identity and fit in among your peers. Who thought cancer could even work its way into that troubled space? But it certainly can, and when it does the disease brings along many special considerations for the adolescent with cancer. According to the National Cancer Institute (NCI), approximately 70,000 young people ages 15 to 39 years receive a diagnosis of cancer annually in the United States, comprising approximately 5% of all cancer diagnoses in the country.1 The prevalence of different types of cancer varies by age among this population. For example, leukemia, lymphoma, testicular cancer (germ cell tumors), and thyroid cancer are most common among people 15 to 24 years old, and breast cancer and melanoma increasingly afflict young adults ages 25 to 39 years.1 Even given the large number of adolescents and young adults who develop cancer, a malignancy is usually not the first thing a doctor thinks of when a patient of this age presents with symptoms. As a result, diagnoses and subsequent treatment may be delayed while physicians rule out more common and recognizable diseases. Patient care may suffer. Because these patients are

neither children nor adults, even after the initiation of a treatment protocol, continuity of care might be lacking. Clinical trials are also a difficult area for patients in this age group. Even if they qualify for clinical trials based on research criteria, adolescent participants rarely meet the age criteria.

The physical areas are specialized units designed to appeal to teens. SUPPORT FOR YOUNG PATIENTS Fortunately, there is an organization that helps teens and young adults with cancer make their lives better and more normal: Teen Cancer America (TCA). The nonprofit organization boasts 2 notable founders: Roger Daltrey and Pete Townshend of the lengendary British rock band The Who. Since its formation in 1964, The Who has not lost its popularity; its music is still relevant today. Roger Daltrey and Pete Townshend became involved with teen cancer awareness in 1990 as honorary patrons of the Teenage Cancer Trust in the United Kingdom. The Teenage Cancer Trust provides inpatient and outpatient services for

young people ages 13 to 24 years who are coping with cancer. The trust is responsible for the design and creation of 28 specialized patient units in National Health Service hospitals. Their goal is to ensure that physicians, nurses, and other staff who specialize in treating young patients with cancer do so in a familiar and friendly environment. Following the successful formula of the Teenage Cancer Trust, Teen Cancer America was developed in cooperation with more than 50 hospital partners established or pending throughout the United States. Daltrey and Townshend, along with Robert Plant, of the rock band Led Zeppelin, are sponsors of the programs located at some of the United States’ most prestigious medical institutions ( Table 1). Teen Cancer America works with oncology care teams to create environments — physical, psychological, and medical — for patients who are neither children nor adults. Even in the finest cancer institutions, these young patients deserve their own treatment in their own space. The physical areas are specialized units designed to appeal to teens. The units are centered around a teen lounge, supplied with computers, games, and guitars and other musicrelated equipment, and equipped with comfortable, colorful furniture that invites young patients to hang out and socialize. Meeting other people their

www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 45

ISSUES IN CANCER SURVIVORSHIP age is an important part of the TCA experience, and the lounge is a good place to do it. Patients say it is perfect for hanging out and feeling normal. Part of feeling normal is listening to music like any other teenager, and this is a hospital space where that is encouraged. No nurse is going to come running in to hush up the listener. RAISING AWARENESS AND FUNDS As befitting a charitable organization founded by giants of the music industry, music has an important role in fundraising events for Teen Cancer America. The Who regularly performs benefit concerts. An ongoing online auction of rock memorabilia offers fan collectibles such as an original 1968 concert poster and an original 1968 “The Who Sells Out” tour program signed by band members, and drumsticks used by Ringo Starr’s son, drummer Zak Starkey. Collectors might be interested in bidding on contemporary guitar picks custom designed for The Who, or guitar strings used by Pete Townshend on tour (and returned to their original package). Sports celebrities also play a role in raising funds for Teen Cancer America. Currently a TCA ambassador, former basketball star Nolan Smith is running

a Twitter and text fundraising campaign for TCA:

TABLE 1. Centers With Teen Cancer America–Sponsored Programs Children’s Hospital of Philadelphia (CHOP)

• Every team needs a strategy. Join #TeamNolan and @TeenCancerUSA to provide specialized #TREATMENT for teens who could use a hand!! • Text NOLAN to 20222 and $5 will go to support teens with cancer.2

Dana-Farber Cancer Institute Fort Worth AYA Oncology Coalition Memorial Sloan Kettering Cancer Center Moffitt Cancer Center Stanford Children’s Health and Stanford Health Care UCLA

Hernan Barangan, a young filmmaker and cancer survivor, recently traveled the country fi lming young people with cancer for an extraordinary film he coproduced with Teen Cancer America: Cancer Rebellion. The fi lm really gives insight into the journeys of these brave young people. SUPPORT AND SERVICES

Teen Cancer America has a comprehensive web site (www.teencancer america. org) offering peer support in the form of patient blogs. Visitors can find ways to get involved and information on fundraisers such as concerts, races, and buying and selling through eBay. The site includes a tool for posting items to the auction and the stress-relieving coloring campaign “Color with Care.” Finally, young patients with cancer and the people who care about them can access

University Hospital Case Medical Center Rainbow Babies & Children’s Hospital and UH Seidman Cancer Center Vanderbilt University Medical Center Yale New Haven Hospital

links to hospital partners, corporate sponsors, and other resources. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. A snapshot of adolescent and young adult cancers. National Cancer Institute web site. https://www.cancer.gov/research/progress/snapshots/adolescent-young-adult. Accessed March 15, 2017. 2. Nolan Smith@NdotSmitty. https://twitter. com/NdotSmitty. Accessed March 15, 2017.

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THE TOTAL PATIENT

Volunteer Programs Provide Companionship to Cancer Patients in Their Last Hours Bette Weinstein Kaplan

ith so many ways to volunteer our time, few people would think sitting with a dying patient is right up there at the top of the list. Yet it is for many people. Hospital staff throughout the United States are aware that patients benefit from the presence of another person throughout their hospitalizations, and even more so at the very end of life. However, many patients are in situations in which no one is available to sit with them in their final hours. A patient may not have relatives living nearby or any relatives at all. Or a patient’s death may be imminent, but the family member who is sitting with the patient is unable to stay. The situation may be that no one knows that a loved one is hospitalized or that the patient is near death. Two programs that address these types of situations are “No One Dies Alone” (NODA) and the “Vanderbilt Vigil Volunteers” (V3).

NO ONE DIES ALONE NODA was conceived by Sandra Clarke, RN, a nurse at Sacred Heart Medical Center in Eugene, Oregon. A patient close to death asked her to stay with him, but she had to tend to other patients on the floor. When she was finally able to get back to the dying man, she saw that he had passed away alone. The experience inspired her to address the problem of patients dying

alone. Her solution became “No One Dies Alone,” and since its conception in 2001, NODA has been adopted by many medical centers throughout the country.1 No One Dies Alone is volunteerbased, using an Internet site for volunteers to sign up. Potential program volunteers must sign a confidentiality agreement, submit to a background check, and undergo current tuberculosis testing. The volunteers, referred to as Compassionate Companions, agree to be available for 1 week at a time and are called in by phone or email when a patient needs a companion.

Two programs that address these types of situations are NODA and V3. Some hospitals require volunteers to stay with a patient for 2 or 3 hours, although most stay as long as necessary during their week. Overnight shifts are usually longer. When a patient is within 72 to 48 hours of death and has no loved one available, the physician notifies the nursing supervisor or chaplain, who relays the information to the NODA

48 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

coverage coordinator. The notification process is established and soon a Compassionate Companion is on the way to the dying patient’s bedside. VANDERBILT VIGIL VOLUNTEERS The program at the Vanderbilt University Medical Center in Nashville, Tennessee, is modeled after “No One Dies Alone.” Rebecca Hixson, a palliative care nurse, developed the program along with Chaplain Matt Frierdich; Mohana Karlekar, MD, medical director of the Palliative Care Unit; and Andy Peterson, director of Pastoral Care and Volunteer Services. Despite always having the intention of doing what’s right and best for the patient, there are so many times that we as nurses feel we are not doing enough, explains Ms Hixson. “This program really helps to close that loop.” Although the 6-month-old V3 program originally required eligible patients to be within 48 hours of death, it is now open to any patients with limited time left and no one to be there with them. Vanderbilt Medical Center serves a multistate area, and patients’ families might be too far away to sit with their dying loved ones. They are often financially stressed and unable to visit as often. In one situation, the cost of gas for the family car was a factor because the round trip from home to hospital was 4 hours.

Patients in situations such as these are candidates for the V3 program, and their families are relieved to know that someone will be at the bedside with their loved one around the clock. The volunteers also provide respite in cases where there is only one person available to sit with the patient. V3 volunteers come from all over, not just from the medical center. Ms Hixson noted that social media has played a role in informing the neighboring community as well as the hospital community about the program, and people are eager to volunteer. A recent training session had 30 volunteers in attendance, 28 of whom said they were there because they had experienced someone in the family dying or they were unable to be close to an ill family member (R Hixson, oral communication, February 2017). FINDING FAMILY IS A PRIORITY

The staff makes every effort to locate people connected to each patient who is alone. Chaplain Frierdich shared the story of the fi rst patient in the program. Finding someone connected to her took the team a long time, and

although a very distant relative was finally contacted, there really was no one available to be with the patient. She was truly at the end of her life and was restless and uncomfortable. Medications helped settle her a bit, but the patient did not actually settle down until the V3 volunteer went into the room that evening. The effect was immediate. The physicians noticed at rounds the next day that she had not needed as much medication as she had in the days prior. In exploring what had made the difference, all anyone could think of was the presence of the volunteer (M Frierdich, oral communication, February 2017). “As a chaplain, I believe that being present with people is healing. To be able to offer that as widely as possible beyond what our chaplain staff can give is just so valuable to all the people that we serve and to our community,” explained Chaplain Frierdich. “This is especially true for our staff, who benefit from [the V3 program] as much as the families and patients do. The program creates a sense that we’re doing the right thing, and this helps people in their daily work throughout the hospital.”

COMPASSION AT THE END OF LIFE In addition to training for the volunteers, these programs provide their volunteers with supplies to help them comfort patients. NODA volunteers attend to dying patients equipped with a bag containing inspirational and soothing CDs and other helpful items. V3 volunteers pick up a kit at the desk packed with snacks and drinks for the volunteer and things such as cards and coloring pages for the patient. Each volunteer on a shift writes a card for the patient. The result is heartwarming: a patient who previously had no one has a bedside table covered with cards and notes, just as if family had been there. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Shiller J. ‘Will you stay with me?’: The No One Dies Alone program. Modern Medicine Network Web site. http://www.modern medicine.com/ modern-medicine/news/modernmedicine/ modern-medicine-feature-articles/ will-you-stay-me-no-one-dies-al. June 1, 2009. Accessed March 15, 2017.

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or many people in distressing and potentially traumatic circumstances, journaling can offer a safe space to express and process emotions without fear of judgment or risk of burdening loved ones.1 Although several studies have more specifically researched the effect of journaling on a patient with cancer’s ability to cope with their diagnosis,2,3 less attention has been given to the potential added benefits of sharing that writing with others who are facing similar struggles. For nearly a decade, CancerCare has offered an online-based therapeutic writing group for people receiving cancer treatments or who have recently completed treatment. The group lasts 15 weeks and is built around a structured program of readings and writing exercises that focus on specific aspects of the cancer experience. One chosen topic, for example, is the experience of sharing diagnosis news with the other people in your life; after reading some related articles and book excerpts, group members are asked to consider the following questions and share their written responses with the group: • Whose reaction to your diagnosis was most surprising? • Which person did you find most difficult to share the news with? • What was most helpful to you when sharing the news of your diagnosis with others? Another group topic focuses on the concept of time as it relates to waiting - waiting for medical news,

Therapeutic Writing in Group Work For Patients With Cancer Caroline Edlund, LCSW-R

test results, certainty, or clarity. One exercise in this topic is metaphorical: participants are asked to write a piece from the perspective of a “rope about to snap,” giving them license to project some of their own feelings of fear, uncertainty, or anger onto this fantasy

scenario, and to express those emotions from a different perspective. As participants add their written responses to the group space, other group members have the opportunity to offer words of support and acknowledgment to one another, ask questions, or provide additional feedback (although the feedback is not about the mechanics of the writing itself as this is not a writing workshop and participants are not seeking to improve their writing craft). Feedback, instead, focuses on the emotional content of what is shared and the creative process. If participants are struggling to complete any of the exercises, there is a designated space where they can request support from the moderator and one another. While CancerCare has not conducted any formal studies on the impacts of participation, the aim and our hope in offering this group is to encourage through the writing process a new understanding or reframing of these significant aspects of someone’s cancer experience. Even more crucially, CancerCare believes the process of sharing one’s writing with others - within the safety of this professionally facilitated group - can offer participants a much-needed sense of community, combating the sense of isolation that so many patients with cancer experience. Over the years, CancerCare has received some wonderful feedback on the program. Upon completion, one participant wrote: “This experience was very helpful in that it made me realize there are people out there

Journaling can offer a safe space to express and process emotions without fear of judgment or risk of burdening loved ones. 50 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

FROM

having the same fears and thoughts that I do. People from all walks of life coming together to embrace something as painful (mentally and physically) as cancer is truly inspirational.” Another shared: “This group made me think more deeply about many of the aspects of my discovery, treatment, and recovery. [The writing prompts] helped me find a richer understanding of what has passed and how I dealt or did not deal with the many aspects of handling cancer.” This kind of feedback has encouraged us to continue offering this program. However, what are the potential limitations of this kind of group and what should you consider before launching similar programming in your own setting? For participants to feel comfortable sharing at times highly personal histories and reflections, we as facilitators must create a sense of safety in the group space. One way we do this is through requiring all registered members to post regularly, essentially

declaring their presence to one another. No members are allowed to “lurk” or only read others’ writings. While we have found this approach helpful in engaging many of the participants, this requirement is not always feasible for everyone. Some group members may be managing significant disease or treatment side effects or navigating other major life stressors that make consistent participation difficult. In such cases, we contact those members privately to offer them the option of joining a future group session or refer them to other supportive services. So how can you incorporate therapeutic writing into your group work with patients with cancer? There are many excellent resources that can help you get started. A simple internet search of “journaling prompts” calls up a number of free websites listing questions designed to spark reflection. These can be further tailored to work for your specific patient population, and integrated into an existing support group or perhaps used to help

structure a new group dedicated to therapeutic writing. If you would like to refer any of your patients to CancerCare’s Healing with Words therapeutic writing group, please encourage them to visit our website to learn more and register at www. cancercare.org/support_groups/89. Caroline Edlund is the Online Support Group program director at CancerCare. REFERENCES 1. Lepore SJ, Smyth JM. The Writing Cure: How Expressive Writing Promotes Health and Expressive Writing and Emotional Well-being. Washington DC: American Psychological Association; 2002. 2. Smith S, Anderson-Hanley C, Langrock A, Compas B. The effects of journaling for women with newly diagnosed breast cancer. Psychooncology. 2005;14(12):1075-1082. 3. Bolton G. “Writing is a way of saying the things I can’t say” – therapeutic creative writing: a qualitative study of its value to people with cancer cared for in cancer and palliative healthcare. Med Humanit. 2008;34(1):40-46.

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www.OncologyNurseAdvisor.com • MARCH/APRIL 2017 • ONCOLOGY NURSE ADVISOR 51

ASK A PHARMACIST

Molecular model of arsenic trioxide

Arsenic and APL: Review of Therapy for an Acute Leukemia I was surprised to see an order for arsenic recently. What is this being used for? I thought arsenic went out with that old Cary Grant movie! —Name withheld upon request

Arsenic is currently supplied in the United States as arsenic trioxide (Trisenox; also known as ATO). Arsenic trioxide is used in the treatment of acute promyelocytic leukemia (APL). Many induction and consolidation regimens for acute promyelocytic leukemia include arsenic trioxide in combination with all-trans retinoic acid (ATRA; tretinoin [Vesanoid]) and may include an anthracycline depending on if the patient’s acute promyelocytic leukemia is high-risk or low-risk. Depending on the initial

APL treatment a patient received, arsenic trioxide may also be a treatment option in cases of relapsed acute promyelocytic leukemia and may be given with all-trans retinoic acid and an anthracycline. Common adverse reactions to arsenic trioxide include leukocytosis, gastrointestinal side effects (eg, nausea, vomiting, diarrhea, abdominal pain), fatigue, edema, hyperglycemia, dyspnea and cough, rash, itching, headaches, and dizziness. Arsenic trioxide may also prolong the QTc interval and may cause AV block or torsades de pointes. Electrolytes should be monitored and corrected throughout treatment. In addition, the patient should be monitored via ECG prior to starting treatment and regularly during treatment with arsenic trioxide to reduce the risk of severe cardiac adverse events. Patients receiving induction therapy for acute promyelocytic leukemia, including those receiving arsenic trioxide, are also at risk of developing differentiation syndrome, which may include fever, dyspnea, weight gain, pulmonary infiltrates, pleural or pericardial effusions, and leukocytosis. If differentiation syndrome develops, patients should immediately be treated with high doses of corticosteroids. Patients receiving arsenic trioxide should be counseled on the signs and symptoms of differentiation syndrome, and to report any symptoms

experienced during the infusion. Arsenic trioxide is typically administered intravenously over 1 to 2 hours, but if patients experience acute vasomotor symptoms during treatment, the infusion can be extended to as long as 4 hours. Patients should also be educated to review any new medications with their health care team, to mitigate potential QTc prolongation. Other symptoms such as gastrointestinal side effects are generally mild and should be managed supportively. ■

2017 DRUG TAKE-BACK DAY The next DEA National Prescription Drug Take-Back Day is scheduled for Saturday, April 29, 2017. These events are designed to combat the abuse of prescription drugs by giving patients a safe means to dispose of medications they no longer use. Sites typically accept controlled substances as well as other medications, although patients needing to dispose of oral chemotherapy or other hazardous medications may need to check with their local sites to ensure these will be accepted. More information on Take-Back Day events, as well as a useful search function, are available at www.deadiversion.usdoj.gov/ drug_disposal/takeback/index.html

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

52 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2017 • www.OncologyNurseAdvisor.com

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